Term
The nurse practices nursing in conformity with the code of ethics for professional registered nurses. This code:
A) Improves self-health care
B) Protects the client from harm
C) Ensures identical care to all clients
D) Defines the principles by which nurses' provide care to their clients |
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Definition
| The code of ethics is the philosophical ideals of right and wrong that define the principles the nurse will use to provide care to clients. A code of ethics does not ensure identical care to all clients (which would not be acceptable). The nursing code of ethics does not protect clients from harm or improve self-health care. |
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Term
An 18-year-old woman is in the emergency department with fever and cough. The physician asks the nurse to measure vital signs, auscultate lung sounds, listen to heart sounds, determine the level of comfort, and collect blood and sputum samples for analysis. The nurse is performing what aspect of practice?
A) Diagnosis
B) Evaluation
C) Assessment
D) Implementation |
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Definition
| The nurse is assessing the client. Diagnosis occurs after all assessments are completed. Then a plan is developed and implemented. The process is completed with evaluation. |
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Term
A client is wheezing and short of breath. The physician orders a medicated nebulizer treatment now and in 4 hours. The nurse is providing what aspect of care?
A) Planning
B) Evaluation
C) Assessment
D) Implementation |
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Definition
| Implementation is the actual delivery of care. Assessment is data gathering. Then the information is developed into a diagnosis and the planning occurs with the diagnosis. Evaluation is the final step of the nursing process. |
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Term
| The nurse is caring for a client with end-stage lung disease. The client wants to go home on oxygen therapy and be comfortable. The family wants the client to undergo a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the client's wishes with the family. The nurse is acting as the client's: |
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Definition
| An advocate helps speak for the client, communicating the client's concerns and wishes to family and other caregivers. A caregiver assists in meeting all health care needs of the client, including taking measures to restore emotional, spiritual, and social well-being. A manager coordinates all the activities of the members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibilities for a specific nursing unit or agency. An educator explains concepts and facts about health, demonstrates procedures such as self-care activities, reinforces learning or client behavior, and evaluates the client's progress in learning. |
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Term
Evidence-based practice is defined as:
A) Nursing care based on tradition
B) Scholarly inquiry embodied in the nursing and biomedical research literature
C) A problem-solving approach to clinical practice based on best practices
D) Quality nursing care provided in an efficient and economically sound manner |
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Definition
| Evidence-based practice is a problem-solving approach to clinical practice that uses the best available evidence, along with the nurse's expertise and the client's preference and values, in making decisions about care. The other answers are incorrect. |
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Term
The examination for the registered nurse (RN) licensure is exactly the same in every state in the United States. This examination:
A) Guarantees safe nursing care for all clients
B) Ensures standard nursing care for all clients
C) Ensures that honest and ethical care is provided
D) Provides a minimal standard of knowledge for practice |
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Definition
| The RN licensure examination provides a minimum standard of knowledge for nurses. The examination cannot guarantee or ensure care for clients. |
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Term
Advanced practice nurses (APNs) generally:
A) Work in acute care settings
B) Function independently
C) Function as unit directors
D) Work in the university setting |
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Definition
| APNs are generally the most independently functioning nurses. An APN can work in a primary, acute, or restorative care setting. The setting may be a private, public, or university facility. The APN may function as a clinician, educator, case manager, consultant, or researcher. |
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Term
Nursing practice in the twenty-first century is an art and science that is centered on:
A) The client
B) The nursing process
C) Cultural diversity
D) The health care facility |
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Definition
| The client is the correct choice. The health care facility is where the client goes to receive treatment. The nursing process is how nurses proceed to plan care for the client. Cultural diversity is not the correct choice. |
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Term
Who acted to decrease mortality by improving sanitation in the battlefields, which resulted in a decline in illness and infection?
A) Dorothea Dix
B) Lillian Wald
C) Clara Barton
D) Florence Nightingale |
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Definition
| Florence Nightingale is the correct choice. Barton founded the Red Cross. Dix organized hospitals, nurses, and supply lines to support the troops of the Union Army. Wald opened the first community health service for the poor. |
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Term
The professional nurse responsible for increasing respect for the individual and awareness of cultural diversity was:
A) Harriet Tubman
B) Mary Mahoney
C) Isabel Hampton
D) Mary Adelaide Nutting |
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Definition
| Mary Mahoney, the first African American professional nurse, worked to bring respect to individuals regardless of race, color, background, or religion. Tubman assisted slaves to freedom during the Civil War. Hampton founded the Nurses Associated Alumnae of the United States and Canada, which later became the American Nurses Association (ANA). Nutting was instrumental in the affiliation of nursing education with universities. |
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Term
The document that developed goals and objectives to meet the health of the public is known as:
A) Notes on Nursing
B) Last Acts Campaign
C) Healthy People 2010
D) Nursing Principles and Practice 2010 |
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Definition
| Healthy People 2010, a federal document, outlines goals for the public. Notes on Nursing set forth Nightingale's first nursing philosophy. The Last Acts Campaign has developed standards and policies for end-of-life care. Nursing Principles and Practice 2010—current readings in journals are necessary for all nurses in practice. |
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Term
A nurse who uses critical thinking in the decision-making process to provide effective quality care to individuals is known as:
A) An advanced care nurse
B) A clinical decision maker
C) A member of a multidisciplinary practice
D) An evidence-based practitioner |
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Definition
| This process may be carried out with other members of the health care team, and client and family members may be included. All nurses use critical thinking. An advanced care nurse has advanced educational preparation. An evidence-based practitioner draws on research findings as well as clinical expertise and client values. A multidisciplinary practice includes health care members from various fields of activity, such as physical therapy and dietary therapy, along with nursing. |
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Term
Which of the following assures clients that they will receive quality care from a competent nurse?
A) Standards of care
B) Nurse Practice Act
C) Accreditation certification
D) National council licensure |
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Definition
| Standards of care describe the competency level of nursing care as described by the ANA. The Nurse Practice Act regulates the licensing and practice of nursing; it describes the scope of practice. Accreditation allows the facility, school, or hospital to operate and be recognized in good standing according to standards set by peers. National council licensure is the standardized national examination that assess for a minimum knowledge base relevant to the client population that the nurse serves. |
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Term
The licensure and practice of nursing is regulated by:
A) The NCLEX-RN
B) The Nurse Practice Act
C) The certification examination
D) The ANA Congress for Nursing |
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Definition
| The Nurse Practice Act regulates the license and practice of nursing; it describes the scope of practice and is the correct answer. The NCLEX-RN national licensure examination is administered in each state to test that candidates have the minimum knowledge level required for practice. Passage of an examination and requirements for certification signify additional knowledge and competence in a specific area. The ANA Congress for Nursing is an organization that addresses legal aspects of nursing practice. |
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Term
A nurse who has filled a position on the same unit for 2 years understands the unit's organization and the care of the clients on that nursing unit. Benner defines this nurse as able to anticipate nursing care and to formulate long-range goals; this nurse is given the title:
A) Expert nurse
B) Proficient nurse
C) Competent nurse
D) Advanced beginner |
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Definition
| The nurse who has held the same position for 2 to 3 years and understands the specific area and client population is termed a competent nurse. The expert is a nurse with diverse experience who can focus on a specific problem and offer multidimensional solutions. The proficient nurse has more than 2 to 3 years' experience and applies knowledge and experience to a situation. The advanced beginner nurse has at least some level of experience. |
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Term
An APN is the most independently functioning of all professional nurses. All of the following are examples of a clinically focused APN except:
A) Care provider
B) Case manager
C) Nurse specialist
D) Nurse practitioner |
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Definition
| Care provider is a staff position, a nurse who provides direct care. The nurse specialist has clinical expertise in a specific area. The nurse practitioner has advanced training in assessment and pharmacology and is able to provide health care in specific settings. The case manager has additional experience and is able to coordinate activities of other members of the health care team. |
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Term
An APN is pursuing a job change. Which of the following positions would the APN be unable to fill without meeting additional criteria?
A) Case manager
B) Nurse manager
C) Nurse educator
D) Certified registered nurse anesthetist |
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Definition
| Additional training in anesthesia medicine would be required to be a certified registered nurse anesthetist. |
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Term
Which of the following professional organizations was created to address concerns of members in the nursing profession?
A) NLN
B) MSN
C) PHA
D) NIH |
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Definition
| National League for Nursing (NLN) is the correct answer. The master of science in nursing (MSN) degree is earned through advanced educational preparation in nursing. Public Health Administration (PHA) is concerned with areas of public health. The National Institutes of Health (NIH) addresses health on a national level. |
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Term
Contemporary nursing requires that the nurse possess knowledge and skills to carry out a variety of professional roles and responsibilities. Examples include which of the following? (Select all that apply.)
A) Autonomy and accountability
B) Advocacy
C) Provision of bedside care
D) Health promotion and illness prevention |
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Definition
| Each of the options is an example of a professional role or responsibility of the professional nurse. |
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Term
Which of the following is the biggest consumer of health care?
A) Hospitals
B) Businesses
C) Federal government
D) Private insurance companies |
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Definition
| The federal government, which pays for the Medicare and Medicaid programs, is the biggest consumer of health care. The other options are incorrect. |
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Term
Which of the following was most significant in influencing competition in health care costs?
