fundis ch 1-17
Using Maslow's framework, which statement characterizes the highest level of need? 1. "Nurse, my pain is severe.... is it time for my shot?" 2. " I felt welcomed when I first joined the group and I look forward to the monthly meetings." 3. " I'm very proud of receiving the Employee of the Month Award." 4. " There have been home break-ins with burglary in our neighborhood. We are thinking of moving."
" I'm very proud of receiving the Employee of the Month Award."
A nursing student is employed and workingas an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in teh nursing program. When the UAP says "Yes," the nurse asks him to help her out by doing a urinary catheterization on a postsurgical client. What is the best response by the UAP?
"I can't do it. Is there something else I can help you with?" Rationale: A sterile, invasive procedure that places the client at significant risk for infection is generally outside the scope of practice of a UAP. Even though the UAP is a nursing student, the agency job description should be followed. The job description is the standard of care in this situation.
Which statement by the client best reperesents the contemplation stage of the stages of behavior change
"I currently do not exercise 30 minutes three times a week, but I am thinking about starting to do so within the next six months." Rationale: A person in this stage recognizes there is a problem, is seriously considering changing actively gathers information , and verbalizes plans to change in the near future
The nurse concludes that effective discharge panning (hospital to home) has been conducted when the client states
"I have the phone numbers of the home care nurse and the therapist who will visit me at home tomorrow." Rationale: Effective discharge planning would have included an assessment of home care needs prior to the client leaving the hospital. The kind of care is determined before the client leaves the current setting. That is why it is called discharge "planning."
Which of the following statement would be most helpful when a nuse is assisting cients in clarifying their values?
"Some people might have made a different decision. What led you to make your decision?" Rationale: In values clarification, clients are assisted to think about the factors that influence their beliefs and decisions
The nurse wishes to determine the client's feeling about a recent diagnosis. Which interview question is most likely to elicit this information?
"Tell me about your reactions to the diagnosis" Rationale: Eliciting feelings requires an open-ended question
A client insists that the practitioner uses a treatment method discovered on an internet website. Which is the most approptiate nursing response?
"The treatment must be examined to see if it is appropriate." Rationale: Each website is different and the practitioner is compelled to evaluate the site and the treatment to determine if it is evidence-based, safe, and appropriate for the client
A client in a cardiac rehabilitiation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hat it!" Which is the mose appropriate response by the nurse?
"What do you think is so difficult about following a low-sodium diet?" Rationale: The nurse recognizes the need to obtain further information from the client in order to respond directly to the client's statement
A primary care provider's orders indicate that a surgical consent form needs to be signed. Because the nurse was not present when the PCP discussed the surgical procedure, which statement best illustrates the nurse fulfilling the client advocate role?
"What were you told about the procedure you are going to have?" Rationale: This is the best answer because the nurse is assessing the client's level of knowledge as a result of the discussion with the PCP. Based on the assessment, the nurse may initiate other action (ie call teh PCP if the client has many questions)
Place the steps of evidence-based practice change in sequencial order.
1) Assess the need for change 2) Ask the clinical question 3) Locate the best evidence 4) Analyze the evidence 5) Integrate the change with client preferences 6) Implement and evaluate the change
Which of the following represent effective planning of the interview setting?
1) Ensure that no one can overhear the interview conversation 2) Keep approximately 3 feet from the client during the interview 3) Use a standard form to be sure all relevant data are covered in the interview Rationale: 1) The nurse plans the interview so that privacy is observed. 2) A comfortable distance between nurse and client to respect the client's personal space is about 3 feet 3) Using a standard form will help ensure the nurse doesn't omit gathering any vital information
Which nursing actions could result in professional negligence?
1) Forgets to complete the assessment of a client 2) Does not follow up on client's complaints Rationale: Standards of practice require a complete assessment. A nurse needs to be sure the client's needs have been met. They both can impact client safety and do not follow standards of care.
In nursing administration, technology facilitates which activities?
