Week 1 Theory flexiquiz
The nurse is working with a patient diagnosed with posttraumatic stress disorder related to chikdhood seual abuse. The patient is crying and states, Ishould be over this by now, this happened years ago." Which responses) by the nurse will facitate communication? (Select all that apply.)
"The abuse you endured is very painful for you." "Crying is a way of expressing the hurt you're experiencing." "I can see that this situation really bothers you."
The client is concerned about "catching the flu" Which statement by the nurse is most appropriate?
"The best way to prevent the spread of illness is by washing your hands."
A patient is admitted to the hospital with cirhosis of the liver caused by long-term alcohol abuse. Which is the best response by the nurse when the patient says. "1 realy don't believe that my drinking a couple of beers a day has anything to do wth my liver problem?
"You find it hard to believe that beer can hurt the liver."
A nurse is caring for an elderly client with a throat infection at the client's residence The nurse uses a stainless steel tongue depressor to examine the client's throat. At what termperature should the nurse boil the equipment to sterilize ?
15 minutes at 212'F
Which assessment requires the nurse to assess the patient further?
65-year-old man with a respiratory rate of 10
When evaluating the vital signs of a group of patients the nurse takes into consideration the circadan rhythm of body temperature. At which time of day is body temperature usually at ts highest?
8 p.m. to 10 p.m.
Which nursing action protects the patient as a susceptible host in the chain of infection?
Administering childhood immunizations
The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating. "You did not wash your handst" Which response by the nurse is most appropriate?
Alcohol based hand rub provides the greatest reduction in microbial counts on the skin.
The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification?
"Am I correct in understanding that."
A licensed practicalvocational nurse asks the registered nurse (RN) preceptor what could be done to become more professional What is the preceptor's best response?
"Attend nursing educational me etings."
A patient states, "I had a bad nightmare. When I woke up. I fet emetionally drained, as though t hadn't rested wel Which response by the nurse would be an example of interpersonal therapeutic communication?
"Can you give me an example of what you mean by a bad nightmare?"
In a nursing unit, the RN delegates nursing tasks to the LPN Keeping in mind the delegation guidelines, which statement denotes the right task for the LPN?
Assist clients with nasogastric tube feeds.
A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facity. Which remark by the nurse would be an appropriate way to begin an interview session?
"How shall we start today?"
The nurse is admitting a patient to the medical surgical unit. Which communication technique would be considered appropriate for this interaction?
"I'd like to sit with you for a while to help you get comfortable talking to me."
A patient is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's best response?
"I'm not quite sure I heard what you were saying about your work."
The nurse understands that the skin protects the body from infections because the:
Cells of the skin are constantly being replaced, thereby eliminating external pathogens
An adult patient's vital signs are: oral temperature 99"F, pulse 88 beats per minute with a regular thythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mm Hg. Which sign should cause concem?
blood pressure
Nursing students are discussing the American Nursing Association (ANA) Nursing's Social Policy Statement. Which actions made by the nurse demonstrate proper understanding of the ANA Nursing's Social Policy Statement? (Select all that apply.)
caring for clients and their families . coordinating client care / developing interventions based on client-desired outcomes/ monitoring client responses to interventions/
A nurse is assessing a patient's bilateral pulses for symmetry: Which pulse site should not be assessed on both sides of the body at the same time?
carotid
The nurse is caring for a patient with a high fever secondary to septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieve heat loss via:
conduction
A nurse is caring for a patient with a high fever secondary to septicemia. The primary health-care provider orders a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss?
conduction/
The nurse identifies that a patient condition unrelated to infection is
decreased metabolic activity
A nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use?
direct questions
A patient has a wound infection. Which local human response should the nurse expect to identify?
edema
A nurse at a health care facility provides information, assistance, and encouragement to clients during the various phases of nursing care. in which activity does the nurse use counseling skills?
educating a group of young girls about AIDS
The nurse identifies that a patient has an inflammatory response. Which local patient adaption supports this conclusion?
erythema
A patient has had a 101'F fever for the past 24 hours. How often should the nurse monitor this patients temperature?
every 4 hours
A nurse is explaining the different procedures used to break the chain of intection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?
exit route
A nurse is caring for a newbom. The nurse knows that the body temperature of infants and older adults is prone to flucttuations. Which of these is the most probable cause for fluctuations in the infants body temperature?
great surface area relative to mass and very high metabolic rate
A student nurse is preforming hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?
has manicured nails that are 1-inch long
A dient has an allary temperature of 102.6 F. Which dinical manifestations would the nurse anticipate? (Select al that apply)
headache; respiratory rate 30min; red or flushed skin
The nurse is studying nursing models for a Baccalaureate course. Which action made by the nurse eemplifies proper application of the Adaptation model?
