Wellness Exam 2
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation
A
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? a. Chamomile b. Ginseng c. Ginger d. Echinacea
A
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? a. Offer information on a relaxation technique and ask the client if they are interested in trying it. b. Request a social worker see the client to discuss meditation c. Attempt to use biofeedback techniques with the client. d. Tell the client many people feel the same way before surgery and to think of something else.
A
A nurse is caring for a client who has a new prescription for anti hypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? a. knowledge b. experience c. intuition d. competence
A
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as a appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address" b. "I will review the past medical history on the client's record to get more information." c. "I will carry out the new prescriptions from the provider" d. "I will ask the client if their nausea has resolved"
A
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.
A
A nurse is admitting a client who has acute cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure? (select all that apply) a. Explain the roles of other care delivery staff b. Begin discharge planning c. Inform the client that advance directives are required for hospital admission d. Document the client's wishes about organ donation e. Introduce the client to their roommate
A, B, D, E
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply) a. Ensure that the client has possession of their valuables b. Confirm that the rehabilitation center has a room available at the time of transfer c. Assess how the client tolerates the transfer d. Give a verbal transfer report via telephone e. Complete a transfer form for the receiving facility
A, B, D, E
A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (select all that apply) a. Guided imagery b. Massage therapy c. Meditation d. Music therapy e. Therapeutic touch
A, C, D
A nurse is reviewing the effect of culture on nutrition during a staff in-service. Which of the following groups prescribes eating specific foods to balance forces in the body during illness? (select all that apply) a. Asian culture b. African culture c. Roman Catholicism d. Hispanic/latinx culture e. Buddhism
A, D
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply) a. Respiratory rate is 22/ min with even, unlabored respirations b. The client's partner states, "they said they hurt after walking about 10 minutes." c. The client's pain rating is 3 on a scale of 0 to 10 d. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp
A, D, E
A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching? a. "Most clients who practice roman Catholicism do not drink caffeinated beverages." b. "Most clients who practice orthodox Judaism do not eat meat with dairy products" c. "Most clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines" d. "Most clients who practice Hinduism do not eat diary products"
B
A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicated culturally responsive care to the client? a. "I will make sure the menu includes kosher options." b. "I will ask the client if they want to schedule some times to pray during the day." c. "I will avoid discussing care when the client's family is around." d. "I will make sure daily communion is available for this client."
B
A nurse is evaluating how well a client learned the information presented in a instructional session about following a heart-healthy diet. Which of the following actions should the nurse take to evaluate the client's learning? a. Encourage the client to ask questions b. Ask the client to explain how to select or prepare meals c. Encourage the client to fill out an evaluation form about how the nurse presented the information d. Ask whether the client has resources for further instruction on this topic
B
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of following is the priority action to take before attempting this particular mind-body intervention? a. Tell the client the goal of the therapy is to promote healing b. Ask whether the client is comfortable with using prayer c. Encourage the client participate actively for best results d. Instruct the client to relax during the therapy
B
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? a. Fairness b. Responsibility c. Risk-taking d. creativity
B
In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. "What do I know about this situation?" b. "What additional details do I need to gather?" c. "Does the clinical presentation correlate with the diagnosis?" d. "Are the treatments appropriate for the diagnosis?"
B
The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. problem solving b. decision making c. inference d. reasoning
B
A nurse is preparing the discharge summary for a client who has had had knee arthroscopy and is going home. Which of the following information about the client should the nurse include in the discharge summary? (select all that apply) a. Advance directives status b. Follow up care c. Instructions for diet and medications d. Most recent vital sign data e. Contact information for the home health care agency
B, C, E
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicated with a client and family members? (select all that apply) a. Talk to the interpreter about the family while the family is in the room. b. Determine client understanding several times during the conversation. c. Look at the interpreter when asking the family questions. d. Use lay terms if possible. e. Do not interrrupt the interpreter and the family as they talk.
