N117 Exam 2

An older adult patient diagnosed with cataracts asks the nurse about the cause of this eye disorder. Which cause should the nurse provide? Age Obesity Hypertension Gout

Age

The nurse is caring for a patient who has been diagnosed with renal failure and is receiving a loop diuretic. The nurse knows that which other medication, when used with loop diuretics in renal failure patients, can cause ototoxicity? Beta blocker Aminoglycoside Antiviral Nitrate

Aminoglycoside

What are the two components of the sensory​ process? A. Reception and perception B. Stimulus and receptor C. Visual and auditory D. Kinesthesia and stereognosis

A. Reception and perception

What is​ vertigo? A. Involuntary rapid eye movements B. Impaired olfaction C. A feeling of rotation or imbalance D. An infection of the vestibular nerve

C. A feeling of rotation or imbalance

The nurse is preparing to assess cranial nerve III, the oculomotor nerve. Which assessment should the nurse use? Enchroma Cardinal fields Visual acuity Corneal light reflex

Cardinal fields

When a patient reports feeling dizzy earlier in the morning, the nurse asks, "Did this occur before breakfast?" Which method of therapeutic communication is the nurse using? Acknowledging Clarifying time Focusing Giving information

Clarifying

Which term best describes the measure of a nurse's accountability? Professionalism Behavior Competence Collaboration

Competence

A patient has inflammation in the ears and temporary hearing loss. Which drug should the nurse expect to be prescribed? Sulfonamide Cephalosporin Macrolide antibiotic Corticosteroid

Corticosteroid

The nurse is discussing stress reduction techniques to prevent burnout with a colleague. Which action should the nurse include? Learn techniques to increase aggressiveness. Establish and follow a regular exercise program. Direct the energy inward. Minimally participate in workplace issues.

Establish and follow a regular exercise program.

The nurse is listing examples of e-health. Which examples should the nurse include? Automated input of data into a medical record, trending vital signs Fitbit, Map-My-Walk, Healthgrades Electronic health records, medical history, family history Teleneurology, teleradiology, remote access to specialties

Fitbit, Map-My-Walk, Healthgrades

The nurse is assessing a patient with glaucoma. Which clinical manifestation should the nurse expect to find? Halos around lights Distorted straight lines Central vision distortion Sudden loss of vision

Halos around lights

The nurse is caring for a patient diagnosed with macular degeneration. Which problem is most appropriate for the nurse to include in the plan of care? Injury risk Pain Ineffective airway clearance Constipation

Injury risk

Which is the most common cause of conductive hearing loss? Ototoxic drugs Loud impulse noises Use of media devices Obstruction of the external ear canal

Obstruction of the external ear canal

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? Implementation Planning Nursing diagnosis Assessment

Planning

The nurse is preparing for a job interview. Which personal work ethic should the nurse discuss during the interview? Punctuality Optimism Self-confidence Organization

Punctuality

A new nurse decides to join a professional organization that represents his practice specialty. Which type of commitment does this action exemplify? A) Affective B) Normative C) Subjective D) Continuance

A

A student nurse says, "I'm nervous about taking the NCLEX, and I'm a little worried about all the responsibility that comes with being a registered nurse. At the same time, I'm eager to pass the test so I can start working. I think the rewards of nursing are well worth the hard work and sacrifice." This statement suggests that the student nurse is in which stage of commitment? A) The integrated stage B) The testing stage C) The passionate stage D) The exploratory stage

A

The nurse assessing the cardinal fields of vision of a patient observes an oscillation of the eyes. Which diagnosis is characterized by the nurse's finding? A. Nystagmus B. Presbyopia C. Strabismus D. Anisocoria

A An oscillation of the eyes observed during the assessment of the cardinal fields of vision is diagnostic of nystagmus. The cardinal fields of vision do not test for strabismus, anisocoria, or presbyopia.

Which is the most common cause of conductive hearing loss? A. Obstruction of the external ear canal B. Ototoxic drugs C. Use of media devices D. Loud impulse noises

A Conductive hearing loss is the interference of the transmission of sound from the external auditory meatus to the inner ear. The most common cause associated with conductive hearing loss is the obstruction of the external ear canal. Use of media devices, ototoxic drugs, and loud impulse noises are causes of sensorineural hearing loss.

By which age should hearing loss be diagnosed in an infant? A. 3 months B. 9 months C. 12 months D. 6 months

A Infants who fail the hearing test should undergo additional testing and be diagnosed with hearing impairment by 3 months of age. Early diagnosis and intervention is needed to develop communication skills.

The nurse is preparing a teaching for a patient diagnosed with macular degeneration. Which topic is appropriate for the nurse to include? A. Using assistive devices B. Using throw rugs on hardwood floors C. Encouraging a diet high in iron D. Enforcing strict bedrest

A Patients with macular degeneration will need to be taught how to use assistive devices in order to maintain as much independence as possible. The patient should be taught not to use throw rugs, because they are a safety hazard. The patient should be taught to balance rest with exercise. The patient should be encouraged to consume foods high in antioxidants, zinc, and copper, but not iron.

The nurse is caring for an older adult patient who is experiencing visual loss resulting from cataracts. The nurse should understand that which factor contributes to the development of cataracts? A. Breakdown of the proteins in the lens B. Retinal damage C. Increase in intraocular pressure D. Damage to the structure of the eye

A The nurse understands that cataracts occur due to the breakdown of protein in the lens, resulting in the lens no longer being able to change shape to focus. Increased intraocular pressure is associated with glaucoma. Retinal damage is associated with age-related macular degeneration. Damage to the structure of the eye results from injury.

The nurse is caring for a patient with newly diagnosed open-angle glaucoma. The patient is prescribed a medication as part of the treatment plan. Which describes the primary purpose of the medication? A. To control intraocular pressure B. To improve the opacification of the eye C. To decrease injury to the cornea D. To decrease the loss of central vision

A The nurse understands that the primary purpose of the medication is to control intraocular pressure and preserve vision. Loss of central vision occurs with age-related macular degeneration. Opacification occurs in patients with glaucoma. Injury to the cornea occurs as a result of an eye injury.

The nurse is caring for an older adult patient who is experiencing visual loss that has manifested as opacification of the lens of the eye. Based on this manifestation, the nurse should understand that this patient has which condition? A. Cataract B. Age-related macular degeneration C. Glaucoma D. Myopia

A The older adult experiencing visual loss that has manifested as opacification of the lens of the eye has a condition known as cataracts. Cataracts occur from a breakdown of proteins within the lens, which results in the lens no longer being able to change shape to focus. Glaucoma is an optic neuropathy with gradual loss of peripheral vision. Age-related macular degeneration is a progressive disorder that involves loss of central vision due to damage to the retina. Myopia results from changes in distant vision.

The nurse is reviewing the plan of care for a patient who is ready for discharge. Which is an application of decision support that can be utilized in the home care setting? A patient's electronic health record issuing an alert when a patient's vital signs are out of normal range A home health nurse contacting a provider to report a change in patient assessment A home health nurse's notes being printed out and delivered to the provider's office A patient keeping a daily log of blood glucose levels

A patient's electronic health record issuing an alert when a patient's vital signs are out of normal range

The nurse is caring for a client who receives vitamin B12 injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and toes, and she asks the nurse what this means. How should the nurse reply? A) "The tingling suggests that you are due for another injection." B) "The tingling means that the injections are not producing their intended effect." C) "The tingling is a common side effect of B12 injections." D) "The tingling is most likely unrelated to your injections."

A) "The tingling suggests that you are due for another injection."

The urgent care clinic nurse is treating a client who is experiencing abdominal pain. The client states, "I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the healthcare provider does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A) Ask the client open-ended questions to further assess the situation. In problem solving, the nurse obtains information that clarifies the nature of the problem. This is the first step. The nurse cannot make decisions such as calling an ambulance or telling the client not to see a healthcare provider before knowing all the essential information. The nurse should not give advice about taking a medication.

When speaking with a client newly diagnosed with chronic obstructive pulmonary disease (COPD), the nurse knows that therapeutic communication has been achieved when which action has occurred? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her life living with COPD.

A) Attentive or "mindful" listening involves listening and absorbing the content and feeling of what an individual is conveying, without selectivity. It is more than being quiet as the other individual talks: It involves paying attention to the total message, both verbal and nonverbal, and noting whether these communications are congruent. The listener does not select or listen solely to what the listener wants to hear; the nurse focuses not on the nurse's own needs but rather on the client's needs. Attentive listening conveys an attitude of caring and interest, thereby encouraging the client to talk.

Which degree of alcohol use has been implicated in the development of alcohol-related neuropathy? A) Chronic and heavy B) Short term and light C) Intermittent and severe D) Acute and toxic

A) Chronic and heavy

Which client should the nurse identify as having the greatest risk for hearing loss? A) Construction worker who typically works in urban centers B) Adolescent who occasionally listens to loud music on headphones C) Teacher who works at a large high school D) Lawyer who enjoys snowmobiling once a year

A) Construction worker who typically works in urban centers

The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

A) Examine the current interventions for pain relief. The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. The goal of pain management is pain relief, and that goal would not change; what might change is the interventions to meet the goal. Contacting Meals on Wheels may not be appropriate if the problem is pain relief. Pain relief is a medical issue that is addressed by the nurse and physician, not social services.

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? "A nursing diagnosis is developed after the nurse evaluates the interventions provided." "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." "A nursing diagnosis is based on clinical judgment that is derived from assessment data." "A nursing diagnosis is determined by the medical diagnosis and current patient needs."

"A nursing diagnosis is based on clinical judgment that is derived from assessment data."

An older adult patient is being referred to an audiologist. The patient asks why there is a need to see another healthcare provider. Which explanation by the nurse is accurate? "An audiologist determines hearing loss and the extent of the loss." "An audiologist is used to determine mobility issues." "An audiologist is used to help children develop communication skills." "An audiologist is used to help find funding for hearing aids."

"An audiologist determines hearing loss and the extent of the loss."

A family member asks the nurse about the best way to communicate with the parent who has hearing impairment. Which statement by the nurse is best? "Use short phrases for easier understanding." "Make sure to speak in a loud voice so the patient can hear." "Overarticulate words so the patient can read lips better." "Before talking, move to a position where the patient can see you."

"Before talking, move to a position where the patient can see you."

The nurse teaches the wife of a patient diagnosed with macular degeneration ways of increasing her husband's independence and quality of life. Which statement by the wife indicates that teaching was successful? "I will make sure that a magnifying glass is always available." "I will purchase him a digital clock so he can always know the time." "I will make sure I dim the lights for him." "I will purchase him a mini tablet so he can communicate with friends."

"I will make sure that a magnifying glass is always available."

The nurse is caring for a patient newly diagnosed with a terminal disease. Which statement reflects the nurse's compassion? "I know you will get through this, just give it some time." "I know there are treatment options that you can speak to your healthcare provider about." "I feel like this is a good time for me to contact the chaplain for you." "If you need me, I will be right here with you."

"If you need me, I will be right here with you."

Prior to having an intravenous catheter inserted, a child asks the nurse, "Is this going to hurt?" Which response should the nurse use to promote rapport and trust with the child? "It might hurt, but I am not sure." "No. As long as you hold still, it shouldn't hurt." "It is going to hurt, but once I am done, it shouldn't hurt anymore." "Yes, it is going to hurt. Hold really still or it will hurt much worse."

"It is going to hurt, but once I am done, it shouldn't hurt anymore."

The nurse is discussing treatment options for a patient with macular degeneration. Which statement by the nurse is accurate? "Laser surgery for macular degeneration can only slow the progress of the disease." "Laser surgery cures macular degeneration." "Surgery and medication can restore vision." "Surgery for macular degeneration offers a 50% chance of vision restoration."

"Laser surgery for macular degeneration can only slow the progress of the disease."

The nurse is explaining the benefits and limitations of using the electronic health record (EHR). Which statement should the nurse include? "The use of EHRs often increases patient readmission rates." "EHRs increase the challenges related to care coordination." "Trending patients' progress is not a function of EHRs." "The EHR promotes observation of quality metrics."

"The EHR promotes observation of quality metrics."

The nurse is teaching a patient about the purpose of a newly prescribed medication for glaucoma. Which patient statement demonstrates effective teaching? "The eyedrops will lower the pressure in my eye." "The eyedrops will moisten my dry eyes." "The eyedrops will cure my glaucoma." "The eyedrops will help to restore my vision."

"The eyedrops will lower the pressure in my eye."

While transferring a patient back into bed after a procedure, the patient states that it wasn't very nice for the nurse to say that the "cow was coming down the hall." Which is the most appropriate response by the nurse in this situation? "The term 'cow' stands for a computer on wheels." "I was just joking with that person!" "I didn't mean to call someone a cow!" "You must have misunderstood what I said."

"The term 'cow' stands for a computer on wheels."

A patient who had a lens implant performed asks the nurse why there is a need for a stool softener. Which response by the nurse is best? "This prevents straining, which increases the pressure in your eye and harms the surgical repair." "This pill reduces the risk of constipation, which is a side effect of other medications." "This prevents straining during a bowel movement, which causes nausea and vomiting." "Blood vessels in your eye may burst when defecating, causing intraocular hemorrhage."

"This prevents straining, which increases the pressure in your eye and harms the surgical repair."

An older adult patient just returned to the patient's room after physical therapy. Which question should the nurse ask to demonstrate support? "Sweetie, did you have fun?" "Did that make you tired?" "Are you hungry?" "What did you do in physical therapy today?"

"What did you do in physical therapy today?"

A community health nurse is teaching a newly licensed nurse about social determinants of health. Which of the following should the newly licensed nurse identify as a physical determinant of health? -Limited income to purchase food -Poor quality school system -Inability to read food labels -Poor air quality

-Poor air quality The nurse should identify that poor air quality is a physical determinant of health. Physical determinants of health are related to the client's physical environment. Other physical determinants of health can include leaky pipes, lead paint, housing that requires maintenance, and living in a confined area with multiple families.

A nurse is discussing hospice care with a newly licensed nurse. Which of the following should the nurse identify as the goal of hospice care? -Provide comfort measures for clients who are receiving active treatment for illness -Allow a client's caregiver to take a break from caring for their loved one -Provide care for a client who has less than 6 months to live -Offer services such as strength exercises for the client within the client's home

-Provide care for a client who has less than 6 months to live Hospice care is provided for clients when the provider has determined the client has less than 6 months to live. The goal is to not treat or cure the client's illness but to provide comfort and supportive services.

) A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate injecting the child with epinephrine (EpiPen)? Select all that apply. A) Skin that is cold and clammy to the touch B) Skin that is warm and dry to the touch C) Hyperverbal behavior D) Extreme anxiety and agitation E) Facial swelling

A, D, E

Which behaviors by a new nurse are likely to reduce stress and burnout? Select all that apply. A) Meditate or take a long soak in a tub. B) Join a local aerobics class. C) Participate in a professional organization. D) Refuse to acknowledge personal limitations. E) Don't accept failure; try, try, and try again.

ABC

The nurse is caring for a patient who is scheduled for evaluation and a prescription for a hearing aid. Which collaborative referral should the nurse anticipate will be prescribed for the patient? Occupational therapist trained in sound therapy Otolaryngologist Audiologist Vestibular rehabilitation therapist

Audiologist

The nurse is caring for an older adult experiencing a loss of hearing. Which prescribed procedure should the nurse anticipate being used to evaluate the hearing loss? Otoacoustic emissions Audiometry Accommodation Weber test

Audiometry

The nurse is providing care to a patient experiencing hearing loss due to impacted cerumen. The nurse should provide teaching for which procedure? A. Reconstruction of the tympanic membrane B. Irrigation with warm water and ear wax softener C. Insertion of ear tubes D. Administration of medication ear drops

B The nurse will provide teaching for treatment with warm water and ear wax softener to aid in the removal of the impacted cerumen. Treatment with medicated ear drops, insertion of ear tubes, and reconstruction of the tympanic membrane are not necessary procedures.

Which best describes photophobia? A) Fear of light B) Aversion to light C) Reactive to light D) Need for light

B) Aversion to light

The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this​ teaching? A. Schedule an annual hearing test until the age of 50 and then have a test every 6 months. B. Have a hearing test every 10 years until age 50 and then every 3 years. C. Annual screenings are recommended for adults with diabetes. D. For individuals without​ comorbidities, hearing exams should be repeated every​ 1-3 years for ages​ 55-64, and every​ 1-2 years for ages 65 and above.

B. Have a hearing test every 10 years until age 50 and then every 3 years.

A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial​ nerve? A. XI B. XII C. VIII D. VI

B. XII

A patient no longer requires care at the outpatient clinic. When should the nurse start preparing the patient's transition to independence? Before the termination interview During the working phase Before the preinteraction phase After the introductory phase

Before the termination interview

The nurse is assessing a patient for signs of impaired hearing, forgetfulness, and depression. The healthcare provider has diagnosed the patient with presbycusis. Which therapy should the nurse anticipate will be ordered? A. Stapedectomy B. Tympanoplasty C. Steroid agent D. Aminoglycoside medication

C Clinical therapies for presbycusis include hearing aids, or steroids or decongestants for inflammation. Aminoglycosides are a class of drugs used to treat bacterial infections. A stapedectomy is a surgery used to treat hearing loss related to otosclerosis, and a tympanoplasty is used to treat conductive hearing deficits of the middle ear.

Which of the following scenarios is consistent with secondary congenital glaucoma? A) A newborn is diagnosed with glaucoma at birth. B) An infant is diagnosed at 6 months with glaucoma. C) A 1-year-old infant develops glaucoma following neurofibromatosis. D) A 5-year-old child is diagnosed with glaucoma.

C) A 1-year-old infant develops glaucoma following neurofibromatosis.

The nurse is caring for a client with a corneal abrasion. Which collaborative intervention should the nurse anticipate being included in the client's care? A) Bedrest and an eye shield B) Surgery C) Applying antibiotic ointment and an eye shield D) Flushing the eye with normal saline

C) Applying antibiotic ointment and an eye shield

The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this condition? A) Working as an automobile mechanic on weekends B) Playing tennis every Saturday C) Drinking one six-pack of beer per day D) Typing on the computer for several hours each day

C) Drinking one six-pack of beer per day

The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care

C) Leaning toward the client during conversation

The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this teaching? A) Set the water heater at 120°F. B) Avoid hand and foot massages. C) Use a mirror to inspect feet daily. D) Increase medication for pain as necessary.

C) Use a mirror to inspect feet daily.

A patient who is visually impaired and has Parkinson disease is assigned a nurse to coordinate care from a number of specialists. Which type of framework does this care coordination indicate? Patient-focused care Managed care Team nursing Case management

Case management

The nurse is conducting a home visit for a patient who indicates feeling depressed due to not progressing as fast as expected after surgery. The nurse states, "Everyone heals differently. What do you think is hindering your progression?" Which factor supports the nurse-patient relationship by being direct and showing concern to the patient's issue? Credibility and adaptability Simplicity and relevance Clarity and brevity Timing and relevance

Clarity & brevity

The nurse is assessing a patient and suspects cataracts. Which finding supports the nurse's suspicion? Cloudy or opaque lenses Halos around lights Fixed pupils Difficulty in recognizing faces

Cloudy or opaque lenses

The nurse is creating a care plan for an older adult patient in the clinic who has a hearing impairment. Which nursing diagnosis may be appropriate for inclusion in the plan of care? Health Maintenance, Ineffective Lifestyle, Sedentary Communication: Verbal, Impaired Nutrition, Imbalanced: Less than Body Requirements

Communication: Verbal, Impaired

The nurse is preparing to assess a patient reporting loss of smell. Which cranial nerve should the nurse suspect is a factor in the patient's symptoms? Cranial nerve II (optic nerve) Cranial nerve V (trigeminal nerve) Cranial nerve I (olifactory nerve) Cranial nerve XII (hypoglossal nerve)

Cranial nerve I (olifactory nerve)

A patient with hearing loss and their family are frustrated due to the lack of ability to communicate. The family asks about communication techniques they could learn. Which type of communication uses hand shapes for sounds? Cued speech Total communication Oral speech Sign language

Cued speech

The nurse is preparing to assess cranial nerve I. Which action should the nurse perform to assess this nerve? A. Perform an eye exam using a Snellen chart. B. Ask the patient to identify an object placed in a hand. C. Initiate the Weber test. D. Test the patient's sense of smell.

D Cranial nerve I is the olfactory nerve that is responsible for the sense of smell. The nurse will assess cranial nerve I by testing the patient's sense of smell. A Snellen chart is used to test cranial nerve II, the optic nerve. Cranial nerve VIII, the acoustic/vestibulocochlear nerve, can be assessed using the Weber test. Placing an object in the patient's hand to identify is a test for tactile sensation.

A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this client? A) Risk for Infection B) Anxiety C) Acute Pain D) Risk for Injury

D) Risk for Injury

The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory​ deficits? A. Large-print reading material B. Adequate room lighting with night lights C. Amplified telephone D. Flashing alarm clock with large numbers

D. Flashing alarm clock with large numbers

The nurse suspects that a patient may have macular degeneration. Which manifestation supports this diagnosis? Difficulty adjusting to low-light areas after being in bright areas Poor peripheral vision Intact central vision Colored halos around lights

Difficulty adjusting to low-light areas after being in bright areas

The nurse states, "Informatics can provide a global overview of a patient's health, encompassing multiple clinicians and disciplines. Further, it can provide a means of communication about the care of the particular patient." The nurse is referring to which type of informatics? Electronic medical records (EMRs) Statewide prescription tracking system Discharge database Electronic health records (EHRs)

Electronic health records (EHRs)

The nurse is caring for a patient who has just been diagnosed with heart failure. Which nursing action reflects an achievement of a meaningful use objective as required by the Centers for Medicare and Medicaid Services? Allowing the patient's family members to review the patient's electronic health record Encouraging the patient's family members to be involved in the patient's teaching sessions Limiting communication among members of the patient's healthcare team Recognizing that safety and quality of patient care are unrelated to health disparities

Encouraging the patient's family members to be involved in the patient's teaching sessions

Which nursing care model for delivery can be the most cost effective? Functional nursing Team nursing Primary nursing Positive nursing

Functional nursing

The nurse is assessing a teenager at the clinic. Which lifestyle habits can affect hearing to a greater extent? Nutrition history Growth development Headphone use Vaccination history

Headphone use

The nurse is assessing a child with a history of otitis media. The nurse observes a reddened, inflamed tympanic membrane in the right ear. Based on the child's history of recurrent otitis media, which procedure should the nurse expect to be recommended? Reconstruction of the tympanic membrane Cochlear implant Removal of the stapes Insertion of ear tubes

Insertion of ear tubes

The nurse is caring for a newly admitted patient. Which skills should the nurse use to build rapport and trust with the patient? Cognitive Interpersonal Multidisciplinary Technical

Interpersonal

The nurse who filed a complaint of sexual harassment against a coworker states, "I do not want to work on that unit anymore because I am afraid." Which term best describes the nurse's work environment? Authoritative Controlling Violent Intimidating

Intimidating

The nurse is providing care to a patient experiencing hearing loss due to impacted cerumen. The nurse should provide teaching for which procedure? Insertion of ear tubes Reconstruction of the tympanic membrane Administration of medicated ear drops Irrigation with warm water and ear wax softener

Irrigation with warm water and ear wax softener

A patient is being admitted for dehydration. The patient can understand English but has difficulty speaking the language. Which strategy should the nurse implement in this situation? Google the patient's heritage. Use proper medical terminology to communicate because of the patient's education. Use gestures commonly used in the United States. Know how individuals in the patient's culture greet one another.

Know how individuals in the patient's culture greet one another.

As the newly hired nurse completed a procedure, a colleague stated, "You forgot to put away the canula!" The newly hired nurse was very apologetic and offered to do other tasks to compensate for the forgetfulness. The newly hired nurse is presenting as which type of communicator? Aggressive communicator Passive communicator Active communicator Assertive communicator

Passive communicator

The nurse is designing an online course about the use of patient portals for consumer and patient e-health. Which item should the nurse include? Patients must provide user identification and a password for each portal visit. Protected health information is encrypted and securely transmitted via the portal. To use the portal, the patient must first register in person at the healthcare facility. Prescription refill requests are not permitted when using a portal

Patients must provide user identification and a password for each portal visit.

The nurse is providing discharge teaching for the family caring for a patient who is newly diagnosed with impaired vision. Which information should the nurse include? Avoid the use of bright colors in the environment. Keep the current living environment as is. Use a flashing alarm clock. Place shades on windows.

Place shades on windows.

Before meeting a patient, the nurse reviews the patient's demographics, including the patient's name, address, age, medical history, and social history. Which phase of the therapeutic relationship is reflected by this action? Termination Working Preinteraction Introductory

Preinteraction

The nurse is determining a nursing care delivery model for a new intensive care unit (ICU). Which model will provide the safest care for the patients? Team nursing Functional nursing Primary care nursing Patient-centered care nursing

Primary care nursing

The nurse is discussing consequences of workplace incivility. Which factor should the nurse include? Patient satisfaction Unit revenue Attendance Productivity

Productivity

A patient asks the nurse, "How did I get cataracts in both eyes?" Which characteristic of the disease process should guide the nurse's response? Proteins clump and cloud the lens of the eye as the lens ages. Episodes of vertigo may result from distortion of straight lines. Colors may become dull and distorted because of irregular scar tissue development. There may be a reduction in peripheral vision because of thickened ocular blood vessels.

Proteins clump and cloud the lens of the eye as the lens ages.

The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? Evaluate the patient's response to the plan of care. Identify a time frame for an action to occur. Provide direction for nursing interventions. Measure the end result of nursing action.

Provide direction for nursing interventions.

The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? Provide culturally competent care. Follow prescribed dietary needs. Promote contentment in the patient. Determine need for special services.

Providing culturally competent care.

The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? Talk to the healthcare provider. Reassess the wound. Change the interventions. Set a new, reachable goal.

Reassess the wound.

A nurse is assessing an older adult patient with hearing loss. Which potential problem related to hearing loss should the nurse prioritize when screening the patient? Impaired communication Unsociable behavior Depression Reduced mobility

Reduced mobility

When the patient tells the nurse, "I can't tell my family that I have cancer," the nurse replies, "What do you think would be best?" Which method of therapeutic communication is the nurse using with this patient? Focusing Acknowledging Reflecting Presenting reality

Reflecting

The nurse is caring for a patient who has difficulty breathing. Which nursing action would be considered independent? Sitting the patient up in bed Ordering chest physiotherapy Administering medication to relax breathing Prescribing oxygen therapy

Sitting the patient up in bed

A patient states, "I think I have a cataract." The nurse should prepare the patient for which diagnostic exam? Snellen chart Cardinal fields of vision Convergence Accommodation

Snellen chart

The nurse is admitting a patient with visual impairment to the hospital. Which communication technique should the nurse utilize? Touch the patient before explaining what assessment will be done. Use longer phrases that are easier to understand. Speak in a pleasant tone of voice. Decrease background noises.

Speak in a pleasant tone of voice.

