Test One Transition to nurisng

A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess our children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so that the children cannot get into the kitchen."

1. "We will be sure not to leave hot liquids unattended."

The parent of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse would tell the parent that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A jack set with marbles 4. A farm set with small animals

1. A wagon

The nurse is instructing a client on how to perform a testicular self-examination (TSE). The nurse would explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

1. After a shower or bath

The nurse is preparing to provide instructions to new parents regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the parents to take which measure? 1. Allow the newborn infant to signal a need. 2. Anticipate all needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

1. Allow the newborn infant to signal a need.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or diseas

1. Auscultating lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1. Crusting

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 6 hours

1. Every 2 hours

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse would monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1. Gait

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse would plan to tell the parent that which factor motivates good and bad actions for the child at the preconventional level? 1. Peer pressure 2. Social pressure 3. Parents' behavior 4. Punishment and reward

1. Peer pressure

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1. Private room or cohort client

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1. Rhythmic respirations with periods of apnea

The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1. The acuity level of the clients 5. Client needs and workers' needs and abilities

A nursing student is preparing to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student would plan to explain to the group that which characteristic relates to the anal stage? 1. This stage is associated with toilet training. 2. This stage is characterized by oral gratification. 3. This stage is characterized by repression of sexuality. 4. This stage is associated with identification with the same-sex parent.

1. This stage is associated with toilet training.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan specific to the facility. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.

2. Activate the emergency response plan specific to the facility.

Which car safety device should be used for a child who is 8 years old and 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2. Booster seat

The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

2. Contact the electrical maintenance department for assistance.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Determine whether a family member supervises medication administration. 4. Call the prescribing primary health care provider (PHCP) and report polypharmacy.

2. Determine whether there are medication duplications.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the pediatrician. 4. Reassess the respiratory rate in 15 minut

2. Document the findings.

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the pediatrician. 4. Elevate the head of the bed to 90 degrees.

2. Document the findings.

The nurse is providing medication instructions to an older client with chronic heart failure who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin 2. Increased risk for digoxin toxicity 3. Decreased therapeutic effect of digoxin 4. Increased risk for side effects related to digoxin

2. Increased risk for digoxin toxicity

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 6. Ingestion of contaminated undercooked meat

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next? 1. Check the client's temperature. 2. Isolate the client in a private room. 3. Check a complete set of vital signs. 4. Contact the primary health care provider.

2. Isolate the client in a private room.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received

2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions would the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun.

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.

2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed.

The nurse caring for a client who is taking an aminoglycoside would monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? 1. Have one of the client's family members interpret. 2. Page an interpreter from the hospital's interpreter services. 3. Have the triage receptionist who speaks the client's language interpret. 4. Obtain a translation dictionary in the client's language and attempt to triage the client.

2. Page an interpreter from the hospital's interpreter services.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that two fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse would implement which assessment technique to assess for muscle weakness in the eye? 1. Test the corneal reflexes. 2. Test the six cardinal positions of gaze. 3. Test visual acuity, using a Snellen eye chart. 4. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2. Test the six cardinal positions of gaze.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The parent reports that the child is having intermittent episodes of diarrhea. 4. The parent reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The parent reports that the child has recently been exposed to an infectious disease.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system.

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2. Uses a cup to drink

The parent of an 8-year-old child tells the clinic nurse of a concern that the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would plan to make which response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, children are developing their own personalities." 4. "You need to provide more praise to the child to stop this behavior."

3. "At this age, children are developing their own personalities."

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim 3 times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

3. "I drink hot chocolate before bedtime."

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3. A blowing or swooshing noise

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3. A client who requires urine specimen collections

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1. A person who has moderate hypertension 2. A person who has newly diagnosed cataracts 3. A person who has advanced Parkinson's disease 4. A person who has early diagnosed Lyme disease

3. A person who has advanced Parkinson's disease

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A defect in the cochlea 2. A defect in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3. A physical obstruction to the transmission of sound waves

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid twitching of the eyeballs 2. A dorsiflexion of the great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3. A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm.

The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. What vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Blood pressure

A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

3. Call the Poison Control Center.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

. Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Hearing loss

The nurse is caring for a client who has been taking a sulfonamide and would monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the primary health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3. Serum amylase level

The nurse is preparing to describe Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would plan to tell the staff that which child behavior is characteristic of the formal operations stage? 1. The child's basic abilities to think abstractly and problem-solve are similar to an adult's. 2. The child learns to think in a concrete fashion and expects others to view the world in the same way. 3. The child begins to understand the environment and conceptualize objects that are no longer visible. 4. The child is able to classify, order, and sort facts and is able to see a variety of solutions to a problem.

3. The child begins to understand the environment and conceptualize objects that are no longer visible.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss? 1. They are often distracted. 2. They have middle ear changes. 3. They respond to low-pitched tones. 4. They develop moist cerumen production.

3. They respond to low-pitched tones.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3. Wheezes

The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply. 1.Individuals move through all six stages in a sequential fashion. 2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5.In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5.In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly measurement of vital signs 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first? 1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

The nurse is assigned to care for four clients. In planning client rounds, Which client would the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted their ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse would ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4. A previous dose of hepatitis B vaccine or component

A 16-year-old client is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in their same age group.

4. Allow the client to interact with others in their same age group.

The nurse is caring for an older client in a long-term care facility. Which action does the nurse plan that will contribute to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4. Allowing the client to choose social activities

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP). 4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.

4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention would the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4. Apply a cold pack to the injection site.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change.

