Nursing 120 exam 1 Flashcards
(438 cards)
1
Q
A nurse educator is teaching a group of students about professionalism. The educator informs the students that a profession is distinguished from other kinds of occupations by a number of characteristics. Which of the following are among those characteristics? Select all that apply.
A) The members of a profession are financially liable for their actions.
B) The members of a profession participate in ongoing research.
C) The members of a profession must acquire specialized education.
D) The members of a profession possess autonomy.
E) The members of a profession regularly socialize with one another
A
Answer: B, C, D
Explanation: A) A profession is generally distinguished from other kinds of occupations by its requirement of prolonged, specialized training to acquire a specific body of knowledge; its emphasis on service to others; its support of ongoing research to expand the profession’s body of knowledge; its development of a code of ethics; the autonomy of its members; and the existence of a professional organization. Financial liability and socialization with other nurses are not among the criteria that distinguish nursing as a profession.
2
Q
A nurse would like to implement an evidence-based practice change that will influence client care on the medical-surgical unit. The nurse works with the nurse manager and other members of the leadership team to write a new policy and produce educational materials for the unit's staff and clients. In carrying out these actions, the nurse is practicing which standard of professional performance? A) Leadership B) Collaboration C) Evaluation D) Collegiality
A
Answer: B
Explanation: A) The nurse is practicing collaboration by working with other staff members to implement a policy change. Collaboration involves working with clients, their families, and others in the conduct of nursing practice. Collegiality describes interaction with and contributions to the professional development of peers and colleagues, as would be the case in a mentoring relationship. Leadership involves providing direction in a professional practice setting. Evaluation involves a comparison between one’s own nursing practice and professional practice standards.
3
Q
A nurse faculty member is speaking to prospective students of the Bachelor of Science in Nursing (BSN) program at their educational institution. Which of the following reasons should the nurse faculty member cite as a major incentive for students to select a BSN program over an Associate of Science in Nursing (ASN) program? Select all that apply.
A) Greater autonomy in the practice setting
B) Receipt of a fuller liberal arts education
C) Easier transition to graduate school
D) Ability to work in critical care areas
A nurse faculty member is speaking to prospective students of the Bachelor of Science in Nursing (BSN) program at their educational institution. Which of the following reasons should the nurse faculty member cite as a major incentive for students to select a BSN program over an Associate of Science in Nursing (ASN) program? Select all that apply.
A) Greater autonomy in the practice setting
B) Receipt of a fuller liberal arts education
C) Easier transition to graduate school
D) Ability to work in critical care areas
A
Answer: A, E
Explanation: A) Nurses who hold a BSN enjoy greater autonomy, responsibility, participation in institutional decision making, and career advancement than nurses who hold only an ASN. All RNs, regardless of their education level, can work in critical care areas. There are some institutions that offer RN-to-MSN educational programs, but the ease of transition is not the ultimate incentive, which is career advancement. Having a liberal arts education is also a plus, although not as major an incentive for career advancement
4
Q
) \_\_\_\_\_\_\_\_ establishes and maintains the social, political, and economic arrangements that give professionals the means to control their professional affairs. A) Autonomy B) Governance C) Socialization D) Accountability
A
) \_\_\_\_\_\_\_\_ establishes and maintains the social, political, and economic arrangements that give professionals the means to control their professional affairs. A) Autonomy B) Governance C) Socialization D) Accountability
5
Q
A nurse educator is conducting a continuing education in-service for the nurses in a pediatric intensive care unit. Why is it so important for the professional nurse to attend these in-services?
A) Most states require it to maintain licensure.
B) It is a good way to receive overtime pay.
C) Research and new technology demand that nurses stay current.
D) New diseases are discovered every day.
A
Answer: C
Explanation: A) Research and technology are constantly changing and improving client care. Professional nurses are accountable for staying abreast of new information by attending continuing education courses. Receiving overtime pay is not a reason to attend continuing education courses. Although new diseases are discovered regularly, nurses wouldn’t necessarily need ongoing training on the diseases themselves, but rather on new ways of treating diseases. Finally, although many states do have continuing education requirements for nurses, new technology and research are the most important reasons for staying current. In fact, these changes are the reasons why continuing education is required by most states.
6
Q
A registered nurse (RN) who now works as a nursing supervisor at a local hospital is asked to talk about nursing during career day at a local high school. When explaining to the students why nursing is a profession rather than a job, which criteria should the RN include? Select all that apply.
A) Nurses engage in ongoing research.
B) Nurses receive high salaries.
C) More nurses are needed to meet current and predicted demand.
D) Nursing has a service orientation.
E) Nurses must have broad general knowledge of a variety of topics.
A
Answer: A, D
Explanation: A) Several characteristics make nursing a profession rather than a job. For instance, a service orientation differentiates nursing from occupations pursued primarily for profit. Also, as professionals, nurses engage in ongoing research to improve practice and expand the field’s body of knowledge. As with other professions, nursing’s knowledge base is well defined and specific rather than broad and general. Salary level is not a criterion for a profession, nor is the number of practitioners in the field.
7
Q
Answer: A, D
Explanation: A) Several characteristics make nursing a profession rather than a job. For instance, a service orientation differentiates nursing from occupations pursued primarily for profit. Also, as professionals, nurses engage in ongoing research to improve practice and expand the field’s body of knowledge. As with other professions, nursing’s knowledge base is well defined and specific rather than broad and general. Salary level is not a criterion for a profession, nor is the number of practitioners in the field.
A
Explanation: A) Although an associate’s degree is usually sufficient for nursing licensure, the ANA recommends a bachelor’s degree to enter professional practice. Having a bachelor’s degree can also lead to more career opportunities, because many magnet hospitals and academic health centers require that their RNs have at least this level of education. A master’s degree is usually undertaken to provide specialized nursing education, such as that required to become a nurse practitioner. A doctorate involves advanced training, which may focus on clinical or organizational skills and usually involves research.
8
Q
) What is the most powerful factor in encouraging adoption of the attitudes and behaviors that characterize professionalism in nursing? A) Employment opportunities B) Licensure requirements C) Interaction with peers D) Specialized training
A
Answer: C
Explanation: A) Employment opportunities and licensure requirements are not associated with adopting the attitudes and behaviors of professional nursing. Specialized training provides nurses with the knowledge and skills necessary to do their job, but it doesn’t necessarily lead a nurse to internalize the attitudes and behaviors that characterize professionalism in nursing. Rather, one of the most powerful mechanisms of professional socialization is interaction with fellow students and nurses.
9
Q
How does accountability differ from responsibility?
A) Responsibility involves specific tasks that must be completed in order to fulfill a role, whereas accountability involves being answerable for the outcomes of those tasks.
B) Accountability involves specific tasks that must be completed in order to fulfill a role, whereas responsibility involves being answerable for the outcomes of those tasks.
C) Responsibility involves the professional standards used to determine what a nurse should or should not do, whereas accountability involves taking ownership of the actions of others.
D) Accountability involves the professional standards used to determine what a nurse should or should not do, whereas responsibility involves taking ownership of the actions of others.
A
How does accountability differ from responsibility?
A) Responsibility involves specific tasks that must be completed in order to fulfill a role, whereas accountability involves being answerable for the outcomes of those tasks.
B) Accountability involves specific tasks that must be completed in order to fulfill a role, whereas responsibility involves being answerable for the outcomes of those tasks.
C) Responsibility involves the professional standards used to determine what a nurse should or should not do, whereas accountability involves taking ownership of the actions of others.
D) Accountability involves the professional standards used to determine what a nurse should or should not do, whereas responsibility involves taking ownership of the actions of others.
10
Q
A novice nurse on a medical-surgical unit is released from the orientation phase of training. The nurse is able to care for a four- to five-client assignment independently and is assigned a coach on the unit who will help with problem solving if needed. According to Benner's stages of nursing expertise, this nurse would belong in which stage? A) Stage II B) Stage V C) Stage III D) Stage IV
A
Explanation: A) The new graduate nurse who is fresh out of the orientation phase is considered to be in Stage II. A Stage II nurse is an advanced beginner, meaning he or she demonstrates marginally acceptable performance. Stage III is the competency stage; the nurse in this stage has 2 or 3 years of experience and demonstrates organizational and planning abilities. Stage IV is the proficiency stage. The Stage IV nurse has 3 to 5 years of experience, has a holistic understanding of the client that improves decision making, and focuses on long-term goals. The nurse at Stage V is considered an expert. His or her performance is fluid, flexible, and highly proficient. The expert nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. This individual has highly intuitive and analytic abilities in new situations.
11
Q
One of the roles of the community health nurse is to educate individuals about health promotion and wellness. Which activity would the nurse dismiss as irrelevant to health promotion and wellness? A) Holding classes for teenagers regarding prevention of sexually transmitted infections B) Teaching a class about smoking cessation C) Initiating infant care classes for new parents D) Implementing an exercise class for clients who have had a heart attack
A
Answer: D
Explanation: A) Teaching clients about recovery activities, such as exercises that accelerate recovery after a heart attack, would fall under the category of health restoration, not health promotion. All of the other activities listed here promote health and wellness by teaching activities and behaviors that enhance clients’ quality of life and maximize their personal potential, including their physical fitness and emotional health.
12
Q
A nurse educator is talking to a group of staff nurses about the importance of continued competence in nursing practice. One of the staff nurses asks about activities that can help professional nurses maintain competence. Which action should the nurse educator recommend?
A) Working overtime whenever hours are available
B) Designing a poster presentation on current research on care for the dying client
C) Volunteering to take blood pressures at a health and wellness fair
D) Organizing a seminar to educate new nurses about hospital policies
A
A nurse educator is talking to a group of staff nurses about the importance of continued competence in nursing practice. One of the staff nurses asks about activities that can help professional nurses maintain competence. Which action should the nurse educator recommend?
A) Working overtime whenever hours are available
B) Designing a poster presentation on current research on care for the dying client
C) Volunteering to take blood pressures at a health and wellness fair
D) Organizing a seminar to educate new nurses about hospital policies
13
Q
A nurse, who has been working in a small rural hospital for 4 years since obtaining a nursing license, participates on an interdisciplinary task force to improve client care. Which skill level is this nurse demonstrating according to Benner's stages of nursing expertise? A) Advanced beginner B) Competent C) Proficient D) Expert
A
Answer: C
Explanation: A) According to Benner’s stages, this nurse would be considered proficient, because he or she has 3 to 5 years of experience and a holistic understanding of the client, which improves decision making. In comparison, an advanced beginner nurse has less than 2 years of experience and demonstrates marginally acceptable performance; a competent nurse has 2 or 3 years of experience and demonstrates organizational and planning abilities; and an expert nurse has more than 5 years of experience and demonstrates highly skilled intuitive and analytic ability in new situations.
14
Q
A school nurse in a large urban high school regularly delivers presentations on nutrition, smoking cessation, and prevention of sexually transmitted infections (STIs). What area(s) of nursing competence is this nurse demonstrating? Select all that apply. A) Health restoration B) Health and wellness promotion C) Caring for the dying D) Illness prevention E) Care cost savings
A
A school nurse in a large urban high school regularly delivers presentations on nutrition, smoking cessation, and prevention of sexually transmitted infections (STIs). What area(s) of nursing competence is this nurse demonstrating? Select all that apply. A) Health restoration B) Health and wellness promotion C) Caring for the dying D) Illness prevention E) Care cost savings
15
Q
An experienced nurse practitioner is always conscious of the need to maintain a high level of competence within professional nursing practice. Which activities support this nurse’s goal? Select all that apply.
A) Reading professional journals
B) Collaborating with peers
C) Counseling clients
D) Attending professional workshops and seminars
E) Administering medications appropriately
A
Answer: A, B, D
Explanation: A) Lifelong competence can be promoted by attending seminars offered by colleges and professional organizations, reading professional and peer-reviewed journals, and having formal and informal discussions with peers and other members of the healthcare team. Providing counseling to clients and administering medications are ways to implement nursing knowledge, not methods for increasing it.
16
Q
) \_\_\_\_\_\_\_\_ is a state of being in which individuals engage in behaviors that enhance their quality of life and maximize their personal potential. A) Health promotion B) Wellness C) Prevention D) Health restoration
A
Answer: B
Explanation: A) Wellness can be described as a state of being in which individuals engage in activities and behaviors that enhance their quality of life and maximize their personal potential, including their physical fitness and emotional health. In comparison, health promotion is a process that enables individuals and communities to increase their control over the determinants of well-being, thereby improving their overall health; prevention focuses on maintaining health by working to stop illnesses and injuries from occurring; and health restoration involves efforts to return clients to their optimal state of health following illness or injury.
17
Q
) Providing wound care, referring clients to post-trauma psychological counseling, and assisting clients with physical and occupational therapy are all activities associated with which area of nursing competence? A) Health promotion B) Illness prevention C) Health restoration D) Holistic care and support
A
Answer: C
Explanation: A) These activities all fall under the umbrella of health restoration, the area of nursing competency that involves efforts to return clients to their optimal state of physical, cognitive, psychological, and spiritual health following illness or injury. Health promotion is the area of nursing competency that involves enabling individuals and communities to increase their control over the determinants of well-being, thereby improving their overall health. Illness prevention is the area of nursing competency that involves helping individuals maintain optimal health by preventing disease and injury. Although holistic care and support are important aspects of nursing, they are not considered a core competency in the same sense as health promotion, illness prevention, health restoration, and caring for the dying.
