final for theory - Flashcards

Q: A nurse observes a student nurse caring for a patient with diarrhea. Which quality in the student nurse reflects cognitive maturity?

Considering multiple solutions for the patient\'s condition (has to do with critical thinking) #10.

Q: During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient\'s home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, \"This hurts too much. I don\'t see why I have to do this so many times.\" The nurse applies the critical thinking attitude of integrity in which of the following actions?\"

\"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let\'s go a bit more slowly and try to relax.\" #10.

Q: Which outcome allows you to measure a patient\'s response to care more precisely?

The patient\'s wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. #14

Q: A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101 degrees Fahrenheit. Following an initial interview and assessment; the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label?

Inflammation of the pancreas\' #12

question

A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self management? Select all that apply.

answer

orem

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Which critical thinking attitude should the nurse possess to come up with new solutions to patient-related problems?

answer

creativity #10.

question

A nurse observes a student nurse caring for a patient with diarrhea. Which quality in the student nurse reflects cognitive maturity?

answer

Considering multiple solutions for the patient's condition (has to do with critical thinking) #10.

question

A diabetic patient has come to the nurse with symptoms suggestive of hypoglycemia. What would be the first appropriate nursing intervention?

answer

Offer foods rich in glucose #5 have to do with implementation.

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A patient who has undergone an appendectomy complains of pain. On assessment, the nurse finds that the patient is anxious and this condition is increasing the pain perception. What nursing intervention is appropriate in this situation?

answer

Administer drugs that relieve anxiety per standing orders. #13.

question

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:

answer

Clinical reasoning. #10.

question

Which process helps in linking the thoughts and ideas to make a solution

answer

Reasoning

question

During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?"

answer

"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." #10.

question

An elderly debilitated patient is bed ridden. The patient has reduced libido, is unable to eat, and is incontinent of urine. Which intervention would be the priority for this patient?

answer

measures to improve skin integrtiy #18?

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Which outcome allows you to measure a patient's response to care more precisely?

answer

The patient's wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. #14

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What should the nurse know about evaluation in the nursing process?

answer

Evaluation is dynamic and ever changing. #5

question

Setting a time frame for outcomes of care serves which of the following purposes?

answer

Indicates when the patient is expected to respond in the desired manner #14

question

A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101 degrees Fahrenheit. Following an initial interview and assessment; the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label?

answer

Inflammation of the pancreas' #12

question

The nurse is determining the short-term and long-term goals for a patient. What point should the nurse consider to differentiate between a short-term goal and a long-term goal?

answer

A short-term goal is achieved in a week #14

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The nurse observes during a physical assessment that the patient's right knee is swollen and is larger than the left knee. The patient reports pain in the swollen area as well. Which assessment technique does the nurse need to use in this case?

answer

Palpation #

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what is the purpose of risk nursing diagnoses?

answer

To identify potential problems of the patient #12

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What does the nurse recognize as a "related factor" in the nursing diagnosis?

answer

Etiological factors #12

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The nurse formulates a nursing diagnostic statement for a patient with severe pain due to a femur fracture as evidenced by grimacing. What should the nurse include in the "defining characteristics" segment of the nursing diagnosis?

answer

grimacing

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What should the nurse include when writing an actual nursing diagnosis?

answer

Diagnosis label, related factors, and defining characteristics #12

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What is a health promotion diagnosis, according to the North American Nursing Diagnosis Association International (NANDA-I)?

answer

It describes a person's readiness to enhance specific health behaviors for well-being. #12

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A nurse is assessing patients in a medical unit. What priority level is assigned to the patient diagnosed with impaired gas exchange?

answer

high priority

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Which situation would require the most collaboration with the health care team?

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When the patient is being transferred to a long-term care facility ##9

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What is the measurable criterion used to evaluate goal achievement?

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expected outcome #14

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The nurse writes an expected-outcome statement in measurable terms. An example is:

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Patient will report pain acuity less than 4 on a scale of 0 to 10. #14

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A goal describes a desired change in a patient's condition or behavior. Identify the patient for whom a short-term goal is appropriate.

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A patient who has acute pain related to incisional trauma #14

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A patient is admitted to the hospital for acute exacerbation of asthma. The patient outcomes include that the patient will be able to walk for 100 meters by the second day and will not report breathlessness during walking. The patient's respiratory rate will remain normal during walking; the patient needs to be observed for breathlessness during walking. Which of these is an evaluative measure?

answer

The patient needs to be observed for breathlessness during walking.

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A patient is admitted to the hospital for the management of chest pain. At the time of admission, the patient's BP was 180/100 mm of Hg. Six hours after receiving antihypertensive drugs and other medications, the BP decreased to 130/82 mm of Hg. What should the nurse interpret this response as?

answer

Evaluative measure

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The nurse writes a change-of-shift report, which includes the complete patient data and the interventions provided. Which documentation system does the nurse use to write patient data?

answer

narrative charting #24

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Which organization sets the standards for bedside clinical nursing documentation?

answer

american nurses association

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Which documentation system includes realistic patient- and family-centered outcomes?

answer

case management charting #24

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A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?

answer

Surgeon #27

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the registered nurse (RN) is caring for three patients in a medical unit. The RN takes instructions from the nurse practitioner regarding treatment. The RN receives help from the unlicensed assistive personnel (UAP) when providing care and comfort to the patients. In this instance, what is the role of the RN while caring for the patients with the other health care personnel?

answer

Nurse collaborator

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A nurse is working in a hospital that has been awarded Magnet Recognition by the American Nurses Credentialing Center (ANCC). What is the criterion for awarding Magnet Recognition?

answer

Excellence and innovation in nursing

question

Evidence-based practice is defined as:

answer

A problem-solving approach that integrates best current evidence with clinical practice

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A nurse is caring for an older-adult couple in a community-based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. They note that they go to two different health care providers. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which Quality and Safety in the Ed ucation of Nurses (QSEN) competency?

answer

safety

question

A patient is admitted to an acute care area. The patient is an active business man who is worried about getting back to work. He has had severe diarrhea and vomiting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, identify this patient's immediate priority.

answer

Air, water, and nutrition

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Theory-based nursing practice uses a theoretical approach for nursing care. This approach moves nursing forward as a science. This suggests that:

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Theories will be tested to describe or predict patient outcomes.

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After reviewing the medical reports of a patient, the nurse finds that the patient has a urinary tract infection. The nurse instructs the patient to increase fluid intake. Which step of the nursing process has the nurse followed?

answer

Implementation

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A 75-year-old patient who is in the terminal stages of cancer has moderate pain and severe dyspnea. Her husband informs the nurse that she believes in prayer and her last wish is to die while listening to prayer. What should the nurse do first?

answer

Administer oxygen.

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An elderly patient has been put on a potentially toxic drug for treatment of arthritis. The patient and her family have expressed concern about the drug. What is the role of the nurse in this situation?

answer

Help the patient decide whether to accept the treatment or refuse.

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An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?

answer

Assessment

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A nurse is teaching a patient with diabetes how to self-administer intravenous insulin. What key element does the nurse keep in mind before teaching the patient about medications?

answer

Match the teaching with patient's capabilities.

