PrepU: Nur

Which statement is true regarding addressing a priority problem

A priority problem requires a nursing intervention before another problem is addressed

The nurse will be starting an intravenous line on a client who is hard of hearing. The nurse will implement which interventions? Select all that apply.

Ask, "May I turn down the sound on your television?" Speak directly to the client. Look at the client's face as much as practical.

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

Decrease background noises, as much as possible, before speaking

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

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

assess how the client would like to communicate

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next

notify the physician of the change and document the finding.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

the nurse uses open-ended questions when working with a crying client

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain

I just don't have time to take a shower

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? You Selected: Knowledge Deficit: Medications related to new medical diagnosis

Knowledge Deficit: Medications related to new medical diagnosis

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

Monitor the client frequently.

Which are examples of subjective data? Select all that apply.

Nausea Light-headedness Anxiety

The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client?

Neonatal Jaundice

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure

Reporting signs and symptoms related to the client's kidney failure

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing

sensory overload

Which is the purpose of a focused assessment

Adds depth to existing information

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination

Bowel Incontinence

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing

When communicating with a client, the nurse uses reflection for which purpose?

To have the client elaborate on thoughts and feelings

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care

Add the nursing diagnosis: Risk for Self-Harm

As part of an assessment, the nurse assesses the client's sensory experience. Which question would best assess sensory stimulation?

Do you feel bored?

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

Do you work around loud noises at work

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family?

Impaired Parenting associated with failure to provide stimuli for growth

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action

Notify the physician for additional orders

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

Please tell me your thoughts about treating this diagnosis

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

Talk to the client in a normal tone of voice

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

Talk to the client in a normal tone of voice.

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding

We need to validate the information obtained in this assessment

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing

functional assessment

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first

inspect

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to

sensory reception

Which statement correctly describes a nurse-initiated intervention? You Selected: Nurse-initiated interventions are derived from the nursing diagnosis.

Nurse-initiated interventions are derived from the nursing diagnosis

A nurse is assessing clients in a burn unit for sensory alterations. Which factors contribute to severe sensory alterations? Select all that apply

Sensory overload Sensory deprivation Sleep deprivation

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information?

The agency's critical path

The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority

Impaired skin integrity

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing

discharge planning

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase

The client is being discharged, and the nurse observes the client crying. What is the nurse's most appropriate response?

Would you like to talk about anything before you go home

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client?

A focused assessment of the specific problems identified

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in

total disorientation

Which client is at greatest risk of sensory overload

an 88-year-old on a ventilator in an intensive care unit

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.

38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg)

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

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

Sensory Deprivation

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

What makes you think the food is poisoned?

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques

When did you first notice the rash on your leg

The nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by

a result of disease, trauma, treatment, or diagnostic studies.

An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply.

"Are you having any dizziness?" "Have you experienced any falls and hit your head?" "Is the headache affecting your vision?

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply.

-The client has ample financial resources. -The client is willing to attend counseling sessions.

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

-The client has been accompanied by family members to every appointment. -The client states a belief in a reward in heaven after death. -The client has demonstrated effective coping skills in the past.

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

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

A nurse is caring for an older adult client hospitalized following a hip fracture. Which action(s) by the nurse will promote the development of a therapeutic relationship? Select all that apply

-asking the client when the client would like to have the bed linens changed -encouraging the client to talk about the client's life

Which information ensures accuracy when the nurse is developing a nursing diagnosis

A cluster of clinical cues

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before

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

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

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type

Actual

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information?

Are you allergic to any medications

When is the best time for a nurse to take a client's health history? You Selected: As soon as possible after a client presents for care

As soon as possible after a client presents for care

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with the newborn.

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

Be silent and allow the client to continue speaking when ready

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

Consultation

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

Delusions

Which describes the best approach for the development of nursing diagnoses

Develop nursing diagnoses from clusters of significant data

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

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

Eliminating disturbing odors with adequate ventilation

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices?

How do you protect yourself when having sex?

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate

I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes

Which best describes the purpose of nursing diagnoses? You Selected: Identification of client problems that nurses can treat independently

Identification of client problems that nurses can treat independently

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client

A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child

Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client?

Introduce oneself to the client

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?

Just take your time. I am listening

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order

Which elements are common to any type of plan of care? Select all that apply

Nursing diagnoses Client goals Nursing interventions

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs

On the client's admission to the hospital

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse

Please tell me your thoughts about treating this diagnosis

The older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan?

Provide a consistent, predictable pattern of stimulation

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client

Risk for Impaired Parenting

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.

The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20

Which factor is most likely to contribute to the nurse making a diagnostic error

The client withholds information during the client assessment.

What is an advantage of using the functional health patterns model for assessment?

The nurse can identify client strengths and assets

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis

The parent states, "I cannot allow anyone else to help because they won't do it right

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond

This must be very difficult for you to hear. How do you feel right now

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client

Time-lapsed assessment

Which traits of the nurse are most important for an assessment to be successful?

Trustworthy and confident

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

Validate the data

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

Were you tired and depressed before starting the new medication?

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as

adaptation

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

allowing more time for the processing of the information

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis

anxiety

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation

client states, I dont see the point in trying anymore

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

educational

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic

have you ever though of laser surgery

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having a caregiver in the home for the first few days after surgery

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

impaired memory

for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment

initial assessment

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

objective data

Which nursing skill uses all five senses

observation

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining

outcome

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of

premature closure

The primary purpose of developing expected client outcomes is to:

provide individualized care

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible

A client who is blind is said to be experiencing:

sensory deficit

The nurse is caring for a client who has been placed in respiratory isolation. The nurse understands that the client is at risk for:

sensory deprivation

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by

swaddling the child and gently stroking its head

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is

the initial comprehensive client assessment

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

the nurse

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: You Selected: uses broad, open statements to communicate with the client.

uses broad, open statements to communicate with the client

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority

Assess the client's blood pressure

What must the nurse do to identify actual or potential health problems?