A) Medicare and Medicaid
B) Diagnosis-related groups
C) Prospective payment system
D) Managed care organizations |
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Definition
| The prospective payment system is one of the most significant factors influencing payment for health care. The prospective payment system groups payments into diagnosis-related groups for Medicare and Medicaid clients. Managed care organizations are systems in which there is administrative control over primary health care services for a defined client population. |
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Term
Which of the following statements is true about evidence-based practice? (Select all that apply.) Evidence-based practice:
A) Is based only on the results of research
B) Assists nurses in meeting standards of practice
C) Helps nurses solve dilemmas in the clinical setting
D) Requires nurses to review and critique research and practice findings |
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Definition
| Evidence-based practice helps nurses to solve dilemmas in the clinical setting because it combines scientific research with clinical expertise and local values. Evidence-based practice does require nurses to review and critique research and practice findings. Nurses are expected to always meet the standards of practice. |
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Term
The nurse found that using tympanic thermometers was quick, easy, and yielded temperatures as reliable as those obtained using oral thermometers. This finding represents:
A) Primary care
B) Critical thinking
C) Competency testing
D) Evidence-based practice |
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Definition
| Evidence-based practice draws on both research and clinical experience. Competencies are evidence that skills have been demonstrated. Critical thinking is the questioning thought process that nurses need to use in practice. Primary care is health care provided in the community by one caregiver who takes responsibility for managing a client's care. |
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Term
A client is receiving health care from a health care provider who is a salaried employee. Which model is being followed by the managed care organization (MCO) to which the client belongs? (Select all that apply.)
A) Staff model
B) Group model
C) Network model
D) Independent practice association |
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Definition
| In the staff model of an MCO, the physicians are salaried employees. In the group model, the MCO contracts with a single group practice. An independent practice association is a group of physicians who are under contact to the organization but are not members of it and whose practices include fee-for-service and capitated clients. The MCO contracts with multiple group practices and/or integrated organizations in the network model. |
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Term
The purpose of a utilization review committee is to:
A) Review quality, quantity, and cost of care
B) Review the utilization of the payment mechanism
C) Review reimbursement fees and appropriation of funds
D) Review admissions, diagnostic tests, and treatments ordered by physicians |
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Definition
| The utilization review committee reviews admissions, diagnostic procedures, and treatments ordered by physicians. Review of the quality, quantity, and cost of care is more similar to the functions of a professional standards review organization. Review of reimbursement fees and appropriation of funds involves review of diagnosis-related groups. Reviewing the utilization of the payment mechanism is similar to capitation. |
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Term
The client's health insurance changed, and instead of having a limited number of physicians from whom to choose, the client is voluntarily enrolled in a plan in which medical care is provided by a special group of caregivers. This arrangement is known as:
A) Medicare
B) Private insurance
C) Managed care organization (MCO)
D) Preferred provider organization (PPO) |
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Definition
| This is the description of an MCO. In a PPO, choice of care providers is limited to those listed in the group. Medicare is a federally funded national health insurance program. Private insurance is a traditional fee-for-service plan. |
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Term
Recent research provided evidence that a professional nursing staff affects health care financing. These results indicated that the positive benefit of a professional nursing staff is:
A) Decreased length of stay
B) Decreased rate of readmission
C) Increased rate of nosocomial infections
D) Decreased need to hire ancillary personnel |
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Definition
| A positive benefit of a professional nursing staff is a decreased length of stay. The diagnosis-related group has greater influence on the rate of readmission. The ancillary personnel need to remain so that registered nurses can spend the necessary time to assess and manage clients. Nosocomial infections decrease with a professional nursing staff. |
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Term
The nurse is giving discharge instructions to a client with newly diagnosed diabetes. The nurse discusses with the client what the dietary intake should be. This is an example of which health care service?
A) Tertiary care
B) Restorative care
C) Health promotion
D) Illness prevention |
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Definition
| Health promotion includes dietary counseling. Blood glucose monitoring at the pharmacy is an example of illness prevention. Restorative care is care of a client who, for instance, is recovering from complications of diabetes. Any diagnostic procedure or tests completed in the hospital would be examples of such care. |
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Term
A nurse volunteers to take blood pressure measurements after church services. This is an example of which level of health care service?
A) Secondary care
B) Restorative care
C) Health promotion
D) Illness prevention |
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Definition
| Taking blood pressure measurements is illness prevention. Health promotion includes activities like exercise classes. Secondary care is often known as traditional care. It would include rehabilitation after a stroke in an individual with a history of elevated blood pressure. |
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Term
The nurse completes the standard orders on a client's first day postoperatively. The instrument that is used to coordinate the client's care is:
A) A Medicare plan
B) A discharge plan
C) A critical pathway
D) Standard nursing care |
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Definition
| A critical pathway is a multidisciplinary treatment plan with interventions prescribed within a structured framework. A discharge plan includes an assessment and anticipation of the client's needs. Medicare is a federal health insurance plan for those 65 years of age and older. Standard nursing care is the minimum care to be given to a client. |
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Term
The multidisciplinary care model used to move clients efficiently from admission to discharge is known as:
A) Team nursing
B) Nursing process
C) Case management
D) Interdisciplinary care |
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Definition
| Case management is a model of organizing care in which the case manager monitors, directs, and advises the nursing care personnel on specific care issues and the progress of a client. In team nursing, care might be provided by groups composed of registered nurses, licensed practical nurses, and possibly assistive personnel. Nursing process is used to plan the nursing care for a client. Interdisciplinary care is care provided by a team whose members come from a variety of disciplines. |
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Term
A client discharged after suffering a stroke is transferred from a tertiary care facility to another facility for additional care to help the client recover and continue to regain function. This type of care facility is known as:
A) Home care
B) Assisted care
C) Extended care
D) Restorative care |
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Definition
| Restorative care assists an individual in regaining the maximum possible level of functioning. Home care includes professional and paraprofessional services that are rendered in the home setting. Extended care is intermediate medical or nursing care for individuals with an acute or chronic illness or disability. Assisted care is a setting in which the client is able to function at a higher level of autonomy within a homelike environment but in which care can be given when needed. |
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Term
Which of the following is an example of respite care?
A) Day care
B) Home care
C) Nursing home
D) Nurse extender |
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Definition
| Day care is an example of respite care because it allows the family to maintain normalcy while the client is under their care. A nursing home client receives 24-hour care in the facility. Home care is an intermittent service in which only certain tasks are performed. Nurse extenders may be hired to perform a specific task, such as bathing. |
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Term
Which task is it not appropriate for a professional nurse to delegate to assistive personnel?
A) Ambulate a client
B) Complete a bed bath
C) Obtain a sterile urine specimen
D) Complete the intake and output (I&O) record |
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Definition
| Obtaining a sterile specimen requires insertion of a catheter, a procedure that must be performed by a licensed nurse. Therefore, this would not be an appropriate task to delegate to an assistive person. Assistive personnel would be able to ambulate a client, give a bed bath, and add to the I&O record. |
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Term
A nurse is working in an acute care hospital that uses a case management model. About which of the following activities should the nurse communicate with the case manager? (Select all that apply.)
A) Management of a client transfer to the radiology department
B) Coordination of a client transfer to the step-down rehabilitation unit
C) Follow-up after a client's discharge to evaluate whether needs have been met
D) Permission for a family to bring in special food for a client |
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Definition
| The case manager coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care for the client, with a focus on discharge planning. Therefore, coordination of transfer to a step-down rehabilitation unit and follow-up after discharge to evaluate that needs have been met are the correct answers. |
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Term
A nurse is planning a client's discharge from a subacute care unit to home. Education should be provided on which of the following topics? (Select all that apply.)
A) Medication administration
B) Stress reduction techniques with blood pressure assessment
C) Circumstances in which the client should call the health care provider
D) Hand-washing hygiene when assisting with transfer to the bathroom |
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Definition
| Clients being discharged home need education regarding how to take their medication and when to call their health care provider. There is not enough information here to determine if options 2 and 4 are appropriate, although hand hygiene after toileting is always important. |
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Term
Which of the following clients should be cared for in an extended care facility with skilled nursing? (Select all that apply.)
A) Client who had a stroke, can talk, and has lost bowel and bladder control
B) Severely brain injured client on a ventilator who is receiving intravenous medications
C) Client with Alzheimer's disease who is abusive, combative, and a threat to self and others
D) Young child who recently had a spinal cord injury and is living with quadriplegia and needs to learn a new way of life |
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Definition
| Extended care encompasses intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities. Extended care facilities include intermediate care facilities and skilled nursing facilities. |
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Term
Healthy People 2010's overall goals are to:
A) Assess the health care needs of individuals, families, or communities
B) Develop and implement public health policies and improve access to care
C) Gather information on incident rates of certain diseases and social problems
D) Increase life expectancy and quality of life and eliminate health disparities |
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Definition
| Healthy People 2010 was established to create ongoing health care goals, including increasing life expectancy and quality of life, and eliminate health disparities through improved delivery of health care services. Gathering information, assessing needs, and developing and implementing public health policies are steps in achieving the goals set forth by Healthy People 2010. |
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Term
Substance abusers frequently avoid health care providers because of:
A) Fear of the cost of health care
B) Fear of institutions and people
C) Fear of being turned in to the criminal authorities
D) Fear of being without the recreational drug of choice |
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Definition
| Substance abusers avoid health care for fear of judgmental attitudes by health care providers and concern about being turned in to the criminal authorities. Options 1, 2, and 4 are not primary concerns that result in avoidance of health care. |
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Term
| Vulnerable populations of clients are those who are more likely to develop health problems as a result of: |
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Definition
| Vulnerable population are defined as clients who are more likely to develop health problems as a result of excess risks, who have limits in access to health care services, or who are dependent on others for care. |
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Term
The local health department received information from the Centers for Disease Control and Prevention that the flu was expected to be very contagious this season. The nurse is asked to set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention?
A) Primary intervention
B) Tertiary intervention
C) Nursing intervention
D) Secondary intervention |
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Definition
| Secondary intervention includes disease prevention after a health issue has been identified. Primary intervention is prevention of a health problem that has not yet occurred in the community. Tertiary intervention occurs after a problem has occurred and aims at preventing long-term negative impacts or recurrences in a population. |
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Term
The local school has an increasing number of adolescent parents. The nurse works with the school district to design and teach classes about infant care, child safety, and time management. These are examples of which nursing role?