18
Q
Which of the following individuals is widely considered to be the founder of public health nursing? A) Lavinia Dock B) Lillian Wald C) Mary Mahoney D) Linda Richards
A
Which of the following individuals is widely considered to be the founder of public health nursing? A) Lavinia Dock B) Lillian Wald C) Mary Mahoney D) Linda Richards
19
Q
) The nurse is administering a bed bath to a client in a long-term care facility. The nurse is careful to cover the client during the bath. Which nursing role does this action reflect? A) Communicator B) Caregiver C) Client advocate D) Teacher
A
Answer: B
Explanation: A) The caregiver role includes those activities that assist the client physically and psychologically while preserving the client’s dignity. In this scenario, the nurse is acting in the role of a caregiver. As a communicator, the nurse identifies client problems, then communicates these verbally or in writing to other members of the health team. As a teacher, the nurse helps clients learn about their health and the healthcare procedures they need to perform to maintain or restore their health. As a client advocate, the nurse acts to protect clients and represents their needs and wishes to other health professionals.
20
Q
Answer: B
Explanation: A) The caregiver role includes those activities that assist the client physically and psychologically while preserving the client’s dignity. In this scenario, the nurse is acting in the role of a caregiver. As a communicator, the nurse identifies client problems, then communicates these verbally or in writing to other members of the health team. As a teacher, the nurse helps clients learn about their health and the healthcare procedures they need to perform to maintain or restore their health. As a client advocate, the nurse acts to protect clients and represents their needs and wishes to other health professionals.
A
Answer: C
Explanation: A) Discussing the situation with the nursing supervisor is the appropriate decision because the supervisor is the next highest link in the chain of command. As such, the supervisor is responsible for making the appropriate decision about how to deal with the potentially impaired charge nurse. Confronting the other nurse would not be appropriate given that the nurse seems impaired. Although the nurse manager will need to be notified, the charge nurse must first notify the nursing supervisor so he or she can determine how to proceed. Security may need to be notified eventually, but again, that decision would be made by the nursing supervisor.
21
Q
A nurse is overseeing a group of students who are completing a clinical rotation on a medical-surgical unit. The students are providing direct client care with the assistance of the nurse. The nurse who is overseeing the students is functioning in which capacity? A) Clinical nurse specialist B) Nurse practitioner C) Nurse entrepreneur D) Nurse educator
A
Answer: D
Explanation: A) Nurse educators are responsible for classroom and often clinical teaching—as is happening in this scenario. A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice. He or she provides direct client care, educates others, consults, conducts research, and manages care. A nurse practitioner has an advanced education, is a graduate of a nurse practitioner program, and usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research.
22
Q
A student nurse is trying to explain nursing to family members. Which contemporary aspects of nursing might the student nurse include in the explanation? Select all that apply. A) Nursing is a science. B) Nursing is easy. C) Nursing is a new profession. D) Nursing is focused on illness. E) Nursing is holistic.
A
Answer: A, E
Explanation: A) The American Nurses Association (ANA) recognizes the influence and contribution of the science of caring to nursing philosophy and practice. Nursing is complex and involves the interrelationship among nurses, nursing, the client, the environment, and the intended client outcome. Florence Nightingale defined nursing nearly 150 years ago. The nurse is concerned with both healthy and ill individuals and approaches care holistically, considering its physical, cognitive, psychological, and spiritual elements.
23
Q
A client who has been diagnosed with terminal pancreatic cancer states to the nurse, "I do not want any further treatment, but I am afraid my doctor will insist that I continue chemotherapy." Which role is the nurse performing when informing the healthcare provider of the client's choice to stop treatment? A) Change agent B) Case manager C) Advocate D) Teacher
A
Answer: C
Explanation: A) Here, the nurse is acting as client advocate, because this role involves representing the client’s needs and wishes to other health professionals. As change agents, nurses assist clients to make modifications in their behavior. Nurse case managers work with the multidisciplinary healthcare team to measure the effectiveness of the case management plan and monitor outcomes. As teachers, nurses help clients learn about their health and about healthcare procedures used to restore or maintain their health.
24
Q
) A nurse working in the emergency department (ED) notes that a healthcare provider smells strongly of alcohol and appears confused. Which action by the nurse is appropriate?
A) Contact the charge nurse to report the problem.
B) Tell the healthcare provider to seek alcohol rehabilitation.
C) Report the healthcare provider to the hospital CEO.
D) Report the healthcare provider to the state licensing board.
A
Answer: A
Explanation: A) In a hospital, problems like this one are usually first reported to the charge nurse, then to the unit manager. If the problem is still not resolved, the nurse may approach someone in middle or upper management. Making suggestions to the healthcare provider about rehabilitation does not address the nurse’s responsibility to clients and the organization. The nurse should address the problem through the chain of command within the hospital.
25
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A nurse obtains certification to provide direct client care, educate others, consult, conduct research, and manage oncology care. Which expanded nursing role best describes this nurse's career position?
A) Nurse anesthetist
B) Clinical nurse specialist
C) Nurse educator
D) Nurse researcher
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A nurse obtains certification to provide direct client care, educate others, consult, conduct research, and manage oncology care. Which expanded nursing role best describes this nurse's career position?
A) Nurse anesthetist
B) Clinical nurse specialist
C) Nurse educator
D) Nurse researcher
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26
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) A staff nurse serves as a valuable source of expertise and advice to other nurses on the unit. However, the nurse does not have the authority to direct their work. Which characteristic does this nurse have?
A) Staff authority
B) Responsibility
C) Line authority
D) Organizational authority
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Answer: A
Explanation: A) This nurse possesses staff authority, or the power to provide advice and support to employees or departments but not to assign tasks. In contrast, line authority is the power to direct the activities of subordinates within an organization. Responsibility means being accountable for meeting personal or organizational objectives and performing required tasks. Organizational authority is not a term used to describe this type of situation.
27
The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate?
A) Respecting the parents' decision
B) Telling the parents they are making the right decision
C) Asking to be assigned to a different client
D) Referring the parents to social services
Answer: A
Explanation: A) The nurse best advocates for the family by supporting the family's right to make this decision. Telling the clients they are making the right decision is inappropriate and does not support advocacy. Referring the parents to another entity points to feelings of unease about the parents' choice. Asking to be assigned to another client does not honor the right of clients and families to make decisions about healthcare.
28
By providing volunteer client care to an inadequately insured population, the nurse is demonstrating which value of client advocacy?
A) The client has the right to make choices and decisions.
B) The nurse has the responsibility to ensure the client has access to healthcare services.
C) The client has the right to expect a nurse-client relationship based on shared respect.
D) The nurse has the responsibility to make choices and decisions.
Answer: B
Explanation: A) The nurse has the responsibility to ensure the client has access to healthcare services that meet health needs. Although the client does have the right to make choices and decisions, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. Although the client does have the right to expect a nurse-client relationship based on shared respect, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. The nurse's responsibility to make choices and decisions is not one of the values basic to client advocacy.
29
A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation?
A) Ask a staff nurse to question the client about the situation.
B) Discuss the situation with the client in a private setting.
C) Ask the other staff members if abuse is involved.
D) Ignore the situation until the client shows a willingness to talk.
A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation?
A) Ask a staff nurse to question the client about the situation.
B) Discuss the situation with the client in a private setting.
C) Ask the other staff members if abuse is involved.
D) Ignore the situation until the client shows a willingness to talk.
30
Which of the following is an advocacy intervention that a nurse may perform?
A) Ensuring that clients and their families understand their legal rights.
B) Deciding whether clients need to know information regarding their care.
C) Following organizational policies and procedures in all cases without question.
D) Leaving monitoring of clients' care to the clients themselves.
Answer: A
Explanation: A) Educating clients and their families about their legal rights regarding informed decision-making is a specific advocacy intervention a nurse may make. Nurses should ensure that clients have all the information they need to give informed consent. They should review organizational policies and procedures to ensure protection of client rights, and they should monitor client care to ensure client rights.
31
The nurse notices that there is broken equipment on the playground in a neighborhood where care is provided to low-income residents. The nurse tries unsuccessfully to get the owner to address this safety issue. Which additional action is most consistent with the role of the nurse as a public advocate?
A) Write an article in the local newspaper to gain public attention.
B) No action is required; this is a civil problem beyond the realm of the nurse.
C) Call the police to report the owner's neglect.
D) Tell the parents they should not pay their rent until the playground is fixed.
Answer: A
Explanation: A) Prevention of injury to clients is very much a part of nursing. The nurse should initially contact the owner. Because this was ineffective, it is appropriate for the nurse to write an article or talk to an individual on the town council. The police are a protection against crime and are not likely to do anything about the situation. Telling the parents not to pay their rent until the playground is fixed is not appropriate. Civil problem or not, the nurse has an obligation to protect the neighborhood children from injury and should act on it.
32
The nurse has been working in a long-term care facility for 1 week. The nurse notes that during the evening meal, an unlicensed assistive personnel (UAP) gives a tray to a client who is unable to cut up and eat the food independently, and then leaves. After the nurse assists the client with eating the meal, which action is appropriate to advocate for this client?
A) Report the UAP for neglect.
B) Notify the healthcare provider.
C) Call the client's family to have them assist with evening meals.
D) Discuss the situation with the director of nursing.
Answer: D
Explanation: A) The nurse would advocate getting the client's plan changed because the goal is to have someone available to help the client eat for every meal. Notifying the doctor will not help the client. The family might be able to help at times but cannot be expected to come for every meal. The nurse assesses that this happens at every meal and seeks to change how this client is cared for, not just changing one healthcare worker. The UAP is not neglecting the client. The UAP is assigned tasks by the nurse in charge of the client.
33
) The nurse is caring for a client on a mental health unit who is yelling at other clients and some of the staff. Which verbal intervention by the nurse is most consistent with the concept of advocacy?
A) "You should be ashamed of your behavior. No wonder you ended up on a mental health unit."
B) "You seem upset. Can you tell me what you think might help to calm you down?"
C) "You need to behave. If this doesn't stop you are going to be placed in restraints."
D) "You are out of control. You have no choice but to take more medication."
Answer: B
Explanation: A) The nurse's role is to advocate for the rights of the individual with mental illness or disability. The nurse should validate the meaning of the behavior and encourage safe coping methods. Disparaging the client or threatening to restrain them or sedate them is inconsistent with client rights.
34
An older adult client with metastasized breast cancer informs the nurse that her doctor is insisting that she participate in a course of chemotherapy, even though the client does not want to have any further treatment. Which actions by the nurse exemplify advocacy for this client? Select all that apply.
A) Tell the client that it is in her best interest to follow the doctor's advice.
B) Inform the doctor about the client's clear wishes not to have further chemotherapy.
C) Ascertain whether or not the client has an advance care directive and, if not, assist her in creating one.
D) Discuss the implications of various choices with the client.
E) Avoid interfering in the doctor-client relationship
Answer: B, C, D
Explanation: A) Nurses acting as advocates should honor the moral principles and standards and respect clients' right to make their own choices. The nurse should continuously advocate for the client in a professional manner. The nurse serves as both a teacher and an advocate by informing clients about their rights. When the client makes decisions about his or her treatment other than what is recommended, it is the nurse's role to ensure that the client is making an informed decision and, if so, to advocate for the client's right to make autonomous choices.
35
Which of the following advocacy interventions might nurses provide that are within their role and scope of practice? Select all that apply.
A) Educating clients and their families about their legal rights regarding informed decision-making
B) Ensuring that clients have the necessary information to make an informed decision or give informed consent
C) Evaluating organizational policies and procedures to ensure protection of client rights
D) Supporting medical authority even when this goes against the client's wishes
E) Declaring clients incompetent so family members can make medical decisions for them
Answer: A, B, C
Explanation: A) Clients must understand their rights in order to be able to defend them. As an advocate, the nurse provides clients with the information they need to make informed decisions and supports the clients' rights to make their own healthcare decisions. Nurses should evaluate organizational policies and procedures and monitor clients' care to ensure protection of client rights. A nurse should understand that advocacy may require political action. Conflicts may arise over issues that require consultation, confrontation, or negotiation between the nurse and administrative personnel or between the nurse and primary care providers. Declaring clients incompetent is not the role of the nurse, and it should not be done just to please family members.
36
A nurse suspects another healthcare provider is under the influence of alcohol at work. Which actions by the nurse are correct? Select all that apply.
A) Assume that healthcare provider is handling any problem.
B) Immediately report it to a supervisor.
C) Respect the privacy of the healthcare provider.
D) Assist the provider while care is provided to clients.
E) Follow the state board guidelines.
Answer: B, E
Explanation: A) A nurse who suspects a colleague of engaging in illegal, immoral, or unethical conduct and fails to act is in direct violation of the ANA Code of Ethics for Nurses. Nurses have a legal responsibility to report any professional whom they suspect of engaging in illegal, immoral, or unethical activities. Although an impaired healthcare provider may view this intervention as an invasion of privacy, such prompt action will safeguard the client from harm, at the same time offering the impaired healthcare provider a chance at recovery. Impairment of a coworker or team member is the most common situation encountered by healthcare professionals. Nurses should follow guidelines set forth by the board of nursing for the state in which they work.
37
A school nurse who is concerned about an increase in sports injuries related to ineffective protective equipment decides to hold a community seminar related to the importance of proper protective equipment. Which advocacy activities is this nurse demonstrating? Select all that apply.
