HESI practice

A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? Correct1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus

A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.

A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Tomato juice, raisin bran cereal, and tea Correct3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee

Applesauce, cream of wheat, and apple juice are bland foods that do not irritate the gastric mucosa. Orange juice, fried eggs, sausage, tomato juice, raisin bran cereal, tea, sliced oranges, and coffee are not bland; they may be irritating to the mucosal lining. Caffeine should be avoided.

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? 1 Helping the client enter into group recreational activities 2 Convincing the client that the hospital staff is trying to help Correct3 Helping the client learn to trust the staff through selected experiences 4 Limiting the client's contact with others while in the hospital

Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust.

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? Correct1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide

Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Correct1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.

Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? Correct1 The child is developing a conscience. 2 The child is learning about gender roles. 3 The child is developing a sense of security. 4 The child is learning about the political process.

Learning the sociocultural mores of the family implies that the child is developing a conscience. This does not imply that the child is learning gender roles, developing a sense of security, or learning about the political process.

Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. Correct2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.

Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? Correct1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care 4 Using medical and surgical aseptic techniques at all times

Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 1 150 to 250 mL 2 250 to 350 mL 3 300 to 500 mL Correct4 500 to 750 mL

In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

What did the nurse observe during a home visit that indicates effective teaching about avoidance therapy provided to a client with type I rapid hypersensitivity reaction? Select all that apply. 1 Pet dog sitting on the floor Correct2 Pillows covered with ultra-mesh fabric Correct3 Cloth drapes removed from all windows Correct4 Air-conditioning unit running in the home Correct5 Carpeting replaced with hard wood floors

In avoidance therapy, clients should be instructed to cover pillows with ultra-mesh fabric, remove cloth drapes, use an air-conditioning unit to remove airborne pathogens, and remove carpeting. Pets should be restricted to outdoors to decrease allergen exposure.

The nurse at the mental health clinic is counseling a client with obsessive-compulsive disorder who spends a lot of time each day engaged in handwashing and has trouble keeping appointments on time as a result. What is the most therapeutic initial intervention by the nurse? 1 Discouraging the frequent handwashing to prevent skin breakdown 2 Encouraging the client to hasten the ritual so appointments can be kept on time 3 Telling the client how angry others become when activities are delayed for handwashing Correct4 Accepting the ritualistic behavior with a matter-of-fact attitude without displaying criticism

Responding to the ritualistic behavior in a matter-of-fact way prevents reinforcing the behavior; allowing time for rituals helps prevent an increase in the anxiety level. Attempts to discourage ritualistic behavior often increase the anxiety level and intensify the performance of the ritual. Attempts to hasten ritualistic behavior will increase the level of anxiety. Disparaging the client will decrease self-esteem, will increase anxiety and guilt, and may worsen the client's symptoms.

A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating? 1 Liquefy food in a blender. Correct2 Eat a mechanical soft diet. 3 Take frequent sips of water with meals. 4 Use a local anesthetic mouthwash before eating.

Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face; a mechanical soft diet includes foods that limit the need to chew and are easier to swallow. Liquefied foods are difficult to swallow; esophageal peristalsis is decreased, and liquids are aspirated easily. Taking frequent sips of water with meals will not help; it is equally difficult to swallow solids and liquids, and aspiration may result. Using a local anesthetic mouthwash before eating is not necessary; oral pain is not associated with scleroderma.STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? 1 Irish Americans 2 African Americans Correct3 Chinese Americans 4 Egyptian Americans

Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1 Wear support hose continuously. 2 Lie down for 30 minutes after taking medication. 3 Avoid tasks that require high-energy expenditure. Correct4 Sit on the edge of the bed for 5 minutes before standing

Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). Which food choice picked by the client determines that teaching was effective? Correct1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice

Skim milk contains about 12 grams of CHO per cup. There are about 30 grams CHO in 1 cup of apple juice. There are about 16 grams CHO in 1 cup of nonfat yogurt. There are about 25 grams CHO in 1 cup of orange juice.

What is the recommended length of insertion of the enema tube in a child of 3 years? 1 1 to 2.5 cm Correct2 5 to 7.5 cm 3 7.5 to 10 cm 4 2.5 to 3.7 cm

For a 3-year-old child, the recommended length of insertion of the enema tube is 5 to 7.5 cm. The length of 1 to 2.5 cm is incorrect, as it is too small. Even the insertion length of the enema tube used in infants is longer than this. For infants, the length of insertion of the enema tube should be 2.5 to 3.7 cm. For adolescents and adults, this length is 7.5 to 10 cm. Topics

What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa? Correct1 Observing the client after meals Incorrect2 Weighing the client before meals 3 Measuring the client's fluid balance 4 Limiting the client's interaction with peers

Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse assess the client's electrolyte or nutritional status. An accurate intake and output record is difficult to obtain unless the individual is closely observed throughout the day. There is no need to isolate the client from peers.

The nurse is providing care to several clients in the emergency department (ED). Which client is the priority when using the three-tiered triage system? 1 A client with a simple fracture 2 A client experiencing renal colic 3 A client with severe abdominal pain Correct4 A client with chest pain and diaphoresis

The client with chest pain and diaphoresis is classified as emergent and would require priority care. The client with renal colic and severe abdominal pain are classified as urgent. The client with a simple fracture is nonurgent.

A nurse is helping a client determine and articulate personal values about health problems. The nurse also explains the effect of these problems on lifestyle adjustments. Which Gardner's task of leadership is the nurse leader applying? 1 Explaining Incorrect2 Managing 3 Motivating Correct4 Affirming values

Values are the connecting thoughts and inner driving forces that give purpose, direction, and precedence to life priorities. According to the Gardner's tasks of leadership, helping the client sort out and articulate personal values that are related to health problems is affirming values. It also involves explaining the effect of these problems on lifestyle adjustments. Explaining includes teaching and interpreting information to promote well-being in the client. Managing involves assisting the client with planning, priority setting, and decision making. This also includes ensuring that organizational systems work on behalf of the client. Motivating includes inspiring clients or family members to achieve their vision.