A) Educator
B) Advocate
C) Collaborator
D) Case manager |
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Definition
| An educator helps clients, families, and communities gain greater skills and knowledge to provide their own care. An advocate is someone who helps clients walk through the system, identifies services, and plans for accessing appropriate resources. A collaborator is an individual who engages in a combined effort with other individuals to develop a mutually acceptable plan that will achieve common goals. A case manager develops and implements a plan of care. |
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Term
A nurse is practicing in an occupational health setting. There are a large number of employees who smoke, and the nurse designs an employee assistance program for smoking cessation. This is an example of which nursing role?
A) Educator
B) Counselor
C) Collaborator
D) Case manager |
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Definition
| A counselor helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. An educator helps the community gain greater skills, including through the presentation of educational programs. A collaborator is an individual who engages in a combined effort with other individuals to develop a mutually acceptable plan that will achieve common goals. |
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Term
What are the three elements included in a community assessment?
A) Environment, families, and social systems
B) People, neighborhoods, and social systems
C) Structure or locale, people, and social systems
D) Health care systems, geographic boundaries, and people |
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Definition
| The community has three components: structure or locale, people, and social systems. To develop a complete community assessment, the nurse must take a careful look at each of the three components to begin to identify needs for health policy, health programs, and health services. |
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Term
The focus of community health nursing differs from that of public health nursing because the nursing care:
A) Is directed at the individual client only
B) Is provided by nurses with a graduate degree in community health nursing
C) Provides direct care to subpopulations who make up the community as a whole
D) Is administered to a collection of individuals who have in common one or more personal or environmental characteristics |
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Definition
| Option 3 defines the focus of community health nursing. Community health nursing focuses on the individual, family, and community. Educational requirements for community-based nurses are not as clearly defined as those for public health nurses. An advanced degree is not always required. |
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Term
In Healthy People 2010, assurance refers to the role of public health in:
A) Providing disease prevention, health protection, and health promotion
B) Making essential community-wide health services available and accessible
C) Providing leadership in developing policies that support the population's health
D) Achieving a healthy environment for each individual, family, and community |
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Definition
| In Healthy People 2010, the assurance role of public health is defined as making essential community-wide health services available and accessible. In Healthy People 2010, public development and implementation refer to the role of health professionals in providing leadership in development of policies that support the population's health. Population-based public health programs focus on disease prevention, health promotion, and health protection. A healthy environment for each individual, family, and community is the overall goal of Healthy People 2010. |
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Term
A home care nurse educator has repeatedly counseled a 33-year-old male diabetic client concerning the need for dietary compliance. In writing an effective teaching plan the nurse will first:
A) Reprimand the client for noncompliant behavior
B) Assess the client's learning needs and readiness to learn
C) Repeat the old teaching plan to ensure the client's comprehension
D) Provide a detailed description of complications associated with the disease process |
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Definition
| Assessing the learner's needs and readiness to learn are important to increase the success of the learning process. Options A and D are negative responses and would block the learning process. Repeating the old teaching plan is nonproductive and an inefficient application of the nursing process. |
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Term
Vulnerable populations are more likely to develop health problems. Which of the following is true of these populations?
A) They are specific populations with unique health care problems.
B) They are limited to the very young and older adult age groups.
C) They live in communities with similar cultures, beliefs, and values.
D) They frequently experience positive outcomes in response to community health interventions. |
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Definition
| Vulnerable populations are defined as specific populations with unique health care problems. Vulnerable populations are not limited to the very young or older adults. Such individuals are those living in poverty, homeless persons, abused clients, substance abusers, and so on. Members of most vulnerable populations come from different cultures and have different beliefs and values. Vulnerable populations are at risk of experiencing poorer outcomes in response to interventions because of the multiple stressors that affect their daily lives. |
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Term
A competent community-based nurse must be skilled in fulfilling a variety of roles. The ability to establish an appropriate plan of care that is based on assessment of clients and families and coordinates the provision of needed resources and services across a continuum of care defines the competency of:
A) Collaborator
B) Change agent
C) Case manager
D) Client advocate |
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Definition
| A case manager's competency is defined as the ability to establish an appropriate plan of care that is based on assessment of clients and families and coordinates the provision of needed resources and services across a continuum of care. A collaborator's competency is described as engaging in a combined effort with all those involved in care delivery. A change agent's competency is to implement new and more effective approaches to problems. A client advocate presents the client's point of view so that appropriate resources can be obtained. |
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Term
When completing an individual total assessment of a client, the community-based nurse will include consideration of:
A) The type of pollution present in the community
B) The amount of industrial development in the past 5 years in the community
C) The predominant cultural and religious groups found in the community
D) The community structures, the population, and the local social system in which the client lives |
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Definition
| No individual client assessment should occur in isolation from the environment and conditions of the client's community. Industrial development, types of pollution, and cultural and religious groups are individual elements in the community. |
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Term
During a well-baby visit, the community-based nurse observed patterned bruises and skin abrasions on the face, arms, and throat of the infant's 21-year-old mother. In questioning the mother, the nurse discovers that she is a recent victim of spousal abuse. An important principle in dealing with this client is:
A) Ensuring the protection of the mother
B) Informing the authorities of the attack
C) Educating the mother on well-baby developmental issues
D) Continuing with the well-baby examination and disregarding the mother's situation |
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Definition
| When dealing with clients who are at risk for or may have suffered abuse, it is important to provide protection. Educating the mother on the developmental issues of her infant is important but provides no protection for the victim. Providing protection and eliminating the fear of retribution is a priority upon discovery of abuse. By disregarding the mother's situation, the nurse has failed to intervene for the family in crisis in the community. |
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Term
A proposal written by a community-based nurse for a new, higher quality older adult care center will have increased probability of acceptance if the proposal includes:
A) All building plans and a list of contractors to complete the job
B) Compliance with the codes and building requirements of local government agencies
C) The up-front cost and managerial framework of the new older adult center
D) Description of how advantageous, realistic, compatible, and adaptable the change will be when implemented |
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Definition
| Change must be perceived as advantageous, compatible with existing values, and easily adaptable to be successful and accepted. Up-front cost, managerial framework, building plans, contractors, compliance with building codes, and regulations for governmental agencies are all incorporated in proposals but do not provide convincing reasoning that leads to change. |
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Term
A nurse is caring for a 64-year-old homeless woman with a chronic respiratory disease in the local community-based clinic. The nurse realizes that the client is at risk of experiencing exacerbation of the disease process related to:
A) Poor attire and cleanliness practices
B) The client's lack of education and ability to read
C) The individual's lack of concern about the disease
D) The client's lack of a storage site for medication and the inability to obtain nutritious meals |
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Definition
| The homeless person's lack of a storage site for medication and inability to obtain nutritious meals are factors that contribute to poor management of chronic disease. Homeless people are often stereotyped as having a lack of concern for their situations. Poor attire and lack of hygiene are not causes of chronic illness exacerbation. They are signs of the client's status as a member of an at-risk population. It is incorrect for the nurse to assume that the client lacks education and the ability to read. |
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Term
A community health nurse is caring for members of a Bosnian community. The nurse determines that the children are undervaccinated and that the community is unaware of this resource. As the nurse assesses the community, the nurse determines that there is a health clinic within 5 miles. The nurse meets with the community leaders and explains the need for immunizations, the location of the clinic, and the process for accessing the health care resources. Which of the following is the nurse doing? (Select all that apply.)
A) Improving children's health care
B) Teaching the community about illness
C) Educating about community resources
D) Promoting autonomy in decision making |
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Definition
| In this case, all four options are correct. The community health nurse is providing information for the community and helping its members learn to access the help that is available, but not dictating the steps that need to be taken. |
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Term
A nurse at the community clinic nurse cares for a 40-year-old woman who takes insulin to manage diabetes. She is having increasing difficulty controlling the disease, and the nurse wants her to try a new insulin pump to help her manage her diabetes. Which of the following change factors increase the likelihood that she will accept this new insulin pump? (Select all that apply.)
A) The innovation or change must be perceived as more advantageous than other alternatives.
B) The innovation or change must be compatible with existing needs, values, and past experiences.
C) The innovation must be tried on a limited basis.
D) Simple innovations or changes are more readily adopted than those that are complex. |
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Definition
| All are factors that will impact the client's potential to change. |
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Term
A parish nurse for a Catholic church provides a free blood pressure screening the first Sunday of every month. This is what level of prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention |
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Definition
| Primary prevention is true prevention that precedes disease and is aimed at clients considered physically and emotionally healthy. Secondary prevention involves individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Quaternary prevention is not a recognized term. |
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Term
A 72-year-old man diagnosed with chronic obstructive pulmonary disease 5 years ago has been participating for the last 2 years in a pulmonary rehabilitation exercise class offered by the local hospital at a fitness facility. This is what level of prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention |
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Definition
| Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Primary prevention is true prevention that precedes disease and involves clients considered physically and emotionally healthy. Secondary prevention is aimed at individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Quaternary prevention is not a recognized term. |
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Term
Based on the transtheoretical model of change, what is the most appropriate response to the following client statement: "Me, exercise? I haven't done that since Junior High gym class and I hated it then!"
A) "That's fine. Exercise is bad for you anyway."
B) "OK. I want you to walk 3 miles four times a week and I'll see you in 1 month."
C) "I understand. Can you think of one reason why being more active would be helpful for you?"
D) "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every day." |
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Definition
| The transtheoretical model of change describes a series of changes that clients move through, starting with precontemplation and ending with maintenance. The first stage for this client would be to validate the client's opinion and move to the first part of precontemplation. The other options are later steps in the model. |
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Term
A client says, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the client through the stages of change toward regular exercise?
A) "Walking is OK. I really think running is better."
B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?"
C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start eating more fruits and vegetables, too."