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The primary health care provider suggests that a patient who is in labor lie in the lithotomy position. The nurse informs the primary health care provider that the patient prefers to deliver in the squatting position. What nursing role is depicted by the behavior of the nurse?

answer

Advocate

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A patient is newly diagnosed with diabetes. The diagnosis has made the patient feel stressed, and the patient eats more carbohydrates. Which theory explains this phenomenon?

answer

Neuman's theory

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A nurse is creating the right environment for change. The nurse is in which phase of Lewin's change theory?

answer

Unfreezing

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A nurse practitioner is assessing a female patient who has been admitted for congestive cardiac failure. The nurse suspects a pulmonary pathology and asks for a chest X-ray to confirm the findings. Which standard of practice is the nurse performing?

answer

Prescriptive authority

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A group of nurse researchers are working on a project that aims at improving nursing interventions to help patients with paralysis regain their mobility.

answer

The main purpose of the research is to design interventions that would help patients regain strength and independence as

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A patient is diagnosed with myocardial ischemia. His blood pressure reading is 180/100 mm Hg, and his total blood cholesterol is 300 mg/dL. The nurse teaches him simple exercises that help reduce cholesterol level and increase the tolerance to stress through adaptation. Which nursing theory is this an example of?

answer

Roy's theory

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Middle-range theory:

answer

Addresses specific phenomena and reflect practice

question

A 75-year-old patient who is in the terminal stages of cancer has moderate pain and severe dyspnea. Her husband informs the nurse that she believes in prayer and her last wish is to die while listening to prayer. What should the nurse do first?

answer

Administer oxygen.

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The nurse is caring for a patient with anxiety. Which theory would be most helpful in relieving the patient's anxiety?

answer

Neuman's Systems Model

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The nurse is assessing a geriatric patient who believes in following a healthy lifestyle to stay healthy. The patient is found to have an increased heart rate. The nurse observes that the patient has become extremely upset due to this finding. Which belief system could be the reason for the patient being upset?

answer

First-order belief

question

Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes?

answer

Enabling

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A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring?

answer

The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

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A patient is admitted to a hospital after a miscarriage. The nurse offers the patient realistic optimism. Which process of care is this?

answer

Maintaining belief

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How can nurses negotiate a difference of opinion and values with patients? .

answer

Nurses should be clear about their values

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A quadriplegic patient complains of being chilly and asks for an extra blanket. The nurse covers the patient up properly, and draws the room's curtains. Which process did the nurse follow?

answer

Doing for

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Which initiative in health care information technology seeks to move the traditional paper patient chart to an online format?

answer

Electronic health record (EHR)

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A nurse is documenting in an electronic medical record (EMR). Which statement describes an EMR?

answer

It is used to document a single episode of care

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Which initiative in health care information technology seeks to move the traditional paper patient chart to an online format?

answer

Electronic health record (EHR)

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A patient shows the nurse a website that recommends weight loss medications. What question does the nurse ask the patient in order to evaluate the authority of the website?

answer

"Who are the authors, sponsors, and publisher?"

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You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?

answer

You need to use words the patients can understand when writing the directions.

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What is the focus of nursing informatics in the health care system?

answer

The management and communication of data and information

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Which technology can the nurse use to deliver emergency interventions when the primary health care provider is not available in the emergency room?

answer

Telemedicine

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The nurse is using Braille boards to teach a patient who is visually impaired. Which area of the verbal, aural, read/write, kinesthetic (VARK) learning style is the nurse using to teach this patient?

answer

Kinesthetic

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A nurse is about to teach school-age children about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes?

answer

Use clear, simple explanations to promote understanding

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A 69-year-old patient is diagnosed with myocardial infarction. The patient is scheduled for coronary artery bypass grafting surgery. The nurse is planning to teach breathing exercises and coughing techniques to the patient to prevent respiratory complications. When is the most appropriate time to teach breathing exercises and coughing techniques to this patient?

answer

Before the surgery

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When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use?

answer

Analogy

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A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient?

answer

Provide only the information that the patient needs to go home

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The nurse is training the nursing staff on how to provide formal patient education. Which example should the nurse give to the staff?

answer

The nurse teaches a patient about self-care and follow-up after discharge

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The nurse is caring for a patient who has nearsightedness. Which would be the best method to educate this patient?

answer

Provide a booklet with enlarged fonts

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A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing?

answer

Health promotion and illness prevention

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During which step of the teaching process does a nurse determine the outcomes of teaching and measure a patient's level of achievement of learning objectives?

answer

Evaluation

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A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient's ability to perform the examination?

answer

The patient will perform breast self-examination correctly on herself before the end of the teaching session.

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The nurse is caring for a patient who has diabetes mellitus. During the assessment, the patient says, "I feel really drowsy lately." The nurse notices that the patient's blood glucose level is 305 mg/dL. Which information should the nurse teach the patient's caregiver?

answer

"If this happens at home, you should immediately call the primary health care provider."

question

A nurse is assessing a patient who was diagnosed as diabetic 5 years ago. During the assessment, the nurse finds out that the patient does not log daily blood sugar levels because he cannot operate the home glucometer properly even though he tries. What does this finding indicate?

answer

The patient needs further teaching on glucose testing.

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Which nursing action indicates that the nurse is facilitating the patient's psychomotor domain of learning?

answer

Teaching a patient with a new diagnosis of hypertension how to check blood pressure

question

A patient needs to learn to use a walker. Which domain is required for learning this skill?

answer

Psychomotor domain

question

What is the first important criterion of the American Nurses Association (ANA) standards of professional performance?

answer

The nurse should use research findings in practical decision-making.

question

The nurse is preparing the nursing care plan to improve the outcomes of labor in a pregnant patient. Which PICO format does the nurse use to develop a question for this condition?

answer

Problem: Preterm birth; Interventions: Educating the patient; Outcome: Increase in gestation period

question

A nurse is referring to various research articles in order to acquire information about a PICO question for which no pilot study has been done. After studying the references, the nurse finds that the evidence is not strong enough to apply in practice. What should the nurse do to investigate the PICO question? Choose the best answer.

answer

Conduct a pilot study.

question

Critiquing the evidence is one of the most important steps in the process of implementing evidence-based practice. Of the following, which is the most important information required while critiquing evidence?

answer

Whether the findings of the research are clinically applicable

question

What is the first important criterion of the American Nurses Association (ANA) standards of professional performance?

answer

The nurse should use research findings in practical decision-making.

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A nurse is unable to form the PICO question that addresses the "effectiveness of chest physiotherapy in removing chest secretions in patients with cystic fibrosis." Which elements of the PICO question are missing in this research question?

answer

Comparison of interest

question

When recruiting subjects to participate in a study about the effects of an exercise program on balance, the researcher provides full and complete information about the purpose of the study and gives the subjects the choice to participate or not participate in the study. This is an example of:

answer

Informed consent.

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Which statement is true regarding Magnet status recognition for a hospital?

answer

Magnet is a special designation for hospitals that achieve excellence in nursing practice.

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A nurse who works in a newborn nursery asks, "I wonder if the moms who breastfeed their babies would be able to breastfeed more successfully if we played peaceful music while they were breastfeeding." In this example of a PICO question, the I is:

answer

Peaceful music.