B, D, E
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (select all that apply) a. Find a mentor b. Use a journal to write about the outcomes of clinical judgments c. Review articles about evidence based practice d. Limit consultations with other professionals involved in a client's care e. Make quick decisions when unsure about a client's needs
B,C,E
A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism? a. Asking the client about some favorite food choices b. Notifying the dietitian to complete the menu C. recommending one's own favorite foods d. Asking the client's family to fill out the menu
C
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? a. Members of the same religion share similar feelings about their religion. b. A shared religious background generates mutual regard for one another. c. The same religious beliefs can influence individuals differently. d. The nurse and client should discuss the differences and commonalities in their beliefs
C
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (select all that apply) a. Writing a prescription for morphine sulfate as needed for pain b. Inserting a NG tube to relieve gastric distention c. Showing a client how use progressive muscle relaxation d. Performing a daily bath after the evening meal e. Re positioning a client every 2 hr to reduce pressure injury risk
C, D, E
A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? (select all that apply) a. Art therapy b. Acupressure c. Yoga d. Therapeutic touch e. Biofeedback
C, E
A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? a. "I believe in this care you should really make an exception and accept the blood transfusion." b. "I know your family would approve of your decision to have a blood transfusion." c. "Why does your religion mandate that you cannot receive any blood transfusions." d. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."
D
A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. encourage the client to participate actively in learning b. Select instructional materials c. identity goals the nurse and the client agree are reasonable d. Determine what the client knows about stress incontinence
D
A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
D
As part of admission process, nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family? A: BMI B: usual times for meals/snacks C: favorite foods D: any difficulty swallowing
D
6. What aspect of culture is a full-time employed granddaughter of an elderly Asian female exhibiting if she asks the social worker to place her grandmother in an extended-care facility against the wishes of her parents? a. System change b. Gender role c. Cultural norms d. Shared attributes
a
7. Culturally competent care would encourage which action by a patient's family? a. Asking the family's spiritual advisor to visit the patient b. Speaking English to everyone involved in patient care c. Adhering to highly publicized restrictive unit visiting hours d. Limiting food consumption to items provided by the cafeteria
a
A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. What should the nurse do before placing the NG tube? a. Assess the presence of any family members who may speak English and the patient's native language. b. Take two additional staff members into the room when placing the tube so the patient can be restrained if needed. c. Request an interpreter by leaving a voicemail on his or her office extension. d. Do not place the NG tube because the physician would not want to frighten the patient.
a
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? a. basic b. Commitment c. complex d. integrity
a
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? a. orient the client to their room b. conduct a client care conference c. Review medical prescriptions d. develop a plan of care
a
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.
a
A weight-loss program that combines nutrition instruction with exercise is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive
a
During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance
a
In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient's medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath
a
What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests
a
Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Readiness for Enhanced Knowledge b. Knowledge Deficit c. Information Processing d. Health-Seeking Behaviors
a
Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure to pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement
a
Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.
a
The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. ) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient
a, b, c
4. Which of the following questions is/are appropriate to ask during a transcultural assessment? (Select all that apply.) a. How do you act when you are angry? b. What is your role in your extended family? c. Why do you continue to speak German at home? d. When communicating with friends, how close do you stand? e. What is the purpose of not preparing beef with milk products?
a, b, d
A nurse is teaching a group of female clients about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? (select all that apply) a. inactivity b. family history c. obesity d. hyperlipidemia e. cigarette smoking
a, b, e
3. Which statement(s) reflect/s the practice of transcultural nursing? (Select all that apply.) a. May be considered a general and specialty practice area b. Focuses on the world view rather than patient needs c. Challenges traditional ethnocentric nursing practice d. Aims to identify individual patient care preferences e. Focuses patient care on the nurse's cultural norms
a, c, d
The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning
a, d, e
A nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (select all that apply) a. Poor wound healing b. Dry hair c. Blood pressure 130/80 d. weak hand grips e. impaired coordination
a,b,d,e
2. Which action taken by a nurse would reflect application of an appropriate generalization in a patient care setting? a. Assigning same-gender nurses to all patients admitted to the unit b. Sharing with unlicensed assistive personnel that typically Muslim patients do not eat pork c. Telling the radiology technician that every Latino family is late for appointments d. Assuming that Asians share financial responsibility for medical bills
b
5. How best can a nurse evaluate goal attainment for a patient with a culturally diverse background? a. Assume that gender roles will be a challenge to overcome regardless of the patient's ethnicity. b. Base decisions on feedback from the patient and the nurse's professional judgment. c. Collaborate with future community care providers to determine patient strengths. d. Seek input from members of the patient's support system to avoid biased patient responses.
