Fundamentals of nursing Exam 2
which patient statement best reflects generativity according to Erikson's generativity versus stagnation developmental stage?
"I am single and act as a mentor to the new employees of my organization"
if a patient is scheduled for surgery under anesthesia, which statement by the patient requires the nurse to take action and provide additional teaching?
"I can eat a snack with my morning medicine before the procedure"
the nurse is preparing to reinforce teaching about how to administer an insulin injection with an adolescent patient. The patient asks the nurse, "can I watch a video on how to administer the injection?" which response would the nurse provide to the patient?
"I can incorporate a video into the teaching"
which statement by the parent of a 4 year old regarding time out reflects an appropriate application of this method of discipline?
"I explain the reason for time out before and after disciplining him"
which statement by a young adult would indicate meeting Schaie's developmental task of achievement?
"I have found a job that I love and builds on my education"
which statement made by a teenager to the nurse during an interview would indicate that the teen is successfully achieving an age specific developmental task according to Erikson's theory?
"I have recently come out to my parents that I am gay"
which statement by a child would lead the nurse to conclude that the child is part of a blended family?
"I live with my mother, step father, and his children at our home in New York"
which statement by a young adult to the nurse during a wellness visit would indicate not achieving a developmental task according to Erikson's theory?
"I seem to have difficulty forming lasting relationships with people outside my family"
Which statement by a patient would the nurse correlate with Schaie's stage of cognitive development for older adults?
"I spend a lot of time with my grandchildren"
which statement by a patient presenting for an annual physical examination requires further assessment?
"I take naps during the day because I wake up too early in the morning"
which statement by the nurse demonstrates self awareness and confidence in one's clinical competence? select all that apply
"I was incorrect when I said the patient had returned from x-ray" "I believe I can perform this procedure without assistance" "I'm not certain, so please confirm I have the right steps in mind first" "that's a great question that I don't know how to answer yet. Let me look that up before doing this"
which response by an older adult patient at risk for osteoporosis indicates an understanding of teaching regarding health promotion?
"I will include extra dairy in my diet"
a pregnant mother is talking about physical development with the nurse. Which statement by the mother indicates a need for additional teaching?
"It begins during adolescence"
the parents of a 16 year old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?
"adolescents love to sleep late in the morning"
which statement reflects an effective technique for a patient to learn how to change their dressing?
"after discussing dressing changes with you, I am going to review with you how to perform a dressing change while I change your dressing"
which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?
"all individuals move through all six stages in a sequential fashion"
which question would the nurse ask a couple who is struggling to adjust to their last child leaving the home?
"are there any hobbies or other interests you would like to pursue?"
which assessment question would the nurse include when gathering a sexual history from an older adult who is postmenopausal?
"are you in a monogamous relationship"
which statement would the RN include when instructing a LPN about appropriate times to start implementing the teaching plan for a patient?
"at a time previously agreed on between the nurse and the patient"
the parents of an 8 year old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?
"at this age, the child is developing his or her own personality"
which question would be appropriate for the nurse to ask before beginning the teaching technique of demonstration to an older patient?
"can I clean your glasses for you"?
the nurse is preparing to teach a patient how to inject insulin. Which question would the nurse ask before demonstrating the procedure?
"can you show me where you can administer your insulin"
when gathering data, which question would the nurse ask an older adult patient to assess short term memory loss?
"can you tell me the date"
after providing education to a patient with gout, the patient tells the nurse they are "confused about their treatment plan". Which question would the nurse ask the patient?
"can you tell me what you understand about your condition?"
which response by the nurse would be appropriate when an 80 year old patient asks, "Which hormonal change may be caused by my age"?
"delayed insulin response can occur" "there is a decrease in metabolic rate" "production of all hormones is slowed"
which response can help a patient resolve their feelings when the patients states, "there are so many things that I wished I did when I was younger, but I was too busy working and raising a family"
"do you have a good relationship with your family?"
which question would the nurse ask a young adult to determine if the patient is satisfactorily achieving an appropriate developmental task according to Freud's theory of development?
"do you have a job that you enjoy"
which response by the nurse would be appropriate when an 80 year old patient asks why she has lived longer than her twin sister and how there can be such a great difference?
"genes determine only 20% to 30% of longevity in people who live up to 85 years of age"
a family member accompanies their 82 year old father to the primary health care provider's office and states, "my father is ordering things online he does not need"
"has your father displayed any other concerning behaviors"
which question is most important for the nurse to ask an adolescent who reports feeling "down" or "blue"?
"have you ever had thoughts of suicide or of harming yourself"?
which statement by the caregiver of an older adult patient indicates that the patient may have dementia related memory loss?
"he is not as active at night as in the day"
which statement by the student nurse indicates the need for further teaching regarding interdisciplinary care maps?
"interdisciplinary care maps list only actions to be carried out by the primary health care provider"
a new mother is intrigued by the tube that attaches her with the infant. The mother asks the nurse what this tube is called. Which response by the nurse is accurate?
"it's called the umbilical cord"
a charge nurse is debriefing with an LPN who strained her back while assisting a patient in transferring from the bed to a chair. Which directive provides constructive criticism for the LPN? select all that apply
"it's important to take care of your back, so next time, move the bed to its lowest position and the chair to its highest before helping the patient move. Let's practice right now" "back pain can be uncomfortable, so focus on allowing the machinery in the room to help us do the heavy lifting. Work with another nurse next time to ensure you're doing it properly"
which statement exemplifies self confidence? select all that apply
"let me know if you'd like help starting that IV" "I'm having trouble finding a vein. Could you help me start this IV?" "I don't think I'll need help, but I'll let you know if the situation changes"
which response would the nurse provide the parent of a young child who asks, "what is the best way to prevent my child from getting the flu?"
"make sure your child gets an annual flu shot"
which statement by a child would lead to the conclusion that the family pattern is patriarchal?
"my father makes all decisions regarding my education"
which statement made by an older adult patient during a routine physical examination requires the nurse to gather additional information?
"my hands and feet always feel cold"
which statement by an older adult patient regarding physiologic changes in older adults would indicate the need for further teaching?
"older adults are unable to remember words"
which statement would the nurse document as objective data during an admission and data collection interview?
"patient's eyes are downcast, and patient has a flat affect"
which statement by a nursing leader demonstrates effective communication? select all that apply
"please take Ms. Clarks temperature at 2:00 pm and let me know right away what it is so I can let her primary care provider know" "tell me immediately if Mr. Garcia's temperature rises above 101.2 F" "do you have any questions for me?" "Please come find me after you take next vital signs"
which response by the nurse would be appropriate when a 75 year old patient states, "at my age, there is no benefit in quitting smoking"?
"quitting will give you several benefits"
which response by a young adult during an education session regarding risky behaviors would require further education?
"substance use has now become the leading cause of death for people in my age group"
the nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?
"the moon follows me, and goes to bed when I go to bed"
which statement by the nurse is an example of a call out? select all that apply
"the patient is tachycardic" "oxygen levels have fallen to 85%" "blood pressure has fallen to 80/40" "cross type and match two units of blood"
which statement is an example of the CUS communication technique?
"the patient's low blood pressure is troubling and I am uncomfortable with this discharge order, especially considering the patient's age and likelihood of a fall"
which response would be appropriate when a patient with Alzheimer disease asks the nurse what makes people grow old?
"the reasons are unknown"
which response would the nurse provide the parents of an elementary school child who states, "Our child's school gave our child an intelligence quotient test. What should we know about it"
"the test examines the extent of your child's language and mathematical skills"
which response by the nurse would be appropriate when a patient asks which respiratory changes are associated with aging? select all that apply
"there is a decreased number of cilia" "there is a decreased vital capacity and tidal volume"
which statement by a care giver indicates effective learning regarding behavioral changes that take place in older adult patients with dementia related memory loss?
"this group may neglect personal hygiene and dressing"
the parent of a 4 year old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?
"this is common during hospitalization"
a patient has given birth to fraternal twins. Which statement by the patient indicates a need for additional teaching?
"twins have nearly the same genes
which information would the nurse include in the safety education for an older adult patient who received corrective lenses for presbyopia?
"use colors of contrast between walls and rugs"
which statement by the nurse indicates a need for further instruction about the methods of teaching cildren?
"using idioms while teaching is helpful"
the nurse is reinforcing discharge instructions to the parents of a 2 year old who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?
"we will be sure not to leave hot liquids unattended"
the nurse is assigning one of the staff nurses the task of taking a patient's temperature. which statement by the nurse indicates effective communication?
"will you please take the patient's temperature before lunch?"
a patient receiving education on diet and insulin administration states, "I did not understand anything that I was taught today" Which response would the nurse provide?
"would it be helpful to focus on one thing"
the nurse is preparing to provide education to a patient who speaks English as a second language. which question would the nurse ask the patient?
"would you prefer an interpreter to be present?"
which response by the nurse would be appropriate when a 25 year old patient asks how to increase height?
"you cannot become taller now; the body stops growing after a certain age"
which therapeutic response would the nurse recommend to a 56 year old patient who is concerned about an increase in forgetfulness?
"you may need to work harder to remember things; activities such as jigsaw puzzles can support cognitive health"
which response will be made by a nurse caring for a client scheduled for hysterectomy who starts to sob and says, "I told my husband that after this operation I'll only be half a woman. He told me not to worry, but I know that he was just putting up a front?
"you think this operation will affect how your husband feels about you as his wife?"
which statement exemplifies competence in nurse leadership?
"your provider usually makes rounds every morning. Let me find out what time they will be here for you"
the parent of a child who is dying of cancer asks the nurse whether he should tell his 7 year old son that his sister is dying. Which response by the nurse is the most appropriate?
"your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's possible death"
which response would be most appropriate to address the concern of a patient who states, "I frequently get up to the bathroom at night"
'How many times a night do you get up?'
which statement would lead the nurse to determine that an adolescent is engaging in egocentrism?
'no one understands what I am going through'
which instruction would the nurse give the parents of a newborn infant to keep the child safe?
'test the bathwater before putting the infant into the water'
a client with gastroesophageal reflux is to receive metoclopramide 15 mg orally before meals. The concentrated solutions contains 10 mg/mL. How much solution should the nurse administer?
1.5 mL
how many functional patterns would the nurse assess when using Gordon's model of functional health patterns?
11
which is an appropriate response by the nurse when a patient asks how old the longest living person lived?
130 years old
according to Erikson, intimacy versus isolation occurs during which age period?
18 to 35 years of age
which percentage of older adults has been reported to experience depression?
18%
which age range is physically the best years for reproduction?
19 to 26 years of age
levothyroxin 12.5 mcg orally each day is prescribed for a client with hypothyroidism. Six weeks later, the health care provider increases the dose to 25 mcg daily. The client asks the nurse whether the original pill prescription can be completed before starting the new dose. How many of the original pills should the nurse instruct the client to take daily?
2
Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1 mg scored tablets. How many tablets would the nurse administer?
2.5
a mother takes her child to the primary health care provider for a 1 year well visit. The mother tells the primary health care provider that the child weighed 8 lbs at birth. What should the approximate weight of this child be at 1 year of age?
24 lbs
when do the external genitalia appear in the infant?
3 months of age
at which point during a pregnancy does the fetal heart begin to beat?
3.5 weeks
which proportion of people who are older than 75 years of age experience hearing loss?
50%
the nurse knows that menopause generally occurs at which age?
51
a parent has brought a 1 year old child to the community clinic for a checkup. The nurse records the weight of the child as 22.5 pounds. If the child grew in the expected percentile, what would have been the weight of the child at birth?
7.5 lbs
which percentage of the population has been reported to be lesbian, gay, bisexual, or transgender?
8.1%
which agency would fine a long term care facility for incomplete or inaccurate documentation of resident care?
DHHS (Department of Health and Human Services)
which data collection method includes a functional model to represent the interaction between the patient and the environment?
Gordon's health patterns
which statement regarding medication adherence by the caregiver of an older adult patient with memory and vision impairment indicates effective learning?
I arrange the weekly pill minder box with a compartment for each day
which antibody is the first to be formed after exposure to an antigen?
IgM
which theorist developed a theory about how children learn and stressed the principles of organization and adaptation?
Jean Piaget
which type of leader assumes that the members of the team are competent and self directed and will do what must be done correctly and efficiently
Laissez-faire
the nurse knows that prioritizing patient problems is usually based on which factor?
Maslow's hierarchy of needs
which approach to data collection is the nurse using when gathering data on areas of basic needs?
Maslow's hierarchy of needs approach
a patient is fasting for 12 hours prior to surgery. Which status is recorded in the chart?
NPO
a 9 year old child measures ingredients and follows a simple recipe to make cookies. Which stage does this describe?