The nurse is teaching a client about automatic epinephrine injectors. Which statement made by the client indicates a need for additional education? Correct1 "I will keep the device in the refrigerator." 2 "I will keep the device away from light." 3 "If the cap is loose, I will obtain a replacement device." Incorrect4 "I will have at least two drug-filled devices on hand at all times."

The device should be protected from extreme temperatures. Therefore the device should not be refrigerated. The device should be protected from light. If the cap is loose or comes off accidentally, the client should obtain a replacement device. The client should have at least two drug-filled devices on hand in case more than one dose is required.

A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse? Correct1 Baby cereals 2 Soft-boiled eggs 3 Fruits and puddings 4 Meats and vegetables

The first solid food added to the infant's diet should be easily digestible; fortified cereals are easy to digest and are a rich source of iron. Eggs are one of the last foods to be added to the diet because they may cause an allergic reaction. Puddings contain eggs, which are one of the last foods to be added to the diet because they may cause allergic reactions. Meats and vegetables are more difficult to digest than cereal is.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction Correct4 Excessive mechanical ventilation

The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Correct1 Assess her breastfeeding techniques to identify possible causes. 2 Provide a nipple shield to keep the infant's mouth off the nipples. 3 Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. 4 Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.

The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? Correct1 Third 2 Fourth 3 Second 4 Seventh

The third cranial nerve (oculomotor) contains autonomic fibers that innervate the smooth muscle responsible for constriction of pupils. The trochlear nerve is concerned with eye movements; lesions result in diplopia, strabismus, and head tilt to the affected side. The optic nerve is concerned with vision; lesions result in visual field defects and loss of visual acuity. The facial nerve is concerned with facial expressions; lesions result in loss of taste and paralysis of the facial muscles and the eyelids (lids remain open).

A nurse is caring for a client with continuous bladder irrigation. Which action should the nurse take? 1 Monitor urinary specific gravity to determine hydration. Correct2 Subtract irrigant from output to determine urine volume. 3 Record urinary output every hour to determine kidney function. 4 Obtain a 24-hour urine specimen to determine urine concentration.

The total amount of irrigation solution instilled into the bladder is eliminated with urine and therefore must be subtracted from the total output to determine the volume of urine excreted. An accurate specific gravity cannot be obtained when irrigating solutions are instilled into the bladder. Hourly outputs are indicated only if there is concern about renal failure or oliguria. A 24-hour urine test is not accurate if the client is receiving continuous bladder irrigations.Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. Correct1 Minimizing medications Correct2 Modifying the home environment 3 Teaching clients about the safe use of the Internet Correct4 Manage foot and footwear problems 5 Providing information about the effects of using alcohol

The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment and managing foot and footwear problems. Teaching clients about the safe use of Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? Correct1.Checking for a patent airway Correct2.Maintaining effective circulation Correct3.Performing adequate fluid replacement Correct4.Caring for the burn wound

The priority nursing intervention for a client with severe burn wounds is checking for a patent airway. The next priority is to maintain effective circulation. Then, adequate fluid replacement is established. Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan? Correct1 Importance of cleanliness around the site of the stoma 2 Necessity of covering the tube opening while swimming 3 Establishment of a regular schedule for suctioning the tube 4 Usage of sterile technique when caring for the tracheostomy tube

The procedure should be explained so the client understands that the tracheostomy can serve as an entrance for bacteria and that cleanliness is imperative. Clients with a laryngectomy may no longer swim because water will flood the lungs. Suctioning must be performed only as needed; a pattern is not necessary. Sterile technique is not required; medical aseptic technique is adequate and realistic.

A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1 Easing the client's feelings of guilt Correct2 Maintaining a supportive, structured environment 3 Pointing out reality through continued communication 4 Broadening the client's contacts with other people on the unit

These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not the priority. Reality orientation is not needed as much as maintaining a safe structured environment is. The client needs minimal, not increased, stimuli.

The mother of a 6-year-old boy tells the nurse in the pediatric clinic that her son has become incontinent of stool. The nurse plans to assess the child to determine the cause of his encopresis. In what order should the nurse perform the assessments? Correct1.Bowel habits Correct2.Nutrition history Correct3.Psychosocial factors Correct4.Physical examination

First, a physical cause of the encopresis should be investigated. This includes the toilet training process and changes in bowel habits or routines. If there are no changes in bowel pattern, a nutrition history may reveal any changes in the child's eating habits that caused the encopresis. Next, the nurse should explore psychosocial factors that may have influenced the development of the encopresis. Finally, a physical examination should be performed.

The nurse manager uses operant conditioning when managing the staff by providing positive reinforcement to motivate them to repeat constructive behavior. Which leadership theory is reflected in this practice? 1 Hierarchy of needs 2 Transformational theory 3 Situational contingency theory Correct4 Organizational behavior (OB) modification

OB modification theory is applied by providing positive reinforcement to the staff to motivate them to repeat constructive behaviors in the workplace. Awareness of the hierarchy of needs can be used to understand what motivates staff; for example, the need for security will override social needs. Transformational theory does not utilize operant conditioning for motivation. Situational contingency theory is applied to consider the challenge of a situation and encourages an adaptive leadership style to complement the issue being faced.

A toddler in the pediatric intensive care unit is on a ventilator. One of the nurses asks what should be done when condensation collects in the ventilator tubing. How should the nurse manager respond? 1 Notify the physician assistant. 2 Decrease the amount of humidity. Correct3 Empty the fluid and reconnect the tubing to the ventilator. 4 Measure the fluid and mark it on the intake and output record

The correct course of action is to empty the fluid from the tubing and reconnect it because accumulated fluid may flood the trachea. Removing condensation from the tubing does not require help from a physician assistant; the nurse or respiratory therapist, depending on hospital protocol, is responsible for this remedial action. Humidity is necessary to preserve moisture in the respiratory tract. The amount of condensation is irrelevant in terms of recording intake and output.