A) Advocating for vulnerable populations
B) Advocating for fair and equitable access to high-quality care for all clients
C) Ensuring that clients have the necessary information to make an informed decision or give informed consent
D) Informing the public about issues and concerns
E) Speaking publicly for the health, welfare, and safety of their clients
Answer: A, C, D, E
Explanation: A) Clients from vulnerable populations, such as children, particularly benefit from nursing advocacy. Through this seminar, the nurse is providing clients with information to make an informed decision and informing the public about issues and concerns that are important to them. The nurse is also speaking publicly to encourage safety practices for students. These are all important advocacy activities. Advocating for fair and equitable access to high-quality care is also an important advocacy activity, but it is not being demonstrated in this situation.
38
) The nurse is planning to carry out advocacy interventions when caring for a client with brain cancer. Which value should the nurse recognize as most basic to client advocacy?
A) The client is a holistic, autonomous being who has the right to make choices and decisions.
B) The nurse has the responsibility to ensure the client's decisions guide care regardless of whether the client is mentally competent.
C) Clients should be advised that making their own care decisions is almost invariably detrimental to their well-being.
D) The client is a dependent being who has the right to expect the nurse to solve all healthcare needs.
Answer: A
Explanation: A) Safeguarding clients' autonomy is the first core attribute of advocacy. It requires respecting and promoting each client's right to self-determination, except in those situations when the client is incompetent to decide or does not wish to be involved in decision making. Clients should not be discouraged from making their own decisions or be treated as naturally dependent.
39
The home health nurse suspects that another nurse providing home care to a client has been taking the client's narcotics. Which action should the nurse carry out?
A) Follow the reporting procedures for her agency.
B) Tell the client to confront the other nurse.
C) Confront the other nurse about the suspected theft.
D) Have the client file a police report.
Answer: A
Explanation: A) Nurses have a legal responsibility to report any professional whom they suspect of engaging in illegal, immoral, or unethical activities. Normally, the nurse making such a report will do so following established procedures at the facility at which the nurse is employed. Both state nurse practice acts and the ANA Code of Ethics require nurses to report unethical nurse behaviors, including boundary violations. The nurse should not leave the responsibility of addressing this problem to the client or directly confront the other nurse.
40
) A nurse involved in promoting client advocacy efforts in the community is assessing the vulnerability of populations in the area served by the healthcare facility where he works. This is a high-ozone area. Which of the following clients would have the lowest risk for ground-level ozone?
A) A 73-year-old female client with a high level of financial security
B) A 23-year-old male client with a regular salaried job able to pay his bills
C) A 33-year-old female client with COPD and without a job living at the poverty line
D) A 13-year-old male client whose parents both work at mid-level professional jobs
) A nurse involved in promoting client advocacy efforts in the community is assessing the vulnerability of populations in the area served by the healthcare facility where he works. This is a high-ozone area. Which of the following clients would have the lowest risk for ground-level ozone?
A) A 73-year-old female client with a high level of financial security
B) A 23-year-old male client with a regular salaried job able to pay his bills
C) A 33-year-old female client with COPD and without a job living at the poverty line
D) A 13-year-old male client whose parents both work at mid-level professional jobs
41
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A nurse is organizing a client advocacy committee focused on improvements in water quality to protect the health of vulnerable populations. As she examines her own workplace, what is a likely area of improvement for her to focus on?
A) Disposal of disinfectants
B) Oil spills
C) Pollution of water resources
D) Use of arsenic
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Answer: A
Explanation: A) Water supplies may be contaminated with either natural or human-made substances. Contaminants in the public drinking supply that can cause health hazards include disinfection by-products. The nurse's facility is not likely to use arsenic, be involved in oil spills, or directly pollute water resources such as lakes, rivers, and streams, but the disposal of disinfectants could be a concern.
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A nurse is organizing a community effort to reduce the rate of birth defects in the area. A nuclear power plant provides most of the electricity for the community. What aspect of this power plant's operation should the nurse identify as problematic?
A) Production of particulate matter such as smoke
B) Production of ionizing radiation
C) Production of hazardous waste
D) Production of nuclear-generated electricity
A nurse is organizing a community effort to reduce the rate of birth defects in the area. A nuclear power plant provides most of the electricity for the community. What aspect of this power plant's operation should the nurse identify as problematic?
A) Production of particulate matter such as smoke
B) Production of ionizing radiation
C) Production of hazardous waste
D) Production of nuclear-generated electricity
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Which action by the nurse working in the emergency department best demonstrates advocacy for better environmental quality?
A) Improving prioritization skills for nurses in the ED
B) Adapting practices in the ED to cultural needs of clients
C) Revising policies for telephone triage to ensure better distribution of resources
D) Ensuring that bandages and dressings are properly disposed according to protocol
Answer: D
Explanation: A) A nurse working in an ED may advocate for better environmental quality for her clients by ensuring that bandages and dressings are properly disposed of according to protocol. Improved prioritization skills for nurses, more culturally aware practices, and telephone triage policies that make a better use of ED resources are all useful interventions but do not relate to environmental quality.
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The nurse is working in a community health setting. Which of the following should the nurse identify as a threat to environmental quality?
A) Many residences appear to be vulnerable to intrusion, with open garage doors or ground-floor windows.
B) Children in many neighborhoods are playing in the street with no adult supervision.
C) Many people walking their pets do not clean up their pets' waste.
D) On many residential streets, cars are parked in a way that blocks traffic and creates potential driving hazards.
Answer: C
Explanation: A) Improper disposal of pet waste is a danger to clean water that the National Resource Defense Council has identified as an area of concern. This would be an environmental quality concern. Vulnerability to intrusion, children playing in the street, or improperly parked cars are all areas of concern but do not relate to environmental quality.
45
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The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan?
A) The client's occupation
B) The client's diet
C) The client's usual sleep schedule
D) The client's marital status
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Answer: B
Explanation: A) For clients who have heart failure, the nurse should ask questions aimed at obtaining information about lifestyle habits that may be contributing to the heart failure, such as smoking and diet. Although sleep schedule is a lifestyle habit about which the nurse should inquire, it is less likely than diet to be a contributing factor to heart failure. Gathering psychosocial information such as the client's marital status and occupation is also important, but in this case, it is not directly related to the client's current problem and teaching needs
46
) The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client's abdomen, which nursing action is appropriate?
A) Administering 10 L of oxygen to the client
B) Having the client remain upright
C) Placing the client in a modified Sims position
D) Asking the client to bend over a table
Answer: B
Explanation: A) Abdomen palpation is usually done in the supine position, but a client with difficulty breathing would not tolerate that position well. Instead, the nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in a modified Sims position could compromise the client's ability to breathe effectively. A client who is experiencing dyspnea would not be asked to bend over a table. Depending on the client's underlying condition, administering 10 L of oxygen may be excessive
47
The nurse is preparing to conduct a physical examination of a client's head and neck area. The client is paralyzed from the neck down. Which action by the nurse is appropriate when conducting the physical assessment of this area?
A) Supporting the client during the examination
B) Placing the client in an armless regular chair
C) Placing the client in Sims position
D) Placing the client in supine position
Answer: A
Explanation: A) The client who is paralyzed from the neck down is not able to support his or her body. When considering positioning, the nurse should recognize that the client will require support during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. Sims position would not allow the nurse to observe the client adequately.
48
A client is complaining of pain in the lower-left quadrant of his abdomen. The nurse prepares to auscultate the lower abdomen and notes that the client has a great deal of hair there. Which action by the nurse is appropriate prior to auscultating the client's abdomen?
A) Moistening the abdominal hair
B) Documenting that the client has hirsutism
C) Cutting the client's hair over the entire abdomen
D) Discontinuing the use of auscultation and palpating the abdomen only
Answer: A
Explanation: A) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for auscultation. The client complains of abdominal pain, so auscultation would be a necessary part of a thorough examination because the nurse would need to listen to bowel sounds. Hirsutism includes excess hair all over the entire body, not just the abdomen
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An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate?
A) Ask the spouse for more information.
B) Assess for pedal edema.
C) Assess skin turgor.
D) Repeat the temperature measurement.
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Answer: C
Explanation: A) A client who presents with hyperthermia, vomiting, diarrhea, and pale, dry mucous membranes is likely dehydrated and requires assessment to confirm this suspicion. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support for a diagnosis of dehydration. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. Only measurements that are extremely abnormal need to be repeated in stable clients.
50
The nurse is preparing to examine a toddler's ear canals with an otoscope. Which actions by the nurse are appropriate? Select all that apply.
A) Having the child sit on the examination table
B) Having the child play with the equipment
C) Having the child sit on the parent's lap
D) Telling the child the examination will not hurt
E) Asking the child to tilt the head
Answer: B, C
Explanation: A) The best way to get a child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, as well as to have the child sit on the parent's lap. Asking the child to tilt the head does not encourage cooperation. Most children of this age need to see for themselves that a procedure will not hurt; simply telling the child that the procedure won't be painful is not effective.
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Answer: B, C
Explanation: A) The best way to get a child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, as well as to have the child sit on the parent's lap. Asking the child to tilt the head does not encourage cooperation. Most children of this age need to see for themselves that a procedure will not hurt; simply telling the child that the procedure won't be painful is not effective.
Answer: B
Explanation: A) To assess the range of motion of the knees, the client should be placed in a sitting position. The client should be instructed to alert the nurse at the first sign of discomfort when checking range of motion of the knees. The knee should not be forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of motion of the hips. The client should not be asked to stand when assessing range of motion of the knees.
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) The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply.
A) Speech and language
B) Body development and growth
C) Sleeping patterns
D) Ability to carry out activities of daily living (ADLs)
E) Body mass index (BMI) measurement
Answer: D, E
Explanation: A) Areas of assessment that are relevant to middle-aged adults include BMI measurement to assess for disease risk and the ability to carry out ADLs. Speech and language, body development and growth, and sleeping patterns are more appropriate to assess in pediatric clients.
53
The nurse is caring for a new older adult client who speaks a foreign language and who does not speak English. Which action by the nurse is appropriate when conducting the health history portion of the assessment?
A) Speaking in a loud tone when addressing the client
B) Providing the client with educational materials that are written in English
C) Asking the client's adult son to translate during the assessment
D) Having a medical translator available during the health history
Answer: D
Explanation: A) Because the client speaks a foreign language, the nurse will need a medical translator to be available during the health history portion of the assessment. Although the nurse may need to increase the volume of speech because of age-related changes in the client's hearing, this is not an appropriate action until the nurse determines that the client is hard of hearing. Educational material should be provided to the client in the client's native language. Asking a family member to translate during an assessment can violate the client's privacy.
54
The nurse is conducting a health history as part of a nursing assessment. The client says to the nurse, "I am allergic to penicillin." Which assessment question would best help the nurse learn more about the client's allergy?
A) "Where did you experience the reaction?"
B) "What type of reaction occurred?"
C) "How long did your symptoms last?"
D) "Do any other family members have this same allergy?"
Answer: B
Explanation: A) The nurse should ask the client to provide more information about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important, but the priority is determining the type of reaction the client experienced. Asking whether any other family members have the same allergy will not provide the nurse with useful information
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Answer: B
Explanation: A) The nurse should ask the client to provide more information about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important, but the priority is determining the type of reaction the client experienced. Asking whether any other family members have the same allergy will not provide the nurse with useful information
Answer: C
Explanation: A) The dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is usually contraindicated for clients with cardiopulmonary problems because of the increased physiologic stress that this position places on the body. The other positions listed here—sitting (with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)—are typically better tolerated by clients with cardiopulmonary illness
56
The nurse is assessing an older adult client who is confused. The client is accompanied by his adult son. Who can the nurse employ as a primary source of data when assessing this client?
A) The client himself
B) The client's adult son
C) A nurse who cares for the client at the retirement home
D) The client's primary healthcare provider
Answer: A
Explanation: A) The client is the only person who is considered a primary source of data. Family members, other support people, health professionals, medical records, laboratory and diagnostic reports, and any other information sources beyond the client himself are considered secondary sources of data.
57
A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply.
A) "Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart."
B) "Use standard precautions during the history and physical examination process."
C) "Perform invasive procedures like pharyngeal and otic exams at the end of the assessment."
D) "Use age-appropriate terminology for explaining procedures and actions."
E) "Use the assessment process to teach about exam procedures and findings."
A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply.
A) "Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart."
B) "Use standard precautions during the history and physical examination process."
C) "Perform invasive procedures like pharyngeal and otic exams at the end of the assessment."
D) "Use age-appropriate terminology for explaining procedures and actions."
E) "Use the assessment process to teach about exam procedures and findings."
58
A nurse is reviewing the medical record for a school-age client prior to a scheduled health maintenance visit. Which data from the record indicates that the client is overweight?
A) Body mass index (BMI) >85th percentile
B) BMI >95th percentile
C) 25% increase in weight in a 6-month period
D) 35% increase in weight in a 6-month period
Answer: A
Explanation: A) A child with a BMI greater than the 85th percentile is considered overweight. A child with a BMI greater than the 95th percentile is considered obese. Percentage of weight gain in a 6-month period (regardless of baseline) does not determine whether a client is overweight or obese.
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The nurse is assessing an older adult client who experienced a myocardial infarction (MI) a few months ago. The client states, "I don't feel like doing much. I feel okay physically, but I just don't want to be around anyone." Based on this data, which tool should the nurse use to further assess the client?