helping the client adjust to blood sugar testing each morning
A nurse in the emergency department is caring for a patient who is diagnosed with hypothermia. The presence of which factor in the patient's history may have precipitated this condition?
high alcohol intake
Which patient information collected by the nurse reflects a systemic adaptation to a wound infection?
hyperthermia
A nurse is assessing a client's vital signs at a health care facity. The nurse observes that the clent is sweating profusely. What body area causes a dient to sweat?
hypothalamus
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
immediately
A group of students are studying modern day nursing practices. What is the theme that enhanced the practice of nursing in the 21st century?
improved treatment of women
Which is being communicated when the nurse leans forward during a patient interview?
interest
The nurse and the patient are conversing face to face. What communication technique is being demonstrated?
linguistic
The nurse is concerned about a patient's abiaty to withstand exposure to pathogens. What blood component shouid the nurse monitor?
neutrohils
The nurse understands that subclinical infections most commonly occur in:
older adults
A nurse is caring for four dients. Which client has the highest risk of infection?
older male with an enlarged prostate
A client presents to the Emergency Department with a temperature of 100.6F and BP of 108/60 mm Hg. What intervention does the nurse anticipate providing?
oral fluids
A patient has an elevated temperature and reports feeling cold. Which additional physical changes should the nurse expect during the onset phase (cold or chill phase) of a fever? Select all that apply.
pale, cold skin and shivering
A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?
palpation
Which method of examination is being used when the nurse's hands are used to assess the temperature of a patient's skin?
palpation
A nurse is planning care for a patient who has intolerance to activity. Which is the first assessment that should be made by the nurse?
pattern of vital signs
9. When brushing a patient's hair, the nurse notes white oval partides attached to the hair behind the ears. The nurse should assess the patient further for signs of
pediculosis
When brushing a patient's hair, the nurse identifi es white oval particles attached to the hair behind the ears. For which should the nurse assess the patient?
pediculosis
When sterilizing the endoscope used for a client, what should the nurse use?
peracetic acid
The nurse is providing for the nutrition needs of several patients. The nurse identifies the need for an increase in caloric intake above average requirements for the patient who has:
pneumonia
A nurse in the cinic must obtain the vital signs of each patient via an electronic thermometer before patients are assessed by the primary health-care provider. Which patient characteristics indicate that the nurse should take the patients lemperature via the rectal, rather than the oral, route? Select all that apply.
presence of confusion; mouth breather
A nurse is unable to palpate a patient's brachial pulse. Which pulse should the nurse assess to determine adequate brachial blood flow in this patient?
radial
A nurse has assessed a cient's blood pressure near the beginning of a shit and obtained a systolic blood pressure of 138 mm Hg and a diastolic blood pressure of 71 m Hg. The systolic blood pressure:
represents peak pressure in the client's arteries
A nurse is caring for a client with Lyme disease. What causes Lyme disease?
rickettsiae
The registered nurse (RN) is delegating the task of assisting a post-operative dient to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions, and knows the UAPis competent to perform the task. The nurse has communicated how to get the client out and back into bed. and told the UAP not to alow the cient to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse?
right circumstance
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a itle bie more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
thready pulse
A nurse is assessing a patient who states "Ifeel cold." Which mechanism that helps regulate body temperature will increase body heat?
vasodilation
A nurse is teaching a cancer prevention community health class. Which recommended cancer screening guideline for asymptomatic people not at risk for cancer should the nurse include?
Colonoscopy at 50 years of age and every 10 years thereafter
Which statement about communication should the nurse consider to be accurate?
Communication is inevitable.
The nurse notes that a client's temperature has increased from 102"F to 103.6"F Which is the most appropriate action for the nurse to take in this situation?
Consult the physician and give antipyretics to the client.
A team of nurses who provide care in a community hospital have been enicouraged to participate in continuing educational activities. Why is continuing education needed in nursing?
Continuing education has the potential to partially alleviate the nursing shortage.
The nurse is caring for patients with a variety of wounds. The nurse understands that healing by primary intention most ikely Occurs with:
Cuts in the skin from a kitchen knife
One of the nursing achievements in the Crimean War was that the death rate of soldiers dropped from 60% to 1%. What is the most appropriate reason for the fal in the death rate?
Decreased rate of infection and gangrene
Beginning with Florence Nghtingale, many definitions of nursing have been put forth by individual nurses and by nursing organizations. Which statement best describes an aspect of the changes in these definitions over time?
Definition of an independent health care practice that is not solely dependent on physicians
A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites corresponds most closely to the client's core body temperature?
Ear
A nurse is caring for a cient with postural hypotension. Which nursing interventions are most appropriate to decrease the risk of tals? (Select all that apply.)
Encourage removal compression stockings; Encourage the use of the call light for help to the bathroom; Encourage oral fluid intake. Encourage intake of sodium-rich foods; Encourage slow movement from the bed to the chair.
