Nursing: clinical Decision making
D
A nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse using? A. Confidence B. Concreteness C. Independence D. Creativity
B
Dena, the nurse at a local clinic, is determining the best way to communicate test results to a client who has requested all communication go to his e-mail address. The test results showed some abnormalities. Which is the best option for Dena in this situation? A. E-mail the test results directly to the client B. E-mail the client with a request to call the office C. Send the test results by regular mail D. Ask the healthcare provider to e-mail the test results to the client
ACD
How does intellect help nurses with critical thinking? (Select all that apply.) A. Differentiate fact from opinion B. Think outside the box C. Clarify concepts D. Approach situations objectively E. Evaluate performance
A
The leader of a group of staff nurses is encouraging all members to work towards achievement of a common goal. Which behavior is the leader demonstrating? A. Power B. Monopolizing C. Brainstorming D. Commitment
C
The nurse educator asks the nursing students to describe the stage of commitment development during which the student discovers negative aspects of a chosen profession. Which student's response is accurate? A. "The passionate stage." B. "The quiet-and-bored stage." C. "The testing stage." D. "The integrated stage."
C
The nurse is a member of a work group in which the members like and trust each other and provide each other with support. Which characteristic is this group demonstrating? A. Atmosphere B. Creativity C. Cohesion D. Power
B
The nurse is making general statements about current events in an attempt to engage the client. Which phase of the therapeutic relationship does this indicate? A. Preinteraction B. Introductory C. Working D. Termination
C
The nursing instructor assigns Carol, a senior nursing student, to create a concept map for a client recently assigned during clinical. The concept map is going to be showcased during the School of Nursing's scheduled open house for nursing student candidates in a week. What should be a priority for Carol when preparing this concept map? A. Individualize the care by using checklists and blank lines B. Highlight medical treatments provided by other providers C. Follow the sequence of the nursing process D. Include the rationales for each nursing intervention
B
The staff development trainer provides a program on assertive communication for the staff of a care area. At the end of the program, the trainer states, "I can't believe I had to waste my time on this." Which response made by a nurse who attended the training indicates effective teaching has occurred? A. "I'm sorry you had to spend so much time with us today." B. "I needed this training, and it wasn't a waste of time for me." C. "Maybe you should read your own notes." D. "It's your job. You want to do mine instead?"
ABE
What are the components of a nursing diagnosis? (Select all that apply.) A. Etiology B. Defining characteristics C. Variations D. Data clusters E. Diagnostic label
BDE
What behaviors will the nurse demonstrate as a member of a group that is highly committed? (Select all that apply.) A. Members give priority to the opinions of the leader. B. Members enjoy working with each other. C. Members strive to place blame on one person. D. Members support each other with difficulties. E. Members value each other's opinions.
C
Which clinical situation best exemplifies a nurse who is choosing between alternatives when making a clinical decision? A. The nurse has a "gut reaction" to the client's pain and calls the client's physician. B. The nurse determines the client's nursing diagnosis is acute pain. C. The nurse administers an IV narcotic instead of an oral narcotic. D. The nurse changes the client's position numerous times until the client appears in less pain.
C
William is a nurse working on the pediatric cancer unit at a large urban hospital. One of his clients, Angela, is a 16-year-old who is recovering from surgery. Her mother, Carlotta, has been by her side almost constantly, but Angela's father has not been to visit since she was transferred to the unit. Angela is frequently rude to William, and it often takes him several attempts to get her to participate in interventions when William is on duty. The nurse from the night shift, who is female, shared that she does not have any difficulty with Angela. William recognizes that Angela's hostility toward him is most likely due to which factor? A. Countertransference B. Apathy C. Transference D. Scapegoating
CE
A client tells the nurse, "My blood sugars have been all over the place lately." 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 skills is the nurse displaying during this interaction with the client? (Select all that apply.) A. Clarifying B. Confronting C. Paraphrasing D. Genuineness E. Concreteness
CDE
A healthcare organization is adopting the use of a three-column nursing care plan. What information will be documented in these columns? (Select all that apply.) A. Assessment B. Evaluation C. Goals/desired outcomes D. Nursing interventions E. Nursing diagnoses
BE
A healthcare provider yells at a novice nurse for not knowing a client's latest laboratory values. Which responses by the novice nurse would demonstrate assertive communication? (Select all that apply.) A. "I'm sorry. I'll see where those results are." B. "I will locate the values and get them to you." C. "I can't do anything right for you." D. "You can look them up on the computer." E. "The lab has not phoned in the results yet."
D
A novice nurse is working independently on a maternal-newborn unit after 12 weeks of orientation with a preceptor. The nurse is assigned several newborns to care for during the shift. Based on the clinical pathway for a mother and baby of a vaginal birth, which intervention by the nurse is appropriate? A. Administering vitamin K to the mother within 24 hours of delivery B. Ensuring the newborn is breastfed 6 times per day at 48 hours of life C. Administering erythromycin ointment to the newborn's eyes at 48 hours of life D. Scheduling bottle feedings for the newborn of 15 to 30 mL every 4 hours at 24 hours of life
B
A nurse auscultates a client's breath sounds after the client receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the client is still wheezing despite the therapy. Which aspect of the Tanner clinical judgment model is the nurse displaying? A. Reflecting B. Noticing C. Interpreting D. Responding
B
A nurse caring for clients across the life span must consider the age, development level, and functional status of clients when helping them in clinical decision making. Which action by the nurse indicates support for a preschooler's decision making ability? A. Showing the client the materials that will be used to stich up the wound in her knee B. Asking the client if she would like to have her snack before or after going for an x-ray C. Inviting the client to the interdisciplinary meeting D. Soothing the client by rocking her until she calms down
AC
A nurse educator asks the student nurse to describe chronic obstructive pulmonary disease (COPD) and nursing interventions used to treat the condition. The student nurse states, "COPD is a chronic pulmonary disease, and the nurse should place the client in high Fowler position." Which clinical reasoning concepts is the student nurse using in this statement (Select all that apply.) A. Opinion B. Inquiry C. Fact D. Inference E. Judgment
A
A nurse educator chooses to implement scenario-based simulations for educating a group of student nurses regarding clinical judgment. Which approach is the educator using? A. Lasater's assessment rubric B. Benner's skill acquisition model C. Tanner's clinical judgment model D. Maslow's hierarchy of needs
BCDE
A nurse educator is teaching a group of student nurses about the development of professional decision making and the types of approaches related to clinical judgment. Which statements made by the student nurse reflect understanding of Benner's skill acquisition model? (Select all that apply). A. "An advanced beginner is intentional in planning care." B. "A novice acts by following rules" C. "Proficient nurses can see the whole picture." D. "A competent nurse usually has 2-3 years of experience." E. "New graduates are typically considered advanced beginners."