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? 1 Call the chaplain to convince the client to receive the blood transfusion. 2 Discuss the case with coworkers. Correct3 Notify the primary healthcare provider of the client's refusal of blood products. 4 Explain to the client that they will die without the blood transfusion.

The nurse serves as an advocate for the client to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary healthcare provider. Therefore the primary healthcare provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against beliefs. It is a Health Insurance Portability and Accountability Act (HIPAA) (Canada: Personal Health Information Protection Act [PHIPA]) violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

A client with catatonic schizophrenia who is in a vegetative state is admitted to the psychiatric hospital. The nurse identifies short- and long-term outcomes in the client's clinical pathway. What is the priority short-term outcome of care that the client should be able to attain? 1 Talking with peers 2 Performing activities of daily living 3 Completing unit activities and assignments Correct4 Ingesting adequate fluid and food with assistance

A client in a vegetative state may not eat or drink without assistance; fluids and foods are basic physiologic needs that are necessary to prevent malnutrition and starvation; therefore the intake of adequate fluid and food is a priority short-term goal. The client is in total withdrawal; talking with peers, performing activities of daily living, and completing activities and assignments are not priority outcomes at this time.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A client has a severe, unilateral throbbing headache that has lasted for 2 days. What should be the priority nursing care? 1 Administering gabapentin Correct2 Administering sumatriptan 3 Administering propranolol 4 Administering botulinum toxin A

A client with a unilateral throbbing headache which lasts from 4 to 72 hours is likely a migraine. The nurse should administer sumatriptan to reduce the symptoms of migraines, but it is most effective when taken at the onset of a migraine headache. Gabapentin is an antiseizure medication that is used in migraine prevention. Propranolol is an antihypertensive used as a prophylactic treatment. Botulinum toxin A is an effective prophylactic medication for treating chronic migraines and for migraines that do not respond to other medications.

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? Correct1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high

A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? Select all that apply. Correct1 Taking on parental roles 2 Adjusting to a reduction in family size 3 Development of intimate peer relationships Correct4 Adjusting the marital system to make space for children Incorrect5 Realigning relationships to in-laws and grandchildren

A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

What is the rationale for performing sponge, needle, and instrument counts in the operating room? 1 The hospital is not liable if a client is injured due to a retained sponge or instrument. 2 The nursing student is liable for client injuries due to a retained sponge or instrument. Correct3 A nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. 4 The primary healthcare provider is responsible for providing an accurate count of sponges and instruments.

A nurse should perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury due to a retained sponge or instrument, the hospital is liable if the nurse had recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary healthcare provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

Which outcome best demonstrates a healthcare institution's commitment to providing a supportive environment for its psychiatric nursing staff? 1 Psychiatric nursing units are well staffed with qualified personnel. 2 The psychiatric units are equipped with the most modern client care equipment. Correct3 Psychiatric nurses are regularly recognized for their contributions to client healthcare. 4 The psychiatric nursing staff is represented in each client's multidisciplinary healthcare team.

A supportive nursing environment is one that fosters and supports open, honest communication among all disciplines involved in a client's care. This demonstrates respect for the professional psychiatric nurses and their influence on client healthcare. A sufficient number of qualified nursing personnel is a requirement on any nursing unit and shows a commitment to client care but not necessarily support for the unit's nursing staff. A modern, well-equipped nursing unit shows a commitment to client care but not necessarily support for the unit's nursing staff. Recognition of professional levels of nursing care is likely to have a positive effect on nursing morale but does not necessarily foster a supportive nursing environment.

A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider? 1 A loud Korotkoff sound 2 An irregular pulse of 92 beats per minute Correct3 A diastolic blood pressure that remains greater than 90 mm Hg 4 A throbbing headache over the left eye when arising in the morning

A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and could indicate hypertension. A loud Korotkoff sound is unrelated to hypertension. An irregular pulse of 92 beats per minute reflects the heart rate and rhythm, not the pressure within the arteries. Initially hypertension usually is asymptomatic; although headaches can be associated with hypertension, there are other causes of headaches.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1 Weak upper arm strength and impaired stamina 2 Weight bearing as tolerated and unilateral paralysis 3 Partial weight bearing on the affected extremity and kyphosis Correct4 Strong upper arm strength and non-weight bearing on the affected extremity

A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1 Assign articles about various cultures so that they can become more knowledgeable. 2 Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3 Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. Correct4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

A workshop provides an opportunity to discuss cultural diversity; this should include identification of one's own feelings. Also, it provides an opportunity for participants to ask questions. Although articles provide information, they do not promote a discussion about the topic. Relocation is not feasible or desirable; clients from other cultures are found in all settings. Rotating the nurses' assignments probably will increase tension on the unit.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse in the pediatric clinic receives a call from the mother of an infant who has been prescribed digoxin. The mother reports that she forgot whether she gave the morning dose of digoxin. How should the nurse respond? 1 "Give the next dose immediately." 2 "Wait 2 hours before giving the medication." Correct3 "Skip this dose and give it at the next prescribed time." 4 "Take the baby's pulse and give the medication if it's more than 90 beats/min."

An additional dose may cause overdosage, leading to toxicity; it is better to skip the dose. Giving the dose without waiting may cause an overdose, which could result in toxicity. Even waiting 2 hours may cause an overdose, leading to toxicity. Taking the pulse is not a reliable method for determining a missed dose; 90 to 110 beats/min is within the expected range for this age.

While performing the physical assessment of an infant, the nurse notices the infant has developed a color preference for red and yellow. What is most likely to be the age of the infant? 1 4 weeks 2 8 weeks 3 15 weeks Correct4 20 weeks

An infant develops a color preference for yellow and red between 20 to 28 weeks of age. At 4 weeks, the infant can follow a range of 90 degrees. Between 6 to 12 weeks of age, the infant develops peripheral vision to 180 degrees. Between 12 to 20 weeks of age, the infant is able to accommodate to near objects.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply. Incorrect1 The nurse is organized and focused. 2 The nurse trusts one's own reasoning process. Incorrect3 The nurse accepts multiple solutions to a problem. Correct4 The nurse uses evidence-based knowledge for clinical decision-making. Correct5 The nurse anticipates possible results or consequences in a given situation.