A nurse is preparing a sterile field in order to perform a dressing change for a cient Which step should the nurse take when preparing to pour a sterile solution into the dressing tray?
First pour and discard a small amount of the solution.
A nurse identifies that a patient with a fever has cool skin. Which additional signs confirm the onset (cold or chill phase) of a fever? Select all that apply.
Goose bumps on the skin; Cyanotic nail beds
Health care professionals are required to follow certain principles to ensure that nosocomial infections do not occur in the health care facilty. What contributes to infections in health care settings?
Health professionals donning artificial nails
The nurse is caring for a group of hospitalized patients. What should the nurse do fest to prevent patient infedions?
Identify patients at risk
The nurse understands that a secondary line of defense against infection is the:
Immune response
A nurse is attending to a client with an infectious disease. Afer changing the linen and caring for the patient, the nurse does a hand antisepsis with an alcohol-based hand rub Which of the following is a reason for the nurse to use an alcohol-based hand rub?
It provides the greatest reduction in microbial counts.
A nurse is caring for a patient who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this patient?
Knock on the door and request permission to enter before approaching the patient
Which statement describes the following proverb? What you do speaks so loudly I cannot hear what you say
Nonverbal messages are often more meaningful than words.
A nurse working in a cinic is assessing patients of a variety of ages. Peopie within which age group should the nurse particularly assess for subtle signs and symptoms of subcinical infections?
Older adults
A nurse has completed a hospital-based educational program that has allowed the nurse to become cross-trained. A nurse who is cross-trained is able to:
Perform certain non-nursing duties in addition to traditional nursing duties.
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?
Perform surgical hand scrub using detergent.
The nurse understands that a rise in body temperature is associated with the presence of infection because
Phagocytic cells release pyrogens that stimulate the hypothalamus
Which nursing action protects the patient from infection at the portal of entry?
Positioning an indwelling urine collection bag below the level of the patient's pelvis
A nurse needs to visit the intensive care unit to administer an enema to a dient. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?
Pour and discard a small amount of the solution.
A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs?
Provide warm fluids.
A patient tells the nurse, "I think I have an ear infection." The nurse should assess this patient for which objective human response to an ear infection?
Purulent drainage
The nurse is performing client education with a 58-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to hep the client control their blood pressure?
Reduce sodium intake.
A patient with hypertension is given discharge instructions to take the blood pressure every day. Anurse is evaluating a famly m ember taking the patient's blood pressure as part of the patient's discharge teaching plan. Which behaviors indicate that the family member needs additional teaching? Select all that apply.
Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat; Positions the arm higher than the level of the heart; Inserts the earpieces of the stethoscope into the ears so that they tilt slightly backward
Nursing demonstrates dedication to improving public health through which avenue?
Scope of practice
The scope of professional nursing practice is determined by the rules promulgated by which organization?
State Board of Nursing
A medical-surgical unit manager intends Licensed Practical Nurses (LPN) in the unit to administer intravenous push (MP) medications. What source would the manager contact to include this procedure in the LPN practice?
State Nurse Practice Act (NPA)
A labor and delivery nurse will be participating in a client's emergency caesarean section and intends to apply the principles of surgical asepsis appropriately. Surgical asepsis is most clearly characterized by:
Steps are taken to render an item completely free of microorganisms.
What nursing recommendations are published in the Institute of Medicine (1OMrs) report The future of nursing Leading change, advancing health?
Teach, advocate, assess, and nurture
The nurse understands which primary (nonspecific) defense protects the body from infection?
Tears in the eyes
To interrupt the transmission link in the chain of infection, the nurse should:
Wash the hands before and after providing care to a patient
A cient with TB has been discharged from the health care facity. What care should be taken with regard to cleaning the bed linens used by the client during his stay at the facility?
Wash them with boiling water.
A nurse is informing a nursing student about the Centers for Disease Control and Prevention (CDC) guidelines for hand asepsis. Which guideline is in compliance with the CDC guidelines for hand washing?
Washing when hands are visibly soiled
A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when dleaning a client's s open wounds to protect the nurse from infection?
Wear a clean pair of latex or latex-free gloves.
When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take in order to prevent becoming infected?
Wear a mask when caring for the client
The nurse understands that an eample of an iatrogenic infection is a
Wound infection caused by unwashed hands of a caregiver
A nurse needs to measure the blood pressure of a cient with an electronic manometer. Which advantage does an electronic manometer provide over an aneroid manometer or mercury manometer?
accurate for practitioners with hearing loss
A nurse condudes that a patient is experiencing pyrexia. Which assessment precipitated this conclusion?
airway clearance
The nurse assesses that a clent is shivering. Which intervention is most appropriate to prevent further stress on the body?
applying a blanket
