Fundamentals of Nursing Final
A patient tells the nurse, "I feel that God has abandoned me. I am so angry that I cannot even pray." The patient refuses to see the minister. Which nursing diagnosis is most appropriate for this patient? a. Spiritual distress b. Risk for spiritual distress c. Impaired religiosity d. Moral distress
a
In what distance(s) do most nurse-client interactions occur?
18 inches- 4 ft
Stages of GAS
ALARM- Fight or Flight) stimulation of sympathetic NS, increase in hormones: CRH, ADH, ACTH, aldosterone, cortisol, epinephrine, and norepinephrine.Involves involuntary body responses. Causes: vasoconstriction, elevated BP, dilated bronchioles, increased availability of glucose, sodium and water retention, decreased peristalsis, increased blood flow to muscles. RESISTANCE- (maintenance of homeostasis) use coping mechanisms to return vital signs to normal or find psychological balance. Failure to adapt leads to third stage. EXHAUSTION- (or recovery) when adaptive mechanisms become ineffective or nonexistent. Cause decreased BP, elevated pulse and respiration. Usually ends in disease of death.
nursing process
Assessment Diagnosis Planning Implementation Evaluation
The nurse is providing care for a patient following a debilitating stroke. Which type of care will the nurse recognize as the best choice for this patient? a. primary care b. secondary care c. tertiary care d. preventative care
C
What are five qualities of therapeutic communication?
Empathy, Respect, Genuineness, Concreteness, Confrontation.
What are the major factors that affect communication?
Environment, life span variations, gender, personal space, territoriality, sociocultural factors, roles and relationships
Mary Mahoney
First African American graduate nurse
Clara Barton
Founded the American Red Cross
Moral Model
M-massage the dilemma O-outline the options R-resolve the dilemma A-act by applying the chosen option L-look back and evaluate
What is PICOT
P-patient/population I-intervention C-comparison O-outcome T-timing
What are the five rights of teaching?
Right context Right goal Right content Right method Right time
JAREL
Spiritual Well-Being Scale was developed as an assessment tool to provide a way of establishing a nursing diagnosis of sprituality; clinical use of the JAREL scale assessment data is one method to build on the order client's strengths, as well as to foster personal growth.
Developmental stress
Stress associated with life stages
Physiological stress
affects the body, health, mobility
The unlicensed assistive personnel (UAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. a. Patient reminded not to climb OOB after falling b. Patient found on floor after falling out of bed and verbalizes (L) hip pain c. Patient found on floor by UAP Smith and verbalizing (L) hip pain d. Patient fell out of bed but is currently in bed
b
Under which circumstance is deferral of informed consent allowable? a. The patient is confused and does not appear to understand the plan of treatment or the consent form b. The patient who is in cardiac arrest is transported to the emergency department without accompaniment by family members. c. The surgeon requests that the patient be transferred to the surgical suite before the nurse has an opportunity to obtain the patient's informed consent. d. The patient is crying due to severe pain and is unable to verbalize understanding of the treatment plan
b
Which statement best describes the difference between a "DNAR" and an "AND" order? a. There is no difference in the two terms. Both are used synonymously. b. A DNAR is an order not to resuscitate; an AND is an order to attempt to resuscitate. c. AND contains the word death, so the intent of the order by the provider is clear. d. A DNAR order provides specific instructions for hydration and feeding, while an AND does not.
c
Which statement made by the student nurse to a patient who is a Jehovah's Witness indicates a need for further learning? a. "I documented in your medical records that you do not want blood transfusions or blood products." b. "I am your nurse and I will help prepare you for a corneal transplant." c. "Happy birthday. I will have the dietary department send up a cake for you." d. "The organ procurement (donation) center was notified that you did not want to donate an organ."
c
Brevity
can be achieved by using the fewest words possible.
psychosocial stress
caused by life events or relationships
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is a. Exchange information among health care members. b. Provide information about patients from one unit to another unit. c. Ensure proper care for the patient. d. Aid in the hospital's quality improvement program.
d
During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits to drinking at least six alcoholic beverages every night before going to bed. Which type of grief does this best illustrate? a. Delayed b. Uncomplicated c. Disenfranchised d. Masked
d
Monotone
does not vary the pitch, cadence, and volume
communication
dynamic, reciprocal process of sending and receiving messages using words, sounds, expressions, body movements, written symbols, and behaviors.