A) Get-Up-and-Go Test
B) Barthel Index of Activities of Daily Living
C) Geriatric Depression Scale
D) Short Portable Mental Status tool
The nurse is assessing an older adult client who experienced a myocardial infarction (MI) a few months ago. The client states, "I don't feel like doing much. I feel okay physically, but I just don't want to be around anyone." Based on this data, which tool should the nurse use to further assess the client?
A) Get-Up-and-Go Test
B) Barthel Index of Activities of Daily Living
C) Geriatric Depression Scale
D) Short Portable Mental Status tool
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Data that are detectable by an observer or can be measured or tested against an accepted standard are known as
A) subjective data or symptoms.
B) objective data or symptoms.
C) subjective data or signs.
D) objective data or signs.
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Data that are detectable by an observer or can be measured or tested against an accepted standard are known as
A) subjective data or symptoms.
B) objective data or symptoms.
C) subjective data or signs.
D) objective data or signs.
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Which of the following sounds would not be detected during percussion of a healthy client?
A) Tympany
B) Hyperresonance
C) Dullness
D) Flatness
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Answer: B
Explanation: A) Percussion elicits five types of sound: flatness, dullness, resonance, hyperresonance, and tympany. Flatness is an extremely dull sound produced by very dense tissue, such as muscle or bone. Dullness is a thudlike sound produced by dense tissue such as the liver, spleen, or heart. Resonance is a hollow sound, such as that produced by lungs filled with air. Hyperresonance is not produced in the healthy body. It is described as booming that can be heard over an emphysematous lung. Tympany is a musical or drumlike sound produced from an air-filled stomach
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For which client would the Denver II tool not be an appropriate choice for the nurse to use during a well-child assessment?
A) A male client
B) A client aged 7 or older
C) A female client
D) A client aged 6 or younger
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Answer: B
Explanation: A) The Denver II tool is a screening test administered to well children between birth and 6 years of age. It is designed to test 20 simple tasks and items in four sectors: personal-social, fine motor adaptive, language, and gross motor. This tool is used with both male and female clients, but it would not be used for clients aged 7 or older.
63
What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale?
A) The client is at risk for falls.
B) The client is at risk for pressure ulcers.
C) The client is at risk for malnutrition.
D) The client may be unable to complete activities of daily living.
What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale?
A) The client is at risk for falls.
B) The client is at risk for pressure ulcers.
C) The client is at risk for malnutrition.
D) The client may be unable to complete activities of daily living.
64
A nurse is providing care to a client who is scheduled for a colonoscopy. The client requires a bowel prep prior to the diagnostic test. Which approach should the nurse use to facilitate the client's understanding of the procedure?
A) Use layman's terms to explain the procedure, then ask the client to describe the procedure in her own words
B) Use medical terminology when explaining the procedure to the client to ensure maximum accuracy and clarity
C) Focus on intonation when describing the procedure to the client
D) Speak slowly and loudly when providing client teaching about the procedure
Answer: A
Explanation: A) Good verbal communication incorporates simplicity, brevity, and completeness. Simplicity involves the use of commonly understood words rather than medical terminology. For example, the term "bowel prep" may be completely meaningless to the client, so telling the client that she needs to drink a gallon of laxative-like medication will get the point across better. Asking the client to repeat the information back in her own words gives the nurse a chance to evaluate whether the teaching has been successful. While intonation can modify the feeling and impact of a message, focusing on intonation is less important than using easily understood terminology. Speaking too slowly or too loudly could be interpreted by the client as patronizing or aggressive.
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) A nurse is teaching a client about a dressing change that should be done three times per day. The client is from a culture that is "present oriented." Based on this data, at which times should the nurse tell the client to perform the dressing changes?
A) At whatever times the client selects, as long as they are 8 hours apart
B) At 9 a.m., 3 p.m., and 9 p.m.
C) At whatever times the client selects, as long as the dressing is changed three times each day
D) After breakfast, lunch, and dinner
Answer: D
Explanation: A) For clients who are "present oriented," it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments, such as in the morning or after breakfast, and in the evening or before going to bed. Relating the dressing changes to regular daily activities would be a good approach for a client who is not focused on times of the day, such as 9 a.m., 3 p.m., and 9 p.m. It is not necessary for the dressing changes to be exactly 8 hours apart. Leaving it up to the client to change the dressing at any time as long as it is changed three times a day does not allow for any regularity in the dressing changes.
66
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A nurse educator in a medical-surgical unit is demonstrating the use of new equipment to the rest of the nurses on the unit. After initial efforts at having the class gather closely around the models were met with discomfort and inattention, the nurse educator sets up the models in the front of the classroom. Which level of proxemics would be ideal for this situation?
A) 4 to 12 feet
B) 1 1/2 to 4 feet
C) 12 to 15 feet
D) Less than 1 1/2 feet
```
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A nurse educator in a medical-surgical unit is demonstrating the use of new equipment to the rest of the nurses on the unit. After initial efforts at having the class gather closely around the models were met with discomfort and inattention, the nurse educator sets up the models in the front of the classroom. Which level of proxemics would be ideal for this situation?
A) 4 to 12 feet
B) 1 1/2 to 4 feet
C) 12 to 15 feet
D) Less than 1 1/2 feet
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67
The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client?
A) Placing the client in a private room, away from others
B) Speaking to the client in a soft, calm tone
C) Administering a prn medication to sedate the client
D) Using short sentences when talking to the client
The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client?
A) Placing the client in a private room, away from others
B) Speaking to the client in a soft, calm tone
C) Administering a prn medication to sedate the client
D) Using short sentences when talking to the client
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The nurse is starting preoperative teaching when the client receives a phone call. When the call ends and the nurse resumes teaching, the client is visibly upset and begins to cry. Which therapeutic initial response by the nurse is appropriate?
A) "You can deal with whatever is upsetting you once we have finished."
B) "It's very important to focus on this teaching so that you will recover quickly after surgery."
C) "I can see that phone call has upset you. Let's talk about why you are upset before we move on with teaching."
D) "What can you do to solve the problem?"
The nurse is starting preoperative teaching when the client receives a phone call. When the call ends and the nurse resumes teaching, the client is visibly upset and begins to cry. Which therapeutic initial response by the nurse is appropriate?
A) "You can deal with whatever is upsetting you once we have finished."
B) "It's very important to focus on this teaching so that you will recover quickly after surgery."
C) "I can see that phone call has upset you. Let's talk about why you are upset before we move on with teaching."
D) "What can you do to solve the problem?"
69
A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The healthcare provider prescribes an enema. Which reaction by the client would the nurse anticipate when planning care?
A) "May I have a visitor in the room with me for support during the procedure?"
B) "I would rather have my doctor perform this procedure."
C) "I don't know what an enema is."
D) "I am afraid of having an enema."
Answer: B
Explanation: A) The nurse would anticipate that most young adult clients will be embarrassed by this procedure when the nurse and client are of different genders. When the client states that he would rather have his doctor perform the enema, he is probably motivated by embarrassment and acting on the assumption that the doctor is male. The nurse should approach the client beforehand to address the issue. Most clients would only experience annoyance, not fear, in relation to this procedure. Most clients in this age group would also be familiar with what an enema is, even if they have not had an enema themselves. The nurse would definitely not expect the client to request the presence of another individual in the room for this procedure
70
The nurse is caring for a young adult client after a cervical biopsy. The client has expressed anxiety about the results. The healthcare provider peeks into the client's room and says, "The biopsy is negative." The nurse later finds the client sobbing. Which response by the nurse is most appropriate?
A) "What did the healthcare provider tell you about the biopsy?"
B) "You seem upset. Do you want to talk to me about the test results?"
C) "Why are you crying after getting such good news?"
D) "In this case, the term ‘negative' is good!"
Answer: B
Explanation: A) The nurse does not know specifically what the client is upset about and should ask the client an open-ended question so she can talk. The healthcare provider, in delivering important news to the client, should have taken time to sit with her and discuss the test results. In telling the client that the test was negative, the provider did not clarify what "negative" actually meant. Using medical jargon without explanation can lead to misinterpretation by the client. Asking the client why she is crying about good news does not allow the client to express concern regarding the results. Asking the client what the provider told her assumes that she is crying because of what the provider said and does not allow her to express her concern in an open-ended manner. Saying that the test results are good in this case assumes that the client has misunderstood the results, which may be true but does not allow the client to express her concerns.
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) A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that it is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse, the preceptor should note a need to work on which aspect of communication?
A) Credibility
B) Congruence
C) Timing
D) Clarity and brevity
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) A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that it is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse, the preceptor should note a need to work on which aspect of communication?
A) Credibility
B) Congruence
C) Timing
D) Clarity and brevity
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72
A nurse is providing care for a client who has vocal cord damage and wants to implement strategies that will promote communication with this client. Which interventions would be appropriate? Select all that apply.
A) Facing the client when speaking
B) Having pen and paper on hand for the client
C) Making sure that the language spoken is the client's dominant language
D) Using a picture board to facilitate communication
E) Employing an interpreter
Answer: B, D
Explanation: A) The client who is nonverbal would respond best to use of a picture board or pen and paper. Because the client cannot communicate verbally, facing the client when talking, using an interpreter, or using the client's dominant language would not address the client's inability to communicate.
73
The nurse is caring for a client who was admitted to the emergency department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, which action by the nurse is appropriate?
A) Ask the interpreter to translate as closely as possible.
B) Ask the client's family to be included in the interpreting process and exchange of information.
C) Direct questions to the interpreter and not the client.
D) Request that the interpreter use the same dialect as the client to promote understanding
Answer: A
Explanation: A) An interpreter is an individual who mediates spoken or signed communication between people who use different languages without adding, omitting, distorting meaning, or editorializing. It is not the interpreter's responsibility to determine the dialect with which the client is most familiar. The nurse should direct all questions to the client, not the interpreter. The nurse should also avoid asking the client's family, especially a child or spouse, to help interpret
74
The nurse is providing care for a client who is about to be discharged. The nurse is discussing the discharge orders with the client's primary healthcare provider. Which statement by the nurse is an appropriate example of using assertive communication?
A) "Can we talk about this client prior to discharge?"
B) "That new medication you prescribed for the client is ineffective."
C) "I am worried about the client's blood pressure. It remains high even with the new medication."
D) "Excuse me, Doctor, I think you need to do something about the client's blood pressure."
Answer: C
Explanation: A) The nurse who expresses concern because the client's blood pressure remains high even with new medication is being assertive, clear, and concise. Stating that the new medication is ineffective could be interpreted as an inflammatory remark by the provider. Asking whether the provider can talk about a client does not give the provider enough information. Saying the provider must do something about the client's blood pressure may cause the provider to become defensive.
75
A young adolescent client is in the hospital preparing for major surgery for the removal of a tumor on the kidney. The client's mother tells the nurse that she doesn't want her child to receive narcotics for postoperative pain. What is the nurse's best response?
A) "Okay, I'll tell the healthcare provider not to order any. Are you sure you want to do this?"
B) "The pain will be severe. Why don't we ask your child about this?"
C) "Your child's pain will be severe after the surgery. Can you tell me why you feel this way?"
D) "You do not have a choice of medication. Decisions involving pain relief are up to the healthcare providers."
Answer: C
Explanation: A) As a client advocate, the nurse should defend the need for effective pain medication by using assertive communication. Thus, the best response is for the nurse to tell the mother the truth about the client's pain and then explore the mother's objection to the drugs. Acceding to the mother's request is submissive communication and would not be in the best interests of the child. Telling the mother she does not have a choice is aggressive and untrue. Putting the child in the middle of the discussion is a divisive maneuver.
76
The nurse is caring for a client who is having difficulty understanding the dressing changes that need to be completed in the home as part of postdischarge wound care. The client asks the nurse to demonstrate the procedure again and allow the client's spouse to perform the procedure while the nurse watches. What is the most likely outcome of this assertive request by the client?
A) A slightly increased chance that the wound will become infected due to exposure during dressing changes
B) Less compassionate care for the client due to the nurse's irritation by the request
C) A greater likelihood that the wound will heal appropriately
D) A guarantee that the spouse will change the dressings correctly
Answer: C
Explanation: A) The client used assertive communication to ensure that the dressing changes would be performed correctly, which will likely result in appropriate healing of the client's wound. No information is provided about the nurse's response to the request, and even if the nurse is irritated, these feelings should not affect the quality of care. There is no guarantee that the client's spouse will always perform the task correctly, because humans make mistakes. Infection of a wound that is dressed correctly is not the likely result of this request.
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The nurse is caring for a client with a new colostomy. The client has been taught how to perform colostomy care and has been successful with return demonstration to the staff. Although the client is able to perform care independently and has asked to do so, the charge nurse has instructed the nursing staff to continue performing colostomy care for this client. When addressing this issue directly with the charge nurse, which statement by a staff nurse is the most appropriate?
A) "The client will change the apparatus whether you like it or not."
B) "The client has been trained to change the apparatus and has expressed interest in performing this procedure independently."
C) "You have no right to continue delegating this task to nurses when the client has been trained to change the apparatus."
D) "I am going to tell the nurse manager that you won't allow the client to change the apparatus independently."
Answer: B
Explanation: A) The nurse should make a clear, assertive statement saying that the client learned the procedure and wishes to execute it. Saying "You have no right . . ." is a challenge to the charge nurse and will only result in escalation of the argument. Telling the charge nurse that the nurse manager will be notified is a threat and inflames the situation. Insisting that the client will continue to change the apparatus will likely result in the charge nurse taking further action to prevent the client from performing self-care.