D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good." |
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Definition
| This option supports the preparation stage in which the client is beginning to consider making small changes. The other options are not good ones for this client. |
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Term
All of the following are examples of active strategies of health promotion except:
A) Exercise training
B) Weight reduction
C) Smoking cessation
D) Fluoridation of drinking water |
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Definition
| Passive strategies of health promotion benefit individuals without any action by the individuals themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. Weight reduction is considered an active strategy of health promotion. With active strategies of health promotion, individuals are motivated to adopt specific health programs. Smoking cessation requires clients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk of disease. Exercise training meets the criteria for active strategies of health promotion because it actively involves the client in his or her own health. |
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Term
A nurse routinely asks clients if they take any vitamins or herbal medications, encourages family members to bring in music that clients like to help them relax, and frequently prays with clients if that is important to them. The nurse is using which model of care?
A) Holistic
B) Health belief
C) Transtheoretical
D) Health promotion |
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Definition
| The holistic model attempts to create conditions that promote optimal health. The holistic model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions. The health belief model addresses the relationship between a person's beliefs and behaviors. The transtheoretical model of change discusses a series of changes through which clients move, starting with precontemplation and ending maintenance. The health promotion model defines health as a positive, dynamic state and not merely the absence of disease. |
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Term
Different attitudes about illness cause people to react in different ways when illness does occur. Medical sociologists call the reaction to illness:
A) Health belief
B) Illness behavior
C) Health promotion
D) Illness prevention |
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Definition
| Illness behavior is the client's reaction to illness. The other three options are models of health. |
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Term
The health belief model addresses the relationship between a person's belief and behaviors, therefore:
A) A person who smokes does not follow the model.
B) This model provides a basis for caring for clients of all ages.
C) A person who does not take necessary medications does not follow the model.
D) It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens. |
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Definition
| The health belief model provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens. |
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Term
A nurse working in a special care unit for children with severe immunologic problems cares for a 3-year-old boy from Greece. The nurse is having difficulty communicating with the father. What is the appropriate action?
A) Care for the boy the same as for any other client.
B) Ask the manager to talk with the father and keep him out of the unit.
C) Have another nurse care for the boy, because maybe that nurse will communicate better with the father.
D) Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community. |
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Definition
| Acquiring cultural and language assistance will help the nurse understand the needs of both the father and the son. The other three options are not culturally sensitive or helpful to the client and his father. |
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Term
A nurse teaches the importance of folic acid intake to a group of pregnant women. This is considered which level of preventive care?
A) Illness behavior
B) Primary prevention
C) Tertiary prevention
D) Secondary prevention |
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Definition
| Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual. |
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Term
A person's ideas, convictions, and attitudes about health and illness can be described as:
A) Moral beliefs
B) Health beliefs
C) Holistic views
D) Negative health behaviors |
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Definition
| Health beliefs are an individual's perceptions of health or illness, which may be based on factual information or misinformation, common sense or myths, or reality or false expectations. Moral beliefs are learned behaviors that are in accordance with the principles of right or wrong. Holistic views consider the emotional and spiritual well-being of the individual. Negative health behaviors include behaviors that are typically harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take appropriate medications. |
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Term
Which of the following models of health or illness defines health as a positive, dynamic state, not merely the absence of disease?
A) Maslow's hierarchy of needs
B) Rosenstoch's health belief model
C) Pender's health promotion model
D) The holistic health model of nursing |
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Definition
| Pender's health promotion model was developed to be a "complementary counterpart to models of health protection." This model defines health as a positive, dynamic state, not merely the absence of disease. Maslow's hierarchy of needs defines what is necessary for human survival and health, such as food, water, safety, and love. Rosenstoch's health belief model addresses the relationship between a person's belief and behaviors. It predicts how clients will behave in relation to their health and how they will comply with their health regimen. The holistic health model creates conditions that promote optimal health. |
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Term
All of the following are considered internal variables that influence a client's health beliefs and practices except:
A) Emotional factors
B) Developmental stage
C) Socioeconomic factors
D) Perception of functioning |
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Definition
| Socioeconomic factors are considered external variables. A person seeks approval and support from neighbors, peers, and co-workers; this affects health beliefs and practices. Economic variables may affect a client's level of health. For example, a client with a fixed income who needs long-term medications may determine that food and shelter are more important than the medication; therefore, the client's health suffers. Perception of functioning is an internal variable. It is defined as the way an individual perceives his or her physical functioning and how it affects health beliefs and practices. Emotional factors are internal variables. These include a client's degree of stress, depression, or fear, which can influence health beliefs and practices. An individual's developmental stage is considered an internal variable. A client's thinking about health is dependent on his or her level of development. |
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Term
Clients maintain health or enhance their health by routine exercise and proper nutrition. This is known as:
A) Illness
B) Health promotion
C) Control of external variables
D) Wellness education |
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Definition
| Health promotion activities help clients maintain and enhance their present level of health. Wellness education instructs persons on how to care for themselves in healthy ways and includes topics such as physical awareness, stress management, and self-responsibility. Illness is defined as poor condition or disease. External variables are outside factors that influence a person's health beliefs and practices. They include family practices, socioeconomic factors, and cultural background. |
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Term
The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care?
A) Illness prevention
B) Tertiary prevention
C) Primary prevention
D) Secondary prevention |
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Definition
| Secondary prevention is prevention geared toward individuals who are already experiencing health problems or illness and who are at risk of experiencing complications or a worsening of their condition. |
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Term
A client comes into the clinic for a complete physical examination. The nurse obtains a health history and determines that the client is at risk for heart disease. Which of the following would lead the nurse to conclude this?
A) The client is 25 years old.
B) The client lives near a chemical plant.
C) The client's father died of a heart attack at age 40.
D) The client works as a carpet salesman. |
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Definition
| Genetic predisposition to specific illnesses is considered a major physical risk factor. The client's father died of a heart attack at the age of 40, which increases the client's risk of heart disease and heart attack. Age may increase or decrease a client's susceptibility to certain illnesses. Age risk factors are often closely associated with other risk factors, such as family history and personal habits. The client is 25 years old; therefore, based on age alone, risk is low for heart disease at this time. The client lives near a chemical plant; this constant exposure to chemicals may lead to health problems. The physical environment in which a person works and lives can increase the likelihood that certain illnesses will occur, but without further information the nurse cannot assess the heart disease risk related to the client's possible chemical exposure. |
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Term
Which of the following statements is the World Health Organization's definition of health?
A) "Complete freedom from disease"
B) "Mental, social, and spiritual well-being"
C) "State of complete physical, mental, and social well-being, not merely the absence of disease"
D) "A state of being that people define in relation to their own values, personality, and lifestyle" |
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Definition
| The World Health Organization defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." There are several definitions of health. Health is a state of being that people define in relation to their own values, personality, and lifestyle. Health and illness must be defined in terms of the individual. Health can include conditions previously considered to be illness. Pender, Murdaugh, and Parsons note that views of health include mental, social, and spiritual well-being. Pender notes that not all people who are free of disease are equally healthy. |
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Term
Which of the following terms is defined as a mental self-image of strengths and weaknesses in all aspects of one's personality?
A) Body image
B) Family roles
C) Self-concept
D) Emotional change |
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Definition
| Self-concept is a mental self-image of strengths and weaknesses in all aspects of one's personality. Self-concept is important in relationships with other family members. When a client is ill, his or her self-concept changes and this may lead to tension and conflict. Body image is defined as a subjective concept of physical appearance. Many illnesses can cause changes in physical appearance, and clients and families react differently to these changes. Clients react differently to illness or the threat of illness. Individual behavioral and emotional reactions depend on the nature of the illness. Illness impacts family roles. When an illness occurs, parents and children try to adapt to major changes resulting from a family member's illness. |
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Term
A nurse hears a colleague tell a student nurse that it is best not to touch the clients unless performing a procedure or an assessment. Why is this not the best practice?
A) She does not touch the clients either.
B) Touch is a type of verbal communication.
C) There is never a problem with using touch.
D) Touch forms a connection between nurse and client. |
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Definition
| Touch is relational and helps create a connection between the nurse and the client. Touch is best used when there is a caring connection between nurse and client. |
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Term
The nurse demonstrates the concept of "knowing the client" when he or she:
A) Gathers pertinent data about the client's condition
B) Predicts the need for certain interventions based on the disease process
C) Encourages the client to depend on the nurse to make important decisions
D) Is able to detect changes in the client's condition based on shared information and bonding |
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Definition
| The nurse who knows the client can predict responses, capacity, and endurance because the two have a mutual sense of bonding. Truly knowing the client is much more than gathering data; a relationship is necessary. The nurse must avoid assumptions based on knowledge of the disease process and rely on information revealed by the client. The client should make decisions, and the nurse should work with the client to help so that it is a mutual process. |
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Term
A client is fearful of upcoming surgery and a possible cancer diagnosis. The client has discussed a love of the Bible with the nurse, who then recommends a favorite Bible verse. The nurse is reprimanded and told that there is no place in nursing for spiritual caring. Which of the following would be an appropriate response?
A) "It is true that spiritual care should be left to a professional."
B) "You are correct, religion is a personal decision."
C) "Spiritual, mind, and body connections can affect health."