1) Institutional compliance with accreditation health and safety requirements 2) Tracking the most expensive client conditions 3) Current budget expenditures 4) Client satisfaction with care Rationale: Technology can facilitate almost every aspect of nursing administration. 1) Both individual employee and overall institutional compliance with accreditation standards and criteria are tracked. 2) Most common medical diagnoses and costs of all care can be retrieved from the electronic databases 3/4) Financial performance, as well as the results of client satisfaction surveys, are common computer applications
The nurse notices that a colleague's behaviors have changed during the past month. Which behaviors could indicate signs of impairment?
1) Is increasingly absent from the nursing unit during the shift. 2) "Forgets" to sign out for administration of controlled substances 3) Offers to administer prn opioids for other nurses' clients Rationale: Warning signs for impairment
Who were America's first two trained nurses?
1) Linda Richards was America's first trained nurse 2)Mary Mahoney was America's first Black trained nurse
Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions
1) No intervention should be carried out without the nurse having clear rationales 2) When possible, give the client options in how interventions will be implemented 3) Each intervention should be accompanied by client teaching
A student nurse observes the change-of-shift report. Which begavior(s) by the reporting nurse represents effective nursing practice?
1) Provides the medical diagnosis or reason for admission 2) States the time the client last received pain medication 3) States priorities of care that are due shortly after the report
Curricula for nursing education are strongly influenced by
1) State boards of nursing set minimum educational requirements for licensure 2) Professional organizations establish educational criteria for program accreditation 3)The National Council of State Boards of Nursing conducts practice studies and creates the NCLEX-RN
Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions is/are most appropriate?
1) The nurse needs to know the God Samaritan Act for the state 2) The nurse is not held liable unless there is gross negligence 3) The nurse offers to help but cannot insist on helping Rationale: The nurse is subject to the limitation of the state law and should be familiar with the Good Samaritan laws in the specific state. Gross negligence would be described by the individual state law. The same client rights apply at the scene of an accident as well as those in the workplace
Which of the following would indicate a significant cue when comparing data to standards?
1)The client has moved partway toward a set goal (ie weight loss) 2) A recently widowed woman states she is "unable to cry" 3) A 16yo high school student reports spending 6 hours doing homework 5 nights/week Rationale: A client's movement toward a goal or whose behavior is inconsistent with population norms represents a cue that further analysis toward creating a nursing diagnosis is required
"A group of related ideas or statements" best defines
A conceptual framework Rationale: A group of related ideas or statements is a conceptual framework
Which one of the following is an example of the emotional component of wellness? A: The client chooses health foods B: A new father decides to take partenting classes C: A client expresses frustration with her partner's substance abuse D: A widow with no family decides to join a bowling league
A client expresses frustration with her partner's substance abuse Rationale: Frustration is an example of an emotion
A major characteristic of the nursing process is
A focus on client needs Rationale: The nursing process focuses on client needs
A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most predictable client contribution would be seen with
A health maintenance organization (HMO) Rationale: An HMO involves a set monthly membership fee and predictable visit or deductible costs
Which individual appears to have "taken on" the sick role? A: A client who is obese states, "I deserve to have a heart attack." B: A mother is ill and says, "I won't be able to make your lunch today." C: A man with lbp misses several PT appts D: An older adult states, "My horoscope says I will be well again."
A mother is ill and says, "I won't be able to make your lunch today." Rationale: The mother has taken on the sick role by expecting to be excused from her usual role responsibility. The sick role states that individuals are not answerable for their illness
"A set of shared understandings and assuptions abut reality and the world" is a definition for
A paradigm Rationale: A set of shared understandings and assumptions about reality and the world is a paradigm
In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status?
A risk nursing diagnosis Rationale: A risk nursing diagnosis is appropriate when the evidence for the problem indicates that a condition exists that makes the client vulnerable to a problem
A QUALITATIVE research approach is mose appropriate for which study?
A study examining client reactions to stress after open heart surgery. Rationale: This study investigates the subjective experience of stress, through the collection of narrative data.
A QUANTITATIVE research approach is most appropriate for which study?
