1.What is the rationale for using the nursing process in planning care for clients?
A. As a scientific process to identify nursing diagnoses of a
... [Show More] clients' healthcare problems.
B. To establish nursing theory that incorporates the biopsychosocial nature of humans.
C. As a tool to organize thinking and clinical decision making about clients' healthcare needs.
D. To promote the management of client care in collaboration with other healthcare professionals.
C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process.
Correct Answer: C)
2.What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client outcomes.
In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes.
Correct Answer: D
3.Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results.
The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue.
Correct Answer: D
4.What action by the nurse demonstrates culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and cultural folk remedies.
D. Applies knowledge of a cultural group unless a client embraces Western customs.
Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness.
Correct Answer: A
5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?
A. Suggest that other cultural practices be substituted by the family members.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
C. Explain to the family that multiple visitors are exhausting to the client.
D. Allow the situation to continue until a family member's action may harm the client.
Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family.
Correct Answer: B
6.Which technique is most important for the nurse to implement when performing a physical assessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic approach.
D. An approach related to a nursing model.
The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems.
Correct Answer: C
7.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history.
Correct Answer: B
8.The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
A. Does not check capillary blood glucose as directed.
B. Occasionally forgets to take daily prescribed medication.
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in health.
The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintenance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit.
Correct Answer: D
9.Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
C. Upon discharge, the client will list three ways to protect the feet from injury.
D. After instruction, the nurse will ensure the client understands foot care rationale.
An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements.
Correct Answer: C
10.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?
A. Generativity.
B. Ego integrity.
C. Identification.
D. Valuing wisdom.
Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory.
Correct Answer: A
11.Which statement best describes durable power of attorney for health care?
A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.
B. The healthcare decisions made by another person designated by the client are not legally binding.
C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding.
D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.
The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time.
Correct Answer: A
12.A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?
A. Low fat and low sodium foods.
B. Combination of plant proteins to provide essential amino acids.
C. Limited complex carbohydrates and fiber.
D. Increased amount of vitamin C and beta carotene rich foods.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs.
Correct Answer: B
13.A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide?
A. The responses to biofeedback have not been well established and may be a waste of time and money.
B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses.
C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms.
D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. (D) is an accurate statement concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide correct information about biofeedback.
Correct Answer: D
14.A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?
A. Most herbs are toxic or carcinogenic and should be used only when proven effective.
B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health.
C. Herbs should be obtained from manufacturers with a history of quality control of their supplements.
D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.
The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading.
Correct Answer: C
15.A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?
A. Sensory pattern, area, intensity, and nature of the pain.
B. Trigger points identified by palpation and manual pressure of painful areas.
C. Schedule and total dosages of drugs currently used for breakthrough pain.
D. Sympathetic responses consistent with onset of acute pain.
The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A).
Correct Answer: A
16.A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
A. Continue gabapentin.
B. Discontinue ibuprofen.
C. Add aspirin to the protocol.
D. Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests.
Correct Answer: A
17.To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?
A. Can you describe where your pain is the most severe?
B. What is your pain intensity on a scale of 1 to 10?
C. Is your pain best described as aching, throbbing, or sharp?
D. Which activities during a routine day are impacted by your pain?
A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors illicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number.
Correct Answer: D
18.A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?
A. Document the client's request in the medical record.
B. Ask the client if this decision has been discussed with his healthcare provider.
C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts.
D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.
Correct Answer: B
19.The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan?
A. Fiber.
B. Folate.
C. Ascorbic acid.
D. Vitamin B12.
Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegtables and fruits.
Correct Answer: D
20.The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
A. Pre-medicate the client with an analgesic.
B. Inform the client of the plan for moving to the chair.
C. Obtain and place a portable commode by the bed.
D. Ask the client to push the IV pole to the chair.
E. Clamp the indwelling catheter.
F. Assess the client's blood pressure.
The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated.
Correct Answer: A, B, D, F [Show Less]