Edward Lyon
first male nurse to receive commission as a reserve officer
Eustress
good stress
secondary care
health services to which primary caregivers refer clients for consultation and additional testing
connotation
is the implied or emotional meaning of the word.
Denotation
is the literal (dictionary) meaning of a word.
Feedback
may be verbal, nonverbal, or both
Situational stress
random and unpredictable (extreme weather)
encoding
refers to the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message.
innotation
reflects the feeling behind the words.
Clarity
requires (1) that you select words that convey your intended meaning and (2) that you make sure your spoken words and the nonverbal language send the same message
tid
three times a day
Time stress
unable to meet demands (multiple demands, rushing)
The nurse is aware that which situations can lead to the family caregiver's feeling of "burnout"? Select all that apply. 1. Caring for an infant during eruption of a first tooth 2. Caring for an adolescent child with schizophrenia 3. Caring for a child being treated for a broken leg 4. Caring for a spouse with Alzheimer's disease 5. Caring for grandchildren once a week, as needed
2 4
Dunn believes that an individual's state of health should be evaluated in the context of the person's environment. Which is an approach that illustrates Dunn's belief? 1. An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individual's health. 2. Adequate income, food, and shelter create a healthful environment and always improve physical health status. 3. Physical environment, family, and social support may help or hinder the health status of an individual. 4. The environment that should always be assessed is the client's immediate surroundings; extended boundaries do not apply in an ill state.
3
A patient who is 80 years old arrives in the emergency department experiencing a severe heart attack. The patient's condition is deteriorating and the physician informs the spouse that the patient is not expected to survive. The spouse becomes distraught and tells the nurse, "We have been married for 60 years. What am I going to do?" Which is the most appropriate response by the nurse? 1. "You had a good life together. You just need to understand that death is part of life, too." 2. "I understand how you feel, but living to 80 years of age is a good long life." 3. "I will get a social worker to see you for some help you may need at home." 4. "I understand that this is an incredible and unexpected loss for you."
4
Some people readily become ill when under stress, while others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person's level of hardiness. In which manner does the nurse apply this knowledge to nursing care? 1. The nurse cannot use the presented information. People are innately hardy or not, a state that the nurse must merely recognize. 2. Nurses need to encourage all people to develop some level of hardiness to help them get through difficult physical and emotional times. 3. Nurses need to assess for their own level of hardiness. If nurses are hardy, they will be better nurses; if not, nurses can learn more about hardiness. 4. Nurses assessing for hardiness in patients can encourage hardy patients to learn about their illness as a means for them to be more comfortable.
4
HOPE model
H: Sources of hope, comfort, strength, peace, love and connectedness O:Organized religion P: Personal spirituality and practice E: Effects on medical care and end-of-life issues
An older adult patient is admitted to the hospital with heart failure. The patient's best friend is present during admission. The two have shared a home since they were widowed 3 years ago. Both have grown children who live out of state. Which family nursing approach does the nurse use? a. Involve the friend in the care, discharge planning, and home care b. Encourage the friend to wait until discharge to provide care for the patient at home c. Explain to the friend an inability to be involved in patient care for confidentiality reasons d. Encourage liberal visiting hours by the friend and patient's children
a
Living in a healthy family is an important dimension of wellness. Which condition most accurately describes a characteristic of healthy families? a. A family in which individual members live a health promoting lifestyle b. A family that responses to its members' needs only during serious illness c. A family that may avoid or withhold the truth to prevent hurting someone's feelings d. A family that understands a family member is powerless when experiencing severe illness
a
The nurse applies the MORAL model to decision making. After recognizing a problem, which action does the nurse take next? a. Define the main issues associated with the dilemma. b. Consult a member of the organization's ethics committee. c. Outline available options for all involved parties. d. View the situation using alternate ethical frameworks.