A study measuring the effects of sleep deprivation on wound healing. Rationale: Quantitative research collects numberical data. Sleep deprivation can be defined by numbers of hours without sleep and wound healing can be measured by the size of the wound in relation to a period of time.
"A supposition or system of ideas that is proposed to explain a given phenomenon" best defines
A theory Rationale: A suppostition or system of ideas proposed to explain a given phenomenon is a theory
Because a client with HIV is scheduled to begin several meds to manage the infection, the nurse will need to provide client education. Which client characteristics ar emost likely to predict adherence with the tx program?
A trusting relationship with the health care provider An expectation that the medications will be helpful Being able to take with meds BID instead of QID
A reserch critique can best be defined as a/an
Appraisal of a study's strengths and weaknesses Rationale: A research critique is .the thoughtful consideration of a study's strengths and weaknesses, and how theseaffect the quality and usefulness of study results.
Which of the following principles does the nurse use in selecting interventions for the care plan? A: Actions should address the etiology of the nursing diagnosis B: Always select independent interventions when possible C: There is one best intervention for each goal/outcome D: Interventions should be "doin," not just "monitoring"
Actions should address the etiology of the nursing diagnosis Rationale: Interventions should address the etiology of the nursing diagnosis.
The nurse's partner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most approptiate?
Access to the chart requires a signed release form Rationale: The only person entitled to information without written consent is the client and those providing direct care. The nurse has open access to information regarding assigned clients only.
Which social force is most likely to significantly impact the future supply and demand for nurses?
Againg - this population contributes to more older adults needing specialized care (increasing the demand).
A client with diarrhea also has a PCP's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "The PCP does not know the client has diarrhea." What type of statement is this?
An inference Rationale: the nurse has inferred and concluded something that is beyond the available information
What is the primary advantage of using computers while conducting nursing research?
Analyzing the quantitative data Rationale: Although all steps of the research process can be accomplished with and without computers, electronic analysis of quantitative data helps ensure accuracy and speeds the process immensely
A large disaster in a community resulted in the destruction of many family homes and many individuals were injured. The assistance of community health nurses and home health nurses is needed. The home health nurse is most likely to perform which of the following?
Assess and treat individual clients Rationale: The home health nurse more commonly works with one person or family at one time-addressing their particular needs that may be similar to or different from those of others.
A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills the nurse should perform
Assess why the client is not ingesting the food provided Rationale: The nurse recognizes that many assumptions (beliefs) could interfere with the client eating-such as that the food presented is not culturally appropriate
Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of
Battery Rationale: Battery is the willful touching of a person without permission
When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is
Be able to defend the morality of one's own actions Rationale: A nurse's actions in an ethical dilemma must be defensible according to moral and ethical standards.
Person, environment, health, and nursing constitute the metaparadigm for nursing because they
Can be utilized in any setting when caring for a client Rationale: Person/client, environment, health, and nursing ar relevant when providing care for any client whether in the hospital, at home, in the community, or in elementary school systems. These elements can be used to understand diseases, conduct and apply research, and develop nursing theories, as well as implement the nursing process.
The ANA's Health System Reform Agenda (2008) included
Case management should be focused on clients with enduring health care needs Rationale: The Health System Reform Agenda called for case management of those with ongoing health care needs
A client recently diagnsed with a chronic illness asks for help in understanding the term chronic. It would be correct for the nurse to say
Chronic illnesses are considered incurable
Which charting entry would be the most defensible in court? 1. Client fell out of bed 2. Client drunk on admission 3. Large bruise on left thigh 4. Notified Dr. Jones of BP of 90/40
Client fell out of bed
Characteristic of nursing care provided in community-based health
Clients are individuals in groups according to their geographic commonalities Rationale: In community-based health care, clients are cared for according to their geographic locations such as where they live or work, rather than at a major medical center or similar provider setting, which facilities access
A client c/o SOB. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifestations. What do these actions represent?
Clinical reasoning Rationale: Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of clinical reasoning. Past experiences in care enhance the nurse's ability to recognize and respond in the delivery of client-centered care.