The nurse has been determining a method of communicating with a patient who is recovering from a stroke. Which patient observation indicates that an effective communication method has been established by the nurse? Holding a pen to write on paper Groaning to get the nurse's attention Spelling words on a bedside table using tiled letters Slapping the nurse's hand to refuse an action

Spelling words on a bedside table using tiled letters

The nurse is assessing a patient for signs of impaired hearing, forgetfulness, and depression. The healthcare provider has diagnosed the patient with presbycusis. Which therapy should the nurse anticipate will be ordered? Stapedectomy Steroid agent Tympanoplasty Aminoglycoside medication

Steroid agent

The nurse is assessing a patient for signs of impaired hearing, forgetfulness, and depression. The healthcare provider has diagnosed the patient with presbycusis. Which therapy should the nurse anticipate will be ordered? Tympanoplasty Stapedectomy Aminoglycoside medication Steroid agent

Steroid agent

The nurse is performing an eye exam on a newborn and observes strabismus. Which statement describes the nurse's interpretation of the assessment finding? Strabismus will result in visual impairment. Strabismus occurs due to a genetic defect. Strabismus in a newborn is a normal finding. Strabismus will require surgery.

Strabismus in a newborn is a normal finding.

A patient presents to the emergency department with high fever and coughing. Which information should the nurse collect for analysis? Opinions Judgments Subjective data Inferences

Subjective data

The nurse is completing the health history of a patient and starts the discussion with, "Yesterday we discussed your past illnesses, treatment, and other medical conditions." Which communication technique is the nurse using? Summarizing Paraphrasing Confronting Clarifying

Summarizing

The nurse is caring for a patient diagnosed with cataracts. Which treatment option should the nurse expect will be ordered for the patient? Surgery Eye drops Dietary changes Increase in physical activity

Surgery

A 10-year-old came in for a visit for allergy testing, accompanied by his mother. Which action is appropriate by the nurse? Proceed to the testing. Explain the procedure to the mother. Tell the patient to lay on their stomach. Talk to the child at their eye level.

Talk to the child at their eye level.

The nurse caring for a patient who is newly diagnosed with diabetes requests a dietary consult. Which type of care is the nurse implementing? Secondary prevention Primary prevention Case management Tertiary prevention

Tertiary prevention

The nurse should understand that which statement reflects the difference between a task force and an ad hoc committee? The type of work Where the work takes place The duration of work The number of people required for the work

The duration of work

The nurse is implementing reverse triage during a disaster. Which patient should the nurse select to receive priority treatment? The patient who utilizes an oxygen generator for chronic obstructive pulmonary disease (COPD) The patient with type 1 diabetes and severe food allergies The patient experiencing angina with no previous history of cardiovascular disease The patient on dialysis who has recently refused treatment

The patient experiencing angina with no previous history of cardiovascular disease

The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to poor oral intake secondary to cancer treatment. Which goal set by the nurse is an example of a specific and measurable goal? The patient will take in 80 grams of protein per day. The patient will experience no further nausea and vomiting. The patient will gain weight over the next few months. The patient will verbalize foods that are needed to gain weight.

The patient will take in 80 grams of protein per day.

A patient reports buzzing in their ears after attending a concert the night before. Which clinical manifestation is the patient exhibiting? Obstruction of the ear canal Loss of high-frequency tones Loss of balance Tinnitus

Tinnitus

The nurse is caring for a patient with newly diagnosed open-angle glaucoma. The patient is prescribed a medication as part of the treatment plan. Which describes the primary purpose of the medication? To improve the opacification of the eye To control intraocular pressure To decrease the loss of central vision To decrease injury to the cornea

To control intraocular pressure

The nurse is discussing the process of formation with the student nurse. Which best describes the process? Demonstration of accountability Attainment of an expert level of nursing practice Ability to demonstrate compassion and cultural awareness Transformation from a layperson to a professional

Transformation from a layperson to a professional

The nurse is meeting via teleconference with a group and discussing the trial-and-error approach to problem solving. Which statement should the nurse include? Trial and error is how we come to evidenced protocols. Trial and error is evidence-based. Trial and error should be used as a first line of treatment. Trial-and-error has been replaced by evidence-based practice.

Trial-and-error has been replaced by evidence-based practice.

The nurse is caring for a patient undergoing the Weber test. Which piece of equipment is needed to conduct this diagnostic test? Reflex hammer Tympanogram Otoscope Tuning fork

Tuning fork

The nurse is caring for an older adult patient with a hearing deficit. Which initial intervention should the nurse include in the plan of care when communicating with the patient? Use longer phrases. Encourage the patient to do more reading. Shout when communicating with the patient. Request a service dog for the patient.

Use longer phrases.

The nurse is caring for a patient diagnosed with cataracts. Which nonpharmacologic treatment should the nurse discuss with the patient? Using a brighter light when reading Maintaining bedrest Utilizing an eye patch Wearing sunglasses indoors

Using a brighter light when reading

The nurse is reviewing a patient's medical orders that include an electrocardiogram (ECG). Which is the most appropriate action by the nurse in light of the point-of-care model? Documenting completion of the ECG results in the patient's paper chart Using a portable ECG machine to complete the patient's testing Obtaining prior authorization from the patient's insurance company for the ECG Notifying the patient that there may be a delay in obtaining the ECG test results

Using a portable ECG machine to complete the patient's testing

The nurse suspects that a patient may be visiting multiple providers in order to obtain narcotics. Which function of informatics should the nurse use to obtain this information? Sharing of electronic health records through programs such as meaningful use Calling local pharmacies to check if the patient has had multiple prescriptions filled Using the patient portal Using state-level tracking of prescriptions for opioids

Using state-level tracking of prescriptions for opioids

The nurse is looking for an effective strategy for eliminating inappropriate or unnecessary medical care. Which strategy should the nurse use? Point of care Current procedural technology Utilization review Risk management

Utilization review

A patient states she is "feeling dizzy and having trouble with balance." The nurse should recognize that the patient is experiencing which alteration in sensory perception? Perception Nystagmus Vertigo Kinesthesia

Vertigo

The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? Inability to walk two steps Previous health history Weakness Activity Intolerance

Weakness

The nurse is discussing groups of patients who are at risk for developing cataracts. Which group should the nurse discuss as being at the greatest risk? Women Men Caucasian Americans Hispanics

Women

2) The nurse determines that a client is at risk for developing cataracts. What did the nurse assess in this client? A) Age 75 years B) Hypertension C) Minimal direct sun exposure D) Nonsmoker

a

4) A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. What will the nurse use to assess this client? A) Rosenbaum eye chart B) Penlight C) Cover-uncover test D) Snellen eye chart

a

5) A client with impaired hearing is scheduled for a test to measure the compliance of the middle ear to sound transmission. For which diagnostic test will the nurse instruct the client? A) Tympanometry B) Weber test C) Rinne test D) Whisper test

a

9) A nurse is caring for a client with a genetic nerve disorder who has a deficit when attempting to move the tongue. When performing the nursing assessment, the nurse understands that this deficit relates to which cranial nerve? A) XII B) XI C) VIII D) VI

a

The home health nurse brings supplies into the patient's room and lays them down on the carpet before beginning to assess the patient.Which safety risk does this pose? a)It may result in infection transmission. b)The patient could trip over the supplies. c)The nurse might kick over the bag. d)The heavy bag of supplies could harm the carpet fibers.

a

The nurse asks a family member of an older adult patient to bring in the patient's medicines that they take at home.What is the nurse's primary purpose for this request? A)Performing medication reconciliation B)Providing the patient medications until the hospital can supply C)Checking the expiration dates of the patient's medications D)Saving the patient the cost of hospital medications

a

The nurse recommends removing scatter rugs, installing easy grip faucets, providing adequate lighting, and installing raised toilet seats in the patient's home.Which is the rationale for these environmental safety improvements? a)These services make the patient feel safe and secure. b)All these services are paid for by Medicare. c)They are paid for by insurance. d)Promoting patient independence takes stress off caregivers.

a

The nurse should identify which intervention as one that will reduce the risk of falls in the healthcare environment? a)Encouraging the use of the call button b)Keeping patients in a wheelchair whenever possible c)Using restraints d)Installing video cameras in every room

a

The nurse who is physically, mentally, and emotionally depleted states, "I just want to retire. I don't care anymore."Which condition is the nurse experiencing? a)Compassion fatigue b)Cynicism c)Frustration d)Poor attitude

a

Which symptom in a patient should the nurse identify as an acute functional change? a)Sudden numbness and weakness in a limb b)Hypotension and diaphoresis c)Confusion and drowsiness d)Excitability and agitatio

a

While performing patient care, the nurse notes an area of skin breakdown and excoriation along the area where the indwelling urinary catheter is affixed to the patient's inner thigh.Which is the priority nursing intervention? a)Change the catheter using one without latex b)Dust the skin with cornstarch c)Cleanse the skin with soap and water d)Check the acidity level of the patient's urine

a)Change the catheter using one without latex

10) A client is recovering from cochlear implant surgery. What is true regarding cochlear implants? A) They restore normal hearing to those who could not hear any sound prior to implantation. B) Their function is more similar to the way the ear normally receives and processes sounds than it is to that of a hearing aid. C) They may be the only hope for restoring sound perception for the client with a total and permanent hearing loss. D) With implantation, the structures

b

2) The nurse identifies potential safety concerns for a client with a sensory disorder. Which intervention should the nurse include in this client's plan of care? A) Teach how to adapt to the sensory deficit. B) Identify assistive devices. C) Provide meaningful interaction and stimulation. D) Teach the need to take antibiotics as prescribed.

b

An older patient tells the nurse, "I take the water pill and a red one every day, and after dinner I take a vitamin."Which is a nursing intervention to safely reconcile the patient's home medications with those to be given in the hospital? a)Contacting the patient's primary healthcare provider b)Asking a family member to bring in a list of the patient's medications with dosages c)Encouraging the patient to try to remember the names of the pills d)Administering the medications the hospital has prescribed

b

The nurse is caring for an older adult patient who walks with a cane and needs help with household chores.Which type of decline represents the patient's current status? a)Motivational b)Functional c)Cognitive d)Behavioral

b

7) The nurse is planning care for a client with an uncorrectable hearing loss. Which strategies for communication should the nurse add to the client's plan of care? Select all that apply. A) Magic slate B) Total communication C) Hearing aids D) Cued speech E) Sign languag

b, d, e

A nurse is discussing the care for the shift with the client. The nurse is including the client in decision making about when various planned activities would be most convenient for the client. The nurse benefits from this professional behavior for what reason? a. Work will be completed on time. b. The nurse gains the trust of the client. c. The client will do most of the work. d. The client's family will help with the work.

b. The nurse gains the trust of the client.

2) An older client, reporting a significant loss of hearing after being involved in an explosion, asks when hearing will return. Which response by the nurse is most appropriate at this time? A) Surgery will help restore the hearing you have lost. B) The most common cause of hearing impairments is exposure to loud noises. C) Loud noises can cause immediate, permanent loss of hearing. D) Hearing loss attributed to loud noises is normally reversible.

c

The nurse instructs parents not to allow a 6-year-old patient to race their younger sibling down the hospital halls.Which is the primary reason behind this action? a)To prevent disruption on the unit b)To prevent the patient from overexertion c)To prevent injury to the patient and others d)To keep the children from disrupting other nurses

c

The nurse is caring for a patient with a hearing impairment and with special needs.Which safety measure should the nurse suggest to the family member of the patient? a)Audio books b)Handrails c)Smoke detector that uses a light d)Gait belt

c

The nurse is conducting a program on summer safety for families of a residential community.Which participant statement indicates that the teaching has been effective? a)"Air-filled floats should be kept around the pool." b)"A bump on the head is nothing to be concerned about." c)"Children should learn how to swim." d)"Head gear while playing touch football is not necessary."

c

3) The nurse is planning care for an older client with early dry macular degeneration. What should the nurse expect the client will be prescribed? Select all that apply. A) Laser surgery B) Eye patches C) Antioxidants D) Eye drops E) Zinc

c,e

The charge nurse from Generation X is having concerns about the new nurse who is a Millennial. The charge nurse tells the nurse manager the new nurse expects feedback after every task completed. What is the best response by the nurse manager? a. "It sounds like the new nurse lacks some confidence. Give it a few days and see how things go." b. "Confront the new nurse and explain that the expectation is not acceptable in this work situation." c. "This is a generational difference between the two of you. Let me help you come up with a plan." d. "The nurse is new. Don't you remember how it was when you started? Be patient during this time."

c. "This is a generational difference between the two of you. Let me help you come up with a plan."

A nurse's coworker makes a practice of telling offensive jokes or stories with a sexual undertone during the shift. What is the best action by the nurse? a. Ignore the coworker and walk away from the situation. b. Report the incident to the nurse manager for action to be taken. c. Tell the coworker to stop the activity because the conduct is offensive. d. Ask to be scheduled opposite this coworker without any explanation.

c. Tell the coworker to stop the activity because the conduct is offensive

10) Which nursing action is most appropriate when communicating with a client who has a hearing deficit? A) Over articulating words in order for the client to understand B) Using shorter phrases, which tend to be easier to understand than longer ones C) Varying the volume of voice, which is easier to understand than one consistent volume D) Writing ideas or pantomiming as appropriate in order for the client to understand

d

3) The mother of a premature newborn asks the nurse why the baby's eyes are cloudy. What should the nurse respond to the mother? A) "It is because of an allergic reaction." B) "It happens with most newborns." C) "It is because you developed an illness while carrying the baby before birth." D) "It is seen with premature infants."

d

6) The nurse is preparing a seminar for community members on actions to protect sensory functioning when aging. What should the nurse recommend regarding hearing tests for older adults? A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months. B) A hearing test is needed when changing medications. C) A hearing test should be done biannually after the age of 60. D) Have a hearing test every 10 years until age 50 and then every 3 years.

d

6) The nurse provides postoperative teaching to a client recovering from cataract removal surgery. Which client statement indicates that preoperative teaching has been effective? A) "I will be hospitalized for several days recovering from this surgery." B) "I will need to return to activity as soon as possible." C) "I will use the eye drops if I have eye pain" D) "I will notify the doctor if I have itching or redness of the eye after the surgery."

d

A client recovering from surgery to repair fractured bones in the face tells the nurse that dinner "tastes horrible." What should the nurse respond to this client? A) "The meal on your tray is the best the cafeteria has to offer today." B) "Let me see if I can order something else for you from the cafeteria." C) "You do not have to eat anything you don't want to." D) "The facial injuries are affecting your sense of taste and flavor."

d

Exemplar 18.1 Hearing Impairment 1) The nurse suspects that a client has a hearing disorder; however, the client denies not being able to hear. What initial action should the nurse take to assess the client's hearing? A) Use an otoscope to visualize the inner ear. B) Schedule a Weber and Rinne test. C) Confront the client with the suspicion. D) Observe the client's interaction with family.

d

The nurse should understand that which personnel are responsible for ensuring that patients will not experience injury, harm, or death in a hospital setting? a)Primary healthcare provider b)Patient c)Patient family d)All hospital employees

d

While removing a trash bag from the room of a patient in protective isolation, the nurse sustains a needlestick.Which educational topic is a priority for nurses on the unit to discuss during the next staff meeting? a)Technique to remove biohazard trash from isolation rooms B)Actions to take when exposed to contaminated sharps c)Personal protective equipment to wear when disposing of trash d)Appropriate disposal of used sharps

d

The nurse is integrating one of the six principles from the Joint Principles of the Patient-Centered Medical Home by extending clinic hours on the weekend. Which one of the six principles is the nurse addressing? Whole person orientation Access to care Coordinated and integrated care Quality and safety

Access to care

The nurse is preparing to explain the insertion of an intravenous catheter into the arm of a patient who has never been hospitalized. Which explanation by the nurse is the most appropriate for this procedure? "A small tube is put in a blood vessel, and liquid is dripped into your body." "An angiocath is inserted in a vein, and fluids are administered." "A needle is inserted in a vein so that this bag of fluid is pushed into your body." "An intracath is placed in a vein, and the IV is set to administer 100 mL per hour."

"A small tube is put in a blood vessel, and liquid is dripped into your body."

A pregnant woman is being assessed for syphilis and herpes. The patient asks why this screening is needed. Which is the best explanation from the nurse? "Certain infections are screened during pregnancy, because they can affect the developing fetus." "Certain viruses can affect the fetus and need to be cured before birth of the fetus." "Diseases need to be cured before pregnancy so that a fetus is not affected." "Diseases need to be cured during pregnancy before they affect the fetus."

"Certain infections are screened during pregnancy, because they can affect the developing fetus."

The nurse asks colleagues from other institutions for suggestions on how to use informatics to improve patient safety and incorporate nursing research at the point of care. Which suggestion by a colleague is appropriate? "Consider using clinical care classification." "Consider using current procedural technology." "Consider using a clinical decision support system." "Consider using perioperative nursing data sets."

"Consider using a clinical decision support system."

A patient asks the nurse why their family members have started turning down the volume on the television when they speak. Which statement by the nurse is best? "Decreasing background noise makes it easier for you to hear the conversation." "The television can distract you from hearing the conversation." "The television is confusing you due to your hearing loss." "The television interferes with the function of your hearing aid."

"Decreasing background noise makes it easier for you to hear the conversation."

The nurse caring for a patient diagnosed with open-angle glaucoma is concerned about the patient's safety. Which information is most important for the nurse to provide? "Do not let anyone move or rearrange the furniture." "Use your eye medication exactly as prescribed." "Local transportation companies are available to transport you safely to your appointments." "The library might have books with large print so that you can continue to read."

"Do not let anyone move or rearrange the furniture."

The nurse recommends short, simple communication for older adult patients with cognitive impairment to colleagues. Which statement by a colleague requires correction? "Do you remember what Dr. Jones told you?" "Please lift your arm up." "Please sign your name here?" "Is she your daughter?"

"Do you remember what Dr. Jones told you?"

The nurse is discussing accountability and reliability. Which statement should the nurse include? "Follow through on commitments." "Avoid negativity." "Seek input from others as needed." "Leave personal problems at home."

"Follow through on commitments."

The nurse is giving a presentation about the applications of geographic information system (GIS) technology. Which statement should the nurse include? "GIS technology is not useful for tracking acute health problems." "GIS technology is not dependent on satellite imaging or global positioning systems." "GIS technology is used strictly within the healthcare system." "GIS technology can be used to plot and analyze lifestyle choices."

"GIS technology can be used to plot and analyze lifestyle choices."

The school nurse prepares for responsibilities during an emergency by participating in quarterly fire drills. Which slogan best captures the nurse's responsibility? "Most intense help for most severe injuries." "Fastest triage for physical injuries." "Greatest good for the greatest number." "Scope of practice changes with circumstances."

"Greatest good for the greatest number."

A student nurse is in the integrated stage of commitment. Which statement made by the nursing student reflects this? "I am ready to get out of nursing school, it is boring." "I cannot wait to take my NCLEX-RN exam." "I am running for office in the Student Nurses Association." "I cannot wait to start my clinical rotations."

"I cannot wait to take my NCLEX-RN exam."

The nurse manager is taking a newly hired nurse on a tour of a clinical unit. Which statement by the new nurse best demonstrates the exploratory stage of commitment? "I cannot wait to use my new stethoscope." "I am so afraid that I am going to make a mistake." "The smell is making me sick." "I have been volunteering at the hospital for the past year."

"I cannot wait to use my new stethoscope."

The nurse is caring for a patient who is newly diagnosed with type 2 diabetes mellitus. Which statement by the nurse should facilitate the development of a therapeutic relationship with this patient? "This disease isn't so bad. At least you don't have to take insulin." "I don't know how many grams of carbohydrates you can have, but I will find out for you." "Losing some weight will help control your blood glucose level." "I'll be back to take your sugar before dinner arrives."

"I don't know how many grams of carbohydrates you can have, but I will find out for you."

The nurse provides information about Medicare to a 65-year-old patient who is on Medicaid. Which patient statement indicates that further information is needed? "I don't want to pay a premium for Medicare every month." "I know I can use the health department for routine care until my Medicare comes through." "I have an appointment with a social worker to help me apply for Medicare." "I understand that Medicare will not cover everything."

"I don't want to pay a premium for Medicare every month."

The nurse is evaluating the use of e-health in a group of patients. Which patient statement reflects an effective use of e-health? "I have started a diet that came highly recommended by a doctor who is on television." "I looked up my symptoms on a website and I think I know what medications I should take." "I got a Fitbit to help me monitor my physical activity and I'm up to 12,000 steps per day." "I use an accucheck device to monitor my blood glucose levels on a daily basis."

"I got a Fitbit to help me monitor my physical activity and I'm up to 12,000 steps per day."

The nurse is developing a presentation that describes the benefits of using a clinical decision support system in the electronic health record. Which statement should the nurse include? "It has an inability to function as a stand-alone system." "There is a decreased need for critical thinking at the point of care." "It has no impact on errors and adverse events." "There are fewer challenges when incorporating current nursing research."

"There are fewer challenges when incorporating current nursing research."

The nurse is working at a facility that utilizes primary care nursing as the model for delivering nursing care. Which statement by the nurse best demonstrates an understanding of the role of the primary care nurse? "I have 24/7 authority and responsibility for the patients assigned to my group." "I will be delegating tasks to others, and they will be responsible for the tasks." "I will be providing all the care for my patients and delegate tasks if necessary." "I am responsible for the care of the patients assigned to my team."

"I have 24/7 authority and responsibility for the patients assigned to my group."

The nurse is providing discharge teaching for a patient who has absent tactile sensation below the umbilical area. Which patient statement indicates that further teaching is needed? "I will check if my skin clean and dry." "I will adjust the temperature on the water heater." "I will avoid taking baths." "I will make sure I change positions frequently."

"I will avoid taking baths."

The nurse is concerned about the dosage of a medication ordered by the healthcare provider. Which statement by the nurse indicates the best way to avoid a sentinel event? "I am going to call the pharmacy." "I will notify the charge nurse." "I will call the healthcare provider." "I am going to notify the risk management department."

"I will call the healthcare provider."

The nurse is admitting a patient for a diagnostic procedure. The patient states, "I am not comfortable with my decision to have this procedure." Which response by the nurse reflects advocacy? "Do you need me to explain anything about the treatment?" "What exactly are you uncomfortable with?" "I understand, it is normal to feel nervous before a procedure." "I will notify the healthcare provider of your concern."

"I will notify the healthcare provider of your concern."

The nurse caring for a patient diagnosed with macular degeneration taught the patient's family about assistive devices and recommendations for treatment. Which statement by the patient's family indicates the need for further teaching? "There is no reason to have regular eye exams." "We can buy magnifying glasses at the drugstore." "Large-print books are available in many stores." "We will remove throw rugs in the house to prevent falls."

"There is no reason to have regular eye exams."

The nurse reviewed the dress code. Which statement by the nurse indicates an understanding of the purpose of the dress​ code? A."My professional appearance maintains professional​ boundaries." B."My professional appearance supports my​ credibility." C."Professional dress will help the client identify my​ role." D."The dress code prevents client​ confusion."

"My professional appearance supports my​ credibility." Rationale: The purposes of adhering to the dress code include supporting the​ nurse's credibility. How a nurse​ dresses, behaves, and communicates sets the stage for the development of trust or mistrust. The dress code does not prevent client confusion or help the client identify the role of the nurse. It is important for nurses to introduce themselves and inform clients of their​ role, as well as to wear appropriate identification. Professional appearance does not maintain professional boundaries. Professional boundaries are maintained by the demeanor of the nurse

The nurse is discussing guidelines for protecting the patient's privacy when using an electronic health record. Which guideline is essential for the nurse to include? "Never leave computer screens with protected health information unattended." "Always obtain written permission before posting patient information on any social network." "Only share computer passwords with trusted colleagues or nurse administrators." "Never destroy paper documents that contain protected health information."

"Never leave computer screens with protected health information unattended."

After testing, it is determined that an older adult patient has hearing loss that is caused by presbycusis. The patient questions why her hearing is getting worse. Which response by the nurse is accurate? "An abnormality in the bone formation in your inner ear prevents sound waves from being transmitted." "You have a tumor of your acoustic nerve." "The hair cells in your ear, which act as sensory receptors, degenerate as you age." "Your ear is occluded with wax, so the sound waves cannot reach the nerve in your ear."

"The hair cells in your ear, which act as sensory receptors, degenerate as you age."

The nurse is providing the rationale to support the purchase of an electronic health record system that allows the use of multiple nursing language terminologies in a standardized format. Which statement should the nurse include? "The use of uniform language only applies to communication between nurses." "The use of uniform language reduces the steps in the nursing research process." "Retrieval of evidence-based information about patient care is easier with uniform language." "Most computerized systems use uniform language to integrate nursing terminologies into the health record."

"Retrieval of evidence-based information about patient care is easier with uniform language."

A patient diagnosed with glaucoma asks the nurse why eyedrops must be used every day. Which response by the nurse is appropriate? "The drops lower the pressure in the eye." "The drops moisten your eyes and make you feel more comfortable." "The drops cure glaucoma and restore your vision." "The drops are prescribed by your healthcare provider, so I recommend you use them."

"The drops lower the pressure in the eye."

During a meeting with hospital administrators, the nurse is using the Surgical Care Improvement Project to illustrate the use of informatics in quality care. Which statement should the nurse include in the presentation? "The goals of the study include reducing complications among surgical patients." "The study objectives include identifying nurses who make medication errors." "The study will not affect reimbursement for hospital stays or surgical procedures." "The study's target population is all nurses who work in the surgical setting."

"The goals of the study include reducing complications among surgical patients."

The nurse is caring for a patient who is taking an adrenergic drug, pseudoephedrine. The patient asks why there is a need to take this medication. Which explanation by the nurse is accurate? "This medication is used to treat the bacterial infection." "This medication is used to help with the fullness you are feeling in the sinuses." "This medication is used to reduce the immune response in the body." "This medication is used to treat the viral infection."

"This medication is used to help with the fullness you are feeling in the sinuses."

The nurse is caring for a patient who has managed care insurance. The patient states, "I am not too sure about this new insurance. I have never had this type of coverage before." Which statement by the nurse provides the patient with an accurate response? "Your new insurance is excellent in decreasing your out-of-pocket expenses." "The insurance you have allows you to go wherever you want to receive care." "This type of coverage by design promotes receiving high-quality, cost-effective care." "You will receive patient-focused care with your insurance plan."

"This type of coverage by design promotes receiving high-quality, cost-effective care."

The nurse is performing a hearing assessment using the Weber test for a patient experiencing hearing loss. The patient asks the nurse, "What is the reason for this test?" Which information should the nurse include in the response? "To assist in determining the type of hearing loss you may have" "To diagnose your conductive hearing loss" "To diagnose an ear infection" "To diagnose your sensorineural hearing loss"

"To assist in determining the type of hearing loss you may have"

The nurse attends class regarding statewide tracking mechanisms that identify providers who are not practicing sound medicine. Which statement by the nurse indicates that learning occurred? "A financial incentive is given to healthcare providers who refrain from prescribing opioids." "Law enforcement can run periodic surveillance of patient records." "Tracking helps remind a healthcare provider to write a prescription for opioids for pain management." "Tracking helps identify healthcare providers who are writing opioid prescriptions for financial kickback."

"Tracking helps identify healthcare providers who are writing opioid prescriptions for financial kickback."

While conducting a health interview the nurse wants to make sure that the information collected is correct before moving to a new area of focus. Which statement should help the nurse summarize the content of the conversation? "We have discussed previous illnesses and hospitalizations. Did I miss anything?" "In other words, you have not had any major illnesses or hospitalizations for 5 years?" "I sense that you don't like hospitals. Do I understand you correctly?" "I am not sure that I completely understand the symptoms that you are experiencing."

"We have discussed previous illnesses and hospitalizations. Did I miss anything?"

A patient with a newly delivered baby asks the nurse, "How do I know if my baby can hear?" Which information should the nurse provide? "When you speak to the baby, the baby will look at you." "We will perform a hearing screening prior to discharge from the hospital." "At your baby's 6-month pediatric visit, a hearing screening will be performed." "The baby's hearing is not fully developed and will be tested later."

