Details of Test Bank on Essentials of Dental Radiography 9th EditionBy Evelyn Thomson,Orlen Johnsonnurse understands the purpose of the Rapid Response
... [Show More] Team?
a. Monitoring the client for changes in postoperative status such as wound infection
b. Documenting all changes observed in the client and maintaining a postoperative flow sheet
c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm Hg systolic
d. Notifying the physician of the client’s increase in restlessness after medication change
The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission’s main objective?
a. Performing range-of-motion exercises on the client three times each day b. Ensuring that the client is eating 100% of the meals served to him or her c.
Assessing the client’s respirations when administering opioids d. Delegating to the nursing assistant to give the client a complete bath daily
Which action by the nurse shows an understanding of the principle of self-determination? a.
Allowing a postoperative client to decide to take medication with fruit juice rather than water
b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is having profuse vaginal bleeding
c.
Allowing a parent to decide not to proceed with a lifesaving operation for a 12year-old client
d. Allowing an older client with dementia to decide not to take cardiac medication throughout the shift
The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s highest-priority, client-centered action before beginning the session? 1 | P a g eEnsure that the client’s family is present and will participate.
b. Make certain that the client is wearing his glasses.
c. Have printed handouts ready to use during the session.
d. Schedule the session for early evening after the client’s meal.
a.
Which action best demonstrates the nurse using client-centered care
when planning a menu for a Vietnamese client who is newly diagnosed with diabetes?
a.
Asking the client what food he or she would eat on a standard diabetic menu
b. Asking family members to make selections for the client from a diabetic menu
c.
Ordering a typical diabetic meal for the client and planning diet teaching
d. Researching the Vietnamese culture before discussing diabetic meal planning
The Institute for Healthcare Improvement (IHI) identified interventions to save client lives.
Which actions are within the scope of nursing practice to improve quality of care?
a.
Insert a central line to give intravenous fluid to a dehydrated client.
b. Use sterile technique when changing dressings on a new surgical site.
c.
Intubate a client whose oxygen saturation is 92%.
d. Prescribe aspirin for a client who presents with an acute myocardial infarction
Which action by the nurse demonstrates the best practice for nursing
documentation on a computerized record?
a. Deleting all documentation errors on the computerized record
b. Using red font to denote all significant events that have occurred
c. Waiting until the end of the shift to record a summary of information
d. Documenting assessment data at the point of care
2 | P a g eA client is scheduled for a mastectomy. As she is about to receive the preoperative medication,
she tells the nurse that she does not want to have her breast removed but wants a lumpectomy.
Which response indicates that the nurse is acting as a client advocate?
a.
Telling the client her surgeon is excellent and knows what is best for her condition
b. Calling the surgeon to come and explain all treatment options to the client
c. Holding the client’s hand and offering to pray with her for a good outcome
d. Arranging for a postoperative visit from a cancer survivor
What priority assessment data should be shared with the interdisciplinary team
from a client admitted to the emergency department with a lacerated artery?
a.
Information regarding next of kin to notify in case the client dies
b. History about what medications the client is currently taking
c. Measurement of blood pressure and pulse
d. Assessment of rate and depth of respirations
Which intervention can the client expect to receive from a medical- surgical nurse in an
ambulatory care setting?
a.
Drawing blood for routine or preoperative testing
b. Teaching the client how to change a dressing on an incision
c. Obtaining the client’s signature on a surgical consent form
d. Performing a comprehensive physical examination
An emergency department (ED) nurse gives report on a client who is being transferred to the
medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the
floor nurse contact a sitter and behavioral health. This statement represents which part of the
SBAR hand-off?
a.
Situation
b. Background
3 | P a g ec.
Assessment
d. Recommendation
The nurse is present when the physician discusses the potential effects of a chemotherapy
regimen for a client with cancer. Weighing the benefits of the chemotherapy against possible
side effects is an example of which ethical principle?
a. Paternalism
b. Beneficence
c.