b
8. If a patient's primary language differs from that of the health care professionals providing care, which action is most appropriate for the nurse to take? a. Use colorful pictures, white boards, and gestures to communicate all important information. b. Recognize that continuous affirmative answers by the patient require verification of understanding. c. Arrange for a professional language translator to sit with the patient throughout the hospitalization. d. Decrease interaction with the patient and family to avoid making them uncomfortable for not understanding.
b
A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. cognitive b. Affective c. psychomotor d. kinesthetic
b
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique B. The client is able to demonstrate the appropriate technique c. The client states an understanding of the process d. The client is able to write the steps on a piece of paper
b
A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state? a. Blood albumin 3.5 g/dl b. Negative nitrogen balance c. BMI of 18.5 d. Blood prealbumin 15 mg/dl
b
The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.
b
The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference
b
What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice
b
Which is true about patient teaching sessions? a. Present all of the information so the patient can learn all that is needed. b. Present the patient with one idea at a time. c. Ensure the presence of a family member at each session. d. End with a written quiz to ensure understanding of the information.
b
A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork. b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—these just don't work" c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms d. Setting the clipboard aside and staring tearfully out the window e. Returning the forms only partially filled out, with missing or inaccurate information
b, c, e
Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Noncompliance b. Readiness for Enhanced Knowledge c. Ineffective Coping d. Health-Seeking Behaviors e. Anxiety
b, d
1. Which statement best serves as a guide for nurses seeking to learn more about ethnicity? a. Ethnicity, like culture, generally is based on genetics. b. A patient's ethnic background is determined by skin color. c. Ethnicity is based on cultural similarities and differences in a society. d. Culture and socialization are unrelated to the concept of ethnic origin.
c
9. Which nursing diagnosis is most appropriate for a young Middle Eastern immigrant who expresses concern for the safety of his family members who were unable to relocate with him out of a war zone? a. Risk for Spiritual Distress b. Impaired Role Performance c. Interrupted Family Processes d. Ineffective Coping
c
A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? a. Contact the hospital's spiritual services b. Ask what is making the client cry c. Ensure no visitors or staff enter the room for a short time period d. Turn on the television for a distraction
c
A nurse in a nutrition clinic is calculating body mass index for several clients. The nurse should identify which of the following client BMIs as overweight? a. 24 b. 30 c. 27 d. 32
c
A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition? a. Incorporation of plant-based foods in the diet b. consumption of raw fruits c. Preparation of foods using sodium d. Focus on shellfish in the diet
c
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you give me pain medicine after the surgery." c. Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say."
c
On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses
c
The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint b. Request that another nurse be assigned to this patient c. Review data about the medical diagnosis and routine management d. Complete a physical assessment of the patient
c
The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented.
c
What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.
c
What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team
c
Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.
c
Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relationship of this information to other data?
c
Written instructions showing pictures of the steps necessary to test a blood sugar, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive
c
10. What is the best method for the nurse to ensure that a Croatian patient's nutritional needs are met during hospitalization? a. Preorder a diet that is consistent with the typical Croatian patient's dietary preferences. b. Ask a Croatian co-worker for ideas on what would be best to order for the patient's meals. c. Request that a variety of dietary entrees be provided to the patient to provide options. d. Check with the patient on admission to determine dietary limitations and preferences.
d
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting
d
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient
d
The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication
d