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) Which of the following barriers to communication involves asking a client for information chiefly out of curiosity rather than with the intent to assist the client?
A) Challenging
B) Probing
C) Testing
D) Rejecting
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Answer: B
Explanation: A) Probing involves asking a client for information chiefly out of curiosity rather than out of a desire to assist the client. Probing often places clients in a defensive position and violates their privacy. Challenging refers to giving a response that makes clients prove their statement or point of view. Testing involves asking questions that make a client admit to something. Rejecting is refusing to discuss certain topics with a client. All four of these behaviors are barriers to effective nurse-client communication.
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Answer: B
Explanation: A) Probing involves asking a client for information chiefly out of curiosity rather than out of a desire to assist the client. Probing often places clients in a defensive position and violates their privacy. Challenging refers to giving a response that makes clients prove their statement or point of view. Testing involves asking questions that make a client admit to something. Rejecting is refusing to discuss certain topics with a client. All four of these behaviors are barriers to effective nurse-client communication.
Answer: C
Explanation: A) Testing involves asking questions that make the patient admit to something. These responses permit the patient only limited answers and often meet the nurse's need rather than the patient's. Of the options listed here, "Do you think you're the only client on the unit right now?" best meets this definition. Telling the client that most people have little or no pain after a procedure is an example of stereotyping. Asking about why a client started using marijuana may be an example of probing. Questioning how the client is still in pain after medication administration is an example of challenging, or making clients prove their statements or point of view.
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A nurse case manager spends the morning in a peer discussion and the afternoon in an ad hoc quality management committee meeting that is led by the hospital administrator. Which two types of groups has the nurse case manager participated in?
A) Camaraderie group and information group
B) Work group and administrative group
C) Primary group and secondary group
D) Support group and governance group
Answer: C
Explanation: A) Primary groups are typically informal groups that communicate regularly in face-to-face interactions. The case manager's peer group would be considered a primary group. Secondary groups are larger, more impersonal, and goal-oriented. The quality management committee would be classified as a secondary group. All of the other options–camaraderie, information, work, administrative, support, and governance–are functions of groups, not group types.
81
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Which of the following terms encompasses the way a group functions, communicates, sets goals, and achieves objectives?
A) Cohesiveness
B) Group dynamics
C) Commitment
D) Member behavior
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Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
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Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
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A nurse is developing objectives for a charter group of nurses from a national association. Which characteristics should the nurse expect to encounter when working with this semiformal group?
A) The group has a formal structure, with voluntary, selective membership and structured activities during meeting times.
B) The group has a formal structure, with structured activities, leadership selection from above, and easily recognized basic objectives.
C) The group has an informal structure, with voluntary, selective membership and negotiable day-to-day operating standards.
D) The group has an informal structure, with superimposed rules and managers who are symbols of authority.
Answer: A
Explanation: A) There are three levels of group formality: formal, semiformal, and informal. Most groups move in and out of all three levels, but traditionally, a charter group of an association is a semiformal group with a formal structure, carefully delineated hierarchy, and selective, voluntary membership with attached prestige and status. Semiformal groups also have structured deliberate activities during meetings, objectives and goals that are not easily changed, negotiable day-to-day operating standards and methods, and a leader who has direct control over the choice of a successor
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Answer: A
Explanation: A) There are three levels of group formality: formal, semiformal, and informal. Most groups move in and out of all three levels, but traditionally, a charter group of an association is a semiformal group with a formal structure, carefully delineated hierarchy, and selective, voluntary membership with attached prestige and status. Semiformal groups also have structured deliberate activities during meetings, objectives and goals that are not easily changed, negotiable day-to-day operating standards and methods, and a leader who has direct control over the choice of a successor
Answer: A, B, C
Explanation: A) Groups function most effectively when they listen to the ideas of all members, use group members' expertise, and have a positive atmosphere. In an effective group, members feel satisfied with their participation and time is well used—that is, the discussion focuses on the major decisions to be made, and members feel committed to these decisions and responsible for their implementation.
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A nurse is providing teaching for an inpatient support group meeting. Which group behavior indicates that the teaching was effective?
A) The group members appear relaxed and interested in the topic.
B) The group members are tentative in expressing their feelings.
C) The group avoids discussion about their signs and symptoms.
D) The group members appear self-conscious when asked questions about their condition.
Answer: A
Explanation: A) To be effective, a group must accomplish its goals, maintain cohesion, and develop/modify its structure to improve effectiveness. The features of an effective group include an informal, comfortable, and relaxed atmosphere; goals, tasks, and objectives that are clear and understood; leader and member participation; an emphasis on goals; open, two-way communication; appropriate decision-making procedures; cohesion; conflict tolerance; and shared power
86
Four groups of nurses are attempting to determine which methods are most effective for teaching patients about proper self-care. Which of these groups is least likely to arrive at a successful decision in a timely manner?
A) The group that launches a pilot project to determine which teaching methods are most effective
B) The group that uses scenario planning to evaluate the potential results of various teaching methods
C) The group that uses trial and error to gauge the effectiveness of various teaching methods
D) The group that uses a decision tree to visualize the potential results of various teaching methods
Answer: C
Explanation: A) Trial-and-error techniques are the most haphazard method for decision making. Managers and groups who use these techniques are typically seen as poor problem solvers, especially in a healthcare context. Use of pilot projects, scenario planning, or decision trees is more likely to result in successful decision making because these methods all involve proposal and analysis of various alternatives prior to taking action.
87
Which of the following situations is an example of countertransference in the group setting?
A) After failing at an assigned task, the members of a group place all blame for this failure on a single group member.
B) A group member reveres the group's leader, largely because the leader possesses many similarities to the member's mother, whom he adores.
C) The members of a group become so caught up in the group's current beliefs and actions that they fail to recognize simple changes that would greatly improve the group's efficiency.
D) The leader of a group distrusts one of the group members solely because the member reminds him of his ex-wife.
Answer: D
Explanation: A) Countertransference occurs when leaders respond to group members because of reactions from earlier relationships. The leader who distrusts the group member because of similarities to his ex-wife is exhibiting countertransference. The scenario in which the members of a group place all blame on one person is an example of scapegoating. The scenario in which a group member reveres the leader because she reminds him of his mother is an example of transference. The scenario in which the group members become excessively caught up in group processes is an example of groupthink.
88
Which of the following statements is true with regard to monopolizing in the group setting?
A) Group members who engage in monopolizing behavior do so intentionally.
B) When one member of a group engages in monopolizing behavior, the other group members may become angry or frustrated with the group's leader.
C) Monopolizing behavior may be motivated by anxiety or a need for attention, recognition, and approval.
D) One useful strategy for dealing with monopolizing is to simply and directly interrupt the individual who is engaging in this behavior.
Answer: B
Explanation: A) Monopolizing is the domination of a discussion by one member of a group. When this behavior occurs, a sense of resentment may develop within the group, and some members may direct their frustration and anger toward the group leader, whom they expect to do something to stop the monopolizer's behavior. Monopolizing behavior may be motivated by anxiety or a need for attention, recognition, and approval, although many compulsive talkers are unaware of their behavior and its effect on others. One useful strategy for dealing with monopolizing is to interrupt the monopolizer simply, directly, and supportively
89
The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client?
A) Facilitating and taking action when needed
B) Maintaining a proper social distance when speaking with the client
C) Leaning toward the client during conversation
D) Being concrete about actions that need to be taken during client care
Answer: C
Explanation: A) The nurse best conveys physical attending by leaning toward the client, which communicates involvement. Facilitating and taking action and maintaining social distance do not convey physical attending. Being concrete is a method of communicating information to the client, not a method of conveying physical attending
90
A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication?
A) When a client's family member is making inappropriate comments to the nurse
B) When an upset spouse is alone and the client has just expired
C) When speaking to a client with a history of physical abuse
D) When a young male client asks a young student nurse for a hug
A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication?
A) When a client's family member is making inappropriate comments to the nurse
B) When an upset spouse is alone and the client has just expired
C) When speaking to a client with a history of physical abuse
D) When a young male client asks a young student nurse for a hug
91
The nurse completes a teaching session on wound care for a client who will require dressing changes after discharge. The nurse then evaluates the effectiveness of the teaching session and determines that more education is required. Which statement by the nurse is appropriate in this situation?
A) "Let me clarify again some of the steps that are required during wound care."
B) "You didn't pay attention, did you?"
C) "Here, let me do it for you."
D) "I don't think you understood me correctly the first time."
Answer: A
Explanation: A) Responding with some clarifications indicates that the client understood some of the teaching and preserves the client's dignity and trust in the nurse. Saying that the client did not understand the information is belittling. Beginning a negative phrase with "you" is assigning blame, which impedes the therapeutic relationship. Telling the client that the nurse can take care of the task defeats the goal of feedback; the nurse would want to instill self-confidence in the client, and this type of action will hurt that goal.
92
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A nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." Which skill associated with the working phase of the nurse-client relationship does the nurse's statement best reflect?
A) Confronting
B) Respect
C) Concreteness
D) Genuineness
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Answer: B
Explanation: A) Respect is correct because the nurse is validating the client's feelings. This situation is not an example of genuineness because the nurse is giving information versus making a personal statement. Rather than being confrontational by pointing out discrepancies between thoughts, feelings, and actions that inhibit the client's self-understanding or exploration of specific areas, the nurse is being supportive by respecting the client's feelings. Concreteness involves assisting the client by giving specific examples rather than speaking in generalities.
93
A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy?
A) "I wouldn't be afraid if I were you."
B) "You shouldn't have done it that way."
C) "You seem to be frightened by the procedure. Tell me how you are feeling."
D) "I know just how you feel, because my mother has the same illness."
Answer: C
Explanation: A) To be able to empathize with patients, the nurse must be able to understand and acknowledge the ideas that the patient is expressing or that the patient feels are important to the situation. By stating that the client seems frightened and asking the client to describe his or her feelings, the nurse is demonstrating empathy. The nurse should not say he or she knows how the client feels; such a statement will likely be met with disbelief, because one individual never knows how another individual is feeling unless that individual tells them. Telling the client not to be afraid is demeaning; instead, the nurse should ascertain the source of the client's fear and provide appropriate teaching. Saying the client should not have done something is passing judgment and inappropriate.
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) The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic?
A) "Would you like some toys from the playroom?"
B) "I'm going to go get the doctor."
C) "You shouldn't cry. You are not in pain."
D) "It is okay to cry. I know this is scary."
Answer: D
Explanation: A) Assertive communication is appropriate in the group setting, but for this client, the nurse should be accepting of the client's feelings of fear. Telling the client not to cry invalidates the client's feelings. Leaving to get the doctor could be seen by the child as abandonment and would signal that the nurse is uncomfortable with the child. Distraction is not appropriate when the client is clearly upset, so the nurse should not ask whether the client wants toys. Instead, the nurse should attempt to seek more information about what the child is feeling.
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) The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication?
A) The nurse asks appropriate questions about the client's medical history.
B) The nurse closes the conversation with an anecdote about breathing.
C) The nurse plans to tell the client about a COPD support group.
D) The nurse bonds with the client by describing her own experiences living with COPD.
Answer: A
Explanation: A) Attentive or "mindful" listening is a therapeutic communication technique that involves listening and absorbing the content and feeling of what an individual is conveying, without selectivity. This technique requires paying attention to the client's total message, both verbal and nonverbal, and noting whether these communications are congruent. During attentive listening, the nurse focuses not on the nurse's own needs but rather on the client's needs. By asking appropriate questions about the client's medical history and carefully noting the client's responses, the nurse is engaging in attentive listening and thus in therapeutic communication
96
The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of therapeutic communication with this client? Select all that apply.
A) "I am so happy today! I just found out that I got accepted into nurse practitioner school!"
B) "Well, I guess your lifestyle finally caught up to you."
C) "One of my cousins has AIDS. It is hard to watch him die."
D) "Tell me your feelings about the diagnosis."
E) "Would you like to talk about the new medications you've been prescribed?"
Answer: A, B, C
Explanation: A) Various obstacles to attentive listening can inhibit the development of therapeutic communication. Being concerned with oneself, assuming, and identifying are all common obstacles to attentive listening. In contrast, using open-ended questions and providing general leads-in are actions that enhance therapeutic communication
97
The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client?
A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure."
B) "I heard raised voices when I was coming down the hall to your room. Are you upset?"
C) "It is 3 p.m. and time to take your blood pressure before I give you your medication."
D) "Is the blood pressure medication making your head hurt?"
Answer: A
Explanation: A) An informational confrontation describes the visible behavior of another individual, whereas an interpretive confirmation expresses thoughts and feelings about behavior and draws inferences. Of the options provided, only the one that begins with "I noticed you rubbing your head and your eyes" is an example of an informational confrontation
98
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What is the first phase in the therapeutic nurse-client relationship?
A) Introductory phase
B) Working phase
C) Preinteraction phase
D) Anticipatory phase
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Answer: C
Explanation: A) The therapeutic nurse-client relationship can be described in terms of four sequential phases: the preinteraction phase, introductory phase, working (maintaining) phase, and termination phase. During the preinteraction phase, the nurse plans for the initial face-to-face meeting with the client.
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Which of the following statements by the nurse is an example of the therapeutic communication technique of offering self?