Piaget's concrete operations stage of cognitive development
which action will the nurse take to reduce situational factors that may impede patient education? select all that apply
Present material in a calm and relaxed manner move the patient to a conference room place a "do not disturb" sign on the door offer the patient an anti-emetic because of nausea and wait for relief before beginning to teach
which information would the nurse consider before delegating a task to unlicensed assistive personnel? select all that apply
UAPs orientation to the facility UAPs training in the task to be performed task is within the nurse's purview to delegate facility policies and procedures
which intervention would be included in the plan of care for an elderly client who has a right hip fracture?
Venous thromboembolism prevention
the nurse is caring for a 5 year old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?
a 10 piece puzzle
which client is most likely at risk to become a victim of elder abuse?
a 90 year old woman with advanced Alzheimer's disease
which statement about reimbursement for care delivered and equipment used in long term care facilities is accurate? select all that apply
a comprehensive resident assessment must be completed the nurse must make sure the minimum data set is completed fines may be imposed if documentation is incomplete state and federal agencies have deadlines for transmitting required information
which finding is expected by the nurse reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS)?
a decrease in CD4 T cells
a patient who has a blood pressure of 140/96 mm Hg is unable to afford the costly medication. Which alternative would the nurse suggest to help the patient control blood pressure?
a diet low in sodium
a computer would allow which patient to be easily identified by a nurse within the hospital setting? select all that apply
a high acuity patient an individual with special diets one who needs postsurgical care a patient with an upcoming procedure
which statement by the nurse indicates effective learning about the characteristics of an effective leader? select all that apply
a leader is a role model for the staff a leader is an effective communicator a leader is consistent in managing conflict
the nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which of the following?
a normal psychosocial response
which patient would be the priority when the nurse is caring for several patients?
a patient with coronary heart disease experiencing chest pain
a family member of an older adult patient who is bedbound tells the nurse that they are worried they will not be able to cope with the care. Which statement by the nurse would be most appropriate in addressing the family member's concern?
a social worker will be discussing community resources with you
which statement regarding the delegation of tasks to unlicensed assistive personnel is correct? select all that apply
a task requiring clinical judgment should not be delegated to a UAP a UAPs competency in the task should be documented prior to delegation the person who delegates a task to a UAP is accountable for the outcome of the task
when caring for a 3 year old child, the nurse would provide which toy for the child?
a wagon
which type of family is an example of a blended family
a woman bringing her adopted son into a new family when she remarries
which cue would be the nurse's priority for when transferring a patient from the bed to a wheelchair?
ability of the patient to assist
which factor would interfere with receiving proper telephone orders? select all that apply
accents distractions call interruption background noise unclear pronunciations
when attempting to administer an antiemetic to a patient who reports nausea and vomiting, the patient asks if the problem can be managed by taking a ginger supplement. Which action would the nurse take to ensure patient safety? select all that apply
accepting multiple solutions applying one's own judgment convincing the patient that multiple solutions exist
arrange the causes of death among adolescents in the United States according to the order of frequency
accidents homicide suicide drug overdose
which is the young adult stage of cognitive development according to the theory by K. Warner Schaie?
achievement stage
which is the main purpose of evaluating nursing care in a hospital?
achieves quality improvement
when giving constructive criticism to unlicensed assistive personnel, which action would the licensed practical nurse take?
acknowledge the feelings of the UAP
which theory proposes that people who continue to be interested in life and stay active will live longer?
activity
a patient is receiving pain medication via intravenous infusion after reduction of an open fracture. When entering the room, the nurse notices that the patient has a rash on the arms and neck. Which problem would the nurse need to address for the patient?
address the patient's reaction to the infusion
which health consideration would the nurse focus on when caring for an 8 year old patient? select all that apply
adequate sleep regular dental care nutrition education keeping kids busy with outside activities
a client with type 1 diabetes mellitus has a glucose level of 258 mg/dL at bedtime. A prescription for sliding scale regular insulin exists. Which action would the nurse take?
administer the insulin as prescribed
which action is an example of a dependent nursing intervention?
administering acetaminophen as prescribed for fever above 101 F
which task is prohibited to delegate to an unlicensed assistive personnel?
administering intravenous infusions to patients
the nurse is planning to educate a patient about basic hygiene measures. The patient complains of a headache and informs the nurse that he will not be able to attend the session. Which action would be most appropriate?
administering oral analgesics before the session
a child reports to the nurse, "I lost my parents in an accident and I live with new parents." which type of family is reflected in this situation?
adoptive
which service to provide structured, age appropriate activities for aging parents would help a middle aged child who works?
adult day care
the nurse is planning to teach self care and hygiene methods to a group of people in a community center. The nurse decides to explain the benefits of good hygiene before teaching the hygiene measures. Which domain of learning would the nurse be using?
affective
the nurse is teaching a patient with a newly diagnosed congestive heart failure about behavioral and lifestyle modifications. On which domain of learning would the nurse focus while teaching this patient? select all that apply
affective cognitive
which would be the most likely cause of memory decline in a 70 year old patient who reports frequent memory lapses but is otherwise a lively and optimistic person?
age related decline
which term is used to describe discrimination of an older adult worker in favor of a young adult worker?
ageism
which statement is correct regarding older adults?
ageism is illegal in the United States
which patient problem would the nurse give priority?
airway issues
which is the highest priority of nursing care?
airway management
which component would be needed for a concept map for a newly diagnosed diabetic? select all that apply
alc of 8.5 glucometer teaching initiated follow up after discharge with an endocrinologist notation that the patient is experiencing polyuria, polydipsia, and polyphagia metformin 1000 mg PO twice a day and insulin glargine 10 units SQ at bedtime prescribed
which factor is associated with risky sexual behavior among adolescents and teen pregnancy?
alcohol abuse
a 16 year old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development?
allow the child to participate in activities with other individuals in the same age group when the condition permits
what is the most appropriate suggestion the nurse should provide when a parents asks if her 2 year old child can take a bath alone?
allow the child to wash herself with supervision
the nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents?
allow the infant to signal a need
which action would the nurse perform when collecting information from an older adult patient?
allowing more time for responses
the nurse would plan which to encourage autonomy in the client who is a resident in a long term care facility?
allowing the client to choose social activities
how does the knowledge of human development help nurses in their daily practice?
allows nurses to understand expected behaviors and anticipate problems
which phase of the scientific method is similar to the identification of problems in the nursing process?
analyzing the information
which priority action would the nurse take when preparing to provide morning care for a newly admitted patient who was diagnosed with diabetes type 1?
analyzing the patient's health care record
which health problem would the nurse suspect in a late middle age male patient who is reporting symptoms of reduced libido, depression, fatigue, and mood changes?
andropause
which preventive examination would the nurse recommend to a 27 year old female patient? select all that apply
annual pelvic examination periodic Mantoux test annual physical examination periodic Papanicolaou test
which nursing intervention would reduce effective communication?
answering the patient spontaneously without a second thought
which assessment would the nurse perform before administering digoxin to a client?
apical heart rate
the nurse has been asked to apply topical analgesic cream to a patient with muscle pain. The patient tells the nurse he prefers using coconut oil to relieve pain rather than an analgesic cream. Which nursing action would be most appropriate in this case?
applying both coconut oil and analgesic cream to the affected area
which task can be delegated to unlicensed assistive personnel? select all that apply
applying cold packs assisting with ambulation giving a bath feeding patients
the nurse informs a patient about which health problem that people who are older than 75 years of age commonly experience? select all that apply
arthritis hypertension heart disease
which health problem would the nurse associate with people older than 75 years of age? select all that apply
arthritis hypertension heart disease
which action would the nurse take when accepting telephone orders in the nursing care setting? select all that apply
ask the provider to wait until you have the screen open to the patient's medical record enter the order verbatim as it is given by the provider verify the spelling of any medications or diagnostic tests with the provider ask another nurse to listen in and verify orders given late at night
which consideration would the nurse make when teaching self care instructions to a patient?
asking for feedback at frequent intervals
which teaching principle would be helpful in promoting learning in older adults? select all that apply
asking for feedback from the patient presenting one idea or concept at a time using audio and visual cues while teaching
the primary health care provider prescribes 4 units of insulin injection for a patient and asks the nurse to teach the patient about self administration. After teaching, the nurse asks the patient to demonstrate. The patient draws 1 unit more than what is prescribed. Which action would be appropriate?
asking patient to draw it again and evaluating the demonstration
the nurse is teaching a group of people with heart disease about dietary modifications. Which action by the nurse would maintain the attention and participation of the class? select all that apply
asking questions making eye contact providing a demonstration
the nurse is teaching an older patient to monitor blood sugar. Which information would the nurse include in the teaching?
asking questions frequently to check for comprehension
the nurse is teaching a patient with chronic obstructive pulmonary disease who has a low level of education about management of care at home. Which nursing intervention would help the patient learn effectively? select all that apply
asking the patient to demonstrate the use of an inhaler showing the patient a placard with a "no smoking" symbol showing a poster with a picture of a person wearing a mask
the nurse is obtaining a urine sample from a patient for urinalysis. The nurse must attend to another patient immediately and cannot take the specimen to the laboratory within 15 minutes. Which nursing action would be appropriate in this case?
asking the unlicensed assistive personnel to take the specimen to the laboratory
a client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch, the nurse identifies that the client is diaphoretic and trembling. Which action would be implemented by the nurse?
assess the client's blood glucose level
the nurse is caring for a patient with diabetes mellitus who is hospitalized. Which priority intervention would the nurse perform for the patient?
assessing blood glucose regularly
the nurse has prepared a list of tasks to be completed. Which task would be the priority when providing care?
assessing the patient who is unconscious
place the steps of the nursing process in correct order
assessment diagnosis planning implementation evaluation
the nurse leader is organizing the work of a unit. Which action would the nurse leader take to achieve this task effectively? select all that apply
assigning and delegating tasks to the staff dividing patients quickly among the staff being flexible about time for unforeseen events analyzing the strengths of each team member
which nursing action is an example of an interdependent action?
assisting a stroke patient perform arm strengthening exercises
when creating a plan of care, which action would the nurse take during the implementation stage of the nursing process? select all that apply
assisting the patient with activities of daily living using nursing knowledge and skills to promote and maintain health observing, recording, and reporting significant changes in the patient's condition
a group of children around 2 to 4 years of age are playing among themselves and sharing their toys and activities. Which type of play are the children demonstrating?
associative play
when would the nurse enter time fixed tasks in the work schedule?
at the set time
a patient who has undergone an appendectomy is ready for discharge. Ideally, when would discharge planning begin?
at the time of admission
which action would the nurse take initially for a client experiencing moderate to severe anxiety after the health care provider has explained the head and neck surgery that is scheduled?
attempt to discover what the client is concerned about
which action would the nurse take when performing a focused assessment?
auscultating breath sounds on a patient diagnosed with pneumonia
when the nurse is completing a physical assessment of a patient's chest as part of the admission process, in which step would the nurse use stethoscope?
auscultation
what type of family pattern are the parents dominant and the children do not have a say?
autocratic
which theory of aging would the nurse associate with rheumatoid arthritis?
autoimmune
which action would the nurse take when educating a pediatric patient? select all that apply
avoid using big words and idioms use dolls and play equipment to teach skills instruct in short, but meaningful sessions
which component is in the psychanalytic theory of Sigmund Freud? select all that apply
awareness levels personality components psychosexual development
which appropriate coping strategy would the nurse recommend to patients suffering from middle age stress related problems? select all that apply
becoming involved in hobbies engaging in social activities participating in a religious organization
a patient delivered an infant before her due date. When is an infant considered premature?
before 38 weeks of gestation
the nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?
beginning of toilet training
which action is required as part of the patient's discharge planning? select all that apply
beginning the plan for discharge at the time of admission assessing if the patient requires special needs assessing for appropriate teaching moments providing brief, focused learning opportunities to teach about self care
which action would lead the nurse to determine that a child is in the intuitive thought substage of Piaget's stage of preoperational thought?
begins to solve problems
which term represents the desired changes or additions to current behaviors and attitudes?
behavioral objectives
which action demonstrates an effective communication strategy? select all that apply
being courteous being respectful actively listening using a warm tone of voice
which kind of biologic change would be demonstrated when a 32 year old patient with depression asks the nurse, "why can't I look as young as I did when I was a teenager?"
benign senescence
which theory describes aging as a wear and tear of the body?
biologic
which theory claims that people are programmed to live for a certain period
biologic clock
the nurse is teaching a newly pregnant patient about embryo development during a routine procedure. The patient asks the nurse which term is used to describe the structure that develops in her uterus. Which response by the nurse would be appropriate?
blastocyst
which type of family is formed when both parents bring children from previous relationships into a joint living situation?
blended
based on the physiologic changes in the older adult, in which vital sign would the nurse most likely find pathologic changes for an older patient with poorly controlled type 2 diabetes?
blood pressure
which stage is part of a patient interview? select all that apply
body closing opening
which term best describes a young adult patient who returns to the parental home?
boomerang child
which characteristics define a preterm infant?
born before 37 weeks of gestation and weighs less than 5 lbs
a patient has given birth to twins and asks the nurse what food would be best for the babies for the first 6 months. Which response would the nurse give?