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Which activity regarding the research process should the nurse conduct to determine what has already been studied about the research problem of interest?

answer

Review the literature.

question

Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the healthcare system?

answer

Patient safety

question

A nurse caring for patients in an inpatient unit asks a clinical question using a PICO format. What does C stand for in a PICO question?

answer

Comparison of interest

question

A registered nurse (RN) is delegating a task to an unlicensed assistive personnel (UAP). The RN tells the UAP, "Measure the blood pressure of Room 32." Which statement is true about the nurse's delegation skill?

answer

The nurse has violated the principle of right communication.

question

The registered nurse (RN) delegates the task of providing hygienic care to the unlicensed assistive personnel (UAP). Shortly thereafter, the RN modifies the assignment based upon patient acuity and asks the UAP to obtain vital signs on another patient. Which delegation right is represented by the nurse's action of modifying the assignment?

answer

Right circumstance

question

A registered nurse (RN) is preparing to delegate a task to the licensed practical nurse (LPN). The RN checks if the task involves assessment, nursing judgment, or evaluation and then delegates the task to the LPN. Which principle of delegation has the RN followed?

answer

First principle

question

Your nursing manager distributes biweekly newsletters of ongoing unit or health care agency activities and posts minutes of committee meetings on a bulletin board in the staff break room. This is an example of:

answer

Staff communication.

question

Which task is appropriate for a registered nurse (RN) to delegate to the nursing assistant?

answer

Assisting the patient to the bathroom before leaving for the operating room

question

Which example demonstrates the nurse performing the skill of evaluation?

answer

After completing the teaching, the nurse observes the patient draw up and administer an insulin injection

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When unit staffing includes nursing assistive personnel (UAP), which scenario is characteristic?

answer

The RN is accountable for the tasks delegated to UAP.

question

The registered nurse (RN) has prepared a care plan for a patient with cancer and delegated some tasks to the unlicensed assistive personnel (UAP). The UAP is unable to carry out the assignment. What does the RN expect the UAP to do in this situation?

answer

Notify the person who delegated the task

question

Which task could a staff nurse delegate to a certified nursing assistant?

answer

Feeding a stroke patient who has minimal dysphagia

question

A nurse is assessing a patient who has diarrhea. While inserting the intravenous catheter, the nurse asks the nursing assistant to help stabilize the patient's hand. Which type of clinical care coordination is the nurse following?

answer

Use of resources

question

Hospital administrators have warned the healthcare team about a patient's invasion of privacy. What could have been the reason for this warning?

answer

The nurse read text messages on the patient's cell phone.

question

A nurse is working the night shift in an emergency room. A patient suffering from cardiac arrest is brought to the hospital. The patient previously underwent a coronary artery bypass graft (CABG) and angioplasty and has been chronically ill since then. The patient has requested in writing that he not be resuscitated (DNR) in case of emergency. What is this known as?

answer

Living will

question

A nurse is caring for a 79-year-old patient. The patient has been a diabetic for 10 years and comes to the hospital for regular check-ups. The nurse finds that the patient has developed a non-healing wound on the left foot. The nurse is dressing the patient's wound. While performing the dressing, the nurse is unsure about the dilution of the antiseptic solution to be used. What should the nurse do?

answer

Refer to the clinical practice protocol

question

A nurse is assessing patients in the unit. Which action of the nurse indicates that the nurse follows fidelity? .

answer

Prepare a plan to manage the pain of the patient and monitor the responses

question

The nursing instructor is teaching a student about the "Four D's" of negligence that provide proof for malpractice. Which statement by the nurse indicates dereliction?

answer

"There should be evidence that the nurse did not provide standard care."

question

A nurse is caring for a patient with a bacterial infection. After administering an antibiotic, the nurse realizes that the wrong dose was given. The nurse immediately informs the patient and the primary healthcare provider. Which principle of the nursing code of ethics has the nurse followed?

answer

Accountability

question

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principal, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you deleted all patient identifiers?

answer

No because even though patient identifiers are removed, someone could identify the patient based on other comments that you make online about his or her condition and your place of work

question

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)?

answer

Posting medical information about the patient on a message board in the patient's room

question

A patient is scheduled for surgery. Before the surgery the patient read the consent form and signed it. Which principle does the patient follow?

answer

Autonomy

question

A student nurse is reluctant to touch a patient who is suffering from a noncommunicable skin disorder. What should be the most appropriate action of a nurse?

answer

Inform the student that touch comforts the patient.

question

A patient with chronic renal failure is admitted to a hospital. The patient is very religious and carries a Bible. The nurse quotes a few lines from the Bible which helps to reinforce the patient's beliefs. Which component of Swanson's theory has the nurse used?

answer

Instilling faith

question

A nurse is providing compassionate and empathic care to a patient. Which nursing theory is the nurse using to provide care?

answer

Travelbee's Human-to-Human Relationship Model

question

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient"?

answer

Gaining an understanding of what a woman's health examination means to the patient

question

The nurse is developing a plan of care for a patient to focus primarily on the cultural practices of the patient. Which theory has the nurse followed?

answer

Madeline Leininger's theory

question

Of the five caring processes described by Swanson, which describes "knowing the patient"?

answer

Establishing an understanding of a specific patient

question

A nurse has long conversations with a patient with respect to medical, family, religious, and cultural practices. What would be the impact of such a conversation on the healing relationship?

answer

It helps to assist the patient in using social resources

question

Which of these is not one of the carative factors in Watson's carative theory?

answer

Restraining expression of negative emotions

question

A 60-year-old patient is undergoing treatment for a brain tumor. The patient is depressed due to his ailment. The nurse tries to understand the patient's feelings without making any assumptions. Which caring process of Swanson's theory is this?

answer

Knowing

question

A nurse is caring for a patient who has lost her husband in an accident. The nurse is helping the patient cope with this loss in her life. Which caring process is the nurse applying?

answer

Enabling

question

Which caring process from Swanson's Middle Range Theory of Caring is the nurse using when offering realistic optimism to a patient?

answer

Maintaining belief

question

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process?

answer

Feedback

question

In the communication process, who is referred to as a receiver of the message?

answer

A person who decodes a message

question

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address?

answer

The patient is short of breath

question

A patient says to a nurse, "I have been drinking 4 glasses of whiskey daily for the past 20 years, and I never had any problems. I don't know why my primary health care provider has asked me to stop drinking." How should the nurse paraphrase this statement?

answer

"You are not convinced that you need to stop drinking."

question

The nurse evaluates the goals of nursing care with a patient who underwent surgery for breast cancer. Which phase of the helping relationship does this nursing action represent?

answer

Terminating

question

The nurse is caring for a 50-year-old patient. The patient had the gall bladder removed and it is day two post-surgery. The nurse finds that the patient is uncomfortable and in pain. The nurse also notices some oozing from the site of the surgery. What nursing actions are needed for the patient?

answer

Gather information about his problem, identify the exact problem, plan appropriate nursing action, perform the required nursing actions, and then evaluate the outcome.

question

What could be the effect of an incorrect nursing diagnosis?

answer

It could affect the quality of patient care.

question

A mother finds her 26-year-old daughter unconscious at home. She takes her to the hospital along with her 1-year-old granddaughter. Who would be the primary source of information in this case?

answer

Mother

question

Which step of the nursing process involves the gathering of information while providing patient care?

answer

Assessment

question

The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step?

answer

Planning

question

The nurse is assessing a patient who reports back and bilateral knee pain. The nurse observes slight swelling and redness over the patient's knees. The nurse obtains the patient's x-ray reports, nutritional details, medical history, and family background. What will be the first step of formulating a nursing diagnosis in this case?

answer

Clustering data related to the primary patient problem

question

While caring for a patient, the nurse determines that the patient's goals are not being met. The nurse modifies the care plan and adds further interventions. Which phase of the nursing process led to modification of the care plan?

answer

Evaluation

question

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which is an example of a collaborative intervention?

answer

Consult with dietitian on initial foods to offer patient.

question

What does the nurse recognize as a "related factor" in the nursing diagnosis?

answer

Etiological factors

question

A nurse is assessing a patient at home post splenectomy. The patient tells the nurse that he realizes that strain on the incision site could cause tearing of the stitches. Nevertheless, the nurse finds that some of the patient's stitches are pulled out. What should be the most appropriate nursing action?

answer

Ask if the patient understands which activities can cause strain at the incision site.

question

What measure does the nurse take to ensure effective planning of patient care?

