NRS104L Exam #2: PrepU Practice Questions ALL Chapters

An adult child accompanies an older adult client to the clinic and states, "I am not sure what is going on with my parent but I think it is depression." What questions should the nurse ask the client to determine if he or she is depressed? Select all that apply.

"Can you tell me what your sleep patterns are?" "Have you had any changes in weight recently such as a gain or loss?" "Have you lost interest in things you previously found pleasurable?"

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?

"Create a bedtime routine."

A nurse is asking a colleague about a situation. Which response best demonstrates assertive communication?

"I think there is a better way to handle this."

Which statement shows that the nurse does not practice ageism?

"Neither intelligence nor personality normally decline because of aging"

What factor has been hypothesized by researchers regarding current thoughts on sleep?

Chronic sleep deprivation is present.

A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns?

Discuss the sleep pattern with the health care provider.

A nurse has accepted numerous overtime shifts over the past several months. Which behavior indicates the nurse is experiencing burnout?

Dozing at the desk during downtime

An older adult voids a small amount of urine in the toilet but experiences a large volume of incontinence while walking back to the bed. Which nursing intervention would be appropriate for this client?

Implement a prompted, timed voiding schedule.

An elderly client is becoming progressively confused due to Alzheimer's disease. The family can no longer manage the client at home due to wandering. Which of the following living arrangements could the nurse recommend?

Extended-care facility

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

Nutritional consult

The reason that governments carefully regulate treatment given in licensed health care facilities, particularly long-term care facilities, is expressed by which statement?

Older adult clients are vulnerable.

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse assisting a new mother in the act of breastfeeding represents which form of learning?

Psychomotor

In SBAR, what does R stand for?

Recommendations

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation.

Stop lifting the client and reassure him.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

A client has been hospitalized for the past 3 days with a diagnosis of hepatitis B. Knowing that the client has darker skin, where would the best location for the nurse to observe jaundice?

The sclera of the eye.

A toilet trained toddler was admitted to the hospital for dehydration. Upon returning home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent?

This behavior is called regression.

A client who responds to bad news concerning laboratory results by crying uncontrollably is handling stress by using:

coping mechanism.

A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:

homeostasis

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:

overload

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following?

"Sundowning is a common problem of dementia."

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"Take your blood pressure medications exactly as your doctor prescribed them"

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?

"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?

"The most common cause of dementia in the elderly is Alzheimer's disease."

A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and the yearly after that"

An older adult asks what can be done to prevent the deterioration of the bones and muscles that often occurs with aging. Which response will the nurse make?

"Add more leafy greens to your diet."

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Does it hurt when I touch you here?" "Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?"

An older client seeks medical attention for injuries caused by a fall. What education will the nurse provide for this client?

"Ensure proper footwear is worn at all times."

A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate?

"Evidence shows that there are changes in nerve cells and brain chemicals."

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?"

A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities?

"I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes."

A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement?

"I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance?

"I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart."

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but the IV location needs to be changed."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?

"Legal policy requires nursing practice to be permanently integrated into the client record."

A nurse enters the client's room and begins the process of establishing a nurse-client relationship. The nurse introduces oneself and informs the client how long the nurse will be caring for the client. What additional statement does the nurse need to communicate with the client?

"Let me know if you have concerns regarding your care."

A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan? Select all that apply.

*Cough and deep breathe every 2 hours. *Avoid massaging over bony prominences. *Auscultate breath sounds every 1-2 hours.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

*Depression *Sleeplessness *Decreased interest in activities

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document?

*Reports of abdominal pain of 4 on a 0-10 point scale. *The client states "I feel nauseated" *Client informs the nurse there is a floater in the left eye.

A nurse is preparing a presentation for a local senior center about the health status of older adults. What trends in health promotion and disease prevention activities would the nurse explain as contributing to declining death rates in the older adult population? Select all that apply.

*decreased smoking *improved nutrition *screening for hypertension *early detection of elevated cholesterol levels

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

*inaccurate perception of sights, sounds, tastes, and smells *difficulty with memory, problem solving, and task performance *inability to control direction of thought content

A nurse is counseling the caregivers of an older adult male. The caregivers feel that they want to do everything to prevent hospitalization of their loved one. Which of the following can the nurse recommend? Select all that apply.

*vitamin D supplementation *daily exercise *throw rugs with nonslip backing

The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours in a 24 hour period?

14 to 18 hours

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

Abandonment

The nurse is caring for an older adult client who is confused and agitated. When the client's family comes to visit the nurse asks how long the client has been confused. The family states that the client has been confused for a long time and the confusion is getting worse. The client is subsequently diagnosed with dementia. What is the most common cause of dementia in an older adult client?

