Nursing Sciences - EAQ's JG OG - Part II
Attention to personal hygiene is a part of .
primary prevention
type of record used when up-to-date information about a client's condition, required care, treatments, medications, services, and any recent or anticipated changes is to be communicated.
A hand-off record is
Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.
A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
Define critical thinking
An active organized cognitive process used to examine one's thinking and the thinking of others. A process that involves using one's mind in framing conclusions, making decisions, drawing inferences and reflecting.
What type of research explores the interrelationship among variables of interest without any active intervention by a researcher?
CORRELATIONAL RESEARCH
The nurse uses evidence-based practice while providing nursing care to clients. What distinguishes research-based practice different from evidence-based practice?
It uses knowledge based only on research studies
a data-driven approach to process improvement that reduces variation in the process.
Six Sigma
focuses on the *improvement of processes*. It studies each step of a process to determine if that step adds value to that process. It also determines if the process reduces the organization's time, cost, and resources.
Value Stream Analysis
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress?
**Sharing humor** is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress.
While caring for a group of clients from different ethnicities, the nurse observes that a client from Ireland is stoic and not complaining about pain. Which theory should the nurse follow in this situation?
*Leininger's theory* recognizes the importance of culture and is about providing *culturally specific nursing care.* According to this theory, the nurse should skillfully incorporate the client's cultural practices in the assessment of the client's level of pain.
A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what?
Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.
Which is the best nursing intervention while assessing a client with anxiety?
Divide the assessment and do it over shorter amounts of time R: The client with anxiety easily gets irritated, even over small issues. Therefore to reduce any aggressive behavior, the nurse does the assessment in multiple smaller appointments. The nurse may not gather adequate information if they complete the assessment in a shorter amount of time. Postponing the assessment may increase the risk for the client. Doing the assessment for a longer duration in a soft-spoken voice may cause irritation in the client.
an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena.
Exploratory research is
Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply.
Fatigue Morning Sickness Breast Enlargement R: Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.
given by a nurse includes *restoration and rehabilitation* of clients. The nurse provides *work therapy* in hospitals, *helping clients be more productive*. The nurse also *makes provisions in hospitals and facilities for client retraining* and *education to maximize clients' capabilities*.
Tertiary care
The 3rd stage of behavioral change
The third stage is *preparation* when the client believes that advantages outweigh disadvantages of behavior change. The client needs assistance planning for a change in the next month.
2nd level of Maslow's hierarchy of needs
"The second level includes safety and security needs, which involve physical and psychological security
A nurse developed and implemented a discharge teaching plan based on the specific needs of a hospitalized client. Which element of decision-making does the primary nurse exhibit in this situation?
*Autonomy* refers to the freedom of making choices and the responsibility for making those choices. A professional nurse can make independent decisions and plan nursing care for a client within the scope of the nursing practice. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to duties and activities an individual is employed to perform. Accountability refers to individuals being answerable for their actions.
Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.
*Growth and development* and *emotional status* are two psychophysiologic factors that influence communication between a nurse and a client. R: Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.
a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.
Descriptive research is
What is the most important skill of the nurse leader?
The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.
A nurse is recalling Piaget's theory of cognitive development. Which statement is a characteristic of the concrete operations stage?
"A child is able describe a process without actually doing it." R: In the concrete operations stage, a child is able to perform mental operations and describe a process without actually doing it. In the preoperational stage, a child faces difficulty in conceptualizing time, and he or she believes that everyone experiences the world exactly as they do. In the formal operations stage, an individual believes that his or her actions and appearances are scrutinized constantly.
A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which client statement indicates a need for further instruction?
"I should obtain a pneumococcal vaccination each year." R: The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.
According to Peplau, the three phases that characterize the nurse-client interpersonal relationship are
1. orientation, 2. working phase, and 3. termination.
A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client?
Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instructing the client to call for help with elimination needs is not helpful, because the client is confused and unable to use the call bell. Placing a waterproof pad beneath the client helps to prevent soiling of the bed but does not keep feces away from the client's skin and therefore does not prevent skin breakdown. Toileting the client every 2 hours to prevent incontinence is not helpful, because the client is confused and unable to follow commands and has no control over elimination needs.