4. Confront the AP to encourage verbalization of feelings regarding the change.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4. Crayons and a coloring book

A parent brings a 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield

4. Gloves, gown, goggles, and a mask or face shield

A parent arrives at a clinic with a toddler and tells the nurse how difficult it is to get the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the parent? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4. Inform the child of bedtime a few minutes before it is time for bed.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4. Placing the client in a semiprivate room at the end of the hallway

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take? 1. Report the observation to the pediatrician. 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

4. Provide additional lighting for the child during play activities.

The visiting nurse observes that an older client is confined by their child to the room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my child needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the child, "Confining your parent to their room is inhumane." 2. Suggest to the client and child that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and child, such as respite care and a senior citizens center.

4. Suggest appropriate resources to the client and child, such as respite care and a senior citizens center.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. That the client has developed another infection caused by leukopenic effects of the medication

Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

A diabetes mellitus

The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

A, B, D, F

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A. Beneficence B. Social justice C. Autonomy D. Fidelity E. Veracity

A. Beneficence D. Fidelity E. Veracity

Which assessment findings indicate to the nurse that a client taking Warfarin may have decreased clotting? (Select all that apply) a. Frequent nosebleeds b. Lower leg swelling c. Upper extremity bruising d. difficulty breathing e. Intermittent chest pain f. Dark stool

A. Frequent nosebleeds C. Upper extremity bruising F. Dark Stools

The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? Select all that apply. A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts F. Has thin papery skin

A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts

Which environments of care will the nurse recognize as components of the health care system? Select all that apply. A. Long-term care B. Primary care C. Free-standing emergency department D. National League of Nursing E. Patient-centered medical home F. World Health Organization

A. Long-term care B. Primary Care C. Free-standing emergency E. Patient-centered medial center

2. The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

A. Quality Improvement D. Systems Thinking E. Teamwork and Collaboration

The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D. Recommendation

A. Situation

Which teaching method is most effective when providing health care instructions to members of specific populations? A. Teach-back B. Video instruction C. Written materials D. Verbal explanation

A. Teach-back

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. A. Caring B. Teaching C. Collaborating D. Advocating E. Researching F. Prescribing

A.Caring B. Teaching C. Collaborating D. Advocating E. Researching

Examples of risk factors that can alter a person's fluid and electrolyte balance include:

Acute illnesses • Severe burns • Serious injury or trauma • Chronic kidney disease • Major surgery • Poor nutritional intake

What serum levels do you monitor to ensure that the patient has adequate protein for preventing tissue impairment or healing any existing wound?

Albumin and Prealbumin

Which nursing activities may be safely delegated to competent assistive personnel (AP)? Select all that apply. A. Discharge teaching B. Blood pressure monitoring C. Gastrostomy feeding D. Oxygen administration E. Ambulation assistance

B. Blood glucose monitoring Ambulation assistance

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action? a. Refuse to float to the ICU based on lack of unit orientation. b. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. c. Ask the nursing supervisor to review the hospital policy on floating. d. Submit a written protest to nursing administration, and then call the hospital lawyer.

B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.

A client reports increasing diffuse pain in the entire right leg. What is the nurses Priority action at this time? a. Elevate the right leg b. Performa a peripheral vascular assessment. c. Check for swelling in the right leg. d. Notify the Rapid response team.

B. Perform a peripheral vascular assessment

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which action(s) to correct the error in the MAR? Select all that apply. a. Complete and file an occurrence report. b. Right-click on the entry and modify it to reflect the correct information. c.Document the correct information and end with the nurse's signature and title. d. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. e. Document in a nurse's note in the client's record detailing the corrected information.

B. Right-click on the entry and modify it to reflect the correct information. C. Document the correct information and end with the nurse's signature and title. D. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. E. Document in a nurse's note in the client's record detailing the corrected information.

An older adult's furosemide dosage was increased 2 days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? A. Encourage fluid intake. B. Withhold this morning's dose of furosemide. C. Review the most recent serum electrolyte levels. D. Place the patient on strict intake and output.

B. Withhold the morning's dose of furosemide.

A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority action at this time? A. Elevate the right leg on a pillow. B. Perform a peripheral vascular assessment. C. Check for swelling in the right leg. D. Notify the Rapid Response Team immediately.

B. perform a peripheral vascular assessment

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond? a. "Health care is very limited in the prison setting." b. "Living in a prison isn't different than living at home." c. "Living in a prison can predispose a person to different health conditions." d. "Living in a prison is similar to living in a condominium complex or dormitory."

C. "Living in a prison can predispose a person to different health conditions."

The nurse working in a community outreach program for foster children plans care, knowing that which health conditions are common in this population? Select all that apply. A. 1.Asthma B. 2.Claustrophobia C. 3.Sleep problems D. 4.Bipolar disorder E. 5.Aggressive behavior F. 6.Attention-deficit/hyperactivity disorder (ADHD)

C. 3.Sleep problems D. 4.Bipolar disorder E. 5.Aggressive behavior F. 6.Attention-deficit/hyperactivity disorder (ADHD)

The nurse is caring for a client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrants a need for follow-up? a. Reddened sclera of the eyes b. Dry flaking noted on the scalp c. A reddish-purple mark on the neck d. A scaly rash noted on the elbows and knees

C. A reddish-purple mark on the neck

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the occurrence. d. Call the laboratory, and ask for the name of the individual who sent the photograph.

C. Call the nursing supervisor and report the occurrence.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the coworker in the medication room until help is obtained.