answer

Identify the most urgent needs of the patient.

question

Which is an evaluative measure used in the nursing process?

answer

Determine if nursing care was effective and patients met the expected outcomes.

question

Which of the Six Rights of Medication Administration would prevent another nurse from duplicating the administration of a medication?

answer

Right documentation

question

The nurse describes a patient's problems to a primary health care provider using the SBAR technique. Which statement falls under 'B' in the SBAR technique?

answer

The patient had total knee replacement surgery the day before.

question

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note?

answer

Enter only objective and factual information about the patient.

question

A nurse works in an emergency room. An 8-year-old girl is brought to the hospital with severe abdominal pain. The nurse has to get consent before medical treatment can be started. The parents of the child are divorced and the mother has custody. The patient is accompanied by her mother, father, and elder sister, who is 19 years old. Who should sign the consent form of the patient?

answer

The patient's mother

question

A nurse assesses a patient on day 3 after surgery and charts a progress note in the SOAP (subjective data, objective data, assessment, plan) format. Which is considered objective data?

answer

The patient's incision site looks clean without any purulent drainage or erythema.

question

A patient on insulin comes for routine blood tests and the nurse finds that his blood sugar is very high. The patient informs the nurse that he measured his blood sugar at home before coming to the clinic, and it was normal. What is the most appropriate nursing action?

answer

Ask the patient to show his technique for checking blood sugar levels

question

A nurse is asked to perform a complex intervention for a patient. However, the nurse is unable to perform it successfully. What would be the appropriate action by the nurse?

answer

Ask for assistance from a senior nurse

question

A patient was shifted from the intensive care unit to the cardiac unit. What kind of reports are used to communicate between the two units?

answer

Transfer report

question

The nurse finds abnormal clinical signs and abnormal laboratory values in a patient. Which documentation system is most appropriate and conducive to documentation of these abnormal findings?

answer

Charting by exception system

question

As the nurse prepares to administer medication to a patient, the nurse asks the patient's name and date of birth. This verbal information is compared to the medical record and the patient's wristband. Which right of medication administration does the nurse follow by performing this action?

answer

Right patient

question

Which is a nonpermanent documentation system for nursing records, prescriptions, and patient information?

answer

Kardex

question

Which condition indicates the need for short-term nursing interventions?

answer

Knee pain

question

What is the purpose of risk nursing diagnoses?

answer

To identify potential problems of the patient

question

Which statement made by the nurse is an example of applying the principle of patient-centered care while focusing on alleviation of a patient's fear and anxiety?

answer

"Let's talk about the concerns that you have about going home."

question

What is the measurable criterion used to evaluate goal achievement?

answer

Expected outcome

question

Priority setting is helpful to solve collaborative problems. What is a high-level priority?

answer

One related to life-threatening needs of the patients

question

When does the nurse initiate discharge planning for a patient admitted with tonsillitis?

answer

Upon admission

question

Which statement represents a properly worded measurable nursing goal?

answer

"The patient's hemoglobin level will be 12 g/dL in 5 days."

question

The nurse is assessing a patient who states, "I feel so lonely without my spouse, and it's been keeping me awake at night." The objective data that the nurse collects in this case are the loss of spouse, a family history of substance abuse, and an introverted personality. What can the nurse conclude about the patient by clustering these data?

answer

The patient is at risk for suicide.

question

The nurse writes an expected-outcome statement in measurable terms. An example is:

answer

Patient will report pain acuity less than 4 on a scale of 0 to 10

question

Which factor does the nurse consider while formulating an actual nursing diagnosis for a patient?

answer

The existing problems of the patient

question

What should the nurse include when writing an actual nursing diagnosis?

answer

Diagnosis label, related factors, and defining characteristics

question

How does the nurse formulate nursing diagnosis statements?

answer

By clustering related patient assessment information

question

A patient reports a migraine headache, which sometimes causes disruptions in daily functioning. The patient is obese and appears stressed. What should the nurse focus on during assessment of this patient?

answer

Collecting primary data

question

A patient tells the nurse, "I feel as if I have no purpose in life." What does the nurse document in the patient's medical record?

answer

Documents the patient's statement verbatim in quotes

question

A patient is admitted to the hospital for severe dehydration. A nurse asks the patient about bowel movements, urine output, and sweating. On the basis of Gordon's functional health patterns, which pattern is the nurse assessing?

answer

Elimination pattern

question

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?

answer

Health perception-health management pattern

question

The nurse formulates a nursing diagnostic statement for a patient with severe pain due to a femur fracture as evidenced by grimacing. What should the nurse include in the "defining characteristics" segment of the nursing diagnosis?

answer

Grimacing

question

A nurse finds a written order in the ICU that in case of cardiac arrest, epinephrine is to be given to the patient. What is this order known as?

answer

Standing order

question

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer?

answer

Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation.

question

The nurse assesses a 4-year-old child and documents the finding as "tender abdomen." How did the nurse arrive at this conclusion?

answer

Through palpation

question

The nurse finds that the patient outcomes have not been achieved after the implementation of interventions. The nurse also identifies aspects of the nursing care plan that need to be modified. Which step of the nursing process do these actions address?

answer

Evaluation

question

The nurse is administering oxygen therapy to a patient with severe respiratory distress. The nurse places the patient in the Fowler's position and calls the respiratory therapist to administer a prescribed bronchodilator. Which type of nursing skill is the nurse using in treating this patient?

answer

Collaborative

question

A patient visits the emergency room complaining of abdominal pain. The RN measures the vital sign of the patient, reports it to the primary health care provider, and obtains the prescription. The RN instructs the LPN to administer an oral analgesic to the patient as per the prescription. Which step of the nursing process did the nurse assign to the LPN?

answer

Implementation

question

What is the final step of the nursing process?

answer

Evaluation

question

While collecting a patient's history, the patient reports to the nurse, "I've had diabetes since I was 10 years old." What is the most accurate way to record this data?

answer

The patient says, "I've had diabetes since I was 10 years old."

question

The registered nurse overhears a statement while the licensed practical nurse (LPN) is collecting data from a patient. Which statement documented by the LPN does the nurse need to validate immediately?

answer

The patient reports bleeding at the surgical wound incision

question

The nurse is performing a physical assessment. Which technique of physical assessment does the nurse use to hear bowel sounds?

answer

Auscultation

question

Which phase of a helping relationship involves activities such as reviewing available medical and nursing history?

answer

Preinteraction

question

While interviewing a patient with a hearing impairment, a nurse closes the door to reduce the environmental noise and greets the patient to get the patient's attention. The nurse speaks in a normal volume and asks the patient to reduce carbohydrate intake. The patient does not understand what the nurse says, so the nurse restates what was said. Which part of the communication should be avoided?

answer

Staying within 2 feet of the patient

question

When caring for a patient, a nurse identifies factors that affect the outcomes of the treatment. To which phase of the nursing process does this nursing activity belong?

answer

Evaluation

question

The nurse asks a patient admitted for depression, "How are you?" The patient replies, "I feel more energetic and better than yesterday." The nurse assesses that there has been no improvement in the patient's mental status. Which defense mechanism is the patient using in this conversation?

answer

Denial

question

Which verbal technique demonstrates that the nurse is actively listening to the patient?

answer

Paraphrasing

question

The nurse is admitting a patient with a sexually transmitted disease, who reports the formation of a new lesion. The nurse takes the patient to a private area and asks the patient to give more information about the lesion. What is the rationale for the nursing intervention?