Analyticity is one of the concepts of a critical thinker and involves the use of evidence-based knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or a given situation. Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.

A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of what? 1 Providing individual and family therapy 2 Using positive reinforcement to reduce guilt 3 Uncovering unconscious conflicts and fantasies Correct4 Providing a supportive environment to benefit the client

Any aspect of the treatment environment can be used to benefit the client in milieu therapy. Individual and family therapy are separate treatment modalities, not part of milieu therapy. Using positive reinforcement to reduce guilt is part of behavioral modification, not milieu therapy. Uncovering unconscious conflicts and fantasies is part of psychoanalytical, not milieu, therapy.

What role is the nurse expected to have in a community-based nursing practice if there is a sudden spread of malaria? 1 Educator 2 Collaborator Correct3 Epidemiologist 4 Client advocate

As an epidemiologist, the nurse is responsible for community surveillance for risk factors such as the sudden spread of malaria. An epidemiologist nurse protects the health level of the community, develops sensitivity to changes in the health status of the community, and helps identify the cause of these changes. As an educator in a community-based setting, the nurse provides knowledge to clients and families so they can learn how to care for themselves. As a collaborator in a community-based nursing practice, the nurse collaborates with hospice staff, social workers, and pastoral care to initiate a plan to support end-of-life care for the client and support the family. As a client advocate in a community-based setting, the nurse provides necessary information for clients to make informed decisions in choosing and using services.

Which of these cultural groups is known to practice Ayurveda to prevent and treat illness? 1 East Asian 2 Hispanic Correct3 Asian Indian 4 Native American

Asian Indians are known to practice Ayurveda (a healing system comprised of a combination of dietary, herbal, and other naturalistic therapies) to prevent and treat illness. Many East Asians use yin and yang treatment to restore balance. Hispanic groups tend to use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans are known to rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychological, and physical factors.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Correct1 Monitor for nonverbal cues of pain 2 Check the pressure dressing for bleeding 3 Assist the client to ambulate around his room 4 Irrigate the client's nasogastric tube with sterile water

Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A physically ill client is being verbally aggressive to the nursing staff who is performing intravenous therapy on the client. What is the most appropriate initial nursing response? Correct1 Tell me why you are upset. Incorrect2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions

At this time the client is using this behavior as a defense mechanism. Using an open-ended question regarding the client's verbal aggression can be an effective interpersonal technique because it is nonjudgmental and allows the client to elaborate on feelings at the time. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies nonacceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? 1 Enteric 2 Contact Correct3 Droplet 4 Standard

Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.

What is the priority when the nurse is establishing a therapeutic environment for a client? Correct1 Ensuring the client's safety 2 Accepting the client's individuality 3 Promoting the client's independence 4 Explaining to the client what is being done

Safety is the priority before any other intervention is provided. Accepting the client's individuality, promoting the client's independence, and explaining to the client what is being done are all important, but less of a priority.

Which clients should be considered for assessing the carotid pulse? Select all that apply. Correct1 Client with cardiac arrest 2 Client indicated for Allen test Correct3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand

Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1 Using medication to induce elimination Correct2 Adhering to a definite time for attempted evacuations Incorrect3 Considering previous habits associated with defecation 4 Timing of elimination to take advantage of the gastrocolic reflex

Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Correct1 Barrel chest 2 Cyanosis 3 Hyperventilation 4 Lordosis

Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. This also causes the lungs to have less flexibility. Cyanosis is a bluish discoloration, especially of the skin and mucous membranes, caused by excessive concentration of deoxyhemoglobin in the blood caused by deoxygenation. COPD sufferers can exhibit this, but barrel chest is the most obvious sign, as other respiratory/cardiovascular disorders can cause cyanosis as well. Hyperventilation is the act of breathing faster or deeper than normal, which causes excessive expulsion of circulating carbon dioxide. This causes the arterial concentration of carbon dioxide (PaCO2) to fall below normal, raising blood pH, and results in alkalosis. COPD sufferers can experience hyperventilation, but barrel chest is the classic sign of COPD. Lordosis is an unusual inward curving of the spine in the lower part of the back. It can be considered medically significant; however, it is not associated with classic signs of COPD.Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

Which information should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1 Maintaining sterility of the exposed bladder 2 Measuring output from the exposed bladder Correct3 Protecting the skin surrounding the exposed bladder 4 Applying a pressure dressing to the exposed bladder

Constant drainage of urine on the skin promotes excoriation and infection, so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated, because it will traumatize the exposed bladder.

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? 1 Increased cultural sensitivity 2 Decreased cultural imposition 3 Decreased cultural dissonance Correct4 Increased cultural competence

Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.

The nurse leader is teaching the staff that the health care provider continuously strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining? 1 Cultural diversity 2 Cultural sensitivity 3 Cultural imposition Correct4 Cultural competence

Cultural competence is the process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of a client, individual, family, or community. Cultural diversity describes a vast range of cultural differences among individuals or groups. Cultural sensitivity describes the affective behaviors in individuals such as the capacity to feel, convey, and react to ideas, habits, and customs or traditions unique to a group of people. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for various reasons.

A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating Correct2 Hyperpnea 3 Bradycardia 4 Hypertension

Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

When planning nursing care for a 5-year-old child with acute poststreptococcal glomerulonephritis, what should the nurse emphasize that the child and family must maintain? 1 A bland diet high in protein 2 Bed rest lasting at least 4 weeks Correct3 Isolation from children with infections 4 A daily intramuscular dose of penicillin

During the acute stage, anorexia and general malaise lower the child's resistance to infection. A bland diet is not necessary, but high-protein and high-sodium foods should be avoided. Bed rest is not a necessary restriction. It is encouraged when the child is easily fatigued. Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.

Which statement describes the latency stage of Freud's psychoanalytic model of personality development? 1 During this stage, genital organs are the focus of pleasure. Correct2 During this stage, sexual urges are repressed and channeled into productive activities. 3 During this stage, an infant begins to think that his or her parent is separate from the self. 4 During this stage, sexual urges reawaken and are directed to an individual outside the family circle.