The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
Collection of all necessary information for a thorough appraisal Rationale: Frameworks help the nurse be systematic in data collection
A client is admitted for heart failure. The nurse assess that the client's bp is below normal range and the apical pulse is 110 beats/min. The nurse knows that the increase in the client's pulse ilustrates which aspet of the client's homeostatic mechanism?
Compensation Rationale: The compensatory mechanism of increasing the heart rate is the body's way of trying to balance an ineffective cardiac output since the BP has decreased
A nurse with 2-3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner's stages of nursing expertise?
Competent
In the validating activity of the assessing phase of the nursing process, the nurse performs
Confirms data are complete and accurate. Rationale: In validating, the nurse confirms that data is complete and accurate
When the nurse considers that a client is from a developing country and many have a positive tuberculosis test due to a prior vaccination which critical thinking attitude and skill is the nurse practicing?
Creating environments that support critical thinking Rationale: Nurses must embrace exploration of the perspective of individuals from different ages, cultures, religions, socioeconomic levels, and family structures to create environments that support critical thinking
This represents application of the components of evaluating
Data related to expected outcomes must be collected Rationale: Evaluating requires that client behavior be compared to expected outcomes
In the diagnostic statement "Excessive Fluid Volume r/t decreased venous return amb lower extremity edema," the etiology of the problem is
Decreased venous return Rationale: Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem
Which one of the following might be the best way to measure adherence to a prescribed regime? A:Direct observation of medication admin B: Evidence of illness complications or exacerbations C: Monitoring bla values of elements influenced by med D: Questioning client about med routine
Direct observation of medication admin Rationale: Although not always practical, direct observation is the best method to measure adherence
The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?
Delineate the client's problems and strengths Rationale: In diagnosing, data from assessment are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established
The primary purpose of the evaulation phase of the care planning process is to determine whether
Desired outcomes have been met Rationale: The desired outcomes and indicators statements reflect the parameters by which success will be measured
In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the following before implementing a plan?
Determines the logical course of action should an intervening problem arise Rationale: It is important to project what problems might interfere with the plan and have appropriate responses prepared to prevent the interferences
Which of the following is the purpose of assessing?
Establish a database of client responses to his or her health status. Rationale: Assessing provides a database of the client's physiological and psychosocial responses to his or her health status
Which of the folloing is a nursing responsibility when reading published nursing research?
Evaluate wheter the findings are applicable to the nurse's speific clients. Rationale: Since the primary purpose of reserch is to improve the quality of client care, the nurse should determine if published research reslts are applicable to the specific client population.
A key function of study's methodology is to
Exercise control over contaminating factors in the study environment. Rationale: The key pupose of a study's methodology is to generate data that are reliable and valid, thus controlling extraneous variables is a major function.
In most cases, clients must have a PCP in order to receive helath insurance benefits. If a client is in need of a PCP, it is most appropriate for th enurse to recommend
Family practice physician Rationale: PCPs are limited to generalist physicians and advanced practice nurses. In some cases, a gynecologist may qualify as a PCP and in other cases not.
A registered nurse is interested in functioning as a health care advocate for individuals whose lives are affected by violence. This nurse will be investigating which expanded career role?
Forensic nurse specifically integrates forensic skills into nursing practice.
These women made significant contributions to the nursing care of soldiers during the Civil War.
Harriet Tubman Dorothea Dix Sojourner Truth
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represent a properly stated goal/outcome? The client will A: Turn in bed q2h B: Report the iportance of applying lotion to skin daily C: Have intact skin during hospitalization D: Use a pressure-reducing mattress
Have intact skin during hospitalization Rationale: The goal or outcome should state the opposite of the nursing diagnoses stem, and thus healthy intact skin is the reverse condition of impaired skin integrity
Because a client recently diagnosed with DM is confident that bs control can be improved with diet and exercise alone, and recently checked out a video on teh management of DM at the HMO education center, the client's actions are most representative of which model?