breast milk or infant formula
which disorder is characterized by binge eating followed by inducing vomiting or using laxatives to eliminate foods from the body?
bulimia
how should the nurse assess a newborn's grasp reflex?
by pressing the examining fingers against the palms of the newborn's hands
a Chinese patient has been admitted to the hospital and does not speak English. Which action would the nurse perform to obtain information about the present medical condition of the patient?
calling for an interpreter
which question would be appropriate for the nurse to integrate into the assessment of an older adult patient newly diagnosed with hypothyroidism? select all that apply
can you describe your energy level? how many hours a night do you sleep? have you noticed any change in your bowel habits? have you noticed any changes in your memory?
which kind of change exhibits the signs of slow red blood cell production and delayed immune response?
cardiovascular
which topic according to Erikson's theory would the nurse cover when helping a depressed middle age patient find new meaning in life? select all that apply
caring for older adult parents contributing to the development of younger people volunteering in community work or as a hospital aide
which eye problem is common during middle adulthood (35-64 years of age)? select all that apply
cataracts presbyopia
although motor development occurs rapidly in newborns, they can lift their heads sooner than they can lift their chests. Which pattern of development is this?
cephalocaudal
which response by the nurse would be most appropriate when a young adult female patients asks about which health screenings she should be undergo?
cervical cancer, hypertension, and breast cancer
which nursing intervention would help provide quality care to a patient who is receiving intravenous fluids prescribed at 500 mL over 8 hours?
changing the intravenous cannulas per the facility's policy
which time management technique would the nurse use when making rounds? select all that apply
check all equipment during your initial assessment determine what supplies will be needed for each patient during the initial assessment
a patient who was injured in a fire is brought to the emergency department and is unconscious with a serious burn injury and blistering of the skin. In which order would the nurse provide care for this patient?
check for consciousness prevent further blistering evaluate the burn dress the wounds
place in the correct order interventions the nurse would follow for a patient who was admitted to the emergency department after an accident?
check whether the patient has patent airway assess the patient's heart rate and rhythm administer analgesics to the patient assess the patient's nutritional status
which intervention would the nurse use during data collection when planning to assess a patient with rheumatoid arthritis of the left knee? select all that apply
checking mobility asking about current and past medication use considering the use of any over the counter drug and alternative therapy
which action would provide the nurse information about chronic conditions the patient may have that may not be initially evident?
checking the medication administration record (MAR)
which action would the licensed practical nurse perform to obtain the weight of a patient who has been in the inpatient unit for the past 3 days?
checking the patient database
which statement describes an effective way to initiate patient teaching?
choose an appropriate moment that is good for the patient
the nurse is providing education to a 7 year old patient and their parent regarding the treatment of lice. Which educational statement would the nurse provide?
close your eyes when you are getting your hair washed
in which part of the patient interview would the nurse ask a patient if they have any questions?
closing
which learning domain would the nurse focus on when providing education to a patient who says, "If I'm supposed to wear a mask, I want proof that it will protect me from illness"
cognitive
the nurse is teaching a patient with chronic diabetes how to self administer insulin and adjust the dosage according to blood sugar levels. Which domain would be required for this learning? select all that apply
cognitive psychomotor
the nurse is caring for a patient who was revived after a heart attack. The nurse finds that the patient has a total cholesterol of 240 mg/dL. In which order would the nurse perform the interventions in the patient's care plan?
collect the patient's data and analyze the reports. Plan patient treatment based on how he or she prioritizes the problems. The nurse would determine measures to reduce risk. Administration of medication on time. Suggest dietary changes. Evaluate the effectiveness of treatment by assessing blood pressure and monitoring for adverse drug reactions
place the steps in correct order when developing a preliminary nursing care plan
collect the patient's data for a database, and analyze the database choose the appropriate nursing diagnoses and rank them based on priority plan the nursing care by defining goals and listing expected outcomes implement the nursing interventions evaluate the actual outcomes of each nursing intervention
a patient who requires education tells the nurse they learn best by hearing the information. Which mode of earning would the nurse incorporate when teaching the patient how to change a surgical dressing?
combination of teaching
which action would the nurse take when performing the evaluation step of the nursing process on patient care?
comparing actual patient outcomes to the expected outcomes
which action would be important for the licensed practical nurse to take when caring for a patient who has intravenous fluids running?
comparing the information from the IV container that is hanging with the primary health care provider's prescription
which would be the primary cause of a 60 year old female patient who has lost 1 inch in height but has not been diagnosed with osteoporosis?
compression of the spinal column occurs as intervertebral disks shrink
which statement about computers in the nursing care setting is accurate? select all that apply
computers are essential to documenting patient care needs computers assist nurses in providing patient care computers allow for various departments to track equipment and supply orders and usage computers allow team members to share patient care information in real time
the nurse suggests that a patient avoid eating cabbage because the patient's thyroid stimulating hormone is 4.12 mlU/L. Which skill would be most effective for the nurse to correlate the relationship between diet and condition?
concept mapping
the nurse suggests that a patient avoid eating cabbage because the patient's thyroid-stimulating hormone is 4.12 mlU/L. Which skill would be most effective for the nurse to correlate the relationship between diet and condition?
concept mapping
in which cognitive development stage is a child at 8 to 11 years of age?
concrete operational thought
the nurse is caring for a patient with diarrhea. Which quality in the nurse would reflect cognitive maturity?
considering multiple solutions for the patient's condition
the nurse has completed the initial data collection from a patient with chronic kidney disease. How would the nurse arrive at the nursing diagnosis?
considering the assessment database
a patient who received education from an occupational therapist states to the nurse, "I did not understand the information that the occupational therapist provided." which action would the nurse take?
contacting the occupational therapist
a nurse is working in a health care facility that does not have a patient education flow sheet. Which information about patient education would the nurse include in the nurse's notes?
content taught to the patient
which action indicates that the licensed practical nurse conducted a patient's assessment and data collection interview correctly?
continuing to collect data during every patient encounter
which advice would the nurse offer to help a patient in early middle age who is suffering from depression?
contribute to the community through social activities
two children are playing together with a board game. The children take turns rolling a die and drawing a card to gain parts used to complete a toy animal figure. Which type of play is being described?
cooperative play
damage to which cranial nerve may lead to a decrease in the client's olfactory acuity?
cranial nerve I
a patient with blood pressure of 150/96 mm Hg and a migraine headache has been advised to avoid foods rich in sodium. Which skill would be required to depict the relationship between diet and the patient's condition?
critical thinking
which element is required to carry out an independent nursing action? select all that apply
critical thinking nursing judgment
which data from the patient record would the licensed practical nurse read to identify patient problem areas?
cues
which data would the nurse use to make decisions about patient problems?
cues
which factor that affects learning would the nurse assess for an in group of patients before teaching them? select all that apply
cultural factors family members
which datum in a patient's database record reflects an interaction between the patient and the environment? select all that apply
cultural factors lifestyle factors
which order of the nursing process would the nurse follow while caring for a patient with tuberculosis?
data collection nursing diagnosis planning implementation evaluation
a mother is talking to the nurse about her son's new girlfriend. Which statement by the mother about dating would be appropriate from the perspective of human development?
dating helps young people discover their identity
after a cardiac event with a patient, the charge nurse calls the team of nurses who handled the case together to discuss what happened. Which type of communication strategy does this scenario describe?
debrief
when the nurse is collecting data from the older adult, which findings would be considered normal physiological changes? select all that apply
decline in visual acuity increased susceptibility to urinary tract infections increased incidence of awakening after sleep onset
which physical assessment finding would the nurse anticipate based on the physiologic changes in an older adult patient who is physically active?
decreased cardiac output
which therapeutic effect would the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema?
decreased intracranial pressure
an older client has been prescribed digoxin. The nurse determines that which age related change would place the client at risk for digoxin toxicity?
decreased lean body mass and glomerular filtration rate
which focus does risk management have in health care facilities?
decreases the risk for harm to patients
arrange the steps of the problem solving process in the correct order
define the problem consider all possible alternatives consider the possible outcomes predict the likelihood of each outcome choose the alternative with fewest undesirable outcomes
arrange the order in which the nurse would solve a problem effectively
defines the problem looks at the alternatives estimates the outcomes of each alternative chooses one of the possible alternatives discards the alternatives if the problem is not solved
in which section of the nursing diagnosis/problem statement would the nurse include information from the patient who states, "my stomach hurts"?
defining characteristic/ symptom
which step would the nurse include while constructing a nursing care plan? select all that apply
defining the overall goals and listing specific expected outcomes grouping the data according to body system and reviewing them for abnormalities considering all nursing interventions known to be useful for the type of probelm
which process would the nurse leader follow when problem solving? select all that apply
defining the problem estimating outcomes of the alternatives implementing the solution to the problem repeating the process if the chosen alternative does not work
which neurologic change would the nurse find in a patient with dementia?
degeneration of brain tissue
which change affects the endocrine system in an older adult? select all that apply
delayed insulin response decreased metabolic rate slowed production of all hormones
which component is included in emotional intelligence? select all that apply
delaying gratification empathizing with others motivating oneself despite persistent setbacks developing rapport with others
in which way is assignment of a nursing task different from delegation of a nursing task?
delegation is sharing part of a specific task with UAP
which statement is correct regarding delegation?
delegation occurs when LPNs transfer the authority to perform a selected nursing duty to unlicensed assistive personnel
the nurse knows that which factor would most affect the learning process?
dementia
the nurse knows that vitamin E is recommended for which problem? select all that apply
dementia heart attack
which type of condition would cause an older adult patient to have memory lapses and need instruction on the use of memory aids?
dementia-related
which type of family pattern favors negotiation, compromise, and growth?
democratic
which type of family pattern is reflected when all family members agree with individual opinions?
democratic
the nurse is teaching a child about management of epistaxis. Which teaching method would be most appropriate for effective learning?
demonstrating how to squeeze the nostrils on a doll
an infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. Which nursing intervention would be included to promote parent infant attachment?
demonstrating positive acceptance of the infant
the nurse is teaching a patient about the technique of blood sugar testing and must evaluate patient teaching for outcomes or effectiveness of the teaching. Which evaluation technique would be most reliable to ensure that the patient understands the information that has been taught?
demonstrating the technique of blood sugar testing
the nurse is preparing to educate a patient on how to use a monitor to measure blood pressure at home. Which instructional method would be the best to accomplish this?
demonstration
the nurse is educating a diabetic patient on how to self administer insulin. Which method would be appropriate for the nurse to use to educate this patient? select all that apply
demonstration return demonstration
a family member states to the nurse, "since my mother was diagnosed with dementia 1 year ago, I have noticed a significant cognitive decline" for which condition would the nurse anticipate assessing the patient? select all that apply
depression hypertension peripheral arterial disease
which activity of a 30 year old patient discussed during an assessment characterizes achievement of the appropriate stage of cognitive development according to Schaie's theory? select all that apply
describes reasonable goals for career development earns a living that supports personal, social, and financial survivial continues with post undergraduate education to expand career options
which information would be documented in the patient's medical record for a phone based medication order? select all that apply
description of the circumstances prompting the phone order name of any nurse or medical personnel verifying the phone orders note that orders were read back to provider after entering them into the system acknowledgment that accuracy of the orders were confirmed verbally by the provider
which is the purpose of a nursing audit?
determines that standards and outcomes are met
which rationale would be appropriate for advising a patient with incontinence to keep a voiding schedule at the bedside?
determines the usual pattern for voiding
which action by the registered nurse would be an example of clinical judgment?
determining a necessary change of treatment based on laboratory values
according to Erikson, an infant has which important task during the first 18 months of life?
developing an attachment to the mother
which step is involved in the scientific method of problem solving? select all that apply
developing solutions defining the problem analyzing the information
which change is brought on by aging? select all that apply
development of cataracts increased wax production decreased elasticity of ligaments and tendons
using Piaget's theory of cognitive development, which behavior would the nurse expect to observe in a 5 year old child?
develops routines for meals, bathing, and going to bed
the nurse is caring for a diabetic patient. Which topic would the nurse address while providing information about self care strategies to the patient? select all that apply
diabetic diet side effects of medications
which patient condition would be the nurse's priority?
difficulty breathing
the nurse in the preoperative ward must obtain a urine sample for a patient and help another patient ambulate down the hallway. Which nursing action would be the priority if another patient experiences a sudden drop in blood pressure that is associated with altered consciousness?
directing care to the patient who is experiencing falling blood pressure
which action would the nurse perform if a patient who recently has been taught crutch walking is now able to walk using crutches without assistance?
discontinuing the current interventions and developing new ones
which primary psychosocial task occurs during adolescence?
discovering an identity
which action will the nurse take to help the patient who feels overwhelmed or lacks confidence in their ability to learn? select all that apply
discuss the patient's feelings enhance the patient's self esteem break down education into small steps
which response by the nurse would be appropriate when the caregiver of an 83 year old patient states, "I am apprehensive to inform my mother that we are moving from our house; she may not want to leave the house where she spent 60 years of her life?" select all that apply
discuss the plan with all family members together respect your mother's feelings, and give her time to think
which aging theory proposes that older adults withdraw from society?