a
The nurse is assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse develops a plan of care. Which action will the nurse initially perform? a. Make an assessment b. Make a diagnosis c. Plan outcomes d. Plan interventions
a
The nurse is caring for a 68-year-old patient who has terminal cancer. Which specific assessment tool would the nurse use for this patient? a. JAREL b. SPIRIT c. HOPE d. LOVE
a
The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess? a.Depression b. Hypochondriasis c. Somatization d. Malingering
a
The nurse is providing care for a patient who needs extensive acute care, which the patient is refusing because of financial and family stressors. Which healthcare worker does the nurse consult to counsel this patient? a. Social worker b. Occupational therapist c. Physician's assistant d. Technologist
a
The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment? a. Obtaining a patient's temperature 1 hour after giving acetaminophen b. Examining a patient's throat after soreness with swallowing is reported c. Requesting a patient to rate pain intensity level on a scale of 0 to 10. d. Asking a patient the details of a plan to return to normal exercise activities.
a
The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? a. Repeat the order to the prescriber, even if the nurse believes the order was understood correctly b. Immediately notify the pharmacy of the order, and verify it with a pharmacist. c. Ask the unit secretary to listen to the prescriber on the phone to verify the order. d. Transcribe the order on notepaper, and verify the dosage in a drug handbook.
a
What is clinical judgment defined as? a. Processes that promote safe client care decisions and outcomes b. Avoids clinical thinking and decision making c. Applying the same treatment regardless of a patient's needs or health problems d. Is addressing a patient's response to a health problem
a
Which characteristics do the various definitions of critical thinking have in common? a. Requires reasonable thought b. Asks the questions "Why?" or "How?" c. Is a hierarchical process d. Demands specialized thinking skills
a
Which of the following is an example of what the nurse recognizes as a cluster of related cues? a. Complains of nausea and stomach pain after eating b. Has a productive cough and states stools are loose c. Has a daily bowel movement and eats a high-fiber diet d. Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg.
a
Which situation is most reflective of a life change for managing chronic illness? a. Beginning self-injection of insulin for diabetes mellitus b. Taking an antibiotic for a streptococcal throat infection c. Going to the gym and participating in an exercise program d. Taking prescribed pain medication after a tooth extraction
a
How does sleep nourish our bodies? Select all that apply. a. Tissue regeneration b. Formation of red blood cells c. Mental rejuvenation d. Synthesis of bone e. Mood disturbances
a b c d
The EHR is used to document client care. Which purposes are applicable to the EHR? Select all that apply. a. Is a legal document b. Is used for utilization review c. Provides continuity of care d. Is used for quality improvement e. Acts as an occurrence report
a b c d
The nurse is aware that homelessness is a growing problem in the United States. The nurse is aware of which primary causes of homelessness? Select all that apply. a. Lack of job skills b. Lack of social skills c. Underlying mental illness d. Substance abuse e. Loss of a job
a b c d e
The nurse believes a patient is experiencing high levels of stress at home. The patient is angry and states, "It is too much for me to handle. You don't know what I am going through." Which are the most appropriate responses by the nurse? Select all that apply. a. "I don't know what you are going through. Can you tell me more?" b. Please don't be angry with me. We all do the best we can here." c. "How long have you been dealing with this stress?" d. "How do you usually manage your stress?" e. "Can we set up some family counseling?"
a c d
The nurse is aware that the study of genomics and the use of a genogram are playing a larger role in personalizing a patient's plan of care. In which manner are genomics and the use of a genogram helpful to the nurse in personalizing a patient plan of care? Select all that apply. a. Assists in development of better preventative care by identifying at-risk individuals b. Increases the trust a patient and family have in the healthcare professionals c. Helps to more accurately detect illness, even before symptoms appear d. Prevents a disease-related crisis from developing for patients and families e. Provides insight to how people respond differently to specific drugs and treatments
a c e
A nurse who administers the wrong medication to a patient does not notify anyone of the error. Instead, the nurse documents administration of the correct medication. Ultimately, the error is discovered and the nurse is reported to the state board of nursing. Which action does the state board of nursing take against the nurse in this situation? a. Termination of the nurse's employment b. Disciplinary action against the nurse's license to practice c. Criminal misdemeanor charges against the nurse d. Medical malpractice lawsuit against the nurse
b
A patient refuses a dose of medication. How should the nurse document the event? a. Patient is uncooperative and refuses the prescribed dose of digoxin. b. Patient refuses the 0900 dose of digoxin. c. Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. d. 0900 dose of digoxin not given.