C
A nurse is caring for a client who has been diagnosed with liver cancer but has not shared this diagnosis with family members. The client 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 client? A. Acknowledging B. Presenting reality C. Reflecting D. Focusing
C
A nurse is caring for a client who is scheduled to have a chest x-ray at 0900 and will be off the unit. The client is also due to have medication at 0900. Which action by the nurse is most appropriate? A. Administer the client's medication at the start of shift B. Wait to administer the medication at the next dosage time C. Administer the client's medication at 0845 D. Administer the medication after the client returns from x-ray
A
A nurse is caring for a client who will undergo a cholecystectomy surgery in two hours. To assess that the client has informed consent, the nurse asks the client, open double quote"Can you tell me what your surgery will involve?close double quote" Which method of therapeutic communication is the nurse using with this client? A. Open-ended questioning B. Seeking clarification C. Paraphrasing D. Giving information
D
A nurse is caring for a client with a history of a heart dysrhythmia. The nurse notifies the client's healthcare provider after noticing a decreasing trend in the client's serum potassium level, client muscle spasms, and changes in ECG pattern. Which critical thinking concept is the nurse using? A. Approaching situations objectively B. Seeking new knowledge C. Differentiating fact from fiction D. Recognizing salient cues
C
A nurse is caring for a client with a history of diabetes mellitus. The nurse notices an upward trend to the client's daily fasting serum blood glucose and notifies the client's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? A. Advanced beginner B. Competent C. Proficient D. Novice
C
A nurse is caring for a pediatric client who is recovering from a recent open appendectomy surgery. The nurse states to the client, "I saw that you walked up and down the hallway twice today already. Good job!" Which therapeutic communication technique is the nurse using to establish rapport with the client? A. Validating perceptions B. Offering self C. Giving recognition D. Listening actively
C
A nurse is caring for a pediatric client who requires IV antibiotic therapy. Prior to inserting the IV catheter, the client asks the nurse, open double quote"Is this going to hurt me?close double quote" Which response by the nurse best promotes rapport and trust with the client? A. "No. As long as you hold still it shouldn't hurt." B. "It might hurt, but I am not sure." C. "It is going to hurt, but once I am done it shouldn't hurt anymore." D. "Yes, it is going to hurt. Hold really still or it will hurt much worse."
C
A nurse is caring for a pediatric client with possible pneumonia who is about to go for an X-ray. The nurse states, "The doctor needs to X-ray your chest so she can get a picture of what's happening in your lungs. Let me tell you what's going to happen." Which therapeutic communication technique is the nurse using to develop a therapeutic relationship with the client? A. Clarifying time B. Acknowledging C. Giving information D. Focusing
B
A nurse is caring for a client, with a right femur fracture, who complains of pain in the right leg. The nurse asks the client, open double quote"Please tell me how you would rate your pain on a scale of zero to ten.close double quote" Which method of therapeutic communication is the nurse using with this client? A. Seeking clarification B. Being specific C. Giving information D. Providing general leads
B
A nurse is interviewing for a staff position on a medical-surgical unit. Which portion of the hiring process best represents the hospital's efforts to evaluate the nurse's commitment to the profession? A. Offering the candidate the option of completing a four-week unit orientation and preceptorship B. Exploring the candidate's desire to maintain membership in the profession C. Inviting current staff nurses to serve as members of the candidate's interview committee D. Requiring the candidate to provide official copies of college transcripts
D
A nurse is participating in a group in which all members are voicing ideas to address an issue. Their ideas will be analyzed later. Which kind of decision-making method is the group using? A. Quantitative analysis B. Consensus C. Nominal group D. Brainstorming
C
A nurse working in the ICU has decided to attend a professional critical care conference. What critical thinking attitude is exemplified by this nurse's actions? A. Independence B. Integrity C. Awareness of self-limits D. Confidence
AB
A nurse working in the emergency department uses a clinical decision tree to determine the best course of action for a client who presents with signs and symptoms of a myocardial infarction (MI). Which statements are true regarding this clinical decision tool? (Select all that apply.) A. It can assist in decision making. B. It requires standardization of care. C. It requires no decision making. D. It cannot be implemented by all nurses. E. It requires higher-level decision making.
C
A nurse working on a telemetry unit is caring for a client with sick sinus syndrome. The client tells the nurse, open double quote"I felt dizzy earlier this morning.close double quote" The nurse responds by asking the client, open double quote"Did this occur after breakfast?close double quote" Which method of therapeutic communication is the nurse using with this client? A. Giving information B. Focusing C. Clarifying time D. Acknowledging
A
A nursing assistant is overheard telling a client, open double quote"I don't have all day. Let me put those shoes on you.close double quote" What type of communication style is the assistant demonstrating? A. Aggressive B. Passive C. Assertive D. Passive-aggressive
BC
A pediatric client is alone in the room after the client's mother leaves to make a phone call. The client is crying and tells the nurse, "I want my mommy to come back." The nurse responds by stating, "It's okay to cry when you miss your mommy. I will sit with you until she comes back if you want." Which therapeutic communication techniques is the nurse using to establish rapport with the client? (Select all that apply.) A. Exploring B. Accepting C. Offering self D. Broad openings E. Clarifying
C
A staff nurse is overhead counseling a newly hired nurse about limiting suggestions to improve the functioning of the unit because the manager"does not like suggestions" and will "put you down." Which characteristic of an ineffective group is the manager influencing? A. Goal setting B. Cohesion C. Creativity D. Problem solving
B
An adolescent client is sitting in a chair waiting for the nurse to complete a health history. After entering the room, where should the nurse sit to conduct the history with the client? A. Against the wall near the door B. Between 1 ½ to 4 feet from the client C. About 4 to 12 feet from the client D. One foot away from the client
D
As part of hospital orientation for a group of nurses, the human resources representative is discussing intimidation. Which information is most appropriate for the human resources representative to include in the discussion? A. Overt forms of intimidation may include standing too close to someone. B. Intimidation may include repeatedly asking another individual for favors. C. Covert forms of intimidation may include making verbal threats. D. Intimidation may include unintentional nursing behaviors and statements made to clients.
BCDE
At which times should nursing care be evaluated? (Select all that apply.) A. At the end of a scheduled shift B. Immediately after implementing an intervention C. During a time-specified interval D. When discharging a client from nursing care E. During the implementation of an intervention
ACD
During a classroom discussion, the nurse educator asks the nursing students to describe intimidation. Which students' statements most accurately describe intimidation? (Select all that apply.) A. "Intimidation can include threatening someone with consequences for disobedience." B. "Nurses always realize when their behaviors toward clients are forms of intimidation." C. "Intimidation includes experienced nurses who bully new nurses." D. "Covert and overt behaviors may qualify as being intimidation." E. "Intimidation includes having negative thoughts about nursing peers or colleagues.
D
During a health history interview, the client denies having any health problems but then crosses her arms and looks away. What does this behavior indicate to the nurse? A. The client is bored with the nurse asking too many questions. B. The nurse is rushing the client to complete the health history. C. The nurse is taking too long, and the client is uncomfortable sitting in a chair. D. The client's verbal communication and nonverbal communication are not congruent.