D) "I will be more careful not to share my religious beliefs with clients." |
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Definition
| Research shows a link between spirit, mind, and body, and an individual's beliefs and expectations do have effects on the person's well-being. Nurses should not force their beliefs on clients, but sharing is a part of caring. |
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Term
A number of strategies have the potential for creating work environments that enable nurses to demonstrate more caring behaviors. Some of these include:
A) Increasing working hours
B) Raising monetary compensation
C) Providing flexibility, autonomy, and improved staffing
D) Increasing input from physicians concerning nursing functions |
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Definition
| Strategies to create work environments that allow nurses to demonstrate more caring behaviors include introducing greater flexibility in the work in environment structure, rewarding more experienced nurses in non-monetary ways, improving nurse staffing, and providing nurses with autonomy over their practices. |
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Term
Listening includes not only taking in what a client says but also:
A) Incorporating the views of the physician
B) Correcting any errors in the client's understanding
C) Injecting the nurse's personal views and statements
D) Interpreting and understanding what the client means |
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Definition
| Listening includes taking in what a client says as well as interpreting and understanding what the client is saying and communicating that understanding back to the person talking. |
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Term
"Presence" involves a person-to-person encounter that:
A) Enables the client to care for the self
B) Provides personal care to the client
C) Conveys closeness and a sense of caring
D) Puts the nurse in close physical contact with a client |
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Definition
| Presence involves "being there" and "being with" a client, including communication and understanding. It includes a sense of closeness and caring. |
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Term
Clients' perceptions are important because health care organizations are:
A) Required always to act in the best interest of the client
B) Placing greater emphasis on client satisfaction
C) Under investigation for misappropriation of funds
D) Carefully watched and regulated by the federal government |
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Definition
| A study of clients' perceptions is important because health care organizations are placing greater emphasis on client satisfaction. |
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Term
The caring aspect of nursing may be negatively affected in clinical practice today primarily because of:
A) Lack of time constraints in nursing care
B) Increased emphasis on the nurse-client relationship
C) Prevalence of chronic conditions that slow the pace of nursing
D) Rise in technology that takes nurses' attention away from clients |
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Definition
| Increased technology tends to take the nurse away from the bedside. The prevalence of chronic conditions has a positive, not a negative, impact. The trend is toward greater acuity in clients' conditions. There are more time constraints because of disease acuity and technology. |
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Term
The nurse demonstrates caring behavior when he or she:
A) Leaves the light off in the client's room
B) Pats the client's arm when approaching the bed
C) Asks the client if he or she needs anything while exiting the room
D) Traces the intravenous (IV) tubing from the arm to the fluid bag while checking for kinks |
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Definition
| Physical contact is a means of expressing caring. Leaving the lights off interferes with eye contact and clear communication. Caring for the IV shows attention to technology and details rather than to the client. Although asking if the client needs anything is kind, if the nurse does not wait for an answer and is not offering presence, this is not a caring behavior. |
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Term
According to Watson's transpersonal caring theory, the nurse should understand which of the following?
A) The act of caring is personal and cannot be shared.
B) Caring can increase healing and promote well-being.
C) Expressions of human caring are the same for all individuals.
D) Nurses must use caring behaviors specific to their own cultures. |
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Definition
| Conscious caring by the nurse can promote healing and is complementary to conventional nursing practice. Caring can be shared and is a powerful connection between individuals. It is important for the nurse to appreciate the culture of the client and incorporate this into the care. Caring is individual and is different for all. |
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Term
Because clients and nurses may differ in their perceptions of caring, it is important that the nurse:
A) Focus on keeping the relationship on a business level.
B) Follow his or her own beliefs about what is appropriate.
C) Seek information regarding what is important to the client.
D) Allow a more experienced nurse to establish the nurse-client relationship. |
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Definition
| It is important to assess the client's needs and expectations of care. Clients relate to nurses on a personal level. The client's beliefs must be considered. Personnel at all levels of nursing should have effective relationships with clients. |
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Term
Which of the following nurses is showing behavior that indicates that the nurse is providing presence in a caring relationship?
A) The clinic nurse who pats the client on the back for reassurance
B) The newly licensed nurse who braces the client as he or she gets out of bed
C) The home care nurse who focuses attention on the older adult client sharing a story
D) The staff nurse who stays with a client who is undergoing an unfamiliar procedure |
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Definition
| Coaching a client through an experience is an example of presence, as is sitting by a client's bedside. The nurse is providing safety while helping the client get out of bed. In option 3, the nurse is listening. |
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Term
The nurse demonstrates listening skills by:
A) Blocking nonverbal communication so that the verbal communication is more defined
B) Waiting until mealtimes so that the conversation can be more sociable
C) Surrounding the client with family and friends to make him or her comfortable
D) Paying attention to the tone of voice in addition to the client's words so the meaning is clear |
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Definition
| The client's tone of voice supplies cues that allow the nurse to better understand the client's frame of reference. Nonverbal cues add meaning to the verbal communication and increase understanding. Surrounding the client with family and friends serves as a distraction to communication between client and nurse. A client's hunger, pain, or other distractions can hinder communication. |
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Term
The nurse can best demonstrate caring to a client who has recently suffered a loss through miscarriage by:
A) Sitting with the client in silence
B) Sharing a personal account of a similar loss
C) Offering some literature on the grieving process
D) Asking the hospital chaplain to visit the client |
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Definition
| Offering self is a powerful demonstration of caring and allows the client to trust and feel the presence of a caring person. Therapeutic communication should focus on the client, not the nurse. Offering literature may be helpful at some point when the client indicates she is ready and asks for information. Chaplain visits may be helpful but do not replace the need for a caring relationship with the nurse. |
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Term
A nurse who normally uses touch when caring for clients might consider this inappropriate for which of the following clients?
A) A client of the opposite sex
B) A client from a different culture than that of the nurse
C) A psychiatric client who is displaying suspicion and fear
D) A client who has many family members present in the room |
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Definition
| A psychiatric client may interpret a gesture as a threat, and further assessment is required. There is no contraindication to touching a client of the opposite sex or to touching a client when family members are present unless the client indicates that he or she is uncomfortable. |
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Term
Family members make the following comments about the nursing care being received. Which one should be investigated further?
A) "The nurses showed us how to keep Mother's arm propped on a pillow."
B) "Our nurses don't seem too optimistic about the outcome of Dad's stroke."
C) "The night nurse tells us to wait and ask the doctor the questions we have."
D) "The nurses have written down the turn schedule and taped it above the bed." |
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Definition
| A caring nurse should show interest in answering questions and giving clear explanations. The comment in option 3 indicates that the nurse is shirking responsibility. Teaching the family is important and gives the family the feeling of being useful. Keeping the family informed and included in care is a sign of good nursing. Honesty is a quality of caring. False reassurance is dishonest and is not helpful. |
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Term
17. In caring for a client, the nurse would describe learning about the client's family as:
A) Essential
B) Unnecessary
C) A waste of time
D) Okay to do when one has the time |
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Definition
| Each individual experiences life through their relationships with others, so learning about the client's family is essential in learning about the client. |
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Term
During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking?
A) Integrity
B) Discipline
C) Confidence
D) Perseverance |
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Definition
| Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved. |
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Term
A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the technician to learn his side of the story as well. This is an example of:
A) Fairness
B) Curiosity
C) Risk taking
D) Responsibility |
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Definition
| Fairness involves analyzing all viewpoints to understand the situation completely before making a decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more. Risk taking involves trying different ways to solve problems. |
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Term
The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which intellectual standard?
A) Depth
B) Specificity
C) Relevance
D) Consistency |
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Definition
| Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the assessment to provide information about the particular problem of interest. |
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Term
During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the client makes two attempts it is clear that the client does not understand how to prepare the correct dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an example of:
A) Reflection
B) Risk taking
C) Problem solving
D) Client assessment |
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Definition
| This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a different approach. Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client assessment is the first step in the process of instruction. |
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Term
A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is:
A) Commitment
B) Scientific method
C) Basic critical thinking
D) Complex critical thinking |
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Definition
| At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step. Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently. Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others. The scientific method is a process of problem solving. |
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Term
A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:
A) Planning
B) Evaluation
C) Assessment
D) Intervention |
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Definition
| Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan. |
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Term
The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion the nurse reviewed information about loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making |
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Definition
| The nurse sought appropriate information to be able to communicate more knowledgeably with the client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for problem resolution. |
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Term
Before performing a procedure for the first time at a new agency, the travel nurse:
A) Refuses to perform the procedure
B) Asks the charge nurse how to perform the procedure
C) Reads about the procedure in the policy and procedure manual
D) Performs the procedure as at the agency where the nurse previously worked |
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Definition
| Every agency has its own policies and way of performing procedures. The charge nurse may not know how the procedure should be performed or may explain it incorrectly. The procedure may be performed differently than in the previous agency. If the nurse refuses to perform procedures that are covered by the Nurse Practice Act, the nurse could be fired. |
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Term
Which of the following is the most accurate information to give a nurse during change-of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery. |
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Definition
| The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication. |
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Term
On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. The best action for the nurse to take at this time is to:
A) Introduce himself or herself and begin discharge teaching.
B) Proceed with the tasks the nurse was intending to perform.
C) Say nothing and leave quickly, closing the door behind.
D) Ask the client and spouse if they need some time alone right now. |
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Definition
| The situation suggests that the nurse entered during a stressful time. Offering privacy would be appropriate. Because the situation indicates tension between the couple, this is not the time to initiate teaching. |
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Term
The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask?
A) "How many times do you get up at night?"
B) "How long have you been getting up at night?"
C) "Why do you get up at night?"
D) "How easily do you go back to sleep after you get up?" |
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Definition
| Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions. |
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Term
A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment |
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Definition
| The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia. |
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Term
The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous cerebrovascular accident. What tool should be used to plan her care?
A) Care plan
B) Care map
C) Concept map
D) Critical thinking |
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Definition
| A concept map is a visual representation of client problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client. |
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Term
A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.)
A) Pain intensity
B) Location of pain
C) Character of pain
D) Radiation of pain
E) Meaning of pain to the client
F) Family history of myocardial infarctions |
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Definition
| The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation. |
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Term
The purpose of assessment is to:
A) Make a diagnostic conclusion.
B) Delegate nursing responsibility.
C) Teach the client about his or her health.
D) Establish a database concerning the client. |
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Definition
| The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment. |
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Term
Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not:
A) Include subjective data from the client.