A) "Would you like to talk with me about your emotions right now?"
B) "I'm not sure I understand. Please tell me more about the situation."
C) "I don't know the answer to your question, but I will check with the physician."
D) "I'll stay here with you until your family arrives."
Answer: D
Explanation: A) Offering self involves suggesting one's presence, interest, or wish to understand the client without making any demands or attaching conditions that the client must comply with to receive the nurse's attention. The nurse's offer to stay with the client until the family arrives is an example of offering self. In comparison, asking whether the client wants to talk about his or her emotions is an example of providing general leads; asking the client to provide more details about a situation is an example of using open-ended questions; and offering to get answers from the physician is an example of giving information.
100
A nurse has just been hired as a medical information system (MIS) trainer at a hospital where an electronic medical record system is being installed. The nurse has been asked to assess the security of clients' medical records. According to HIPAA's Security Rule, which recommendations by the nurse will enhance security? Select all that apply.
A) Assign each staff member a unique username and password.
B) Install a firewall.
C) Store computer-generated worksheets in a locked vault.
D) Turn monitors away from view when unattended.
E) Assign each unit unique passwords.
Answer: A, B
Explanation: A) To comply with HIPAA's Security Rule, institutions should assign individual passwords to each staff member for logging on and off computer files. Firewalls should be installed to enhance the security of client records. Client information should not be displayed on unattended terminals, regardless of which direction the monitor faces, and computer-generated worksheets should be shredded when no longer needed.
101
The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain. The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate?
A) "You will be able to read the record and review your care."
B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you."
C) "Your family can review the record and ensure that your care is appropriate."
D) "A record ensures there are no breaches of confidentiality."
Answer: B
Explanation: A) A client's record serves as a vehicle by which different health professionals who interact with the client communicate with one another. This prevents fragmentation, repetition, and delays in client care, and it relieves the client from having to repeat information to each provider offering care. The client can read the record, but that is not a reason to keep one. The client's family does not have access to the record. Recordkeeping does not prevent breaches of confidentiality.
102
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The nurse is caring for a client who received analgesic medication via central line to treat pain associated with cancer. After reassessing the client's response, which section of the PIE record will the nurse use when documenting the client's care?
A) Evaluation
B) Progress notes
C) Problem
D) Intervention
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Answer: A
Explanation: A) The PIE documentation model groups information into three categories: problems (P), interventions (I), and evaluation (E) of nursing care. Reassessing the client's pain level after medication administration is considered evaluation and would be documented under "E." Interventions such as medication administration would labeled "I," whereas the problem statement would be labeled "P." Progress notes are not part of the identified labels of PIE charting.
103
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Use of flow sheets would be most appropriate during which phase of the nursing process?
A) Evaluation
B) Diagnosis
C) Implementation
D) Planning
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Answer: C
Explanation: A) Flow sheets use specific assessment criteria in a particular format. They are frequently used on a client's chart to record routine nursing tasks and assessment data. Examples of flow sheets include a graphic record, fluid balance record, daily nursing assessments record, patient teaching record, patient discharge record, and skin assessment record. Typically, flow sheets are used during the assessment and implementation portions of the nursing process.
104
A nurse manager is educating staff nurses about the types and frequency of documentation required for clients being cared for in long-term care facilities. These requirements originate from which of the following laws and regulatory bodies? Select all that apply.
A) Problem-Oriented Medical Record (POMR) Act
B) Omnibus Budget Reconciliation Act (OBRA)
C) Health Care Financing Administration (HCFA)
D) Minimum Data Set (MDS) Act
E) American Recovery and Reinvestment Act (ARRA)
Answer: B, C, E
Explanation: A) Long-term care facilities must comply with documentation requirements set forth in the Omnibus Budget Reconciliation Act (OBRA) of 1987 and the American Recovery and Reinvestment Act (ARRA) of 2009, as well as with regulations established by the Health Care Financing Administration (HCFA). The POMR is a system of medical recordkeeping, not a law or regulatory body. The Minimum Data Set (MDS) is an effort to establish standards for collecting standardized, essential nursing data for inclusion in computer databases. Although established under OBRA, the MDS is not a specific law or regulatory body.
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)The nurse is documenting care in a client's medical record. The nurse provides narrative documentation only for abnormal assessment findings. Based on this information, which type of charting is the nurse using?
A) Computerized documentation
B) Charting by exception (CBE)
C) SOAP charting
D) Focus charting
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Answer: B
Explanation: A) Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.
106
The healthcare provider prescribes digoxin for a client who will be discharged in the morning. When documenting the order in the medical record, which action by the nurse is most appropriate?
A) Entering "digoxin, .0125 mg QD"
B) Entering "digoxin, 0.0125 mg QD PO"
C) Entering "digoxin, 0.0125 mg, once daily by mouth"
D) Entering "digoxin, 1 pill each day"
Answer: C
Explanation: A) Although many healthcare facilities supply an approved list of abbreviations and symbols, the nurse can best prevent confusion by writing out the order in full. This means the nurse should place a zero before the decimal when recording the dosage. The nurse should also write out "once daily" instead of using the abbreviation "QD," which may be interpreted incorrectly. Similarly, writing "by mouth" is preferable to using the abbreviation "PO." Simply recording "1 pill each day" is not appropriate because it does not specify a dosage amount.
107
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The nurse educator is teaching a group of nursing students about the purposes of documentation and medical records. Which of the following purposes is not appropriate for the educator to include in the teaching session with the students?
A) Communication
B) Planning
C) Employee discipline
D) Research
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Answer: C
Explanation: A) Client records are kept for a number of purposes. These include communication among healthcare professionals who are treating the same client, planning client care to evaluate care plan effectiveness, tracking services provided for reimbursement purposes, research to help all clients, education for students in health disciplines, healthcare analysis to determine agency needs, and quality assurance purposes. Although recordkeeping provides necessary legal evidence of the care provided and can thus be referenced during the employee discipline process, employee discipline is not a primary purpose of the medical record.
108
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) Traditional client records employ which of the following documentation systems?
A) Source-oriented record
B) Problem-oriented medical record
C) PIE model
D) Focus charting
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Answer: A
Explanation: A) The traditional client record is a source-oriented record, in which each individual or department makes notations in a separate section or sections of the client's chart. In many healthcare environments, this traditional system has been replaced by newer methods of documentation, such as the problem-oriented medical record (POMR), the PIE model, and focus charting.
109
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The nurse is assigned to provide care to a client with chronic obstructive pulmonary disease (COPD). Overnight, the client's oxygen saturation levels decreased and the client has been placed on oxygen by the respiratory therapist. To review specific information about the care received from the respiratory therapist, which portion of the medical record should the nurse review?
A) The consultation report
B) The nurses' notes
C) The medication record
D) The diagnostic report
```
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The nurse is assigned to provide care to a client with chronic obstructive pulmonary disease (COPD). Overnight, the client's oxygen saturation levels decreased and the client has been placed on oxygen by the respiratory therapist. To review specific information about the care received from the respiratory therapist, which portion of the medical record should the nurse review?
A) The consultation report
B) The nurses' notes
C) The medication record
D) The diagnostic report
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110
A novice nurse asks the preceptor why the staff spends time talking about clients between shifts when the oncoming nurses can read the clients' charts instead. Which is the best response by the preceptor?
A) "Maybe we should suggest primary nursing as an alternative."
B) "Change-of-shift reporting ensures that oncoming staff know the most critical information about the clients they'll be caring for."
C) "Shift changes have always been done this way."
D) "You're right. Talking about clients during shift changes is a waste of time."
Answer: B
Explanation: A) Nurses often do not have time to read clients' charts prior to assuming care, which could result in errors and assumptions. By participating in change-of-shift reports, outgoing nurses can ensure that oncoming staff are aware of critical information. The preceptor should not tell the new nurse that change-of-shift reports are a waste of time because these reports allow for communication of valuable client data. Stating that shift changes have always been done a certain way does not help the novice nurse understand why a change-of-shift report is necessary. Primary nursing promotes continuity of care, but even the primary nurse would need to be informed of client changes that occurred during his or her absence.
111
The nurse is caring for a client who is reporting a pain level of 8 on a 0-to-10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse re-evaluates the client 1 hour later, the client is still reporting a pain level of 8. Which action by the nurse is appropriate at this time?
A) Wait for the healthcare provider to make rounds to report the problem.
B) Report to the healthcare provider by telephone.
C) Increase the dosage of the medication.
D) Include an entry in the nursing report indicating that the medication is ineffective.
Answer: B
Explanation: A) In this case, reporting to the healthcare provider by telephone is appropriate. The nurse would address the client's distress immediately and later include the event in the end-of-shift report to the oncoming nurse. The nurse cannot alter the dose of medication. Waiting for the provider to arrive could cause the client to experience a great deal of pain in the interim.
112
A new nurse on a unit asks to speak to the nurse manager because several clients have complained that family members were able to hear the verbal report outside their loved one's room during nursing rounds. The nurse manager asks the nurse for suggestions that could enhance client privacy. Which suggestion by the new nurse is appropriate?
A) Nursing rounds should take place in each client's room.
B) The unit should be closed to family and visitors during rounds.
C) Nurses should tape-record their reports outside the room.
D) Clients should be allowed to choose whether a written or oral report is used.
Answer: B
Explanation: A) Closing the unit during nursing rounds permits nurses to talk freely and relate important information regarding clients and their care while minimizing the risk of violating client privacy. Rounds could take place in each client's room, but if a client's family is present, confidentiality is compromised. The nursing staff and manager should determine what form of report is used, keeping in mind the confidentiality of the client. Taped reports are acceptable if conducted in private but not appropriate if conducted out on the unit.
113
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) The nurse is preparing to document care provided to a client during the day shift. The nurse notes that the client experienced an increased pain level while ambulating and thus required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply.
A) The extra dose of pain medication
B) The client's visit with family
C) The client's response to ambulation
D) The last antibiotics given
E) The client's taking a shower
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Answer: A, C
Explanation: A) To best provide for the client's safety, the nurse should pass on information about the client's response to ambulation so that the oncoming staff can take fall precautions. The nurse should also report any as-needed medications that were given and when they were last administered. The client's visit with family need not be mentioned at change of shift but should be documented. Likewise, taking a shower does not need to be reported, only documented. Antibiotic administration would be reflected on the medication administration record (MAR).
114
Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff?
A) To avoid lawsuits
B) To make sure all documentation is complete
C) To facilitate quality improvement
D) To ensure client safety
Answer: D
Explanation: A) Ineffective communication is the primary cause of sentinel events, making client safety the primary objective of the handoff communication process. Handoff communication may be scrutinized during a lawsuit, but avoiding litigation is not a primary objective. Similarly, engaging in handoff communication can help a nurse determine whether all documentation related to a particular client's care is complete, but this is not a primary objective. Finally, analysis of handoff communication may be a quality improvement criterion, but it is not a primary objective.
115
The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff?
A) "The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders."
B) "The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully."
C) "The client in room 315 received an enema at 2100."
D) "The client in room 311 was transferred from room 212."
The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff?
A) "The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders."
B) "The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully."
C) "The client in room 315 received an enema at 2100."
D) "The client in room 311 was transferred from room 212."
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) When the nurse receives a telephone order from the healthcare provider's office, which guidelines should the nurse use to ensure the order is correct? Select all that apply.
A) Ask the provider to repeat or spell out medication.
B) Read the order back to the provider.
C) Ask the provider to speak slowly.
D) Know agency policy for telephone orders.
E) Sign the provider's name and credentials.
Answer: A, B, C, D
Explanation: A) When receiving a telephone order from a provider, the nurse should ask the provider to repeat or spell out any medications and speak slowly. The nurse should also read the order back to the provider once the order is complete. In addition, the nurse should know the agency's policy regarding telephone orders. The nurse should not sign the provider's name and credentials; the nurse only transcribed the prescription, so the provider will need to countersign it within a time period prescribed by organizational policy.
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The nurse is providing care to a client diagnosed with end-stage renal disease. When organizing a care plan conference for this client, whom should the nurse invite to participate?
A) The client's family members
B) A psychiatrist
C) An oncologist
D) The hospital CEO
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Answer: A
Explanation: A) Care plan conferences allow for collaborative reporting among the healthcare professionals who provide care to a client. They are most often used for clients who have complex care needs. During the conference, the client's healthcare providers discuss possible solutions to client problems. The choice of healthcare professionals who are invited to attend the conference is based on the needs of the client; given this client's diagnosis, it is unlikely that an oncologist or psychiatrist would be part of the healthcare team. However, family members are an important part of the care plan conference, especially for clients who are unable to advocate for themselves.
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What are the four steps of the SBAR communication technique?
A) Scenario, Basics, Analysis, and Reaction
B) Situation, Background, Assessment, and Recommendation
C) Scenario, Background, Analysis, and Recommendation
D) Situation, Basics, Assessment, and Reaction
Answer: B
Explanation: A) The SBAR technique provides a framework for safe, efficient communication between members of the healthcare team. In the first or "Situation" step, the nurse provides a concise statement of the problem. In the second or "Background" step, the nurse relates information relevant to the situation. In the third or "Assessment" step, the nurse provides an analysis and consideration of options. Finally, in the fourth or "Recommendation" step, the nurse provides a recommendation based on the relevant evidence.