D
During a home visit, the nurse observes a client 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? A. Explain that the client is at risk for a wound infection B. Place the instructions on the top of the stack for the client to use C. Tell the client that a new set of instructions will be brought at the next visit D. Verbally review the wound care process with the client again
B
During a meeting to discuss the implementation of a new computerized documentation system, one staff nurse asks about the ease of use, preloaded templates, and online nursing resources. What behavior is the staff nurse demonstrating? A. Information giver B. Information seeker C. Opinion seeker D. Opinion giver
B
During a staff meeting, the manager asks staff members to identify any and all ways to reduce unnecessary waste of supplies when providing client care. Which type of decision-making technique is the manager using with the staff? A. Groupthink B. Brainstorming C. Monopolizing D. Delphi technique
D
During an annual evaluation, the nurse manager is assessing the staff nurse's work ethic. Which statement by the staff nurse is most reflective of a strong work ethic? A. "I believe in the importance of earning a good income." B. "I have never made an error at work." C. "I let others remind me to start an assigned task." D. "I believe in the moral worth of work"
C
During hospital orientation, the human resources specialist is defining and explaining sexual harassment. Which statement should be included in the human resource specialist's discussion of sexual harassment? A. "Discrimination is one type of sexual harassment." B. "Physical contact is required for a behavior to be considered sexual harassment." C. "Sexual harassment interferes with performance in the workplace." D. "Sexual harassment requires the victim and violator to be of different genders."
BCDE
During post-clinical conference, a student nurse expresses a desire to work on the same unit where clinical is being held because of the nursing staff. What did the student likely observe to form this opinion? (Select all that apply.) A. Staff members focus on their individual assignments. B. Staff nurses compliment each other for a job well done. C. Staff nurses ask about each other's families. D. Staff members laugh with each other. E. Staff members help each other complete assignments.
B
Esther Wulfman, an 83-year-old client with a hearing deficit, is admitted for exacerbation of heart failure. What should Marta, the nurse, do to support Esther's communication needs during the assessment process? A. Sit beside the client during the assessment B. Close the door to the room when conducting the assessment C. Ask if a family member is available to complete the assessment D. Shout into the client's good ear when talking
ACD
Following the collection of assessment data, what does the nurse do next? (Select all that apply.) A. Clusters cues to generate tentative hypotheses B. Identifies strengths and resources C. Analyzes the data for gaps and inconsistencies D. Measures the data against standards to identify significant cues E. Compares the data with suspected medical problems
A
For which reason should it be documented that a problem is resolved? A. Potential problem has been prevented and risk factors no longer exist B. Actual problem goals partially met C. Risk problem has been prevented but the risk factors are still present D. Actual problem goals have been met but the problem still exists
B
Gordon Sullivan, a 58-year-old client with acute pain and bleeding from prostate cancer, rates his pelvic pain as an 8 on a pain rating scale from 1 to 10. He is considering surgery to remove the prostate before beginning chemotherapy and radiation. When writing a three-part nursing diagnosis for Gordon, what should the nurse use as the etiology? A. Surgery B. Prostate cancer C. Bleeding D. Acute Pain
B
Hannah Classen, the nurse, is conducting a health interview with Jensen McCormack. Before moving to a new area of focus, Hannah wants to make sure that all of the content collected thus far is correct. Which statement would help Hannah to summarize the content of their conversation? A. "In other words, you have not had any major illnesses or hospitalizations for five years?" B. "So far we discussed your previous illnesses and hospitalizations. Is there anything that I've missed?" C. "I am not sure that I completely understand the symptoms that you are experiencing." D. B"I sense that you don't like hospitals. Do I understand you correctly?"
B
In an annual evaluation, the nurse unit leader describes the staff nurse as "skilled at analyzing a complex situation and able to pick out the most important aspects of a clinical scenario." According to Patricia Benner's model of nursing development, which developmental stage best matches the nurse unit leader's evaluation of the staff nurse? A. Novice B. Proficient C. Expert D. Competent
D
Jasmine Riddle is a novice nurse in the telemetry unit of a large hospital. While assessing her client, 72-year-old Albert Griswald, Jasmine notes that his pulse feels irregular. When she calls the telemetry monitoring station, the monitoring technician, Miguel, tells Jasmine that Mr. Griswald just developed atrial fibrillation. The technician praises Jasmine for catching the change in Mr. Griswald's cardiac rhythm so quicklylong dash—even before the telemetry technician recognized it. In her response, which action would reflect Jasmine's nursing integrity? A. Notifying the telemetry technician's supervisor of his failure to recognize the change in cardiac rhythm B. Telling the telemetry technician that noticing the client's change in cardiac rhythm was "pure luck" C. Advising the telemetry technician to focus on his job and monitor clients' heart rhythms more closely D. Thanking the telemetry technician for praising her and for being part of the client's care team
B
Jiao Liu, a 64-year-old client, is receiving chemotherapy for breast cancer. After morning report, the nurse finds Ms. Liu nauseated, vomiting light green emesis, and crying because her hair is falling out in clumps. Her pulse is 110 beats per minute and thready, and her blood pressure is 96/50 mmHg. Which intervention should the nurse make a priority for Ms. Liu? A. Premedicate for nausea before next chemotherapy dose B. Begin intravenous fluids at 100 mL/hr C. Cleanse skin and apply a clean hospital gown D. Teach Ms. Liu some deep breathing exercises to help her calm down
D
Linda is a member of a nursing journal club that meets every 2 weeks. Linda does not agree with most of the group members' opinions about proposed changes that would expand the membership of the group, but she does not speak up. Which behavior is Linda demonstrating at this time? A. Scapegoating B. Monopolizing C. Apathy D. Groupthink
B
Mitchell Asplund, a clinical nursing instructor, is assigned to serve as a student faculty advisor. Mitchell's responsibilities include determining which stage of commitment to nursing his students are experiencing. He is evaluating nursing student Don Rowlands, who is a junior in nursing school. During his evaluation, Don states, "I want to join the National Student Nurses Association. I'm also volunteering to participate in the student health fair. I know I'm really busy, but my schedule will be crazy when I'm working as a nurse, too. It's worth it to me." Mitchell recognizes that Don is in which stage of making a professional commitment to nursing? A. Integrated B. Passionate C. Testing D. Exploratory
A
Planning is underway to transfer Agnes Watson, a 76-year-old client, to a long-term care facility. Agnes wants to live near her family; however, the facility that would best meet her needs is a few miles further away. What should the nurse do when helping Agnes make the choice of facility? A. Discuss with Agnes the advantages of the facility that is a bit further away B. Tell Agnes that being near family is not always a good idea C. Tell Agnes that the facility that is closer to family is not accepting admissions D. List other facilities so that Agnes can make a better decision
B
Prior to meeting a client, the mental health nurse reviews the client's demographics, including the client's name, address, age, medical history, and social history. Which phase of the therapeutic relationship is reflected by this action? A. Termination B. Preinteraction C. Introductory D. Working
B
Prior to performing an assessment, a nurse states to the client, "This weather we are having is crazy, isn't it?" Which phase of the therapeutic relationship is the nurse displaying? A. Termination B. Introductory C. Preinteraction D. Working
A
Rosario, the manager of a 20-bed unit, is evaluating the success of assertiveness training classes that staff nurses attended to improve communicating with physicians. Which behavior by Yvonne, a staff nurse, indicates she needs more training? A. Apologizing to the neurosurgeon for "bothering him" with a question B. Focusing on the situation before speaking and requesting help C. Identifying an area where both the nurse and client agree D. Stating "I would like some help" when planning care with other team members Using a neutral voice when discussing a client's abnormal laboratory values
B
Sakura, the nurse manager, assigns staff nurse Doreen to attend an education program on communication skills after hearing a conversation that Doreen had with a newly admitted client. Which statement by Doreen to the client prompted Sakura to send Doreen to a communication skills class? A. "Can I borrow your chair for about an hour?" B. "You are going to be okay." C. "How are you feeling today, Mr. Smith?" D. "Please step on the scale."
