Flashcards in Final Deck (467)
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect, compassion, client education, and empowerment. By assessing the effect of the clients culture on health care,
this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client
and family to the room is an important safety measure, but not directly related to demonstrating client-centered
A student nurse asks the faculty to explain best practices when communicating with a person from the
lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is
a. Avoid embarrassing the client by asking questions. b. Dont make assumptions about their health needs. c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population
Many members of the LGBTQ community have faced discrimination from health care providers and may be
reluctant to seek health care. The nurse should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any
health care need is more likely to answer honestly.
A nurse working with older adults in the community plans programming to improve morale and emotional
health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
All activities would be beneficial for the older population in the community. However, failure in performing
ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program
designed to maintain and/or improve physical functioning would best address this need.
A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
a. Cut some sodium out of your diet.
b. Dehydration can cause incontinence.
c. Have something to drink every 1 to 2 hours.
d. Take your diuretic in the morning.
Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy
is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some
sodium from the diet will not address this issue. Although dehydration can cause incontinence from the
irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing
the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.
A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete
steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe
on the steps?
a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.
As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of
where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase
awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an
alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not
help if the client is unaware of where the foot is on the step.
An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
Medication side effects and adverse effects are common in the older population. Something as simple as a new
antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new
medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once
more is known about the clients condition.
An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The
client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which
medication should he or she suggest in place of the morphine?
a. Cyclobenzaprine (Flexeril)
b. Hydromorphone hydrochloride (Dilaudid)
c. Ketorolac (Toradol)
d. Meperidine (Demerol)
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers
list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse
should suggest hydromorphone hydrochloride.
A nurse admits an older client from a home environment where she lives with her adult son and daughterin-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the
nurse is most appropriate?
a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can
then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult
Protective Services is notified in the community setting.
A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes
which components? (Select all that apply.)
c. Slowed physical activity
e. Weight gain
ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and
weakness. Weight gain and dementia are not part of this cluster of manifestations.
A nurse working with older adults assesses them for common potential adverse medication effects. For what
does the nurse assess? (Select all that apply.)
d. Urinary incontinence
ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and
incontinence are not among the common adverse effects, although urinary retention is.
A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in
the hospital. The nursing staff assesses for which factors? (Select all that apply.)
b. Evidence of abuse
d. Problems with behavior
e. Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of
A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.)
a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately.
c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.
ANS: A, B, D
Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about
transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her
to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper
nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other
objective observations. However, the most accurate way to assess pain is to get a self-report from the client
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
a. Being able to sleep doesn't mean pain doesn't exist.
b. Have you ever experienced any type of pain?
c. The client should be assessed for drug addiction.
d. You're right; I would put the medication back.
A clients description is the most accurate assessment of pain. The nurse should believe the client and provide
pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not
supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had
pain is judgmental and flippant, and does not provide useful information. This amount of information does not
warrant an assessment for drug addiction. Putting the medication back and ignoring the clients report of pain
serves no useful purpo
A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain
assessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is
preferred by both cognitively intact and cognitively impaired adults.
The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on
functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be
best to ask the client for completing a comprehensive pain assessment?
a. Are you worried about addiction to pain pills?
b. Do you attach any spiritual meaning to pain?
c. How high would you say your pain tolerance is?
d. What pain rating would be acceptable to you?
A comprehensive pain assessment includes the items listed in the question plus the clients opinion on a
functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not
warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important
information, but getting the basics first is more important. Asking about pain tolerance may give the client the
idea that pain tolerance is being judged
A nurse is assessing pain in an older adult. What action by the nurse is best?
a. Ask only yes-or-no questions so the client doesn't get too tired.
b. Give the client a picture of the pain scale and come back later.
c. Question the client about new pain only, not normal pain from aging.
d. Sit down, ask one question at a time, and allow the client to answer.
Some older clients do not report pain because they think it is a normal part of aging or because they do not
want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and
allow the client enough time to answer it. Yes-or-no questions are an example of poor communication
technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have
time for the client. Plus the client may not know how to use it. There is no normal pain from aging.
A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the findings and continue to monitor.
d. Try a small dose of analgesic medication for pain
Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this
population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the
presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be
holding very still to prevent more pain. Documenting pain is important but not the most important action in
this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult
to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent
surgery), the nurse does need to treat the client for pain.
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which
result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
c. Potassium: 2.9 mEq/L
d. Sodium: 134 mEq/L
A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should
communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is
normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be
A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?
a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.
For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in
50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel
blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant
hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring
the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority
over treating the potassium imbalance.
The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?
a. Introduce himself or herself.
b. Make the family comfortable.
c. Explain the purpose of the interview.
d. Give an assurance of privacy.
The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurse’s role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.
Which action is most likely to encourage parents to talk about their feelings related to their child’s illness?
a. Be sympathetic.
b. Use direct questions.
c. Use open-ended questions.
d. Avoid periods of silence.
Closed-ended questions should be avoided when attempting to elicit parents’ feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.
What is the single most important factor to consider when communicating with children?
a. The child’s physical condition
b. The presence or absence of the child’s parent
c. The child’s developmental level
d. The child’s nonverbal behaviors
The nurse must be aware of the child’s developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child’s physical condition is a consideration, developmental level is much more important. The parents’ presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Nonverbal behaviors vary in importance based on the child’s developmental level.
What is an important consideration for the nurse who is communicating with a very young child?
a. Speak loudly, clearly, and directly.
b. Use transition objects such as a doll.
c. Disguise own feelings, attitudes, and anxiety.
d. Initiate contact with the child when the parent is not present.
Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This facilitates communication with this age child. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children.
When the nurse interviews an adolescent, it is especially important to:
a. focus the discussion on the peer group.
b. allow an opportunity to express feelings.
c. emphasize that confidentiality will always be maintained.
d. use the same type of language as the adolescent.
Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age-group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently.
The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to:
a. ask her, “Are you sexually active?”
b. ask her, “Are you having sex with anyone?”
c. ask her, “Are you having sex with a boyfriend?”
d. ask both the girl and her parent if she is sexually active.
Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as:
a. inappropriate, because of child’s age.
b. a way to establish rapport.
c. too distracting, when cooperation is important.
d. acceptable, if there is adequate time.
A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic.
Kyle, age 6 months, is brought to the clinic. His parent says, “I think he hurts. He cries and rolls his head from side to side a lot.” This most likely suggests which feature of pain?
The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears indicate pain in the ear. The child’s behavior indicates the location of the pain. The behavior does not provide information about the type, severity, or duration.
Physiologic measurements in children’s pain assessment are:
a. the best indicator of pain in children of all ages.
b. essential to determine whether a child is telling the truth about pain.
c. of most value when children also report having pain.
d. of limited value as sole indicator of pain.
Physiologic manifestations of pain may vary considerably and may not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease or stabilize. These signs are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.