"We will perform a hearing screening prior to discharge from the hospital."

The nurse asks for feedback about their body language. Which statement should the nurse receive to be most effective? "When you cross your arms while speaking, I feel your apprehension." "When you talk and cross your arms, it bothers me." "When you cross your arms, I feel like you don't care." "When you talk to me, you cross yours arms as if to defend yourself."

"When you cross your arms while speaking, I feel your apprehension."

The nurse manager assigns a staff nurse to attend a program on communication skills after hearing a conversation that the staff nurse had with a patient. Which statement prompted the nurse manager to send the staff nurse to a program on communication skills? "How are you feeling today, Mr. Smith?" "Please step on the scale." "You are going to be okay." "Can I borrow your chair for about an hour?"

"You are going to be okay."

The nurse is preparing to provide the parents of a child that is being seen for a well visit some general education. Which statement by the nurse reflects secondary prevention education? "It is important that your child get exercise for at least 20 minutes a day." "You child is due for another immunization in 1 year." "It is important to include fresh fruits and vegetables in your child's diet." "Your child should be seen by the dentist every 6 months."

"Your child should be seen by the dentist every 6 months."

An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply. A) Blurred vision B) Intermittent loss of eyesight C) Headaches D) Clouding of the eyes E) Change in eye color

A) Blurred vision E) Change in eye color

A nurse is teaching a clients about the Affordable Care Act (ACA). Which of the following information should the nurse include? -The ACA does not provide coverage for pre-existing conditions -The ACA enforces a lifetime limit to covered benefits -Clients who have insurance pay a fee for preventable screenings -A focus of the ACA is disease prevention

-A focus of the ACA is disease prevention. Aside from making insurance coverage more affordable and available, a focus of the ACA is disease prevention. Clients are encouraged to sign up for insurance and seek preventative care before they get sick, so they can stay well.

A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category? (Select all that apply.) -Access to foods that support healthy eating patterns -Access to health care -Crime and violence -Environmental conditions -Civic participation

-Access to foods that support healthy eating patterns -Crime and violence -Environmental conditions

A nurse in a clinic is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Which of the follow care facilities should the nurse anticipate the client be admitted to? -Skilled nursing facility -Long-term care hospital -Acute care hospital -Assisted living facility

-Acute care hospital. Acute care facilities specialize in clients who require short term treatment, such as IV medications, diagnostic procedures, and dressing changes.

A nurse in a provider's office is speaking with a client who needs a refill for a prescription that has expired. The nurse should identify that which of the following members can assist the client with the refill? (Select all that apply.) -Social worker -Advanced practice registered nurse (APRN) -Physician Assistant (PA) -Pharmacist -Physician

-Advanced practice registered nurse (APRN) -Physician Assistant (PA) -Physician

An infant is scheduled for a myringotomy due to repeated episodes of otitis media. The parent asks the nurse to describe the procedure. Which explanation by the nurse is accurate? An implant is used to restore hearing deficit. A small hole is made in the tympanic membrane and then tympanostomy tubes are placed. The structures of the middle ear are reconstructed to improve conductive hearing deficits. Removal and replacement of the stapes is used to treat hearing loss.

A small hole is made in the tympanic membrane and then tympanostomy tubes are placed.

A nurse is reviewing a report by the Institute of Medicine (IOM). Which of the following competencies should the nurse identify health care professionals need in order to reduce errors? (Select all that apply.) -Competition -Cooperation -Communication -Resolution -Coordination

-Cooperation -Communication -Coordination

A nurse is caring for a client who has Parkinson's disease and needs assistance with ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe? -Social worker -Dietitian -Physical therapist -Occupational therapist

-Dietitian -Physical therapist -Occupational therapist

A nurse is caring for a client who reports that they have recently lost their job and do not have insurance coverage. Which of the follow social determinants of health is challenging for this client? -Economic stability -Education -Social and community context -The neighborhood environment

-Economic stability Social determinants of health are economic and social conditions that affect health promotion and disease prevention. Economic stability is a social determinant of health that encompasses employment. Lack of employment can lead to food insecurity, housing instability, and poverty.

A nurse in a provider's office is speaking with a client about a Press Ganey survey. The nurse should inform the client that this survey will be conducted by which of the following methods? -Email -Automated phone attendant -Postal mail -Telephone call

-Email The nurse should inform the client that they will receive a Press Ganey survey via email following their office visit. The Press Ganey survey evaluates client satisfaction with health care delivery and is sent to all clients who receive care.

A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expect to perform? -Facilitate transfer of clients to meet the required level of care -Perform physical assessments on clients -Administer medications to clients -Provide wound care to clients

-Facilitate transfer of clients to meet the required level of care Case managers are responsible for managing resources, reviewing care delivery in the acute care setting, and facilitating transfer to the required level of care, either within the facility or to another facility.

A nurse is teaching a client about hospice care. Which of the following statements by the client indicates an understanding of the teaching? -I understand that services provided will include just what is needed to keep me comfortable -While I am receiving hospice care, I will continue treatment for my illness -I need to be in the hospital to receive hospice care -The hospice team will no longer support my family after I have passed away

-I understand that services provided will include just what is needed to keep me comfortable The goal of care is not to treat or cure the illness, but to provide comfort and support for clients who have less than 6 months to live.

A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should the nurse include? (Select all that apply.) -Initiatives to reduce health care disparities -Activities to improve social determinants of health -Providing prevention care services -Improving access to health care -Reducing the infection rate

-Initiatives to reduce health care disparities -Activities to improve social determinants of health -Improving access to health care

A nurse is completing the Minimum Data Set (MDS) assessment for a resident in a skilled-nursing facility. Which of the following information should the nurse include in the assessment? (Select all that apply.) -Input from members of the client's interdisciplinary team -The client's cognitive status -Description of the client's home environment -Each physical therapy visit -The client's need for assistance with activities of daily living

-Input from members of the client's interdisciplinary team -The client's cognitive status -Each physical therapy visit -The client's need for assistance with activities of daily living

An 80-year-old patient reports a gradual loss of peripheral vision over the last several months without any other clinical manifestations. Which condition should the nurse suspect in this patient? Open-angle glaucoma Angle-closure glaucoma Secondary cataracts Traumatic cataracts

Open-angle glaucoma

A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred to for further treatment? -Skilled nursing facility (SNF) -Long-term care hospital (LTCH) -Assisted living -Hospice care

-Long-term care hospital (LTCH) LTCHs specialize in hospitalization for long-term care, such as clients who have severe burns, trauma, or ventilation needs. LTCHs provide a higher level of care than a SNF, such as is required for a client who is receiving mechanical ventilation,

The patient tells the nurse, "I keep seeing halos around all the lights." Which condition should the nurse suspect in the patient? Open-angle glaucoma Angle-closure glaucoma Cataracts Age-related macular degeneration

Open-angle glaucoma

A nurse in a provider's office is calling a client's insurance company to obtain permission prior to scheduling a magnetic resonance imaging (MRI) test. Which of the following is the nurse obtaining? -Fee-for-service -Diagnosis-related group (DRG) -Retrospective review -Precertification

-Precertification. The nurse is obtaining precertification from the client's insurance company prior to scheduling the client's MRI. Before an elective surgery, hospital admission, or procedure such as a magnetic imaging study, a client needs to obtain precertification or authorization approval from the insurance company, or the service can risk denial of payment.

A nurse is teaching a newly licensed nurse about Medicare reimbursement. Which of the following should the nurse include in the teaching? -Diagnosis-related groups (DRGs) establish reimbursement amounts based on the client's length of hospitalization -Reimbursement amounts will be adjusted for clients who contract hospital-acquired conditions (HAC) -Clients must recover before the facility can be reimbursed -The Inpatient Prospective Payment System (IPPS) allows for facilities to be reimbursed in advance for client care

-Reimbursement amounts will be adjusted for clients who contract hospital-acquired conditions (HAC). To encourage hospitals to provide quality care to their clients, Medicare requires payment reduction to facilities that have poor outcomes related to hospital-acquired infections.

A home health nurse is caring for a client who is receiving hospice care. The client's partner reports feeling overwhelmed from caring for the client. Which of the following types of facilities should the nurse recommend? -A skilled nursing facility (SNF) -A long-term care hospital (LTCH) -Respite care -Assisted living

-Respite care. The nurse should recommend that the client's partner consider placing the client in respite care. Respite care is a benefit offered under hospice care that allows clients to receive up to 5 days of care. This can help provide client caregivers relief and rest from the duties of caring for their loved one.

A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include? -TJC is a for-profit organization -Accreditation by TJC is required for all inpatient facilities -Accreditation by TJC is restricted to inpatient facilities -TJC ensures organizations remain up-to-date with state guidelines

-TJC ensures organizations remain up-to-date with state guidelines TJC monitors state legislative and regulatory changes and updates its standards accordingly. This monitoring acts as a two-part system to ensure that accredited organizations remain current with state requirements.

A nurse is teaching a class about the Hospital-Acquired Condition Reduction Program (HACRP). Which of the following information should the nurse include? -The HACRP reimburses a medical facility based on the client's primary diagnosis -The HACRP links Medicare payments to health care quality -The HACRP determines the length of hospitalization for clients who have the same diagnosis -The HACRP is not used in the acute care setting

-The HACRP links Medicare payments to health care quality The HACRP reduces reimbursement to facilities that have poor outcomes related to five different hospital-acquired infections. Centers for Medicare & Medicaid services will not reimburse the facility for the costs associated with treatment for the infection and the extended stay of the client. The HACRP was implemented to incentivize hospitals to provide high-quality care for their clients.

A nurse is teaching a newly licensed nurse about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include? -The HCAHPS tool is provided to clients upon admission to a facility. -The HCAHPS tool is issued to every client who is admitted to the facility. -The HCAHPS tool is issued to measure client satisfaction with the health care service. -The HCAHPS tool is emailed to clients.

-The HCAHPS tool is issued to measure client satisfaction with the health care service. The HCAHPS tool is issued to measure client satisfaction with the health care service. The information is publicly reported and ensures the accountability and transparency of the facilities that participate. The HCAHPS tool uses a broad range of questions issued to the client regarding their care. This information is published publicly to show how the facility is performing and their accountability.

A graduate nurse notes that a hospital with Pathway to Excellence recognition is hiring staff. Which of the following should the nurse expect from this facility? -The facility has practices in place that lead to a healthy workplace environment -The facility must have underwent an on-site review to receive the Pathway to Excellence award -The facility emphasizes shared governance -The facility emphasizes practices that positively affect a nurse's well-being -The facility focuses on improving clinical quality indicators

-The facility has practices in place that lead to a healthy workplace environment -The facility emphasizes shared governance -The facility emphasizes practices that positively affect a nurse's well-being

A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make? -Your income will determine if you are eligible for Medicaid -You must be age 65 of older to qualify for Medicaid -Laboratory services are not covered by Medicaid -Medicaid is fully funded by the government

-Your income will determine if you are eligible for Medicaid To qualify for Medicaid, the client must meet eligibility requirements based on the client's income in relation to the poverty level.

A nurse is always on time, neat in appearance, and caring toward clients. Which statement best characterizes this nurse's level of professional commitment? A) The nurse is demonstrating a pattern of behaviors congruent with nursing's professional code of ethics. B) The nurse is demonstrating a strong belief in and acceptance of the unit's goals, values, and morals. C) The nurse is demonstrating a willingness to exert control over personal behaviors. D) The nurse is demonstrating a strong desire to be part of a group.

A

The nurse is caring for a patient who is diagnosed with diabetes mellitus. Which evaluation statement should indicate that the plan of care is working? 04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content. 04/03/2018: Goal unmet: Patient demonstrates use of insulin injection successfully. 04/03/2018, 1750: Goal met: Patient voices understanding of treatment therapy. 04/03/2018, 1830: Goal partially met: Patient demonstrates use of home oxygen machine.

04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content.

Which rationale should the nurse understand is a patient-centered advantage of chemical restraints versus seclusion? a)The patient treated with a chemical restraint maintains freedom of movement. b)It is easier on the staff to use drugs than to sit in a seclusion room and monitor the patient. c)There are no side effects with chemical restraints. d)Staff can subdue a patient more quickly and easily using a chemical restraint

A

To determine informed consent, the nurse asks a patient, "Can you tell me what your surgery will involve?" Which method of therapeutic communication is the nurse using? Open-ended questioning Giving information Paraphrasing Seeking clarification

Open-ended questioning

The nurse is planning to teach a class about device integration. Which example should the nurse use? Linking a policy to a particular communication with a colleague Manually entering blood glucose values into an electronic medical record A blood pressure monitor transferring vital signs to the electronic medical record Forwarding a desk phone to a cell phone

A blood pressure monitor transferring vital signs to the electronic medical record

By which age should hearing loss be diagnosed in an infant? 12 months 9 months 6 months 3 months

3 months

The nurse is caring for a patient who sustained an injury that caused separation of the sensory portion of the eye from the choroid. Which eye condition should the nurse suspect the patient has? A. Detached retina B. Blunt trauma C. Penetrating trauma D. Corneal abrasion

A A detached retina is defined as the separation of the sensory portion of the eye (the retina) from the choroid. A corneal abrasion is the disruption of the superficial epithelium of the cornea. Blunt trauma interrupts the uveal tract of the eye, leading to hemorrhage of the anterior chamber. A penetrating wound has a single entrance wound. Layers of the eye spontaneously reapproximate after entry of a sharp-pointed object.

The nurse is caring for a patient who is scheduled for evaluation and a prescription for a hearing aid. Which collaborative referral should the nurse anticipate will be prescribed for the patient? A. Audiologist B. Otolaryngologist C. Vestibular rehabilitation therapist D. Occupational therapist trained in sound therapy

A An audiologist is trained to provide hearing exams and to provide prescriptions for hearing aids. Otolaryngologists are physicians who are trained to diagnose and treat ear, nose, and throat disorders, including surgery if needed. Patients who develop smell or taste disorders can also consult with otolaryngologists. Occupational therapists trained in sound therapy and vestibular rehabilitation therapists do not evaluate and prescribe hearing aids.

A patient with a bacterial ear infection is receiving a corticosteroid and a macrolide antibiotic. Which food on the patient's breakfast tray should cause the nurse to intervene? A. Grapefruit B. Hash browns C. Coffee with creamer D. Scrambled eggs

A Both corticosteroids and macrolide antibiotics can be affected by grapefruit or grapefruit juice and may lead the nurse to intervene. Eggs, hash browns, and coffee with creamer do not affect these medication classes.

A patient with hearing loss and their family are frustrated due to the lack of ability to communicate. The family asks about communication techniques they could learn. Which type of communication uses hand shapes for sounds? A. Cued speech B. Oral speech C. Total communication D. Sign language

A Cued speech uses eight hand shapes that represent groups of consonant sounds and four positions about the face that represent groups of vowel sounds. Oral approach uses only spoken language for face-to-face communication. Total communication uses speech and sign, fingerspelling, lip reading, and residual hearing simultaneously. Sign language uses hand movements and is a separate language that allows the user to communicate quickly and accurately with others who understand signs.

The nurse is assessing a teenager at the clinic. Which lifestyle habits can affect hearing to a greater extent? A. Headphone use B. Vaccination history C. Nutrition history D. Growth development

A Ear buds and headphones can cause noise-induced hearing loss (NIHL). It continues to be a serious public health concern. It should be addressed during checkups. Vaccination, growth, and nutrition are important aspects, but headphones are directly related to hearing loss.

The nurse is caring for a patient diagnosed with cataracts. Which nonpharmacologic treatment should the nurse discuss with the patient? A. Using a brighter light when reading B. Wearing sunglasses indoors C. Maintaining bedrest D. Utilizing an eye patch

A Early cataracts can be managed by using a magnifying glass, stronger prescription lenses, or using a brighter light when reading. Maintaining bedrest, utilizing an eye patch, and wearing sunglasses indoors are not ways to manage a cataract.

The nurse caring for a patient diagnosed with open-angle glaucoma is concerned about the patient's safety. Which information is most important for the nurse to provide? A. "Do not let anyone move or rearrange the furniture." B. "The library might have books with large print so that you can continue to read." C. "Use your eye medication exactly as prescribed." D. "Local transportation companies are available to transport you safely to your appointments."

A For the patient with impaired vision, it can be difficult to adapt to changes in the environment, so maintaining the same position of belongings is important for patient safety. Large-print books, transportation, and medication compliance are not directly related to home safety.

The nurse is preparing the patient for ear wax removal due to impacted cerumen. The nurse should recognize that this patient has which type of hearing impairment? A. Conductive hearing loss B. Conductive hearing deficit C. Sensorineural hearing loss D. Tinnitus

A Impacted cerumen can cause conductive hearing loss. A tympanoplasty is used to reconstruct the structures of the middle ear to improve conductive hearing deficits. Tinnitus is not a type of a hearing loss; it is the perception of sound or noise in the ears without stimulus from the environment. A cochlear implant is used for a patient who is experiencing a sensorineural hearing loss.

A pregnant woman is being assessed for syphilis and herpes. The patient asks why this screening is needed. Which is the best explanation from the nurse? A. "Certain infections are screened during pregnancy, because they can affect the developing fetus." B. "Certain viruses can affect the fetus and need to be cured before birth of the fetus." C. "Diseases need to be cured before pregnancy so that a fetus is not affected." D. "Diseases need to be cured during pregnancy before they affect the fetus."

A In utero infections with TORCH pathogens (toxoplasmosis, rubella, cytomegalovirus, syphilis, herpes) can affect the development of the fetus and are screened during pregnancy. The TORCH pathogens are viruses and bacteria that cannot always be cured, but they need to be identified during or before pregnancy.

The nurse is caring for a patient diagnosed with macular degeneration. Which problem is most appropriate for the nurse to include in the plan of care? A. Injury risk B. Ineffective airway clearance C. Pain D. Constipation

A Injury risk, ineffective self-management of health, and fear are potential problems for a patient with macular degeneration. Pain, ineffective airway clearance, and constipation are not common symptoms of macular degeneration.

The nurse is teaching a patient about the purpose of a newly prescribed medication for glaucoma. Which patient statement demonstrates effective teaching? A. "The eyedrops will lower the pressure in my eye." B. "The eyedrops will moisten my dry eyes." C. "The eyedrops will cure my glaucoma." D. "The eyedrops will help to restore my vision."

A Medications prescribed for glaucoma are used to decrease intraocular pressure rather than to provide moisture and comfort. Medications do not cure glaucoma, but they help to manage glaucoma.

After telling a patient that cataracts occur when proteins clump and cloud the lens of the eye as a result of aging, the patient asks the nurse, "Which symptoms may occur as a result of this process?" Which response by the nurse is accurate? A. "Cloudy vision and difficulty reading even with glasses" B. "Vertigo and a distortion of straight lines" C. "Increased color vision" D. "Reduction in central vision with good peripheral vision"

A Most cataracts are considered a normal part of the aging process. As the lens ages, fibers and proteins change and degenerate. The proteins clump and cloud the lens. This process usually begins at the periphery of the lens and spreads to involve the central portion. As the cataract continues to develop, the entire lens may become opaque. The lens may also discolor over time, which affects the ability to discriminate color.

The nurse is reviewing the chart of a patient diagnosed with nystagmus. Based on the patient's diagnosis, which assessment finding should the nurse anticipate? A. Involuntary eye movements B. Failure of the pupils to respond to light C. Pupils that are unequal in size D. One eye that deviates from the other

A Nystagmus is characterized by involuntary eye movements. Strabismus is characterized by one eye deviating from the other. Pupils that are unequal in size are indicative of a neurologic problem. Failure of the pupils to respond to light may indicate degeneration of the retina or destruction of the optic nerve.

An older adult patient is brought to the healthcare facility by a family member who reports that the patient has been having difficulty hearing. Which assessment finding supports the diagnosis of hearing loss? A. Difficulty understanding conversation when the nurse turns away B. A raised voice when angry C. Unable to state which day of the week it is D. Appropriate responses to questions

A Patients with hearing loss will often have difficulty understanding verbal communication when they cannot see the speaker's face. This assessment finding supports the diagnosis of hearing loss. The inability to state the day of the week indicates impaired cognition. Appropriate responses to questions and a raised voice when angry do not indicate hearing loss.

The nurse is caring for a patient who is taking an adrenergic drug, pseudoephedrine. The patient asks why there is a need to take this medication. Which explanation by the nurse is accurate? A. "This medication is used to help with the fullness you are feeling in the sinuses." B. "This medication is used to treat the viral infection." C. "This medication is used to treat the bacterial infection." D. "This medication is used to reduce the immune response in the body."

A Pseudoephedrine is a drug used to enhance norepinephrine and epinephrine activity by stimulating alpha-adrenergic receptors. This causes vasoconstriction and reduces inflammation. This medicine does not reduce the immune system or treat viral or bacterial infections.

The nurse is assessing a patient with a history of myopia. Which deficit should the nurse expect to find in this patient? A. The patient is unable to read the 20/20 line on the Snellen chart. B. The patient has a misalignment of the eyes. C. The patient has difficulty reading small print. D. The patient has a loss of peripheral vision.

A The deficit the nurse expects to find for the patient with myopia are changes in distant vision. Changes in near vision are referred to as presbyopia. A loss of peripheral vision occurs with glaucoma. A misalignment of the eyes is referred to as strabismus.

The nurse is caring for an older adult patient with a hearing deficit. Which initial intervention should the nurse include in the plan of care when communicating with the patient? A. Use longer phrases. B. Encourage the patient to do more reading. C. Shout when communicating with the patient. D. Request a service dog for the patient.

A The nurse will use longer phrases when communicating with the patient. Longer phrases tend to be easier to understand than short ones. It is not necessary to initially encourage the patient to do more reading or obtain a request for a service dog. Shouting is an ineffective means of communication for a patient with a hearing deficit. Shouting does not make the sounds more distinct and may make it more difficult for the patient to comprehend the speech. A moderate tone of voice, with well-articulated words, is more appropriate.

The nurse is planning care for a patient newly diagnosed with glaucoma. Which nursing intervention is most important for the nurse to include? A. Preventing injury B. Teaching about the disease process C. Reducing anxiety D. Supporting self-care

A The priority intervention for a patient with newly diagnosed glaucoma is preventing injury. Supporting self-care, reducing anxiety, and teaching about the disease process are all important, but they are not priorities.

The nurse is assessing a child with a history of otitis media. The nurse observes a reddened, inflamed tympanic membrane in the right ear. Based on the child's history of recurrent otitis media, which procedure should the nurse expect to be recommended? A. Insertion of ear tubes B. Removal of the stapes C. Reconstruction of the tympanic membrane D. Cochlear implant

A The procedure that will be considered for a child with recurrent otitis media is insertion of ear tubes (myringotomy). A myringotomy is a common procedure that is performed in young children with recurrent otitis media. In this procedure, a small hole is created in the tympanic membrane and then a tympanostomy tube is placed. Removal of the stapes (stapedectomy) is used to treat hearing loss related to otosclerosis. Reconstruction of the tympanic membrane (tympanoplasty) is performed to improve conductive hearing related to the scarring from chronic otitis media and necrosis. Cochlear implants are used to improve sound perception.

The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn​ child? A .Lack of immunity to rubella B. History of otitis media C. Brief case of moderate conjunctivitis D. Immunity to varicella

A .Lack of immunity to rubella

Which of the following statements best describes the physiologic response of the layers of the eye in response to a penetrating injury? A) They pull away from the penetration. B) They reform following the penetration. C) They degenerate and atrophy immediately. D) They begin to tear away from one another.

B) They reform following the penetration.

The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of therapeutic communication with this client? Select all that apply. A) "I am so happy today! I just found out that I got accepted into nurse practitioner school!" B) "Well, I guess your lifestyle finally caught up to you." C) "One of my cousins has AIDS. It is hard to watch him die." D) "Tell me your feelings about the diagnosis." E) "Would you like to talk about the new medications you've been prescribed?"

A) "I am so happy today! I just found out that I got accepted into nurse practitioner school!" B) "Well, I guess your lifestyle finally caught up to you." C) "One of my cousins has AIDS. It is hard to watch him die."

A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social isolation? A) "I ask others to face me when they talk because I can hear them better." B) "I keep the television volume raised to a high level." C) "I don't use my hearing aid unless someone seems to need to talk to me." D) "I might use the hearing aid when I go shopping."

A) "I ask others to face me when they talk because I can hear them better."

A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A) "I do not know, but I will find out." The student nurse best exhibits integrity and awareness of self-limits by admitting not knowing the answer, but offering to find out and get back to the client. Honesty by the student nurse will build trust with the client. Just saying "I don't know" and leaving it at that will make the nurse appear untrustworthy and possibly uncaring. Questioning the client about the need for the information is defensive and might also be construed as a challenge by the client. Referring the question to the doctor is also not good ethics; nurses need to continue learning throughout their practice.

The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client? A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"

A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure."

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply. A) "It is recommended that the child wear a medical alert bracelet." B) "This medication does not come prefilled and must be measured." C) "Keep the medication in the car at all times." D) "Frequently check the expiration date of the medication." E) "Keep the medication in one location that is easy to remember."

A) "It is recommended that the child wear a medical alert bracelet." D) "Frequently check the expiration date of the medication."

The nurse completes a teaching session on wound care for a client who will require dressing changes after discharge. The nurse then evaluates the effectiveness of the teaching session and determines that more education is required. Which statement by the nurse is appropriate in this situation? A) "Let me clarify again some of the steps that are required during wound care." B) "You didn't pay attention, did you?" C) "Here, let me do it for you." D) "I don't think you understood me correctly the first time."

A) "Let me clarify again some of the steps that are required during wound care."

The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff? A) "The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders." B) "The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully." C) "The client in room 315 received an enema at 2100." D) "The client in room 311 was transferred from room 212."

A) "The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders."

Which is the decibel level for mild hearing loss? A) 16-40 dB B) 41-70 dB C) 71-90 dB D) 91+ dB

A) 16-40 dB

Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts? A) Age 75 years B) Hypertension C) Moderate alcohol use D) Smoker

A) Age 75 years

The nurse is caring for a client in an allergy clinic. After completing the client history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the client's history supports the need for this nursing diagnosis? A) Anaphylactic reaction to shellfish B) A drug reaction to penicillin causing a rash C) Glomerulonephritis D) Dermatitis resulting from a response to laundry detergent

A) Anaphylactic reaction to shellfish

The nurse is caring for a client who was admitted to the emergency department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, which action by the nurse is appropriate? A) Ask the interpreter to translate as closely as possible. B) Ask the client's family to be included in the interpreting process and exchange of information. C) Direct questions to the interpreter and not the client. D) Request that the interpreter use the same dialect as the client to promote understanding.

A) Ask the interpreter to translate as closely as possible.

When the nurse receives a telephone order from the healthcare provider's office, which guidelines should the nurse use to ensure the order is correct? Select all that apply. A) Ask the provider to repeat or spell out medication. B) Read the order back to the provider. C) Ask the provider to speak slowly. D) Know agency policy for telephone orders. E) Sign the provider's name and credentials.

A) Ask the provider to repeat or spell out medication. B) Read the order back to the provider. C) Ask the provider to speak slowly. D) Know agency policy for telephone orders.

Which statement about cataract surgery is correct? A) Cataract surgery should be quick but may have to take place in stages. B) Cataract surgery may only be done on an inpatient basis with general anesthesia. C) Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule. D) Cataract surgery is typically bilateral and can be performed in a single day.

A) Cataract surgery should be quick but may have to take place in stages.