During the latency stage, Freud believed that sexual urges from the earlier Oedipal stage are repressed and channeled into productive activities that are socially acceptable. During the phallic stage, the genital organs are the focus of pleasure. During the oral stage, infants begin to think that the parent is something separate from the self. During the genital stage, sexual urges reawaken and are directed to an individual outside the family circle.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Correct1 Encouraging regular dental checkups Incorrect2 Facilitating smoking cessation programs Incorrect3 Administering influenza vaccines to older adults Correct4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group

Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? 1 "It will keep your baby from going blind." 2 "This ointment will protect your baby from bright lights." 3 "There is a law that newborns must be given this medicine." Correct4 "This antibiotic helps keep babies from contracting eye infections."

Erythromycin ophthalmic ointment is used to treat gonorrhea and Chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.

In which order should the nurse explain the process of phagocytosis? Correct1.Exposure/invasion Incorrect2.Recognition Incorrect3.Attraction Incorrect4.Adherence Correct5.Cellular ingestion Correct6.Phagosome formation Correct7.Degradation

Exposure and invasion occur as the first step in response to injury or invasion. Attraction is the second step because phagocytosis can occur only when the white blood cell comes into direct contact with the target. Adherence allows the phagocytic cell to bind to the surface of the target. Recognition occurs when the phagocytic cell sticks to the target cell and "recognizes" it as non-self. Cellular ingestion is needed because phagocytic destruction occurs inside the cell. Degradation is the final step. The enzymes in the phagosome digest the engulfed target.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

Four nurse leaders are performing Gardner's tasks. Which nurse leader is implementing Gardner's task of "serving as symbol"? Correct1 A 2 B 3 C 4 D

Gardner's task of "serving as symbol" includes the representation of the nursing profession, values, and beliefs of the organization to clients, their families, and other community groups. Therefore nurse leader A implements Gardner's task of "serving as symbol." Being honest and keeping promises to clients and families in the nursing profession indicates the implementation of Gardner's task of "developing trust" by nurse leader B. Nurse leader C implements Gardner's task of "managing" by assisting clients and their families with planning, priority setting, and decision making. Nurse leader D implements Gardner's task of "managing" by ensuring that the organizational systems work on the client's behalf.Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

A registered nurse is educating a client with acquired immune deficiency syndrome about safe sexual practices. Which statement made by the client indicates a need for further education? 1 "I should use a dental dam during oral sex." Correct2 "I can participate in anal intercourse safely without using condoms." 3 "I should ask my partner to use a female condom while engaging in sexual activity." 4 "I should use condoms even while receiving highly active antiretroviral therapy (HAART)."

Having anal intercourse indicates the client needs more teaching because this statement is incorrect. The client should wear a condom or use other genital barriers to prevent the transmission of human immunodeficiency virus (HIV). Anal intercourse is a risky sexual practice that allows contact between the seminal fluid and the rectal mucous membranes. Anal intercourse also tears the mucous membranes, making an infection more likely. All the other statements are correct and do not indicate further education is needed. Barriers such as female condoms and dental dams are recommended while participating in sexual activity. Though the viral load may decrease with the use of HAART, the risk for transmission still exists. Therefore the client should use condoms during sexual contact

The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions? 1 Private room with the door closed Incorrect2 Gown, mask, and gloves for all persons entering the room Correct3 Gown and gloves when handling articles contaminated by urine or feces 4 Gowns and gloves only when handling the client's soiled linen, dishes, or utensils

Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? 1 Report these findings to the healthcare provider. Correct2 Encourage the family to bring in special foods preferred in their culture. 3 Order a high-protein milkshake to supplement between meals. 4 Call the dietitian to work with client to plan high calorie meals for the client to eat

In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression Correct4 Acceptance

In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the client's current condition. Which characteristic of communication has interfered with the delegation process? Correct1 Information decay 2 Information salience 3 Confidence in abilities 4 Synergy between team members

Information decay can occur in a rapidly changing situation when reported information is no longer relevant to a client's condition. Information salience describes the different ways individuals from different backgrounds might assess the quality, meaning, and clarity of certain information. Trust is developed when there is confidence in the abilities and capabilities of the team members. Healthy relationships among members of the health care team promote synergy between the team members.

Which internal variable influences health beliefs and practices? 1 Family practices Incorrect2 Cultural background 3 Socioeconomic factors Correct4 Intellectual background

Intellectual background is an internal factor that affects the client's health beliefs and practices. A client's knowledge, educational background, and past experiences influence how a client thinks about health. Family practices, cultural background, and socioeconomic factors are among the external factors that influence health beliefs and practices.

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of which response? 1 Facial edema Correct2 Excessive swallowing 3 Pressure around the eyes 4 Serosanguineous drainage on the dressing

Internal bleeding after nasal surgery may flow by gravity to the posterior oropharynx, where it is swallowed. Facial edema is expected after the trauma of surgery. The edema that results from the trauma of surgery may be perceived as pressure around the eye; although it is expected, it is not a priority. Pink-tinged drainage on the nasal packing and nasal drip dressing is expected for 24 to 48 hours after surgery.

What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? 1 Knowledge reduces general anxiety. 2 Capacity to learn decreases with age. Correct3 Continued reinforcement is advantageous. Incorrect4 Readiness of the learner precedes instruction.

Neurologic aging causes forgetfulness and a slower response time; repetition increases learning. Continued reinforcement is an example of repetition. The facts that knowledge reduces general anxiety and that the readiness of the learner precedes instruction reflect principles that are applicable to learning regardless of the client's age. Capacity to learn decreases with age.