D
Sally Waltmoor is caring for Donald Henderson, a 58-year-old client newly diagnosed with type 2 diabetes mellitus. Which statement should Sally make to facilitate the development of a therapeutic relationship with Mr. Henderson? A. "Losing some weight will help control your blood glucose level." B. "I'll be back to take your sugar before dinner arrives." C. "This disease isn't so bad; at least you don't have to take insulin." D. "I don't know how many grams of carbohydrates you can have, but I will find out for you."
C
Scott Nitroskey, a home health nurse, is caring for 67-year-old Martha Miriste, a female client who is diagnosed with diabetes. Scott is completing Mrs. Mireste's client teaching. During the teaching session, which statement might Mrs. Mireste interpret as being Scott's attempt to intimidate her? A. "If you cut back on your sugar intake, you might see some improvement in your diabetes." B. "Increased sugar in your diet can cause your blood sugar to go up and impact your diabetes." C. "If you don't stop eating so much candy, your diabetes is going to get much worse." Your answer is correct. D. "Regular exercise can help with the management of your diabetes."
C
Several nurse managers are having lunch after attending a shared governance committee meeting. Which manager statement indicates that the committee is ineffective? A. "Who knew we had such a nice conference room!" B. "I think the goals are tough but appropriate in the circumstances." C. "I am not sure why the chairperson made all of the decisions." D. "I could have prepared better before today's meeting."
D
Suzanne Garbitieri, an experienced critical care nurse, has just returned to the nursing profession. Although Suzanne retired two years earlier, she realized her retirement funds were not sufficient to pay her bills, much less to allow her to live comfortably. Suzanne's primary motivation for returning to work is income. She describes herself as being "tired of nursing but too broke to quit." Although she is scheduled to work 40 hours each week, Suzanne routinely picks up additional shifts. The nurse manager who is evaluating Suzanne recognizes that she displays which type of commitment? A. Normative B. Organizational C. Integrated D. Continuance
A
The charge nurse is reviewing e-mails and sees a message from the laboratory containing results for a client's blood work. What is the priority action by the nurse regarding this information? A. Print the message and place it in the client's medical record B. Delete the message C. Forward the message to the client D. Phone the healthcare provider and verbally provide the results
D
The clinical nursing instructor is evaluating the student's developmental stage of professional commitment. The student has settled into the nursing program's routine and reports experiencing decreased performance anxiety. Which stage of professional commitment is most appropriate for the clinical nursing instructor to use when describing the student's current level of development? A. The integrated stage B. The exploratory stage C. The testing stage D. The quiet-and-bored stage
D
The clinical nursing instructor is identifying strategies for promoting intergenerational collaboration between nursing students and staff nurses in the clinical setting. Which strategy is most appropriate for the nursing instructor to implement among the nursing students? A. Promoting competition to help the nursing students build their confidence and self-esteem B. Encouraging the nursing students to recognize their superiority due to advanced knowledge about technology C. Discouraging the nursing staff from talking about conflicts related to generation gaps D. Acknowledging the value and contribution of each individual member of the nursing care team
BCD
The director of nursing is reviewing a status report provided by the policy and procedure committee. Which information indicates to the director that the committee has been effective? (Select all that apply.) A. The committee chair resigned due to the volume of work. B. Committee members reviewed all policies prior to the scheduled accreditation survey. C. Subcommittee members provided recommendations as expected. D. Committee members have attended all scheduled meetings. E. Committee member vacancies for two areas remain unfilled.
B
The manager appoints a staff nurse to serve as a member of a semi-formal group. What should the nurse expect as a group member? A. Interactions with group members will be limited. B. Structured activities will take up a large part of the group's meeting time. C. Members function under a strict code of ethics. D. The leader will be replaced if she makes a mistake.
A
The manager is concerned that a novice nurse is being made a scapegoat for an event that occurred on the care area. Which observation supports this manager's concern? A. Staff nurses suggest that the novice nurse is responsible for missing narcotics during a shift when the nurse was not at work. B. Nursing assistants are discussing work assignments and suggesting ways to help each other. C. The novice nurse volunteers to work with other staff on a quality improvement study. D. The charge nurse meets with the oncoming shift to review clients who could be discharged later in the day.
ABD
The manager schedules a nursing assistant to attend a basic communication program after observing the assistant provide client care. Which actions would result in this type of referral? (Select all that apply.) A. Referring to a 70-year-old client's abdominal wound as a "boo-boo" B. Calling an 80-year-old client "Sweetie" C. Talking with a newly admitted client about his grandchildren D. Asking a 65-year-old client, "Are we ready to get out of bed?" E. Referring to a 75-year-old male client as "Mr. Dan"
AE
The novice nurse asks the nurse preceptor to describe normative commitment. Which items should the nurse preceptor include in the description? (Select all that apply.) A. It can manifest as a feeling of obligation to continue in one's profession. B. It develops when professional involvement produces a satisfying experience. C. It may be demonstrated by engaging in profession-specific organizations and service activities. D. It creates ties that are similar to those that emerge as a result of continuance commitment. E. It may be reflected by choosing to enter nursing due to experiences with personal illness.
B
The novice nurse asks the nurse preceptor to explain the relationship between the business of health care and the provision of client care. Which response by the nurse preceptor is the most appropriate? A. "The business of health care is the same thing as the provision of client care." B. "The Institute of Medicine compels nurses to preserve a caring model within health care's business model." C. "When nursing standards conflict with organizational standards, the nurse must maintain commitment to the organization's standards." D. "Nurses are morally responsible for recognizing the business of health care as the main priority."
C
The novice nurse is paired with a nurse preceptor who is a member of the veteran generation. Which characteristic or behavior is most appropriate for the novice nurse to expect the nurse preceptor to demonstrate? A. Encouraging the novice nurse to quickly seek out a leadership role B. Communicating with the novice nurse through e-mail C. Rewarding the novice nurse for working hard D. Promoting an approach in which the novice nurse politely questions authority
A
The nurse educator is explaining the significance of punctuality and attendance in the nursing profession to a class of nursing students. Which statement is most appropriate for the nurse educator to include in the discussion? A. "Chronic tardiness and frequent absenteeism among nurses can compromise client care." B. "The most severe consequence of excessive tardiness for the professional nurse is suspension." C. "During a nursing shortage, hospital attendance requirements usually are less strict." D. "Nurses must be flexible about helping colleagues who routinely need to miss work."