Justice
d. Autonomy
The physician prescribes warfarin (Coumadin) 15 mg daily. The nurse notes that this is three
times the normal dose for this client based on the client’s medication profile and laboratory
work. What does the nurse do first?
a. Give the dose and document the concern.
b. Call the pharmacy for a consultation.
c.
Call the physician to question the order.
d. Hold the medication for that day.
c.
Which statement best describes the process of nursing case management?
a. The coordination of care services to at-risk populations
b. A collaborative process to promote quality and cost-effective care
The implementation of care to acutely ill, underserved populations
d. A cost-effective care delivery model meeting the needs of specially defined groups
4 | P a g eWhich client is best served by a case manager?
a. An older woman with chronic cystitis
b. A middle-aged man with moderate hypertension
c. An older woman with chronic heart failure and diabetes mellitus
d. A young adult with a fractured ankle from a sports injury
The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse
delegate to the unlicensed assistive personnel?
a.
Complete the nursing care plan.
c.
b. Assist the client with meals.
Evaluate the pulse oximetry reading.
d. Assess level of consciousness.
MULTIPLE RESPONSE
The nurse on a medical-surgical unit notices that there has been an increase in the number of
client falls. Which methods would be effective in promoting quality improvement on this issue?
(Select all that apply.)
a.
c.
Identify causes of falls on the unit by looking at specific client cases.
b. Look at the research and the literature on prevention of falls.
Complain to the manager that team members are neglecting the clients.
d. Use sit and stand alarms because they seem to be working on other units.
e.
Try more frequent rounding on clients as suggested by co-workers.
Which settings would require maximum implementation of the nurse supervisor role? (Select
all that apply.)
a.
5 | P a g e
Acute care settingc.
b. Home care setting
Skilled nursing facility
d. Assisted-living facility
e.
Rehabilitation facility
Which activities are within the role of the case manager? (Select all that apply.)
a. Gathering and organizing data about a client from client records and interviews
c.
b. Planning care for a client with emphasis on client satisfaction
Coordinating care among a variety of health care professionals and settings
d. Promoting the client’s interests while negotiating necessary health care
e.
Advocating for the client and the family throughout the continuum of care
f.
Using resources for appropriate client health care services
A client has metastatic lung cancer and is hospitalized for chemotherapy.
Which intervention does the nurse delegate to the unlicensed assistive personnel? (Select all
that apply.)
a.
Assist the client with repositioning.
b. Teach the client to use the incentive spirometer.
c.
Take vital signs every 4 hours.
d. Record intake and output measurements.
e.
Promote the expression of grief and loss.
Chapter 2: Introduction to Complementary and Alternative Therapies Test Bank
MULTIPLE CHOICE
6 | P a g eThe nurse wishes to learn more about the client’s use of natural products and their effectiveness.
The nurse consults the National Center for Complementary and Alternative Medicine because it
is known that this center serves which function?
a.
c.
Educates health professionals about complementary therapies
b. Educates new mothers on the benefits of massage
Engages in fundraising to offset client expenses with medical care
d. Provides a scholarship for a student to study naturopathy
A client is anxious about having a dressing change. Which statement indicates that the nurse is
promoting appropriate complementary therapy?
a.
“I’ll call the doctor and ask for a larger dose of pain medication before the dressing
change.”
b. “As we begin the next dressing change, I want you to think of a beautiful, calm place
where you feel happy and peaceful.”
c.
“I’ll get another nurse to stay in the room with us during the dressing change so
that you have a hand to hold during the procedure.”
d. “Are you familiar with acupuncture? It’s a very effective technique.”
The nurse has designed a treatment plan that includes the use of massage. Which
intervention will the nurse implement first?
a.
Assess the client to determine the most effective type of massage technique to use.
b. Inspect the skin over the tissue to be massaged to ensure that it is not infected or
bruised.
c. Determine whether a licensed therapist will be needed to carry out the massage
technique
d. Obtain permission from the client to implement this type of technique.
7 | P a g eA client who has been using which therapy requires the most immediate intervention by the
nurse?
a.