Alzheimer's disease

The nurse takes into consideration factors that affect sensory stimulation in hospitalized clients when planning care. Which statement is true?

An individual's culture may dictate the amount of sensory stimulation considered normal.

One of the greatest causes of death in the United States and Canada is colon cancer. The nurse instructs the community on which of the following factors?

Annual screening after the age of 50

Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?

Anticipatory guidance

The nurse conducts a health history on a client who has experienced a 15-pound weight loss in the past 3 weeks. Which information would the nurse gather to determine the clients nutritional pattern.

As the client for a 24-hour diet recall.

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?

Cognitive

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?

Cognitive learning theory

A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing?

Cognitive response

A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?

Complaints about frequently waking up during the night

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain?

Demonstrating the technique for insulin self-injection

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life.

Which activity would be appropriate to suggest to the client who states that she has difficulty falling asleep every evening?

Drink a glass of warm milk before bed.

Which activity would be appropriate to suggest to the client who reports having difficulty falling asleep every evening?

Eat some crackers with peanut butter at bedtime.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?

Eliminating disturbing odors with adequate ventilation

Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process?

Encouraging a client to have regular checkups

A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend?

Encouraging clients to avoid cigarette smoking

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to

Ensure that the mother does not have access to car keys or drive an automobile.

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3kg less than the previous day's. What is the nurse's most appropriate action?

Ensure that the scale is correctly calibrated and repeat the assessment.

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the clients anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:

Fissure

The family of an older adult seeks medical attention for the client because of an increase in inappropriate responses and avoidance of social interactions. On which body area will the nurse focus when assessing the client?

Hearing

Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband shared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose which of the following?

Home modification

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following?

Impaired memory

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?

Newborns sleep 16 to 17 hours per day.

A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism?

Personality is not changed by chronologic aging.

A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by

Placing one food at a time in front of the client during meals

A department of nursing within a health care organization is adopting the Functional Consequences Theory when caring for older adults. Which action would the nurse take to faciliate using this theory when caring for a client?

Plan interventions to address consequences of age-related changes.

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation

Which neurotransmitter is implicated in depression?

Serotonin

The nurse is preparing to conduct a health interview with a client who is hearing impaired. which considerations will the nurse make for the alteration in the client's hearing?

Sit directly in front of the client. Ensure any open windows are closed. Determine if hearing aids are required.

A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?

Sleep Deprivation

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:

Sleep Pattern Disturbance related to acute pain.

In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client?

Sleep deprivation

There is an 86-year-old female on the medical inpatient unit. She explains that the hospital is quite noisy and that she is having difficulty sleeping. Which is not true regarding sleep in the older adult?

Sleep medications are usually the first choice in treating sleep disturbance.

A public health nurse is participating in a health fair that is being held at a local community center. The nurse should encourage adult participants to completely eliminate which of the following from their diet and lifestyle?

Smoking

A nurse has attended an inservice workshop that addressed the phenomenon of ageism in the health care system. Which of the following practices is indicative of ageism?

Speaking to older adults with the presumption that they have mild cognitive deficits

A client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client?

Talk to the client in a normal tone of voice.

The nurse is counseling an elderly client. Because of the client's age, the nurse recognizes that she is at risk for macular degeneration. Which of the following is a priority nursing intervention?

Teach the client signals of serious eye problems, such as visual disturbances.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?

The client describes signs and symptoms of hypoglycemia.

Which situation would lead the client's family to suspect onset of dementia?

The client has increasingly experienced disorientation to familiar surroundings.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment.

The client is dehydrated.

A 33-year old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?

The client makes noises when he breaths.

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill?

The client organizes materials needed and gives return demonstration.

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?

The client will likely not be able to sleep.

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?

The client's reaction time will likely be slower than that of a younger adult.

The nurse is planning client education based on the developmental stage of the client. Which nursing actions best reflect this consideration? Select all that apply.

The nurse directs the health education for a 3-year-old to the parents. The nurse includes a school-age child in the teaching and learning process. The nurse determines the learning needs of the client. The nurse provides material that is useful immediately to adult clients.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.

The nurse fails to accept that clients have the right to change their minds. The nurse ignores the restrictions of the client's environment. The nurse uses medical jargon frequently when discussing the teaching plan.

When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners?

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse shows patience with the client and gives the client time to respond. The nurse maintains eye contact with the client. The nurse keeps communication simple and concrete.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

The working phase

The nurse is performing an assessment for a 12-month old child and observes pronation of the child's feet. The parent asks the nurse what is wrong with the child's feet. What is the best response by the nurse?

This is an age-related variation for the child and should go away after about 30 months.