C. Call the nursing supervisor.

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? A. "It is important to provide care consistent with the client's expectation." B. "I will always consider my client's cultural preferences when delivering care." C. "I have been comparing our rates of infection with other units in the hospital." D. "I will look for the policy about family visitation to show my client."

C. I have been comparing our rates of infection with other units in the hospital

A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A. Vitamin D B. Losartan C. Nortriptyline D. Hydrochlorothiazide (HCTZ)

C. Nortriptyline

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report? a. The client fell out of bed. b. The client climbed over the side rails. c. The client was found lying on the floor. d. The client became restless and tried to get out of bed.

C. The client was found lying on the floor.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure. b. Ask the EMS team to sign the informed consent. c. Transport the victim to the operating room for surgery. d. Call the police to identify the client and locate the family.

C. Transport the victim to the operating room for surgery.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own." c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request."

D. "I will call the nursing supervisor to seek assistance regarding your request."

The nurse caring for a refugee considers which health care need a priority for this client? a. Access to housing b. Access to clean water c. Access to transportation d. Access to mental health care services

D. Access to mental health care services

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first? a. Blood pressure 154/72 mm Hg b. Visual acuity of 20/200 in both eyes c. Random blood glucose level of 206 mg/dL (11.77 mmol/L) d. Complaints of pain associated with numbness and tingling in both feet

D. Complaints of pain associated with numbness and tingling in both feet

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D. Obesity

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that they cannot leave the hospital d. Observing care provided to the client without the client's permission

D. Observing care provided to the client without the client's permission

Which nursing action reflects implementation of systems level thinking? A. Conducting a skin assessment on a newly admitted client B. Documenting a pressure injury in the electronic health record C. Notifying the health care provider of a 2″ × 1″ pressure injury on the coccyx D. Participating in a quality improvement project about eliminating pressure injury occurrences

D. Participating in a quality improvement project about eliminating pressure injury occurrence

The nurse planning care for a military veteran needs to prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? a. Hypertension b. Hyperlipidemia c. Substance abuse disorder d. Post-traumatic stress disorder

D. Post-traumatic stress disorder

How will the experienced nurse explain systems thinking to a new nurse? A. Reading a journal article to enhance one's understanding of a specific disorder B. Providing patient-centered care to each individual, recognizing his or her uniqueness C. Engaging in a professional development activity to earn continuing education credit D. Using information from individual client care to improve outcomes at a macro level

D. Using information I from individual client care to improve outcome at a macro level

§ ER Triage for disaster

Red, yellow, black, and greed

An 80-year-old client says to the nurse, "I'm all alone now. My husband is gone. My best friend is gone. My daughter is busy with her work and family. I might as well just go, too." Which is the best response by the nurse? a. "Are you having thoughts of wanting to hurt yourself or take your own life?" b. "You have lots to live for, but we need to talk to your daughter about her priorities." c. "It's hard getting old." d. "Tell me about your family."

a. "Are you having thoughts of wanting to hurt yourself or take your own life?"

A client asks the nurse, "Do you think I should tell my husband about my affair with my boss?" Which is the most appropriate response by the nurse? a. "What do you think would be best for you to do?" b. "Of course you should. Marriage has to be based on truth." c. "Of course not. That would only make things worse." d. "I can't tell you what to do. You have to decide for yourself."

a. "What do you think would be best for you to do?"

The nurse is conducting assessments for clients at potential risk for infection. Which client is most at risk for acquiring an infection? a. A client who had an open incision for abdominal surgery b. A client who has not been immunized for pneumonia or influenza c. A client who works in a high stress job for an accounting practice d. A client who is 85 years old and in good health.

a. A client who had an open incision for abdominal surgery

In a group exercise class, Mr. B., a 79-year-old man with major depression, becomes tired and short of breath very quickly. This symptom is most likely due to which cause? a. Age-related changes in the cardiovascular system b. Anxiety c. The effects of pathological depression d. Medication the physician has prescribed for depression

a. Age-related changes in the cardiovascular system

10. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? a. Arranging for home health care b. Focusing on managing a single illness at a time c. Communicating with one provider only to avoid confusion for the client d. Allowing the client to teach a support person about the treatment regimen

a. Arranging for home health care

A school nurse notices suspicious bruises and scars on a child's body. The nurse suspects that the child is being physically abused. Which action by the nurse is a priority at this point? a. As a health-care worker, report the suspicion to child protective services. b. Check the child again in a week and see if there are any new bruises. c. Meet with the child's parents and ask them how the child got the bruises. d. Initiate paperwork to have the child placed in foster care.

a. As a health-care worker, report the suspicion to child protective services.

During the assessment of a 35-year-old Asian American client, the nurse asks the client her preferences among different group treatment options. The client indicates that she will need to discuss this with her parents because that's how decisions are made in her family. The most likely rationale is that the client: a. Ascribes to collectivist cultural values b. Ascribes to individualistic cultural values c. Has a passive dependent personality disorder d. Comes from an emotionally abusive family

a. Ascribes to collectivist cultural values

A client is admitted to the psychiatric unit with depression. Which of these nursing activities is a priority? a. Assess the client's risk for suicide b. Establish a care plan that includes suicide precautions c. Contact the physician for orders d. Orient the client to unit activities

a. Assess the client's risk for suicide

A SANE nurse's primary role when intervening with a victim of violence is to: a. Conduct a sexual assault examination and preserve evidence b. Conduct a mini mental status examination c. Refer the client to a police officer d. Determine whether the client is lying about the events

a. Conduct a sexual assault examination and preserve evidence

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the PHCP can be contacted. d. Administer the recommended dose until the PHCP can be located.

a. Contact the nursing supervisor.