The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery? A) Ensuring fall hazards are removed from the client's home and additional lighting is provided B) Educating the client about what self-care activities are necessary following surgery C) Making the client's close family aware of the self-care instructions the client has received D) Ensuring the client's employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider

A) Ensuring fall hazards are removed from the client's home and additional lighting is provided

The nurse is caring for a client who received analgesic medication via central line to treat pain associated with cancer. After reassessing the client's response, which section of the PIE record will the nurse use when documenting the client's care? A) Evaluation B) Progress notes C) Problem D) Intervention

A) Evaluation

What is characteristic of conductive hearing loss? A) For loss of hearing to be the same at all frequencies B) For loss of hearing to primarily involve the upper frequencies C) For loss of hearing to primarily involve the middle frequencies D) For loss of hearing to primarily involve the lower frequencies

A) For loss of hearing to be the same at all frequencies

The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease? A) High-antioxidant diet B) Low-antioxidant diet C) Low-fat diet D) High-fat diet

A) High-antioxidant diet

The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client? Seslect all that apply. A) Keep the stairs free of clutter. B) Wear socks without shoes when walking in the home. C) Use one electrical outlet for devices. D) Have grab bars installed in the bathroom. E) Remove scatter rugs from the floors in the home.

A) Keep the stairs free of clutter. D) Have grab bars installed in the bathroom. E) Remove scatter rugs from the floors in the home.

A client comes into the emergency department with an eye injury. Which assessment findings suggest that this injury is the result of blunt trauma? Select all that apply. A) Lid ecchymosis B) Eye pain and decreased sharpness of vision C) Photophobia and eye tearing D) A well-defined bright area of erythema under the conjunctiva E) A feeling of something in the eye

A) Lid ecchymosis B) Eye pain and decreased sharpness of vision D) A well-defined bright area of erythema under the conjunctiva

The nurse has just completed a teaching session on wound care for client who will be going home and will require dressing changes. The nurse is evaluating the effectiveness of a teaching session for wound care with the family. Which statement is most appropriate by the nurse when the family requires more education? A) "Let me clarify again some of the steps that are required during wound care." B) "You did not pay attention, did you?" C) "Here, let me do it for you." D) "I do not think you understood me correctly the first time."

A) Responding with some clarifications indicates the client understood some of the teaching and preserves the client's dignity and trust in the nurse. Saying that the client did not understand the information is belittling. Beginning a negative phrase with "you" is assigning blame, which impedes the therapeutic relationship. Telling the client the nurse can do it better defeats the goal of the feedback; the nurse would want to instill self-confidence in the client, and this type of action will hurt that goal.

The nurse is providing care to a client diagnosed with end-stage renal disease. When organizing a care plan conference for this client, whom should the nurse invite to participate? A) The client's family members B) A psychiatrist C) An oncologist D) The hospital CEO

A) The client's family members

The nurse is preparing to document care provided to a client during the day shift. The nurse notes that the client experienced an increased pain level while ambulating and thus required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply. A) The extra dose of pain medication B) The client's visit with family C) The client's response to ambulation D) The last antibiotics given E) The client's taking a showe

A) The extra dose of pain medication C) The client's response to ambulation

The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her own experiences living with COPD.

A) The nurse asks appropriate questions about the client's medical history.

The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which areas should the nurse focus when performing this reflection? Select all that apply. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A) Things that could have been done differently C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.

The nurse knows that confrontation can be used to therapeutically communicate with clients. Which response by the nurse is an example of informational confrontation with a client diagnosed with hypertension? A) "I noticed you rubbing your head and your eyes, are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"

A) To be effective a group must accomplish its goals, maintain cohesion, and develop/modify its structure to improve effectiveness. The features of an effective group include an informal, comfortable, and relaxed atmosphere; goals, tasks, and objectives that are clear and understood; leadership and member participation; goal oriented; open and two-way communication; appropriate decision-making procedures; cohesion; conflict tolerance; and shared power.

A nurse is providing care to a client who is scheduled for a colonoscopy. The client requires a bowel prep prior to the diagnostic test. Which approach should the nurse use to facilitate the client's understanding of the procedure? A) Use layman's terms to explain the procedure, then ask the client to describe the procedure in her own words B) Use medical terminology when explaining the procedure to the client to ensure maximum accuracy and clarity C) Focus on intonation when describing the procedure to the client D) Speak slowly and loudly when providing client teaching about the procedure

A) Use layman's terms to explain the procedure, then ask the client to describe the procedure in her own words

The nurse doing an admission assessment and interview for client newly diagnosed with HIV knows that which response or responses convey to the client that the nurse is not interested? Select all that apply. A) "You know that you have to make better decisions in the future." B) "My brother went through the same thing last year." C) "When did your symptoms occur?" D) "After your mother left this afternoon, did your sister call?" E) "Does your family know you are gay?"

A, B) There are some specific blocks to listening that may prevent the nurse from actually hearing what the client says. The following blocks may convey a message to clients that what they have to say is not important: rehearsing or planning what to say in the next conversation; being concerned with oneself; making assumptions; judging; identifying by focusing on own experiences, beliefs, or feelings; getting off track; and filtering or hearing only certain aspects of the client's conversation.

A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this​ client's visual sensory​ overload? A. Reduce the amount of light in the room by lowering shades and turning off overhead lights. B. Provide the client with​ large-print reading materials. C.Encourage the patient to employ relaxation techniques to reduce anxiety and stress. D.Suggest the client wear sunglasses that block UVA rays only.

A. Reduce the amount of light in the room by lowering shades and turning off overhead lights.

The nurse manager informed the staff that merit raises would not be given to staff who refused to work overtime. Which unprofessional behavior is the nurse manager exhibiting? Bullying Improper use of authority Abuse of power Intimidation

Abuse of power

Where does​ perception, or the awareness and interpretation of​ stimuli, take​ place? A. The brain B. The nerve receptors C. The peripheral nervous system D. The impulses

A. The brain

What characterizes individuals with​ achromatopsia? A. They perceive only shades of gray and no colors. B. They perceive only the primary colors of​ red, blue, and yellow. C. They perceive some colors as indistinguishable from other colors. D. They perceive only the secondary colors of​ purple, orange, and green.

A. They perceive only shades of gray and no colors.

The nurse is planning care for an older adult client diagnosed with​ age-related macular degeneration​ (AMD) that is nonexudative. Which therapies should the nurse anticipate for this​ client? Select all that apply. A. Zinc B. Antioxidants C. Eyedrops D. Eye patches E. Laser surgery

A. Zinc B. Antioxidants

The veteran nurse has accepted the unit managerial role. Which best describes the contribution of the veteran nurse? Serving as a technology coach for the new staff Providing innovative ideas and creative approaches to the issues on the unit Ability to provide wisdom and organizational history to the team Coaching and mentoring the new staff hired on the unit

Ability to provide wisdom and organizational history to the team

The nurse manager is preparing an annual review for a nurse. Which measure will the manager use to assess the​ nurse's competency? A.Ethics B.Accountability C.Formation D.Integrity

Accountability Rationale: A​ nurse's competence, or ability to perform the job​ correctly, is the practical measure of accountability. Formation is a process that facilitates the transformation of an individual from a layperson to a professional nurse. Ethics are moral principles that govern behavior. Integrity can be defined as an adherence to a moral code.

The nurse is caring for a patient who reports decreased hearing and ear fullness during an upper respiratory infection. Which medication should the nurse expect to be prescribed for this patient? Adrenergic Loop diuretic Macrolide antibiotic Corticosteroid

Adrenergic

The nurse keeps up with current information and is active in several committees. Which level of commitment best describes the nurse's behavior? Affective Integrated Organizational Continuance

Affective

A patient asks, "Why is my blood sugar so high?" The nurse replies, "Well, it's your fault. I see that you have been eating those cinnamon buns your daughter brought you." Which type of communicator is the nurse presenting as? Aggressive communicator Passive communicator Assertive communicator Active communicator

Aggressive communicator

The nurse is screening patients at risk for hearing loss. Which patient is at the highest risk? Worker who runs a lawnmower Airport worker who guides jet airplanes Firefighter who operates the sirens Hair stylist who uses a hair dryer

Airport worker who guides jet airplanes

The nurse is reviewing the chart of a patient that has smoked half a pack of cigarettes a day for the past 25 years. Which subjective assessment finding should the nurse anticipate in this patient? Decreased tactile sensation Altered sense of taste Decreased visual acuity Difficulty hearing

Altered sense of taste

A case manager is reviewing a patient's record. Which situation is an example of decision support? An EHR issuing an alert when a patient has met the criteria for discharge The case manager sending clinical documentation of the patient's care to the insurance company through an encrypted email The case manager reviewing a medication that has been prescribed and realizing that there is a less costly alternative, recommending it to the provider The case manager documenting that a message has been sent to the provider

An EHR issuing an alert when a patient has met the criteria for discharge

A case manager is reviewing a patient's record. Which situation is an example of decision support? The case manager reviewing a medication that has been prescribed and realizing that there is a less costly alternative, recommending it to the provider The case manager documenting that a message has been sent to the provider The case manager sending clinical documentation of the patient's care to the insurance company through an encrypted email An EHR issuing an alert when a patient has met the criteria for discharge

An EHR issuing an alert when a patient has met the criteria for discharge

The supervisor of the materials management department asks the nurse to recommend a method of standardization that will improve efficiency and reduce costs. Which recommendation should the nurse suggest? A Global Location Number instead of a custom item number. A Global Trade Item Number instead of an account number. An electronic system that uses a bar-code scanning system. A computerized system that features a dashboard.

An electronic system that uses a bar-code scanning system.

1) A toddler who has just been admitted to the pediatric unit is crying and scared. No treatment has been initiated at this point. The nurse needs to start an IV, and the parent asks, "Can I stay with my child and help through the procedure?" In providing care for the family, how does the nurse respond? A) "I can teach you ways to help your child throughout the procedure if you would like to be involved." B) "We do this all the time, so don't worry. I will come get you when we are done" C) "Be ready to hold the child down when I tell you to." D) "I will be very quick so there is no need for you to stay for the procedure."

Answer: A Explanation: A) A part of nurse competency is knowing the procedures to follow when performing skills. The nurse who is going to initiate an IV on a pediatric client should always seek assistance from the parent if the parent is willing and capable of offering assistance. Telling the parents that they need to hold the child without giving them a Choice is not appropriate; many parents do not want to participate in activities that cause pain to their child. The nurse does not know how long the procedure will be, and telling the parent not to worry is pointless.

5) The nurse on third shift missed the last chance for the unit competency, stating, "Oh well, it's not like I don't know what I'm doing." The nursing student knows that this is which type of attitude? A) Arrogance, which keeps the nurse from developing and from accurate assessment of her strengths and weaknesses B) Pessimism, which endangers the nurse's professionalism C) Optimism, which helps the nurse realize that things will turn out for the best D) Sarcasm, which threatens the nurse's job performance

Answer: A Explanation: A) Arrogance, or excessive pride and a feeling of superiority, can be an extremely dangerous characteristic in the nurse, as it can lead to a false belief that the nurse is always right and does not need input from others. For example, when the unit begins using a new IV infusion pump, the arrogant nurse does not bother attending the in-service and believes that it is possible to "figure things out" independently. Accurate self-assessment of strengths and weaknesses, as well as acceptance of feedback from others, promote both safety and growth and are therefore abilities essential for the nurse.

4) The nurse taking care of clients on the medical-surgical unit is habitually late and often leaves work for nurses on the other shift to complete. The nurse knows that in order to keep his job, which action must occur? A) The nurse must take responsibility and accept any corrective action. B) The nurse must continue the same behaviors. C) The nurse must have a positive attitude. D) The nurse must trade shifts in order to be on time.

Answer: A Explanation: A) Being reliable and being accountable are key factors in professionalism. From a systems perspective, each nurse is responsible for completing the duties of the job appropriately so that others can complete their work, too. Almost everyone must miss work or arrive late on occasion. But when poor attendance or lack of punctuality becomes a habit, it also becomes a performance issue and possible grounds for corrective action (steps taken to overcome a job performance problem) or dismissal (termination of employment).

6) The nurse observes the student nurse's behavior on the unit, and notes the student is always on time, neat in appearance, and caring toward clients. Which factor best indicates to the nurse the student level of professional commitment? A) A pattern of behaviors congruent with the nurses' professional code of ethics B) A strong belief in and acceptance of the company's goals, values, and mores C) A willingness to be able to exert control over personal behaviors D) A strong desire to be a part of a group

Answer: A Explanation: A) Factors associated with professional commitment include a strong belief in and acceptance of the profession's code, role, goals, values, and morals; a willingness to exert considerable personal effort on behalf of the profession; a strong desire to maintain membership in the profession; and a pattern of behaviors congruent with the nurses' professional code of ethics.

7) The nurses in a nursing home have a unique nursing team consisting of all four generational cohorts. The nursing management knows that the best nursing teams utilize which generation's contributions? A) The contributions from each generation's strengths B) Those of the hardworking, loyal veterans C) Those of the adaptable, techno-savvy Generation Xers D) Those of the young, optimistic Millennials

Answer: A Explanation: A) Learning from the unique strengths of each generation can decrease interpersonal tension and facilitate personal growth. Nurses who learn to acknowledge and appreciate their colleagues from different backgrounds, including generational backgrounds, have a distinct advantage. The best teams utilize the contributions of each generation's skill set and strengths. The hardworking, loyal veterans; the idealist, passionate baby boomers; the technoliterate, adaptable Generation Xers; and the young, optimistic Millennials can come together in a powerful network of nurses with a remarkable ability to support each other and maximize each nurse's contribution to client care.

6) A nurse has just received a shift report for a 12-hour shift. As the nurse is preparing to enter a client's room, the nurse overhears a coworker telling an offensive joke with a sexual undertone to the client. What is the best action for the nurse at this time? A) Tell the nurse, in private, that such conduct is offensive and not professional. B) Ignore the coworker and walk away. C) Report the incident to the nurse manager. D) Ask to be scheduled opposite this coworker.

Answer: A Explanation: A) Nurses must develop skills of assertiveness to deter sexual harassment in the workplace. Telling the coworker to stop, and why, is the first step in putting an end to the situation. Ignoring the situation or asking to be scheduled opposite this individual is not addressing the situation in an assertive manner. Reporting the incident to the nurse manager would be a second step if the behavior doesn't stop after the nurse's approach.

3) A charge nurse is making assignments for the shift. The charge nurse notes that a client from a different culture was recently admitted and will require a thorough admission assessment during the upcoming shift. Which generation of nurse is likely to be the most culturally sensitive and to be the best choice for this client assignment? A) The Millennial nurse B) The Generation X nurse C) The veteran nurse D) The baby boomer nurse

Answer: A Explanation: A) The Millennial generation nurse would most likely provide the most culturally sensitive viewpoints and would be the best choice for this assignment. The Millennial generation nurse received the most education regarding culturally sensitive care and can be a unit resource for the other generations of nurses on the unit.

6) The nurses on the cardiology unit are unhappy with their nurse manager. The nurses complain that he is "inflexible and impersonal." The nurses realize that he is which type of leader? A) Bureaucratic B) Autocratic C) Laissez-faire D) Situational

Answer: A Explanation: A) The bureaucratic leader does not trust anyone to make decisions and instead relies on the organization's rules, policies, and procedures to direct the group's work efforts. Group members are usually dissatisfied with the leader's inflexibility and impersonal relations with them.

7) When speaking with a nursing student about the nursing profession, the student states, "I'm so nervous about taking the NCLEX, but I'm excited also; your nurse manager asked if I wanted to work here!" The nurse knows that the student is in which stage of commitment development? A) The integrated stage B) The testing stage C) The passionate stage D) The exploratory stage

Answer: A Explanation: A) The commitment to a profession develops in five stages; exploratory, testing, passionate, quiet and bored, and integrated. The integrated stage is the final stage of commitment. Individuals who reach this stage have integrated both positive and negative elements of the profession into a more flexible, complex, and enduring form of commitment. They act out their commitment as a matter of habit. These students are in the final stages of their nursing program and are beginning to see themselves as nurses, eager to take the NCLEX-RN ® and begin employment.

3) The nurse working in a neonatal intensive care unit (ICU) is caring for a critically ill 28-week-old preemie. The parent calls the nurse and asks if it would be possible to bring the client's 2-year-old sibling to visit because the sibling is having nightmares about the client's death. Small children are not permitted to visit because of the risk of infection to the infants on the unit. What should the nurse do? A) Seek permission from unit management and the physician to allow the sibling to visit. B) Offer to make counseling available to the sibling. C) Tell the parent that visiting is not permitted and offer to take pictures of the client. D) Tell the parent to bring the sibling in to visit in the middle of the night.

Answer: A Explanation: A) The nurse realizes that certain rules are in place for the protection of clients. The nurse would be compassionate enough to seek permission to allow the sibling to visit and see that the infant is alive and being cared for. Telling the parent what the rules of the unit are will only increase the family's frustration when they are looking to the nurse for assistance. Offering counseling may or may not be an effective means of assisting the family. The sibling needs to be reassured that the infant is alive. The nurse would not make the decision without the permission of the management team.

4) The nurse manager on the neurology unit helps the other nurses on the unit become more involved with the local neurological association and providing healthcare in-services to the community. The nurses on the unit know that the nurse manager shows which type of commitment to the nursing profession? A) Affective commitment B) Normative commitment C) Obsessive commitment D) Continuance commitment

Answer: A Explanation: A) There are three types of commitment: affective, normative, and continuance. Affective commitment is an attachment to a profession and includes identification with and involvement in the profession. Affective commitment develops when involvement in a profession produces a satisfying experience.

5) The charge nurse on first shift was never officially hired for that position, but the nurses on the unit recognize her as the charge nurse because she has been on the unit for 20 years. The nurses know the charge nurse has which type of position? Select all that apply. A) Informal leader B) Nursing leader C) Mentor D) Formal leader E) Official

Answer: A, B Explanation: A) A leader does not require an official position to lead. Leaders are people with the ability to rule, guide, or inspire others to think or act as they recommend. A leader influences others to work together to accomplish a specific goal. Leadership may be formal or informal. The formal leader, or appointed leader, is selected by an organization and given official authority to make decisions and to act. An informal leader is not officially appointed to direct the activities of others but, because of seniority, age, or special abilities, is recognized by the group as a leader and plays an important role in influencing, facilitating, and mentoring colleagues, coworkers, and other group members to achieve the group's goals.

6) The charge nurse, who is a member of Generation X, is training a new nurse, who happens to belong to the Millennial generation. The student nurse knows that which aspect(s) of the two nurses' work ethics are in conflict? Select all that apply. A) Self-directed versus need for feedback B) Loyal to profession versus rush of new challenges and opportunities C) Workaholic versus need for work-life balance D) Respect authority versus questioning authority E) Prefer personal form of communication versus personal cell phones

Answer: A, B Explanation: A) Workplace ethics for Generation X include: seek challenges; are self-directed; are comfortable with technology; expect instant access to information; desire employment where they can create balance in work and personal life; prefer managers to be mentors and coaches; have limited motivation to stay with the same employer but are loyal to their profession; desire more control over their own schedule; pragmatic focus on outcomes rather than process. The Millennial generation's work ethics include: being social, confident, optimistic, talented, well-educated, collaborative, open-minded, and achievement-oriented; having expectations of daily feedback; high maintenance; having the potential to become the highest-producing workforce in history; thriving on the adrenaline rush of new challenges and new opportunities; having personal cell phones a necessity for daily life and interpersonal communication.

5) The nurse working on the adult psychiatric unit complains of feeling "burnt out." Which suggestion(s) will help the nurse reduce stress? Select all that apply. A) Meditate or take a long soak in a tub. B) Join a local Zumba class. C) Participate in a professional organization. D) Accept an extra shift. E) Don't accept failure; try, try, and try again.

Answer: A, B, C Explanation: A) Nurses can prevent burnout by using healthy techniques to manage stress. To do so, they must first recognize their stress and become attuned to responses such as feelings of being overwhelmed, fatigue, angry outbursts, physical illness, and increases in coffee drinking, smoking, or use of alcohol or other mood-enhancing substances. Once attuned to stress and their own personal reactions, nurses must identify which situations produce the most pronounced reactions. Suggestions that help reduce stress include planning daily relaxation activities, establishing a regular exercise program, learn to say no, accepting errors and failures as learning experiences, accepting change and limitations, developing collegial support groups, participating in professional organizations, and seeking counseling if needed.

7) You are a newly hired nurse manager who believes in the theory of shared governance and you direct your unit using that style. As the nurse manager, you know that which skills ensure that you are an effective nurse leader? Select all that apply. A) Modeling the way B) Empowering others C) Giving feedback D) Receiving feedback E) Being political

Answer: A, B, C, D Explanation: A) Nurses are encouraged to design new models of care to improve quality, efficiency, and safety. Effective nurse leaders mentor and direct client care; actively advocate at the point of care; are expert clinicians and apply evidence-based care; model the way; are risk takers and inspire others to create a shared vision; are assertive and challenge the status quo; enable others to act and encourage the heart; empower others to embrace their passions and talents; value point-of-care nurses as equal partners; are trustworthy and model honest communication; are transparent and share information; give and receive feedback; are energetic and committed; collaborate and educate; are responsible and ethical; are creative and flexible; network and build teams; and are politically astute.

Answer: A, B, D Explanation: A) Good communication skills are essential to successful leaders and include assertiveness, clear expression of ideas, accuracy, and honesty. Critical thinking is a creative process that includes problem solving and decision making. Networking is a process whereby professional links are established through which people can share ideas, knowledge, and information; offer support and direction to each other; and facilitate accomplishment of professional goals.

Answer: A, B, C, E Explanation: A) The transformational leader empowers the group, facilitating independence, individual growth, and change. The leader enlists others to participate in attaining the goal and share in the organization's vision but does not expect unreflective obedience.

3) A nurse manager has had to interact with a particularly difficult physician who is demanding of and demeaning to the nurses on the unit. Through this situation, the nurse manager has learned that which are characteristics of successful communication? Select all that apply. A) Accuracy B) Assertiveness C) Critical thinking D) Honesty E) Networking

Answer: A, B, D Explanation: A) Good communication skills are essential to successful leaders and include assertiveness, clear expression of ideas, accuracy, and honesty. Critical thinking is a creative process that includes problem solving and decision making. Networking is a process whereby professional links are established through which people can share ideas, knowledge, and information; offer support and direction to each other; and facilitate accomplishment of professional goals.

2) During a staff meeting, the new nurse manager informs the staff that they will be getting an e-mail account that will need to be checked every day for information from the manager. Which response(s) would be expected of a "Generation X" new graduate nurse? Select all that apply. A) "Can we access the e-mail from home?" B) "That sounds like a great idea." C) "I would rather get the information directly from you." D) "I would rather receive the information in a unit newsletter." E) "Can we e-mail one another?"

Answer: A, B, E Explanation: A) Generation X, Generation Y, and Millennial nurses would all support the new policy and would ask if the nurses could e-mail each other and if the e-mails could be accessed from home.

1) A 52-year-old veteran nurse working on the medical-surgical unit of an urban hospital is frequently consulted by other staff members on clinical issues that she has experience with and new procedures that she assimilates quickly. What characteristic(s) of the informal leader does this nurse demonstrate? Select all that apply. A) Seniority B) Insecurity C) Special abilities D) Age E) Supervisory position

Answer: A, C, D Explanation: A) Informal leaders are recognized by the group as leaders and play an important role in influencing colleagues, coworkers, and other group members to achieve the group's goals. They often become leaders because of seniority, age, or special abilities. Leaders tend to be informed and confident. An informal leader is not officially appointed.

2) A student nurse accidentally left an elderly client's bed up after giving a bed bath. Luckily, another nurse found that the bed was not left in the lowest position and was able to rectify the matter before something happened. The student responded, "I know better. I should've double-checked the bed before I left the room." Which characteristic is this student demonstrating? A) Compassion B) Integrity C) Fidelity D) Justice

Answer: B Explanation: A) Integrity means adhering to a strict moral or ethical code. By admitting to not double-checking the position of the bed, the student shows accountability and integrity. Justice has to do with being fair. Fidelity means to be faithful to agreements and promises. Compassion is an awareness of and concern for the suffering of others.

Answer: A Explanation: A) The nurse realizes that certain rules are in place for the protection of clients. The nurse would be compassionate enough to seek permission to allow the sibling to visit and see that the infant is alive and being cared for. Telling the parent what the rules of the unit are will only increase the family's frustration when they are looking to the nurse for assistance. Offering counseling may or may not be an effective means of assisting the family. The sibling needs to be reassured that the infant is alive. The nurse would not make the decision without the permission of the management team.

Answer: C Explanation: A) Nursing integrity ensures that patients' rights are respected in the healthcare setting. If the nurse were to confront the two colleagues on the elevator, it could be overheard by others. The nurse should wait to speak to the other nurses privately about the breach of confidentiality. The nurse could report the incident to the unit manager, but it would be best for the nurse to confront the two colleagues in a professional way. The nurse should confront the two colleagues in a private manner in a professional way. If that cannot be done, then notifying the nurse manager would be the next step. The risk manager is only involved in situations where there is an injury to the staff or a client.

1) A new graduate nurse has been hired to work in a busy cardiac intensive care unit at the local hospital. The nurse will spend 12 weeks in orientation to the unit. How does the new nurse demonstrate commitment? A) Joining the ANA B) Questioning the preceptor during all procedures C) Attending every shift on time D) Exhibiting clinical competence

Answer: C Explanation: A) The new nurse can demonstrate commitment by showing up for all shifts in a timely fashion. It should not be necessary for the new nurse to question every procedure, as the new nurse has some clinical experience. Joining the ANA is a commitment, but is not relevant to this question. Clinical competence develops over time, and the new nurse is not likely to exhibit competence yet; showing up on time is a better predictor of the nurse's commitment.

2) A student nurse is caring for an elderly client with dementia who is confused, agitated, and forgetful. The student leaves for a break and forgets to put the call light within reach of the client. When checking on the student's clients, the instructor discovers the student's negligence and determines which of the following? A) The student is appropriately taking care of self. B) The student's workload is too difficult. C) The student is demonstrating inappropriate safety measures for the client. D) The student is demonstrating appropriate comfort measures for the client.

Answer: C Explanation: A) The student is demonstrating inappropriate safety measures by not leaving the call light within reach of the client. There is no evidence that the student's load is too difficult. The student has ignored basic safety measures for this client. It is appropriate for nurses and students to take breaks; however, the safety of the client is the first commitment for the nurse.

1) A nurse mistakenly gave a client who was NPO for surgery a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client's surgery; and documented the situation in the client's medical record. This nurse demonstrates which of the following? A) Social justice B) Human dignity C) Reliability D) Accountability

Answer: D Explanation: A) Accountability is accepting responsibility and the consequences of one's actions. By taking the responsibility for the mistake, the nurse is accountable with the physician as well as the client and provides accurate documentation of the action. Reliability implies that the nurse is dependable, such as arriving at work in a timely fashion. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the worth and uniqueness of individuals and populations.

2) The new graduate nurse is interviewing with managers in the hospital. The nurse has decided that working for a manager who demonstrates an autocratic style of leadership would be the best match for the nurse. To determine the manager's style, what should the nurse asks the manager? A) "What is your view of nurses working overtime?" B) "How do you implement orientation?" C) "What shift will I be working?" D) "Do you seek input from staff when implementing new policies?"