Which critical thinking skill does the nurse associate with the concept of maturity?
Maturity is the *ability of a critical thinker to reflect on his or her own judgments*
A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions?
You will need to apply them in the morning before you lower your legs from the bed to the floor." R: Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.
The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education?
"I should administer insulin only if there are any symptoms." The client should administer insulin throughout his or her lifetime and should maintain the dose and daily schedule as ordered by the primary healthcare provider. Before administering insulin, the client should check the expiration date. The client should maintain a daily logbook of insulin injections. The client should keep the medication in its original labeled container and refrigerate if needed.
The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?
"I should carry objects close to my body" R: By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.
The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?
***Exploring*** is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.
A nursing student is recalling the hierarchy of evidence available for conducting research. In which order should the nurse give priority to the findings of a study?
1. Systematic reviews and meta-analysis of randomized controlled trials (RCTs) 2. One well designed randomized controlled trial (RCT) 3. Well-designed controlled trials without randomization 4. Well-designed case control studies 5. Systematic reviews of descriptive and qualitative studies 6. Single descriptive or qualitative studies 7. Opinions of authorities or expert committees
records that are not part of a client's medical record. They are useful for determining the hours of care and staff required for a given group of clients. .
Acuity records
A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy?
Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. R: Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign the consent.
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?
Assess the client's condition per hospital protocol. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every two hours. Generally, output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.
The parents of an adolescent child are worried about their daughter's use of laxatives. Which other behavior in the child does the nurse associate with bulimia nervosa?
Bulimia nervosa is an eating disorder characterized by *binge eating* and the use of laxatives and self-induced vomiting to prevent weight gain. Anorexia nervosa is a clinical syndrome with both physical and psychosocial components. Clients with anorexia nervosa refuse to maintain body weight at the minimal normal weight for their age and height. An individual with anorexia nervosa has an intense fear of gaining weight. This individual often starves to lose weight.
After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. 1 Peptic ulcer 2 Chronic renal failure 3 Cognitive impairment 4 Congestive heart failure 5 Chronic obstructive lung disease
Chronic Renal Failure, CHF, Chronic Obstructive Lung Disease R: Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these clients do not require palliative care.
A child is being treated with oral ampicillin for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?
Complete the entire course of antibiotic therapy R: Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the healthcare provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however, the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1 to 2 hours after meals. Antibiotic therapy should be completed as prescribed.
a study that explores the interrelationships among variables of interest without any active intervention by the researcher.
Correlational research is
Which nursing intervention is performed for a middle-aged adult in restorative and continuing care?
Determining the coping mechanisms of the client and the family R: The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.
he nurse is assessing a client with an illness. Which questions asked by the nurse indicates that he or she is gathering a client's physical and developmental health history? Select all that apply.
Do you have any marital problem? Are you able to complete your activities of daily living? R: While gathering information about client's physical and developmental status, the nurse may ask the client about marital problems or the client's ability to perform activities of daily living. While gathering information about a client's emotional status, the nurse may ask the client about emotional control. When the nurse asks about the memories of the client, the nurse is gathering information about the client's intellectual status. When the nurse asks about the number of family members present, the nurse is collecting information about the client's social status.
A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition?
Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.
what could be the reason for cataracts in a 36-year-old client? Select all that apply.
Glass workers are exposed to heat and metal powders for prolonged periods, which may increase their risk of developing cataracts. A prolonged exposure to pesticides may cause pesticide poisoning. Prolonged exposure to cement dust may cause bronchitis. Prolonged exposure to anesthetic gases may have reproductive effects.
a standardized survey developed to measure client perceptions of their hospital experience. The survey asks 27 questions about the client's hospital experience. The survey is taken by clients who were discharged from the hospital between 48 hours and six weeks ago.
HCAHPS
The database of choice for the Centers for Medicare and Medicaid Services. collectS various data to measure the quality of care and services provided by different health plans
HEDIS (CREATED BY The National Committee for Quality Assurance (NCQA)
Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client?