b
A patient's wife has told nurses that she wants to be with her husband when he dies. The patient's respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? a. "Certainly, go ahead. Your husband will most likely hold on until you return." b. "Your husband could live for days or a few hours. You can do whatever you are comfortable with." c. "I'll stay continuously at his bedside while you are gone." d. "Don't worry. Your husband is in good hands. I'll look out for him."
b
After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data? a. The client's blood pressure reading is 132/68 mm Hg, and their heart rate is 88 beats/min. b. The client's cholesterol is elevated, and they admit to liking and eating fried food. c. The client reports having trouble sleeping and admits drinking coffee in the evening. d. The client verbally reports having frequent headaches and taking aspirin for the pain.
b
For which patient in the emergency room is it most important that the nurse conduct a thorough assessment for abuse and neglect? a. A 6-year-old male with complaints of abdominal pain b. A 2-year-old male with injuries from a fall c. A 7-year-old female with a broken arm from a motor vehicle accident d. A 4-year-old female who complains of an earache
b
The nurse develops a plan of care for a patient who is at risk for impaired skin integrity. Interventions include changing the patient's position every 2 hours and keeping the skin clean and dry. During the evaluation phase of the nursing process, which finding validates the effectiveness of the plan of care? a. Documentation reflects the performance of care interventions. b. Reassessment indicates maintenance or improvement of the condition. c. Intervention performance is verbally validated by the assigned personnel. d. Patient states that care was provided in an effective and timely manner.
b
The nurse has been explaining advance directives to a patient. Which response by the patient would indicate successful teaching? a. "It identifies the activities considered to be evidence of quality care." b. "It specifies your healthcare instructions should you become unable to make self-directed decisions." c. "It allows you the autonomy to leave the hospital when you decide, even if it is against medical advice." d. "It verifies your understanding of the risks and benefits associated with a procedure."
b
The nurse is aware the client's risk of breast cancer is dramatically increased because both her sister and her mother had breast cancer. Which of the multidimensional aspects of health does this scenario illustrate? a. Personal relationships b. Biological factors c. Lifestyle choices d. Environmental factors
b
The nurse is providing care for an older adult patient in an acute care setting for various age-related health issues. When planning for discharge, the patient states concern about being able to adequately provide for health maintenance and self-care needs. Which type of facility does the nurse recognize for this patient? a. skilled nursing facility b. assisted living c. nursing home d. independent living facility
b
The nurse uses the concept of the wellness-illness continuum for developing a nursing plan of care. Which plan for a chronically ill patient does the nurse select? a. Educate the patient about every possible complication associated with the specific illness. b. Encourage positive health characteristics within the limits of the specific illness. c. Limit activities because of the progressive deterioration associated with chronic illnesses. d. Recommend activity beyond the scope of tolerance to prevent early deterioration.
b
The postoperative care unit (PACU) nurse is caring for a person who practices the Jehovah's Witness religion and has undergone a total hip replacement. The primary care provider orders 2 units of packed red blood cells (PRBCs) to treat severe postoperative anemia while the client is very drowsy and unable to discuss the plan of care. The nurse is aware of the patient's religious beliefs and that PRBCs may be lifesaving. Which term best describes the conflict the nurse is experiencing? a. Ethical agency b. Ethical dilemma c. Moral outrage d. Moral distress
b
The primary care provider orders limited treatments for patients who are diagnosed with a terminal illness and distributes the majority of resources to patients who have a high likelihood of survival. The primary care provider's intention is to serve the greater good. Which ethical principle best describes the primary care provider's approach to allocation of resources? a. Ethics of care b. Utilitarianism c. Deontology d. Categorical imperative
b
Which patient is at most risk for experiencing difficult grieving? a. The middle-aged woman whose grandmother died of advanced Parkinson's disease b. A young adult with three small children whose wife died suddenly in an accident c. The middle-aged person whose spouse suffered a chronic, painful death d. An older adult whose spouse died of complications of chronic renal disease
b
Which statements indicate the nurse has a good understanding of religion? Select all that apply. a. "Religion is like a lifelong journey." b. "Religion provides a code for a way of living." c. "Religion describes the relationship between patients and the divine." d. "Religion is a dynamic relationship that transcends." e. "Religion is experienced by all patients at some point in time."