disengagement
which theory suggests that it is normal for older people and society to withdraw from each other?
disengagement
the nurse knows that which of these signs is an early indication of dementia?
disordered thinking
which item is assessed using the "resolve' portion of the Adaptation, partnership, growth, affection, and resolve (APGAR) screening tool?
distribution of finances and space
which consideration would the nurse recognize regarding children and adolescents of divorced parents? select all that apply
divorce may pose difficulties for children and adolescents trust in others may be affected they blame themselves for the family breakup children and adolescents may not understand the reason for the divorce
which safety instruction would the nurse include in a teaching session for adolescents?
do not text and drive
upon palpation of the fontanel of a 3 month old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action would the nurse take?
document the findings
by which method would the licensed practical nurse communicate updates to the registered nurse regarding the status of a patient receiving home health care?
documentation
which critical task would be the licensed practical nurse's priority while working?
documentation
which nursing action indicates the end of the planning process of patient care?
documenting of the care plan in the medical record
a nurse determines that a 1 day old newborn has a heart rate of 138 beats per minute. What is the best nursing action at this time?
documenting the heart rate
during the examination of a client who is 16 weeks gestation, the nurse notes bruises on the client's face and abdomen, but there are no bruises on her legs and arms. Further assessment is required to confirm which condition?
domestic abuse
which is an expected finding when caring for an infant who has undergone myringotomy because of recurrent otitis media?
drainage into the external auditory canal
which educational point would the nurse include in a blood pressure reducing teaching plan for a patient who presents to the clinic with hypertension? select all that apply
drinking minimal alcohol decreasing sodium intake participating in regular aerobic exercise
which factor is most important in maintaining healthy pregnancy?
early and regular prenatal care
which key recommendation would the nurse give to a pregnant patient to maintain a healthy pregnancy?
early and regular prenatal health care
which program would the nurse recommend to a single mother who is expecting her first child and seeking help to learn about methods of successful parenting?
early childhood and family education program
which is an important health related educational topic for patients between 18 and 35 years of age? select all that apply
early disease risky behaviors stress related illnesses
which category of independence is a significant milestone signaling that a person is a young adult?
economic
which topic would the nurse address while providing information about milestones that signal young adulthood?
economic independence
which action would the nurse take when accepting verbal orders in the nursing care setting? select all that apply
eliminate as much background noise as possible verify that providers on the unit enter orders into the computer directly only accept telephone orders when an order is time critical document telephone orders in patient's chart
according to Gordon's functional health patterns, which pattern is the nurse assessing when asking a patient who is severely dehydrated about bowel movements, urine output, and sweating?
elimination pattern
during which stage of prenatal development do the arm and leg buds appear?
embryonic
the nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? select all that apply
encourage the expression of feelings, concerns, and fears touch and hold the client's or family member's hand if appropriate be honest and let the client and family know that they will not be abandoned by the nurse
which intervention would the nurse follow to prevent muscle atrophy for a patient who has impaired physical mobility?
encouraging active range of motion exercises
the nurse is caring for a patient with rheumatoid arthritis who has difficulty moving the lower limbs. The nurse finds the patient takes prednisolone. Which action in the implementation phase would help provide better care to the patient?
encouraging activities of daily living and self care of the patient
which purpose of patient education supports the goal of preventing illness?
encouraging proper understandings of immunizations
which goal of patient education can the nurse accomplish by teaching a patient about proper diet after cardiac stent surgery? select all that apply
encouraging self care risk reduction promoting healthy behavior
supporting nursing care at the beginning of the mother infant relationship would include which intervention?
encouraging the mother to help out with simple aspects of her newborn's care
the parents of an 11 year old child with a terminal illness appear overwhelmed and anxious. Which response by the nurse is best?
encouraging the parents to express their feelings
which life event occurs during the senescence stage?
end of life
a nurse directs an unlicensed assistive personnel to perform a finger stick to assess a patient's blood glucose levels? which action would the nurse take prior to delegating this task?
ensure the UAP knows the standard procedures to follow in performing a task
which responsibility does a charge nurse have related to reimbursement for care delivered in the nursing care setting? select all that apply
ensures all staff document correctly ensures staff receive updates regarding new documentation policies ensures agency guidelines regarding frequency of documentation are being followed
which action reported by a parent during an assessment would reflect the family function of protection?
ensuring that children receive wellness examinations according to the recommended schedule
which action by the nurse indicates a need for additional teaching about taking phone prescriptions?
ensuring that the primary health care provider signs off on the prescription within 72 hours
which important consideration would the licensed practical nurse follow when taking verbal orders from the primary health care provider?
ensuring that verbal orders can be accepted
the nurse is caring for a patient who experiences dizziness when standing. Which action would the nurse take?
ensuring the patient's safety
which datum is objective when assessing a patient with gastroenteritis? select all that apply
erthrocyte sedimentation rate (ESR) of 22 mm/h hemoglobin of 11.2 g/dL axillary temperature of 98.6F
which information would the nurse provide to a 22 year old patient to support achievement of the developmental tasks for young adults?
establish a social group
which stage of family development involves decision making, conflict resolution, and communication?
establishment
which hormone is responsible for breast development?
estradiol
which hormone is responsible for the development of female secondary sex characteristics?
estradiol
which hormonal parameter is tested to evaluate whether a patient is entering menopause?
estrogen level
the nurse is caring for a patient with diabetes mellitus who has a foot injury and is on antibiotic treatment. On a follow up visit, the nurse observes that the patient has effective treatment. Which scientific method step would the nurse perform in this situation?
evaluating the decision
the nurse is preparing to provide education to a patient prescribed treatment for type 2 diabetes. Which initial action would the nurse take before initiating the education?
evaluating the patient's health beliefs
during which step of the teaching process would the nurse determine the teaching outcomes and measure a patient's achievement level of learning objectives?
evaluation
in which step of the nursing process is the goal to measure outcomes?
evaluation
the nurse is caring for a patient with hypertension and finds that the patient has improved blood pressure after modifying diet and performing exercise daily. Which phase of the nursing process would this describe?
evaluation
which component of the critical thinking process would the nurse carry out by gathering data to determine if expected outcomes have been achieved?
evaluation
which step of the nursing process includes comparing actual outcomes to expected outcomes to determine the effectiveness of an intervention?
evaluation
which step of the nursing process includes judgment of the effectiveness of the intervention or plan and is a collaborative process?
evaluation
which step of the nursing process is the nurse performing when asking a patient to rate pain on a scale 1 hour after analgesic administration?
evaluation
which step of the nursing process would the nurse perform for a patient who has recently undergone a caesarean delivery, is reluctant to move because of pain, and has refused the prescribed narcotic pain medication?
evaluation
which step of the nursing process would the nurse utilize when considering that a hypertensive patient's blood pressure has decreased from 180/100 to 130/82 mm Hg after receiving antihypertensive medications?
evaluation
which document would verify the competency of unlicensed assistive personnel? select all that apply
evidence of having completed training programs written evidence of competency from a licensed nurse
a young patient was admitted for a surgical procedure that was followed by a lengthy postoperative recovery. The patient is told that biopsies are positive for cancer and that chemotherapy and radiation will be necessary. Which factor would be most important for effective learning when planning a teaching session regarding wound care after discharge?
evidence of the patient's readiness to learn
which action would the nurse take when conducting a nursing audit for quality improvement purposes?
examining a series of patient records to determine whether nursing care met certain standards
which action would the nurse perform when examining a patient who reports pain in the knee during a routine office visit?
examining the joint's range of motion
which statement by an older adult patient is correct regarding the benefits of exercise? select all that apply
exercise helps reduce stress exercise can increase muscle tone it increases joint flexibility
which information would the nurse include in a teaching session for a male patient with a blood pressure of 118/78 mm Hg and a body mass index of 22.5? select all that apply
exercise regularly minimize sodium intake limit alcohol consumption eat a balanced, heart healthy diet
which concept would the nurse address when advising a patient about health habits related to diet and exercise? select all that apply
exercise regularly to increase endurance, strength, flexibility, and muscle tone maintain weight within normal limits, and reduce fat to less than 30% of total calories
which action effectively teaches a post surgical patient how to dress a wound? select all that apply
explain the process of dressing a wound demonstrate how to dress a wound have the patient dress the wound with supervision
which response would the nurse give to a patient who sustained a traumatic wound to the leg and expresses confusion about wound management after discharge?
explaining and demonstrating the necessary action to the patient and the patient's partner
which family consists of a traditional family and an additional family?
extended
which kind of family consists of a man, his parents, his wife, and their two sons?
extended
which data can the nurse use to evaluate the patient's support system?
face sheet
which statement explains why a nurse would need to know how to create a paper medication administration record?
facility computers may go off line
which is an attribute of good leadership? select all that apply
fair calm decisive assertive
which factor would the nurse consider before confronting a child about obesity?
familial and cultural influences are deciding factors in eating habits
which feeding instruction would the nurse give the parent of a 2 month old infant with the diagnosis of heart failure?
feed slowly while allowing time for adequate periods of rest
which reproductive cell is called a zygote?
fertilized ovum
which task can be delegated to unlicensed assistive personnel? select all that apply
filling water pitchers collecting a specimen removing a foley catheter
which activity would the nurse perform during the diagnosis phase of the nursing process? select all that apply
finding cues and patterns in the patient's data making conclusions related to health problems reviewing information collected about the patient
a group of nurses is planning to conduct a health awareness program in a community. Which topic would the nurses include in the program? select all that apply
first aid immunization balanced diet
which is a skill and attribute of a critical thinker? select all that apply
flexibility, curiosity, and insight ability to admit what one does not know recognition of one's own biases and limitation
which skill is an attribute of a critical thinker?
flexibility, curiosity, and insight ability to admit what one does not know recognition of one's own biases and limitations
which type of assessment/data collection method would the nurse use for a patient who presents with intense abdominal pain?
focused assessment
which approach to data collection would the nurse use when a patient is in acute distress?
focused assessment approach
which factor is involved in critical thinking?
focused, purposeful mental activity
the nurse wants to experiment with a new intervention on a patient. How would the nurse confirm the effectiveness of this intervention in an ethical manner? select all that apply
following evidence based practice focusing on the patient's values and beliefs related tot he new intervention
which time management strategy is important in nursing?
formulating general goals for the work day
which is the term used to describe the family type when a child is waiting to be adopted and is not with the natural parent?
foster
which type of family is reflected when a court orders to place the children in a private home after deeming the parents unable to care for them?
foster
which intervention would the nurse identify as decreasing the occurrence of pressure injuries for clients who are quadriplegic?
frequent repositioning of client
determining how well the patient performs activities of daily living is included in which section of the patient assessment?
functional status
which is the developmental task of a 2 year old child according to Erikson's theory of psychosocial development?
gaining basic self control
which intervention by the nurse caring for a patient with severe skin burns would be part of the implementation phase of the nursing care plan?
gathering equipment and supplies to perform a dressing
the nurse knows that which psychosocial stage of development occurs in middle adulthood?
generativity versus stagnation
which factor is most likely to have played a key role in the longevity of a 100 year old patient
genes
according to Freud, in which stage does an individual plan his or her life goals?
genital
which name are specialists in the study of aging given?
gerontologists
which is an independent nursing action?
giving a back massage
which intervention is an independent nursing action? select all that apply
giving a back massage teaching the patient about the side effects of a medication
which action by the nurse is a dependent nursing action?
giving medication to the patient
the nurse is planning to assess the cognitive development of a preschooler. Which task would the nurse pick?
giving the child a picture book
a child remarks, "I share my toys and snacks with my friends so they will like me more". The nurse determines the child is in which stage of moral development?
good boy-nice girl orientation
which statement about human growth and development is correct?
growth is a process that is orderly and predictable
which basic principle would the nurse include in a teaching session about how children grow and develop?
growth occurs in predictable ways development involves physical, cognitive, and psychological aspects
the nurse knows that which type of people generally live longer?
happy optimistic
which action would the RN take while receiving an admitting doctor's phone orders? select all that apply
have the patient's EHRs open enter the order word for word as it is given by the specialist ask another on shift nurse to be on the call to verify the order open the screen to accept a new provider order for the patient
which additional question would the licensed practical nurse include during assessment of a woman in middle adulthood who is complaining of recent "hot flashes" and heart palpitations? select all that apply
have you noticed any vaginal dryness? have you been having any trouble sleeping? have you been experiencing any headaches? do you feel like you are more fatigued than normal? do you feel like your moods change frequently or quickly?
the nurse would implement which activity to promote reminiscence among older clients?
having storytelling hours
which statement is accurate about American family life in the past 50 years?