B) Perform a thorough physical examination.
C) Use interpersonal and cognitive skills.
D) Include inferences or interpretative statements not supported with data. |
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Definition
| The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client. |
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Term
A nurse assessing a client who comes to the pulmonary clinic asks, "Tell me what medications you are taking for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?
A) Value-belief pattern
B) Cognitive-perceptual pattern
C) Coping?stress tolerance pattern
D) Health perception?health management pattern |
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Definition
| The health perception?health management pattern involves the client's self-report of health and well-being, how the client manages his or her health, and knowledge of preventative health practices. The cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and decision-making abilities. The coping?stress tolerance pattern involves the client's ability to manage stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance. The value-belief pattern involves the values, beliefs, and goals that guide the client's choices or decisions. |
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Term
The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview?
A) Working
B) Orientation
C) Termination |
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Definition
| The nurse's questions exemplify the working phase of the interview. |
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Term
During data clustering, a nurse:
A) Provides documentation of nursing care
B) Reviews data with other health care providers
C) Makes inferences about patterns of information
D) Organizes cues into patterns that lead to identification of nursing diagnoses |
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Definition
| During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect. |
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Term
What type of interview technique is the nurse using when the nurse asks the question, "Do you have pain or cramping?"
A) Active listening
B) Open-ended questioning
C) Closed-ended questioning
D) Problem-oriented questioning |
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Definition
| The example is a closed-ended question which the client can answer with a one-word reply. Open-ended questions allow the client to answer with more information. The other options are not correct. |
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Term
Which of the following is subjective information to be entered in the client's medical record?
A) Skin warm and dry.
B) Pain intensity 8 out of 10.
C) Breath sounds clear to auscultation.
D) Amber urine in sufficient quantities. |
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Definition
| Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data. |
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Term
Which of the following is objective information to be recorded in the client's medical record?
A) Anxious over upcoming test.
B) Increasing stress over past 2 months.
C) Performs breast self-examination monthly.
D) Expelled 1 tablespoon of yellow sputum. |
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Definition
| Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the nurse but depend on the client's reports; thus they are subjective data. |
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Term
A client who is alert and awake is being transferred to another hospital with a copy of his medical records. Before the transfer the nurse must:
A) Ask the hospital lawyer if this requires approval from the risk management department.
B) Discuss the need to copy the medical records with the client's family.
C) Be certain that the physician writes an order for the record to be copied.
D) Obtain written permission to copy the medical records for the receiving hospital. |
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Definition
| Obtaining permission to copy the records demonstrates the nurse's understanding of the provisions of the Health Insurance Portability and Accountability Act (HIPAA). Discussing medical records with the client's family is inappropriate because the client's family does not make the decision for a client who is capable of making his own decision. Policies and procedures would already be in place for the nurse with regard to copying medication records. It is not necessary to call the hospital lawyer. Copying a client's medical record does not require a physician's order. |
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Term
Which of the following is an open-ended question the nurse might use when interviewing a client?
A) "Do you have any concerns right now?"
B) "Is your family worried about your being in the hospital?"
C) "What do you mean when you say, 'I don't feel quite right'?"
D) "How many times do you get up to go to the bathroom at night?" |
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Definition
| The way the nurse asks question 3 allows the client to respond completely and with more than a one-word answer. The other options allow the client to respond with one word and make it unlikely that the client will give additional information. |
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Term
The nurse asks the client whether the client has any allergies. This is an example of:
A) Health history data
B) Biographical information
C) History of present illness
D) Environmental history data |
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Definition
| Known allergies are a part of historical data. Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance. The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness. The environmental history includes data about the client's home and working environments. |
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Term
The nursing assessment is which phase of the nursing process?
A) First
B) Second
C) Third
D) Fourth |
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Definition
| The nursing process cannot proceed unless the nurse first conducts a client assessment. The other phases of the nursing process occur after assessment. |
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Term
What techniques encourage a client to tell his or her full story? (Select all that apply.)
A) Active listening
B) Back channeling
C) Use of open-ended questions
D) Use of closed-ended questions |
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Definition
| Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important. |
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Term
The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.)
A) Client is restless.
B) Respirations are 24/min and irregular.
C) Client states feeling short of breath.
D) Fluid intake for 8 hours is 800 ml.
E) Client has drainage from surgical wound.
F) Client reports loss of appetite for over 2 weeks. |
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Definition
| The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia. |
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Term
| The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data. |
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Definition
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Term
| A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data. |
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Definition
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Term
A nursing diagnosis is:
A) The diagnosis and treatment of human responses to health and illness
B) The advancement of the development, testing, and refinement of a common nursing language
C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests |
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Definition
| A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language. |
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Term
The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error?
A) Error in data clustering
B) Error in data collection
C) Error in data interpretation
D) Error in making a diagnostic statement |
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Definition
| When a nurse compares collected assessment data with defining characteristics for two diagnoses, the selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement. There is no indication the data clustering or interpretation were incorrect. |
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Term
One of the purposes of the use of standard formal nursing diagnostic statements is to:
A) Evaluate nursing care.
B) Gather information on client data.
C) Help nurses to focus on the role of nursing in client care.
D) Facilitate understanding of client problems by different health care providers. |
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Definition
| The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs. The other options are not part of the reason for the development of nursing diagnostic statements. |
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Term
The nursing diagnosis Readiness for enhanced communication is an example of which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis |
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Definition
| The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis. |
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Term
The nursing diagnosis Hypothermia is an example of which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis |
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Definition
| An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A potential nursing diagnosis is a risk for diagnosis. |
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Term
In the examples given below, which nurse is acting to avoid a data collection error?
A) The nurse asks her colleague to chart her assessment data.
B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis.
C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her.
D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills. |
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Definition
| A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse reviewing his level of comfort and competence is being complete but can miss his own errors. Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data is incorrect. |
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Term
"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in:
A) Data collection
B) Date clustering
C) Diagnostic label
D) Medical diagnosis |
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Definition
| The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association (NANDA) International. The question does not discuss data collection, medical diagnosis, or data clustering. |
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Term
After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following appropriate client-centered goals?
A) Determine effect of pain intensity on client function.
B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay.
C) Encourage client to implement guided imagery when pain begins.
D) Administer analgesic 30 minutes before physical therapy treatment. |
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Definition
| Option 2 is measurable and objective. "Encourage" is not specific enough. How does one "encourage"? Also, it is not measurable. Determining the effect of pain is part of the assessment or evaluation. Administering an analgesic is an intervention, not a goal. |
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Term
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following?
A) Apply a cold pack to the tibia.
B) Elevate the leg 5 inches above the heart.
C) Perform range-of-motion movement with right leg every 4 hours.
D) Administer aspirin 325 mg every 4 hours as needed. |
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Definition
| Elevation of the leg does not need a physician's order. Applying a cold pack and administering medication do require a physician's order. Range-of-motion movement of the fractured tibia is inappropriate. |
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Term
Which of the following nursing interventions is written correctly?
A) Change dressing once a shift.
B) Perform neurovascular checks.
C) Elevate head of bed 30 degrees before meals.
D) Apply continuous passive motion machine during day. |
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Definition
| Option 3 is specific—it indicates what to do and when. |
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Term
A client's wound is not healing and appears to be worsening with the current treatment. What is the first option the nurse should consider?
A) Notifying the physician
B) Calling the wound care nurse
C) Consulting with another nurse
D) Changing the wound care treatment |
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Definition
| Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. Notifying the physician may be appropriate after the nurse decides on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Unless the nurse is knowledgeable in wound management, changing the wound care treatment could delay wound healing. Also, the current wound management plan might have been ordered by the physician. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan. |
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Term
When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report?
A) Client's concern about the current treatment
B) Length of time current treatment has been in place
C) Spouse's reaction to the client's current treatment
D) Physician's reluctance to change the current treatment plan |
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Definition
| Reporting the length of time the current treatment has been used gives the consulting nurse facts that will influence formulation of a new plan. The other options are subjective and emotional issues or conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a new treatment plan. |
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Term
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following?
A) Implement the specialist's recommendations.
B) Discuss and review advised strategies with the CNS.
C) Report the recommendations to the primary physician.
D) Clarify the suggestions with the client and family members. |
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Definition
| Because the primary nurse requested the consultation, it is important that the primary nurse and the CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's recommendations. A consultation requires review of the recommendations but not immediate implementation. Reporting the recommendations to the physician would be appropriate after the nurse first talks with the CNS about recommended changes in the plan of care and the rationale. Only then should the primary nurse call the physician. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. It is better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family. |
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Term
Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.)
A) Nocturia
B) Frequency
C) Urinary retention
D) Inadequate urinary output
E) Receipt of intravenous fluids
F) Sensation of bladder fullness |
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Definition
| The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA. |
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Term
During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.)
A) Interventions
B) Nursing diagnosis
C) Expected outcomes
D) Client-centered goals
E) Nurse-centered priorities |
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Definition
| Expected outcomes and goals are the main components of the planning phase of the nursing process. The nurse determines these from the assessment. The client should be the focus of the planning stage. Interventions are initially determined by the nurse. |
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Term
A nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment, the nurse anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations?
A) The family comes to visit the client.
B) The client expresses concern about pain control.
C) The client's vital signs change showing a drop in blood pressure.
D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift. |
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Definition
| A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing the client's pain, would be the second priority. The end-of-shift report and the family's visit are lesser priorities. |
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Term
A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the following should be performed first?
A) Reconnect the drainage tube.
B) Inspect the condition of the IV dressing.
C) Improve the client's comfort and turn her to her side.
D) Go to the medication room and obtain the next IV fluid bag. |
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Definition
| The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The client should then be turned (with care taken to ensure that the tubing remains connected), followed by replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should come first. |
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Term
A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame?
A) Indicate which outcome has priority.