b c
The nurse educator teaches a cohort of nursing students about intentional and unintentional torts. Which information does the nurse educator include in the discussion? Select all that apply. Negligence is an example of an intentional tort. a. Battery is an example of an intentional tort. b. Intentional torts include invasion of privacy c. Malpractice is a type of unintentional tort. d. False imprisonment is an example of an unintentional tort.
b c d
What are some possible barriers for nurses in providing spiritual care? Select all that apply. a. Spiritual care is related to end-of-life care, and many nurses do not work in this area. b. Greater emphasis in nursing is placed on meeting patient's physical needs. c. Many nurses experience time constraints and inadequate staffing. d. Many nurses lack an understanding of their own spiritual belief systems e. Many nurses believe that spiritual care is not a component of the professional role
b c d e
During the alarm stage of general adaptation syndrome (GAS), which metabolic changes occur? Select all that apply. a. Rate of metabolism decreases. b. The liver converts more glycogen to glucose. c. Use of amino acids decreases d. Amino acids and fats are more available for energy. e. Physiological responses will last at least 24 hours.
b d
The nurse is using the HOPE approach to perform a spiritual assessment. Which questions would the nurse ask when focusing on the H in HOPE? Select all that apply. a. "Do you belong to a religious or spiritual community?" b. "What are your sources of internal support?" c. "Do you have any dietary restrictions I should know about?" d. "What do you do to get through tough times?"
b d
Which statements indicate the nurse has a good understanding of Dr. Elisabeth Kübler-Ross's theory? Select all that apply. a. Patients must pass through each of the five stages of death and dying b. Kubler-Ross's theory includes psychological responses from the terminal diagnosis to the actual death c. The nurse's role is to help patients move from one stage to the next, and finally to acceptance d. Patients may experience two or three stages at the same time e. Kübler-Ross's theory includes completing one stage and moving on to the next in sequence.
b d
An 18-year-old is accepted to nursing school in another state. The adolescent states to their parents, "I know I am going away to college, but I am nervous about going." Which type of stressor is the student most likely experiencing? a. External b. Developmental c. Situational d. Biophysical
b. This is correct. Developmental stressors are those that can be predicted to occur at various stages of a person's life. For example, most young adults face the stress of leaving home for college or beginning a new career. In this item, the young adult is expressing concern over a normal developmental stressor.
A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using? a. Narrative charting b. Charting by inclusion c. Charting by exception d. Source-oriented charting
c
A nurse is providing care for a patient newly diagnosed with type 1 diabetes mellitus. The patient's spouse states, "We are a family of diabetics." The nurse advises attendance to the free nutrition, cooking, and exercise classes at the health center near their neighborhood. The nurse also provides the name of the public health nurse for their area. Which perspective of family nursing is the nurse practicing? a. Family as a resource and stressor b. Family as a unit of care c. Family as a system d. Family as the context of care
c
A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform? a. Comprehensive b. Ongoing c. Initial Focused d. Special Needs
c
After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of general adaptation syndrome (GAS) does the nurse recognize the patient is most likely experiencing? a. Alarm b. Resistance c. Exhaustion d. Recovery
c
Nursing education does not override or diminish self-knowledge. Which is the most important reason for nurses to develop an awareness about individual self-knowledge? a. Can be used to hide personal cultural biases b. Assists in directing patients to self-understanding c. Helps identify errors in nurse's thinking d. Aids the nurse in protecting personal beliefs
c
The Americans With Disabilities Act (ADA) defines a disability as a physical or mental impairment that substantially interferes with a person's ability to engage in major life activities. Among the various disabilities in the United States, which is the most prevalent? a. Vision b. Hearing c. Ambulation d. Learning
c
The emergency department nurse is providing discharge teaching to a patient. The patient asks the nurse, "I appreciate everything you've done for me and I really like you. Can I take you out for dinner?" Which response does the nurse choose? a. "Yes, that would be nice. It is really great to be appreciated." b. "No, and please do not ask again. Your request is inappropriate." c. "I appreciate your kindness, but I will have to decline your offer." d. "We cannot socialize until 3 days following your hospital discharge."