answer

The patient will be more likely to be open and honest in communication

question

The nurse is caring for a patient who is suffering from lower back pain due to a spinal injury. During a visit to the patient's room, the nurse asks the patient, "How is your pain today?" The patient replies, "It's getting better since I've been performing strength exercises regularly." As the nurse reflects on this conversation, which aspect is the referent?

answer

The pain

question

The primary health care provider instructs the nurse to administer a medication to a patient to relieve anxiety. The patient refuses to take the medicine and wishes to use alternative therapies for anxiety. Which nursing theory is the nurse following when discussing alternative therapies with the patient?

answer

Jean Watson's theory

question

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies:

answer

"Spiritual, mind, and body connections can affect health

question

A patient is admitted to a hospital after a miscarriage. The nurse offers the patient realistic optimism. Which process of care is this?

answer

Maintaining belief

question

A patient is talking to a nurse about being upset after receiving a cancer diagnosis. The nurse attentively listens and touches the patient gently. Which component of Swanson's theory does this action fulfill?

answer

Being with

question

A patient is admitted to a hospital following severe pain in the abdomen. The nurse obtains the patient's complete history and assesses the patient thoroughly. Which process of Swanson's theory is the nurse using?

answer

Knowing

question

While communicating with a patient, the nurse observes that the patient is depressed because of an infertility problem. The nurse informs the patient that there are many therapeutic and surgical methods to improve fertility. Which of Swanson's caring processes is the nurse demonstrating?

answer

Enabling

question

While attending to a patient, a nurse finds that the patient is having difficulty in getting up to a sitting position. The nurse cares for this patient by applying the process of doing for. What is the most appropriate action the nurse can take?

answer

Help the patient in move into the sitting position

question

A nurse is caring for a patient. She is using Swanson's theory. Which actions will be included in "knowing the patient"?

answer

Understanding the patient and the patient's suffering as a whole

question

The nurse is educating a patient to perform self-care skills. Which factor of Watson's caring theory should the nurse apply?

answer

Transpersonal teaching-learning

question

The nursing instructor is discussing various concepts of the Health Belief Model with student nurses. To which concept is the nursing instructor referring when discussing patient's beliefs about the costs of being healthy?

answer

Perceived barrier

question

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing?

answer

primary prevention

question

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness?

answer

"I'm worried about becoming overweight and getting diabetes because my father has diabetes."

question

Which statement best defines health in an individual according to the World Health Organization (WHO)?

answer

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity

question

A nurse has conducted a primary prevention program for school children less than 10 years of age. Which nursing intervention is considered primary prevention?

answer

Explaining the importance of a nutritious diet.

question

During a visit to a family clinic, the nurse teaches a mother about immunizations, car seat use, and home safety for an infant and toddler. Which type of nursing interventions are these? s

answer

Health promotion activities

question

A patient report to the nurse, "I just can't decide what kind of classes I want to take in college. I have no idea what I want to do with my life after high school." What stage of psychosocial development is the patient in, according to Erikson's psychosocial development?

answer

identity versus role confusion

question

You are working in an adolescent health center when a 15-year-old patient shares with you that she thinks she is pregnant and is worried that she may now have a sexually transmitted infection (STI). Her pregnancy test is negative. What is your next priority of care?

answer

Counsel her on safe sex practices.

question

A girl fantasizes about her father as her love interest. According to Freud's psychoanalytical model of personality development, what is this stage of development?

answer

Oedipal

question

A nurse visits a school to conduct an information session for adolescents. What important information should be included in her session?

answer

Inform them about birth control measures.

question

A child between the ages of 3 and 6 years fantasizes about the parent of the opposite sex. Whose developmental theory explains this behavior?

answer

Sigmund Freud

question

Based on knowledge of the developmental tasks of Erikson's Industry versus Inferiority stage, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will:

answer

Increase his self-esteem with mastery of a new skill.

question

While working in the high-school clinic, one of the students tells you that she is worried about her friend who has started to refuse to participate in group activities, no longer cares about how she looks at school, and is not going to all of her classes. Your assessment of these symptoms may indicate that:

answer

She may be at increased risk for suicide.

question

The nurse is teaching a 10-year-old patient about personal hygiene. What observation would indicate that the child has not reached an age-appropriate developmental stage?

answer

Inability to understand and master brushing technique

question

When nurses are communicating with adolescents, they should:

answer

Be alert to clues to their emotional state.

question

According to Jean Piaget's theory, what does an infant in the sensorimotor stage do upon realizing that sucking results in a pleasing effect?

answer

The infant generalizes this action to other things like sucking fingers and blankets.

question

At a well-child examination, the mother comments that her toddler eats little at mealtime, will only sit briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend?

answer

Provide nutritious snacks.

question

A head nurse is teaching student nurses about Sigmund Freud's theory of development. According to Freud, what is the basic instinctual impulse drive to achieve pleasure called?

answer

Id

question

Which question should the nurse ask a mother while assessing the growth and development of a 2-month-old infant?

answer

"Does your baby smile at you?"

question

A 3-year-old child finds finger or thumb sucking pleasurable. According to Freud's theory, what is true about his or her development?

answer

The child's development is delayed.

question

The nurse is outlining a plan of care for a 9-year-old patient. What primary developmental task for this patient should the nurse consider?

answer

Mastery of new skill

question

Which approach would be best for the nurse to use with a hospitalized toddler?

answer

Incorporate routines from home.

question

The type of injury a child is most vulnerable to at a specific age is most closely related to which of the following?

answer

Developmental level of the child

question

The nurse is teaching a group of parents about human development from conception through adolescence. Which age group does the nurse consider to be at higher risk of nutritional disorders?

answer

Adolescents

question

The nurse observes a patient in the play area. The patient is able to think rationally, arrange things in a logical order, and view things from others' perspectives. Which stage of cognitive development is the patient experiencing according to Piaget's theory?

answer

Concrete operational stage

question

The nurse determines that a child is able to understand that objects remain the same even though they may change in appearance. Which cognitive ability does this reflect?

answer

Conservation

question

A major life event such as the death of a loved one, a move to a nursing home, or a cancer diagnosis could precipitate:

answer

Depression.

question

A 34-year-old female executive has a job with frequent deadlines. She notes that, when the deadlines appear, she has a tendency to eat high-fat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. The nurse provides a number of options for the executive, and she chooses yoga. In this scenario yoga is used as a(n):

answer

Stress-management technique.

question

Which is the appropriate nursing intervention while providing discharge instructions to a 68-year-old patient who underwent cataract surgery?

answer

Educate the patient to wear sunglasses in areas with strong light.

question

The nurse is caring for a 78-year-old patient who is terminally ill and needs end-of-life care. What type of care would be most appropriate to alleviate pain and other symptoms?

answer

Hospice care

question

Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result, the older adult is less able to discern:

answer

Salty, sour, and bitter tastes.

question

An older adult is unable to distinguish between the colors blue and black. What is the most likely reason for this condition?

answer

The patient has a discoloration of the eye lens.

question

A 50-year-old male patient is seen in the clinic. He tells the nurse that he has recently lost his job and his wife of 26 years has asked for a divorce. He has a flat affect. Family history reveals that his father committed suicide at the age of 53. The nurse should assess for the following:

answer

Depression

question

While teaching a group of patients, the nurse places an added focus on wellness, health promotion, and disease prevention activities. What is the likely age group of these patients?

answer

Young adulthood

question

Sexuality is maintained throughout our lives. Which answer below best explains sexuality in an older adult?

answer

All older adults, whether healthy or frail, need to express sexual feelings.

question

The nurse includes pork in the diet of a patient of Middle Eastern descent. The patient is offended and informs the nurse that the pork will not be eaten. Which statement explains the nurse's behavior?