health care advances contribute to longer lifespans
the nurse is assessing a patient and trying to identify the patient's learning needs and ability. Which factor would affect the patient's ability to learn optimally? select all that apply
hearing deficit physical strength shortness of breath
which is a leading cause of death for people in their 50s and 60s
heart disease
the nurse receives a report on four patients at the start of a shift. Which patient would be the nurse's priority?
heart patient complaining of chest pains and shortness of breath
how would the nurse help a family composed of two parents and a 21 year old unmarried son achieve an optimal family environment? select all that apply
help the son develop an independent identity help the son develop intimate peer relationships help the son establish a sense of self in his work
which collaborative practice would the nurse include when learning how to work effectively with unlicensed assistive personnel? select all that apply
helping UAP prioritize tasks providing constructive feedback documenting delegated tasks appropriately delegating tasks to UAP
the nurse is delegating a variety of tasks to an unlicensed assistive personnel. Which priority action would the nurse implement?
helping the UAP prioritize the tasks
which intervention is an interdependent nursing action?
helping the patient practice speech exercised introduced by the speech therapist
which priority level is assigned to a patient diagnosed with impaired gas exchange?
high
which type of fracture is the nurse most likely to find in a patient with fall related injuries?
hip
which is the leading cause of death for African American males?
homocide
which is the most common chronic health problem in people who are older than 75 years of age?
hypertension
at 4:30 pm, a client who is receiving human insulin every morning states, "I feel very nervous". The nurse observes that the client's skin is moist and cool. Which condition explains what the client is likely experiencing?
hypoglycemia
which factor is included the steps of the problem-solving process?
identification of the problem
which patient centered goal is the nursing process used to achieve? select all that apply
identify actual or potential health care problems deliver specific nursing interventions to solve problems evaluate caregiving to determine the achievement of outcomes
according to the clinical judgment model, which action occurs immediately after the problem has been defined?
identify possible options to address the issue
in which order would the nurse perform the scientific method of critical thinking to determine the cause of a drug's side effects?
identify the problem collect data from different resources formulate questions or hypotheses test the questions or hypotheses evaluate results of the test or study
after collecting assessment information in a patient database, which step would the nurse take to formulate a problem statement/nursing diagnosis? select all that apply
identifying missing data recognizing, analyzing, and clustering cues making inferences about the meaning of cues reviewing database for signs and symptoms of abnormalities
for which purpose would the nurse perform a quality improvement audit on a hospital unit?
identifying specific areas of patient care that must be changed
which type of discipline is appropriate to teach a parent to use with a 2 year old child who misbehaves?
immediate quiet time without toys
which theory of aging states that cells lose the ability to protect over the years and that death is caused by disease?
immune system failure
in which step of the nursing process are nursing interventions carried out?
implementation
the registered nurse delegates to a licensed practical nurse the task of monitoring intake and output for all patient who were treated for heart failure on a cardiac medical unit. Which component of the nursing process included delegation?
implementation
which step of the nursing process would the nurse carry out after the planning step?
implementation
the nurse is caring for a child with a high fever and instructs the parents to provide a sponge bath at regular intervals. Which scientific method step would the nurse perform?
implementing the decision
which is a goal of an outcome based quality improvement (OBQI) program?
improve nursing practice
which intervention would be the priority for a debilitated older adult patient who is bedridden, has reduced libido, is unable to eat, and experiences urinary incontinence?
improving skin integrity
the nurse is planning to reinforce discharge education for an older adult patient receiving physical therapy after a hip fracture. Which time frame would the nurse consider when providing education to the patient?
in the morning
which behavior would indicate that an older adult needs help? select all that apply
inability to find the right words forgetfulness resulting in unpaid bills unsanitary living conditions
revision of the nursing care plan involves which action?
inactivating resolved problems
which finding would a nurse expect to find when assessing a diabetic client with leg ulcers who has been receiving long term corticosteroid therapy?
inadequate wound healing
which time management technique would the nurse use before making rounds? select all that apply
include time for documentation so that it can be completed as soon as possible after accomplishing a task monitor changes to the eMAR work on assignments that must be done each shift when time permits
which process would the nurse follow when teaching a patient wound care and dressing changes?
including a return demonstration by the patient
the nurse is caring for a malnourished patient and observes that the patient's hemoglobin is low. Which nursing action would help promote the patient's health?
including green, leafy vegetables in the diet
which response would the nurse provide a client who asks, "what is causing my acne"
increased androgenic hormones
which is the rationale for collaborating to set daily goals with a patient who is unable to independently maintain hygiene?
increases participation
which change is the most likely cause of decreasing family size?
increasing living expenses
the nurse knows that which goal is included in Healthy People 2020?
increasing the life span
which cause of death among older adults is the nurse most likely to encounter in a long term care facility?
influenza pneumonia heart disease
the nurse knows that teaching is most effective when which factor is present?
information is offered in a patient's native language
according to Erikson, at which stage would a child know no fear and want to explore the world?
initiative versus guilt
which developmental conflict has Erikson identified for children from age 3 to 5 years?
initiative versus guilt
which care intervention would the nurse need to perform on a patient in a long term care facility? select all that apply
inserting a foley catheter changing a sterile dressing
which behavior would indicate to the nurse that a 3 year old patient is displaying appropriate developmental milestones according to Piaget's theory of cognitive development?
insists on a strict bedtime routine of reading a story before bed
in a hospital setting, the nurse is teaching a patient about steps to take in case of a fire. Which intervention would the nurse include in the teaching plan?
instructing the patient to crawl under the smoke
which action by the student nurse would indicate the need for further education about nursing interventions for a patient with impaired physical immobility?
instructing the patient to limit physical movement
the nurse is teaching a geriatric patient with pedal edema about positioning of legs while sleeping. Which action by the nurse can cause confusion and frustration?
instructing the patient to quickly demonstrate the procedure
a young female nurse is teaching a geriatric male patient who belongs to Japanese culture. The nurse finds that the patient will not pay attention when she is teaching. Which action would the nurse take in this situation?
interacting with the family
which would the nurse assess to determine if a family needs close follow up and a referral to counseling?
interaction between members
which type of nursing action is derived from collaborative planning between two or more health care professionals?
interdependent nursing action
in which section of the patient care plan would the nurse document "instruct the patient to call for assistance before getting out of bed" for a patient who needs support to ambulate?
intervention
which factor would the nurse consider when creating a work schedule for patient care? select all that apply
interventions that must be performed time when family will be in to see patient daily schedule of laboratory tests and x rays that will be done medications that must be administered every 4 hours how many primary health care providers are caring for the patient and when they are expected to visit
which developmental task would the nurse suspect a young adult has not achieved when stating, "I just can't seem to make long lasting friends or find someone to spend my life with?"
intimacy
which statement describes why using the two challenge rule of communication is important?
it ensures that a nurse's concern about a patient has been heard, understood, and acknowledged
the nurse is demonstrating postoperative exercises to help regain motion and strength for a patient who is scheduled for surgery on a fractured foot. The nurse asks the patient to return demonstrate them. Which goal is the nurse trying to obtain?
it improves the patient's self-efficacy
a child's IQ test result is 65. What are the implications of this result?
it indicates delayed development and special learning needs
which description is incorrect regarding the final step of the nursing process?
it is a non-collaborative process
which statement is valid regarding an infant who was born at term and weighs 5.5 lbs?
it is considered healthy
an older adult asks the nurse who is administering metformin if it can be crushed because it is difficult to swallow. Which reason would the nurse give for not being able to crush the drug?
it is released slowly
which statement is incorrect regarding a nursing audit?
it is the examination of patient records to determine if nursing care is cost effective
a patient is breastfeeding her newborn and asks the nurse why breast milk is important for infants. Which explanation would the nurse give about breast milk?
it provides antibodies
which observation would the nurse make to test the functional ability and developmental maturity of a young child using the Denver Developmental Screening Test? select all that apply
jump draw a person stack a pile of blocks
the nurse is demonstrating the sequence and method of exercises and asks the patient to repeat the exercises. Which mode of learning would the patient use to learn the set of exercises?
kinesthetic learning
which action would the nurse perform while working caring for a perioperative patient? select all that apply
label all specimen containers with the patient's identifying information verify that all preoperative orders include diet or NPO status ensure that postoperative orders include directions for care of tubes and dressings check postoperative orders for instructions related to neurologic assessments
which barriers to patient education might the nurse encounter as a teacher? select all that apply
lack of space limited time to prepare for patient education limited time to teach the patient lack of privacy
which enzyme would a nurse consider to be deficient in a client experiencing abdominal discomfort following ingestion of milk?
lactase
the nurse's supervisor believes that the nurse is competent, efficient, and would not attempt to control the nurse supervisor. Which leadership style is this?
laissez-faire
a nurse is assessing a middle aged client whose children have let home in search of work. Which family life cycle stage is the client going through?
launching children and moving on
the nurse leader encourages a two way communication pattern with team members. Which outcome would the leader expect to achieve?
learn what problems the team members face
match the learning domain to its definition
learner processes information by listening to or reading the material: cognitive learner processes information by performing an action: psychomotor material is presented in a way that is valuable to the patient: affective
which altercation is a physical change associated with aging?
less heart and lung efficiency
Freud espoused that there is a primary force that drives all human behavior. To which primary force is Freud referring?
libido
which example demonstrates normal cephalocaudal development in an infant?
lifts the head up before lifting the chest
which tip would help the nurse appropriately delegate patient care to unlicensed assistive personnel? select all that apply
listening attentively to the UAP communicating clearly with the UAP assessing the knowledge and skills of the UAP
the nurse is providing education to a patient using auditory and kinesthetic techniques on how to ambulate with crutches. Which nursing action would provide the nurse with evidence about the patient's learning style?
listening to the patient's responses
which nursing process documentation would the nurse include when caring for a patient with a renal disorder?
listing the interventions that are carried out for the patient
a nurse is caring for a 15 year old adolescent who was admitted to the hospital after an acetaminophen overdose. Which diagnostic study is important for the nurse to monitor at this time?
liver function tests
a patient reports having lower abdominal pain described as a dull ache that does not radiate and expresses concern that it may be a heart attack. Which action would be appropriate if the nurse is convinced that the patient is not having a heart attack?
looking at this situation objectively using criteria to educate the patient supporting the findings and conclusion
a patient reports having lower abdominal pain described asa dull ache that does not radiate and express concern that it may be a heart attack. Which action would be appropriate if the nurse is convinced that the patient is not having a heart attack? select all that apply
looking at this situation objectively using criteria to educate the patient supporting the findings and conclusion
which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? select all that apply
looks at old snapshots of family visits the spouse's grave once a month visits the senior citizens' center once a month
a 9 month old infant is seen for a health checkup. Which example of growth and development would the nurse expect for a child at this age? select all that apply
looks for a toy after it is hidden by the examiner puts hands out toward the mother when held by the examiner
which cue gathered during assessment would be the nurse's priority when caring for a patient with a head laceration?
loss of consciousness
why is an older adult patient less tolerant of cold temperatures?
loss of subcutaneous tissue
a client is diagnosed with type diabetes, and the health care provider prescribes an oral hypoglycemic agent. The nurse should teach the client to monitor for which side effect?
low blood sugar
an older client, with a history of multiple admissions for heart failure, is returned to the hospital by an adult child. After admission for observation to the coronary care unit, the client calmly states, "I know I'm sick, but I really can take care of myself at home". Which result will the nurse conclude the client is attempting to achieve?
maintain independence
for which reason would the nurse recommend cognitive stimulation to a middle age patient?
maintains mental crispness and stimulates the mind
which important point would the nurse consider when teaching a young adult patient who was recently diagnosed with diabetes mellitus? select all that apply
make the goals of teaching clear build on previous knowledge and skills use interactive and problem oriented methods
the nurse knows that recommended safety precautions for infants and children include which preventive measure? select all that apply
marking glass doors with decals removing toxic plants from the home dressing the child in flame retardant sleepwear avoiding giving the child popcorn
what type of family pattern does the adult female assume dominance?
matriarchal
which type of family pattern does the nurse assess when a child states, "my dad moved out, and I live with my mom and grandmother?"
matriarchal
which marker typifies people who have established a philosophy of life based on their own belief system and personal ethics?
mature
which task belongs to the data collection step of the assessment phase?
measuring the height of the patient
which action would a leader with good communication skills take?
mediating differences with open communication
which issue would the nurse suspect in a 51 year old female patient who complains of fatigue, fluctuating moods, heart palpitations, and flushing?
menopause
place in order the steps the nurse would take when preparing to perform a procedure.
mentally review the steps of the task take the equipment and supplies to the patient's room confirm the patient's identity and prepare the patient for the procedure provide privacy by closing the doors arrange the supplies and equipment
which older adult population is the fastest growing group?
middle old
which is the most likely cause for a child to show symptoms of social withdrawal and learning disorders as a member of a family who must move frequently for a job?
mobility
which intervention would be included in the plan of care for an infant who just underwent myelomeningocele repair?