A client is being discharged from the inpatient psychiatric unit and states to their primary nurse, "Everyone abandons me and now you're probably going to abandon me, too." Which of these actions by the nurse best accomplishes termination of the therapeutic relationship? a. Discuss the boundaries of this relationship and assist the client to explore their feelings. b. Terminate the therapeutic relationship while exploring ways to remain connected as friends. c. Provide discharge medication instructions and encourage the client to follow up with their physician. d. Assure the client that they are not being abandoned and remind the client that they can return to the unit in the future.

a. Discuss the boundaries of this relationship and assist the client to explore their feelings.

A client with erectile disorder has a new prescription for sildenafil. The nurse who is providing education about this medication should tell the client about which common side effect of this medication? (Select all that apply.) a. Headache b. Facial flushing c. Constipation d. Nasal congestion e. Indigestion

a. Headache b. Facial flushing d. Nasal congestion e. Indigestion

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the diagnosis step of the nursing process? a. Identifies client as "At risk for suicide" b. Notes that client's family reports recent suicide attempt c. Prioritizes the necessity for maintaining a safe environment for the client d. Obtains a commitment from the client to work collaboratively to identify adaptive coping skills

a. Identifies client as "At risk for suicide"

Which of these actions by the nurse demonstrates an application of the QSEN competency related to informatics? a. Learns how to effectively communicate information using electronic health records. b. Provides a verbal report of client behavioral issues at shift change. c. Asks the supervisor for guidelines on how to prevent lawsuits. d. Reads journals to learn information about new treatments and approaches to nursing care

a. Learns how to effectively communicate information using electronic health records.

A male client, age 79, is admitted to the psychiatric unit for depression. He has lost weight and become socially isolated. His wife died 5 years ago, and his son tells the nurse, "He did very well when Mom died. He didn't even cry." Which is the priority nursing diagnosis? a. Maladaptive grieving b. Imbalanced nutrition: less than body requirements c. Social isolation d. Risk for injury

a. Maladaptive grieving

A client comes to the mental health clinic with a complaint of a lack of sexual desire. In the initial interview, what assessment would the nurse make? (Select all that apply.) a. Mood b. Level of energy c. Medications d. Previous level of sexual activity

a. Mood b. Level of energy c. Medications d. Previous level of sexual activity

Which medication may be prescribed for early ejaculation? a. Paroxetine b. Tadalafil c. Diazepam d. Imipramine

a. Paroxetine

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the planning step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines whether nursing interventions have been appropriate to achieve desired results c. Obtains a commitment from the client to work collaboratively to identify adaptive coping skills d. Identifies that the "Client will not harm self during hospitalization"

a. Prioritizes the necessity for maintaining a safe environment for the client

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Contact the nursing supervisor to update information regarding the fall. d. Document in the nurse's notes that an occurrence report was completed.

a. Reassess the client.

A client says to the nurse, "I've been offered a promotion, but I don't know if I can handle it." The nurse replies, "The thought of this promotion seems overwhelming." This is an example of which therapeutic technique? a. Restating b. Making observations c. Focusing d. Verbalizing the implied 5.

a. Restating

A 15-year-old female client has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5 ft 5 inches tall and weighs 82 lb. She was elected to the cheerleading squad for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be appropriate for this client? a. Social isolation b. Disturbed body image c. Low self-esteem d. Imbalanced nutrition: Less than body requirements

a. Social isolation b. Disturbed body image c. Low self-esteem d. Imbalanced nutrition: Less than body requirements

Which notations indicate accurate nursing documentation by the nurse? Select all that apply. a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. c. The client seemed angry when awakened for measurement of vital signs. d. The client appears to become anxious when it is time for respiratory treatments. e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. a. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse collects the following information during the admission assessment. For which of these data should the nurse take additional action to ensure that "duty to warn" laws are followed? a. The client threatens violence toward another individual. b. The client states they want to kill everyone who has demons. c. The client is having command hallucinations. d. The client reveals paranoid delusions about another individual.

a. The client threatens violence toward another individual.

The nurse is completing the admission assessment of a client who is intellectually disabled. Which part of the client encounter may require more time to complete? a. The history b. The physical assessment c. The nursing plan of care d. The medication reconciliation

a. The history

Which of the following behaviors suggest a possible breach of professional boundaries? (Select all that apply.) a. The nurse repeatedly requests to be assigned to a specific client. b. The nurse shares the details of their divorce with the client. c. The nurse makes arrangements to meet the patient outside of the therapeutic environment. d. The nurse shares how they dealt with a similar difficult situation.

a. The nurse repeatedly requests to be assigned to a specific client. b. The nurse shares the details of their divorce with the client. c. The nurse makes arrangements to meet the patient outside of the therapeutic environment.

Which is most appropriate when communicating with a transgender person? a. Using identified pronouns b. Using their first name to address them c. Using pronouns associated with birth sex d. Anticipating the client's needs and making suggestions

a. Using identified pronouns

The nurse decides to respect family wishes and not tell the client of their terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision? a. Utilitarianism b. Kantianism c. Divine command ethics d. Ethical egoism

a. Utilitarianism

A female client arrives at the emergency department and tells the nurse her husband inflicted the cuts to her face that required sutures. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: a. "How often does he drink too much?" b. "It is not your fault. You did the right thing by coming here." c. "How many times has he done this to you?" d. "He is not a good husband. You have to leave him before he kills you."

b. "It is not your fault. You did the right thing by coming here."