D
The nurse educator is outlining requirements for nursing students who are completing hospital clinical rotations. Which requirement is likely to be the most challenging to nursing students who are members of the Millennial Generation? A. Students must not administer client care without first socially engaging the client. B. Students must collaborate with the clinical nursing instructor when planning client care. C. Students must receive evaluations at the end of each day. D. Students must not bring cell phones into the clinical setting.
D
The nurse educator is teaching a class about professional development in nursing. When describing an area of nursing competence, which component is most appropriate for the nurse educator to include in the teaching? A. Understanding that client populations tend to demonstrate the same personal needs B. Recognizing the nurse's responsibility to remain strictly in a client-centered role C. Knowing and demonstrating adherence to the ethics of primary care providers D. Understanding the culture of the client population and the healthcare institution
C
The nurse educator is teaching a class about significant changes that influenced workplace interaction between intergenerational team members. Which statement is most appropriate for the nurse educator to include in the teaching? A. "Traditionally, the most reliable information and knowledge were perceived as coming from the newest professional nurses." B. "Because of quality improvement, entry-level nurses tend to report to members of the older generation." C. "Technological advances have decreased younger nurses' level of dependence on their older nurse colleagues." Your answer is correct. D. "Due to shared governance structures, younger nurses tend to be subordinate to older nurses."
D
The nurse has been determining a method of communicating with a client recovering from a stroke. Which client observation indicates that an effective communication method has been established? A. Holding a pen to write on paper B. Slapping the nurse's hand to refuse an action C. Groaning to get the nurse's attention D. Spelling words on a bedside table using tiled letters
C
The nurse identifies the diagnosis "Imbalanced Nutrition: Less than Body Requirements related to poor nutrition as evidenced by low serum albumin level" for Isabella DeMarco, a 65-year-old client with osteoporosis. What should the nurse identify as a goal for Ms. DeMarco? A. The client will eat 75% of all snacks in 2 days. B. The client will select healthy food choices when planning meals. C. The client will increase oral intake by 25% within a week. D. The client will consume three meals a day.
ABD
The nurse is a member of a nursing journal club. What interpersonal perspectives would be demonstrated by the group members? (Select all that apply.) A. Promotes a feeling of goodwill among members B. Provides source of collegiality and support C. Empowers group members to promote change D. Provides socialization toward growth and development E. Provides a context for setting priorities
B
The nurse is assessing Julia McMichael, an 82-year-old client with pneumonia. Mrs. McMichael is experiencing dyspnea, has a pulse oximeter reading of 90, and lung assessment reveals rales. Which nursing intervention is the most appropriate for Mrs. McMichael at this time? A. Use a face mask for oxygen even though a request for nasal cannula was made B. Explain that the oxygen will help Mrs. McMichael breath better C. Empty fluid from the oxygen humidifier D. Keep the head of Mrs. McMichael's bed flat
A
The nurse is assessing an 8-year-old client whose parent brought him to the walk-in clinic. The parent reports that the child is tired and has been coughing for 2 days. Which assessment findings may be clustered as significant cues suggesting that the child has influenza? A. The child's vital signs are BP 90/60 mmHg, RR 22, P 80, T 101.5degrees°F. B. The child's lungs are clear on auscultation. C. The child's oxygen saturation is 98%. D. The child's vital signs are BP 95/62 mmHg, RR 23, P 90, T 98.8degrees°F
CDE
The nurse is caring for a client diagnosed with cancer. When formulating the plan of care for this client, what should the nurse consider related to client goals? (Select all that apply.) A. Goals should indicate whether treatment is successful. B. Goals may address multiple actions. C. Goals should be attainable. D. Goals should be measurable. E. Goals should center on the client.
A
The nurse is caring for a client diagnosed with pulmonary hypertension. Which intervention can be considered a direct, dependent intervention? A. Assisting with the prescribed cardiac catheterization B. Teaching the client about a prescribed medication C. Monitoring pulse oximetry for a client receiving oxygen by nasal cannula Your answer is not correct. D. Calling the primary care provider and suggesting a physical therapy evaluation
D
The nurse is caring for a client who is recovering from abdominal surgery. During the morning assessment, the client complains of pain and rates the pain at 7 out of 10. The nurse tells the client that she will prepare pain medication and return in 10 minutes to administer it. Which characteristic of verbal communication is the nurse using? A. Humor B. Intonation C. Pace D. Credibility
BCDE
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is having difficulty breathing. Which will the nurse include in formulating nursing diagnoses? (Select all that apply.) A. The client's twice daily meditation practice B. The client's pulse oximetry reading of 92% C. Evidence of cyanosis in the client's mouth and nail beds D. The client's expressed desire to quit smoking E. The client's report of having difficulty walking in from the parking lot
D
The nurse is caring for a client with schizophrenia. The client is at risk for disturbed thought processes. What is the priority focus for interventions when caring for this client? A. Being an active listener B. Providing anxiety medication C. Discussing expectations D. Providing reality testing
D
The nurse is caring for an adolescent client who is alert but intubated following a C7-T1 spinal cord injury. Which communication strategy is the most developmentally appropriate for the nurse to use with this intubated client? A. Hand signals B. Flash cards C. Grease pencil and white board D. Text messages
B
The nurse is caring for a neonate, Sally, who requires nasogastric tube feedings due to prematurity. Sally's nasogastric tube frequently slips out of position and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? A. Reflection B. Inquiry C. Intellect D. Reasoning
C
The nurse is caring for several clients during a shift. Which observation made during a nursing assessment would be priority? A. A client who begins coughing after 6 minutes of walking B. A client with an oxygen saturation of 94% C. The client who complains of shortness of breath when walking from room to room D. A client with a BP of 96/54 mmHg, HR of 70 bpm, RR of 20 breaths per minute, and T 97.6°F
A
The nurse is evaluating the current plan of care for a client who is receiving care in a long-term healthcare facility. The evaluation indicates that the client is not meeting goals related to mobility. What is the appropriate nursing action at this time? A. Revising the plan of care B. Asking the client to try harder C. Concluding that the problem is resolved D. Determining the client does not have any risk factors
A
The nurse is formulating a plan of care for a client who is pregnant. Which goal is appropriate for the nursing diagnosis dealing with a knowledge deficit related to pregnancy? A. Client will attend prenatal classes through the course of the pregnancy. B. Nurse will facilitate learning readiness. C. Client will attend medication management classes within four weeks. D. Nurse will teach client about prescribed exercise regimen for pregnancy at next appointment.
D
The nurse is implementing care for clients in an acute care facility. Which guidelines should the nurse use when choosing interventions for goal achievement? A. They are interchangeable among clients for optimal applicability. B. They are identified with specific laws and regulations. C. They can be performed with limited resources. D. They are consistent with clients' values, beliefs, and culture.