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The nurse is caring for a client in the intensive care unit (ICU) who was in a motor vehicle crash. The healthcare provider asks the nurse to extubate the client because there is no communication between the brain and body due to a cervical fracture. The family agrees with the decision of the healthcare provider, but the nurse is uncomfortable pulling the tube. Which is the reason the nurse is experiencing difficulty with this task?
A) An ethical conflict
B) Personal values
C) Legal issues
D) Cultural values
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Answer: B
Explanation: A) The nurse is distressed because of personal values, which are in conflict with causing the client's death. The decision is within ethical principles. Cultural values are not in evidence in this instance. Extubating this client would not be a legal decision.
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A nurse is caring for an older adult client with terminal cancer. The client's family wants to continue treatment, but the client would like to discontinue treatment and go home. The nurse agrees to be present while the client tells the family. Which principle is the nurse supporting?
A) Beneficence for the client
B) Autonomy for the client
C) Nonmaleficence for the client
D) Justice for the client
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Answer: B
Explanation: A) Autonomy refers to the right to make one's own decisions. The nurse is supporting this principle by supporting the client in his decision. Nonmaleficence is the duty to "do no harm." Justice is often referred to as fairness. Beneficence means "doing good."
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Which statement accurately describes the purpose of the American Nurse's Association's Code of Ethics for Nurses?
A) It serves as a statement of nurses' personal values and standards.
B) It serves as the profession's nonnegotiable ethical standard.
C) It serves as an announcement of nurses' commitment to the profession.
D) It serves as a standard protocol for performing nursing procedures
Answer: B
Explanation: A) The ANA Code of Ethics for Nurses serves as a statement of nurses' ethical obligations and duties (not their personal values and standards), as the profession's nonnegotiable ethical standard, and as the nursing profession's statement of commitment to society (not the nurse's commitment to the profession). Nurses should refer to the ANA Code of Ethics for Nurses to direct how they perform their duties in daily practice, but it does not provide standard protocols for performing nursing procedures
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A nurse is volunteering time in a local free clinic that provides care to the underinsured population. By volunteering time to work in the clinic, this nurse is demonstrating which professional value?
A) Human dignity
B) Social justice
C) Integrity
D) Autonomy
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Answer: B
Explanation: A) Social justice is upholding fairness on a social scale. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality healthcare. Human dignity is respect for the worth and uniqueness of individuals and populations. Autonomy is respecting the client's right to make decisions about their healthcare. Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice.
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A nurse educator is talking to a student about how to deal with an ethical dilemma in practice. Which does the nurse educator explain to the student as important regarding actions during an ethical dilemma?
A) Examining all conflicts in the situation
B) Investigating all aspects of the situation
C) Relying on nursing judgment
D) Making a decision based on the policy of the agency
Answer: B
Explanation: A) To avoid making a premature decision, the nurse plans to investigate all aspects of the dilemma before deciding. Overconfidence can lead to poor decision making. Reading the agency policy regarding the matter addresses only one aspect of the situation. Examining the conflicts surrounding the issue is only one aspect of the situation to consider
Answer: B
Explanation: A) To avoid making a premature decision, the nurse plans to investigate all aspects of the dilemma before deciding. Overconfidence can lead to poor decision making. Reading the agency policy regarding the matter addresses only one aspect of the situation. Examining the conflicts surrounding the issue is only one aspect of the situation to consider
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The nurse is caring for a client on a medical-surgical unit. The client tells the nurse that the healthcare provider has refused to treat the client further if the client continues to be noncompliant with the healthcare provider's recommendations. Which is the priority nursing action in this situation?
A) Take the issue to the hospital ethics committee.
B) Advise the client to sue the healthcare provider.
C) Have the client contact a consumer agency.
D) Notify the healthcare provider of the client's complaints.
Answer: A
Explanation: A) Acting as a client advocate and protecting the client's rights, the nurse should enlist the help of the hospital ethics committee. The nurse never advises a client to sue but assists the client to find help resolving the issue. A consumer agency is not appropriate because this is an ethical matter. The nurse should act on behalf of the client, and the best way to do that is by taking the issue to the hospital ethics committee, not to the healthcare provider
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The nurse is caring for a 22-year-old client with Down syndrome. Because the client has an intellectual disability, he is under the legal care of his parents. The client needs medical treatment for aspiration pneumonia, but the parents are declining care because they have heard that aspiration pneumonia is often fatal in clients with chronic health conditions. In addition to ethics and advocacy, what other nursing concept must the nurse factor into care decisions made in this case?
A) Informatics
B) Development
C) Mood and Affect
D) Spirituality
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Answer: B
Explanation: A) Down syndrome causes intellectual disability, so the client's developmental stage needs to be taken into consideration when providing care, especially related to client teaching and advocating for the client whose rights appear to be in jeopardy. Informatics, mood and affect, and spirituality do not appear to play a role in this case.
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The nurse administers morphine to a client after surgery to help manage pain even though morphine has a risk of creating dependence and addiction. What ethical principle does the nurse apply in this situation when planning care?
A) Veracity
B) Justice
C) Autonomy
D) Beneficence
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Answer: D
Explanation: A) Beneficence requires that the actions one takes should promote good. This includes giving treatments that have some risks when the nurse and others involved in client care have determined that the benefits outweigh the risks. Autonomy is the right to self-determination. Justice means treating all clients fairly. Veracity is the principle of always telling the truth.
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Every year, the nurse attends a nursing conference and takes several continuing education courses to help maintain licensure. Which section of the ICN Code of Ethics does this uphold?
A) Nurses and people
B) Nurses and practice
C) Nurses and the profession
D) Nurses and co-workers
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Answer: B
Explanation: A) The nurses and practice section of the ICN Code of Ethics states that nurses carry the professional responsibility and accountability for nursing practice and for maintaining competence by continual learning. The other sections of the ICN Code of Ethics do not address continuing education for nurses.
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Answer: B
Explanation: A) The nurses and practice section of the ICN Code of Ethics states that nurses carry the professional responsibility and accountability for nursing practice and for maintaining competence by continual learning. The other sections of the ICN Code of Ethics do not address continuing education for nurses.
Answer: B
Explanation: A) Religion and morals can at times be interrelated within healthcare. The client wants to maintain the baby until natural delivery occurs because having an abortion would be against her religion. The client is demonstrating her morals. The client may or may not be demonstrating sound judgment or a healthy decision. The nurse has no way of knowing if the client is in fear of retribution.
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Which situation indicates a conflict in morality?
A) The nurse provides a terminally ill client a meal that includes foods that should be avoided but were requested.
B) The nurse provides the mother of a dying neonate a cup of coffee in the intensive care unit.
C) The nurse provides over-the-counter pain relievers to the daughter of a client because of a headache.
D) The nurse purchases the daily newspaper for a client who does not have any money but will when his wife comes to visit.
Answer: A
Explanation: A) Morality refers to issues that are either right or wrong. In the situations provided, the nurse who provides a terminally ill client a meal with food that he should avoid but requested would demonstrate a conflict with morality. The nurse is going against the "right" decision, which would be to not provide the client with the foods; however, the client is terminally ill and is requesting foods that he enjoys. The other situations would not involve the same question of morality
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The family of a terminally ill client requests that the client not be informed of the diagnosis. Which moral principle does the request violate?
A) Justice
B) Veracity
C) Beneficence
D) Nonmaleficence
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Answer: B
Explanation: A) Veracity is the duty to tell the truth. The family of a terminally ill client is requesting that the diagnosis be withheld from the client, which would violate the principle of veracity. Beneficence is the duty to "do good." Nonmaleficence is the duty to do no harm. Justice refers to fairness.
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Answer: B
Explanation: A) Veracity is the duty to tell the truth. The family of a terminally ill client is requesting that the diagnosis be withheld from the client, which would violate the principle of veracity. Beneficence is the duty to "do good." Nonmaleficence is the duty to do no harm. Justice refers to fairness.
Answer: B
Explanation: A) The client's decision is to have an abortion even though it is against her religion. The best thing for the nurse to do is to ask the client what she needs to support her decision. The nurse should not provide information about adoption because the client is not planning on carrying the child to term. The nurse should not suggest she talk with clergy because the client did not ask to do so. The nurse should not remind the client that abortion is killing because this would not support the client's resolution of her moral dilemma.
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A nursing instructor is discussing moral principles with a group of students. Which comment made by a student nurse indicates the need for further instruction?
A) "A client choosing not to have a needed blood transfusion is an example of autonomy."
B) "An example of veracity would be if a client asks her nurse if she is going to die and the nurse feels obligated to explain to the client that she is dying."
C) "If a client asks the nurse to please come right back, and the nurse tells the client he will be back in just a couple of minutes, then that would be an example of fidelity."
D) "A home health nurse carefully planning his or her day to assure each client gets an adequate amount of time is an example of beneficence
Answer: D
Explanation: A) Justice is often referred to as fairness, which would be demonstrated by the nurse assuring that each client gets an adequate amount of time with the nurse. Beneficence refers to the fact that nurses are obligated to do good. Autonomy refers to the right to make one's own decisions. Veracity refers to telling the truth. Fidelity means to be faithful to agreements and promises.
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Answer: D
Explanation: A) Justice is often referred to as fairness, which would be demonstrated by the nurse assuring that each client gets an adequate amount of time with the nurse. Beneficence refers to the fact that nurses are obligated to do good. Autonomy refers to the right to make one's own decisions. Veracity refers to telling the truth. Fidelity means to be faithful to agreements and promises.
Answer: A
Explanation: A) Social isolation led to the client's current medical manifestations. The priority nursing diagnosis based on the data is Social Isolation. Noncompliance and Interrupted Family Processes are not supported by the scenario presented. Impaired Gas Exchange is not a psychosocial nursing diagnosis; it is a physiologic nursing diagnosis.
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The nurse is caring for a client who has chosen to discontinue hemodialysis. The client's family, however, is not supportive of the decision. The nurse who uses the theory of principles-based reasoning would make which statement regarding the current situation?
A) "The client understands the decision and the advanced stage of the disease. If the client quits treatment, the client will die."
B) "I need to try to help the family understand the client's decision so they can work through this situation together."
C) "This client is of sound mind and is capable of making independent decisions regarding healthcare. It really is the client's decision to make."
D) "This client's health is so deteriorated that the treatment is not saving the client's life. It is prolonging the ultimate outcome, which is death."
The nurse is caring for a client who has chosen to discontinue hemodialysis. The client's family, however, is not supportive of the decision. The nurse who uses the theory of principles-based reasoning would make which statement regarding the current situation?
A) "The client understands the decision and the advanced stage of the disease. If the client quits treatment, the client will die."
B) "I need to try to help the family understand the client's decision so they can work through this situation together."
C) "This client is of sound mind and is capable of making independent decisions regarding healthcare. It really is the client's decision to make."
D) "This client's health is so deteriorated that the treatment is not saving the client's life. It is prolonging the ultimate outcome, which is death."
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) The nurse on a committee to determine the funding that each part of the hospital receives would be most concerned with which moral theory?
A) Consequence-based theory
B) Principles-based theory
C) Relationship-based theory
D) Legal-based theory
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Answer: A
Explanation: A) Consequence-based theories tend to view a moral act as one that brings about the most good and the least harm to the greatest number of people. This moral theory would be a driving force when allocating funding in a hospital. Principles-based theory determines morality based on an impartial, objective principle and is more concerned with the individual than the group. Relationship-based theories judge actions according to a perspective of caring and responsibility, which is less likely to be needed when determining funding. Legal-based theory is not a moral theory
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A hospice nurse is working closely with a client who, on several occasions, has asked about guidance and support in ending life. The nurse recognizes which in regard to making ethical and moral decisions in this circumstance?
A) Euthanasia has legal implications along with moral and ethical ones.
B) Passive euthanasia is an easy decision to arrive at.
C) Active euthanasia is supported in the Code for Nurses.
D) Assisted suicide is illegal in all states.
Answer: A
Explanation: A) Determining whether an action is legal is only one aspect of deciding whether it is ethical. Legality and morality are not one and the same. The nurse must know and follow the legal statutes of the profession and boundaries within the state before making any decision. Passive euthanasia involves the withdrawal of extraordinary means of life support and is never an easy decision. Active euthanasia and assisted suicide are in violation of the Code for Nurses, according to the position statement by the ANA (2013). Some states and countries have laws permitting assisted suicide for clients who are severely ill, are near death, and wish to commit suicide.
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) The nurse is talking with a parent who decides to decline treatment for a 3-year-old client whose cancer has metastasized. There is a conflict between the parents and the rest of the family regarding the withdrawal of care from the child. Which should the nurse consider when determining the appropriate action for this client?
A) The beliefs of the child
B) The values of the parents
C) The age of the child
D) The values of the rest of the family
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Answer: B
Explanation: A) When confronted with a conflict regarding care, one of the first actions by the nurse is to consider the values and beliefs of the parents who are making the decision. The age of the child is not a relevant factor in the decision making if the child is under 18 years. The child is too young to have values and beliefs. The nurse is respectful with the rest of the family but should consider the parents' decision only.
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A client comes to the clinic and is found to have a sexually transmitted infection (STI). The client states to the nurse, "Promise you won't tell anyone about my condition." According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which action must the nurse take?
A) Honor the client's wishes.
B) Respect the client's privacy and confidentiality.
C) Communicate only necessary information.
D) Not disclose any information to anyone.
A client comes to the clinic and is found to have a sexually transmitted infection (STI). The client states to the nurse, "Promise you won't tell anyone about my condition." According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which action must the nurse take?