Which components should the nurse include when documenting a critical pathway? Select all that apply.

Timeline Care plan Expected outcomes

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

Tuning Fork

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. Which of the following would be an unexpected assessment finding?

Unable to palpate client's peripheral pulses.

A nurse is preparing to auscultate a clinet's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope.

The nurse is interviewing a client to obtain the health history. Which questions would the nurse ask first?

What brings you here today?

Upon auscultation of a clients lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes

Which group of individuals in the older adult population is most likely to be widowed?

Women over the age of 75

Which client is at greatest risk of developing sensory deprivation?

a 32-year-old with a fractured pelvis, on bed rest in a private room

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9 a.m. and 9 p.m.

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement?

repression

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention?

seek assistance from family and friends

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as:

severe.

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the client to explain the statement.

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important?

soft music

An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for:

suicidal thoughts.

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:

they may be disoriented on awakening.

A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in?

Resistance

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?

Risk for falls.

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

Role-playing

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older"

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement?

"What makes you think the food is poisoned?"

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?

"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?

"You seem unsure. Tell me your concerns about your surgery."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?

A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment

Which statement describes the person who is likely the most motivated to learn?

A 70-year-old female who is the client's spouse and is learning the care so the client can come home

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

The nursing diagnosis Risk for Sensory Deprivation is best suited for which client?

A client whose room at the end of the hallway has the door closed most of the time

A nurse should use the bell of the stethoscope during auscultation of:

A client's heart murmur

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the clients weight, what should the nurse do first?

Assess the client's ability to stand or sit.

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?

Assess the client's vital signs and pulse oximetry.

A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs?

Attempt to calm the client and administer oxygen

A 66-year old female client is reporting that it has been several days since the last bowel movement. The nurse begins an assessment of the client's abdomen by first inspecting the abdomen. What should the nurse do next?

Auscultate the client's abdomen.

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Auscultation of a bruit.

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Auscultation of high-pitched continuous sounds during inspiration.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

Auscultation.

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique.

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready.

A gerontologic nurse practitioner has a large client population with heart disease problems. This nurse practitioner is aware that heart disease is the leading cause of death in the aging adult. What is the cause of this trend?

Blood vessels lose their elasticity with age.

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition?

Delirium

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?

Crackles

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to

Ingest five or six small meals each day.

An elderly client is hospitalized for treatment related to leukemia. Family members want to visit with a toddler who has a cold. It would be best for the nurse to

Instruct the family to remove the toddler from the room for the protection of the client.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic?

Irregular edges. Larger than 1/4 inch in diameter Change in the mole.

The client does not speak the dominant language. The nurse plans on providing preoperative teaching and uses an interpreter to communicate with the client. What intervention(s) will the nurse employ to aid in interpretation? Select all that apply.

Look at the client while speaking. Speak slowly, using nontechnical terms. Inform the interpreter of the expected outcome of the communication exchange.

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do?

Minimize background noises and ensure that lighting is adequate to see the nurse's face.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?

Positive feedback

A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply.

Providing a back massage Promoting daytime exercises Assisting with progressive relaxation

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?

Psychomotor

A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment?

Pull the curtain dividing the two beds.

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?

Remind him of where he is and assess why he is having difficulty sleeping.

The home care nurse is visiting an older adult client in the home to assess a leg wound and change the dressings. The nurse is aware that the client receives money monthly but there is no food in the house, no adequate heat, and the client states, "My sister takes my check and cashes it every month." What is the correct action by the nurse?

Report the incident to social service informing them the client has no food or heat.

A 65-year-old client has experienced the death of a parent and a family pet in the span of 1 month. Which action is a coping mechanism that demonstrates adaptation?

joining the local garden club

Which behaviors represent effective coping mechanisms? Select all that apply.

learning relaxation techniques taking a vacation setting limits with family members who upset you

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client?

alcohol use

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

allowing more time for the processing of the information

When creating a nursing care plan, what information should the nurse elicit from a client having difficulty sleeping?

amount of caffeine consumed per day

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

limit the family visits to once daily

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

The nurse is preparing a teaching tool that focuses on elder abuse. Which type of abuse will the nurse highlight as being the most common?

neglect

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?

cheese and crackers

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario?

compensation

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:

critical thinking.

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care

An age-related change associated with the cardiovascular system is

decreased cardiac output.

The nurse is caring for a hospitalized 90-year-old client. What will the nurse include in the care plan?

decreasing environmental noise

Which are considered internal stressors? Select all that apply.

hormonal change illness fear

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

identifying demographics, including diagnosis current orders any abnormal occurrences with the client during the shift

A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?

insomnia