Increased expired carbon dioxide The first sign of malignant hyperthermia [1] [2] is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.
Which intrinsic factor is associated with the fall of an older adult?
Intrinsic risk factors associated with the fall of an older adult may include **deconditioning**. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.
Which statement best describes a diagnostic label?
It describes the essence of the client's response to health conditions R:A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.
An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? 1. Minimize environmental stress to reduce confusion 2. Let the client continue to think in his or her own way 3. Prompt the client to recognize the correct date and time 4. Ask the client to recall the past to understand the present situation
Let the client continue to think in his or her own way R: Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.
Which points about nursing care and nursing practice have been accurately stated? Select all that apply.
Nursing theories help to describe, explain, predict, and/or prescribe nursing care measures. The scientific work used in developing theories expands the scientific knowledge of the profession. The expertise required to interpret clinical situations and make clinical judgments is the essence of nursing care and the basis for advancing nursing practice and nursing science. Expertise in nursing is a result of clinical experience as well as knowledge. Nursing theories offer well-grounded rationales for how and why nurses perform specific interventions and for predicting client behaviors and outcomes.
What is the primary focus of the nurse when providing evidence-based care to the client?
Problem solving approach R: Evidence-based practice is first and foremost a problem-solving approach to care. This problem-solving approach incorporates application of current best practice along with knowledge from research studies and clinical expertise.
A client has a paracentesis, and the healthcare provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, what should the nurse assess for?
TACHYCARDIA Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that cannot be measured objectively. The fluid shift can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis decreases the degree of abdominal distention.
in which of these activities does a nurse engage when providing tertiary care at a rehabilitation center? Select all that apply.
Providing work therapy for hospitalized patients Making provisions to help clients maximize their capabilities
What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.
Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.
uses knowledge based only on research studies.
Research-based practice
Which order should be followed in a research process for conducting the study?
The first important step for conducting the study is: 1. to obtain necessary approvals, such as approval from the institutional review board. 2. The next step involves recruiting subjects for the study. 3. After recruiting the subjects, a pilot study should be performed to improve the study design prior to the performance of a full-scale study. 4. After a pilot study, the methodology should be assessed continuously.
4th level of Maslow's hierarchy of needs
The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth.
4th Stage of Behavior Change
The fourth stage is *action*, which will last up to six months. During this stage the client is actively engaged in strategies to change behavior while the nurse identifies barriers to change.
Which of these databases should the nurse use to obtain a broad view on biomedical and pharmaceutical studies?
The *EMBASE* database is a good source of biomedical and pharmaceutical studies. PubMed is the health science library at the National Library of Medicine; this database offers free access to many journal articles. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. PsycINFO is a good resource for psychology and psychology-related healthcare disciplines.
Which system is used by a health care facility to determine certain aspects of client satisfaction?
The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)
A nursing student is trying to understand the elements of an article. What are the characteristics of the abstract section of an article? Select all that apply.
The abstract section summarizes the purpose of the article. The abstract section mentions the major themes and implications for nursing practice The abstract section is a brief summary that informs the reader whether the article is research or clinically based
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply.
The average newborn weighs between six to nine pounds (2,700 to 4,000 g). T he hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.
A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what?
The client is at risk for *falls* related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the client scenario of impaired cognition, imbalanced nutrition, or impaired gas exchange.
5th Stage of Behavior Change
The fifth stage is the *maintenance stage*, which begins six months after the change has started and continues indefinitely.
What should the nurse teach the young mother about the nutritional needs of the newborn?
The newborn should be breastfed for the first twelve months R: he nurse recommends breastfeeding for the first 12 months. After the first year, the infant may change to whole cow's milk. If breast feeding is not possible, the newborn should be fed on iron-fortified commercially prepared formula. Whole milk, 2% milk, or alternate milk products should not be given to an infant below 12 months of age because these products can cause intestinal bleeding, anemia, and increased incidence of allergies. Solid foods are not recommended for infants under six months of age because the extrusion reflex pushes the food out of the mouth. The breastfed infant absorbs adequate iron from breast milk during the first four to six months of life. After six months iron-fortified cereal may be given to the infant.