monitoring for cerebrospinal fluid leakage
which reflex is elicited when a newborn reacts to hearing a loud noise?
moro
which factors can affect a patient's ability to learn about implementing a heart healthy diet after a heart attack? select all that apply
motivation cultural values self confidence levels literacy language skills
which medication order for a hospitalized patient must be renewed every 48 to 72 hours, depending on facility policy and state law? select all that apply
narcotics hypnotics antibiotics anticoagulants
which patient condition listed is a nursing diagnosis? select all that apply
nausea acute pain
which statement describing prenatal development is correct?
nearly 95% of body parts are formed by the eighth week of gestation
which system is affected when an older adult patient has delayed leg movement during a knee reflex test?
neurologic
which group of people have been reported to live longer? select all that apply
non smokers married people
which action by the nurse while teaching a patient with migraines how to check blood glucose levels using a glucometer indicates a need for further teaching?
not talking to the patient while performing the procedure
a 1 month old infant is prescribed digoxin and presents at a follow up visit with an apical pulse of 88 beats/min. Which is the nurse's responsibility regarding this pulse rate?
notifying the health care provider immediately
which parental situation is an integral part of a nuclear family?
nuclear
which section of the chart would provide the licensed practical nurse an update about a patient's current status?
nurse's notes
the nurse is reviewing medical reports and determines that the patient has an inflamed appendix based on symptoms and laboratory reports. Which phase of the nursing process would this indicate?
nursing diagnosis
which step of the nursing process includes problem identification?
nursing diagnosis
which step of the nursing process would the nurse carry out after collecting and analyzing a patient's data?
nursing diagnosis
which component is included in the care plan of a patient? select all that apply
nursing diagnosis expected outcome nursing interventions
which factor is a primary influence on the age at which a person experiences puberty?
nutrition
the mother of an 11 year old patient with acne asks the nurse if there are factors that influence the onset of puberty. Which factor would the nurse identify? select all that apply
nutrition genetics
for which patient problem would the nurse anticipate monitoring an older adult patient who reports a decreased sense of smell? select all that apply
nutrition imbalance environmental injury
a 10 month old infant looks for an attractive soft toy that was shown moments ago. Which developmental ability is the infant demonstrating?
object permeance
which action would the licensed practical nurse include in the plan of care for a patient who is receiving a continuous intravenous infusion?
observing the IV fluid container at the bedside
the registered nurse is assessing a patient who has recently undergone surgery before discharge to determine if the patient can perform self care. Which action would the nurse expect to be included in the assessment plan?
observing the patient lifting a glass from the table
which is the most appropriate information the nurse would provide a patient who is prescribed calcium regarding vitamins or minerals that help calcium absorption?
obtain sufficient vitamin D from sunlight or supplementation
an adolescent who was admitted to the hospital with ketoacidosis is stable and receiving insulin subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. Which intervention is the nurse's priority?
obtaining a blood glucose reading
in a previous session, the nurse taught a diabetic patient the technique of using a portable glucometer. In the present session, the nurse is teaching the patient about subcutaneous self administration of insulin. Which technique from the previous session would the nurse ask the patient to return demonstrate before beginning the session?
obtaining a capillary glucose reading with a portable glucometer
which nursing intervention would be considered a dependent nursing action?
obtaining a heating pad and applying it to the patient
which nursing action would be appropriate to prevent barriers of communication with a patient who speaks English as a second language?
obtaining an interpreter
which precaution would the nurse take when communicating with team members? select all that apply
obtaining feedback about orders given speaking tactfully and in a friendly manner listening to team members' complaints actively listening to team members' suggestions
which interpersonal relationship skill would the nurse use to be an effective leader of a team?
obtaining feedback about suggestion
which task would the licensed practical nurse perform when assisting a registered nurse during a patient's initial physical examination? select all that apply
obtaining vital signs taking a brief medical history recording history of drugs and drug allergies
the nurse knows that a nursing audit must have which requirement?
occurs in every hospital to maintain accreditation
which nursing action would be appropriate when a diabetic patient arrives with symptoms suggestive of hypoglycemia?
offering foods in rich in glucose
which myth is prevalent about older people? select all that apply
older adults cannot contribute to society it is not possible for older adults to learn new things genetics is the main factor in longevity isolation from families is common
which factor makes it difficult for older adults to have large meals?
older people often have smaller appetities
the nurse is using the adaption, partnership, growth, affection, and resolve screening tool to evaluate a family's ability to function. Which finding indicates the need for home. care services?
one parent exerts control over others
an unlicensed personnel makes an error while caring for a patient and admits to lacking competency at handling the task. The nurse delegated the talk to the UAP. In this context, who is held responsible for the error?
only the nurse
the nurse knows that which factor contributes to a longer life? select all that apply
optimism education good hygiene
which statement about the medical diagnosis correct? select all that apply
osteoarthritis is a medical diagnosis medical diagnoses may be based on the results of diagnostic tests primary health care provider is licensed to describe medical diagnoses
a nurse observes an 11 month old child sitting on the parent's lap crying and tugging at the child's right ear. Which problem would this behavior likely indicate?
otitis media
besides prenatal care, which factor would the nurse include in teaching about maintaining a healthy pregnancy? select all that apply
overall health of the mother whether the mother smokes or drinks alcohol mother's nutritional stage before and during the pregnancy
the nurse is obtaining the history of a client in the third trimester who is visiting the prenatal clinic for the first time. She tells the nurse she has two toddlers at home, that their father abandoned the family last month, and that she doesn't know what to do. Which would the nurse conclude about the client?
overwhelmed by the situation
which situational factor can hamper learning?
pain
which technique would the nurse perform during a patient's physical assessment? select all that apply
palpation inspection percussion
which statement describes the procedure for using computerized orders? select all that apply
paper medication administration records may be used during a power outage follow facility policies for medication administration when computers are down whether receiving written orders or provider orders through the CPOE, nurses must read and acknowledge orders according to protocol
the practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts which study?
parent child attachment
which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat and cold and sharp and dull sensory stimulation after a cerebrovascular accident?
parietal
which statement is incorrect regarding the implementation phase of the nursing process?
part of the implementation phase is identifying the patient's problem and the cause of the problem
which section of the patient chart would the nurse refer to for information on the presence of malignancy or infection?
pathology report
which statement about patient education is accurate?
patient education is based on collaboration on the patient education plan among the various health professionals involved in the patient's care
when thinking of the factors that affect patient learning, which statement expresses the nurse's understanding for setting up a successful education session?
patient education is more successful when the patient is comfortable and there are minimal interruptions
which components are included in Gordon's approach to data collection?
patient strengths and weaknesses
which outcome would be acceptable for a patient who is diagnosed with pneumonia?
patient will breathe freely without any crackling in the lungs within 2 weeks
which patient would be considered a low priority in the emergency department?
patient with a sore throat
which consideration must be assessed when creating a patient education plan? select all that apply
patient's ability to learn family support and availability patient's dominant learning style materials available for education
which statement explains why patient education has become a higher priority in health care?
patients undergo more same day surgery procedures and have minimal hospital stays
what type of family does the adult male assume dominance?
patriarchal
which is the key reason people live longer today than in the past?
people are healthier throughout their lives
which technique is included in a physical examination?
percussion of an area
which advice would the nurse provide a patient who previously performed intense aerobic activity for 75 minutes per week and is transitioning to a less intense routine because of physical changes? select all that apply
perform 150 minutes of moderately intense aerobic activity per week perform muscle strengthening activities twice per week with vigorous aerobic exercise
which would be the priority nursing action when visiting a patient who has been in the unit for 3 days?
performing a head to toe examination
which intervention would the nurse expect to be beneficial for a patient who has suffered a stroke and has impaired physical mobility? select all that apply
performing physical therapy with a walker teaching exercises for strengthening range of motion
which advice would the nurse give an older adult patient to prevent falls?
performing resistance training
which action would the nurse take when engaging in clustering of care for a patient?
performing several nursing interventions during the same patient visit
which finding by the licensed practical nurse would be an expected outcome for a patient who is admitted to the hospital with right sided muscular weakness post-cerebrovascular accident and a goal to improve the ability to perform activities of daily living within 2 weeks? select all that apply
performs range of motion exercises two times during shift participates in physical therapy twice per shift
a father discovers his son stealing money from the neighbor's wallet but ignores it. He is similarly indifferent to several of his son's mistakes. Which kind of parenting style is the father showing?
permissive
which parenting style is shown by parents who hug their children often and have rules that are enforced in a flexible manner?
permissive
according to Freud's theory, in which stage of development can a child identify with the parent of the same sex?
phallic
which change occurs in younger adults compared with older adults?
physical illnesses have a lower incidence
the nurse is caring for a patient after an appendectomy. When entering the room, the nurse notices that the patient is stretching to reach the call bell. Which action would be the priority for the nurse?
placing a call bell within reach
a nurse is caring for an adolescent in the postoperative care unit. Which action would the nurse take to ensure accuracy of a pulse oximeter reading?
placing the probe on a finger or earlobe
when interacting with a patient who is scheduled for surgery, the nurse finds that the patient is allergic to penicillin. The nurse reports the allergy to the primary health care provider. Which part of the nursing process would the nurse be performing?
planning
which is the third step in the nursing process?
planning
which step of the nursing process is third?
planning
which role would the licensed practical nurse have in the nursing process? select all that apply
planning data collection implementation
which step is included in the evaluation of possible outcomes for potential treatments for a critical patient? select all that apply
planning the steps of approach for each option estimating impacts on the patient's other health conditions analyzing which treatment would cause subsequent issues
which statement is correct regarding the plan of care for a patient?
plans of care should be collaborative process
which action by the LPN teaching a child through visual learning indicates a need for further instruction?
playing an audio recording that gives tips for pain management
which intervention decreases the mental decline of old age? select all that apply
playing stimulating mental games engaging in regular physical exercise
which nursing intervention would provide effective teaching to a Spanish speaking patient with stomach ulcers? select all that apply
playing videos in the Spanish language asking the patient questions after giving printed materials providing printed materials to the patient in the Spanish language
which factor would the nurse assess before carrying out a specific intervention in a patient plan of care? select all that apply
potential dangers standard of care reason for the intervention rationale for the intervention
which item would the nurse include in creating a problem statement/nursing diagnosis for a patient? select all that apply
potential problems signs and symptoms factors that are likely causing the problem area in which the patient is not responding well
which nursing intervention would help promote self esteem for a patient who is upset about nocturnal enuresis?
praising the patient for every 2 hour period of continence
a 7 year old child steals a cookie from the kitchen when his mother is watching television, knowing that he will be punished if caught. Which level of moral development is the child exhibiting according to Lawrence Kohlberg's theory of moral development?
preconventional reasoning
when children begin to use language and justify their behavior at all costs, which stage of development is this according to Piaget's theory?
preoperational
an 11 year old boy is showing signs of sexual development. The boy's mother asks the nurse which stage of development the child is in? how would the nurse respond?
prepuberty
which disorder is symptomatic of the inability to hear high pitched sounds such as female voices and phones ringing?
presbycusis
the nurse understands that which change occurs during middle adulthood?
presbyopia occurs
which age group of children has imaginary playmates?
preschoolers
a newborn was delivered at 37 weeks and weighed 4 lbs. How would the nurse classify this infant?
preterm
which is the best nursing intervention to ensure patient safety for the diagnosis of risk for injury related to stroke?
preventing falls
which topics would the nurse include in patient education? select all that apply
prevention of illness self care disease process restoration health promotion preoperative and postoperative care
why would the primary health care provider prescribe frequent periods of rest for a patient who has left arm paralysis while performing activities of daily living?
prevents frustration
the staff is assigned multiple nursing tasks for the day. Which time management strategy would the nurse employ to complete the given tasks on time? select all that apply
prioritizing unstable patients over stable patients making a to do list before the shift starts each day identifying patients who must be checked frequently delegating appropriate tasks to unlicensed assistive personnel
which advice would be appropriate for the nurse to give a middle age patient who is a member of the sandwich generation and is experiencing anxiety and angry episodes?
promote open communication within the family
which phrase represents ultimate goals of patient education? select all that apply
promotion of wellness restoration of health
which key function does the vernix caseosa have for the newborn?
protect's the newborns skin
which objectives are included in Healthy People 2030? select all that apply
protecting health ensuring access to high quality health care strengthening community health promotion programs promoting healthy behaviors
which interventions are appropriate for the care of an infant? select all that apply
provide swaddling hang mobiles with black and white contrast designs caress the infant while bathing or during diaper changes
which is a developmental theory characteristic?
provides a dynamic, rather than a static, view of the family
the charge nurse is providing constructive criticism to an unlicensed assistive personnel for poor performance of a delegated task. Arrange the steps in which the nurse would provide the criticism
provides privacy to the UAP acknowledtes the UAPs feelings and expresses empathy describes the behavior that is inaccurate states an expectation for future compliance states the consequences if the expected action is not performed
which action would the nurse leader perform to foster growth among team members? select all that apply
providing constructive feedback instilling confidence in team members communicating with staff in a tactful way inspiring trust and spirit in team members
which function describes a bereavement support group?