c
The nurse admits a patient to the medical-surgical unit of the hospital. During the admission process, the nurse asks whether or not the patient has an advance directive. The basis for the nurse's inquiry is: a. The International Council of Nurses (ICN) Code of Ethics for Nurses. b. Values clarification. c. Patient Advocacy d. The Health Insurance Portability and Accountability Act (HIPAA).
c
The nurse is aware that when a patient becomes alarmed, the body will release a substance to promote a sense of well-being. Which substance is released? a. Aldosterone b. Thyroid-stimulating hormone c. Endorphins d. Adrenocorticotropic hormone
c
The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior? a. Taking frequent notes b. Asking for more details c. Answer Leaning toward the patient d. Sitting comfortably with legs crossed
c
The nurse is working in a community health-promotion clinic. Which is an example of an illness prevention activity? a. Encouraging the use of a food diary b. Joining a cancer support group c. Administering immunization for human papillomavirus (HPV) d. Teaching a diabetic patient about their diet
c
The nurse works at a busy trauma center and needs to establish a relationship of caring, respect, and understanding with clients during a time of extreme physical and emotional stress. Which behavior from the nurse is most likely to convey a sense of compassion? a. Extend kindness to the client and family. b. Display competency during procedures c. Provide a healing presence. d. Remain professionally aloof.
c
Which concept refers to conflicts that arise between two or more ethical principles in patient care scenarios? a. Nursing ethics b. Bioethics c. Ethical dilemma d. Moral distress
c
Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance? a. Autonomy b. Fidelity c. Justice d. Nonmaleficience
c
Which is the most important reason for nurses to be critical thinkers? a. Nurses need to follow policies and procedures. b. Nurses work with other healthcare team members. c. Nurses care for clients who have multiple health problems. d. Nurses have to be flexible and work variable schedules.
c
Which patient assessment finding must be addressed first according to Maslow's hierarchy of needs? a. The patient is unable to reposition in bed without assistance. b. The patient verbalizes anxiety about upcoming surgery. c. The patient is cyanotic and feels short of breath. d. The patient refuses to participate in physical therapy.
c
Which set of topics makes up a handoff report given in a recommended format? a. Data-action-response (DAR) b. Subjective, objective, assessment, plan (SOAP) c. Situation, background, assessment, recommendation (SBAR) d. Flowsheets, assessment, concise, timely (FACT)
c
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of a. Pie documentation b. Soap documentation c. Narrative charting d. Charting by exception
c.
The nurse filled out an incident report after a patient fall but makes no mention of the incident report in her notes in the patient's chart. What is the reason for this? a. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. b. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. c. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. d. The incident report is confidential and not intended to be used as evidence in a malpractice suit.
d
The nurse is admitting a 62-year-old patient with a diagnosis of hypertension to the hospital. Which question by the nurse is most important when performing the initial assessment interview? a. "What medications do you take at home?" b. "Do you have any environmental, food, or drug allergies?" c. "Do you have an advance directive?" d. "What greatest concern are you dealing with today?"
d
The nurse understands that the most important reason for the development of a definition for the profession of nursing is that it: a. Will result in more informed people being recruited as nurses. b. Is a means for evaluating the degree of role satisfaction in nurses. c. Helps dispel the stereotypical images about nurses and nursing. d. Differentiates the nursing role from those of other health professionals
d
The parents of three children, aged 3, 6, and 8 years, comment that although the children are close in age, they each seem to have different needs. The nurse teaches the parents what tasks the children should accomplish based on the different age groups and provide strategies to help meet the children's needs. Which theory best explains the nurse's teaching plan? a. Family interactional theory b. General systems theory c. Family as a context d. Developmental theory
d
What is the American Nurses Association's (ANA) position on assisted suicide? a. Since it is legal in some states, nurses can participate in assisted suicide. b. Nurses must follow the policies of their employing agency c. Because it is illegal in some states, the ANA refuses to take a position that may contradict a state law. d. Participation by nurses in assisted suicide is prohibited.