Answer: D Explanation: A) In order to determine the leadership style of the manager, the nurse would ask the manager how he or she handles new unit policies. If the manager states that policies are determined by leadership who will give orders and directions to the group, then the new graduate knows this manager is autocratic in nature. Asking about the shift will not tell the nurse about leadership style. How the manager implements orientation would not necessarily reveal the manager's leadership style. Working overtime is a unit or hospital rule, not a leadership style.

3) The student nurse is attending a lecture about commitment to the profession of nursing. The instructor is grading the student's commitment to nursing during this rotation. The instructor knows the student is committed to the nursing profession when the student does which of the following? A) Calls in sick for clinical to study for a class exam B) Declines to observe a new procedure to give a necessary bath C) Misses class to attend a political rally D) Calls in sick for clinical because of a respiratory infection

Answer: D Explanation: A) Whereas calling in sick for a frivolous reason demonstrates a lack of commitment, calling in sick with a bona fide illness demonstrates protection of the clients who are already compromised. Attending a political rally may be important, but for the student attending class demonstrates the greater commitment. Studying for a class exam is also important, but not more important than learning clinical skills. The student who demonstrates commitment seeks out as many new learning experiences as possible.

The nurse manager is evaluating the success of assertiveness training classes that staff nurses attended to improve communicating with physicians. Which behavior by a staff nurse indicates the need for further training? Apologizing to the neurosurgeon for "bothering him" with a question Using a neutral voice when discussing a patient's abnormal laboratory values Stating "I would like some help" when planning care with other team members Identifying an area where both the nurse and patient agree

Apologizing to the neurosurgeon for "bothering him" with a question

The nurse is providing care to a patient who recently had back surgery. Which nursing action is a collaborative nursing activity? Assessing the patient's surgical wound site Arranging for physical therapy to ambulate the patient Assisting the patient with bathing Adjusting the head of the patient's bed for comfort

Arranging for physical therapy to ambulate the patient

The nurse tells a peer, "Well, you would know what to anticipate if you had more experience." Which attitude is the nurse exhibiting? Pessimism Insubordination Arrogance Optimism

Arrogance

The nurse is preparing to assess kinesthesia in a patient. Which technique should the nurse use? Ask the patient to identify an object in their hand with the eyes closed. Write a number on the patient's hand and ask the patient to identify it. Ask the patient to move their finger up or down and describe the movement. Ask the patient to differentiate the touch on both sides of the body with a sharp and dull object.

Ask the patient to move their finger up or down and describe the movement.

The manager schedules an unlicensed assistive personnel (UAP) to attend a basic communication program after observing the UAP provide patient care. Which action by the UAP most likely resulted in this type of referral? Referring to a 75-year-old male patient as "Mr. Dan" Talking with a newly admitted patient about his grandchildren Referring to a 70-year-old patient's abdominal wound as "your incision" Asking a 65-year-old patient, "Are we ready to get out of bed?"

Asking a 65-year-old patient, "Are we ready to get out of bed?"

The nurse prepares to assess an older adult patient who has a hearing deficit. Which action by the nurse indicates the need for training in effective communication? Asking the family to wait in the hall Facing the patient when speaking Turning down the volume on the television set Closing the door to the room

Asking the family to wait in the hall

The nurse is formulating a plan of care for a pregnant patient. One goal set by the nurse is that the patient should attend all prenatal classes. Which step should the nurse take to motivate the patient to attain the goal? Inform the patient that insurance will not pay for the hospital stay for nonattendance at prenatal classes. Tell the patient that it is in her best interest to attend classes. Associate the goal with a personal meaning for the patient. Attend the classes with the patient to ensure compliance.

Associate the goal with a personal meaning for the patient.

After reviewing the health history of a patient diagnosed with glaucoma, the nurse questions administering a beta-adrenergic blocking agent to the patient. Which health problem did the nurse discover in the patient's health history? Asthma Hypertension Gastric acid reflux Diabetes mellitus

Asthma

During which stage of commitment do nursing students tend to focus on the negative elements of nursing and weigh their ability to handle those elements? A) Passionate stage B) Testing stage C) Exploratory stage D) Quiet-and-bored stage

B

The nurse is concluding a visual assessment for a patient and determines the patient is unable to read the 20/20 line on the Snellen chart. Which is the appropriate interpretation of this clinical finding? A. Hyperopia B. Myopia C. Accommodation D. Presbyopia

B A patient unable to correctly read the 20/20 line on the Snellen chart is experiencing myopia. Normal findings are that when standing 20 feet from the chart, the patient can read the smallest line of letters with or without corrective lenses (recorded as 20/20). Changes in distance vision are most commonly the result of myopia (nearsightedness). Presbyopia is an impairment in near vision resulting from a loss of elasticity of the lens related to aging. In younger patients, this condition is referred to as hyperopia (farsightedness). Near vision is assessed using a Rosebaum chart. Accommodation is the ability of the eye to change focus from distant to near objects.

The nurse is evaluating the plan of care for an older adult patient with hearing loss. Which evaluation shows success in the plan of care? A. The patient prefers reading at home as an activity. B. The patient has joined a group for older adults. C. The patient is refusing to learn alternative communication methods. D. The patient is looking into buying a hearing aid but has not done it yet.

B Joining a group for older adults shows socialization and involvement. Reading at home is a solitary activity. Putting off buying a hearing aid shows that the patient is not actively participating in care. Refusing to learn alternative communication methods shows a lack of acceptance of the hearing loss.

A patient who had a lens implant performed asks the nurse why there is a need for a stool softener. Which response by the nurse is best? A. "This prevents straining during a bowel movement, which causes nausea and vomiting." B. "This prevents straining, which increases the pressure in your eye and harms the surgical repair." C. "Blood vessels in your eye may burst when defecating, causing intraocular hemorrhage." D. "This pill reduces the risk of constipation, which is a side effect of other medications."

B Addressing the connection between straining when having a bowel movement and increasing pressure in the eye, as well as the desire for a positive, expected surgical outcome, enhances compliance with taking the medication. Stating the action of the medication in simple terms increases the likelihood of compliance. The stool softener is not a laxative. Using strong terms with medical implications, such as "intraocular pressure," "intraocular hemorrhage," and "potential blindness," which the patient may not understand, may instill fear or cause the patient to disregard the instructions. Although there is a correlation between actions that increase intraocular and intracranial pressure, increased intracranial pressure is not of concern to this patient and serves to confuse the instructions.

The nurse is caring for an older adult experiencing a loss of hearing. Which prescribed procedure should the nurse anticipate being used to evaluate the hearing loss? A. Weber test B. Audiometry C. Accommodation D. Otoacoustic emissions

B Audiometry will be prescribed for the patient to evaluate the hearing loss. Otoacoustic emissions is a hearing test almost exclusively performed on infants. A test for accommodation involves assessing the reflex of the eye when focusing on an object far away to an object that is closer. A Weber test is part of an assessment for hearing loss.

A patient states she is "feeling dizzy and having trouble with balance." The nurse should recognize that the patient is experiencing which alteration in sensory perception? A. Perception B. Vertigo C. Nystagmus D. Kinesthesia

B Based on the subjective findings, the nurse understands the patient is most likely experiencing vertigo. Vertigo is a feeling of rotation or imbalance. Nystagmus is rapid eye movement. Perception is an awareness and interpretation of stimuli. Kinesthesia refers to awareness of the position and movement of body parts.

An older adult patient diagnosed with cataracts asks the nurse about the cause of this eye disorder. Which cause should the nurse provide? A. Hypertension B. Age C. Obesity D. Gout

B Cataracts can occur as a result of the normal aging process. Hypertension, gout, and obesity are not causes of cataracts.

A patient has inflammation in the ears and temporary hearing loss. Which drug should the nurse expect to be prescribed? A. Sulfonamide B. Corticosteroid C. Macrolide antibiotic D. Cephalosporin

B Corticosteroids are used to reduce inflammation in the ears. Cephalosporins, macrolides, and sulfonamides are antibiotics used to treat bacterial infections.

A parent brings their 4-year-old child into the clinic. The child has a history of multiple occurrences of otitis media. Which assessment should lead the nurse to suspect hearing loss? A. Startled by a loud noise B. Speech delays C. Watching television with family D. Playing with other children

B Depending on the severity and frequency of otitis media, hearing loss associated with this condition ranges from mild, temporary hearing impairment to permanent hearing loss. Signs of hearing loss in older children include speech delays. Playing with other children, startling to loud noises, and watching television with the family are not clues to hearing loss.

A patient asks the nurse why their family members have started turning down the volume on the television when they speak. Which statement by the nurse is best? A. "The television can distract you from hearing the conversation." B. "Decreasing background noise makes it easier for you to hear the conversation." C. "The television is confusing you due to your hearing loss." D. "The television interferes with the function of your hearing aid."

B Explaining that decreasing background noise will makes it easier for the patient to hear the conversation is the best way to explain. The nurse mentioning the distraction that the television causes is not accurate, because it is not the distraction that is the issue. The television does not interfere with the function of hearing aids, but hearing aids can amplify background noise. Stating that the television is confusing due to the patient's hearing loss is not a therapeutic or accurate response.

A patient diagnosed with exudative macular degeneration asks the nurse what consequences may occur. Which information should the nurse provide? A. Capillaries in the eye become sclerotic and are unable to transport oxygen to the retina. B. Permanent loss of central vision may occur due to bleeding episodes that lead to scar tissue. C. Clouding of the lens of the eye interferes with light transmission into the retina. D. Gradual loss of peripheral vision and increased intraocular pressure occur in the eye.

B Exudative, or wet, macular degeneration can lead to permanent loss of central vision caused by significant or repeated bleeding episodes, which lead to scar tissue. Glaucoma, not exudative macular degeneration, is characterized by optic neuropathy with gradual loss of peripheral vision and increased intraocular pressure. A cataract, not exudative macular degeneration, is an opacification, or clouding of the lens of the eye, that interferes with light transmission into the retina. Retinopathy, not exudative macular degeneration, is a vascular disorder in which the capillaries become sclerotic and lose their ability to transport oxygen and nutrients to the retina.

The nurse is assessing a patient and suspects cataracts. Which finding supports the nurse's suspicion? A. Difficulty in recognizing faces B. Cloudy or opaque lenses C. Fixed pupils D. Halos around lights

B In cataracts, the lens becomes cloudy or opaque. Halos around lights and fixed pupils are indications of glaucoma. Difficulty recognizing faces is a sign of macular degeneration.

The nurse is providing discharge teaching for a patient who has absent tactile sensation below the umbilical area. Which patient statement indicates that further teaching is needed? A. "I will check if my skin is clean and dry." B. "I will avoid taking baths." C. "I will make sure I change positions frequently." D. "I will adjust the temperature on the water heater."

B It is not necessary that the patient avoid baths; however, the patient should be instructed to check the temperature of the water with a thermometer prior to getting into the bath water. Changing positions frequently, keeping skin clean and dry, and adjusting the temperature of the water heater are important in preventing pressure ulcers, skin infection, and burns.

The family member of a patient with a visual field deficit asks the nurse what they should do to prevent injury. Which suggestion by the nurse is most appropriate? A. Use soft lighting. B. Keep the floor free of obstacles. C. Provide reading glasses. D. Encourage the use of a walker.

B Keeping a room free of clutter and obstacles for a patient with a visual deficit supports the goal of injury prevention. A walker would be used if the patient had problems with balance. Patients with visual field deficits often have normal vision. Lighting does not specifically affect visual field deficit, but would be a safety factor for all patients.

The nurse is preparing to assess kinesthesia in a patient. Which technique should the nurse use? A. Ask the patient to differentiate the touch on both sides of the body with a sharp and dull object. B. Ask the patient to move their finger up or down and describe the movement. C. Write a number on the patient's hand and ask the patient to identify it. D. Ask the patient to identify an object in their hand with the eyes closed.

B Kinesthesia is the patient's awareness of the position and movement of the body parts. The technique the nurse will use to assess the kinesthesia in a patient is to ask the patient to move a finger up or down and describe the movement. Writing a number on the patient's hand and asking the patient to identify it tests graphesthesia. Discriminating fine touch can be done by asking the patient to identify an object in the hand with eyes closed. Asking the patient to differentiate the touch on both sides of the body with a sharp and dull object is a test for tactile sensation.

A nurse is assessing an older adult patient with hearing loss. Which potential problem related to hearing loss should the nurse prioritize when screening the patient? A. Unsociable behavior B. Reduced mobility C. Depression D. Impaired communication

B Mobility issues can be a safety hazard for the patient and should be assessed first. Depression, unsociable behavior, and impaired communication are also problems in patients with hearing loss; however, they are not the most important ones that need to be addressed.

The nurse is caring for a patient with meningitis. The nurse should assess the patient for which type of hearing loss? A. Conductive B. Sensorineural C. Tinnitus D. Presbycusis

B Sensorineural hearing loss occurs when certain conditions affect the inner ear, the auditory nerve, or the auditory pathways of the brain. A cause of this type of hearing loss is viral meningitis. The assessment data does not support the diagnosis of tinnitus, conductive hearing loss, or presbycusis.

The nurse is caring for a patient diagnosed with cataracts. Which treatment option should the nurse expect will be ordered for the patient? A. Eye drops B. Surgery C. Dietary changes D. Increase in physical activity

B Surgery is the most beneficial treatment option for patients with cataracts. Surgery is typically done when the cataracts interfere with activities of daily living. There is no pharmacologic treatment for cataracts. Dietary changes and increased physical activity are not considered treatments for cataracts.

The nurse makes keeping the floor clear of obstacles in a patient's room a priority of care for a patient with a visual deficit. Which goal does this support? A. Preventing sensory overload B. Preventing injury C. Facilitating communication D. Promoting effective coping

B The goal of keeping a room free of clutter and obstacles for a patient with a visual deficit supports the goal of injury prevention. Remaining in a patient's visual field would support the goal of facilitating communication. Counseling the patient would promote effective coping. Avoiding loud or sudden noises could help prevent sensory overload.

The nurse is screening patients at risk for hearing loss. Which patient is at the highest risk? A. Hair stylist who uses a hair dryer B. Airport worker who guides jet airplanes C. Firefighter who operates the sirens D. Worker who runs a lawnmower

B The jet engines are at a higher decibel than a siren, hair dryer, and lawnmower. This puts the airport employee at the highest risk for hearing loss.

The patient with cataracts is scheduled to undergo a procedure to remove the cataracts. The nurse should plan to teach the patient about which procedure? A. Laser photocoagulation B. Extracapsular extraction C. Gonioplasty D. Trabeculectomy

B The nurse should provide education about an extracapsular extraction because this procedure removes the anterior capsule, nucleus, and cortex of the lens, leaving the posterior capsule intact. A plastic, acrylic, or silicone intraocular lens is implanted to improve binocular vision and depth perception. Laser photocoagulation is a procedure to treat proliferative retinopathy, but it seals leaking microaneurysms and destroys proliferating vessels. Gonioplasty is surgery to treat angle-closure glaucoma. Trabeculectomy is surgery to treat open-angle glaucoma.

The nurse is teaching a patient diagnosed with macular degeneration about assistive devices to increase independence and quality of life. Which assistive device should the nurse include? A. Digital clock B. Magnifier C. Dim lighting D. Mini tablet

B The patient with macular degeneration experiences decreased vision. The assistive device that will be helpful for this patient is a magnifier. A talking clock, not a digital clock, would also be helpful. High-intensity lighting, not dim lighting, would be an appropriate assistive device. Audio functions are needed on any tablet that the patient will use; a mini tablet may or may not have these functions.

The nurse teaches the wife of a patient diagnosed with macular degeneration ways of increasing her husband's independence and quality of life. Which statement by the wife indicates that teaching was successful? A. "I will purchase him a digital clock so he can always know the time." B. "I will make sure that a magnifying glass is always available." C. "I will make sure I dim the lights for him." D. "I will purchase him a mini tablet so he can communicate with friends."

B The patient with macular degeneration experiences decreased vision. The assistive device that will be most helpful for this patient is a magnifier. A talking clock, not a digital clock, would also be helpful. High-intensity lighting, not dim lighting, would also be an appropriate assistive device. Audio functions are needed on any tablet that the patient will use; a mini tablet may or may not have these functions.

A patient states, "I think I have a cataract." The nurse should prepare the patient for which diagnostic exam? A. Accommodation B. Snellen chart C. Cardinal fields of vision D. Convergence

B Utilizing a visual acuity test, such as the Snellen chart, is the simplest way to diagnose cataracts. Cardinal fields of vision will test extraocular eye movement and will not aid in the diagnosis of cataracts. Convergence indicates a neuromuscular disorder or improper eye alignment. Accommodation tests are used for neurologic problems.

The nurse is assessing a patient with glaucoma. Which clinical manifestation should the nurse expect to find? A. Central vision distortion B. Halos around lights C. Distorted straight lines D. Sudden loss of vision

B Visualization of halos around lights is a symptom of glaucoma. Distorted straight lines and central vision distortion are common clinical manifestations of macular degeneration. Sudden loss of vision is a manifestation of retinal detachment.

The patient tells the nurse, "I keep seeing halos around all the lights." Which condition should the nurse suspect in the patient? A. Angle-closure glaucoma B. Open-angle glaucoma C. Age-related macular degeneration D. Cataracts

B Visualization of halos around lights is a symptom of glaucoma. Distorted straight lines, central vision distortion, and blurriness of printed words are common clinical manifestations of macular degeneration.

After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate? A) "Only your doctor can tell if you have a cataract in your left eye." B) "Cataracts develop at different rates, so one eye may be more affected than the other." C) "The changes being confined to one eye indicate a less severe cataract." D) "Surgery is still necessary for both eyes."

B) "Cataracts develop at different rates, so one eye may be more affected than the other."

A novice nurse asks the preceptor why the staff spends time talking about clients between shifts when the oncoming nurses can read the clients' charts instead. Which is the best response by the preceptor? A) "Maybe we should suggest primary nursing as an alternative." B) "Change-of-shift reporting ensures that oncoming staff know the most critical information about the clients they'll be caring for." C) "Shift changes have always been done this way." D) "You're right. Talking about clients during shift changes is a waste of time."

B) "Change-of-shift reporting ensures that oncoming staff know the most critical information about the clients they'll be caring for."

The nurse is providing teaching to a client who was prescribed an ophthalmic beta blocker for glaucoma. The client is having difficulty understanding how to self-administer the medication. Which instruction by the nurse is best? A) "Occlude your lacrimal duct." B) "Close your eyes." C) "Guard against systemic absorption." D) "Use punctal occlusion."

B) "Close your eyes."

The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain. The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate? A) "You will be able to read the record and review your care." B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you." C) "Your family can review the record and ensure that your care is appropriate." D) "A record ensures there are no breaches of confidentiality."

B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you."

A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The healthcare provider prescribes an enema. Which reaction by the client would the nurse anticipate when planning care? A) "May I have a visitor in the room with me for support during the procedure?" B) "I would rather have my doctor perform this procedure." C) "I don't know what an enema is." D) "I am afraid of having an enema."

B) "I would rather have my doctor perform this procedure."

The nurse is caring for a client with a new colostomy. The client has been taught how to perform colostomy care and has been successful with return demonstration to the staff. Although the client is able to perform care independently and has asked to do so, the charge nurse has instructed the nursing staff to continue performing colostomy care for this client. When addressing this issue directly with the charge nurse, which statement by a staff nurse is the most appropriate? A) "The client will change the apparatus whether you like it or not." B) "The client has been trained to change the apparatus and has expressed interest in performing this procedure independently." C) "You have no right to continue delegating this task to nurses when the client has been trained to change the apparatus." D) "I am going to tell the nurse manager that you won't allow the client to change the apparatus independently."

B) "The client has been trained to change the apparatus and has expressed interest in performing this procedure independently."

The nurse is caring for a young adult client after a cervical biopsy. The client has expressed anxiety about the results. The healthcare provider peeks into the client's room and says, "The biopsy is negative." The nurse later finds the client sobbing. Which response by the nurse is most appropriate? A) "What did the healthcare provider tell you about the biopsy?" B) "You seem upset. Do you want to talk to me about the test results?" C) "Why are you crying after getting such good news?" D) "In this case, the term 'negative' is good!"

B) "You seem upset. Do you want to talk to me about the test results?"

Which of the following clients most likely will require assistance with properly taking medications for macular degeneration? A) 72-year-old client, no dementia, no arthritis, hypertension B) 67-year-old client, dementia, arthritis, no hypertension C) 47-year-old client, no comorbidities D) 52-year-old client, gastroesophageal reflux disease (GERD), hypertension

B) 67-year-old client, dementia, arthritis, no hypertension

Which client's clinical manifestations are most consistent with Guillain-Barré syndrome? A) A 13-year-old client feels weakness in the feet, ankles, and legs. B) A 5-year-old client feels leg pain and wants to be carried. C) A 55-year-old client experiences a lack of hand strength. D) A 23-year-old client with peripheral neuropathy has poor glycemic control.

B) A 5-year-old client feels leg pain and wants to be carried.

Which client is most at risk for eye injuries? A) A firefighter who wears all required safety gear on calls B) A baseball player who wears nothing over the eyes C) A self-employed home worker who wears ANSI Z87 eyewear when doing any household cleaning or yard work D) A construction worker who wears OSHA-required eyewear at all times while on site

B) A baseball player who wears nothing over the eyes

A nurse is working with several clients who are experiencing hearing loss. Of these clients, which is the best candidate for a cochlear implant? A) A client with a perforated tympanic membrane B) A client with sensorineural hearing loss from long-term exposure to loud noise C) A client with an obstruction of the external ear canal D) A client with a tumor of the middle ear

B) A client with sensorineural hearing loss from long-term exposure to loud noise

A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action? A) Notify the healthcare provider. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

B) Complete a thorough cardiopulmonary assessment. The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.

The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment? A) Eye pain and redness B) Floaters in the visual field C) Subconjunctival hemorrhage D) Hyphema

B) Floaters in the visual field

A nurse is providing care for a client who has vocal cord damage and wants to implement strategies that will promote communication with this client. Which interventions would be appropriate? Select all that apply. A) Facing the client when speaking B) Having pen and paper on hand for the client C) Making sure that the language spoken is the client's dominant language D) Using a picture board to facilitate communication E) Employing an interpreter

B) Having pen and paper on hand for the client D) Using a picture board to facilitate communication

The nurse is caring for a client who has been using timolol (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug? A) Eye pain B) Heart rate of 57 C) Urinary frequency D) Blurred vision

B) Heart rate of 57

Which of the following statements regarding idiopathic neuropathy is true? A) Idiopathic neuropathy is hereditary in nature. B) Idiopathic neuropathy has no known cause. C) Idiopathic neuropathy is caused by nutritional deficits. D) Idiopathic neuropathy is caused by disease or illness.

B) Idiopathic neuropathy has no known cause.

Which of the following statements is true with regard to food allergies and children? A) Over the past decade, the prevalence of peanut allergy has decreased in the pediatric population. B) Many children eventually outgrow egg, milk, and soy allergies. C) Teenagers with food allergies are at lower risk for an allergic reaction than younger clients because they are more aware of their trigger foods and how to avoid them. D) Peanut allergies are most common in pediatric clients over 5 years of age.

B) Many children eventually outgrow egg, milk, and soy allergies

A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the healthcare provider and prepare to perform iced saline lavage. Which features of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A) Presencing B) Noticing C) Reflecting D) Interpreting E) Responding

B) Noticing D) Interpreting E) Responding The four features of the Tanner model include noticing, interpreting, responding, and reflecting. The nurse noticed that something was wrong with the client, interpreted the cues to gain an understanding of the situation, and responded by choosing the best course of action. The nurse has not yet reflected on the situation because she is still caring for the client. Presencing is being present for a client and engaging in face-to-face contact, which is not part of the Tanner model.

Which strategy for communication enhancement incorporates the use of shapes? A) Sign language B) Oral approach C) Total communication D) Cued speech

B) Oral approach

The nurse suspects that the client is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? A) Indirect Coombs test showing no agglutination B) Patch test with a 1-inch area of erythema C) 2% eosinophils in the WBC count D) Rh antigen test with negative results

B) Patch test with a 1-inch area of erythema

The nurse who uses clinical decision making to start CPR on a client is concerned about what other nursing concept? A) Cognition B) Perfusion C) Thermoregulation D) Acid-base balance

B) Perfusion Cardiopulmonary resuscitation (CPR) is used to help restore circulation to major organs, which is a function of perfusion. Cognition, acid-base balance, and thermoregulation may also benefit from CPR, but this is not the nurse's primary concern when CPR is needed.

Which of the following barriers to communication involves asking a client for information chiefly out of curiosity rather than with the intent to assist the client? A) Challenging B) Probing C) Testing D) Rejecting

B) Probing

The nurse is planning care for an adolescent client recently diagnosed with Charcot-Marie-Tooth syndrome. Which intervention is the highest priority? A) Managing the client's chronic pain B) Reducing the client's risk for injury C) Addressing the client's perfusion problems D) Relaxing the client to reduce stress

B) Reducing the client's risk for injury

A nurse is caring for a client with seasonal hypersensitivity reactions. What teachings should the nurse provide to improve this client's comfort? Select all that apply. A) Keep doors and windows open on high-allergen days to circulate air. B) Remain indoors if possible on high-allergen days. C) Maintain a clean, dust-free environment. D) Take antihistamine and leukotriene medications as ordered. E) Stop taking oral corticosteroids immediately once symptoms disappear.

B) Remain indoors if possible on high-allergen days. C) Maintain a clean, dust-free environment.

The nurse is caring for a client who is reporting a pain level of 8 on a 0-to-10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse re-evaluates the client 1 hour later, the client is still reporting a pain level of 8. Which action by the nurse is appropriate at this time? A) Wait for the healthcare provider to make rounds to report the problem. B) Report to the healthcare provider by telephone. C) Increase the dosage of the medication. D) Include an entry in the nursing report indicating that the medication is ineffective.

B) Report to the healthcare provider by telephone.

A nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." Which skill associated with the working phase of the nurse-client relationship does the nurse's statement best reflect? A) Confronting B) Respect C) Concreteness D) Genuineness

B) Respect

The nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." The nurse is displaying which skill that is often associated with the working phase of the nurse-client relationship? A) Confronting B) Respect C) Concreteness D) Genuineness

B) Respect is correct because the nurse is validating the client's feelings. It is not genuineness because the nurse is giving information versus making a personal statement. Rather than being confrontational by pointing out discrepancies between thoughts, feelings, and actions that inhibit the client's self-understanding or exploration of specific areas, the nurse is being supportive by respecting the client's feelings. Concreteness involves assisting the client by giving specific examples rather than speaking in generalities.

Why are second-generation antihistamines often preferred to first-generation histamines in the treatment of hypersensitivity reactions? A) Second-generation antihistamines are faster acting than first-generation antihistamines. B) Second-generation antihistamines are less likely than first-generation antihistamines to cause drowsiness. C) Second-generation antihistamines are available over the counter, whereas first-generation antihistamines require a prescription. D) Second-generation antihistamines can be administered either orally or parenterally, whereas first-generation antihistamines can only be given via the oral route.

B) Second-generation antihistamines are less likely than first-generation antihistamines to cause drowsiness.

A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts? A) Congenital B) Secondary C) Radiation D) Traumatic

B) Secondary

A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to do? A) Understand the actions and drug interactions of aminoglycosides. B) Self-monitor for hearing loss. C) Use total communication. D) Understand cued speech.

B) Self-monitor for hearing loss.