During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding?
The nurse builds self-esteem by asking about a client's previous achievements. R: Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory. Reality orientation is associated with the restoration about the sense of reality. Validation therapy is associated with agreeing with a confused older client's incorrect statement. The nurse may use therapeutic communication to address the expressed and unexpressed needs of the client.
Which example indicates that the nurse is following evidence-based practice?
The nurse reads current nursing journals and uses the latest scientific methods. R: Evidence-based practice requires the nurse to read current nursing journals and use the latest scientific methods. It also requires the integration of best current evidence with clinical expertise and client preferences while providing health care. The nurse uses informatics to document client care in an electronic health record. The nurse uses flowcharts and diagrams to record the client's progress and monitor the outcomes of client care. This helps the nurse to improve the quality of care. The nurse provides client-centered care by encouraging the hospitalized client's family to bring home-cooked food.
is a method of documentation that places emphasis on the client's problems. In this record, data is organized by problem or diagnosis
The problem-oriented medical record (POMR)
identified from the client's assessment data and associated with the diagnosis.
The related factor of a nursing diagnosis is
The second stage of behavioral change
The second stage is the *contemplation stage*. The client begins to consider a change within the next six months as he or she develops more belief in the value of change.
A student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse?
The student nurse should not confuse palliative care with hospice care. Palliative care can be provided to any client at the time of diagnosis of a serious disease, whereas hospice care is only provided to clients at the very end of life. Palliative care is mainly focused on client care and symptom management to improve the quality of life. The entire healthcare team is involved in delivering palliative care to the client.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?
This is the definition of *primary care nursing*. In team nursing there is a mix of staff members who provide care along with a team leader who usually is a registered nurse. In modular nursing clients are assigned according to geographic location and a variety of professionals are involved; this is similar to team nursing, but the teams are smaller. In functional nursing the nurse manager makes work assignments with specific tasks for each nurse.
A registered nurse is teaching a nursing student about Peplau's theory, which focuses on interpersonal relations. Which statements of the nursing student indicate an understanding of the theory? Select all that apply.
This theory creates a maturing force." "This theory involves the nurse acting as a resource and surrogate." "This theory includes three phases that characterize the interpersonal relationship."
Why does the nurse establish "moderately hard" client-centered goals? Select all that apply.
To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal R: Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.
The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client?
You are worried about paying your bills? R: Reflection can help the client to elaborate. The statement "Don't worry; your bills will get paid eventually" offers false assurance; the statement "When was the last time you were admitted for hyperglycemia?" uses professional jargon; and the statement "You really shouldn't be drinking alcohol because of your diagnosis of diabetes" is offering advice, all of which can all restrict the client's response.
According to Roy's theory, the goal of nursing is to
help the person *adapt to changes in physiological needs, self-concept, role function*, and interdependent relations during health and illness.
Benner and Wrubel's theory explains that
personal concern is an inherent feature of nursing practice.
Specific immunizations, such as the influenza vaccine, are provided as part of
primary prevention.
Nurses should focus care for middle-aged adults around their need to be what, according to Erikson's psychosocial developmental tasks?
productive A psychosocial task for middle adulthood according to Erikson is generativity; this task is concerned with the sense of productivity and accomplishment. Controlling, being independent, and being autonomous are not involved in any task of middle adulthood identified by Erikson.
The hierarchy of basic human needs includes five levels of priority. The second level includes: safety and security needs, which involve physical and psychological security.
safety and security needs, which involve physical and psychological security.
Selective examination of clients for the cure and prevention of disease is part of secondary prevention.
secondary prevention.
Inference skills
focus on the meaning of the findings and its significance.
A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs?
level 2 - . Safety needs - protection from elements, security, order, law, stability, freedom from fear
Explanation is the act of
supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.
The first stage of behavioral change
the *precontemplation stage*. During this stage, the client may be defensive when confronted with information about the behavior. The client does not intend to make any changes within the next six months.