A college-age female client is brought to the emergency department by their roommate after she confided that she was raped by her date who invited her to a frat party. The client says to the nurse, "It's all my fault. I shouldn't have gone to a party where I knew there was going to be alcohol." Which of these is the best response by the nurse? a. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to get you drunk." b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d. "You'll just have to see that he is arrested so he won't do this to anyone else."

b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."

An adolescent who has just returned from group therapy is crying. The client says to the nurse, "All the other kids laughed at me! I try to fit in, but I always seem to say the wrong thing. I've never had a close friend and I guess I never will." Which is the most therapeutic response by the nurse? a. "What makes you think you will never have any friends?" b. "You're feeling pretty down on yourself right now." c. "I'm sure they didn't mean to hurt your feelings." d. "Why do you feel this way about yourself?"

b. "You're feeling pretty down on yourself right now."

The nurse assists the physician with electroconvulsive therapy on their client who has refused to give consent. With which of the following legal actions might the nurse be charged because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

b. Battery

The nurse decides to go against family wishes and tell the client of their terminal status because that is what they would want if the nurse were the patient. Which of the following ethical theories is considered in this decision? a. Kantianism b. Christian ethics c. Natural law theories d. Ethical egoism

b. Christian ethics

The nurse begins to conduct a psychosocial assessment and recognizes that the client speaks very little English and is having difficulty responding to questions. Which is the priority nursing action? a. Medicate the client to reduce anxiety. b. Contact an interpreter before conducting the assessment. c. Ask a family member to translate questions. d. Ask the questions in different ways.

b. Contact an interpreter before conducting the assessment.

The nurse, who is an adult child of an alcoholic, is working with a client who abuses alcohol. The client has experienced a successful detoxification process and is beginning a rehabilitation program. The client says to the nurse, "I'm not going to go to those stupid AA meetings. They don't help anything." The nurse, whose father died of complications from alcoholism, responds with anger: "Don't you even care what happens to your children?" The nurse's response is an example of which of the following? a. Transference b. Countertransference c. Self-disclosure d. A breach of professional boundaries

b. Countertransference

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the evaluation step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines whether nursing interventions have been appropriate to achieve desired results c. Obtains a commitment from the client to collaboratively work to identify adaptive coping skills d. Identifies that the "Client will not harm self during hospitalization"

b. Determines whether nursing interventions have been appropriate to achieve desired results

A male client, admitted for major depressive disorder, reports to the nurse that he has been having sexual difficulties ever since he started taking the antidepressant fluoxetine. Which is the most appropriate action by the nurse at this point? a. Instruct the client that it is not appropriate for a nurse to discuss his sexual problems and he will have to report this to the doctor. b. Educate the client that this is a potential side effect of fluoxetine and discuss with the client his concerns. c. Hold the medication and contact the doctor immediately. d. Assess the client's frequency of sexual activity and his personal preferences in a sexual partner.

b. Educate the client that this is a potential side effect of fluoxetine and discuss with the client his concerns.

7. A newly married client, age 24, is seeking treatment for pain and vaginal tightness that is significant enough to prevent penile entry. Sexual history reveals that the client was raped when she was 15 years old. Which of the following would be the most appropriate initial nursing diagnosis? a. Genitopelvic pain/penetration disorder b. Ineffective sexuality patterns related to inability to have vaginal intercourse c. Sexual dysfunction related to history of sexual trauma d. Maladaptive grieving related to loss of self-esteem because of rape

b. Ineffective sexuality patterns related to inability to have vaginal intercourse

A 75-year-old male client, who is taking a selective serotonin reuptake inhibitor (SSRI) for depression, reports to the nurse that he recently began having erectile dysfunction. Which is the most appropriate action by the nurse? a. Set clear boundaries that this is not an appropriate topic to discuss with the nurse. b. Instruct the client that this is a potential side effect of his medication and ask whether he would prefer to explore other treatment options. c. Educate the client that this is a normal age-related change and cannot be treated. d. Reinforce that this is a common symptom of depression and should subside after 4 to 6 weeks of antidepressant treatment.

b. Instruct the client that this is a potential side effect of his medication and ask whether he would prefer to explore other treatment options.

A client on the psychiatric unit begins yelling loudly that no one is listening to them and that they are going to "blow up" soon. The orderly asks the nurse if they should go ahead and put the client in restraints for the safety of others. Which of these responses by the nurse is most appropriate? a. Educate the orderly that restraints may never be initiated without a physician's order. b. Instruct the orderly that it would be best to see if the client can be assisted to calm down by listening to their concerns. c. Instruct the orderly to put the client in restraints but make sure to assess the client every 15 minutes for issues regarding circulation, nutrition, respiration, hydration, and elimination. d. Instruct the orderly to get others to assist them in restraining the client, but be aware restraints should be discontinued at the earliest possible time regardless of when a physician's order is scheduled to expire.

b. Instruct the orderly that it would be best to see if the client can be assisted to calm down by listening to their concerns.