Aromatherapy to treat depression
b. Herbal preparations to treat hypertension
c. Therapeutic touch to decrease level of pain
d. Tai Chi to improve joint flexibility
A client scheduled for surgery has been taking garlic supplements.
Which action is most important for the nurse to take?
a. No action is necessary because the herbal agent is harmless.
b. Notify the charge nurse that the client has been taking garlic.
c. Note the information on the client’s record and place in the chart.
d. Notify the surgeon that the client has been taking garlic capsules.
For which client does the nurse arrange animal-assisted therapy?
a.
Middle-aged adult in a psychiatric facility with a history of schizophrenia
b. Older adult client with end-stage lung cancer in hospice care
c.
Older adult client in a nursing home who is unresponsive
d. Adolescent in a drug treatment facility with a history of violent outbursts
Which statement indicates that the nurse understands the risks associated with herbal
preparations?
a. Herbs are guaranteed to be safe and effective but are not necessarily natural.
b. Herbs require a different type of prescription than is required for standard prescribed
medications.
c. Herbs are not classified as drugs and are regulated less strictly by the U.S. Food and
Drug Administration (FDA).
d. Herbs are guaranteed to be all natural and of high quality but are not necessarily
effective.
8 | P a g eA client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is
the correct response?
a.
“Yes, let’s pray together.”
b. “No, I’m sorry, I can’t do that.”
c.
“No, I don’t believe in prayer.”
d. “I’ll hold your hand while you pray.”
The client has been diagnosed with cancer and is experiencing depression and insomnia as side
effects of chemotherapy. The client tells the nurse that she has been supplementing her
antidepressant medication with lavender oil and sandalwood but they aren’t working. Which
statement by the nurse is the best response?
a.
c.
“Tell me more about exactly what you are taking, how much you take, and when you
take the antidepressants and use the oils.”
b. “Perhaps you’re not using enough of the oil or are using it incorrectly.”
I’ll speak with your doctor to get you some medication that you can take while continuing
the aromatherapy.”
d. “You don’t want your doctor to put you on sleeping pills and antidepressants.
Keep using them.”
The client is undergoing treatment for cancer and is experiencing a high level of anxiety. The
client expresses interest in complementary therapies that might decrease the level of anxiety.
Which action is the best choice for the nurse to implement with this client?
a.
Direct the client to an imaginative peaceful setting using imagery.
b. Provide assistance in finding an acupuncturist.
Suggest Tai Chi during chemotherapy treatments.
c.
d. Encourage the use of acupressure over tumor sites.
9 | P a g eWhich clients would benefit most from relaxation therapy?
a.
Middle-age client who is undergoing chemotherapy treatments
b. Young client who is diagnosed with schizophrenia
c.
Older client who is comatose and unresponsive
d. Young client who is diagnosed with major depression
A nurse is assisting a client in preparing for surgery by using progressive muscle relaxation.
Which rationale best supports the use of this therapy at this time?
a.
It rebalances or repatterns a person’s energy field.
c.
b. It improves flexibility and assists with positioning during surgery.
It applies pressure, releasing congestion and promoting energy flow.
d. It uses intentional tensing and releasing of successive muscle groups.
A client tells the nurse that he or she is considering using herbal supplements. What is the
nurse’s best response?
a.
c.
“Herbs are not classified as drugs in the United States, so there is no contraindication to
using them.”
b. “Herbs have pharmacologic effects on the body and can interact with some
prescription medications.”
“It is never permissible to use herbal supplements with prescription medications.”
d. “I will refer you to an herbalist, who can help you decide which medications you can
take.”
10 | P a g eA client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily
and has started taking Ginkgo biloba. What is the priority action for the nurse to take?
a.
c.
Encourage the use of Ginkgo biloba to enhance the client’s systemic circulation.
b. Assess the client for any bruising or petechiae.
Explain that replacing Ginkgo biloba with garlic would be much safer.
d. Assess for any forgetfulness or inappropriate speech.
Which statement indicates that the client needs further teaching about complementary therapy?
a.