Gather data from sources

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase

Examine goals of the relationship to determine whether they were achieved

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

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

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

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

Which piece of client information is subjective?

Generalized myalgia or muscle pain

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be

aggressive

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client

pain

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

Assess how the client would like to communicate

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually

does not contain documented scientific rationales

When a person selects, organizes, and interprets sensory stimuli, the process is termed

perception.

A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. In this case, the nurse plays the role in the process of communication of the

sender

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump.

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

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

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate

A health promotion nursing diagnosis

A nurse is developing a client's plan of care. As part of planning interventions, the nurse incorporates a set of steps to follow as a means for decision making for care. Which structured methodology is the nurse including in the plan

Algorithm

The care plan for a client who has been frequently admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) includes a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis

Assess the client's knowledge of COPD.

Which is the best source of information for the nurse when collecting data for an assessment

Client

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what

Clustering significant data cues

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

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

Depression Sleeplessness Decreased interest in activities

The nurse is assessing a neglected child brought to the emergency department. The grandparent of the child reports that the child remains in the crib constantly, and is only removed from the crib when being fed. Which action should the nurse share with the grandparent to avoid sensory deprivation for the child

Frequently talking to and touching the child.

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology

Gastrointestinal upset from food poisoning

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?

Identifying with the client's feelings

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client

Ineffective Impulse Control

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? You Selected: Risk for Community Contamination related to possible environmental pollution

Risk for Community Contamination related to possible environmental pollution

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed

Risk for Impaired Skin Integrity related to bed rest

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and security

An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being?

Sensory overload can cause anxiety and irritability.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

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

overload

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

pain

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

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

The nurse is assessing a client in an outpatient setting. The client states, "I do not want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client

suicide attempt risk

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill

The nurse is caring for a postoperative client who refuses a blood transfusion due to religious beliefs. The nurse is demonstrating trustworthiness when taking which action in response to the client's treatment wishes?

contacting the interprofessional care team to discuss alternative treatment options

The nurse communicates with a newly admitted client. Which nonverbal behavior will the nurse note?

client's gestures

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with this diagnosis that the client's general appearance can nonverbally communicate to the nurse include

easy wrinkling of the skin and sunken eyes

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible.

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique

giving false hope

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to

have group members confront the dominant member to promote the needed team work

The purpose of obtaining a nursing history is to:

identify actual and potential health problems

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should

inform the client of the maintenance of confidentiality

A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply.

"Your doctor knows best." "Don't worry. You will be just fine in another day or two." "Cheer up. Tomorrow is another day." "Everything will be all right.

Which are examples of subjective data? Select all that apply.

-A client describes pain as an 8 on the pain assessment scale. -A client reports being cold and requests an extra blanket. -A client feels nauseated after eating breakfast.

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

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

The nurse cares for a client who is sharing a personal health story. Which behavior(s) demonstrates active listening? Select all that apply

-The nurse makes eye contact while the client is sharing a personal story. -The nurse paraphrases what the client has stated before generating a response. -The nurse observes the nonverbal behavior of the client as the client speaks.

What nursing care behavior by the nurse engenders a client's trust in the nurse?

A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic

All of the people got themselves out of the car

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview

The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client?

Approach the client with empathy and understanding and allow the client to share feelings without being judged

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter when discussing treatment.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

A client reports to a primary health care provider with aggravated chest pain. The health care provider prescribes a stress test. The client tells the nurse about not wanting to take the test and wanting to continue taking medication for now. Understanding that the client is anxious, which action should the nurse take first to provide education needed for this client?

Ask the client "What has your health care provider shared with you about stress tests

A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

Being sensitive to the client's emotional barriers

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take?

Contact a professional interpreter.

Which activities take place during the working phase of the nurse-client relationship? Select all that apply

The client participates actively in the relationship. The client genuinely expresses concerns to the nurse

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client

Disturbed sleep pattern

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?

Empathy

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?

Experience

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

Facial expressions

The client confronts the nurse, stating, "No one has come into my room to give me the pain medication I requested 2 hours ago. I am in pain!" Which response by the nurse indicates the nurse is using a "defending" communication technique?

I have been busy with other clients that required my immediate attention

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse

I know this is hard for you. Is there any way I can help

A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response

It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them

What is true of nursing responsibilities with regard to a physician-initiated intervention ?

Nurses do carry out interventions in response to a physician's order

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand.

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis

The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurological checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?

Recommendation

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Caring Professionalism

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

Speak directly to the client

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply

Spoken words Observation Sight Touch

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe

A nurse is caring for a client who sustained a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." What is the nurse's best response to the client?

The nurse says, "I can only imagine how hard this is on you. How can I help you?"

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? You Selected: Verbally report the finding immediately to the client's physician

Verbally report the finding immediately to the client's physician

The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?

Watching client walk into room

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask

Were you tired and depressed before starting the new medication

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

What did your health care provider tell you about your need to be admitted

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

What is your name

Which is an open-ended question

Why did the health care provider prescribe this medication for you

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?

You are hoping to figure out the cause of your extreme fatigue during this hospital stay

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

You seem unsure. Tell me your concerns about your surgery

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

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

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult

an audiologist

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address the disrespectful remark

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech?

assertive

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

the working phase