It is taught that when parents are informed that their child has been born with a abnormality they respond with a grief reaction. The first step in the
... [Show More] normal grief reaction is:
A) Acceptance
B) shock-denial
C) withdrawal
D) planning correct answer: B) Shock-denial
On entering a client's room during change-of-shift rounds, you notice that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. Which of the following is the best action for you to take at this time?
A) Introduce yourself and begin discharge teaching.
B) Proceed with the tasks you were intending to perform.
C) Say nothing and leave quickly, closing the door behind you.
D) Ask the client and spouse if they need some time alone right now. correct answer: D) Ask the client and spouse if they need some time alone right now.
Response Feedback:
The situation suggests that you 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.
Before performing a procedure for the first time at a new agency, what does the travel nurse do?
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 correct answer: C) Reads about the procedure in the policy and procedure manual
Response Feedback:
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 nursing practice act, the nurse could be fired.
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 correct answer: D) Consistency
Response Feedback:
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.
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. correct answer: B) Client reports sharp pain in left anterior knee.
Response Feedback:
The information in option B 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 A may be true, but accurate data would also report why the client refused medication.
The 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 which of the following?
A) Planning
B) Evaluation
C) Assessment
D) Intervention correct answer: C) Assessment
Response Feedback:
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.
The base level of Maslow's Hierarchy of Needs is...
A) Psychological
B) Belongingness
C) Safety
D) Physiological correct answer: A) Psychosocial
Response Feedback:
Physiologic needs must be met first
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 which of the following?
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgement correct answer: D) Scientifically based clinical judgement
Response Feedback:
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.
The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion, [Show Less]