B) Indicate the time it takes to complete an intervention.
C) Indicate how long the nurse is scheduled to care for the client.
D) Indicate when the client is expected to respond in the desired manner. |
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Definition
| The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals. The other options are incorrect. |
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Term
A client-centered goal is a specific and measurable behavior or response that reflects:
A) The physician's goal for the specific client
B) The client's desire for specified health care interventions
C) The client's response compared to that of another client with a similar problem
D) The client's highest possible level of wellness and independence in function |
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Definition
| A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. The other options do not meet the definition of a client-centered goal. |
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Term
Which of the following is an example of an expected outcome statement in measurable terms?
A) Client will be pain free.
B) Client will have less pain.
C) Client will take pain medication every 4 hours.
D) Client will report pain intensity of less than 4 on a scale of 0 to 10. |
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Definition
| Reporting the level of pain on a numbered scale is a measurable, objective goal. The other options do not specify measurable outcomes. |
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Term
A client is experiencing nausea and abdominal distention postoperatively. The nurse initiates the interventions listed below. Which of the interventions is an example of an independent intervention? (Select all that apply.)
A) Provides frequent mouth care
B) Maintains intravenous infusion at 100 ml/hr
C) Administers prochlorperazine (Compazine) via rectal suppository
D) Consults with the dietitian on initial foods to offer the client
E) Controls aversive odors and unpleasant visual stimulation that trigger nausea |
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Definition
| Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that trigger nausea are examples of independent intervention. The other options are dependent interventions. |
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Term
When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any coughing during meals in the client, who recently experienced a stroke and requires feeding. In this situation the nurse is acting as which of the following?
A) Educator
B) Delegator
C) Client advocate
D) On-the-job trainer |
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Definition
| The nurse is delegating the task of feeding to the aide but is also providing directions. |
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Term
The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to:
A) Have the client void.
B) Place the client in Sims' position.
C) Premedicate the client with analgesics.
D) Insert a peripheral intravenous (IV) catheter. |
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Definition
| The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure. |
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Term
The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating?
A) Cognitive skill
B) Behavioral skill
C) Interpersonal skill
D) Psychomotor skill |
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Definition
| The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client. No psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill. |
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Term
A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of a family member when the nurse implements which of the following interventions?
A) Praying with the family
B) Reminiscing with the family
C) Arranging for the chaplain to visit the family
D) Obtaining a consult with a psychiatric clinical nurse specialist |
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Definition
| Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counseling. |
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Term
The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating?
A) Concern for safety
B) Promotion of client health
C) Colleague health education
D) Control of adverse reactions |
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Definition
| The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting a laxative does not provide education. |
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Term
Which of the following characteristics of a goal is missing from the statement "Client will ambulate daily"?
A) Observable
B) Measurable
C) Client centered
D) Singular goal or outcome |
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Definition
| Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met in this goal statement. |
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Term
When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.)
A) Ability to cook meals
B) Ability to feed oneself
C) Ability to write checks
D) Ability to bathe oneself
E) Ability to take medications |
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Definition
| The correct options are skills that allow the client to live independently in society. They may or may not be performed on a daily basis. The other options are activities of daily living. |
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Term
14. Which of the following are nurse-provided indirect care activities? (Select all that apply.)
A) Delegating
B) Documenting
C) Evaluating new products
D) Administering medications
E) Providing client counseling |
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Definition
| The correct options do not involve direct interaction with the client or family. The other options do require such direct interaction. |
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Term
| The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an electrocardiogram should be obtained immediately. This is an example of a(n) _____________. |
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Definition
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Term
A 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12 noon, the nurse records the client's vital signs on the recovery room flow sheet. What is this an example of?
A) Psychomotor skill
B) Indirect care measure
C) Physical care technique
D) Anticipating complications |
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Definition
| Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a direct care measure and not a physical care technique. |
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Term
Interdisciplinary care plans represent:
A) All nursing personnel having input in the care plan.
B) Contributions of all disciplines in caring for the client.
C) The client's express wishes and advance directives.
D) Physicians and nurses working together to develop a plan of care. |
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Definition
| Interdisciplinary care plans include the contributions of all disciplines involved in the patient's care. The client's advance directives and express wishes may be included, as well as nursing and physician input, but other involved disciplines also contribute their plans. |
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Term
Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?
A) Safety
B) Nurse staffing
C) Confidentiality
D) Adequate pain relief |
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Definition
| Client safety is an environmental factor and is always the first concern. Pain relief, staffing, and confidentiality are important but are not environmental factors. |
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Term
In order to determine whether an intervention was successful, the nurse evaluates the success of attaining a goal. Which of the following is an example of an evaluation?
A) Dressing changed every 8 hours using sterile technique.
B) Client will ambulate 500 feet 4 times a day with minimal assistance.
C) Client performed quadriceps-setting exercises to right leg every 4 hours.
D) Wound filling in with granulation tissue is red to pink without signs of infection. |
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Definition
| Evaluation occurs after an intervention and indicates degree of achievement of goal attainment. The qualifier "will" indicates that this is a future event and does not evaluate current attainment of goal. Doing an intervention is not evaluating whether it was effective or not. |
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Term
A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize?
A) The pain plan needs changing.
B) The client is overrating the pain.
C) Complications from surgery are occurring.
D) Nonpharmacological pain-relieving strategies are now appropriate. |
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Definition
| The current pain medications are not effectively relieving the pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the client says it is. There is no objective way to measure pain. The clinician must accept the client's report of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of pain medications. Pain following surgery is an expectation. |
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Term
The nurse requests a stimulant laxative for a client receiving an opioid around-the-clock. What is the nurse demonstrating by making this request?
A) Concern for safety
B) Promoting client health
C) Colleague health education
D) Controlling adverse reactions |
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Definition
| The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting does not provide education. |
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Term
Which steps do you follow when you are asked to perform a procedure about which you are unfamiliar? Select all that apply.
A) Seek necessary knowledge
B) Reassess the client's condition
C) Collect all equipment necessary
D) Have an experienced nurse available to assist
E) Consider all possible consequences of the procedure |
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Definition
| Each of the five options is important in performing a new procedure. Be sure to seek all necessary knowledge, consider the possible consequences of the procedure, reassess the patient, collect the appropriate supplies, and ask a nurse experienced in the procedure to help out. |
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Term
When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? Select all that apply.
A) Ability to cook meals
B) Ability to feed oneself
C) Ability to write checks
D) Ability to bathe oneself
E) Ability to take medications |
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Definition
| These are skills that allow the client to be independent in society. They may or may not be necessary on a daily basis. The other options are activities of daily living. |
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Term
| For all clients admitted to a cardiac unit, the unit policy and procedure manual states: if client experiences chest pain, administer 1/150 grain nitroglycerine SL and obtain a STAT ECG. This is an example of a _____________ |
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Definition
| A protocol is used for care of clients with select clinical problems. It provides a standard of care and can be individualized. |
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Term
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After the suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides the client with a glass of water. Which of the following is an evaluative measure used by the nurse?
A) Suctioning the airway
B) Sitting the client up in bed
C) Auscultating lung sounds
D) Asking the client to describe the type of discomfort experienced |
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Definition
| Auscultating lung sounds allows the nurse to evaluate the client's lungs and see if the suctioning helped remove secretions from the airway. Evaluation measures are used to determine whether expected outcomes are met, not whether nursing interventions were completed. Sitting the client up in bed and suctioning are interventions. Asking the client to describe the discomfort is an assessment. |
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Term
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides the client with a glass of water. Which of the following would be an appropriate evaluative criterion for the nurse?
A) Client drinks all the water in the glass.
B) Client's lungs are clear to auscultation in bases.
C) Client reports abdominal pain on a scale of 0 to 10.
D) Client's rate and depth of breathing are normal with the head of the bed elevated. |
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Definition
| The evaluation of the intervention (suctioning) is that the client's lungs are clear to auscultation. Drinking the water in the glass is not an evaluative measure given the information presented here. The fact that the client reported his pain level on a scale of 0 to 10 is not an evaluation unless an actual numerical rating is given. |
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Term
The evaluation process, which determines the effectiveness of nursing care, includes five elements. One element is interpreting findings. Which of the following is an example of interpretation?
A) Evaluating the client's response to selected nursing interventions
B) Reviewing the client's nursing diagnoses and establishing goals and outcome statements
C) Selecting an observable or measurable state or behavior that will reflect goal achievement
D) Matching the results of evaluative measures with expected outcomes to determine the client's status |
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Definition
| Matching the results with the expected outcome to determine the client's status represents interpretation. Establishing goals and outcome statements is a function of planning. Selecting an observable or measurable state or behavior that will reflect goal achievement is part of goal setting. Evaluating the client's response to selected nursing interventions is data collection. |
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Term
A goal specifies the expected behavior or response that indicates:
A) Completion of a specific nursing action
B) Validation of the nurse's physical assessment
C) Accuracy of the nursing diagnosis
D) Resolution of a nursing diagnosis or maintenance of a healthy state |
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Definition
| A goal is the expected behavior or response that indicates resolution of a nursing diagnosis or the maintenance of a healthy state. It is a summary statement of what will be accomplished when all expected client outcomes have been achieved. Goals do not confirm the nursing diagnosis, validate the physical assessment, or indicate completion of specific nursing actions. |
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Term
A client is recovering 1 day after surgery to remove an ovarian tumor. Because she has an abdominal incision and dressing the nurse has selected the nursing diagnosis of Risk for infection. Which of the following is an appropriate goal statement for this diagnosis?
A) Client will remain afebrile until discharge.
B) Client's wound will remain free of infection until discharge.
C) Client will receive ordered antibiotic on time over the next 3 days.