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching? Correct1 Cheeseburger and a milkshake 2 Beef barley soup and orange juice 3 Bacon and tomato sandwich and tea 4 Chicken salad sandwich and soft drink

Of the selections offered, a cheeseburger and a milkshake have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair. Although orange juice provides vitamin C, beef barley soup does not provide adequate protein or calories. A bacon and tomato sandwich and tea do not provide an adequate amount of calories and protein; nor do a chicken salad sandwich and a soft drink

A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1 Reviewing the past is depressing. 2 Stimulating new situations are ideal. 3 Dependency increases as age progresses. Correct4 Staying healthy promotes a quality retirement.

Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past is depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? 1 Return of usual tidal volume 2 Decreased adventitious sounds Incorrect3 Absence of additional drainage Correct4 Comparison of chest radiographs

Serial chest x-rays help determine treatment effectiveness. Chest x-ray films or radiographs reveal the degree to which the lung fills the pleural cavity and also the presence or absence of mediastinal shift. Return of usual tidal volume is not specific to expansion of the affected lung. Decreased adventitious sounds are abnormal chest sounds and do not indicate the degree of lung expansion. The chest tube may have minimal drainage and the lung may still not be expanded.

Four clients with osteomyelitis are prescribed antibiotics. Which client is at risk for Achilles tendon rupture? 1 Client A Correct2 Client B 3 Client C 4 Client D

Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Tendon rupture can occur with use of the fluoroquinolones. Therefore client B, prescribed ciprofloxacin, is at risk for Achilles tendon rupture. Client A, prescribed gentamicin, is at risk for visual and hearing problems. Client C, prescribed cefazolin, is at risk for severe watery diarrhea and mouth sores. Client D, prescribed tobramycin, is at risk for nephrotoxicity.Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.In a clinical exam, you may be expected to select instruments, arrange instruments, and/or perform some other task. Acquaint yourself with the physical facility. If the required procedures are not clear to you, ask for clarification.

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring Correct3 Preventing infection 4 Preventing skin breakdown

Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

Which reactions does a nurse expect of a 4-year-old child in response to illness and hospitalization? 1 Anger, resentment over depersonalization, and loss of peer support 2 Boredom, depression over separation from family, and fear of death Correct3 Out-of-control behavior, regression to overdependency, and fear of bodily mutilation 4 Intense panic, loss of security over separation from parents, and low frustration tolerance

Preschoolers experience loss of control caused by physical restriction, loss of routines, and enforced dependency, which may make them feel out of control. Preschoolers are also likely to experience feelings of regression or overdependency and fear of bodily mutilation. Anger, resentment over depersonalization, and loss of peer support are typical feelings expressed in adolescence. Boredom, depression over separation from family, and fear of death are typical feelings expressed by school-age children. Intense panic, loss of security over separation from parents, and low frustration tolerance are feelings usually experienced by toddlers.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A client who had the left hand amputated after a traumatic injury is being fitted for a permanent prosthesis. What should the nurse teach the client about the most important factor for successful adaptation to the permanent prosthesis? 1 Muscles in the upper arm must be developed. 2 Dexterity in the other extremity must be achieved. Correct3 Shrinkage of the residual limb must be completed. 4 Adjustment to the altered body image must be accomplished.

Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis. Although developed muscles in the upper arm and dexterity in the other extremity are desirable, it is the condition of the residual limb that is the most important factor in the fitting of a prosthesis. The prosthesis probably will facilitate an improved body image.

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting the head toward one shoulder. What does the nurse conclude about these clinical manifestations? 1 Expected characteristics of this illness 2 Consistent with an acute exacerbation of the illness Correct3 Possible side effects of the antipsychotic medication 4 Life threatening and requiring immediate intervention

Shuffling gait and torticollis are symptoms of pseudoparkinsonism that are caused by antipsychotic medications, particularly the typical antipsychotics. Expected characteristics of schizophrenia, paranoid type, include delusions, hallucinations, suspiciousness, anger, hostility, and paranoia. An acute exacerbation of the illness reflects an increased intensity of the expected characteristics associated with paranoid schizophrenia, which include pressured speech, suicidal ideation, and aggressive, agitated behavior. Although these physical manifestations require intervention, they are not life threatening.STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it.

In which order should the nurse review the events that occur in stage I of the inflammatory process? Incorrect1.Increased blood flow causes swelling at the site of injury Incorrect2.Cytokine is released to produce more white blood cells Correct3.Capillary leak causes pain Incorrect4.Blood vessel changes cause redness and tissue warmth Incorrect5.Edema from plasma leaking protects further injury

Stage I is the vascular part of the inflammatory response that first involves changes in blood vessels. Blood vessel changes cause redness and warmth of the tissues. Increased blood flow to the area causes swelling at the site of injury. Capillary leakage allows blood plasma to leak into the tissues, which causes pain. Edema at the site of injury protects the area from further injury by creating a cushion of fluid. To enhance the inflammatory response, cytokines are released, which trigger the bone marrow to shorten the time needed to produce white blood cell

A hospice nurse is caring for a dying client while several family members are in the room. When the client dies, the initial nursing intervention during the shock phase of a grief reaction is focused on what? Correct1 Staying with the individuals involved 2 Directing the individuals' activities at this time 3 Mobilizing the support systems of the individuals 4 Presenting the full reality of the loss to the individuals

Staying with the individuals involved provides support until the individuals' coping mechanisms and personal support systems can be mobilized. Directing the individuals' activities at this time is not the role of the nurse. The individuals, not the nurse, must mobilize their support systems. The individuals need time before the full reality of the loss can be accepted.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "alternative medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." Correct3 "Nontraditional approaches to health care can be beneficial." 4 "You are right because they may have a negative impact on people's health."

Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy. Topics

After reading that nutrition during pregnancy is important for optimal growth and development of the baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by doing what? Correct1 Asking the client what she usually eats at each meal 2 Explaining to the client why spicy foods should be avoided 3 Instructing the client to add calories while continuing to eat a healthy diet 4 Providing the client with a list of foods for reference when planning meals

Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.

What instructions should a nurse provide to adolescent boys regarding the usual procedure to be followed and normal findings observed during testicular self-examination. Select all that apply. Correct1 A firm, smooth, egg-shaped organ can be palpated. Correct2 Each testicle is examined individually after relaxing the scrotal skin. 3 A hard mass that can be palpated on anterior or lateral aspect of testicle. Correct4 The thumb and fingers of both hands can be used to apply firm and gentle pressure. Correct5 A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis.