ACD
The nurse is planning to assess a client's communication approach. What client characteristics should the nurse consider when conducting this assessment? (Select all that apply.) A. Developmental level B. Primary health problem C. Age D. Culture E. Employment status
ABDE
The nurse is preparing to assess an older client with a hearing deficit who has just been admitted to the care unit. Which actions should the nurse take to communicate with this client? (Select all that apply.) A. Ask about the client's meal preferences B. Turn down the volume on the television set C. Ask the family to wait in the hall D. Close the door to the room E. Face the client when speaking
A
The nurse is preparing to discharge a client after a hospital stay. What should the nurse take into consideration when evaluating the client's health status at discharge? A. Identification of the client's self-care abilities B. Modification of implemented interventions C. Opportunities to correct intervention deficiencies D. Impact of the evaluation
D
The nurse is preparing to explain the insertion of an intravenous catheter into the arm of a client who has never been hospitalized. Which explanation by the nurse is the most appropriate for this procedure? A. "An angiocath is inserted in a vein and fluids are administered." B. "A needle is inserted in a vein so that this bag of fluid is pushed into your body." C. "An intracath is placed in a vein, and the IV is set to administer 100 ccs an hour." D. "A small tube is put in a blood vessel, and liquid is dripped into your body."
B
The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing action supports collaboration, which is essential to planning care? A. Facilitating a home health consult when the client is discharged B. Discussing appropriate smoking cessation programs with the client, upon request C. Adjusting the head of the client's bed to ease breathing effort D. Administering a breathing treatment to the client, as ordered
C
The nurse is providing care to a 1-year-old pediatric client who is admitted to the emergency department with SaÓ% of 93% on room air, respiratory rate of 50 breaths per minute, with moderate wheezing. Based on the pediatric clinical pathway for asthma, what intervention does the nurse anticipate for this client? A. Continuous anticholinergic medication administration B. Systemic magnesium sulfate C. Nebulizer treatment of albuterol D. IV corticosteroids
C
The nurse is providing care to several clients in the emergency department: A client who arrived by ambulance with stroke symptoms; a client with a fractured femur; a client complaining of sharp, continuous pain radiating from the kidney area; and a young child with a possible fractured arm whose mother is with him. Using the urgency factor, which client will the nurse prioritize for care? A. The client with a fractured femur B. The young child with the possible arm fracture C. The client with stroke symptoms D. The client with sharp, continuous pain radiating from the kidney area
C
The nurse is providing care to several clients on a medical-surgical unit. The nurse needs to prioritize care for the assigned clients. Which action is a common pitfall when prioritizing client care? A. Being cognizant of time when completing tasks B. Completing tasks based on level of difficulty C. Administering medications based on vital signs at admission Your answer is correct. D. Involving the client during the care plan process
A
The nurse is reviewing the plan of care for Nikolai Topolov, a 72-year-old client with liver cirrhosis and bleeding esophageal varices. For which situation should the nurse revise Mr. Topolov's plan of care? A. The client is experiencing a new onset of abdominal pain. B. A mutually agreed upon goal is for the client to attend Alcoholics Anonymous meetings. C. The client agrees that the priority of care is to stop the bleeding. D. Intake and output measurements are balanced
A
The nurse is working with an adult client who has a diagnosis of posttraumatic stress disorder (PTSD). The client shares that he has begun exercising daily at a local gym, and states that this lowers his daily stress level. Which type of nursing diagnosis would best capture the client's exercise behavior? A. Wellness diagnosis B. Risk diagnosis C. Syndrome diagnosis D. Health promotion diagnosis
A
The nurse leader is evaluating the charge nurse's type of commitment to the nursing profession. Which behavior by the charge nurse is most reflective of affective commitment to nursing? A. Joining professional nursing organizations and engaging in nursing service activities B. Expressing a sense of obligation to remain in the nursing profession C. Remaining in the nursing profession to avoid loss of income D. Choosing to stay in nursing due to personal experiences with illness
B
The nurse leader is planning an in-service about integrity in nursing practice. Which statement regarding integrity in nursing is most appropriate for the nurse leader to include in the in-service? A. "Integrity means understanding that negative feedback from peers has little value." B. "Nurses with integrity adhere to a strict moral or ethical code." C. "Integrity means internalizing professional practices that the nurse prefers to follow." D. "Nurses with integrity provide excellent care and do not make errors."
D
The nurse leader is preparing a seminar for nurse administrators about intergenerational collaboration among members of the healthcare team. Which content is most appropriate for the nurse leader to include in the seminar? A. Promotion of intergenerational collaboration requires ignoring certain team members' perspectives. B. Intergenerational conflicts are always rooted in lack of appreciation or misunderstanding. C. Intergenerational conflicts in the workplace tend to stimulate enhanced personal growth. D. Promotion of intergenerational collaboration may positively affect a client's outcome.
C
The nurse leader is preparing a webinar about how to prevent burnout in nursing. To accurately describe strategies for preventing burnout, which activity should the nurse educator include in the webinar? A. Learn to depend on oneself and to avoid expressions of emotions toward colleagues B. Study assertiveness and learn to take on added responsibilities even when feeling overwhelmed C. Actively engage in efforts to produce constructive change if organizational policies create stress D. Develop acceptance and recognize that the limitations of any situation can be changed
ABDE
The nurse leader is presenting an in-service about competence in nursing. Which examples should the nurse leader include in the in-service as examples of nursing competence? (Select all that apply) A.Completion of documentation in an accurate, timely manner B. Knowledge about the culture of the healthcare institution C. Elimination of factors that negatively influence client care D.Acknowledgement of the client's need for individualized care E. Awareness of factors that positively affect client care
A
The nurse manager is interviewing a candidate for a staff nurse position. During the interview, the nurse manager evaluates the candidate's professional commitment to nursing. Which statement by the staff nurse best reflects commitment to the nursing profession? A. "I'm a member of two national nursing organizations, and I belong to one specialty nursing group." B. "Whenever possible, the nurse should try to abide by the professional code of ethics for nurses." C. "I believe the nurse's choices outside of the workplace are unrelated to the nurse's professional role." D. "The values and goals of nursing are honorable, but they are unrealistic and difficult to achieve."