answer

The nurse has failed to plan culturally congruent care.

question

Which assessment data influence patient-centered care?

answer

Cultural beliefs

question

A nurse has to examine a patient and administer an intravenous medication that is not a life-saving drug. The patient is a devout Muslim. When the nurse goes to administer the medication she finds that the patient is getting ready for his namaz (prayers). The nurse understands that the patient prays at certain times, as specified in his culture. What should the nurse do in this scenario?

answer

Allow the patient to pray and come back later to administer the medication.

question

The nursing student is learning about the different types of families. What could be an example of a blended family?

answer

A woman bringing her adopted son into a new family when she remarries

question

A patient uses one-word answers and broken English phrases during an interview with the nurse. As a result, the nurse is unable to understand the patient's concerns. Which action should the nurse take?

answer

Arrange for an interpreter

question

A Haitian patient is admitted to the hospital for arthritic pain. During the nursing assessment, the nurse learns that the patient is using a therapy called cupping for palliation of pain along with traditional Western medicine. Cupping involves placing heated cups on the skin. What is the most appropriate action by the nurse?

answer

Learn about this therapy and avoid cultural imposition.

question

An older Chinese woman is admitted to the hospital after a hip fracture. Once the fracture has healed, the nurse encourages the patient to walk about the room. The patient refuses to walk without her son. What should the nurse do in this scenario?

answer

Respect the patient's wish and ask her to walk when her son is present.

question

An older Hindu patient dies in the hospital after a chronic illness. The nurse goes to speak to the family. The patient's wife tells the nurse that her husband has not left and that he will be back soon. She tells the nurse that he will soon take birth again. How should the nurse interpret this?

answer

Hindus believe in reincarnation, and this older woman is referring to it.

question

Which action taken by the nurse demonstrates unbiased and culturally sensitive care to a patient? Ask the dietician to remove pork from the diet of a Middle

answer

Eastern patient

question

An Arab woman is admitted to the hospital. A male nurse is assigned to examine this patient. The patient is uncomfortable and expresses her displeasure at being assigned a male nurse. What should the head nurse do?

answer

Assign a female nurse to carry out the examination.

question

A senior nurse observes that a newly-appointed American nurse is having trouble relating to a patient from a different culture. What advice can the senior nurse give this nurse to enhance cultural competency?

answer

Obtain sufficient knowledge about a patient's cultures and beliefs.

question

A co-worker asks a nurse what is the difference between assimilation and acculturation. How should the nurse respond?

answer

"Acculturation refers to distinct cultures exchanging features; assimilation involves the merging of cultures."

question

To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own:

answer

Background, recognizing personal biases and prejudices.

question

The nurse observes that a 2-year-old American child slowly grows into the American society that the child lives in. What is this process of socialization into one's primary culture known as?

answer

Enculturation

question

A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is:

answer

Explore what has prevented her from being at the clinic in time for her appointment.

question

The nurse observes that an elderly Hispanic patient frequently nods head and consistently says, "OK. I understand," while learning about the medication schedule. What should the nurse conclude from this behavior?

answer

The patient may not have comprehended what was taught.

question

A nurse is caring for an Egyptian woman in the post-anesthesia care unit (PACU). Who should the nurse choose among the family members to help the patient maintain personal hygiene?

answer

The patient's daughter

question

Which patient demonstrates acculturation?

answer

A Korean student in the U.S. who observes both Thanksgiving and traditional ancestral spirituality.

question

The nurse is providing care for a patient with hypertension who is of Latino origin. The nurse belongs to a culture that believes in consumption of hot juices and foods for hypertension. However, the nurse includes cold juices in the patient's diet plan. Which trait does the nurse demonstrate in this case?

answer

Cultural competence

question

A patient is diagnosed with end-stage renal disease. The patient tells the nurse, "I know I am going to be all right, and I will be healthy again. I believe in God, and He will make things right. My spouse and I are yet to tour the world." What kind of spiritual belief does this patient exhibit?

answer

Hope

question

The nurse is caring for a patient receiving chemotherapy for cancer. The patient does not complain despite the challenges faced. The patient is looking forward to a positive outcome. What term should the nurse use to define this attitude?

answer

Hope

question

A Muslim patient is scheduled for transplant surgery. The patient asks the nurse to postpone the operation for an hour so that the evening prayers can be completed before the operation. How should the nurse respond to such a request?

answer

Agree to the patient's request and postpone surgery.

question

The nurse is caring for a critically ill infant. Which is the best intervention by the nurse to help the mother to bond with the dying infant?

answer

Allow the mother to hold the infant and pray.

question

The nurse is caring for an elderly patient undergoing dialysis. The patient's spouse died of a heart attack a week ago. Which statement made by the patient indicates spiritual distress?

answer

"All my prayers and good deeds were in vain."

question

A patient states, "My religion does not permit me to bathe today." What would be the most appropriate nursing action?

answer

Request a clarification of the patient's beliefs and adapt a plan for bathing accordingly.

question

Which behavioral characteristic of a patient indicates hopelessness?

answer

Failing to follow medical recommendations

question

The nurse is caring for a patient who follows the Hindu religion and holds karma responsible for the illness. What is karma?

answer

The individual's moral conduct

question

The nurse is caring for a patient who declared himself an atheist at the time of admission. The patient was diagnosed with end-stage liver cirrhosis. The patient now asks to see the chaplain. What is the best action by the nurse?

answer

Arrange for the chaplain to meet with the patient.

question

When the nurse provides holistic care to a patient, what should the nurse assess to understand the patient's attitude towards illness?

answer

Spirituality and religion

question

Which of the following questions would best assess a patient's level of connectedness?

answer

Who do you consider to be the most important person in your life at this time?

question

Which of the following statements made by an older adult whose husband recently died most indicates the need for follow-up by the nurse?

answer

"I have been unable to talk with my children lately."

question

A mother of three teenage daughters is diagnosed with a brain tumor and is scheduled to undergo major brain surgery. The patient says, "My daughters are my strength. When they are with me, nothing is going to happen to me." What nursing diagnosis can be attributed to this patient?

answer

Readiness for enhanced spiritual well-being

question

A nurse is caring for a patient who refuses to eat until after the sun sets. Which religion does this patient most likely practice?

answer

Islam

question

A 62-year-old male patient has just been told he has a terminal illness. Which of the following statements supports a nursing diagnosis of spiritual distress related to diagnosis of terminal illness?

answer

"I have nothing to live for now."

question

Which of the following would be the most appropriate outcome for a patient who has a nursing diagnosis of spiritual distress related to loneliness?

answer

The patient will set up a time to speak to a close friend in 1 week.

question

A community nurse is working towards achieving Healthy People 2020. What should be the goal?

answer

To increase the quality of life through better health care services

question

The school nurse is teaching children oral hygiene and prevention of cavities. The nurse is focusing on which level of health care?

answer

Primary prevention

question

A community health nurse is assessing the population of a specific community. She wants to identify people who are at risk of health problems. Which individual is a member of a vulnerable group?

answer

An elderly, homeless immigrant

question

In which environment, should the nurse expect a higher incidence of communicable diseases like tuberculosis?

answer

Individuals in prisons and dormitories

question

Which intervention by the school nurse focuses on secondary prevention of illnesses?

answer

Assessing the body mass index of each child

question

Since the majority of sexually transmitted infections (STIs) have few if any symptoms, it is important for the nurse to:

answer

Encourage regular screenings in all sexually active individuals

question

The nurse is providing education on sexually transmitted infections (STIs) to a group of adolescents. The nurse knows that further teaching is needed when one of the adolescents' states:

answer

"I know I'm not infected if I don't have any symptoms such as discharge or sores."