The 5TH LEVEL IN MASLOW'S is
the need for self-actualization.
A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?
"A 10-mm-diameter area of drainage at 1900 hours." R: A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.
Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
*Red and dry skin is associated with phencyclidine abuse*. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.
When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?
Accidents including thier prevention R: Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.
According to Sigmund Freud's developmental theory, which developmental age is called the latent stage?
According to Sigmund Freud's developmental theory, middle childhood age is the latent stage. Early childhood and toddlers are in the anal stage. Preschool is the phallic stage. Adolescence is the genital stage.
The leader is advising the nursing student to avoid making careless assumptions. Which critical thinking skill does the leader wants the nursing student to learn?
Analysis R: The leader is advising the nursing student to adopt an analysis skill. *Analytical skills involve a nurse being open-minded while looking at the client's information and avoiding the making of careless assumptions*. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.
Which statement is true for attachment in the newborn?
Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.
The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what?
Attempts to minimize the illness R: Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.
While conducting research on a novel anticoagulant, clients are randomly assigned to a control group and treatment groups. The experimental drug is given to the treatment group and the standard anticoagulant drug is given to the control group. The researchers measured the outcomes in both groups and concluded that the novel anticoagulant drug has a better outcome when compared to the standard drug. Which quantitative method does this belongs to?
Experimental research
Which of these programs is least likely to focus on medication delivery process modification?
Experimental research is least likely to focus on medication delivery process modification. *Quality improvement, evaluation research, and performance improvement are all likely to focus on medication delivery process* modification in order to make the process better for the client.
Watson's theory defines the outcome of nursing activity with regard to the
humanistic aspects
Hildegard Peplau's theory focuses on
This theory develops a nurse-client relationship that is influenced by both the nurse's and the client's perceptions and preconceived ideas. Peplau's theory is unique: the collaborative nurse-patient relationship creates a maturing force through which interpersonal effectiveness meets the client's needs. According to this theory, the nurse acts as a resource person, counselor, and surrogate. According to Peplau, the three phases that characterize the nurse-client interpersonal relationship are 1. orientation, 2. working phase, and 3. termination.
1st level of Maslow's hierarchy of needs
Physical Needs: SURVIVAL, oxygen, water, food, shelter, clothes and sleep. COMFORT,Free from pain, maintain body temperature, and sensory stimulation. SATISFACTION, ability to reproduce.
The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model of change.
Precontemplation contemplation preparation action maintenance stage
A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect?
Providing presence The nursing action of providing reassurance and being with the client reflects the caring behavior "providing presence." Providing presence conveys closeness and a sense of caring. Touch conveys concern and support to the client. Spiritual nursing care involves establishing the client's well-being through the individual's beliefs and expectations. Knowing the client involves understanding the client's needs and planning interventions accordingly.
A nurse needs to record a client's data from admission until discharge. Which record will the nurse use?
Source record This record has a separate section for each discipline (such as the admission sheet, nursing records, and medication).
Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring?
The *enabling* process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.
A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response?
The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of ***hand washing*** before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.
Which feature according to Benner is observed in a nurse at the "proficient" level?
The nurse focuses on managing care rather than managing skills.
3rd level of Maslow's Hierarchy of Needs
The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love.
HOW MANY RIGHTS OF DELEGATION ARE THERE IN THE NURSING PRACTICE?
There are five rights of delegation in nursing practice. They are: 1. right task, 2. right circumstances, 3. right person, 4. right direction/communication, and 5. right supervision/evaluation.
What is the goal of nursing according to Watson's theory?
To promote health, restore the client to health, and prevent illness
The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?
To the client from outside sources R: Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.
a problem-solving approach to clinical practice. It involves the conscientious use of current best practice based on research findings. It involves the conscientious use of current best practice based on research findings. The nurse combines clinical expertise with client preferences and values to make health care decisions when implementing evidence-based practice.
Evidence-based practice is
Which are extrinsic factors that determine motivation? Select all that apply.