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the assessment step of the nursing process? a. Identifies the nursing diagnosis: Risk for suicide b. Notes that client's family reports recent suicide attempt c. Prioritizes the necessity for maintaining a safe environment for the client d. Obtains a commitment from the client to work collaboratively to identify adaptive coping

b. Notes that client's family reports recent suicide attempt

Tim, age 18 years, babysits his 11-year-old neighbor, Jeff. Six months ago, Tim began fondling Jeff's genitals. They now engage in mutual masturbation each time they are together. This is an example of which paraphilic disorder? a. Fetishistic disorder b. Pedophilic disorder c. Exhibitionistic disorder d. Voyeuristic disorder

b. Pedophilic disorder

A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority at this time? a. Elevate the right leg on a pillow b. Perform a peripheral vascular assesment c. Check for swelling in the right leg d. Notify the Rapid Response Team

b. Perform a peripheral vascular assessment

A female child, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that the child has numerous bruises on her arms and torso in various stages of healing. She also notices some small scars, and her abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse should screen further for: a. Physical and sexual abuse b. Physical abuse and neglect c. Emotional neglect d. Sexual and emotional abuse

b. Physical abuse and neglect

Which factor is most associated with mental health in older adults? a. Pureed foods and warm beverages b. Physical activity and socialization c. Moderate alcohol and lower calorie intake d. Living alone and adhering to antidepressant medications

b. Physical activity and socialization

A culturally relevant health history considers all except which one of the following? a. Past and present modalities of self-care and self-treatments b. Presence or absence of health insurance c. Prevalence of disease conditions among family and relatives d. Past and present exposure to illnesses, hazardous conditions, and toxic substances

b. Presence or absence of health insurance

A young man who has just undergone a sexual assault is brought into the emergency department by a friend. What is the priority nursing intervention? a. Help him to bathe and clean himself up. b. Provide physical and emotional support during evidence collection. c. Provide him with a written list of community resources for survivors of rape. d. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

b. Provide physical and emotional support during evidence collection.

A client with schizophrenia appears very watchful of others and tells the nurse, "There are infiltrators everywhere and I think they are trying to kill me." Which of these actions by the nurse would best promote development of trust with this client? a. Touch the client's shoulder and state, "I want you to feel safe here." b. State to the client, "I'm interested in hearing your thoughts. Would you like to talk more about this?" c. Ask the client, "Why would you think such a thing?" d. Tell the client, "It is an expectation that we will not talk about things that aren't real."

b. State to the client, "I'm interested in hearing your thoughts. Would you like to talk more about this?"

The client is an American Indian admitted to the psychiatric hospital with a diagnosis of depression. The client reports to the nurse that their problem is "ghost sickness." Which event should be documented by the nurse? a. The client reports experiencing manic symptoms. b. The client reports preoccupation with death and the deceased. c. The client is hallucinating. d. The client is fabricating a nonexistent illness.

b. The client reports preoccupation with death and the deceased.

A client, who has been in the hospital for 3 weeks, has used Valium "to settle their nerves" for the past 15 years. The client was admitted by their psychiatrist for safe withdrawal from the drug. They have passed the physical symptoms of withdrawal at this time but states to the nurse, "I don't know if I will be able to make it without Valium after I go home. I'm already starting to feel nervous. I have so many personal problems." Which is the most appropriate response by the nurse? a. "Why do you think you need drugs to deal with your problems?" b. "Everybody has problems, but not everybody uses drugs to deal with them. You'll just have to do the best that you can." c. "Let's explore some things you can do to decrease your anxiety without resorting to drugs." d. "Just hang in there. I'm sure everything is going to be okay."

c. "Let's explore some things you can do to decrease your anxiety without resorting to drugs."

A client who is being discharged from an inpatient hospital stay has their wife bring a box of chocolates and a bouquet of flowers for the client's primary nurse. The client presents these gifts to the nurse, saying, "Thank you for taking care of me." What is the most appropriate response by the nurse? a. "I don't accept gifts from patients." b. "Thank you so much! It is so nice to be appreciated." c. "Thank you. I will share these with the rest of the staff." d. "Hospital policy forbids me to accept any positive feedback from patients."

c. "Thank you. I will share these with the rest of the staff."

During the admission assessment for a 72-year-old male client the nurse notices an open sore on his arm. When she questions him about it, he says, "I scraped it on the fence two weeks ago. It's smaller than it was." Which of the following is the best interpretation of this finding? a. Lower testosterone levels in older adult men results in injury-prone skin. b. Confusion is common in older adults, so the client probably doesn't remember how long ago he sustained the injury. c. A diminished inflammatory response in older adults increases healing time. d. The supply of blood vessels to the skin increases with age and delays healing time.

c. A diminished inflammatory response in older adults increases healing time.

An American Indian client is admitted to the inpatient psychiatric unit with a substance use disorder. Which action is a priority during the initial assessment? a. Contact a shaman to assist with evaluation of the client's needs. b. Double-check the client's insurance status to assure that this treatment is covered. c. Ask the client if they have any culturally specific preferences for assessment and treatment. d. Educate the client that American Indians often experience legal consequences from drinking too much and ask whether they have ever been in jail.

c. Ask the client if they have any culturally specific preferences for assessment and treatment.

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the implementation step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines whether nursing interventions have been appropriate to achieve desired results c. Collaborates with the client to develop a plan for ongoing safety and suicide prevention d. Identifies that "Client will not harm self during hospitalization"

c. Collaborates with the client to develop a plan for ongoing safety and suicide prevention

A client reports to the mental health clinic and tells the nurse that she is having suicidal thoughts. She acknowledges that she is transgender and reports that she often feels distressed and disconnected from other people. Which is the most important nursing action at this point? a. Refer the client to someone who specializes in transgender medicine. b. Conduct a thorough sexual history. c. Conduct a thorough assessment of suicide risks and lethality. d. Encourage the client to relate to others in a manner more consistent with her biologically assigned sex.

c. Conduct a thorough assessment of suicide risks and lethality.