D) Client's abdominal incision will remain covered with a sterile dressing for 2 days. |
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Definition
| The specific, measurable goal is keeping the wound free of infection. |
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Term
To determine whether an intervention was successful, the nurse evaluates the success in attaining a goal. Which of the following is an example of an evaluation?
A) Dressing was changed every 8 hours using sterile technique.
B) Client will ambulate 500 feet 4 times a day with minimal assistance.
C) Client performed quadriceps setting exercises to right leg every 4 hours.
D) Wound is filling in with granulation tissue and is red to pink without signs of infection. |
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Definition
| Evaluation occurs after an intervention and indicates the degree to which a goal was achieved. |
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Term
A nurse administered the prescribed analgesics to a client after surgery, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize?
A) The pain-control plan needs to be changed.
B) The client is overrating the pain.
C) Complications from surgery are occurring.
D) Nonpharmacological pain-relieving strategies are now appropriate. |
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Definition
| The current pain medications are not effectively relieving the client's pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the client says it is. There is no objective way to measure pain. The clinician must accept the client's report of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of pain medications. Pain following surgery is an expectation. Although it may indicate a complication, from the data given it is impossible to tell at this point. |
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Term
For the past 3 days the nurse has cared for a client with a nursing diagnosis of Impaired physical mobility, and the nurse observes that the client is not eating as expected. The nurse recognizes the need to:
A) Consult with the occupational therapist about feeding aids.
B) Add the nursing diagnosis of Feeding self-care deficit.
C) Order a liquid diet to make it easier for the client to swallow.
D) Place the client on nothing-by mouth status until the physician assesses the client. |
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Definition
| The nurse has assessed the problem and now recognizes that the focus needs to be on self-feeding. Nursing diagnoses should change as the client's condition changes, based on assessment. |
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Term
The nurse determines that the current care plan for a client needs to be changed because the goal has not been reached even after a sufficient period of time. New interventions are implemented. What is essential for the nurse to do after implementation of these new interventions?
A) Reevaluate the interventions.
B) Determine the safety of the interventions.
C) Confirm the availability of the interventions.
D) Ascertain the appropriateness of the interventions. |
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Definition
| The nurse must continuously reevaluate new interventions to see if they are helping to alleviate the problem and/or attain the goal. Only through reevaluation can the nurse determine the effectiveness of the interventions. The other options are all important considerations, but they should be performed before, not after, an intervention is implemented. |
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Term
If goals are unmet and partially met, the nurse must do which of the following? (Select all that apply.)
A) Redefine priorities.
B) Continue intervention.
C) Discontinue the care plan.
D) Gather assessment data on a different nursing diagnosis.
E) Compare the client's response with that of another client. |
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Definition
| If goals are unmet or partially met, intervention must be continued. Goals and expected outcomes, interventions, and priorities may need to be redefined. Care plans are discontinued after goals are met; they are revised when goals are not met. Comparing one client's responses with that of another client in a clinical setting is not an appropriate step. Nursing diagnoses should be changed only if a new diagnosis becomes appropriate, not when goals and objectives are not met. |
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Term
For a nursing quality improvement (QI) process to be successful, which of the following must be true? (Select all that apply.)
A) Recurrent problems are identified.
B) Outcomes are based on standards of care.
C) Client satisfaction is an important indicator.
D) The process is limited to registered nurses. |
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Definition
| The QI process is concerned with exceeding the standard of care, examining ways to be more efficient, improving client satisfaction, and focusing on service. The nursing staff collaborates with all appropriate health care disciplines during the QI process. |
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Term
12. Indicate whether each of the following statements is considered assessment data, evaluation, or both.
A. Assessment
B. Evaluation
C. Both
Lungs clear to auscultation
Wound healing without signs of infection
Voiding without difficulty
Oriented ×3 |
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Definition
| Both:Lungs clear to auscultation, Both:Wound healing without signs of infection, Both:Voiding without difficulty, Assessment:Oriented ×3 |
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Term
The nurse discovers an electrical fire in a client's room. The nurse's first action would be to:
A) Activate the fire alarm.
B) Confine the fire by closing all doors and windows.
C) Evacuate any clients or visitors in immediate danger.
D) Extinguish the fire by using the nearest fire extinguisher. |
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Definition
| The nurse's first step when a fire is discovered is to evacuate any clients or visitors in immediate danger. Then the nurse should activate the fire alarm, confine the fire, and then extinguish it. |
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Term
A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent?
A) Give the child milk.
B) Call the poison control center.
C) Give the child syrup of ipecac.
D) Take the child to the emergency department. |
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Definition
| The poison control center will direct all care given to a child who has ingested a substance. Based on the description of the poison, poison control center staff will tell the parent whether the child needs to go to the emergency department and what substances should be given to the child. |
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Term
A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that adolescents are at a greater risk for injury from:
A) Home accidents
B) Poisoning and child abduction
C) Physiological changes of aging
D) Automobile accidents, suicide, and substance abuse |
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Definition
| Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in substance abuse than are those in other age groups. Children are more susceptible to poisoning and child abduction, and older adults are more susceptible to home accidents and the physiological changes of aging. |
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Term
During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's initial intervention would be to:
A) Insert a urinary catheter.
B) Ask the physician to order a restraint.
C) Assign a staff member to stay with the client.
D) Provide scheduled toileting during the night shift. |
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Definition
| Providing scheduled toileting during the night makes it less likely that a client will wander while being confused and ensures staff presence to decrease confusion at the times when the client is away from bed. Inserting a urinary catheter is not necessary. Assigning a staff member to stay with the client might not be necessary if the scheduled toileting is successful. Restraints are unnecessary in this case. |
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Term
Lisa, a nurse assistant, is working with the nurse during the nurse's shift. One of the nurse's clients has upper limb restraints. In delegating care of this client to Lisa, the nurse would tell her to:
A) Secure the restraints to the side rails.
B) Check to see if the client can have a medication for sleep.
C) Call the physician if the client becomes more agitated with the restraint.
D) Report any signs of redness, excoriation, or constriction of circulation under the restraint. |
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Definition
| The restraint sites much be checked regularly for signs of redness, excoriation, or constriction, and this task may be delegated. Calling the physician and performing medication assessments are nursing responsibilities. Restraints should never be secured to the side rails. |
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Term
The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation is to:
A) Ask them to stay with the client at all times.
B) Inform them of the risks associated with side rail use.
C) Thank them for being conscientious and put the four rails up.
D) Provide the client with a one-to-one sitter while the side rails are up. |
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Definition
| The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the client's safety. |
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Term
During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because of stress at work. One of the expected outcomes for this client will be to:
A) Decrease stress in his life.
B) Teach him ways to promote sleep.
C) Decrease his alcohol intake during times of stress.
D) Provide the client with information about stress management classes. |
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Definition
| Resources for stress management and sleep promotion can help accomplish reduced alcohol intake during times of stress in the client's life. Management of stress is the expectation, but decreasing stress may not be possible. |
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Term
A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention the nurse can do during this situation?
A) Begin cardiopulmonary resuscitation.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from injury. |
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Definition
| An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required only if heart function stops after the seizure. |
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Term
When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent:
A) Food poisoning
B) Spread of hepatitis A
C) Bacterial food infections
D) Salmonella contamination |
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Definition
| The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually arises from uncooked eggs. |
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Term
A student nurse is designing a health fair project aimed at reducing motor vehicle accidents. For which group of clients would this subject be most appropriate?
A) Adolescents
B) Older adults
C) Middle-aged adults
D) School-aged children |
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Definition
| The risk of motor vehicle accidents is higher among teen drivers than in any other age group. |
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Term
As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route?
A) Airborne
B) Ingestion
C) Absorption
D) Blood-borne |
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Definition
| Organisms with an airborne route of transmission can claim many victims and spread very quickly. Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of transmission. |
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Term
After the nurse assists a client with a history of seizures to a recliner chair, the client begins to have a seizure. The nurse should immediately:
A) Turn the client onto his or her stomach.
B) Recline the client's chair all the way back.
C) Return the client to the bed and place the client on his or her side.
D) Slide the client to the floor and cradle the client's head in the nurse's lap. |
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Definition
| The nurse's lap is the safest position for the client's head, and the client is less likely to sustain an injury if the client is already on the floor. Attempting to move the client laterally by oneself could result in injury to the client and/or nurse. Placement in a reclining position could cause excess secretions to accumulate in the oral pharynx and obstruct the airway. Turning the client onto his or her stomach would decrease access to the airway. |
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Term
The nurse delegates to an unlicensed assistant the task of removing the restraints from the client's wrists every ________ hours and reporting any abnormalities.
A) 2
B) 4
C) 6
D) 8 |
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Definition
| Removal of restraints and inspection of the contact area every 2 hours is a requirement of The Joint Commission. The time periods in the other options are too long. The client could experience a serious complication if restraints are not removed and the area under the restraints inspected frequently. |
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Term
Health care workers who have direct contact with individuals suspected of being contaminated with anthrax should do which of the following? (Choose all that apply.)
A) Wear an isolation gown, gloves, and high-efficiency particle arrestor (HEPA) mask
B) Prepare the client for transfer to the radiology department for chest radiography
C) Instruct the client to wash the hands and exposed areas with soap and water
D) Have the client remove clothing and place it in a sealed biohazard bag |
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Definition
| Anthrax is caused by a spore-forming, gram-positive bacillus. Humans become infected through skin contact, ingestion, and inhalation. The nurse should wear an isolation gown, gloves, and a high-efficiency particle arrestor (HEPA) mask. The client should remove potentially contaminated clothing for testing and decontamination. The client should remain in isolation until it is certain that the bacteria have been contained, not transferred to radiology. The client should shower thoroughly with soap and water, not just wash hands and exposed areas. |
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Term
| While the nurse is administering flu immunizations in November to a group of older adults at a community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead virus and explains that this injection will produce _________ immunity, in which the senior's body will make antibodies to the virus. |
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Definition
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