Health belief model Rationale: The behavior is most representative of health promotion, which is the central focus of the health belief model
The purpose of theory in science is to
Help scientists interpret phenomena Rationale: The purpose of any theory is to help interpret phenomena
After recovering from her hip replacement, an older adult client want to go home. The family wants the client to go to a nursing home. If the nurse were acting as a client advocate, the nurse would perform which of the following actions?
Help the client and family communicate their views to each other Rationale: A major role of the client advocate is to mediate between conflicting parties. The nurse needs to assess the situation before offering an intervention
While hospitalized, a client is very worried about business activities. The client spends a great deal of time on the phone and with colleagues instead of resting. Which principle of need therapy applies to this client?
His lower level physiological needs are being deferred while higher needs are addressed Rationale: Choices are often related to learned experiences, lifestyle, and values. The client obviously values the business more than physical health. When a person feels strongly enough, a lower level need (rest) can be postponed until a higher level need (success, safety) is met. It is very likely that no one else can meet that need for him and the lower need must still be met eventually
The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? A: Hospital policies B: Standardized care plans C: Orthopedic protocols D: Standards of care
Hospital policies Rationale: Policy and procedure document provides data about how certain situations are handled.
Which of the following behaviors is the most representative of the nursing diagnosis phase of the nursing process
Identifying major problems or needs Rationale: Identifying problems/needs is part of a nursing diagnosis (ie: a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath-dyspnea-as a nursing dx)
A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis
If both medical and nursing interventions are required to treat the problem
Which of the following are overarching goals of Health People 2020?
Increase quality and years of healthy life Eliminate health disparities Promote healthy behaviors
A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism? 1. Offer to come to the client's home to provide needed physical care. 2. Contact the client's spiritual adviser. 3. Inquire how this will affect other aspects of the client's life. 4. Provide the client with information about how to join a support group.
Inquire how this will affect other aspects of the client's life. Rationale: Holism implies consideration of all aspects of the clients life
The nurse is teaching a client about wound care during a f/u visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence-based practice when the client states, "I just don't know how I can afford these dressings"?
Integrity Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity
The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? A: Cognitive B: Intellectual C: Interpersonal D: Psychomotor
Interpersonal Rationale: This client needs psychosocial support rather than skills related to knowledge or hands on activity
What is one disadvantage associated with electronic courses?
It is harder to establish a sense of community Rationale: Since learners may do their online work at different times and do much of their work offline, it may be harder for them to feel and act like a class group
Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out
It is never acceptable Rationale: It is never acceptable practice for th enurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous.
The client has a high-priority nursing diagnosis for Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? A: Delete the diagnosis since the problem has not occurred B: Keep the diagnosis since the risk factors are still present C: Modify the nursing diagnosis to Impaired Mobility D: Demote the nursing diagnosis to a lower priority
Keep the diagnosis since the risk factors are still present Rationale: Risk factors that prompted it are still present
Which of the following is true regarding the state of the science in regards to nursing diagnosis?
More research is needed to validate and refine the diagnostic labels Rationale: Diagnostic labels are continuously reviewed and revised as indicated by research - much more of which is needed
The case management model using critical pathways would be appropriate for a client with which diagnosis A: MI B: Diabetes, hypertension C: MI, DM, HTN D: DM, HTN, an infected foot ulcer, senile dementia
Myocardial infarction (heart attack)
The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. hip dressing is dry with drains intact. Which element is most liekely to be considered of high prioroity for a change in the current care plan? A: Pain B: Nausea C: Constipation D: Potentian for wound infection
Nausea Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now
A PCP prescibes 1 tab, but the nurse accidentaly administers 2. After notifying the PCP, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for professional negligence?
No, the client was not harmed. Rationale: All elements such as duty, foreseeability, causation, harm/injury, and damages must be present for professional negligence to be proven. The nurse is a licensed professional responsible for individual actions. Notifying the PCP does not exempt the nurse from liability. Because it is apparent the standard of practice was not performed, a breach of duty does exist. Violation/omission of the standard of practice resulted in an excessive dosage. Therefore foreseeability is present; however, no harm occurred to the client.