What are the four steps of the SBAR communication technique? A) Scenario, Basics, Analysis, and Reaction B) Situation, Background, Assessment, and Recommendation C) Scenario, Background, Analysis, and Recommendation D) Situation, Basics, Assessment, and Reaction

B) Situation, Background, Assessment, and Recommendation

The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration? A) Caucasian ancestry B) Smoking 1 pack of cigarettes per day C) 62 years of age D) Family history of AMD

B) Smoking 1 pack of cigarettes per day

The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client? A) Placing the client in a private room, away from others B) Speaking to the client in a soft, calm tone C) Administering a prn medication to sedate the client D) Using short sentences when talking to the client

B) Speaking to the client in a soft, calm tone

The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need? A) Assure the client there is nothing to be afraid of. B) Support the client's use of coping mechanisms. C) Turn off the lights when leaving the client's room. D) Refer the client to a counseling psychologist.

B) Support the client's use of coping mechanisms.

A nurse working in the emergency department is caring for a client with an eye injury. The client describes spots in the field of vision. Based on this finding, which of the following is the nurse's priority concern? A) The possibility that the client will immediately lose all vision B) The possibility that the client will experience a progressive deterioration of vision C) The possibility that the client will begin to experience intense eye pain D) The possibility that the client's conjunctiva will become red and edematous

B) The possibility that the client will experience a progressive deterioration of vision

A new nurse on a unit asks to speak to the nurse manager because several clients have complained that family members were able to hear the verbal report outside their loved one's room during nursing rounds. The nurse manager asks the nurse for suggestions that could enhance client privacy. Which suggestion by the new nurse is appropriate? A) Nursing rounds should take place in each client's room. B) The unit should be closed to family and visitors during rounds. C) Nurses should tape-record their reports outside the room. D) Clients should be allowed to choose whether a written or oral report is used.

B) The unit should be closed to family and visitors during rounds.

A nurse educator is teaching a group of students about therapeutic touch. In which of the following situations should the student use therapeutic touch as a means of communication? A) Touch is appropriate when a family member is making inappropriate comments to the nurse. B) Touch is appropriate when an upset spouse is alone and the client has just expired. C) Touch is never appropriate in the nursing profession. D) Touch is appropriate when a young male client asks a young student nurse for a hug.

B) There are situations when appropriate use of touch reinforces caring feelings. However, the nurse must be sensitive to the differences in attitudes and practices of clients and self. Touch is not appropriate when a family member is making inappropriate comments to the nurse or when a client asks a student nurse for a hug.

The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client's false perception that socks are being worn is accurate? A) Confusion is a part of this disorder, so the client is simply confused as to whether socks are being worn. B) This disorder causes a change in sensation that makes the client feel as if socks are being worn. C) The medications used to treat this disorder cause the client to feel as if socks are being worn. D) Tactile hallucinations are part of this disorder, so the client is hallucinating that socks are present.

B) This disorder causes a change in sensation that makes the client feel as if socks are being worn.

A client has been diagnosed with cataracts of both eyes. The client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client? A) Corrective lenses for the cataracts B) Two surgical procedures, separated by a few weeks, to remove the cataracts C) Two surgical procedures to remove both cataracts at the same time D) Eyedrops to treat the cataracts

B) Two surgical procedures, separated by a few weeks, to remove the cataracts

A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication? A) When a client's family member is making inappropriate comments to the nurse B) When an upset spouse is alone and the client has just expired C) When speaking to a client with a history of physical abuse D) When a young male client asks a young student nurse for a hug

B) When an upset spouse is alone and the client has just expired

A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this​ client? A. Snellen eye chart B. Rosenbaum eye chart C. ​Cover-uncover test D. Penlight

B. Rosenbaum eye chart

The nurse is caring for an older adult patient who is experiencing visual loss resulting from cataracts. The nurse should understand that which factor contributes to the development of cataracts? Retinal damage Increase in intraocular pressure Breakdown of the proteins in the lens Damage to the structure of the eye

Breakdown of the proteins in the lens

The nurse discusses the importance of wearing a clean uniform. Which best describes the nurse's rationale for the discussion? Prevents contamination of sterile fields Builds patient trust Encourages and shows respect for patients Keeps the focus on patient care

Builds patient trust

A novice nurse is caring for an older adult client with dementia. The nurse leaves for a break and forgets to put the call light within the client's reach. When checking on the nurse's clients, a colleague discovers the nurse's negligence. Which conclusion by the colleague is appropriate? A) The novice nurse is appropriately taking care of self. B) The novice nurse's workload is too difficult. C) The novice nurse is demonstrating inappropriate safety measures for the client. D) The novice nurse is demonstrating appropriate comfort measures for the client.

C

Which action by the novice nurse demonstrates commitment to a new job on a busy cardiac care unit? A) Joining the American Nurses Association (ANA) B) Questioning the preceptor during all procedures C) Arriving at every shift on time D) Exhibiting clinical competence

C

The nurse is reviewing the chart of a patient that has smoked half a pack of cigarettes a day for the past 25 years. Which subjective assessment finding should the nurse anticipate in this patient? A. Decreased tactile sensation B. Decreased visual acuity C. Altered sense of taste D. Difficulty hearing

C The nurse can anticipate an altered sense of taste, or gustatory deficit, associated with the use of tobacco. Smoking does not affect tactile sensation, hearing, or visual acuity.

The nurse has observed that a patient has abnormal results for a kinesthesia test. Which causative factor is most likely associated with the abnormal finding? A. Lesions of higher pathways to the spinal cord B. Injury to the posterior column of the sensory cortex C. Lesion on the posterior column of the spinal cord D. Bilateral sensory loss due to polyneuropathy

C A lesion on the posterior column of the spinal cord is most likely the causative factor associated with the abnormal finding for the kinesthesia test. Injury to the posterior column of the sensory cortex, bilateral sensory loss due to polyneuropathy, or lesions of higher pathways to the spinal cord are not causative factors associated with the abnormal finding for the kinesthesia test.

An older adult patient is being referred to an audiologist. The patient asks why there is a need to see another healthcare provider. Which explanation by the nurse is accurate? A. "An audiologist is used to determine mobility issues." B. "An audiologist is used to help children develop communication skills." C. "An audiologist determines hearing loss and the extent of the loss." D. "An audiologist is used to help find funding for hearing aids."

C A referral to an audiologist would be appropriate to determine hearing loss and the extent of the loss. A speech therapist usually works with children with hearing issues to help them develop communication skills. A physical therapist can help if mobility has become an issue.

A patient with a hearing impairment has been referred to an audiologist. Which type of intervention should the nurse expect will be provided? A. Sound therapy B. Vestibular rehabilitation therapy C. Prescription for hearing aid D. Surgical intervention

C An audiologist is trained to provide hearing exams and to provide prescriptions for hearing aids. Otolaryngologists are physicians who are trained to diagnose and treat ear, nose, and throat disorders, including surgery if needed. Patients who develop smell or taste disorders can also consult with otolaryngologists. Occupational therapists trained in sound therapy and vestibular rehabilitation therapists do not evaluate and prescribe hearing aids.

A mother brings her 6-year-old child into the clinic and states that the child is having behavior issues at school and is not startling to loud noises. Which part of the child's history should put them most at risk for hearing loss? A. Noise-induced damage B. Congenital hearing loss C. Otitis media D. Age-related changes

C Depending on the severity and frequency of otitis media, hearing loss associated with this condition ranges from mild, temporary hearing impairment to permanent hearing loss. Age-related change occurs in people with advanced age. Noise-induced damage is more common with occupational issues. Congenital hearing loss is present at birth.

The nurse suspects that a patient may have macular degeneration. Which manifestation supports this diagnosis? A. Poor peripheral vision B. Intact central vision C. Difficulty adjusting to low-light areas after being in bright areas D. Colored halos around lights

C Difficulty adjusting to low-light areas after being in bright areas is a manifestation of macular degeneration. Intact, not poor, peripheral vision is a manifestation of macular degeneration. Blurred, not intact, central vision is a manifestation of macular degeneration. Colored halos around lights are not a manifestation of macular degeneration.

Which independent nursing intervention would support the goal of preventing sensory overload? A. Instruct the patient to take sips of water between foods. B. Encourage the use of email. C. Explain environmental sounds. D. Encourage the use of a radio.

C Explaining environmental sounds can help patients organize them mentally so the stimuli are not overwhelming. The use of email is an intervention to manage sensory deficits and promote communication for a patient with hearing impairment. Taking sips of water between foods enhances the taste sensation. The use of a radio promotes the use of other senses for a patient with a sensory deficit.

A patient is being screened for hearing loss. Which diagnostic test involves using a tuning fork? A. Tympanogram B. Whisper test C. Rinne test D. Otoscope examination

C For screening hearing loss, several diagnostic tests are conducted; however, it is the Rinne and Weber tests that involve the use of a tuning fork. The other diagnostic tests include the whisper test, otoscope examination, and tympanogram.

An older adult patient is being assessed in a clinic. The patient is forgetful, depressed, and has impaired mobility. Which assessment should the nurse conduct first? A. Nutrition assessment B. Cognitive function assessment C. Hearing assessment D. Depression screening

C Hearing loss can cause signs of depression, forgetfulness, and impaired mobility. Depression screening and nutrition assessment are also required; however, it is not the first assessment that is required. Cognitive function may need to be addressed if a decline in ability is noted.

The nurse is caring for a patient who has been diagnosed with renal failure and is receiving a loop diuretic. The nurse knows that which other medication, when used with loop diuretics in renal failure patients, can cause ototoxicity? A. Antiviral B. Beta blocker C. Aminoglycoside D. Nitrate

C Hearing loss is most common in patients with renal failure who have received both loop diuretics and aminoglycosides. Beta blockers, nitrates, and antivirals are not known to cause hearing loss when used with loop diuretics.

The nurse is discussing treatment options for a patient with macular degeneration. Which statement by the nurse is accurate? A. "Surgery and medication can restore vision." B. "Laser surgery cures macular degeneration." C. "Laser surgery for macular degeneration can only slow the progress of the disease." D. "Surgery for macular degeneration offers a 50% chance of vision restoration."

C Laser surgery for macular degeneration does not cure the disease or restore vision. Surgery can only slow the progression of the disease.

A patient diagnosed with glaucoma asks the nurse why eyedrops must be used every day. Which response by the nurse is appropriate? A. "The drops cure glaucoma and restore your vision." B. "The drops are prescribed by your healthcare provider, so I recommend you use them." C. "The drops lower the pressure in the eye." D. "The drops moisten your eyes and make you feel more comfortable."

C Medications prescribed for glaucoma are used to decrease intraocular pressure rather than to provide moisture and comfort. Medications do not cure glaucoma, but they help to manage glaucoma. Stating that the patient should use the medication because it has been prescribed by the healthcare provider does not address the patient's question.

An infant has had repeated episodes of otitis media. Which surgical procedure should the nurse expect to be recommended? A. Cochlear implant B. Tympanoplasty C. Myringotomy D. Stapedectomy

C Myringotomy is a surgical procedure in which a small hole is created in the tympanic membrane and then a tympanostomy tube is placed. This procedure is common among young children with repeated episodes of otitis media. Tympanostomy tubes prevent fluid accumulation or equalization of air within the middle ear. Tympanoplasty is reconstruction of the structure of the middle ear to improve conductive hearing. Cochlear implant provides sound perception but not normal hearing for a patient with sensorineural hearing loss. Stapedectomy is the removal and replacement of the stapes.

An infant is scheduled for a myringotomy due to repeated episodes of otitis media. The parent asks the nurse to describe the procedure. Which explanation by the nurse is accurate? A. An implant is used to restore hearing deficit. B. removal and replacement of the stapes is used to treat hearing loss. C. A small hole is made in the tympanic membrane and then tympanostomy tubes are placed. D. The structures of the middle ear are reconstructed to improve conductive hearing deficits.

C Myringotomy is a surgical procedure in which a small hole is created in the tympanic membrane and then a tympanostomy tube is placed. This procedure is common among young children with repeated episodes of otitis media. Tympanostomy tubes prevent fluid accumulation or equalization of air within the middle ear. Tympanoplasty is reconstruction of the structure of the middle ear to improve conductive hearing. The cochlear implant provides sound perception but not normal hearing for a patient with sensorineural hearing loss. Stapedectomy is the removal and replacement of the stapes.

The nurse is creating a plan of care for a patient diagnosed with macular degeneration. Which problem is not needed in the patient's care plan? A. Fear B. Injury, Risk for C. Pain, Acute D. Health Management, Ineffective

C Pain is not a common symptom of macular degeneration. However, patients with macular degeneration develop symptoms gradually that include needing more light to read, blurriness of print, or blurred or blind spot in their central vision. Because patients often lose central field vision, they must rely on peripheral vision. They also have difficulty going from bright light to lower light situations. For these reasons, patients are at a high risk for injury, may have difficulty managing their health, and may experience fear of blindness and becoming dependent.

After testing, it is determined that an older adult patient has hearing loss that is caused by presbycusis. The patient questions why her hearing is getting worse. Which response by the nurse is accurate? A. "Your ear is occluded with wax, so the sound waves cannot reach the nerve in your ear." B. "You have a tumor of your acoustic nerve." C. "The hair cells in your ear, which act as sensory receptors, degenerate as you age." D. "An abnormality in the bone formation in your inner ear prevents sound waves from being transmitted."

C Presbycusis is a progressive sensorineural hearing loss that occurs as the hair cells of the cochlea degenerate with aging. Otosclerosis is a hereditary hearing disorder that results from abnormal bone formation in the osseous labyrinth of the temporal bone that causes the footplate of the stapes to become fixed or immobile in the oval window. Conductive hearing loss is caused by obstruction of the external ear canal by impacted cerumen and results in equal loss of hearing at all sound frequencies. Presbycusis is not caused by a tumor of the acoustic nerve.

The nurse is caring for a patient being evaluated for hearing loss. Which diagnostic test should the nurse anticipate? A. Caloric testing B. Acoustic reflex testing C. Rinne and Weber tests D. Glycerol test

C Rinne and Weber tests can be used to diagnose hearing loss. The tests show decreased air and bone conduction on the side affected by a sensorineural hearing loss. Caloric testing and the glycerol test are used to diagnose Ménière disease. Acoustic reflex testing uses a tone presented at various intensities to evaluate movement of the structures of the middle ear.

The nurse is performing a hearing assessment using the Weber test for a patient experiencing hearing loss. The patient asks the nurse, "What is the reason for this test?" Which information should the nurse include in the response? A. "To diagnose your conductive hearing loss" B. "To diagnose your sensorineural hearing loss" C. "To assist in determining the type of hearing loss you may have" D. "To diagnose an ear infection"

C The Weber test is used to identify if the patient is experiencing sensorineural hearing loss or conductive hearing loss. Responding to the client that the test is used to diagnose one specific type of hearing loss would be incorrect. This test is not used to diagnose an ear infection.

The nurse is preparing to assess a patient reporting loss of smell. Which cranial nerve should the nurse suspect is a factor in the patient's symptoms? A. Cranial nerve V (trigeminal nerve) B. Cranial nerve II (optic nerve) C. Cranial nerve I (olfactory nerve) D. Cranial nerve XII (hypoglossal nerve)

C The cranial nerve involved in the patient's symptoms is cranial nerve I, the olfactory nerve. Cranial nerve VIII is associated with the sense of balance and hearing. Cranial nerves XII, V, and II are not associated with the symptoms the patient is experiencing.

The nurse is providing teaching about communication for the family of a patient who is hearing impaired. Which statement by the family member indicates further teaching is needed? A. "I will make sure the room is well lit when I am speaking." B. "I will make sure that my presence is known before I begin speaking." C. "I will speak in short sentences." D. "I will not overarticulate my words when I am communicating."

C The family member should be encouraged to speak in longer phases. Longer phrases tend to be easier to understand than short ones. A well-lit room is important for the person with hearing loss to be able to see the person's face that is communicating. It is important to avoid overarticulation when communicating with the hearing impaired. Prior to communicating with someone who is hearing impaired, communicating presence allows the person to refocus attention to better understand what is being communicated.

The nurse is assessing a patient diagnosed with open-angle glaucoma. Which clinical manifestation should the nurse expect to find? A. Intermittent stabbing eye pain B. Progressive reduction of color brightness C. Gradual loss of peripheral vision D. Rapid change in visual acuity

C The increased intraocular pressure noted in open-angle glaucoma leads to a gradual loss of peripheral vision. Intermittent stabbing eye pain, change in color brightness, and rapid change in visual acuity are associated with angle-closure glaucoma.

The nurse is preparing to assess cranial nerve III, the oculomotor nerve. Which assessment should the nurse use? A. Enchroma B. Corneal light reflex C. Cardinal fields D. Visual acuity

C The nurse will assess the cardinal fields of gaze to evaluate the function of cranial nerve III. The corneal light reflex is reflective of cranial nerve VII. Cranial nerve II is tested by assessing visual acuity. Enchroma is used to test for color blindness.

The nurse caring for a patient diagnosed with macular degeneration taught the patient's family about assistive devices and recommendations for treatment. Which statement by the patient's family indicates the need for further teaching? A. "Large-print books are available in many stores." B. "We will remove throw rugs in the house to prevent falls." C. "There is no reason to have regular eye exams." D. "We can buy magnifying glasses at the drugstore."

C The patient with macular degeneration requires frequent eye exams to monitor the progression of the disease. The other answer options indicate understanding of the teaching.

The nurse is caring for a patient who reports decreased hearing and ear fullness during an upper respiratory infection. Which medication should the nurse expect to be prescribed for this patient? A. Corticosteroid B. Loop diuretic C. Adrenergic D. Macrolide antibiotic

C The use of an adrenergic drug, such as pseudoepedrine, can be helpful in treating hearing loss due to an upper respiratory infection or seasonal allergies. Adrenergic drugs improve norepinephrine and epinephrine activity by stimulating alpha-adrenergic receptors. This causes vasoconstriction and reduces inflammation. Corticosteroids, such as prednisone, can be used for treatment initially in patients with sudden sensorineural loss. Corticosteroids mimic hormones produced by the adrenal gland and reduce inflammation and the immune response system. Loop diuretics, such as furosemide, inhibit the ascending limb of the loop of Henle in the kidneys, causing diuresis. Macrolide antibiotics are used to treat infection caused by bacteria.

A patient reports buzzing in their ears after attending a concert the night before. Which clinical manifestation is the patient exhibiting? A. Loss of balance B. Obstruction of the ear canal C. Tinnitus D. Loss of high-frequency tones

C Tinnitus is the perception of sound or noise in the ears without stimulus from the environment. The sound may be steady, intermittent, or pulsatile and is often described as a buzzing, roaring, or ringing. Buzzing in the ears is not loss of tones, balance, or obstruction of the ear canal.

After reviewing the health history of a patient diagnosed with glaucoma, the nurse questions administering a beta-adrenergic blocking agent to the patient. Which health problem did the nurse discover in the patient's health history? A. Diabetes mellitus B. Hypertension C. Asthma D. Gastric acid reflux

C Use of beta-adrenergic blocking agents, including topical use, is contraindicated for patients with asthma because systemic absorption may lead to bronchial constriction. A patient with glaucoma and hypertension may be treated successfully using beta-adrenergic blockers. Gastric reflux and diabetes mellitus are not conditions in which beta-adrenergic blockers are contraindicated.

A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his hearing? A) "If my hearing is damaged on the job, I can have surgery to fix it." B) "Hearing loss from exposure to loud noises actually has a genetic component." C) "Damage to the ear from loud noises can cause permanent hearing loss." D) "Hearing loss attributed to loud noises is normally reversible, especially in younger people."

C) "Damage to the ear from loud noises can cause permanent hearing loss."

Which of the following statements on the part of the nurse is an example of the communication barrier known as testing? A) "Most people have little to no pain after this type of procedure." B) "Tell me when and why you started smoking marijuana." C) "Do you think you're the only client on the unit right now?" D) "How are you still in pain after receiving both doses of medication?"

C) "Do you think you're the only client on the unit right now?"

The nurse is providing care for a client who is about to be discharged. The nurse is discussing the discharge orders with the client's primary healthcare provider. Which statement by the nurse is an appropriate example of using assertive communication? A) "Can we talk about this client prior to discharge?" B) "That new medication you prescribed for the client is ineffective." C) "I am worried about the client's blood pressure. It remains high even with the new medication." D) "Excuse me, Doctor, I think you need to do something about the client's blood pressure."

C) "I am worried about the client's blood pressure. It remains high even with the new medication."

The nurse is starting preoperative teaching when the client receives a phone call. When the call ends and the nurse resumes teaching, the client is visibly upset and begins to cry. Which therapeutic initial response by the nurse is appropriate? A) "You can deal with whatever is upsetting you once we have finished." B) "It's very important to focus on this teaching so that you will recover quickly after surgery." C) "I can see that phone call has upset you. Let's talk about why you are upset before we move on with teaching." D) "What can you do to solve the problem?"

C) "I can see that phone call has upset you. Let's talk about why you are upset before we move on with teaching."

The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective? A) "The eyedrops only need to be used when my eyes hurt." B) "I can stop the eyedrops when the glaucoma has resolved." C) "I must use my eyedrops as prescribed for the rest of my life." D) "I will need to continually increase the dose of my eyedrops."

C) "I must use my eyedrops as prescribed for the rest of my life."

A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, because my mother has the same illness."

C) "You seem to be frightened by the procedure. Tell me how you are feeling."

The nurse is assessing a client who is receiving IV antibiotics. Which item in the client's health history increases the risk for experiencing a hypersensitivity reaction? A) 26 years of age B) Caucasian race C) Previous antibiotic therapy D) Concurrent chronic illness

C) Previous antibiotic therapy

A young adolescent client is in the hospital preparing for major surgery for the removal of a tumor on the kidney. The client's mother tells the nurse that she doesn't want her child to receive narcotics for postoperative pain. What is the nurse's best response? A) "Okay, I'll tell the healthcare provider not to order any. Are you sure you want to do this?" B) "The pain will be severe. Why don't we ask your child about this?" C) "Your child's pain will be severe after the surgery. Can you tell me why you feel this way?" D) "You do not have a choice of medication. Decisions involving pain relief are up to the healthcare providers."

C) "Your child's pain will be severe after the surgery. Can you tell me why you feel this way?"

The nurse is caring for a client who is having difficulty understanding the dressing changes that need to be completed in the home as part of postdischarge wound care. The client asks the nurse to demonstrate the procedure again and allow the client's spouse to perform the procedure while the nurse watches. What is the most likely outcome of this assertive request by the client? A) A slightly increased chance that the wound will become infected due to exposure during dressing changes B) Less compassionate care for the client due to the nurse's irritation by the request C) A greater likelihood that the wound will heal appropriately D) A guarantee that the spouse will change the dressings correctly

C) A greater likelihood that the wound will heal appropriately

The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following is the priority intervention for this client? A) Teach the client regarding use of a kit that contains treatment for allergic reactions. B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider's orders. C) Administer epinephrine 1:1000 by subcutaneous injection per the healthcare provider's orders. D) Collect a detailed history from the client regarding the history of latex allergies.

C) Administer epinephrine 1:1000 by subcutaneous injection per the healthcare provider's orders.

What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway? A) Beta-adrenergic blockers B) Prostaglandin analogs C) Alpha2-adrenergic agonists D) Cholinergic agonists

C) Alpha2-adrenergic agonists

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.

C) Ask the dietary worker to come back later. Involving children in their own care increases cooperation and decreases anxiety. The nurse would ask the dietary worker to come back later to increase the child's involvement in his own care and to avoid disturbing the client or choosing a meal the client won't eat. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.

A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye. Based on this data, what should the nurse do next? A) Note a deterioration in vision. B) Administer ultrasonography to assess the eye for a detached retina. C) Compare this data to the initial assessment. D) Note an improvement in vision

C) Compare this data to the initial assessment.

What is conductive hearing loss? A) Degeneration of the hair cells of the cochlea B) Damage to the hair cells of the organ of Corti C) Disruption of the transmission of sound from the external auditory meatus to the inner ear D) Decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli

C) Disruption of the transmission of sound from the external auditory meatus to the inner ear

The healthcare provider prescribes digoxin for a client who will be discharged in the morning. When documenting the order in the medical record, which action by the nurse is most appropriate? A) Entering "digoxin, .0125 mg QD" B) Entering "digoxin, 0.0125 mg QD PO" C) Entering "digoxin, 0.0125 mg, once daily by mouth" D) Entering "digoxin, 1 pill each day"

C) Entering "digoxin, 0.0125 mg, once daily by mouth"

The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the healthcare provider of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

C) Gain knowledge about the client from family to gain compliance. The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.

Use of flow sheets would be most appropriate during which phase of the nursing process? A) Evaluation B) Diagnosis C) Implementation D) Planning

C) Implementation

The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this client? A) Impaired Verbal Communication B) Social Isolation C) Nausea D) Risk for Injury

C) Nausea

Foreign objects commonly cause what type of injuries among migrant farm workers? A) Burns B) Blunt trauma C) Penetrating trauma D) Abrasions

C) Penetrating trauma

A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which condition? A) Idiopathic peripheral neuropathy B) Mononeuropathy C) Polyneuropathy D) Hereditary peripheral neuropathy

C) Polyneuropathy

What is the first phase in the therapeutic nurse-client relationship? A) Introductory phase B) Working phase C) Preinteraction phase D) Anticipatory phase

C) Preinteraction phase

The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD) and type 1 diabetes mellitus. What should the nurse include in this client's teaching plan? A) Information on assisted-living facilities B) Information on the need to have routine eye examinations every 5 years C) Referral to home care to ensure safety with administering insulin and AMD medications at home D) Information on Stargardt disease

C) Referral to home care to ensure safety with administering insulin and AMD medications at home

A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart.

C) Request a review of the plan with the nurse's preceptor. Part of the critical thinking process is inquiry, or searching for knowledge or facts. One way the novice nurse can implement inquiry is to discuss the care plan with a more experienced nurse to determine if additional or better interventions need to be added to the care plan. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process. The nurse could put the plan on the chart, but the new nurse would learn more about critical thinking by requesting assistance from a more experienced nurse.

An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client? A) Disturbed Body Image B) Decisional Conflict: Cataract removal C) Risk for Ineffective Health Maintenance D) Ineffective Coping

C) Risk for Ineffective Health Maintenance

The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching? Select all that apply. A) Manage eye pain with over-the-counter analgesics. B) Clouding of the affected eye(s) is expected. C) Self-administer prescribed eye medication properly. D) Attend follow-up appointments with the physician. E) Avoid over-the-counter medication unless discussed with the physician.

C) Self-administer prescribed eye medication properly. D) Attend follow-up appointments with the physician. E) Avoid over-the-counter medication unless discussed with the physician.

The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge, and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C) The client with pneumonia may be experiencing respiratory distress. The client with a PaCO2 of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO2 as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiologic needs of the clients are the first consideration of the nurse.

A new graduate nurse is working with a client who has been admitted to a medical-surgical unit. The nurse is working on establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid, if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, as my mother has the same illness."

C) The goal of empathy is to let the client be aware that the nurse understands the client's feelings as well as the words. By stating that the client appears to be frightened and asking the client to describe his or her feelings, the nurse is demonstrating understanding and is giving the client the opportunity to further define feelings. Telling the client that the nurse knows how the client feels is going to be met with disbelief, and rightly so; one individual never knows how another individual is feeling unless that individual tells them. Telling the client not to be afraid is demeaning; rather, the nurse should ascertain the source of fear and then teach. Saying the client should not have done something is passing judgment and inappropriate.

What does it mean to say that a corneal abrasion causes a disruption of the superficial epithelium of the cornea? A) Such injuries are typically painless. B) The superficial epithelium is completely removed. C) The integrity of the superficial epithelium is disturbed. D) The surface of the cornea sustains penetrating trauma.