providing families who have lost loved ones a chance to communicate and share their feelings
which guideline would the nurse bear in mind while teaching older adults about technology? select all that apply
providing good lighting in the room speaking clearly and slowly in a normal tone obtaining feedback at intervals about what has been taught
which action would the licensed practical nurse include as an independent action in a patient's plan of care?
providing patient education
which action is most beneficial when providing patient education?
providing teaching using multiple learning styles
a patient learns to change a wound dressing by performing the task with the supervision of the nurse. This is an example of which domain of learning?
psychomotor
the nurse is observing a parent and 3 year old child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "couches are for sitting, not for jumping." the parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?
punishment-obedience stage
which statement about reading back verbal orders is accurate? select all that apply
readbacks of verbal orders should follow facility policies the nurse receiving the order is responsible for the readback the readback requires the person receiving the order to enter it into the CPOE system
which step would the nurse follow while taking a phone prescription?
reading back the prescription verbatim to the primary health care provider, and verifying spellings of the medications
before carrying out an intervention listed on the nursing care plan, which action would the nurse take to ensure that quality, safe care is given to the patient? select all that apply
recognizing the usual standard of care identifying the reason for the intervention ascertaining the rationale for the intervention determining the expected outcome for the intervention
which topic is most important for the nurse to cover when educating patients about the importance of maintaining health during middle adulthood?
recommended health screenings
which type of family is most likely to present stress that includes jealousies and losses?
reconstituted
which family function would the nurse address when providing information about family centered care to a parent of a cognitively challenged child? select all that apply
recreation nurturance socialization
which action would the nurse take when noting that the dressing of a patient is saturated with drainage the first night after a surgical procedure?
reinforcing the dressing with sterile dressings
the nurse has established that an adolescent patient has a good understanding of their medical condition. Which action would the nurse take when presenting written educational material?
relating the material to the patient's condition
which indicator would the nurse use to determine effectiveness after administration of sublingual nitroglycerin?
relief of anginal pain
after notifying the health care provider, which intervention is appropriate when caring for a 3 month old infant whose temperature is 103F?
removing excess clothing from the infant
the nurse is teaching a geriatric patient with a hearing impairment. Which intervention would the nurse implement to provide effective teaching? select all that apply
repeating the sentences twice at the end of the lesson showing pictures of the steps of the procedure being taught turning on the patient's hearing equipment before starting the lesson
which datum obtained during the patient assessment phase of the nursing process would be considered subjective? select all that apply
report of difficulty swallowing report of severe headache
the nurse notes that a 6 year old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action would the nurse take?
report the observation to the primary health care provider
the nurse caring for a female patient with depression identifies signs of physical abuse. Which action would be appropriate for the nurse?
reporting it to social agencies or law enforcement authorities
which objective is included in the implementation phase of the nursing process?
reporting significant changes observed that require intervention
which action would the nurse take when noting that a child has several bruises in various stages of healing?
reporting the situation to the nurse manager
the nurse leader uses democratic leadership qualities when working with the team. Which action would the nurse take for effective leadership? select all that apply
respecting team members as individuals using team members knowledge and skills accepting responsibility for the team's actions consulting with staff members for decision making
a patient with a sprained ankle is prescribed pain medication but refuses to take it and insists on acupuncture treatment for pain relief. Which action by the nurse would indicate open mindedness? select all that apply
respecting the patient's view developing tolerance to differences of opinion
place the steps the nurse would take in order of occurrence when preparing to perform nursing procedure on a patient
review the steps of the procedure collect the supplies perform hand hygiene check the patient's identification band introduce yourself provide the patient with privacy
which action would the nurse perform when applying critical thinking during implementation of patient interventions?
reviewing all potential complications associated with the interventions
which action would the nurse perform when preparing to perform an unfamiliar procedure on a patient?
reviewing the facility's policies and procedures manual
the nurse notes that a patient with heart failure who has received dietary education is eating a bag of potato chips. Which action will the nurse take before providing additional education?
reviewing the previous method of teaching
which action would the nurse take when preparing to care for a patient the first time?
reviewing the primary care provider's most current prescription
which action would the nurse complete when a goal is not met in the care of a patient? select all that apply
revising the care plan reassessing the patient repeating the entire nursing process
which action would the nurse take when evaluating a nursing plan of care and determining that progress is not being made to reaching expected outcomes?
revising the plan of care
which attribute of a good leader can be found in a nurse manager?
role model
which statement is true regarding the stages of family development?
roles of parenting change during disengagement
which precaution would the nurse take when using a computer to make a nursing care plan for a patient?
safegaurding the electronic patient data
which teaching would be needed to help a patient recover quickly after falling down steps and sustaining a hairline fracture of the hip?
schedule regular physical examination
a health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the medication, the client calls the nurse and complains of feeling tired and looking pale. Which action would the nurse take?
schedule the client for an appointment
which job task requires the use of a computer? select all that apply
scheduling surgery monitoring staffing patterns creating nursing care plans accessing evidence based protocols monitoring patient census on the unit
according to the psychosocial developmental stages of Erikson, which effect can result when a school age child fails to develop social, physical, and learning skills?
sense of inferiority
the parent of a 3 year old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction would the nurse reinforce to the parent?
set limits on the child's behavior
this nurse leader is described as "my way or the highway". Which statement describes such a leader? select all that apply
sets rules without any input from the staff closely supervises the work of each staff member finishes tasks efficiently without regard to people
which process is involved in the planning phase? select all that apply
setting priorities prescribing nursing interventions identifying patient centered goals
which action by the nurse leader would build positive interpersonal relationships with team members?
showing care and concern for team members
which statement about techniques used by nurse's leaders to build relationship is accurate? select all that apply
showing care for others promotes team cooperation positive conversations and interactions help build relationships effective communication is integral to patient safety mediation is a way to settle differences when conflicts arise
the nurse is teaching a patient about prevention of rheumatoid arthritis. Which nursing action would help the patient through cognitive learning? select all that apply
showing pictures of foods to be included in the diet playing a video to demonstrate healthy food and lifestyle habits
a nurse in the postanesthesia care unit is caring for a client who just had a thyroidectomy. Which response is most important for the nurse to monitor?
signs of respiratory obstruction
which type of family is indicated when a divorced person desires to adopt a child?
single parent
which kind of family consists of a mother and her 3 year old daughter?
single parent family
which type of crisis will potentially be experienced by a client who is distressed about a pending divorce?
situational
which sign of a newborn infant would reflect an Apgar score of 1 in the category of respiration?
slow, weak cry
which gastrointestinal change that accompanies aging most likely contributes to a patient's difficulty maintaining regular bowel movements?
slowed liver and pancreatic function
which change in an older adult patient could have caused a fall at home? select all that apply
smaller muscle mass decreased bone calcium decreased depth perception
which type of family involves unmarried couples living together and sharing roles?
social contract
the nurse is teaching about medications for hypertension to an older adult patient. Given the fact that older adults have slower mental processing, which strategy would be most important while teaching the patient?
speaking slowly with frequent pauses
the nurse is teaching a school age child about their newly diagnosed condition. Which action demonstrate's the nurse's understanding when teaching children? select all that apply
speaking to the child at a level the child understands avoiding the use of idioms or figurative language teaching the child in short segments using dolls and play to teach the child
which action reflects the nurse's understanding in working with older adults?
speaking, then stopping to ask the patient if they understand or have any questions
which health care professional would the nurse consult when planning a teaching session with a patient who stutters while speaking?
speech therapist
a child is brought for the Denver Developmental Screening Test. Which activity would the child be asked to perform to determine fine motor skills?
stacking a pile of blocks
the nurse is preparing to communicate with an older client who is hearing impaired. Which intervention would be implemented initially?
stand in front of the client
the charge nurse has just received a written prescription from the primary health care provider. Which prescription would the nurse transcribe first?
stat
which kind of prescription would be completed immediately?
stat
which condition does the nurse recognize when a client is unable to focus both the eyes in the same direction?
strabismus
for which health problem would the nurse plan when a young adult patient whose father unexpectedly died presents with headache, gastric distress, and blood pressure of 130/88 mm Hg
stress related illness
which sign would an older adult patient with dementia related memory problems demonstrate?
struggling to perform
which activity would the nurse recommend for a middle age female patient to improve bone health?
taking calcium 1000 mg/day before menopause
which action would be included in the plan of care for the next few days for a client hospitalized for heart failure who is receiving digoxin and will continue taking the drug after discharge?
taking the apical pulse before drug administration and teaching the client how to count the pulse
which nursing intervention would the nurse implement to provide effective teaching for a patient in a double room?
taking the patient to a conference room
the nurse is learning effective communication strategies to build good professional relationships with patients and co workers. Which strategy would the nurse use to achieve this purpose? select all that apply
taking time to attend to the person establishing eye contact while speaking using polite words like please and thank you
which action of the licensed practical nurse who is teaching a geriatric patient indicates the need for further teaching?
teaching the patient in a dimly lit room
which staff member is not considered an unlicensed assistive personnel? select all that apply
technician unit secretary homemaking aide nursing assistant housekeeping personnel
which group of people is most likely to give birth to a premature infant with a low birth weight?
teenagers
the nurse knows that which patient presentation is objective data?
temperature
which factor would the nurse assess when collecting the vital signs of a patient?
temperature, blood pressure, pulse rate, respiration
which action would a nurse take after observing clear fluid coming from the ear of a client with a head injury sustained during a fall?
test the drainage from the client's ear with a glucose reagent strip
as a charge nurse, which skill is recommended for a licensed practical nurse?
the ability to recognize significant changes in a patient's condition
which response regarding age and fertility would be appropriate when a patient asks the nurse if 30 years of age is too old to start a family?
the average age of first time mothers is 28 years of age. Difficulties arise when conceiving after 30 years of age
which concern would the nurse have about the implementation of a hospitalized patient's care plan that has not been reviewed in 3 days?
the care plan must be reviewed and updated every 24 hours
which behavior would the nurse suggest a parent will notice in her 2 year old child after the death of a family member?
the child exhibits changes in sleeping patterns
the parents of a 2 year old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2 year old child indicates which characteristic about the child?
the child is exhibiting a normal pattern
which finding indicates an 8 year old is a latchkey child?
the child is unsupervised at home after school
which factor in the history of a married 35 year old client scheduled for tubal ligation contributes to the healthy resolution of any emotional problem associated with sterilization?
the client has a son and daughter and feels that her family is complete
which information would a nurse expect to find when reviewing a newly admitted client's medication administration record?
the client's allergies
which statement about the process of prioritizing nursing diagnoses is incorrect?
the diagnoses are determined without input from the patient
on examination, the nurse finds that an adolescent frequently uses ecstasy. The nurse would be most concerned about which consequence associated with the use of the drug?
the drug can cause permanent damage to the brain
which statement by the nurse indicates ineffective learning regarding outcome based quality improvement programs?
the goal of these programs is to increase profits
which scenario exemplifies the nurse appropriately organizing their time in the health care setting? select all that apply
the home care nurse notifies patients to be seen that day of approximate visit times in advance the clinic nurse replenishes supplies in examining rooms before patients arrive to be seen the hospital nurse sets priorities according to patient need the long term care nurse works to prioritize patient safety and comfort
which condition of a 2 day old infant would be cause for concern and require further evaluation?
the infant's head is small in comparison with the rest of the body
a 16 year old single mother and her mother bring a 1 month infant to the emergency department after an accidental fall down the stairs. Which person has the responsibility for signing the consent form for treatment?
the mother despite her age
a nurse understands the stages of parental adjustment that follow the birth of an at risk infant who is in the neonatal intensive care unit. To better plan nursing care, the nurse bases observations and assessments on which recognition?
the mother should be reunited with her infant as soon as possible to enhance adjustment
which preoperative teaching would the nurse reinforce for a patient who is diagnosed with myocardial ischemia and is scheduled for coronary artery bypass graft surgery? select all that apply
the nature of the disease various phases of surgery exercises to be done postoperatively
which statement about the delegation of tasks to unlicensed assistive personnel is accurate? select all that apply
the nurse determines which UAPs are able to take vital signs the nurse reviews the qualifications of the UAPs assigned to the unit before assigning tasks the nurse reviews the health status of the patients on the unit
the nurse knows that which statement is correct regarding teaching plans?
the nurse is responsible for overseeing the plan specifics
when collecting data on a patient with a cognitive impairment, the nurse focuses the assessment on the patient's environment rather than the blood reports. Which indication would explain this nursing action?
the nurse is segregating relevant and irrelevant data
why statement describes why nursing documentation is essential for reimbursement?
the nurse must document equipment used by a patient, otherwise the hospital may not be reimbursed for it
which statement is correct regarding implementation of care in long term care facilities?