A nurse discovers that a PCP has prescribed an unusually large dosage of a mediation. What is the most appropriate action?
Notify the prescriber Rationale: The nurse should call the person who wrote the order for clarification.
The best explanation for describing nursing as a pratice discipline
Nursing focuses on performing the professional role Rationale: Practice disciplines are fields of study in which the central focus is performance of a professional role
Give an example of a primary prevention activity
Nutrition counseling for young adults with a strong family history of high cholesterol Rationale: Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary preventions
Which of the following would be true regarding use of the observing method of data collection?
Observed data should be interpreted in relation to other sources of collection data Rationale: Interpreting collected data is necessary to help validate its accuracy
The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning?
Obtain vital signs and oxygen saturation Rationale: The nurse's intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully.
A nurse proposes that the hospital apply the findings from a recent research study that shows that clients appreciated cassical orchestra music and playing it frequently lowers clients' blood pressure. Which aspect of research suggests that it ay not be apprpriate to implement this as evidence-based practice?
One study would not be sufficient to show that all clients would find orchestral music pleasing. Rationale: There may have been unique aspects to this research that would not be applicable in a different setting or with different clients.
In the PICO format for phrasing research questions and identifying key terms for a literature search, what does the "P" stand for?
P - patient/cilent, population, or problem I - intervention C - comparison O - outcome These are helpful components of a research question and help to identify key terms for a literature search.
A client who is 46 pounds overweight tells you, "I was just born to be fat. I don't have the willpower." Although weigh loss occurred while attending two previous programs that "guaranteed" weigh loss, the weigh returned along with extra pounds after each program. According to the Health Promotion Model, the nurs is most likely to focus on which begavior specific cognition and affect variable for this client
Perceived self-efficacy Rationale: Perceived self-efficacy is the confidence the person has for achieving the desired outcome
An element of quality improvement, rather than quality assurance, is which of the following? A: Focus is on individual outcomes B: Evaluates organizational structures C: Aims to confirm that quality exists D: Plans corrective actions for problems
Plans corrective action for problems Rationale: Quality improvement (QI) plans corrective actions for problems. QI focuses on process rather than outcomes, client care rather than structure, and aims for improvement rather than confirmation of quality
An accurate statement about the role of nursing theory
Practice theories assist nurses to reflect on the effectiveness of what they do Rationale: Practice theories assist the nurse to reflect on nursing care
Whate is the challenge most associated with the utilization of an electronic client record system?
Privacy Rationale: Control over who has access to confidential computerized data is the greatest concern.
Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes?
Problem-solving Rationale: A nurse thinks critically, evaluates possible solutions, and uses problem-solving
If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? A: Structure evaluation B: Process evaluation C: Outcome evaluation D: Audit
Process outcome Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure eval would focus on the setting (how well equipment functions) outcome eval focus on changes in client status (whether reported satisfaction levels vary with type of person who answers the call light) audit would be a chart or documentation review
Instead of debating academic reqirements for RN preparation, nursing is now focusing on academic ___________________ for nursing students and graduates.
Progression
Health promotion is best represented by preventing accidents in the home
Rationale: Health promotion focuses on maintaining normal status without consideration of diseases
Which is the best response by the nurse if a client fails to follow the information or teaching provided?
Reassess the client's importance given to the behavior and readiness to change it Rationale: Change is a complex process and a nurse should not give up or assume that the client does not want to change
When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first?
Reassessing the client Rationale: First step of implementing is reassessing the clientto determine that the activity is till indicated and safe
When written properly, NOC outcomes and indicators: A: Do not require customization B: Address several nursing diagnoses C: Are broad statements of desired end points D: Reflect both the nurse's and the client's values
Reflect both the nurse's and the client's values Rationale: NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved
The nurse who is assisting a client in the action stage of change would use which strategy
Reinforce the importance of providing rewards for positive behavior
When performing collaborative health care, the nurse must implement
Rely on the expertise of other health care team members Rationale: In collaboration, each member of the team, including the client, participates in sharing ideas and reaching consensus on the best plan of care.