C) The integrity of the superficial epithelium is disturbed.

The nurse is caring for an elderly client in a long-term care facility. The nurse has just attended an in-service regarding therapeutic communication. This nurse is conveying respect and an attitude that shows the nurse takes the client's opinions seriously by which of the following behaviors? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care

C) The nurse best conveys physical attending by leaning toward the client, which conveys involvement. Facilitating and taking action do not denote that the nurse is conveying physical attendance. Maintaining social distance does not convey physical attending. Being concrete is a method of communicating needed information to the client.

Which statement is true? A) Eye injuries almost always take place in the home. B) Construction workers have a reduced risk of eye injury because of the many protective measures they take. C) The pathophysiology of an eye injury depends on the nature of the injury. D) Eye injuries are relatively uncommon with advances in safety and risk prevention.

C) The pathophysiology of an eye injury depends on the nature of the injury.

An older adult patient who is postoperative will be discharged in 1 day. The patient expresses concern to the nurse regarding the things that need to be done. The nurse tells the patient, "To better attain your goals and functioning, being discharged to home is better for you." Which barrier to communication is being used here? Giving common advice Probing Unwarranted reassurance Stereotyping

Giving common advice

The nurse is caring for an older adult patient who is experiencing visual loss that has manifested as opacification of the lens of the eye. Based on this manifestation, the nurse should understand that this patient has which condition? Myopia Cataract Glaucoma Age-related macular degeneration

Cataract

An 80-year-old patient reports a gradual loss of peripheral vision over the last several months without any other clinical manifestations. Which condition should the nurse suspect in this patient? A. Secondary cataracts B. Angle-closure glaucoma C. Traumatic cataracts D. Open-angle glaucoma

D The increased intraocular pressure noted in open-angle glaucoma leads to a gradual loss of peripheral vision. Intermittent stabbing eye pain, change in color brightness, and rapid change in visual acuity are associated with closed-angle glaucoma. Cataracts present as opacity of the lens.

A patient who has had a hip replacement is being discharged. The electronic health record (EHR) safety alert indicates that the patient has need of services or equipment after discharge. Which informatics function does this observation describe? Order management Clinical decision support Telehealth Device integration

Clinical decision support

An older adult patient with a hearing deficit is admitted to the unit by the nurse. Which nursing action should the nurse follow to support the patient's communication needs during the assessment process? Ask whether a family member is available to complete the assessment. Sit beside the patient during the assessment. Shout into the patient's good ear when talking. Close the door to the room when conducting the assessment.

Close the door to the room when conducting the assessment.

The nurse is planning to participate in a community dialogue regarding healthcare resource allocation. Which discussion activity would be the most appropriate choice for this nurse? Talking with cancer survivors Networking with healthcare providers Speaking with the hospital administration Collaborating with legislators

Collaborating with legislators

The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? Collect data related to patient-specific outcomes for accrediting bodies. Collect data related to the goal and make decisions about nursing care effectiveness. Collect data to develop new nursing diagnoses for the home health nurse to follow. Collect data to provide discharge instructions to follow when at home.

Collect data related to the goal and make decisions about nursing care effectiveness.

Which concept related to professionalism should the nurse recognize as being most valued by clients and​ colleagues? A.Communication B.Electronic media use C.Advocacy D. Clinical decision making

Communication​ Rationale: Communication and application of culturally​ respectful, caring interventions through the nursing process are key elements valued by nursing students and nurses. Advocacy is an essential component of nursing practice that the new nurse may not yet have experience with. The use of electronic media and clinical decision making influence professional practice and further require professional guidelines to be adhered to.

The nurse is caring for an 18-month-old child diagnosed with amblyopia. The mother asks the nurse what will be done to straighten the child's eye. Which information should the nurse include in the response to the parent? Using corrective lenses and an eye patch over the affected eye to strengthen it Covering the healthy eye to encourage the affected eye to process images and strengthen the eye Treating with surgical procedures as the only corrective option Covering the affected eye to decrease stimulation and allow it to strengthen on its own

Covering the healthy eye to encourage the affected eye to process images and strengthen the eye

Which action by a student nurse is most consistent with commitment to the nursing profession? A) The student calls in sick for clinicals in order to study for a class exam. B) The student declines to observe a new procedure for giving a necessary bath. C) The student misses class to attend a political rally. D) The student calls in sick for clinicals because of a respiratory infection.

D

Which type of commitment involves a feeling of obligation to continue in a profession, usually as a result of having received benefits or having had positive experiences through engagement in the profession? A) Continuance commitment B) Affective commitment C) Reciprocal commitment D) Normative commitment

D

An older adult patient reports hearing loss and presents in the clinic to ask for help. Which referral would be most important? A. Speech therapist B. Social worker C. Physical therapist D. Audiologist

D An audiologist is a referral that would be appropriate for this patient to determine hearing loss and the extent of the loss. Speech therapy is usually used for children with hearing issues to help them develop communication skills. Physical therapy can be used if mobility becomes an issue, and social workers can help the patient navigate assistive devices.

A family member asks the nurse about the best way to communicate with the parent who has hearing impairment. Which statement by the nurse is best? A. "Make sure to speak in a loud voice so the patient can hear." B. "Use short phrases for easier understanding." C. "Overarticulate words so the patient can read lips better." D. "Before talking, move to a position where the patient can see you."

D Before talking, a person should move to a position where the patient can see the face. A hearing-impaired patient will then be able to acknowledge the communication. Speaking in a loud voice can make it more difficult to understand the words. Overarticulation of words makes it more difficult to understand words. Longer phrases make it easier to understand the conversation.

The nurse is creating a care plan for an older adult patient in the clinic who has a hearing impairment. Which nursing diagnosis may be appropriate for inclusion in the plan of care? A. Health Maintenance, Ineffective B. Nutrition, Imbalanced: Less than Body Requirements C. Communication: Verbal, Impaired D. Lifestyle, Sedentary

D Communication: Verbal, Impaired is appropriate as an expected diagnosis for a patient with hearing impairment. Lifestyle, Sedentary, Nutrition, Imbalanced: Less than Body Requirements, and Health Maintenance, Ineffective are not nursing diagnoses for a patient with impaired hearing.

The nurse is performing an assessment on a patient diagnosed with cataracts. Which component should the nurse include in the health history portion of the nursing assessment? A. Snellen chart B. Color of pupil C. Presence of red reflex D. Prescribed medications

D During the health history portion of the nursing assessment, the nurse would ask the patient about prescribed medications. The Snellen chart would be used during the physical examination. The presence of red reflex and the color of the pupil would also be noted during the physical examination.

A pregnant woman is being assessed for infections that can affect the development of the fetus. Which infection is screened for during pregnancy that may impact hearing in the infant? A. Influenza B. Chlamydia C. Diabetes mellitus D. Toxoplamosis

D In utero infections with TORCH pathogens (toxoplasmosis, rubella, cytomegalovirus, syphilis, herpes) can affect the development of the fetus and are screened during pregnancy. Diabetes is a disease, not an infection. Chlamydia and influenza have not been associated with fetal development issues.

The nurse is providing discharge teaching for the family caring for a patient who is newly diagnosed with impaired vision. Which information should the nurse include? A. Avoid the use of bright colors in the environment. B. Keep the current living environment as is. C. use a flashing alarm clock. D. Place shades on windows.

D Shades on windows are recommended to reduce the visual stimulation for the patient with impaired vision and decrease the risk of sensory overload. The living environment should be organized to reduce the risk for injury and increase opportunities for independence. Bright contrasting colors should be used in the environment. A flashing alarm clock is used for the hearing impaired.

The nurse is admitting a patient with visual impairment to the hospital. Which communication technique should the nurse utilize? A. Touch the patient before explaining what assessment will be done. B. Decrease background noises. C. Use longer phrases that are easier to understand. D. Speak in a pleasant tone of voice.

D The nurse admitting a patient with visual impairment to the hospital will communicate in a pleasant tone of voice to the patient. Using longer phrases or decreasing background noise are techniques for communication with patients who are hearing impaired. The nurse will always explain what will be done prior to touching the patient.

The nurse is performing an eye exam on a newborn and observes strabismus. Which statement describes the nurse's interpretation of the assessment finding? A. Strabismus occurs due to a genetic defect. B. Strabismus will result in visual impairment. C. Strabismus will require surgery. D. Strabismus in a newborn is a normal finding.

D The nurse understands that strabismus is a normal finding in a newborn and should resolve spontaneously by 3 months of age. At 3 months of age, if the strabismus is still detectable, then an ophthalmologist consult is recommended. Strabismus in a newborn does not occur because of a genetic defect, will not affect vision, and will not usually require surgery.

The nurse is caring for an 18-month-old child diagnosed with amblyopia. The mother asks the nurse what will be done to straighten the child's eye. Which information should the nurse include in the response to the parent? A. Covering the affected eye to decrease stimulation and allow it to strengthen on its own B. Using corrective lenses and an eye patch over the affected eye to strengthen it C. Treating with surgical procedures as the only corrective option D. Covering the healthy eye to encourage the affected eye to process images and strengthen the eye

D Treatment of amblyopia commonly involves putting a patch over the healthy eye to encourage the "lazy" or affected eye to process images, thus strengthening the eye and building nerve connections between that eye and the brain. Treatment should occur in the first 2 to 4 years of life. Covering the affected eye will not correct the problem. Corrective lenses and an eye patch are used to treat strabismus. Surgery is not the only corrective option.

The nurse is discussing groups of patients who are at risk for developing cataracts. Which group should the nurse discuss as being at the greatest risk? A. Men B. Caucasian Americans C. Hispanics D. Women

D Women are affected more frequently than men and are at greater risk for developing cataracts. African Americans are affected more frequently by cataracts than Caucasian Americans and Hispanics.

Which of the following statements by the nurse is an example of the therapeutic communication technique of offering self? A) "Would you like to talk with me about your emotions right now?" B) "I'm not sure I understand. Please tell me more about the situation." C) "I don't know the answer to your question, but I will check with the physician." D) "I'll stay here with you until your family arrives."

D) "I'll stay here with you until your family arrives."

The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."

D) "It is okay to cry. I know this is scary."

A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include? A) "This drug reduces pressure in the eye by relaxing the muscles of the eye." B) "This medication only needs to be taken when eye pain is experienced." C) "Systemic absorption may occur, resulting in hypotension, bradycardia, and shortness of breath." D) "This drug reduces intraocular pressure by decreasing the production of fluid in the eye."

D) "This drug reduces intraocular pressure by decreasing the production of fluid in the eye."

Which assessment finding is consistent with a diagnosis of open-angle glaucoma? A) A client loses vision intermittently several times over the course of several hours. B) A client has an episode of lost vision when experiencing a panic attack. C) A client loses the ability to see at all during a city-wide blackout. D) A client experiences gradually diminishing vision in both eyes over an extended period.

D) A client experiences gradually diminishing vision in both eyes over an extended period.

Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client? A) A diagram showing a completely closed anterior chamber angle B) A diagram showing a completely occluded outflow of aqueous humor C) A diagram showing a blockage of the trabecular meshwork and canal of Schlemm D) A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm

D) A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm

The nurse is providing teaching to an older adult client related to avoiding eye injury. What should the nurse identify as an intervention to address the number-one cause of eye injuries in older adults? A) Turning down the temperature of the client's home water heater B) Storing all harsh chemicals out of easy reach C) Ensuring the client wears protective goggles when engaging in outdoor activities D) Addressing slippery floors and other fall hazards in the client's home

D) Addressing slippery floors and other fall hazards in the client's home

A nurse is teaching a client about a dressing change that should be done three times per day. The client is from a culture that is "present oriented." Based on this data, at which times should the nurse tell the client to perform the dressing changes? A) At whatever times the client selects, as long as they are 8 hours apart B) At 9 a.m., 3 p.m., and 9 p.m. C) At whatever times the client selects, as long as the dressing is changed three times each day D) After breakfast, lunch, and dinner

D) After breakfast, lunch, and dinner

A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract? A) Two-month-old infant who is asymptomatic B) Six-month-old infant with difficulty noticing toys or faces C) Three-month-old infant with diminished reaction to bright light D) One-month-old infant with no reaction to bright light and failure to notice toys or faces

D) One-month-old infant with no reaction to bright light and failure to notice toys or faces

The nurse is caring for a 9-year-old client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which of the following responses by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."

D) Assertive communication is appropriate in the group setting, but for this client, the nurse should be accepting of the client's feelings of fear. Telling the client not to cry invalidates the client's feelings. Leaving to get the doctor could be seen by the child as abandonment and would signal that the nurse is uncomfortable with the child. Distraction is not appropriate when the client is clearly upset; instead, the nurse should attempt to seek more information about what the child is feeling.

Which of the following best describes tinnitus? A) A ringing sound accompanying perception of high-frequency tones B) Auditory perception from visual stimuli C) Lack of auditory perception of external auditory stimuli D) Auditory perception without external auditory stimuli

D) Auditory perception without external auditory stimuli

A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this time? A) Anxiety B) Ineffective Peripheral Tissue Perfusion C) Ineffective Coping D) Chronic Pain

D) Chronic Pain

An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority? A) Talk with the client to assess for other hallucinations that might be occurring. B) Check the client's medications for side effects of vision changes. C) Ensure the client's safety by raising the bedrails. D) Contact the healthcare provider for an immediate ophthalmologic evaluation.

D) Contact the healthcare provider for an immediate ophthalmologic evaluation.

A client with congestive heart failure (CHF) is having difficulty breathing. Before leaving the room, the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority setting C) Conflict resolution D) Critical thinking

D) Critical thinking After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority setting involves deciding which task to perform first.

Laser surgery and photodynamic therapy are both treatments for what disease of the eye? A) Congenital cataracts B) Age-related cataracts C) Nonexudative macular degeneration D) Exudative macular degeneration

D) Exudative macular degeneration

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Based on this data, which position is the most appropriate for the nurse to place the client? A) Trendelenburg position B) Flat, with legs slightly elevated C) Supine position D) High-Fowler position

D) High-Fowler position

Which diagnostic technique is used to confirm the location and extent of cataracts? A) Visually inspecting the optic fundus using an ophthalmoscope B) Using tonometry to indirectly measure intraocular pressure C) Revealing a dark area instead of the red reflex through ophthalmoscopy D) Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract

D) Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract

The nurse is planning a teaching seminar for parents of school-age children that focuses on eye safety. What should the nurse include in this educational session? A) All children should wear goggles when playing outdoors at all times. B) Sunglasses need only be worn during the summer months. C) Supervise young children when lighting fireworks. D) Keep sharp objects out of the reach of young children.

D) Keep sharp objects out of the reach of young children.

The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP) shunt malfunction. When gathering the history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this data, which product should be avoided when providing care to this client? A) Synthetic rubber gloves B) Polyethylene gloves C) Non-powdered nitrile gloves The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP) shunt malfunction. When gathering the history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this data, which product should be avoided when providing care to this client? A) Synthetic rubber gloves B) Polyethylene gloves C) Non-powdered nitrile gloves D) Latex gloves

D) Latex gloves

An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing? A) Cataract B) Detached retina C) Exudative macular degeneration D) Nonexudative macular degeneration

D) Nonexudative macular degeneration

The nurse suspects that an older adult client has a hearing disorder; however, the client denies not being able to hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the client's hearing is appropriate? A) Use an otoscope to visualize the inner ear. B) Schedule a Weber and Rinne test. C) Confront the client with the suspicion. D) Observe the client's interaction with family.

D) Observe the client's interaction with family.

) The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of latex sensitivity. Which action by the nurse is the most appropriate? A) Ask the family member to leave the unit. B) Transfer the client to a department that does not use latex products. C) Wait until Monday to report the problem to the unit supervisor. D) Obtain latex-free products for the client's room.

D) Obtain latex-free products for the client's room.

A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) Responding to a change in the client's condition

D) Responding to a change in the client's condition Each client has a plan of care, but it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain.

Which statement regarding risk factors for peripheral neuropathy is accurate? A) Extremely short people are at the highest level of risk for developing peripheral neuropathy. B) Height is a risk factor for women but not a proven risk factor for men. C) Height is a risk factor for men but not a proven risk factor for women. D) Risk for peripheral neuropathy is proportional to height for both men and woman.

D) Risk for peripheral neuropathy is proportional to height for both men and woman.

A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority? A) Apply anesthetic drops. B) Apply eye ointment. C) Remove the object. D) Stabilize the object.

D) Stabilize the object.

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

D) The client experiencing shortness of breath The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as that for the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath.

A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate? A) It will increase the effectiveness of surgery. B) It will reverse the effects on the disease. C) It will promote the development of new blood vessels. D) The progression of the disease will be slowed.

D) The progression of the disease will be slowed.

Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff? A) To avoid lawsuits B) To make sure all documentation is complete C) To facilitate quality improvement D) To ensure client safety

D) To ensure client safety

In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions? A) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and develop almost immediately. B) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and develop almost immediately. C) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and take 24 hours or more to develop. D) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and take 24 hours or more to develop.

D) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and take 24 hours or more to develop.

A 10-year-old patient is waiting for the nurse to complete a health history. After entering the room, which place would be most appropriate for the nurse to sit in to conduct the history with the patient? One foot away from the patient About 4-12 feet from the patient From 1½-4 feet from the patient Against the wall near the door

From 1½-4 feet from the patient

Which nursing action is most appropriate when communicating with a client who has a hearing​ deficit? A. Drawing out the articulation of words with extra emphasis in order for the client to understand B. Varying the volume of​ voice, which is easier to understand than one consistent volume C. Using shorter​ phrases, which tend to be easier to understand than longer ones D. Writing ideas or pantomiming as appropriate in order for the client to understand

D. Writing ideas or pantomiming as appropriate in order for the client to understand

The nurse is caring for a patient who sustained an injury that caused separation of the sensory portion of the eye from the choroid. Which eye condition should the nurse suspect the patient has? Detached retina Blunt trauma Penetrating trauma Corneal abrasion

Detached retina

Which best describes the introductory phase of therapeutic communication? Developing trust Working Exploring Reflection

Developing trust

An older adult patient is brought to the healthcare facility by a family member who reports that the patient has been having difficulty hearing. Which assessment finding supports the diagnosis of hearing loss? Unable to state which day of the week it is Difficulty understanding conversation when the nurse turns away Appropriate responses to questions A raised voice when angry

Difficulty understanding conversation when the nurse turns away

The nurse is reviewing the dress code for the hospital unit. Which best describes the nurse's understanding of the relationship between professional dress and professionalism? Dress is a form of nonverbal communication. Dress is representative of behavior. Dress communicates professional demeanor. Dress is characteristic of competence.

Dress is a form of nonverbal communication.

A parent asks the nurse why toddlers are at high risk for accidental death and injuries. Which reason should the nurse include in the response? a)Their small size and developing bones make them vulnerable to injuries. B)They are less dependent on parents than other age groups. c)They are typically unsupervised by their parents. d)Their lack of mobility makes them vulnerable to being dropped.

a

The nurse provides a patient with standardized patient teaching materials prior to discharge. The patient states, "This looks like the same stuff they told me last month. I already know this, but I'll look at it later." Which response by the nurse is most appropriate? Understanding that the patient's lack of desire to review the materials likely reflects a language barrier Encouraging the patient to review the patient teaching materials in the presence of the nurse Respecting the patient's wishes and allowing them to decide when to review the materials Recognizing the patient teaching materials as being redundant and omitting this step

Encouraging the patient to review the patient teaching materials in the presence of the nurse

The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? Ask the healthcare provider for a more reasonable goal. Evaluate factors impeding goal attainment. Document noncompliance with the plan. Compare patient progress with that of other patients.

Evaluate factors impeding goal attainment.

The nurse evaluates the plan of care for a patient admitted with pneumonia who still has difficulty breathing related to an ineffective breathing pattern. Which step should the nurse include to select new interventions for the plan of care? Evaluating the current interventions and patient needs Setting more realistic patient goals and easier interventions Delegating the selection of the new interventions to another nurse Deleting the current nursing diagnosis because it was not meeting the patient's needs

Evaluating the current interventions and patient needs

Which statement describes the evaluation phase of the nursing process? Evaluation focuses on determining changes and preventing complications. Evaluation is performed throughout all phases of the nursing process. Evaluation is performed only after nursing interventions are performed. Evaluation is determined based on gathering subjective and objective data.

Evaluation is performed throughout all phases of the nursing process.

The nurse observes a patient's gait and posture as the patient walks toward the treatment room. Which assessment related to nonverbal communication can the nurse make when observing a patient's posture and gait? Evaluation of the patient's self-concept, mood, and health status Determination of the patient's social and financial status Learning the patient's real reaction to a health problem or situation Determination of the patient's use of cultural cues

Evaluation of the patient's self-concept, mood, and health status

Which independent nursing intervention would support the goal of preventing sensory overload? Encourage the use of a radio. Instruct the patient to take sips of water between foods. Explain environmental sounds. Encourage the use of email.

Explain environmental sounds.

5) A nurse supervisor in a hospital that is about to vote on unionizing nurses has been told by the hospital CFO to schedule union organizers during times that have been arranged for union organizational meetings. How might this nurse respond professionally? Select all that apply. A) Schedule the organizers during union meeting times. B) Schedule the organizers according to clinical staffing needs. C) Reprimand nurses for attempts to unionize. D) Continue to implement the usual staffing procedures. E) Discuss the need for professional nursing integrity with the CFO. Answer: B, D, E

Explanation: A) Administrators may serve their careers and no longer the priorities of client-centered care. Nurses in authority who emphasize principles and who focus on client safety can extinguish negative behaviors and encourage nurses at the point of care. Some administrators can be identified by an attitude of arrogance, control, and acceptance of the hierarchical power structure. Nurses should maintain their integrity and that of their profession.

The patient with cataracts is scheduled to undergo a procedure to remove the cataracts. The nurse should plan to teach the patient about which procedure? Extracapsular extraction Gonioplasty Laser photocoagulation Trabeculectomy

Extracapsular extraction

Which part of the body or movement should the nurse consider to be most expressive when assessing a patient's nonverbal communication? Face Hand Posture Gait

Face

The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals evaluate the patient's response to the plan of care developed by the nurse." "Goals are established by the nurse and used to evaluate patient outcomes." "Goals are patient responses, whereas outcomes are the patient's response to care." "Goals include the subjective and objective data observed by the nurse."

Goals are patient responses, whereas outcomes are the patient's response to care."

The nurse is assessing a patient diagnosed with open-angle glaucoma. Which clinical manifestation should the nurse expect to find? Gradual loss of peripheral vision Intermittent stabbing eye pain Progressive reduction of color brightness Rapid change in visual acuity

Gradual loss of peripheral vision

A patient with a bacterial ear infection is receiving a corticosteroid and a macrolide antibiotic. Which food on the patient's breakfast tray should cause the nurse to intervene? Grapefruit Coffee with creamer Hash browns Scrambled eggs

Grapefruit

The nurse has integrated the six principles of the Joint Principles of the Patient-Centered Medical Home into practice. Which statement defines the goal when providing this type of practice? Patient-centered care is delivered in the home setting. Healthcare is a partnership with the patient and the patient's family. A team of healthcare providers will be available to care for the patient. The cost of the care provided to the patient using this model is moderate.

Healthcare is a partnership with the patient and the patient's family.

The nurse is conducting a teaching session regarding significant potential barriers to telehealth. Which factor should the nurse include? Healthcare provider licensure Cost of services Healthcare quality Access to care

Healthcare provider licensure

An older adult patient is being assessed in a clinic. The patient is forgetful, depressed, and has impaired mobility. Which assessment should the nurse conduct first? Nutrition assessment Hearing assessment Depression screening Cognitive function assessment

Hearing assessment

The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? Urinary Retention Enlarged prostate Impaired

Impaired

A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? ANSWER Impaired Skin Integrity related to motor vehicle crash Impaired Skin Integrity related to time in bed Impaired Skin Integrity related to immobility Impaired Skin Integrity related to skin breakdown

Impaired Skin Integrity related to immobility

The nurse is outlining strategies through which informatics can address the increasing national problem with prescription opioid addiction and overdose. Which strategy should the nurse include? Enhancing electronic tracking of opioid prescriptions at the community level Monitoring data to identify patients who sell opioids and their buyers Improving the ability to identify individuals who engage in "doctor shopping" Linking computerized written orders with patient records to identify prescribers of opioids

Improving the ability to identify individuals who engage in "doctor shopping"

After receiving constructive feedback from the​ supervisor, the nurse registers for a continuing education course. Which behavior is the nurse​ demonstrating? A.Demeanor B.Competence C.Collaboration D.Integrity

Integrity ​Rationale: The nurse who registers for a continuing education course following feedback from the manager is demonstrating integrity. Nurses demonstrate integrity by accepting feedback​ (positive or​ negative) as a tool for improving their delivery of client care and by maintaining accountability for their actions.​ Demeanor, collaboration, and competence are other descriptors of professional behavior.

The nurse calls a healthcare provider to report an abnormal assessment finding. The provider states to the nurse, "If you call me again, I will have you fired. I told you I will see the patient after office hours." Which behavior is the healthcare provider demonstrating? Sexual harassment Intimidation Discrimination Lateral violence

Intimidation

The family member of a patient with a visual field deficit asks the nurse what they should do to prevent injury. Which suggestion by the nurse is most appropriate? Encourage the use of a walker. Keep the floor free of obstacles. Use soft lighting. Provide reading glasses.

Keep the floor free of obstacles.

The nurse has observed that a patient has abnormal results for a kinesthesia test. Which causative factor is most likely associated with the abnormal finding? Injury to the posterior column of the sensory cortex Lesions of higher pathways to the spinal cord Lesion on the posterior column of the spinal cord Bilateral sensory loss due to polyneuropathy

Lesion on the posterior column of the spinal cord

The nurse is caring for a patient who has a sudden loss of feeling and paralysis in a limb. Which is the most accurate description of the type of change the patient is experiencing? a)Functional B)Physical c)Cognitive d)Behavioral

a

The nurse is demonstrating professionalism when following safety guidelines and principles of​ evidence-based practice. Which is reflective of the​ nurse's ability to provide safe​ care? A.Maintaining a sense of physical limitations and boundaries B.Assessing the​ client's insurance status and ability to access healthcare C.Using​ evidence-based standards when practicing primary prevention D.Establishing trust and rapport with the client and team members

Maintaining a sense of physical limitations and boundaries ​Rationale: Maintaining a sense of​ one's own physical limitations and boundaries promotes the safety of the nurse and the healthcare team. Communication is used to establish trust and rapport with the client and team members. Assessing the​ client's insurance status and ability to access healthcare reflects the concept of the use of the healthcare system. Using​ evidence-based standards when practicing primary prevention assists the nurse in the promotion of health in the individual and the community.

The nurse is supervising an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? Determining a patient's hydration status Analyzing urine test results Evaluating color of urine Measuring intake and output

Measuring intake and output

Which generation of nurse is the most adept to work with information technology (IT) to address workflow issues on the unit? Baby boomer Veteran Millennial Generation X

Millennial

Healthcare providers and organizations are expanding their focus to include the family. Which statement reflects the nurse's correct explanation for this approach? Advance directive decisions are easier to make if the primary group is already involved. Most individuals turn to their primary group for support when they have health problems. Many individuals rely on their primary group to make medical decisions for them. Documentation of primary group involvement is directly tied to hospital reimbursement.