question

Establishing trust and encouraging disclosure about sexuality are often facilitated if the nurse begins by asking the patient:

answer

For permission to discuss sexual issues

question

A couple approaches the nurse for advice on contraception. Which method suggested by the nurse does not require a healthcare provider's prescription?

answer

Condom

question

The nurse is caring for a patient who reports erectile dysfunction during sexual intercourse. What could be the reason for this problem?

answer

Decreased blood flow to the penis

question

Which gland in the vagina secretes lubricants during sexual stimulation?

answer

Bartholin's gland

question

A bedridden patient has reduced tactile sensation. What is the major risk for this patient?

answer

Skin injury

question

Which nursing intervention ensures effective communication with a patient with dementia?

answer

Keeping the communication simple

question

A patient is admitted to the hospital for a scheduled cataract surgery. The patient has no major health history and the vital signs are stable. While assessing the patient, the nurse realizes that the patient has a progressive hearing disorder. What should the nurse document this condition as?

answer

Presbycusis

question

When communicating with a patient who has expressive aphasia, the highest priority for the nurse is to:

answer

Offer pictures or a communication board so the patient can point.

question

A patient has reduced taste sensation and is finding food less appealing. What does the nurse instruct the patient?

answer

Avoid blending or mixing foods.

question

An eye examination of a patient reveals myopia. Which condition does the nurse associate with myopia?

answer

Ability to see only a short distance

question

The nurse is caring for a patient with sensory overload. Which nursing intervention helps to reduce time-related confusion in the patient?

answer

Keeping the curtains open during the day

question

Which nursing intervention is beneficial for a patient with tactile deficits?

answer

Examining the patient's extremities frequently

question

Which change is observed in older adults?

answer

Increased difficulty with balance

question

The nurse is caring for a patient who developed receptive aphasia following a stroke. Which nursing action is most appropriate while communicating with the patient?

answer

Using simple pictures to communicate

question

A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which approach best facilitates communication with her?

answer

Face the patient when speaking; speak slower and in a normal volume

question

The laboratory results of a patient indicate hypocalcemia. Which symptoms does the nurse expect to find in the patient?

answer

Tingling fingers

question

Which relaxation technique involves a verbal form of instruction by the nurse to direct the patient away from stressful thoughts?

answer

Guided imagery

question

The nurse is aware that some forms of stress are essential for the normal growth and development of an individual. What term did Hans Selye use to describe this stress?

answer

Motivational stress

question

The nurse asked a patient with depression, "What is on your mind?" The patient responded, "I have had enough in this world. I wish to leave this planet and enter the world of peace." What is the most appropriate immediate intervention of the nurse?

answer

Ask if the patient has made any plan for suicide

question

The nurse is caring for a patient who has been diagnosed with diabetes. Which member of the health care team is most important to assist the patient at this stage?

answer

A dietitian

question

The nurse is caring for a patient who is partially paralyzed on the right side following a stroke. The patient is learning to write with the left hand. What kind of defense mechanism is the patient using?

answer

Compensation

question

A patient asks the nurse to recheck all the laboratory reports following a diagnosis of liver cancer. The patient also wants to consult another health care provider. Which defense mechanism is the patient exhibiting?

answer

Denial

question

When teaching progressive relaxation to a patient, a nurse asks the patient to take deep breaths. What would be the next instruction after breathing deeply?

answer

Intentionally relax tense muscle groups.

question

A 34-year-old man who is anxious, tearful, and tired from caring for his three young children tells The nurse that he feels depressed and doesn't see how he can go on much longer. The nurse's best response would be:

answer

"Are you thinking of suicide?"

question

A child performs poorly in mathematics and finds it difficult to improve even after spending more time on it. Which behavior shows that the child is using compensation as a defense mechanism?

answer

The child is performing well in music as she is good at music.

question

A patient expresses the desire to learn how to meditate. What does the nurse need to do first?

answer

Select a teaching environment that is free from distractions.

question

The nurse is assigned to care for a patient with suppressed anger. What assessment finding is the nurse likely to gather?

answer

The patient has hypertension.

question

For an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes:

answer

A thorough physical assessment

question

Which action by the unlicensed assistive personnel at bedtime requires the nurse to intervene?

answer

Giving a patient a cup of coffee

question

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching?

answer

"My grandmother told me that babies sleep better on their stomachs."

question

A mother gave birth 2 days ago and is going home from the hospital today. Which advice to the parents ensures the infant's safety while sleeping?

answer

Avoid loose-fitting plastic mattress covers.

question

At which age is a patient most likely to have nocturnal emissions?

answer

Adolescents

question

While assessing pain, the nurse asks the patient, "What does your pain feel like?" The patient says, "I have numbness and a tingling sensation interspersed with shooting pain." Which type of pain does the nurse infer from the patient's response?

answer

Neuropathic pain

question

A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The patient complains of pain in the shoulders. A nurse understands that it is a referred pain. What explanation should the nurse give to the patient regarding the referred pain?

answer

It is a pain that is sensed at a site away from its actual origin or pathology.

question

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain?

answer

The patient's report of pain is the best method for assessing the pain

question

When planning patient education, it is important to remember that patients with which diseases or disorders often find relief in complementary therapies?

answer

Chronic back pain and arthritis

question

The nurse understands that providing holistic care includes treating:

answer

Mind-body-spirit of patients and their families

question

A patient with cancer is administered 60 mg oral morphine/day for chronic pain. The response for this dose is decreasing after repeated administration. The patient now needs to increase the dose of the morphine to achieve adequate pain control. What is this phenomenon called?

answer

Tolerance

question

A woman experiences the loss of a very early term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing?

answer

Disenfranchised

question

A patient's caregiver wants to know if there are support services that would give him some time off from caregiving. Which services can the nurse suggest?

answer

Respite care

question

Which statement describes grief?

answer

A person's emotional response to loss

question

The nurse is caring for a young patient with cancer who is intubated and conscious. How does the nurse best assess pain in this patient?

answer

By asking the patient to point out his or her pain score on a pain assessment tool

question

A patient with terminal lung cancer becomes emotional and says,"Why did God let this happen to me?" Which stage of Kubler-Ross's theory does the nurse correlate with the patient's behavior?

answer

Anger

question

Which complementary and alternative therapy involves the application of digital pressure on designated points on the body?

answer

Acupressure

question

The nurse is caring for a patient with severe pain due to muscle cramps. What type of pain is the patient experiencing?

answer

Somatic pain

question

The nurse is collecting data on a group of patients. Which patient does the nurse conclude has referred pain?

answer

A patient with acute appendicitis and severe pain in the umbilical area

question

The patient requests that the primary health care provider suggest a home remedy for constipation. Which herb does the nurse expect the primary health care provider to recommend?

answer

Senna

question

A patient is admitted to the hospital for multiple injuries and is put on an intravenous analgesia. After a couple of hours, the patient is still in severe pain. The nurse finds that the skin around the intravenous catheter is red and swollen. The nurse finds no other changes in the patient's condition. What should be the immediate response of the nurse?

answer

Change the intravenous access line

question

A patient is in the terminal stages of acquired immunodeficiency syndrome (AIDS) and reports chronic dull pain. On assessment the nurse finds that the patient does not have a family, and has nobody to look after her. What is the most appropriate nursing action in this situation?

answer

Provide hospice care to the patient.

question

The nurse is using Kubler-Ross's five stages of grief to assess a patient whose son was murdered. What would be a possible response from the patient during the anger stage?

answer

"I will fight for justice. My son's murderer will pay!"