“I’ve decided to use herb therapy for cancer treatment, so I can cancel my radiation
treatments.”
b. “I’m hoping that massage therapy will help reduce the amount of pain medication I
use for my myalgia.”
c.
“I think it helps me get better faster when I picture the drugs punching out the
germs in my body.”
d. “I intend to pray about my cancer treatment several times a day. It makes me feel so
much better.”
Which teaching strategy is appropriate for a client who wishes to use mind-body
complementary therapy to supplement traditional treatment for cancer?
a. Instruct the client to make a follow-up appointment with the health care provider after using
mind-body treatments to assess the client’s
response to treatment.
b. Instruct the client never to use alternative or complementary treatments for
serious illnesses.
c.
Explain to the client that physicians and nurses are not prepared to recommend and
monitor alternative treatments.
d. Explain to the client that physicians and nurses do not incorporate such treatments into
their practice.
11 | P a g eWhich complementary or alternative therapy would the nurse recommend to a client with
“stiff joints” to improve mobility?
a. Imagery
b. Animal-assisted therapy
c.
Tai Chi
d. Aromatherapy
A client is experiencing nausea and vomiting from chemotherapy. Which alternative or
complementary therapy would be best for the nurse to explore with the client?
a. Meditation
b. Imagery
c.
Yoga
d. Music therapy
The nurse is working in the community and completes home visits with older adult clients.
Which statement by a client demonstrates a need for further instruction about the use of
complementary and alternative
therapies?
a.
c.
“My doctor monitors my kidney function since I started taking calcium.”
b. “I always talk to my doctor first before starting an herbal preparation.”
“I heard that St. John’s wort is good for any type of depression.”
d. “I may start a Tai Chi program to help with my mobility and lift my spirits.”
MULTIPLE RESPONSE
12 | P a g eDuring an initial health assessment interview, the nurse learns that the client is taking warfarin
(Coumadin) for a history of deep vein thrombosis. Later, the client admits to taking several
herbal preparations as well. Which herbal preparations would the nurse caution the client to
avoid? (Select all that apply.)
a. Ginkgo biloba
b. Garlic
c. Ginseng
d. Zinc
e.
St. John’s wort
The nurse wishes to start music therapy with an older adult client who has high anxiety and
hypertension. What essential elements should be considered when music is used with this
client? (Select all that apply.)
a.
Assess the client’s preferences in choice of music.
b. Use fast tempo music to energize and motivate the client.
c.
Consider rap music to provide diversion.
d. Consider live or recorded music such as music performed on a harp.
e.
Consider generation-specific music.
Chapter 3: Common Health Problems of Older Adults Test Bank
MULTIPLE CHOICE
An older client is agitated and develops new-onset confusion on admission to the long-
term care unit. What is the best action for the nurse to take to minimize relocation stress
syndrome for this client?
a. Provide reorientation during hourly rounding.
b. Obtain a certified sitter to remain with the client.
c.
Speak to the client as little as possible to avoid overstimulation.
d. Provide adequate sedation to lessen fear-provoking situations.
13 | P a g eWhich intervention would best support a client who relates a feeling of “loss of control” after
having a mild stroke?
a.
Explain that such feelings are normal, but that expectations for rehabilitation must
be realistic.
b. Encourage the client to perform as many tasks as possible and to participate in
decision making.
c.
Further assess the client’s mental status for other signs of denial or psychopathology.
d. Obtain an order for physical and occupational therapy evaluations.
What will the nurse teach the older client with hypertension who complains that “food does
not taste good without salt”?
a.
Salt can be used as long as blood pressure remains controlled.
b. All salt should be removed from the diet to preserve kidney function.
c.
Table salt can be used in small amounts in conjunction with diuretics.
d. Herbs and spices can be substituted to season food.
What is a priority nursing intervention to prevent falls for an older adult client with multiple
chronic diseases?
a. Providing assistance to the client in getting out of the bed or chair
b. Placing the client in restraints to prevent movement without assistance
c.