d
Which aspect of patient care is guaranteed by the American Nurses Association (ANA) Code of Ethics for Nurses? a. Helping a patient with billing claims b. Assisting a patient who is leaving the hospital c. Ensuring a clean and safe environment d. Protecting the patient from misrepresentation
d
A patient diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? a. Precrisis b. Impact c. Crisis d. Adaptive
d. This is correct. When patients begin to think rationally and attempt to solve problems, they are most likely experiencing the adaptive phase of crisis.
Which ethical priniciple is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure? Autonomy Justice Fidelity Nonmaleficience
nonmalficience
Primary Care
A doctor who provides general medical care and coordinates other health care.
Lavina Dock
A nurse who compiled the first manual of drugs for nurses in 1890
After a massive earthquake, the emergency room staff focuses to provide care to the patients who are likely to survive rather than expending maximum effort on a few critically injured patients. Which ethical theory is demonstrated in this situation? a. Feminist Ethics b. Ethics of care c. Deontology d. Utilitarianism
D
The nurse provides care to a patient who is admitted to the hospital for management of severe migraines. After administering a prescribed pain medication, the nurse states, "I will return in 20 minutes to reassess your pain." By following through on the commitment to return at the specified time, which ethical principle does the nurse display? Nonmalficence Autonomy Beneficience Fidelity
Fidelity
Florence Nightingale
Founder of modern nursing
Which condition listed below is not considered a chronic disease? Diabetes Kidney Disease Arthritis Mononucleosis
Mononucleosis
SBAR
The SBAR technique is used as a mechanism to give a handoff report by enabling a focused communication between healthcare team members.
A client is admitted to a long-term care facility. The nurse would use which form to follow federal law? a. The Minimum Data Set (MDS) for assessment b. Situation, background, assessment, recommendation (SBAR) for reporting c. Health Care Financing Administration (HCFA) guidelines prior to surgery d. The Joint Commission guidelines for discharge planning
a
The nurse is providing care for a patient who suddenly experiences a cardiac arrest. As the nurse responds to this emergency, which substance does the nurse's body secrete in large amounts to help prepare the nurse to react in this situation? a. Epinephrine b. Corticotropin-releasing hormone c. Aldosterone d. Antidiuretic hormone
a. During the shock phase of general adaptation syndrome (GAS), epinephrine prepares the body to react in an emergency situation by increasing heart rate and blood pressure. In response to the epinephrine release, the endocrine system releases corticotropin-releasing hormone, aldosterone, and antidiuretic hormone.
Caring is a central concept in nursing. Which of the following exemplifies a nurse exhibiting the concept of caring and the use of critical-thinking attitudes? Select all that apply. a. Treating clients as unique individuals b. Responding compassionately to client needs c. Acting in ways to preserve human dignity d. Connecting with others to give and receive help e. Using the communication skill of active listening
abcde
The nurse is providing care for a patient diagnosed with lung cancer. The patient and the spouse are 2 years from retirement. However, which typical stage of family development is this couple likely experiencing? a. Family launching young adults b. Postparental family c. Family with frail elderly d. Family with teenagers and young adult
b
Which action is included in step 3 of the MORAL decision-making model? a. Realizing information gaps b. Resolving the dilemma c. Requesting a review of opposing viewpoints d. Recognizing the values and options of all major players
b
Which aspect of electronic documentation systems is most beneficial when compared with written documentation systems? a. Assists collaboration b. Provides different terminology c. Improves legibility d. Serves as a resource
c
Which type of managed care provides patients with the greatest choice of in-network providers, medications, and medical devices? a. Health maintenance organization b. Integrated delivery network c. Preferred provider organization d. Employment-based private insurance
c
Tertiary Care
services requested by a specialist from another specialist