B
The nurse manager is preparing an annual performance appraisal for Alisha, a staff nurse who has worked on a medical-surgical care area for two years. The manager determines that Alisha's level of proficiency is competent. What did the manager observe Alisha perform to make this decision? A. Determined how a new medication would impact a client's other health problems B. Focused on a specific client problem when planning care C. Waited for direction from charge nurse before providing care D. Referred to the procedure manual to change an intravenous site dressing
D
The nurse manager is preparing an evaluation for a staff nurse who is a member of the baby boomer generation. The staff nurse's evaluation includes several recommendations for improvement, as well as some negative reports from nursing peers related to the staff nurse's work ethic. Based on generational characteristics related to work ethic, which response is most appropriate for the nurse unit manager to expect from the staff nurse when reviewing the evaluation? A. Requesting a more personalized work schedule B. Asking to receive performance feedback each day C. Suggesting the manager act as a mentor D. Expressing a sense of low self-worth
C
The nurse preceptor is designing a nursing orientation program that addresses abuse of power in the workplace. Which information should the nurse preceptor include in the program? A. Improper use of authority in the workplace is a form of sexual harassment. B. Nursing research finds limited evidence of bullying and lateral violence among nursing professionals. C. Bullying behaviors and incivility are among the leading causes of sentinel client events. D. The Joint Commission has not taken an official stand on addressing workplace intimidation
ABDE
The nurse preceptor is discussing integrity with the novice nurse. Which examples should the nurse preceptor use to illustrate integrity in nursing? (Select all that apply.) A. Maintaining accountability for personal actions B. Accepting negative feedback from clients C. Delivering error-free nursing care D. Working within the scope of practice E. Accepting positive feedback from peers
D
The nurse prioritizing care for a client with diabetes mellitus utilizes Maslow's hierarchy of needs. Which need is priority for this client? A. The client joins the local American Diabetes Association support group. B. The client attends classes to deal with body image after amputation of right leg. C. The nurse teaches the client proper home safety techniques to prevent diabetic wounds. D. The nurse teaches the client how to properly change dressings on right leg amputation site.
B
The nurse unit manager is giving an in-service about sexual harassment in the workplace. When discussing what constitutes sexual harassment, which statement is most appropriate for the nurse unit manager to include in the in-service? A. Submitting to requests for sexual behaviors must be explicitly considered a condition of an individual's employment. B. Sexual harassment must be considered both a form of discrimination and a violation of an individual's rights. Your answer is correct. C. The sexual behaviors must interfere with the victim's work performance and prevent fulfillment of work functions. D. Behaviors must include unwelcome advances of a sexual nature that are demonstrated through the perpetrator's physical conduct.
A
The nurses on a care area are uncharacteristically quiet. There is no friendly chatter, and nurses are staying in clients' rooms to document until the end of the shift. Which incident might cause the nurses to demonstrate this behavior? A. The charge nurse called everyone incompetent during report. B. The director is identifying staff for promotion. C. The nurse manager is working on the annual budget. D. The medical director is making client rounds.
C
The nursing instructor is evaluating the work ethic of nursing students who are finishing a medical-surgical clinical rotation. Which nursing student's behavior best reflects a strong work ethic? A. Arriving at the clinical site no more than five minutes after the scheduled start time B. Attending the majority of the scheduled pre- and post-conferences at the clinical site C. Having a contingency plan for dealing with transportation issues related to car problems D. Taking preventative measures, such as choosing not to be vaccinated for the flu
D
The nursing student is designing a poster that describes how to recognize burnout among nurses. Which recommendation for identifying manifestations of burnout should be included on the poster? A. Understand that emotional depletion is a natural response to the demands of employment B. Acknowledge feelings of helplessness as signs of inexperience or professional inadequacy C. Recognize that outbursts of anger are normal signs of professional frustration D. Interpret that smoking and an increase in coffee consumption may be potential warning signs
C
The nursing student is experiencing the integrated stage of commitment development. When developing professional commitment, which behavior would the nursing student be most likely to demonstrate during the integrated stage? A. Learning about positive aspects of the nursing profession B. Becoming involved in a student nursing association C. Being eager to take the NCLEX-RN® examination D. Considering switching to a major other than nursing
ACDE
The nursing student is participating in revising the plan of care for a client diagnosed with myasthenia gravis who did not meet care goals. Which will the nurse consider when revising the plan of care? (Select all that apply.) A. Were the goals realistic and attainable? B. What nurses were assigned to the client? C. Were the interventions that were selected appropriate? D. Did the client have access to planned interventions? E. Were interventions implemented as planned?
C
The nursing student is preparing a presentation that describes how varying intergenerational styles can affect peer perceptions. Which example is most appropriate for the nursing student to include in the presentation? A. Younger nurses may view older nurses' goals for developing technological competence as unattainable. B. Younger nurses may view older nurses as being arrogant and lacking professional commitment. C. Older nurses may view younger nurses as having a "slacker" attitude. D. Older nurses may be intrigued by younger nurses' style of dress.
ABDE
The nursing student is writing a care plan for a client who was recently cared for during a clinical rotation. What should the student nurse do when planning nursing interventions for the client? (Select all that apply.) A. Ensure relevancy to situation B. Be realistic C. Be general and brief D. Include priorities of care E. Be specific and concise
C
The nursing team of an extended care facility comprises four generations of healthcare providers. Which characteristic is most appropriate for the nurse administrator to expect to observe among healthcare providers who are generational cohorts? A. Opposing personal values B. Technological expertise C. Shared workforce patterns D. Interpersonal tension
B
The primary nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse arrives at the client's room to complete the morning assessment and finds the client is upset. The client states, open double quote"My nurse overnight referred to me to the assistant as the COPDer.close double quote" The primary nurse tells the client that she will address the issue with the nurse. Which basis of the therapeutic relationship is the nurse displaying by addressing this client issue with the other nurse? A. Identifying B. Respecting C. Assuming D. Reflecting
ABE
The psychiatric nurse practitioner is giving a webinar about prevention of burnout in nursing. Which items should the psychiatric nurse practitioner include when describing tips related to having compassion? (Select all that apply.) A. Learning to ask for help from colleagues or confidantes when needed B. Perceiving errors and failures as opportunities for constructive learning C. Recognizing the limitations associated with any given situation D. Joining nursing associations that promote constructive discussion of work issues E. Acknowledging that most individuals do the best they can do
A
The staff nurse is caring for a client who has recently undergone surgical repair of an inguinal hernia. Despite administration of pain medications as ordered, the client continues to complain of excruciating pain. When the staff nurse offers to reposition the client, the client states, "You don't have any idea what you're doing. I need more medication. I need a nurse who can help me!" Which behavior best illustrates demonstration of compassion by the staff nurse? A. Notifying the primary care provider about the client's complaints of pain despite receiving medication B. Explaining that inguinal hernia repairs usually require significantly less medication for adequate pain relief C. Seeking out a nursing colleague to privately vent about the client's rudeness and inconsideration D. Collaborating with the charge nurse and requesting that another nurse assume the client's care
D
The staff nurse who is working the day shift is scheduled to attend an important event immediately after work. Five minutes after the day shift ends, the evening shift nurse still has not arrived to assume care of the day shift nurse's assigned clients. This is the third time in one month that the evening shift nurse has been late to work. Several of the clients are scheduled for medications and treatments. Which action by the day shift nurse is the most appropriate? A. Inform the clients that administration of their scheduled treatments and medications will be slightly delayed B. Establish a boundary by leaving prior to the evening shift nurse's arrival C. Advise clients that the evening nurse is late and encourage them to report the situation D. Begin completing the clients' scheduled treatments and administering their medications as ordered
ACE
What information is to be included in an evaluation statement? (Select all that apply.) A. A conclusion statement about goal achievement B. A nursing statement about successful interventions C. Date and time the evaluation was conducted D. A client statement about establishing new goals E. A supporting statement about goal achievement
B
What is a purpose of a goal? A. To evaluate the client's response to the plan of care B. To provide direction for nursing interventions C. To identify a time frame for an action to occur D. To measure the end result of nursing action
A
What is the first action that should be made when prioritizing care? A. Assess client situations B. Analyze collected data C. Assign staff to clients D. Ascertain interventions
C
What is the purpose of reflecting within Tanner's clinical decision making model? A. Analyze a situation to choose action B. Sense what is happening in a situation C. Learn from actions to make adjustments D. Gain understanding about a situation
B
What is used as the framework for identifying nursing interventions? A. Previous health history B. Etiology of the problem C. Signs and symptoms D. Healthcare provider's orders
D
What should be done first before implementing a nursing intervention? A. Find someone to help B. Review nursing diagnoses C. Ensure the client's privacy D. Reassess the client
AC
What techniques are associated with assertive communication? (Select all that apply.) A. Negative assertion B. Avoidance C. Fogging D. Name calling E. Submission
A
What would be an appropriate goal when caring for a client with impaired communication? A. The client will effectively communicate needs. B. The client will review discharge instructions at home. C. The client will state ways to reduce communication deficits. D. The client will call for help before getting out of bed.