Keeping all four siderails up while the client is in bed
14 | P a g ed. Requesting that a family member remain with the client to assist in ambulation
An older adult client is in physical restraints. Which intervention by the nurse is the priority?
a.
Assess the client hourly while keeping the restraints in place.
b. Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.
c.
Assess the client once each shift, releasing the restraints for feeding.
d. Assess the client twice each shift while keeping the restraints in place.
An older adult client has become agitated and combative toward health care personnel on the
unit. What is the first action that the nurse will take?
a. Obtain an order for a sedative-hypnotic medication to reduce combative behavior.
b. Attempt to soothe the client’s fears and reorient the client to
surroundings.
c. Obtain an order to place the client’s arms in restraints to protect personnel.
d. Arrange for the client to be transferred to a mental health facility.
An older adult client presents with signs and symptoms related to digoxin toxicity. Which age-
related change may have contributed to this problem?
a.
Increased total body water
c.
b. Decreased renal blood flow
Increased gastrointestinal motility
d. Decreased ratio of adipose tissue to lean body mass
A nurse is assessing a client’s understanding of medication therapy. Which statement indicates
that the client needs further instruction?
a.
“My husband is on the same medication, so we always take our medications
together in the morning.”
15 | P a g eb. “I prepare all my medication for the week and place the pills in a container labeled for
each day.”
c.
“When I don’t sleep well at night, I take two thyroid pills the next day instead of just
one.”
d. “I take my Coumadin every day when the noon news comes on the television.”
An older adult client is being discharged from the hospital on several medications. Which
intervention best reinforces medication teaching for this client?
a. Have the client actively participate in drug administration during hospitalization.
b. Include the client’s children in discussions regarding medication administration.
c. Give the client a pamphlet with the actions, side effects, and doses of all drugs.
d. Make a chart showing which drugs should be taken at specified times during the
day.
An older adult client’s spouse has died, and the family expresses concern that the client has lost
weight recently and now refuses to attend the annual family reunion. The nurse should assess
this client further for what clinical condition?
a. Psychosis
b. Depression
c. Dementia
d. Delirium
Which behavior exhibited by an older adult client alerts the nurse to the possibility that the client
is experiencing delirium?
a.
16 | P a g e
Becoming confused within 24 hours after hospital admissionb. Displaying a cheerful attitude despite a poor prognosis
c.
Becoming withdrawn and sleeping most of the day
d. Beginning to use slurred speech and losing coordination
A client with Alzheimer’s disease has been hospitalized for dehydration.
In making an assessment, the nurse notes the presence of a cluster of bruises on the client’s
buttocks. What is the nurse’s priority action?
a.
Call the local police to report a crime.
c.
b. Notify the client’s physician and social worker.
Confront the client’s caregiver with the suspicions.
d. Alert security to prevent visits by the client’s caregiver.
An older adult client is suspected of being neglected by the caregiver.
What assessment provides the nurse with the best information about this possibility?
a.
Inspect skin in the “bathing suit zone” for bruises.
b. Assess the client for orientation to person, place, and time.
c.
Compare the client’s current weight with prior recorded weights.
d. Perform orthostatic pulse and blood pressure readings.
A nurse is caring for an older adult client who lives alone. Which economic situation
presents the most serious problem for this client?
a.
Stock market fluctuations
b. Increased provider benefits
c.
Social Security as the basis of income
d. Costs of creating a living will
17 | P a g eAn older adult client is in the hospital. To what government resource would the nurse refer the client to help meet the cost of health care?
a. Preferred provider organizations
b. Health maintenance organizations c. Medicare Part A d. Medicare Part B
A nurse is assessing a client at risk for dehydration. Which statement by the client indicates that more education by the nurse is required?
a. c.
“I try to limit coffee to one cup in the morning and one cup in the early evening.” b. “During the day I drink at least six to seven glasses of water.”
“Alcohol causes me to frequently urinate so I cut it out of my diet.” d. “I stop drinking fluids in the afternoon to avoid bathroom trips at night.” [Show Less]