Following a motor vehicle crash, the parents of a child with no apparent brain function refuse to permit withdrawal of life support from teh child. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their deision. Whihc moral principle provides the basis for the nurses actions?
Respect for autonomy Rationale: Autonomy is the client's (or surrogate's) right to make his or her own decision. The nurse is obliged to respect a client's or significant other's informed decision. These parents may modify their decision as time goes on and the child's condition, or their feelings, change.
During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's BP seems high. What is the next step? A: Ask the client about past blood pressure ranges B: Review the graphic record on the client's record C: Examine medication record for antihypertensive meds D: Review the progress notes included in the client's record
Review the graphic record on the client's record
Behavior indicating that the nurse was utilizing the assessment phase of the nursing process to provide nursing care.
Reviews results of laboratory tests. Rationale: During assessment, data are collected, organized, validated, and documented
An 85-year-old client in a nursing home tells a nurse, "Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me." Which client right is being violated?
Right to self-determination Rationale: The right to self-determination means that subjects feel free of constraints, coercion, or any undue influene to participate in a study
Which of the following nursing diagnoses contains the proper components
Risk for Caregiver Role Strain r/t unpredictable illness course Rationale: States the relationship between the stem (caregiver role strain) and the cause of the problem
Place the following activities of planning in the correct ofder of their use A: Establish goals/outcomes B: Write the care plan C: Set priorities D: Choose interventions
Set priorities Choose interventions Establish goals/outcomes Write the care plan
Although not every client progresses in order through each stage, what is the usual sequence in Suchman's stages of illness? 1. The client makes contact with medical care. 2. The client goes into rehabilitation/recovery. 3. Signs and symptoms appear. 4. The client takes on the dependent role. 5. The client takes on the sick role.
Signs and symptoms appear. The client takes on the sick role. The client makes contact with medical care. The client takes on the dependent role. The client goes into rehabilitation/recovery.
A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation?
Six round skin lesions partially healed on the inner thighs bilaterally
Which of the following elements is best categorized as secondary subjective data?
Spouse states the client has lost all appetite Rationale: Primary data come from the client whereas secondary data come from any other source (chart, family)
One of the primary advantages of using a three-part diagnostic statement such as the promlem-etioogy-signs/symptoms (PES) format inclued
Standardizes organization of client data Rationale: The PES format assists with comprehensive and accurate organization of client data.
After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? A: Initial B: Ongoing C: Discharge D: Strategic
Strategic Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time. Of the 3 types of planning that need to be done at this time, initial is the highest priority since he has just had surgery The client also requires ongoing type of planning necessary to determine the care appropriate for this shift. Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency.
Which professional organization developed a code for nursing students?
The National Student Nurses Association (NSNA) developed the Code of Academic and Clinical Conduct for nursing students in 2001.
This is true regarding the relationship of implementing to the other phases of the nursing process
The findings from the assessing phase are reconfirmed in the implementing phase Rationale: During implementation, the nurse also assesses and compares with initial assessment
The nurse recognizes which of the following as a benefit of using a standardized care plan? A: No individualization is needed B: The nurse chooses from a list of interventions C: They are much shorter than nurse-authored care plans D: They have been approved by accrediting agencies
The nurse chooses from a list of interventions Rationale: Standardized care plans provide a list of interventions from which the nurse can choose
Which action by a nurse ensures confidentiality of a client's computer record? A: The nurse logs on to the client's file and leaves the computer to answer the client's call light B: The nurse shares her computer password C: The nurse closes a client's computer file and logs off D: The nurse leaves client computer worksheets at the computer workstation
The nurse closes a client's computer file and logs off
Values, moral frameworks, and codes of ethics influence the professional nurse's moral decisions in which of the following ways?
The nurse is bound to act according to the nurse's code of ethics even if the nurse's values are different Rationale: The nurse is obliged to design care and to act according to the professional code of ethics even if the nurse holds different values.
The PCP wrote a do-no-resuscitate (DNR) order. The nurse recognizes that _________ applies in the planning of nursing care for this client.