Most individuals turn to their primary group for support when they have health problems

The nurse is concluding a visual assessment for a patient and determines the patient is unable to read the 20/20 line on the Snellen chart. Which is the appropriate interpretation of this clinical finding? Hyperopia Accommodation Myopia Presbyopia

Myopia

The nurse states, "I decided to go into nursing 20 years ago because of the care my mother received when she was ill. I wanted to make a difference." Which type of commitment is the nurse demonstrating? Affective Normative Continuance Personal

Normative

The nurse is discussing how the practice of nursing differs from having a job. Which factor should the nurse include? Nursing has a professional code of ethics. A criminal background check is required. Licensure must be obtained to practice nursing. A college education is necessary for nursing.

Nursing has a professional code of ethics.

The nurse assessing the cardinal fields of vision of a patient observes an oscillation of the eyes. Which diagnosis is characterized by the nurse's finding? Anisocoria Strabismus Presbyopia Nystagmus

Nystagmus

A mother brings her 6-year-old child into the clinic and states that the child is having behavior issues at school and is not startling to loud noises. Which part of the child's history should put them most at risk for hearing loss? Congenital hearing loss Noise-induced damage Otitis media Age-related changes

Otitis media

The nurse is creating a plan of care for a patient diagnosed with macular degeneration. Which problem is not needed in the patient's care plan? Pain, Acute Injury, Risk for Fear Health Management, Ineffective

Pain, Acute

A patient tells that their blood sugar testing results have been very labile. The nurse responds, "It sounds like your blood sugar has been difficult to manage. Can I please see your blood sugar log?" Which therapeutic communication skill is the nurse displaying during this interaction with the patient? Genuineness Paraphrasing Clarifying Confronting

Paraphrasing

The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? Axis 2 of the nursing diagnosis Primary identifiable nursing problem Subjective data obtained Pathophysiological disease process

Pathophysiological disease process

The nurse is concerned about consequences to the workplace due to coworkers who are chronically late to work. Which concern is a priority? Increased overtime costs Patient safety Delayed procedures Decreased productivity

Patient safety

The preceptor tells the new nurse, "You are on your own today. You have been on orientation for a week now, so you really should be able to handle these patients by yourself." Which aspect is most negatively affected by the preceptor's behavior? Communication Patient safety Collaboration Advocacy

Patient safety

A patient diagnosed with exudative macular degeneration asks the nurse what consequences may occur. Which information should the nurse provide? Permanent loss of central vision may occur due to bleeding episodes that lead to scar tissue. Gradual loss of peripheral vision and increased intraocular pressure occur in the eye. Clouding of the lens of the eye interferes with light transmission into the retina. Capillaries in the eye become sclerotic and are unable to transport oxygen to the retina.

Permanent loss of central vision may occur due to bleeding episodes that lead to scar tissue.

The nurse is teaching a pregnant patient about measures to prevent injury to herself as well as the fetus.Which recommendation should the nurse include? a)Smoking cessation b)Gaining 50 lb c)Drinking alcohol d)Maintaining prepregnancy weight

a

The nurse is performing an assessment on a patient diagnosed with cataracts. Which component should the nurse include in the health history portion of the nursing assessment? Prescribed medications Snellen chart Presence of red reflex Color of pupil

Prescribed medications

The nurse is discussing how electronic health records improve mortality rates related to sepsis in an acute care hospital. Which feature should the nurse include? Produces an alert when criteria for sepsis is met Creates a monthly report of occurrence of sepsis Calculates percentages of in-facility deaths from sepsis Tracks and trends occurrences of sepsis

Produces an alert when criteria for sepsis is met

A hearing-impaired patient presents with an eye infection. The nurse is tasked to instruct the patient for home treatments. Which is the most effective method of communication that the nurse should use to communicate with this patient? Be clear. Use gestures. Provide written instructions with illustrations. Use simple language and terminology.

Provide written instructions with illustrations.

The nurse is discussing how the HITECH Act promotes the use of electronic health records (EHRs). Which information should the nurse include? Imposing penalties on providers who do not utilize EHRs Mandating the use of electronic medical records in the sharing of information Providing monetary incentives to providers who promote the use of EHRs Promoting a specific brand of EHR with the intention of having all providers use the same system

Providing monetary incentives to providers who promote the use of EHRs

The nurse is discussing the outcomes of using professional behavior during communication. Which outcome should the nurse​ discuss? A.Priorities of care can be established to ensure the best outcome. B.The primary preventative health of the individual can be promoted. C.Reliability and accountability for information are conveyed. D.High-quality and​ evidence-based care occurs at all stages.

Reliability and accountability for information are conveyed. Rationale: Communication using professional behavior promotes reliability and accountability for information. When nurses integrate professionalism during clinical decision​ making, high-quality and​ evidence-based care occurs at all stages. When​ evidence-based care is​ provided, priorities of care can be established to ensure the best outcome. The primary preventative health of the individual can be promoted using professional behavior through healthcare systems.

The nurse who administered a medication to a patient realizes the wrong dosage was given. Which action by the nurse demonstrates integrity? Reporting the medication error Monitoring the patient for adverse effects Administering the correct medication Dismissing the error if no adverse effects occur

Reporting the medication error

The nurse is evaluating the plan of care for an older adult patient with hearing loss. Which evaluation shows success in the plan of care? The patient is refusing to learn alternative communication methods. The patient has joined a group for older adults. The patient is looking into buying a hearing aid but has not done it yet. The patient prefers reading at home as an activity.

The patient has joined a group for older adults.

Although there is a difference in opinion between two nurses, they are able to express their ideas in a direct and nonconfrontational manner to each other. The nurse should recognize that which characteristic is the basis of this therapeutic relationship? Reflecting Assuming Respecting Identifying

Respecting

A patient states, "I've been having stomach pain, nausea, headache, and diarrhea for the past 3 days." The nurse intently nods while writing the patient's symptoms. Which part of the communication process is the nurse demonstrating? Response Sender Receiver Message

Response

A patient tells the nurse that the best way of communicating is through email. Which information would be inappropriate for the nurse to communicate using this method? Results of the patient's pregnancy test What time to report to the hospital for a diagnostic test Change in appointment time with a specialist Name of the pharmacy that has the patient's prescription in stock

Results of the patient's pregnancy test

The nurse is evaluating the current plan of care for a patient who is receiving care in a long-term healthcare facility. The evaluation indicates that the patient is not meeting goals related to mobility. Which is an appropriate nursing action at this time? Determining that the patient does not have any risk factors Concluding that the problem is resolved Revising the plan of care Asking the patient to try harder

Revising the plan of care

A patient is being screened for hearing loss. Which diagnostic test involves using a tuning fork? Whisper test Tympanogram Rinne test Otoscope examination

Rinne test

The nurse identifies the diagnosis Imbalanced Nutrition: Less than Body Requirements related to poor nutrition, as evidenced by low serum albumin level, for a 65-year-old patient with osteoporosis. Which format should the nurse use to write goals for this patient? SBAR PIE SMART CBE

SMART

The nurse is teaching an adolescent patient how to perform a thorough breast self-examination using a realistic model of the breast. Which type of prevention activity is the nurse performing with this patient? Primary prevention Tertiary prevention Secondary prevention Palliative prevention

Secondary prevention

The nurse is caring for a patient with meningitis. The nurse should assess the patient for which type of hearing loss? Sensorineural Conductive Tinnitus Presbycusis

Sensorineural

Which technique should the nurse use to effectively communicate with an older adult patient? Use illustrations. Have the patient write down questions. Speak in simple, short sentences, one subject at a time. Have family members leave the room.

Speak in simple, short sentences, one subject at a time.

The nurse is assessing a patient with a history of myopia. Which deficit should the nurse expect to find in this patient? The patient has difficulty reading small print. The patient has a loss of peripheral vision. The patient has a misalignment of the eyes. The patient is unable to read the 20/20 line on the Snellen chart.

The patient is unable to read the 20/20 line on the Snellen chart.

7) A client tells the nurse about plans to become pregnant. What should the nurse provide to ensure healthy sensory functioning of the newborn? A) Testing for rubella B) The need to limit vitamin A intake C) Importance of ingesting zinc D) Avoiding foods high in folic acid

a

The nurse is caring for an older adult patient who takes many medications due to complex healthcare needs. Which statement describes the risk for the patient for prescription drug expenses when hitting the "donut hole" of Medicare? The patient may be forced to purchase fewer prescription drugs. The patient is given low-cost medications paid for with government funding. The patient is able to get a free year's worth of drugs to use before the next calendar year. The patient can only qualify for generic medications using Medicare payment.

The patient may be forced to purchase fewer prescription drugs.

A patient tells the nurse, "I work full-time at a large company but I do not have any health insurance." Which statement best describes the nurse's understanding of why the patient may have no health insurance? The patient may not be able to afford the health insurance the employer offers. The employer may not offer health insurance due to the employee's job description. The patient may not be able to get insurance due to preexisting conditions. The patient does not understand the importance of caring for health.

The patient may not be able to afford the health insurance the employer offers.

A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? The patient will be given bronchodilators as prescribed. The patient will be instructed in use of the incentive spirometer every hour. The patient will be given supplemental oxygen to use via nasal cannula. The patient will demonstrate correct use of the incentive spirometer after the teaching session.

The patient will demonstrate correct use of the incentive spirometer after the teaching session.

Which is an appropriate goal for a patient with the nursing diagnosis Communication: Verbal, Impaired? The patient will state ways to reduce communication deficits. The patient will call for help before getting out of bed. The patient will effectively communicate needs. The patient will review discharge instructions at home

The patient will effectively communicate needs.

Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? The patient will follow a diabetic diet with 90% compliance within 3 months. The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. The patient will identify ways to prevent complications from diabetes within 2 months. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.

The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.

During a health history interview, the patient denies having any health problems but then crosses their arms and looks away. Which behavior is indicated by this patient? The patient is bored with the nurse asking too many questions. The patient's verbal communication and nonverbal communication are not congruent. The nurse is rushing the patient to complete the health history. The nurse is taking too long, and the patient is uncomfortable sitting in a chair.

The patient's verbal communication and nonverbal communication are not congruent.

The nurse is planning care for a patient newly diagnosed with glaucoma. Which is the priority goal for the nurse? To prevent injury To support self-care To reduce anxiety To teach about the disease process

To prevent injury

The nurse is caring for a patient who lives 50 miles from the clinic and is often unable to obtain transportation for follow-up care. Which barrier to healthcare is most likely responsible for the patient's noncompliance with follow-up clinic visits? Perception of need Uneven distribution of services Lack of healthcare insurance Lack of a usual source of care

Uneven distribution of services

A patient reports hematuria along with the pain. After reviewing the patient's chart and assessing the patient, the nurse documented the following nursing diagnosis: Acute Pain related to urinary obstruction secondary to prostate cancer. Which part of the nursing diagnosis statement reflects the etiology? Urinary obstruction Hematuria Prostate cancer Acute Pain

Urinary obstruction

Which statement provides the best description of telehealth? The ability of a patient to access their medical record from a home computer Use of a personal computer to research medical conditions to better self-diagnose The ability of a patient to call a nurse to obtain medical advice over the phone Use of telecommunication technology to allow patients access to care otherwise inaccessible

Use of telecommunication technology to allow patients access to care otherwise inaccessible

The nurse is preparing a teaching for a patient diagnosed with macular degeneration. Which topic is appropriate for the nurse to include? Using assistive devices Using throw rugs on hardwood floors Enforcing strict bedrest Encouraging a diet high in iron

Using assistive devices

During a home visit, the nurse observes a patient perform wound care that is different from the verbal instructions. The written instructions are crumpled and located at the bottom of a stack of papers. Which action by the nurse is the most appropriate? Tell the patient that a new set of instructions will be brought during the next visit. Verbally review the wound care process with the patient again. Place the instructions on the top of the stack for the patient to use. Explain that the patient is at risk for a wound infection.

Verbally review the wound care process with the patient again.

An older nurse states, "I do not understand why you young people have piercings and tattoos." Which best describes this type of conflict? Professional Ethical Generational Workplace

Workplace

5) The nurse has identified the diagnosis Disturbed Sensory Perception: Auditory for a client. Which intervention would be the most appropriate for this client? A) Replace batteries in hearing aids every week. B) Use facial expressions or gestures when talking. C) Face the client when speaking. D) Use a low voice pitch with normal loudness when talking.

a

6) The nurse is evaluating the care a client with a hearing deficit has received. Which client statement indicates that care has been effective? A) "I ask others to face me when they talk, as I can hear them better." B) "I hear better when the television volume is raised." C) "I will change the battery in my hearing aid once a month." D) "I might use the hearing aid when I go shopping."

a

The nurse observes an energetic coworker take narcotics from the dispensing system. The nurse also observes the coworker fail to administer medication to patients in pain and be short-tempered.Which should the nurse suspect about the coworker? a)The coworker is impaired and unable to work safely. b)The coworker is tired. c)The coworker has the flu. d)The coworker is conducting patient care appropriately.

a

Which action should the nurse identify as a component of standard precautions? a)Washing hands and donning gloves before administering an injection b)Wearing gloves, gown, and a mask to treat a patient with a respiratory disease c)Scrubbing for 2 minutes and changing clothing before entering the hospital unit d)Wearing a respirator, gloves, and gown to treat a patient with a contagious disease

a

Which healthcare-associated infection should the nurse know is prevented by immunizations? a)Hepatitis B b)HIV or AIDS c)Bordetella d)Methecillin-resistant Staphylococcus aureus (MRSA)

a

Which high school students should the nurse identify as having high risk for injury? a)Students with volatile tempers and poor problem-solving skills b)Students who cannot swim c)Students of small size with developing bodies d)Students with unsupervised time after school

a

A healthcare provider refuses to prescribe opioids to a patient. The patient returns to the office and fatally shoots the healthcare provider.This example of a fatality falls into which category? a)An occupational hazard b)Workplace violence c)An unfortunate occurrence d)A preventable death

b

5) The nurse is planning care for a client scheduled for cataract surgery. Which interventions should the nurse include in this client care plan? Select all that apply. A) Instruct on the administration of eye drops. B) Wear sunglasses if necessary. C) Avoid strenuous activity until seen by the ophthalmologist after the surgery. D) Resume normal activities of daily living after the procedure. E) Limit food and fluids until fully recovered from anesthesia.

a, c

A nurse educator teaches students about caring nursing practice. Which situation shows that the student nurse is able to implement the whole idea of caring? a. The nurse is able to carve out time for a favorite hobby, at least once a week. b. The nurse is a volunteer at church and school events. c. The nurse makes lists every morning so the day stays organized and planned. d. The nurse takes care of his elderly parents in addition to providing care to his immediate family.

a. The nurse is able to carve out time for a favorite hobby, at least once a week.

7) A client has been diagnosed with cataracts of both eyes. What should the nurse realize that the treatment of choice for this client will be? A) Treat the cataracts with corrective lenses. B) Remove one cataract and then, in a few weeks, remove the other cataract. C) Remove both cataracts at the same time. D) Treat the cataracts with eye drops.

b

8) A client with glaucoma is experiencing sensory overload. What can the nurse suggest to reduce this client's visual overstimulation? A) Do not go outside during the daytime. B) Wear sunglasses that block UVA and UVB rays. C) Insert artificial tears several times a day. D) Use an over-the-counter eye drop for irritation.

b

8) The nurse is reviewing discharge instructions with a client recovering from out-client cataract removal surgery. What should these instructions include? A) Phone the physician with any signs of eye drainage. B) Do not bend to pick up objects. C) Healing will be complete in 2 weeks. D) Wear the eye patch the day of surgery only.

b

9) A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. On which sensory factor will the nurse focus when concerned about this medication's toxic effects on the body? A) Taste B) Hearing C) Vision D) Swallowing

b

A pregnant patient informs the nurse about her plans to rearrange their bedroom to make room for the baby.Which safety teaching should the nurse provide? a)"Drink enough fluids." b)"Avoid moving heavy objects." c)"Take prenatal vitamins." d)"Eat a proper diet."

b

During a recent community survey on local swimming pools, the public health nurse becomes concerned about the risk of water-related injuries for community members.Which survey result has led to this concern? a)Life preservers available at each pool side b)Home swimming pools lacking four-sided barriers c)Lifeguard classes occurring at the community pool d)School-age children swimming with several adults in attendance

b

Exemplar 18.2 Cataracts 1) After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. What should the nurse respond to this client? A) "Only your physician can tell if you have a cataract in your left eye." B) "Cataracts develop at different rates, so one eye will be more affected than the other." C) "Don't worry about it until you can't see out of your left eye." D) "Your physician must have made an error."

b

The nurse is teaching a class about drowning risks.Which age group should the nurse explain as having the highest risk of drowning in a pool? a)Infants b)Toddlers c)Ages 7-9 years d)Ages 5-7 years

b

The school nurse is preparing to teach high school students how to prevent accidental death and injury.Which type of injury should the nurse consider a priority? a)Suicide b)Motor vehicle crashes c)Unintentional fall d)Poisoning

b

A labor and delivery nurse with no medical/surgical experience has been told to work on an orthopedic unit for the upcoming shift. The nurse arrives to the orthopedic unit and receives an assignment from the charge nurse to care for a full load of post-operative clients. What is the best response by the nurse who has received this assignment? a. "I have no experience caring for this type of client, but I will do my best in this situation during the shift. I am a team player." b. "I have no experience caring for this type of client. I need to talk to the supervisor about a more appropriate assignment this shift." c. "I am not taking this assignment this shift and I am leaving the hospital immediately. You cannot do this to me. This is not safe." d. "I have no experience caring for this type of client. What am I supposed to do in this situation? I am not comfortable with this assignment."

b. "I have no experience caring for this type of client. I need to talk to the supervisor about a more appropriate assignment this shift."

The student nurse has free time on the unit as client care is completed. The student would best show commitment in which way? a. Checking in with each client again b. Reviewing the organizational disaster plan c. Following the charge nurse d. Taking the assigned break early

b. Reviewing the organizational disaster plan

3) The nurse is providing instruction to the parents of a 7-month-old child who has just been diagnosed with hearing loss. What guidance should the nurse provide? A) Hearing loss is not serious until 1 year of age. B) Interventions to support hearing are not useful until the child is at least 9 months old. C) Expect that your child will be enrolled in a special hearing intervention program immediately. D) Keep your child in a quiet environment until additional testing is done.

c

4) An older client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which nursing diagnosis would be a priority for this client? A) Disturbed Sensory Perception: Visual B) Decisional Conflict C) Risk for Ineffective Health Maintenance D) Ineffective Coping

c

4) The nurse is identifying diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be a priority for this client? A) Imbalanced Nutrition: Less than Body Requirements B) Disturbed Sleep Pattern C) Risk for Injury D) Disturbed Sensory Perception: Auditory

c

8) The nurse is providing care to a client with a hearing deficit. Which intervention should the nurse use when providing care to this client? A) Overarticulate words. B) Vary the volume of voice through sentences. C) Face the client during conversation. D) Use short phrases.

c

The nurse smells fumes when one of the housekeeping staff spills a bottle of concentrated cleaner onto the floor.Which action should the nurse perform? a)Tell the housekeeper to clean it up immediately and completely b)Get a towel and place it over the spill so no one is at risk of slipping c)Find out how to safely dispose of the liquid d)Get a pail of water and dilute the concentrate with water so it is safe to remove

c

A client with terminal cancer is dying. For the past several days, the client has refused food and fluids, and pushes the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." What is the most appropriate action by the nurse? a. Honor the family's wishes and have them sign a consent form. b. Talk to the physician so he or she can move forward with the family's wishes. c. Honor the client's refusal and help the family come to terms with the situation. d. Take the case to the hospital's ethics committee.

c. Honor the client's refusal and help the family come to terms with the situation.

The nurse attended a class about how to maintain civility in the workplace. Which statement by the nurse indicates an​ understanding? A. "Do not discuss personal problems at​ work." B. "Abstain from taking personal calls at​ work." C. "Maintain a positive​ attitude." D. "Avoid gossiping with​ coworkers."

​"Avoid gossiping with​ coworkers." ​Rationale: The behavior the nurse will include in the discussion on maintaining civility in the unit is to avoid gossiping with coworkers. Gossiping is a rude and discourteous action that is a form of incivility. Maintaining a positive attitude encourages respect and shows respect for others. Discussing personal problems at work affects professional boundaries. Taking personal calls at work detracts the focus away from the client.

The nurse is planning a class about integrity and nursing practice. Which statement should the nurse​ include? A."Nurses with integrity provide compassionate​ care." B.​"Nurses who practice cultural competency are demonstrating​ integrity." C."Nurses who engage in ethical behavior demonstrate​ integrity." D.​"Nurses who can effectively communicate demonstrate​ integrity."

​"Nurses who engage in ethical behavior demonstrate​ integrity." Rationale: Nurses who engage in ethical behavior demonstrate integrity. Compassion is a caring behavior. Communication and cultural integrity are concepts related to professionalism.

The nurse is discussing ethical practices. Which information should the nurse​ include? A. Adhering to the nurse practice act B. Joining a professional organization C. Integrating caring interventions D. Working toward cultural competency

​Adhering to the nurse practice act Rationale: The information the nurse will include when discussing ethical practice is the importance of adhering to the nurse practice act. Consistent adherence to the practice act is a demonstration of ethical behavior. Joining a professional organization is a reflection of accountability. Integrating caring interventions and working toward cultural competency are concepts related to professionalism.

The nurse is frequently interrupted by personal calls while working. Which area of professionalism is​ compromised? A.Ethics B.Competence C.Communication D.Demeanor

​Demeanor Rationale: The area of professionalism that is compromised is demeanor. The behavior or demeanor of the nurse results in a decreased focus on clients. Other behaviors by the nurse can affect​ ethics, competence, and communication.

The nurse is discussing the benefits clients receive from the​ nurse's caring interventions. Which benefit will the client​ receive? A.Keeps the focus on client care B.Demonstration of respect C.Facilitation of empowerment D.Established trust and rapport

​Facilitation of empowerment Rationale: The facilitation of client empowerment is an outcome of the nurse demonstrating caring behavior. Effective communication allows the nurse to establish trust and rapport with the client. The nurse who maintains a professional demeanor demonstrates respect for the client and keeps the focus on client care.

The nurse consistently adheres to the professional dress code. Which statement describes the effect on the​ client? A.Demonstrates a strong work ethic B.Demonstrates​ self-respect C.Maintains professional boundaries D.Instills client confidence and trust

​Instills client confidence and trust Rationale: Maintaining a professional appearance instills client confidence and trust. The nurse who portrays a professional demeanor demonstrates​ self-respect and maintains professional boundaries. A strong work ethic is a characteristic of professional behavior.

After receiving feedback from​ clients, the nurse​ states, "I understand how I can improve my​ care." Which best describes the​ nurse's behavior? A.Integrity B.Caring C.Commitment D.Decision making

​Integrity Rationale: Nurses demonstrate integrity by accepting feedback​ (positive or​ negative) as a tool for improving the delivery of client care by maintaining accountability for their actions and freely admitting when they make mistakes.​ Caring, commitment, and decision making are concepts related to professionalism.

Which characteristic should the nurse understand is associated with a strong work​ ethic? A.Compassion B.Advocacy C.Collaboration D.Integrity

​Integrity Rationale: The characteristic that is associated with a strong work ethic is integrity. Nurses demonstrate integrity by accepting feedback​ (positive or​ negative) as a tool for improving their delivery of client care by maintaining accountability for their actions and freely admitting when they make mistakes and by following their​ state's nurse practice act and never working outside their scope of practice. Compassion is a demonstration of attitude. Advocacy is the practice of expressing and defending​ clients' needs and is an essential component of professional nursing. Collaboration is a skill defined as the ability to work as a team member.

The nurse frequently volunteers to participate in​ hospital-wide committees. Which type of commitment describes the​ nurse's behavior? A.Ethical B.Organizational C.Collaborative D.Professional

​Professional Rationale: The nurse participating in many​ hospital-wide committees demonstrates professionalism by upholding the ethics of the profession of nursing. Organizational commitment is the relative strength of an​ individual's relationship to and sense of belonging to an organization. Ethical and collaborative behaviors are characteristics of a professional nurse.

Which behavior by the nurse is most reflective of an affective commitment to​ nursing? A.Remaining in the nursing profession to avoid loss of income B.Seeking out opportunities to engage in nursing service activities C.Expressing a sense of obligation to remain in the nursing profession D.Choosing to stay in nursing due to personal experiences with illness

​Seeking out opportunities to engage in nursing service activities Rationale: Affective commitment develops when professional involvement produces a satisfying experience. Characteristics of affective commitment include engaging in​ profession-specific organizations and service activities. Continuance commitment develops when negative consequences of​ leaving, such as loss of​ income, are viewed as reasons to stay. The nurse whose desire to enter nursing stems from personal or family experiences with illness is reflective of normative commitment. Normative commitment manifests as a feeling of obligation to continue in​ one's profession, and it develops in response to benefits or positive experiences gained by way of engagement in​ one's profession.

The nurse is planning a class about sexual harassment in the workplace. Which should the nurse​ include? A.Sexual harassment is a form of discrimination and a violation of an​ individual's rights. B.The sexual behaviors must interfere with the​ victim's work performance and prevent the fulfillment of work functions. C.Sexual harassment includes unwelcome advances of a sexual nature that are demonstrated through the​ perpetrator's physical conduct. D.Submitting to requests for sexual behaviors must be explicitly considered a condition of an​ individual's employment.

​Sexual harassment is a form of discrimination and a violation of an​ individual's rights. Rationale: Sexual harassment is a form of discrimination and as a violation of an​ individual's rights. The Equal Employment Opportunity Commission​ (EEOC) defines sexual harassment as​ "unwelcome sexual​ advances, requests for sexual​ favors, and other verbal or physical conduct of a sexual​ nature" occurring when submitting to such requests or behavior is​ considered, either explicitly or​ implicitly, a condition of an​ individual's employment; when submission to or rejection of such requests or behavior is used as the basis for employment decisions affecting the individual​ (e.g., promotion); or when such conduct interferes with an​ individual's work performance or creates an​ "intimidating, hostile, offensive working​ environment."

The nurse is preparing to obtain a referral to a pain clinic for a client. Which question should the nurse ask the client that is related to healthcare​ systems? A."Can you rate your pain for me on a scale of 1 to​ 10?" B."Do you currently have health​ insurance?" C."Do you have any religious or spiritual​ preferences?" D."Do you have a living will or a durable power of​ attorney?"

​​"Do you currently have health​ insurance?" Rationale: The question that most reflects professionalism related to healthcare systems​ is, "Do you currently have health​ insurance?" By assessing the​ client's insurance​ status, the nurse can assist the client in finding affordable and practical ways of meeting healthcare needs. Inquiring about a religious or spiritual​ practice, rating pain on a​ scale, and inquiring about a living will or durable power of attorney are not questions specifically related to healthcare systems.

The nurse attended a class about intimidation in the workplace. Which statement by the nurse indicates​ understanding? A."Intimidation may include unintentional nursing behaviors and statements made to​ clients." B."Repeatedly asking another individual for favors is​ intimidation." C."Overt forms of intimidation include standing too close to​ someone." D."Covert forms of intimidation include making verbal​ threats."

​​"Intimidation may include unintentional nursing behaviors and statements made to​ clients." Rationale: The nurse indicates understanding by stating that intimidation may include unintentional nursing behaviors and statements made to clients. Overt forms of intimidation include threatening an individual.​ Subtle, or​ covert, forms of intimidation include standing close to someone while maintaining a hostile facial expression. Intimidation includes bullying or frightening others into doing something they may not want to do.