Testicular self-examination is usually performed after a warm bath when the scrotal skin is relaxed. A firm organ with smooth and egg shaped contours that can be palpated is the testicle. Each testicle is examined individually using thumb and fingers of both hands applying firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of testicle is the epididymis. Testicular cancer can be suspected if a hard mass can be palpated on the anterior or lateral aspect of testicle.

What statement by the nursing student indicates understanding of the precautions needed in the provision of care to a 7-year-old child who is HIV positive? 1 "I'll put on a mask." 2 "I'll put on an N-95 mask." 3 "I'll put on a gown and gloves." Correct4 "I'll put on gloves if I'm going to be in contact with body fluids."

The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) recommends standard precautions for the care of individuals with HIV infection or AIDS without opportunistic infections. Droplet precautions are not necessary because HIV is not transmitted in large-particle respiratory droplets. Contact precautions are not necessary unless the HIV infection or AIDS is complicated by the presence of disease or infection, necessitating the addition of these precautions to standard precautions. Airborne precautions are unnecessary because HIV is not spread in airborne droplet nuclei; these precautions are used in addition to standard precautions if an opportunistic infection such as Mycobacterium tuberculosis is present.

A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? 1 Evaluating the client's adjustment to the unit Correct2 Providing the client with a sense of security and safety 3 Exploring the client's memory loss and fear of going out 4 Assessing the client's perception of reasons for the hospitalization

The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia? 1 Drink iced liquids. 2 Avoid oral hygiene. 3 Apply warm compresses. Correct4 Chew on the unaffected side.

The client may avoid stimulating the involved trigeminal nerve and thus prevent pain by chewing on the unaffected side. Food and fluids that are too hot or too cold can precipitate pain. Although oral hygiene may initiate pain, it cannot be avoided. It can be modified to include rinsing the mouth or using a soft swab instead of a toothbrush. Warm compresses may precipitate pain.Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

The nurse is caring for four clients in the emergency department. In what order should the nurse prioritize client care? Correct1.Client with severe respiratory distress Correct2.Client with chest pain due to ischemia Correct3.Client with a gynecologic disorder Correct4.Client with cystitis .

The client with severe respiratory distress should be treated immediately as the condition of the client is critical and may be life-threatening. The client with chest pain due to ischemia may be treated within 10 minutes after treatment of the client with respiratory distress. One of the most common reasons for someone with a gynecologic disorder to come to the ER is for bleeding. This would take precedence over cystitis. Also the client with a gynecological disorder may require multiple diagnostic studies to determine the condition, and this can be delayed up to 1 hour. The client with cystitis may only require a simple diagnostic procedure to determine the condition and begin treatment.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration

Which individual would be an appropriate member of a critical incident stress debriefing (CISD) team for a group of staff nurses? Select all that apply. Correct1 Staff nurse 2 Organization chaplain 3 Organization media representative Correct4 Physician trained in critical debriefing Correct5 Advanced practice mental health nurse

The critical incident stress debriefing (CISD) team includes a peer member of the group being debriefed. For this group, the CISD team would include a staff nurse. The team may include a physician trained in critical debriefing. The team leader would be someone with a background in mental or behavioral health. This role would be appropriate for the advanced practice mental health nurse. The chaplain and the media representative are not identified as being appropriate for the CISD team.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

While caring for a female client, the nursing student feels tenderness and a lump in the client's breast. The nursing student tells the registered nurse, "I think this client has breast cancer." Which statements of the registered nurse would be appropriate in accordance with the knowing element of Swanson's theory? Select all that apply. 1 "Try to comfort the client." Correct2 "Avoid making assumptions." Correct3 "Assess the client thoroughly." Correct4 "Check for other signs of breast cancer." 5 "Try to provide support and care to the client."

The knowing element of the caring process involves understanding an event. Avoiding assumptions, performing a thorough assessment of the client, and checking for other signs of breast cancer and are related to the knowing element of Swanson's theory of caring. The doing for element includes comforting the client. The caring process of being with involves the nurse providing emotional support.

The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond? 1 "Is he able to sit unsupported?" Correct2 "Usually this reflex disappears around 4 months." 3 "Do his toes still flare out when you stroke the sole of his foot?" 4 "Please bring him to the clinic—he may have a feeding problem."

The mother is describing the rooting reflex; when touched on the cheek, the infant reflexively turns the head to that side. The rooting reflex is expected to disappear by 4 months of age. An infant can sit without support at 8 months; this is not expected of a 5-month-old infant. Stroking the sole of the foot elicits the Babinski reflex, which disappears between 8 and 12 months of age. The disappearance of the rooting reflex at 5 months of age does not require further intervention.

A client just has returned from the postanesthesia care unit after having a laparotomy. Which initial sign or symptom indicates to the nurse that peristalsis has begun to return? 1 Stool is evacuated. 2 Nausea is no longer present. Correct3 Borborygmi are auscultated. 4 Abdomen is no longer tender.

The nurse auscultates the abdomen and listens for bowel sounds (borborygmi), which signify the initial return of peristalsis. The first bowel movement occurs after peristalsis returns. Nausea and/or tenderness may be present, even though peristalsis has returned.Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.

According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? Select all that apply. 1 Economic constraints Correct2 Continuity of care by the nursing staff 3 Fewer nurses in the healthcare facility Correct4 Collection of data about the client's clinical condition Correct5 Engagement in a caring relationship without assumptions

The nurse gets to know the client over time with continuity in care. The nurse enters into a caring process by collecting data about the client's clinical condition. The data enables the nurse to use critical thinking and clinical judgments during client care. The nurse should engage in a caring relationship with the client without any assumptions and use knowledge and experience to detect changes in the client's health condition. Economic constraints may lead to the client spending less time in the healthcare facility. This acts as a barrier in providing client-centered care. Changes in the organizational structure may result in fewer nurses caring for more clients. This results in fewer interactions with the client.