The nurses will continue to implement all treatments focused on comfort and symptom management. Rationale: A DNR order only controls CPR and similar lifesaving treatments. All other care continues as previously ordered. Competent clients can still decide about their own care (including the DNR order). Nothing about the DNR order is related to when the client may die. Because clients' medical conditions and their views of their lives can change, a new DNR order is required for each admission to a health care agency. Once admitted, that order stands until changed or until it expires according to agency policy.
The client who is SOB benfits from the head of the bed being elevated. Because this position can results in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision making is the nurse engaging in?
The research method Rationale: The research method uses a research study-based approach to problem-solving.
Which of the following is likely to occur if a goal statement is poorly written? A: There is no standard against which to compare outcomes B: The nursing diagnoses cannot be prioritized C: Only dependent nursing interventions can be used D: It is difficult to determine which nursing intervenitons can be delegated
There is no standard against which to compare outcomes Rationale: Goal statements provide the standard against which outcomes are measured
The care plan includes a nursing intervention "4/2/15 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? A: Action verb B: Content C: Time D: None
Time Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals. The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings
The lowest level of "best evidence" for the evidence-based practice is
Trial and error is not considered valid evidence, and may even be harmful to clients.
Which charting rule(s) will keep the nurse legally safe? Select all that apply. 1. Use military time. 2. Document worries or concerns expressed by the client. 3. Perform most of the charting at the end of the shift. 4. Record only information that pertains to the client's health problems.
Use military time Document worries or concerns expressed by client Record only info that pertains to the clients health prob
The Pew Commissions competencies for future practitioners included the need for providers to become skilled in
Use of technology Rationale: The Pew Commission identifies the need for modern health care providers to be proficient in the use of technology
A situation of a violation of the underlying principles associated with professional nursing ethics is
When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up, I just give what is prescribed." Rationale: The nurse has an ethical responsibility to act only when actions are safe or risks minimized. This nurse is putting the client at unnecessary risk for a medication error.
A nurse is planning a workshop on health promotion for older adults. Which topic will be included? A: prevention of falls B: cardiovascular risk factors C: adequate sleep D: how to stop smoking
adequate sleep Rationale: Learning about sleep will increase the older adult's well-being, which is the focus of health promotion
Continuing education for nurses refers to
formalized experiences designed to enhance the knowledge of skill of practitioners (ie completing a workshop on ethical aspects of nursing)
Which of the following is an internal variable affecting health status, beliefs, or practices? A: living situation B: socioeconomic status C: family structure D: genetics
genetics
Which of the following is least likely to influence a client's personal definition of health/wellness? A: Clients ability to perform usual activities B: cultural traditions that client uses in every day life C: availability and accessibility of health care services appropriate for the client's health cond D: medical diagnostic terminology used to describe the client's signs/symptoms
medical diagnostic terminology used to describe the client's signs/symptoms Rationale: The actual term used to describe the dx is less important because the client may have no frame of reference for it. That is not to say that the dx is unimportant because clients may be familiar with common dx such as heart disease or cancer and ascribe historical meaning to them.
The most significant method for reducing the ongoing increase in the cost of health care in the US includes controlling
numbers of uninsured and underinsured persons Rationale: When people have inadequate insurance for health costs, they tend to avoid early and preventive care. this results in eventual use of much more costly resources w\such as emergency departments. Methods to provide minimum levels of insurance coverage have been successful in other countries.
a married mother of three small children has frequent immobilizing headaches of unknown cause. the nurse anticipates that the woman may have which of the following possible reactions? select all that apply. 1. she feels guilty when unable to perform her usual activities. 2. she is angry and acting out 3. she shifts some responsibilities to the spouse. 4. she takes on a job to help pay for the medical expenses. 5. she has fewer social interactions with her friends.
she feels guilty when unable to perform her usual activities. she is angry and acting out she shifts some responsibilities to the spouse. she has fewer social interactions with her friends.
this is true regarding public health agencies
they are funded by governments to investigate and provide health programs Rationale: City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community