BE
When communicating discharge instructions to a client, the nurse states exactly what needs to be done using the fewest number of words. Which characteristics of verbal communication is the nurse using? (Select all that apply.) A. Intonation B. Brevity C. Pace D. Simplicity E. Clarity
B
When does a nurse make a scheduling decision? A. When deciding what can be completed by a nursing assistant B. When deciding what needs to be done before a client attends therapy C. When deciding when to change a dressing D. When deciding what information to share with other healthcare providers
BCDE
When formulating a nursing diagnosis for a client diagnosed with diabetes mellitus, which information should be taken into consideration to mobilize health and the recovery process for this diagnosis? (Select all that apply.) A. The client requests information on how to control blood pressure. B. The client tells the nurse that he adheres to his 1800 calorie ADA diet. C. The client independently administers insulin. D. The client demonstrates the ability to monitor blood glucose. E. The client joins the ADA support group.
BDE
Which actions are appropriate when the nurse is communicating with a client whose primarily language is not English? (Select all that apply.) A. Speak slowly B. Avoid using slang C. Emphasize words with gestures D. Use an interpreter E. Avoid using medical jargon
ACD
Which are characteristics common to all goals? (Select all that apply.) A. Relevant to the client B. State nursing actions C. Describe a single action D. Identified for each nursing diagnosis E. Measure nursing interventions
ABC
Which are characteristics of a primary group? (Select all that apply.) A. Face-to-face communication B. Unity C. Spontaneity D. Impersonal communication E. Task oriented
CE
Which are characteristics of an advanced beginner within Benner's Skill Acquisition Model of clinical judgment? (Select all that apply.) A. Is able to intentionally plan care B. Can see the whole picture C. Begins to recognize cues D. Follows rules when acting E. Is a new graduate
B
Which attribute of critical thinking is explained as making neutral judgments without bias? A. Perseverance B. Fair-mindedness C. Integrity D. Open-mindedness
BDE
Which behavior indicates a nurse is an aggressive communicator? (Select all that apply.) A. Denying feelings of anger B. Blaming others for errors C. Expressing feelings using "I" language D. Stating that a nursing assistant is "worthless" E. Telling a staff member to move out of the way
B
Which evaluation statement by the nurse is appropriate and indicates a goal has been met for a client diagnosed with a stroke? A. 1750: Goal met: Client voices understanding of treatment therapy. B. 04/03/2015, 1800: Goal met: Client demonstrates self-injection of Lovenox prior to discharge. C. 04/03/2015: Goal not met: Client does not demonstrate use of incentive spirometer. D. 04/03/2015, 1830: Goal partially met: Client demonstrates use of home oxygen machine.
ABE
Which skills are used when implementing client care? (Select all that apply.) A. Cognitive B. Interpersonal C. Physical examination D. Assessment E. Psychomotor
B
Which statement describes a feature of a standardized care plan? A. Care is planned by entering data into columns that correspond to the nursing process. B. A plan of care is selected and then individualized to meet a client's needs. C. Client care is identified in sequence for each day during the projected length of stay. D. A plan of care developed using colored shapes of various sizes.
ABCE
Which statements are true of nursing diagnoses? (Select all that apply.) A. Nursing diagnoses are flexible and change based upon client responses. B. Nursing diagnoses describe responses to a health problem. C. A nursing diagnosis is a judgment statement. D. Nursing diagnoses are uniform between clients. E. A nursing diagnosis is a condition that nurses are licensed to treat.
ABDE
Which statements by the nurse are reflective of a therapeutic nursedash-client relationship? (Select all that apply.) A. "I can wait until after your spouse visits to change the dressing so you can spend some quality time together." B. "Is there anything that I can do to help you feel more comfortable now?" C. "It's a shame you have this disease. You are such a nice person" D. "When would you like to have your bed linens changed?" E. "I know that you don't eat meat on Friday but would you like a piece of fish with dinner?"
B
Which therapeutic communication technique is the foundation on which other therapeutic communication techniques are built? A. Reflecting B. Attentive listening C. Empathizing D. Paraphrasing
A
Which short-term goal does the nurse view as appropriate for a client newly diagnosed with diabetes mellitus? A. The client will demonstrate how to self-inject insulin by end of hospital stay. B. The client will learn the correct way to inject IV insulin. C. The client will demonstrate how to wrap left leg wound. D. The client will be able to identify and prepare meals approved by the ADA within 3 weeks.
A
While preparing medications for administration, the staff nurse is repeatedly interrupted by the charge nurse, as well as by clients who are requesting assistance. Due to being distracted, the staff nurse accidentally crushes a tablet that cannot be administered in crushed form. Immediately afterward, the staff nurse notifies the charge nurse, disposes of the destroyed medication per the hospital's protocol, and resolves to delegate appropriate tasks to the nursing assistant while preparing and administering the client's medications. Which work ethic principle best describes the staff nurse's behavior? A. Accountability B. Reliability C. Optimism D. Arrogance
D
While providing care in the emergency department, the nurse asks the victim of a pedestrian accident open double quote"why did you cross the street in the middle of the block?close double quote" Which communication barrier is this nurse demonstrating? A. Being defensive B. Challenging C. Testing D. Probing
D
While talking with a nursing colleague, the staff nurse states, "I don't drink alcohol, but I smoke marijuana." Which response by the nursing colleague best reflects correct understanding of professional behaviors? A. "If your client care is negatively affected, then you should stop smoking marijuana." B. "Even though you're a nurse, what you do in your personal life is your business." C. "If you're arrested for smoking marijuana, your professional credibility will be negatively affected." D. "Even in your personal life, the same rules of professionalism still apply to your behavior."
A
While transferring a client back into bed after a procedure, the client says that it wasn't very nice for the nurse to say that the "cow" was coming down the hall. Which response by the nurse is most appropriate in this situation? A. "The term 'cow' is used for computer on wheels." B. "I was just joking with that person!" C. "You must have misunderstood what I said." D. "I didn't mean to call someone a cow!"