the nurse performs all sterile procedures
a patient in a long term care facility who had a stroke is receiving physical and occupational therapy. Which initial approach would the nurse take when providing patient and family education on home safety?
the nurse will initially focus on the affective domain
while speaking to a patient, the nurse realizes the patient has difficulty hearing. Which action by the nurse represents the best way to provide the patient with education related to their health?
the nurse will provide education that is predominantly visual and kinesthetic
which statement is incorrect about interdisciplinary care plans?
the nursing care plan is a part of the patient's chart when an interdisciplinary care plan is used
which statement by the nurse indicates incorrect information regarding revision to the nursing care plan? select all that apply
the nursing care plan would be revised weekly in a hospital if the nursing intervention is ineffective, it is marked as resolved in the nursing care plan
the nurse knows that which statement is correct regarding nursing diagnoses?
the nursing diagnosis describes a health problem that needs an intervention
the parents of a critically ill 7 year old child constantly blame each other for their child's illness. Which parental response suggests that the nurse's intervention has been successful?
the parents make an appointment with a family counselor
which statement is a long term goal?
the patient demonstrates relaxation, rest, sleep, and increased activity
the nurse is caring for a 22 year old patient with acne who prefers fast food and sweetened beverages. Which assumption about the patient would the nurse make about the patient's development?
the patient has an unhealthy diet
the nurse is preparing to discuss a treatment plan with a cancer patient. Which requirement would the nurse ensure before beginning the discussion? select all that apply
the patient is not watching television the patient is not having any pain
which evaluation would be appropriate for a patient whose care plan includes the goals of decreased respirations from 33 breaths per minute to 20 bpm, reduced cough, and reduced sputum production within 2 days, but has an average respiratory rate of 25 bpm at the 2 day mark?
the patient needs continued nebulization therapy
the nurse is assessing a patient who has had diabetes for the past 5 years and discovers that the patient does not log daily blood sugar levels because he cannot operate the home glucometer properly, even though he tries. Which reason would the patient have for this finding?
the patient needs further teaching
which expected outcome would be correct for the nurse to write for a patient who has a problem of altered airway clearance related to increased respiratory secretions?
the patient's airway will be clear within 2 days
in which instance would preoperative and postoperative orders be acceptable?
the preoperative orders include the exact procedure to be performed
which step is included within the verbal and telephone order guidelines developed by the Joint Commission?
the receiver must read the order back to the provider after entering it into the computerized provider order entry system
which point would be considered while developing an intervention? select all that apply
the status of a high risk problem must be monitored the patient must reach the expected outcomes there must be scientific rationales for using each intervention
which statement describes why patient assessment and data collection rounds should be done early in a nurse's shift? select all that apply
the status of patients can change quickly identifying if patients need PRN medications is vital to good care assessing patient needs early is important to providing them with the best care ensuring all patient equipment is attached and functioning properly is part of quality assurance
which precaution would the nurse ensure is taken after delegating a task to unlicensed assistive personnel? select all that apply
the task is done safely and correctly the task is performed in a cost effective way the delegation helps complete more work in less time
which factor would the nurse consider when planning time for uninterrupted care? select all that apply
the time of visits the schedule of diagnostic tests the medication administration schedule
the registered nurse tells the licensed practical nurse that identifying the appropriate teaching moment is essential for effective learning. Which definition explains the term teaching moment?
the time when the patient is at an optimum level of readiness to learn the information
which statement correctly describes the use of computers in the nursing care setting? select all that apply
the use of computers is an essential skill for all nurses computers assist in the coordination of patient care use of computers in health care settings is regulated by the Health Insurance Portability and Accountability Act safeguarding all electronic patient data is a legal requirement
which would be the outcome goal for a nursing diagnosis of wound infection in a hospitalized child who is crying and has a temperature of 99.9F?
the wound will completely heal by the time of discharge
which response would be appropriate when a patient asks what the specialists who study aging are called?
they are called gerontologists
why are middle age adults referred to as the sandwich generation?
they become responsible for their children and look after their parents too
which reason would the nurse tell the parents of a 7 month old infant to keep the infant away from battery operated toys?
they may contain lithium batteries
for which reason would the nurse advise a patient to avoid using alternative therapies such as gingko? select all that apply
they may work in some patients, but not others these remedies are not approved by the FDA alternative therapies can interact with many prescription medications
the parents of a gifted 4 year old note that their child has been showing signs of rebellion and acting out. Which is important to teach the parents about gifted children?
they need boundaries like any other child
which action would the nurse take to ensure effective communication while conversing with a peer or another team member?
thinking and assessing the topic before speaking
the spouse of a client who had a cerebrovascular accident tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. Which response by the nurse is appropriate?
this behavior is a common response over which the client has very little control
which factor would the nurse understand when planning care for a member of the sandwich generation?
this group provides for dependent children and elders
an adolescent male patient reports having spontaneous semen emissions at night to the nurse. He asks the nurse if this is abnormal. Which response would be appropriate?
this is quite normal and common. It's called Nocturnal Emissions
which is the correct response by the nurse when asked the reason for a prescribed Papanicolaou (pap) smear?
this test is a cervical cancer screen
which is the most appropriate statement by the nurse when a patient requests information about an upcoming bone density screening?
this test will determine whether you have osteoporosis
which parameter for a patient who is unable to retain urine has been missed in the expected outcome: "Patient will void in bedpan every 2 hours while awake without episodes of incontinence"
timeline
which benefit would concept mapping have for a nursing student?
to develop comprehensive care plans
while teaching basic hygiene measures to a group of kindergarten children, the nurse provides information in short segments and gives frequent breaks. Which reason is most appropriate for the nurse to use this strategy while teaching?
to ensure that the children are able to pay attention during the session
for which reason must the Minimum Data Set 3.0 be completed accurately when assessing residents in long term care facilities?
to ensure the facility receives maximum reimbursement for services
which is the main purpose of interviewing a patient who has just been admitted to the nursing unit?
to find out the patient's major problems
which purpose is served by respite care for a family of an elderly client with dementia?
to give the caregiver a break from the responsibility of providing care
which rationale explains why devising a time management sheet at the beginning of a shift would be helpful to a nurse? select all that apply
to identify all tasks that need to be completed to provide a basic structure for the shift's events to show periods of time that have more flexibility than others to detect how much time may be available for spending with patients who need extra attention
why would the nurses on a unit often rotate as the quality management person?
to involve everyone in the process
which reason explains why it is important to document equipment used on a patient during their hospital stay within their medical record?
to make sure the facility is reimbursed for the charges
which main purpose does a concept map have?
to promote critical thinking
which reason explains why facilities have instituted patient wristbands that identify allergies?
to promote medication safety
which rationale explains why evaluating the effectiveness of on shift time management is important?
to provide details on ways to manage time more effectively
which is the appropriate reason for advising a young adult patient to receive a periodic Mantoux test?
to screen for tuberculosis
for which reason would the nurse use a computer within a health care setting? select all that apply
to send patient laboratory results to input and access patient medical records to research evidence based treatments for communication about and coordination of care for patients within the facility
which hygiene assistance would be required for a patient who has paralysis? select all that apply
toileting bathing mouth care
an unlicensed assistive personnel took five attempts to measure a patient's blood pressure. How would the nurse document the UAPs performance?
took 5 tries to measure blood pressure
a nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. Which items would the nurse include in the bedside setup?
tracheostomy set and oxygen
which criterium is required to be a charge nurse on an acute care floor?
training and experience in nursing administration and supervision
which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident?
transient ischemic attacks (TIAs)
which behavior would indicate that a young adult has attained maturity? select all that apply
trusting others coping with stress displaying self confidence
which treatment can a patient who is experiencing andropause consider after his hormone levels have been tested?
undergoing testosterone replacement therapy
which group is identified as unlicensed assistive personnel? select all that apply
unit secretaries nursing assistants homemaking aides housekeeping personnel
the nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how would the nurse position the client?
upright in the chair
the charge nurse has received a written prescription to discontinue a medication for a patient. Which further action would the nurse take?
use facility guidelines for discontinuing the medication
which intervention needs to be implemented for the older client with presbycusis who has a hearing loss?
use low pitched tones
which action does the nurse take when teaching an older adult patient who has mobility impairments about the importance of using a walker?
use medical terms sparingly
the nurse is teaching a diabetic child about the procedure for an insulin injection. Which action would the nurse expect to be effective when teaching?
using a doll to demonstrate the procedure
which nursing intervention would help in effective communication? select all that apply
using a warm tone of voice asking if there are questions before ending the interaction accepting responsibility for any part played in the development of the conflict
which action is most effective when educating a patient who speaks English as a second language? select all that apply
using an interpreter for teaching sessions offering printed and audiovisual materials in their native language, if available asking frequent intervals to check for understanding
the nurse is preparing to delegate several tasks to unlicensed assistive personnel on the unit. Which communication strategy would the nurse implement to maintain safety?
using check-back
which action by the nurse who is teaching a geriatric patient about self care would indicate a need for correction?
using medical terms to help the patient understand better
a patient who received penicillin develops a rash on the right hand, and the patient asks why the rash developed. In which way would the nurse respond to the patient's question?
using previous knowledge
the nurse is providing printed materials while teaching a group of geriatric patients. Which nursing intervention would be beneficial for effective learning?
using white nonglossy paper with black print
which technique does a nursing leader use for effective communication? select all that apply
valuing team members establishing two way communication seeking feedback being an active listener considering the other person's culture
which muscle would the nurse select for the injection of the second hepatitis B vaccination for a 2 month old infant?
vastus lateralis
which action would the nurse perform when receiving medication orders in the nursing care setting? select all that apply
verbally communicate all stat orders to the nurse check that medication orders include the route check dietary orders for I and O requirements clarify any unclear orders with the ordering provider note all patient allergies at the beginning of each shift
after being instructed on the steps to prevent wound infection, the patient did not wash their hands before changing the dressing. Which action would the nurse take?
verbally reviewing the steps for preventing wound infection
place the actions the nurse would take in the correct order when first entering the room of a newly admitted patient for same day surgery
verify the patient identity
which action must the nurse perform before carrying out a dependent nursing action?
verifying the primary health care provider's prescription
which method would be used for creating nursing care plans?
via facility computers
the nurse knows that which is a mode of learning? select all that apply
visual auditory kinesthetic
multimodal teaching benefits patients with which preferred method of learning? select all that apply
visual kinesthetic aural
which datum would the nurse include in an admission assessment as objective data? select all that apply
vital signs breath sounds laboratory results
which assessment would the nurse make as part of a head to toe assessment? select all that apply
vital signs mentation status peripheral pulses heart and lung sounds pulse oximeter reading type of intravenous catheters and fluids infusing
which scenario demonstrates organizational techniques for nursing leadership? select all that apply
vital signs are scheduled on the even hours and as needed an experienced nurse is assigned to the triage desk the nurse recognizes an older adult patient gets tired by mid afternoon and asks respiratory therapy if they can come earlier in the day the nurse sees that the play therapist will be on the unit that morning and requests that a pediatric patient's x-ray be rescheduled until after lunch
which herb or supplement would the nurse include during an education session with middle age adults interested in supporting cognitive health? select all that apply
vitamin E Gingko biloba
which information provided by a 55 year old patient to the nurse would indicate achievement of the appropriate Erikson's stage? select all that apply
volunteers at the local food bank accepts physical changes caused by aging serves as a mentor for new employees at work enjoys work and feels a sense of accomplishment exhibits pride in children's successes and accomplishments
the nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance?
walking three to five times a week for 30 minutes
which action of the patient with burns indicates effective learning about aseptic techniques of wound dressing?
washing hands before and after dressing
which information would the nurse teach a 31 year old patient regarding the recommended amount of exercise? select all that apply
weekly routines of 150 minutes of moderately intense activity activities that work all major muscle groups twice a week
the nurse is developing a patient education plan for a patient newly diagnosed with diabetes. Which question would the nurse ask to assess the patient's health literacy? select all that apply
what do you already know about diabetes are you familiar with how to check your blood sugar do you understand how diabetes affects the body are you familiar with diabetes medications are you familiar with the signs of low blood sugar
which information would the nurse provide a patient when asked about the relationship between gender and longevity?
women live about 3 years longer than men
which action would the nurse perform when assessing the learning needs of a patient?
working within the patient's values and cultural system
which topic is an appropriate focus of teaching for a patient who had a cesarean section? select all that apply
wound care infant and child care
which statement suggests effective learning about delegation and assignment?
you are accountable for the tasks you delegate
which response by the nurse would be appropriate when a 38 year old patient asks, "I will soon be 40 and start aging, won't I?'
you start aging at birth
which age range is indicative of Schaie's achievement stage of cognitive development?
young adulthood between 18 and 35 years of age
which statement is correct regarding adolescent pregnancy?
young mothers often have low birth weight babies
to which distinct group of aging does a 73 year old patient belong?
young old
which would be the nurse's best response when a patient asks about the recommended level of fat intake?
your fat intake should not be more than 30% of your total calories