question

The nurse is providing bereavement support to a 7-year-old child whose mother died in an accident. What does the nurse do when the child says, "Mama, what happened to you? Please get up and eat something?"

answer

Tell the truth that the child's mother died and will not return.

question

A 62-year-old patient is diagnosed with colorectal cancer and is scheduled for surgery. Following the surgery, the health care provider informs the patient the surgery was successful. However, the patient is told that she needs chemotherapy as the cancer had spread to other organs. The patient asks the nurse whether the spread of cancer will stop if she stops smoking and consuming alcohol. Which stage of grieving is the patient experiencing?

answer

Bargaining

question

A patient diagnosed with terminal lung cancer tells the nurse, "How long can I live if I quit smoking and drinking?" The nurse identifies that the patient is in which stage of grief according to Kubler-Ross?

answer

Bargaining

question

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?

answer

Fluid that has sodium (salt) in it

question

The trainee nurse is caring for a postsurgical patient who has developed pneumonia. The nurse encourages the patient to use an incentive spirometer and instructs the patient to lie in the supine position. The nurse administers oxygen and antibiotics to the patient. Which action implemented by the trainee nurse indicates the need for additional teaching?

answer

Instructing the patient to lie in a supine position

question

In which surgical position is a patient placed flat on the abdomen with the head and feet lowered?

answer

Jackknife

question

During the assessment of a patient scheduled for an appendectomy, the nurse finds that the patient is taking tranquilizers. What complication does the nurse anticipate in the patient?

answer

Respiratory depression

question

A patient is scheduled for surgery. A nurse is administering preoperative medications to the patient. What else does the nurse do after the administration of preoperative medications?

answer

Restrict the patient from leaving the bed.

question

The nurse finds that a postoperative patient has a productive cough, chest pain, dyspnea, fever, and adventitious breath sounds. Which first-line medication does the nurse anticipate administering?

answer

Antibiotic

question

What would be the most effective way for the nurse to validate informed consent? Ask the patient what he or she understands

answer

regarding the procedure.

question

What patient preparation is needed on the day of surgery involving general anesthesia?

answer

Instruct the patient to shower or bathe

question

The nurse observes that a patient appears to be hallucinating. On assessment, the nurse determines that the patient is always thirsty, has an elevated body temperature, and has a low level of consciousness. Which condition does the nurse suspect in this patient?

answer

Hypernatremia

question

While reviewing the urine test results of a patient who performs rigorous exercises, the nurse finds that the urine is unclear and yellowish in color. What does the nurse suggest to the patient?

answer

Increase the intake of water and sports beverage

question

A patient has a partial pressure of carbon dioxide (PaCO2) of 30 mm Hg. What does this value indicate about the patient's condition?

answer

The PaCO2 is lower than normal.

question

What does the nurse teach the patient with a sodium level of 120 mEq/L?

answer

"It is okay to eat cured meat and cheese."

question

The nurse is reviewing the arterial blood gas report of a patient. Which is correct regarding partial pressure of carbon dioxide (PaCO2)?

answer

PaCO2 is a measure of how well the lungs are excreting CO2.

question

A patient is dehydrated and needs an infusion of isotonic fluids to correct the condition. Which intravenous fluid is appropriate for the patient? )

answer

Dextrose 5% in water (D5W

question

A healthcare provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the healthcare provider hang with the transfusion?

answer

0.9% sodium chloride

question

Which patient being cared for by the nurse is at the highest risk of developing respiratory acidosis?

answer

A patient with chronic obstructive pulmonary disease (COPD)

question

Which sign is an indicator of fluid volume imbalance in a patient?

answer

Reduced skin turgor

question

The nurse is caring for a patient who is receiving intravenous (IV) therapy. Which assessment finding in this patient would indicate phlebitis?

answer

Reddened area

question

Which parameter does the nurse monitor to ensure the safety of a patient who presents with hyperphosphatemia?

answer

Serum creatinine levels

question

Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. What total intake should you record?

answer

1000 mL

question

A healthcare provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the healthcare provider hang with the transfusion?

answer

0.9% sodium chloride

question

While reviewing a patient's diagnostic reports, the nurse notices that the sodium levels are 100 mEq/L. Which type of intravenous (IV) solution does the nurse anticipate the primary health care provider to prescribe?

answer

3% normal saline solution

question

Which needle gauge will be best for the nurse to use when providing intravenous therapy for an elderly patient with dehydration?

answer

24 gauge

question

A patient is suffering from syndrome of inappropriate of antidiuretic hormone (SIADH) secretion. For which electrolyte disturbance should the nurse evaluate the patient?

answer

Hyponatremia

question

The nurse is caring for a patient who is receiving intravenous (IV) therapy. After a few minutes, the nurse finds that the patient has confusion, an increased heart rate, and a decreased blood pressure. The nurse also observes a bluish coloring in the patient's skin. Which condition does the nurse infer from these findings?

answer

Catheter embolism

question

While administering medications to a hospitalized patient via the intravenous (IV) route, the nurse finds that the patient's pulse rate is 140 beats/min and blood pressure is 170/90 mm Hg. The nurse also finds that the patient is restless and has distended neck veins. What does the nurse interpret from these findings?

answer

Pulmonary edema

question

The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body?

answer

The lungs excrete carbonic acid

question

The nurse is studying the laboratory results for a patient with Crohn's disease. What electrolyte level does the nurse expect to find in this patient?

answer

Magnesium level of 1.1 mEq/L

question

After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take?

answer

Reinforce to the patient to remain in bed or on the stretcher

question

A patient is scheduled for surgery. The patient has been fasting for the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. What is the most appropriate nursing action?

answer

Give clear liquids to the patient.

question

Which patient is a suitable candidate for administration of dantrolene sodium (Dantrium)?

answer

The patient with malignant hyperthermia

question

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?

answer

Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

question

The nurse is caring for a patient who is experiencing pain due to osteoarthritis. On assessment, the nurse finds that the patient's blood pressure and pulse rate are below normal. What does the nurse document in this patient's assessment?

answer

The patient has chronic pain

question

Which condition leads the nurse to conclude that a patient has referred pain?

answer

Myocardial infarction

question

The primary health care provider shows a patient a chest radiograph and delivers a diagnosis of stage-2 lung cancer.Which statement made by the patient leads the nurse to conclude that the patient is in the first stage of grief according to the Kubler-Ross model?

answer

"I don't think these results are mine."

question

A self-care goal the nurse should set when caring for dying and grieving patients includes:

answer

Maintaining life balance and reflecting on the meaning of his or her work.

question

A nurse is providing postmortem care. Which action is the priority?

answer

Providing culturally and religiously sensitive care in body preparation

question

Two friends were involved in a motor vehicle accident. One of them died, and the survivor attempted suicide due to feeling responsible for the friend's death. Which grief type is indicated by the patient's presentation?

answer

Exaggerated grief

question

A nurse is caring for a terminally ill patient. How can the nurse actively communicate with the patient?

answer

By asking open-ended questions

question

In addition to an adequate patient assessment, when the nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which has occurred?

answer

The patient has provided permission and consent.

question

In which stage of dying does a patient realize the full impact of the loss?

answer

Depression

question

A postoperative patient is currently asleep; therefore, the nurse knows that:

answer

The sedative administered may have helped him sleep, but assessment of pain is still needed.

question

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to:

answer

Assess the characteristics of the pain.

question

A patient asks the nurse about therapeutic touch (TT). Which does the nurse include when providing patient education about TT? Therapeutic touch:

answer

Balances energy fields and restores health by restoring communication among cells, thereby diminishing pain.

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