The nurse is evaluating whether a hospice referral is appropriate for a patient with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program?

The patient wants hospice care and agrees to terminate curative care.There are two criteria for admission to a hospice program. The first criterion is the patient must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness. The second criterion is that the patient must be considered eligible for hospice. Two physicians must certify that the patient's prognosis is terminal with less than 6 months to live.

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? 1 Using disposable diapers Correct2 Placing the infant in the prone position 3 Performing neurologic checks above the site of the lesion 4 Washing the area below the defect with a nontoxic antiseptic

The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.

A 4-month-old infant is admitted directly to the pediatric unit from the primary healthcare provider's office with a diagnosis of bronchiolitis. The mother reports that the infant had a "breathing treatment" about 3 hours ago while in the primary healthcare provider's office. She says she then went home to pack some clothes first before coming to the hospital. The mother says that it has been more than 4 hours since the baby ate and requests formula and rice cereal so she can feed the baby. The admitting nurse reviews the infant's assessment findings and admission prescriptions. How should the nurse recommend that the mother feed the baby? Correct1 Withhold feedings at this time. 2 Offer Pedialyte or other clear liquid. 3 Offer up to 4 oz (120 mL) of formula. 4 Feed baby cereal followed by formula.

The respiratory rate is above 60 breaths/min, so the risk of aspiration is great. The feeding should be delayed until the respiratory rate and general condition have improved. Once the respiratory rate has slowed, the baby will benefit from clear liquids. Liquids are necessary to thin mucus, but milk is thick and may not be the best choice. Rice cereal is not necessary at this time.

The nurse is assessing the clinical data of four clients. Which client is characterized with mixed conductive-sensorineural type of hearing loss? 1 Client A Correct2 Client B 3 Client C 4 Client D

There are four types of hearing loss: Conductive Hearing LossHearing loss caused by something that stops sounds from getting through the outer or middle ear. This type of hearing loss can often be treated with medicine or surgery. Sensorineural Hearing LossHearing loss that occurs when there is a problem in the way the inner ear or hearing nerve works. Mixed Hearing LossHearing loss that includes both a conductive and a sensorineural hearing loss. Auditory Neuropathy Spectrum DisorderHearing loss that occurs when sound enters the ear normally, but because of damage to the inner ear or the hearing nerve, sound isn't organized in a way that the brain can understand. Client B is diagnosed with a retraction in the tympanic membrane, causing obstruction to sound wave transmission. Damaged cochlear hair results in decreased sensory perception. Therefore, this client is characterized by a mixed conductive-sensorineural type of hearing loss. Client A is diagnosed with inflammation in the tympanic membrane resulting in retraction or bulging of the tympanic membrane, leading to obstruction of sound wave transmission thereby causing conductive hearing loss. The type of hearing loss diagnosed in client C is characterized as sensorineural hearing loss, as there is damage to the vestibulocochlear cranial nerve. Client D is diagnosed with fused bony ossicles, which obstructs sound wave transmission thereby causing conductive hearing loss.Test-Taking Tip: Chart/exhibit items present a situation and a variety of objective and subjective information about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, and health history), physical assessment data, and notes about client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Which tasks should a nurse perform in order to comply with public health laws? Select all that apply. Correct1 Report cases of communicable diseases Correct2 Report incidences of domestic violence Incorrect3 Provide emergency assistance at an accident scene Incorrect4 Notify the primary healthcare provider of any client-related problems Correct5 Ensure that clients in a community have received necessary immunizations

To comply with public health laws, the nurse is required to report cases of communicable diseases. The nurse must also report cases of suspected domestic violence, child abuse, or elder abuse. The nurse should ensure that clients in a community have received all necessary immunizations. To comply with Good Samaritan laws, the nurse should provide emergency assistance consistent with his or her level of expertise at an accident scene. Notifying the primary healthcare provider of client-related problems is not an example of complying with public health laws. Topics

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Correct1 Become aware of their personal values 2 Gain information related to their needs 3 Make correct decisions related to their health 4 Alter their value systems to make them more socially acceptable

Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

A critically injured client was brought to the hospital following a car accident and the client should be immediately triaged for determining the nature and acuity of the injuries. Who is delegated to perform the task? 1 Nurse manager Correct2 Registered nurse 3 Licensed practical nurse 4 Primary healthcare provider

When the client arrives at the hospital after a trauma, it is the responsibility of the registered nurse to determine the nature and acuity of injuries. The nurse manager should usually be the delegator for the registered nurses and healthcare providers. Licensed practical nurses' scope of practice does not include caring for critically ill emergency clients. A primary healthcare provider should treat the client by providing required medications and diagnoses.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

A group of clients injured during a wildfire are admitted to an emergency unit. Which order should the nurse follow in disaster management? Incorrect1.Focusing actions on stabilizing the community Incorrect2.Designing a plan to structure the response and assess risk Correct3.Actual implementing of the disaster plan Incorrect4.Attempting to limit a disaster's impact on human health Correct5.Evaluating the response effort to prepare for the future

While dealing the clients injured during disaster, the nurse should first prepare a plan to structure the response, assess risk, and evaluate damage. Secondly, the nurse should attempt to limit a disaster's impact on human health. Then, the nurse should actually implement the disaster plan. After implementing the plan, the nurse should focus actions on stabilizing the community. Lastly, the nurse should evaluate the response effort to prepare for the future.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

A nurse is planning play activities for a 6-year-old child whose energy level has improved after an acute episode of gastroenteritis. What activity should the nurse encourage? 1 Using a set of building blocks 2 Finger-painting on a large paper surface Correct3 Drawing and writing with a pencil or marker

Writing and drawing pictures provides a 6-year-old, who is of school age, with an appropriate way to express feelings. Playing with blocks is appropriate for preschoolers, who have active imaginations. Finger-painting is appropriate for preschoolers, who enjoy experimenting with different textures. Manipulating pieces of a toy is appropriate for preschoolers, who like repetition.