Cultural assessment in the mental health setting should identify individual preferences with regard to which variable cultural dimension? a. Interpreters b. Race c. Distance d. Political party

c. Distance

An older male client with depression says to the nurse, "I don't want to go to that crafts class. I'm too old to learn anything." Which of these is the most appropriate action by the nurse at this point? a. Tell the client that groups are mandatory and escort him by the hand. b. Pat the client on the shoulder and tell him "We all feel that way sometimes." c. Educate the client that people don't typically lose the ability to learn as they age and encourage him to express his thoughts and feelings associated with aging. d. Assess the client for suicide risk and warning signs.

c. Educate the client that people don't typically lose the ability to learn as they age and encourage him to express his thoughts and feelings associated with aging.

A competent, voluntary client has stated that they want to leave the hospital. The nurse hides the client's clothes in an effort to keep them from leaving. With which of the following legal actions might the nurse be charged because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

c. False imprisonment

When there is congruence between what is felt and what is expressed, the nurse is exhibiting which of the following characteristics? a. Trust b. Respect c. Genuineness d. Empathy

c. Genuineness

A 16-year-old male client being treated for depression with an SSRI antidepressant expresses concern that he read about these medications sometimes causing problems with sex. Which nursing action is most appropriate at this point? a. Instruct the client that he will have to get his parents' consent before the nurse can provide this information. b. Instruct the client that the more important concern is risk for worsening suicide ideation. c. Instruct the client that this is a potential side effect of SSRI antidepressants. d. Instruct the client that he should not be focused on sexual issues at his age.

c. Instruct the client that this is a potential side effect of SSRI antidepressants.

The nurse decides to tell the client of their terminal status because the nurse believes it is their duty to do so. Which of the following ethical theories is considered in this decision? a. Natural law theories b. Ethical egoism c. Kantianism d. Utilitarianism

c. Kantianism

CLAS standards apply to all of the following except: a. Health-care organizations b. Individual clinicians and health-care practitioners c. Manufacturers of pharmaceutical products d. Hospitals

c. Manufacturers of pharmaceutical products

The nurse is transferring a client to a different unit and is providing a transfer report to the nurse who will be receiving this client. The receiving nurse asks what medications this client received within the past 2 hours. Which action should the nurse take to convey this information? a. Read the handwritten notes from a shift change report b. Try to recall from memory what was given to the client earlier c. Read the information recorded in the electronic health record d. Ask the unit secretary to read the record and then convey that information to the receiving nurse

c. Read the information recorded in the electronic health record

Trauma-informed care is foundational to all interventions with a victim of violence for which of the following reasons? a. It is a legal requirement in all 50 states. b. Trauma victims are unaware they have been traumatized until they are so informed. c. Victims of violence are at high risk for retraumatization. d. The client has a right to know what will happen to the perpetrator.

c. Victims of violence are at high risk for retraumatization.

A client was involved in an automobile accident while under the influence of alcohol. The client swerved their car into a tree and narrowly missed hitting a child on a bicycle. The client is in the hospital with multiple abrasions and contusions. They are talking about the accident with the nurse. Which of the following statements by the nurse is most appropriate? a. "Now that you know what can happen when you drink and drive, I'm sure you won't let it happen again." b. "You know that was a terrible thing you did. That child could have been killed." c. "I'm sure everything is going to be okay now that you understand the possible consequences of such behavior." d. "How are you feeling about what happened?"

d. "How are you feeling about what happened?"

A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: a. "I just can't believe you have decided to go back to that horrible man." b. "I'm just afraid he will kill you or the children when you go back." c. "What makes you think things have changed with him?" d. "I hope you have made the right decision. Call this number if you need help."

d. "I hope you have made the right decision. Call this number if you need help."

A client who has been in rehabilitation for alcohol dependence returns from a visit to their home and tells the nurse, "We were having a celebration and I did have one drink, but it really wasn't a problem." The nurse notices that his breath smells of alcohol. Which of the following responses by the nurse demonstrates a motivational interviewing style of communication? a. "You are obviously not motivated to change, so perhaps we should discuss your discharge from the treatment program." b. "You need to abstain from alcohol in order to recover, so let me talk to the doctor about the consequences of your behavior." c. "Why would you destroy everything you've worked so hard to achieve?" d. "What do you mean when you say, 'It really wasn't a problem'?"

d. "What do you mean when you say, 'It really wasn't a problem'?"

A nurse reports to the supervisor that a depressed client is refusing medication to treat their heart condition and states they "would rather just die." The nurse is not sure how to intervene because, although clients have a right to refuse medication, this client may be so depressed that the client's behavior represents risk for suicide. Which of these actions by the supervisor is a priority? a. Tell the nurse that medication will have to be given forcibly if the client continues to refuse medication. b. Instruct the nurse that, because the client is elderly, they are unable to make this decision and medication will need to be secretly mixed in their food. c. Educate the nurse that the physician has the final say, so the nurse should ask the physician what to do. d. Activate appropriate hospital resources, such as an ethics committee, so this issue can be explored further.

d. Activate appropriate hospital resources, such as an ethics committee, so this issue can be explored further.