Human resources Community systems Accessibility of facilities Human resources, community systems, and the accessibility of facilities are extrinsic factors that determine motivation. Characteristics such as fear of failure and the educational level of an individual are intrinsic factors that determine motivation.
A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family?
"Please wait; I will update you as soon as I have any information." R: The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. If the nurse does not have any information about the client, the nurse must find out details and inform the client's family. The nurse should not avoid the situation by asking the relatives to speak to the primary healthcare provider.
A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?
*Kussmaul's respiration* is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.
Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?
*Percussion* is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.
The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to?
Health system The nursing care that supports effective use of the healthcare delivery system is classified under the health system domain according to the NIC taxonomy [1] [2] provided. Interventions that support services for delivery care belong to health system. Nursing care that supports psychosocial functioning and facilitate lifestyle change belongs to behavioral nursing intervention. The nursing care that supports the health of the community falls under the community domain. The nursing care that supports physical functioning belongs to physiological nursing intervention.
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?
After abdominal or pelvic surgery clients are at risk for **paralytic ileus** as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next?
Bending and then straightening their knee R: The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs, the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomic structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.
A client is admitted to the hospital because of multiple chronic health problems. What is the priority intervention at this time?
Conducting a multidisciplinary staff conference early during the client's hospitalization Collaboration of all team members involved in the client's care early during hospitalization will allow for efficient planning of care and help prepare for discharge. The client may or may not be ready to join a support group at this time. Assuring the family that staff members will take care of the client's needs may promote dependence. The client should be encouraged to assume self-care gradually. Although this should be done eventually, it is not the priority at this time.
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what?
Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.
Which suggestion should the nurse offer to parents who are concerned about caring for their toddler?
Encourage the toddler to drink from two-handled cups. The rapid development of a toddler's skills leads to a sense of autonomy. The toddler should be encouraged to drink from two-handled cups with a spout to prevent spills during the learning process. The toddler should not have more than two to three cups of milk per day. Increasing in the consumption of milk reduces the toddler's appetite for essential solid foods, leading to inadequate iron intake. Parents should limit opportunities for the toddler to say no. The parents should be firm and ask the toddler to take medicine rather than offering choices. Parents should talk, read, or play with the toddler. Television should never be used in place of parent-child interaction.
a study that tests how well a program, practice, or policy is working.
Evaluation research is
What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply.
Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing Refrain from placing stuffed toys on the infant's bed R: The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.
Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client?
Reinforcing the client's strengths and promoting reminiscing R: Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.
The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it where?
The cane should be used on the stronger (unaffected) side of the body to add strength, decrease dependence on the weaker (affected) side, and aid in balance during ambulation. Correct use of a cane does not involve alternating sides, using the cane on the affected (weaker) side, or using the side of the client's choice.
A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness?
The children do not have a physical shelter and may sleep outdoors or in vehicles. R: Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children from both sections of the community tend to be under-immunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek healthcare only in emergency conditions.
a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions.
The etiology of a nursing diagnosis is
The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern does the assessment include?
The nurse is applying Gordon's *Self-perception-Self-tolerance pattern* to assess the client. This functional pattern describes the client's self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client's choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.
A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply
The nursing assistive personnel can bring equipment to a client's room and transport the client from one place to another. Because the client is on isolation precautions, the registered nurse should assess vital signs, administer injections, and assess wound drainage.
A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond?
Your wish will be respected. R: The client has the right to make this decision, and the staff should accept the client's wishes. The client is a doctor, and the nurse's statement "Why do you want to be called Doctor?" attacks the client's self-concept. The informality of using first names is not encouraged unless it is the client's choice. The nurse can and should honor the client's request.
Which complication does the nurse prevent by addressing the needs of a hyperventilating client?
carbonic acid deficit R: Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but eventually will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis, so the pH is increased rather than reduced. Excess oxygen saturation cannot occur; normal oxygen saturation of hemoglobin is 95% to 98%.
paracentesis
the perforation of a cavity of the body or of a cyst or similar outgrowth, especially with a hollow needle to remove fluid or gas.