A hospitalized client is very restless and is pacing a lot. The nurse says, "If you don't sit down in the chair and be still, I'm going to put you in restraints!" With which of the following legal actions might the nurse be charged because of this nursing action? a. Defamation of character b. Battery c. Breach of confidentiality d. Assault

d. Assault

An African American client is involuntarily admitted to the inpatient psychiatric unit with a diagnosis of bipolar disorder. Which principles should guide the nurse's initial assessment? a. The client is likely violent and should be medicated before conducting the assessment. b. The client should be assessed to identify cultural practices that might impact treatment. c. Racial and ethnic minorities commonly experience disparities in mental health care so care must be taken to assure accurate diagnosis and treatment. d. Both b and c

d. Both b and c

A male client, age 79, is admitted to the psychiatric unit for depression. He has lost weight and has become socially isolated. His wife died 5 years ago, and his son tells the nurse, "He did very well when Mom died. He didn't even cry." Which is the priority nursing intervention? a. Take blood pressure once each shift. b. Ensure that the client attends group activities. c. Encourage the client to eat all of the food on his food tray. d. Encourage the client to talk about his wife's death.

d. Encourage the client to talk about his wife's death.

In evaluating pharmacotherapy interventions, the nurse recognizes that: a. All clients respond to drug therapy in the same manner. b. Dosing and age-specific considerations are minor factors in evaluation. c. Clients from other cultures don't recognize the value of medication as a treatment modality. d. Environmental, cultural, and genetic factors affect pharmacokinetics.

d. Environmental, cultural, and genetic factors affect pharmacokinetics.

A male drives his car up to a strange woman, stops, and asks her for directions. As she is explaining, he reveals his erect penis to her. This is an example of which paraphilic disorder? a. Sexual sadism disorder b. Sexual masochism disorder c. Frotteuristic disorder d. Exhibitionistic disorder

d. Exhibitionistic disorder

The developmental task of transcendence suggests that mental health in older adulthood is contingent upon: a. Being able to ignore the stigmas associated with being old b. Developing the ability to be alone c. Transcending physical limitations imposed by age-related changes in the body d. Having a sense of meaning in life and a sense of satisfaction

d. Having a sense of meaning in life and a sense of satisfaction

The nurse is using nursing process to care for a client who is suicidal. Which of the following nursing actions is a part of the outcome identification step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines whether nursing interventions have been appropriate to achieve desired results c. Obtains a commitment from the client to work collaboratively to identify adaptive coping skills d. Identifies that the "Client will not harm self during hospitalization"

d. Identifies that the "Client will not harm self during hospitalization"

Which of the following nursing diagnoses would be the highest priority diagnosis for the client described in question 7? a. Social isolation b. Disturbed body image c. Low self-esteem d. Imbalanced nutrition: Less than body requirements

d. Imbalanced nutrition: Less than body requirements

The nurse is providing education to a support group for survivors of rape. Which of the following items is evidence-based information to include in this teaching? a. Rapists typically drink alcohol and are not in control of their actions. b. Rape is usually an event that occurs between two people who are sexually frustrated. c. Men who are born into poverty are predisposed to becoming rapists after puberty. d. Rape is an expression of power and dominance by means of sexual aggression and violence.

d. Rape is an expression of power and dominance by means of sexual aggression and violence.

When conducting a physical assessment, the nurse recognizes that biocultural variation is present in: a. Education level b. Oxygen saturation c. Socioeconomic status d. Skin color

d. Skin color

What is the most appropriate way to communicate with an older client who is deaf in their right ear? a. Speak loudly into their left ear. b. Speak to the client from a position on their left side. c. Speak face-to-face in a high-pitched voice. d. Speak face-to-face in a low-pitched voice.

d. Speak face-to-face in a low-pitched voice.

A school nurse notices bruises and scars on a 5-year-old child's body, but the child refuses to say how they received them. Which of the following is an evidence-based approach for further assessment by the nurse? a. Have the child evaluated by the school psychologist. b. Tell the child they may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if they answer the nurse's questions. c. Explain to the child that if they answer the questions, they may stay in the nurse's office and not have to go back to class. d. Use a "family" of dolls to role-play the child's family with them.

d. Use a "family" of dolls to role-play the child's family with them.

Risk factors that increase the probability of impaired Cellular Regulation include:

o Older age (55 years and older, with significant potential for abnormal cell development at ages older than 70) o Smoking o Poor nutrition o Physical inactivity o Environmental pollutants (such as air, water, soil) o Radiation o Selected medications (such as chemotherapy) o Genetic predisposition or risk

dementia

§ A broad term used for a syndrome that involves a slowly progressive cognitive decline, sometimes referred to as chronic confusion. This syndrome represents a global impairment of intellectual function and is generally chronic and progressive.

Delirium

§ An acute and fluctuating cognitive disorder that is characterized by the patient's inattentiveness, disorganized thinking, and altered level of consciousness.

presbyopia

§ Farsightedness that worsens with aging.

presbycusis

§ Hearing loss associated with the aging process.

fluid and electrolyte balance

§ The regulation of body fluid volume, osmolality, and composition; the regulation of electrolytes by the processes of filtration, diffusion, osmosis, and selective excretion.

Differentiate the major ethics principles that help guide professional nursing practice

· Autonomy · Beneficence · Nonmaleficence · Fidelity · Varacity · Social Justice

1. Describe common methods used to ensure effective hand-off communication in health care agencies.

· Situation · Background · Assessment Recommendation

Urgent (yellow) Priority 2

Ø clients who require treatment and whose injuries have complication that are not life-threatening, providing that they are treated within 30 minutes to 2 hours. They require continuous evaluation every 30-60 minutes thereafter.

Emergent (RED) priority 1

Ø life threatening injuries and need immediate attention and continuous evaluation but have a high probability of survival when stable.

No urgent (green) priority 3

Ø local injuries who do not have immediate complications and who can wait at least 2 hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter.

The four major classifications of microorganisms that can cause infection include:

• Bacteria • Viruses • Fungi • Parasites or protozoa