A) Honor the client's wishes.
B) Respect the client's privacy and confidentiality.
C) Communicate only necessary information.
D) Not disclose any information to anyone.
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When faced with ethical dilemmas, which are some of the elements of risk management that can assist nurses in decision making? Select all that apply.
A) Education
B) Peer support and consultation
C) Resource accumulation
D) Righteousness
E) Financial support
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Answer: A, B, C
Explanation: A) In addition to the ANA code of conduct in ethical situations, education and didactic training represent another source for developing primary risk-management skills. A practitioner's professional network, consisting of peers, supervisors, and colleagues, can be a significant resource for primary prevention of ethical challenges. Resource accumulation involves acquiring the requisite resources and skills prior to the occurrence of a dilemma. Righteousness and financial support are not elements of risk management.
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Answer: A, B, C
Explanation: A) In addition to the ANA code of conduct in ethical situations, education and didactic training represent another source for developing primary risk-management skills. A practitioner's professional network, consisting of peers, supervisors, and colleagues, can be a significant resource for primary prevention of ethical challenges. Resource accumulation involves acquiring the requisite resources and skills prior to the occurrence of a dilemma. Righteousness and financial support are not elements of risk management.
Answer: A, B, D
Explanation: A) Strikers may be concerned about client care as it is related to adequate staffing. Strikes may adversely affect client care and outcomes. Nurses may feel allegiance to a hospital where they have worked for years. The desire to take time off and the need for higher pay are not ethical issues.
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Answer: A, B, D
Explanation: A) Strikers may be concerned about client care as it is related to adequate staffing. Strikes may adversely affect client care and outcomes. Nurses may feel allegiance to a hospital where they have worked for years. The desire to take time off and the need for higher pay are not ethical issues.
Answer: C, D, E
Explanation: A) Refusing HIV testing is legal and is not mandatory for obtaining care. However, if the mother-to-be is HIV-positive, the test will help her protect her health and the health of her child by obtaining appropriate treatment. The nurse should emphasize the importance of HIV testing and encourage her to receive the test. Offering counseling would also be appropriate. Refusing to treat the client is against the ANA position statement on risk and responsibility in nursing. Doing the test anyway goes against the client's right to autonomy.
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Answer: C, D, E
Explanation: A) Refusing HIV testing is legal and is not mandatory for obtaining care. However, if the mother-to-be is HIV-positive, the test will help her protect her health and the health of her child by obtaining appropriate treatment. The nurse should emphasize the importance of HIV testing and encourage her to receive the test. Offering counseling would also be appropriate. Refusing to treat the client is against the ANA position statement on risk and responsibility in nursing. Doing the test anyway goes against the client's right to autonomy.
Answer: A, C, D
Explanation: A) A nurse's role as educator is crucial to ethical practice. Inaccurate reassurance or avoidance does not respect client rights. Providing appropriate alternatives and options for the client and the family are correct responses to the client's concerns.
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What are some reasons the nurse might withhold food and fluids from a client? Select all that apply.
A) A competent and informed client refuses them.
B) A son decides that it is his father's time to die.
C) It is determined to be more harmful to administer them than to withhold them.
D) A schizophrenic client believes that they are being poisoned.
E) The nurse thinks that the client is in too much pain.
Answer: A, C
Explanation: A) The autonomy of a competent and informed client must be respected. Family members cannot overrule client choices. Forcing an individual with terminal illness to eat, or starting artificial nutrition, will often make the client feel bloated, feel nauseated, and/or develop diarrhea. Clients must be capable of making informed choices. The nurse's opinion about the client's pain status is not a justification for withholding nourishment.
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A client with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. According to a 2015 American Nurses Association (ANA) position statement, which stance addressing this bioethical issue is appropriate?
A) The nurse is morally obligated to care for the client unless the risk exceeds responsibility.
B) The nurse has the responsibility to ensure the client gets adequate medical care.
C) The client has the right to choose not to disclose his or her condition to staff.
D) The client is morally bound to disclose every aspect of his or her condition to staff.
A client with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. According to a 2015 American Nurses Association (ANA) position statement, which stance addressing this bioethical issue is appropriate?
A) The nurse is morally obligated to care for the client unless the risk exceeds responsibility.
B) The nurse has the responsibility to ensure the client gets adequate medical care.
C) The client has the right to choose not to disclose his or her condition to staff.
D) The client is morally bound to disclose every aspect of his or her condition to staff.
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An adolescent client diagnosed with leukemia decides to stop chemotherapy treatments. The parents of the client, however, want the healthcare team to continue all treatments as necessary. Which action by the nurse is appropriate when providing care to this client and family?
A) Helping the family by providing information and allowing them to voice concerns
B) Confronting the parents and telling them not to be "selfish" in their child's time of need
C) Calling the authorities immediately
D) Obtaining a court order to determine the client legally able to make his or her own decisions
Answer: A
Explanation: A) Parents have the authority to make healthcare decisions for their children. Dilemmas arise when parents and children do not agree on whether or not to go forward with a recommended treatment. In most cases, the nurse and other members of the healthcare team who have developed a therapeutic alliance with the child and family may be able to help the family come to a joint decision by providing additional information and opportunity to discuss their concerns with each other calmly and openly. In some cases, however, the healthcare team may need to seek guidance from the agency's ethics committee.
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) What are some of the rights clients have when receiving care within a healthcare system? Select all that apply.
A) Clients have the right to be given information only in English.
B) Clients have the right to refuse care.
C) Clients have the right to know when something goes wrong with their care.
D) Clients have the right to care that is free from discrimination.
E) Clients have the right to know the titles, but not necessarily the names, of their caregivers.
Answer: B, C, D
Explanation: A) Clients have the right to get important information about their care in their preferred language. Clients may reject as well as accept care. Clients should be informed of problems with their care. Clients should be treated without discrimination. Clients have the right to know the names of the caregivers who treat them.
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A nurse is providing hospice care for an older adult client. The nurse is approached by the client's adult child. The adult child believes that her other parent, who is in a nursing home, is being neglected. What suggestions can the nurse offer in this situation? Select all that apply.
A) Contact the client advocate at the nursing facility.
B) Contact the local newspaper.
C) Encourage the daughter to immediately place her other parent in a different facility.
D) Contact the consumer protection agency.
E) Report suspicions to the licensing agency.
A nurse is providing hospice care for an older adult client. The nurse is approached by the client's adult child. The adult child believes that her other parent, who is in a nursing home, is being neglected. What suggestions can the nurse offer in this situation? Select all that apply.
A) Contact the client advocate at the nursing facility.
B) Contact the local newspaper.
C) Encourage the daughter to immediately place her other parent in a different facility.
D) Contact the consumer protection agency.
E) Report suspicions to the licensing agency.
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A nurse educator is explaining the idea of healthcare as a partnership between provider and client. Which are client responsibilities that some hospitals have included in their client bill of rights? Select all that apply.
A) Involving your family in your healthcare decisions
B) Reporting accurate and complete information about your health to your healthcare team
C) Answering questions asked by your healthcare team
D) Immediately paying all expenses not covered by insurance
E) Accepting the consequences if you fail to comply with instructions given to you
Answer: B, C, E
Explanation: A) It is not essential for clients to involve their family members in healthcare decisions. Clients have the responsibility to provide complete and accurate information about their symptoms, history, and status to their healthcare team. Accepting financial responsibility for treatment does not require immediate payment. Clients must understand that noncompliance with treatment recommendations may result in poor outcomes.
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A client tells his nurse, "I really don't like the nurse on first shift. I was treated badly." Which action should the nurse take as an advocate for this client?
A) Call the agency client advocacy department.
B) Confront the nurse when she comes to work.
C) Tell the client he has the right to switch nurses.
D) Call the local authorities.
Answer: A
Explanation: A) Individual clients who feel their rights have been violated or are endangered have a number of options. Many hospitals and large provider agencies have client advocates who can help clients navigate the system and intervene to ensure that their rights are maintained. Many states have an office designated by the governor or secretary of health to assist clients with issues related to patient rights in long-term care. The state's department of health may also be able to help.
150
The nurse performing an admission assessment on a client must inform the client of client rights and responsibilities. Which client rights are considered standard by many healthcare agencies? Select all that apply.
A) You have a right to be informed about the care you receive.
B) You have the right to safe care.
C) You have the right to be treated with courtesy and respect.
D) You have the right to be listened to.
E) You have the right to be appointed a personal advocate by the healthcare provider.
Answer: A, B, C, D
Explanation: A) The Joint Commission's Speak Up program is dedicated to patient rights and begins as follows: You have the right to be informed about the care you will receive; get important information about your care in your preferred language; get information in a manner that meets your needs; make decisions about your care; refuse care; know the names of the caregivers who treat you; safe care; have your pain addressed; care that is free from discrimination; know when something goes wrong with your care; get a list of all your current medications; be listened to; be treated with courtesy and respect; have a personal representative of your choice, not to have one appointed to you by the healthcare provider.
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Answer: A, B, C, D
Explanation: A) The Joint Commission's Speak Up program is dedicated to patient rights and begins as follows: You have the right to be informed about the care you will receive; get important information about your care in your preferred language; get information in a manner that meets your needs; make decisions about your care; refuse care; know the names of the caregivers who treat you; safe care; have your pain addressed; care that is free from discrimination; know when something goes wrong with your care; get a list of all your current medications; be listened to; be treated with courtesy and respect; have a personal representative of your choice, not to have one appointed to you by the healthcare provider.
Answer: A
Explanation: A) Most hospitals now publish lists of client responsibilities, emphasizing that healthcare is a partnership between the client and caregivers, that other clients have a right to be comfortable too, and that there are consequences if clients don't comply with treatment plans, cooperate with the healthcare team, or be considerate of the staff and other clients.
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Answer: A
Explanation: A) Most hospitals now publish lists of client responsibilities, emphasizing that healthcare is a partnership between the client and caregivers, that other clients have a right to be comfortable too, and that there are consequences if clients don't comply with treatment plans, cooperate with the healthcare team, or be considerate of the staff and other clients.
Answer: D
Explanation: A) Sometimes older adults forget and get confused. However, the nurse should notify the surgeon because the client has the right to informed consent. The client's age is not the reason for the nurse taking action. The family does not make the decision regarding surgery unless the client has been declared incompetent by the court. The nurse would want to have the surgery explained for the client's sake, not because the nurse signed the form.
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A pregnant woman has been rushed to the operating room for an emergency cesarean section. The physician explained the procedure to the parents, and he asked the father to wait in the waiting room until the procedure is complete. The mother asked if the father could be in the room to see the baby delivered and to help make decisions about the baby's care, but the physician explained that because of the emergency situation, that wouldn't be allowed. In this situation, which client right was violated?
A) The right to know when something goes wrong with care.
B) The right to be treated with courtesy and respect.
C) The right to have a personal representative.
D) The right to be listened to.
A pregnant woman has been rushed to the operating room for an emergency cesarean section. The physician explained the procedure to the parents, and he asked the father to wait in the waiting room until the procedure is complete. The mother asked if the father could be in the room to see the baby delivered and to help make decisions about the baby's care, but the physician explained that because of the emergency situation, that wouldn't be allowed. In this situation, which client right was violated?
A) The right to know when something goes wrong with care.
B) The right to be treated with courtesy and respect.
C) The right to have a personal representative.
D) The right to be listened to.
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A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation?
A) "You have placed the nursing student program in danger."
B) "You may be sued by the hospital for the extra care cost to the client."
C) "You are expected to practice like a licensed nurse."
D) "You have set a bad example for the other students."
Answer: C
Explanation: A) A nursing student is held to the standard of conduct of an experienced, licensed professional nurse. Students are required to know the standards and to follow them. Hospitals do not generally sue nurses to recover money for extended care due to an error. It is not likely that the teaching program is in danger, as people do make mistakes and hospitals do rely on nursing schools to help provide care to clients. It is not likely that the other students are apt to follow the example of a student who fails to follow policy.
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The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply.
A) Client fell getting out of bed because the call light was not used.
B) Client name band was checked prior to providing all medications.
C) Client's morning medications were administered in the early afternoon.
D) Client states not understanding activity restrictions and wound eviscerated.
E) Client documentation did not include appearance of infiltrated IV site.
Answer: A, C, D, E
Explanation: A) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care.
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A nurse working on a medical-surgical unit wants to ensure care is provided within the standard of nursing care. Which actions by the nurse are appropriate? Select all that apply.
A) Analyze the position description.
B) Review and become familiar with the policy and procedure manual.
C) Question the value of collaborating with other disciplines.
D) Review applicable state nurse practice act and administrative rules.
E) Adhere to national standards of practice and care.
Answer: A, B, D, E
Explanation: A) Nurses are expected to demonstrate competence within multiple areas of their professional role, including collaboration with the entire care team. The nurse's specific job description will contribute to defining the standard of care. Employers can limit but not expand the scope of practice, and the nurse will be held to functioning within the scope of employment. Agency policies and procedures serve in defining the standard of care. The applicable state nurse practice act and administrative rules form the basis of the standard of care to which each nurse is held. A primary source for defining the standard of care is the prevailing national nursing standards. Nurses who follow national standards of practice and standards of care will provide their clients with the best care possible and be far less likely to commit any unintentional act that may rise to the level of malpractice.
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The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A) The provider's disapproval if the surgery is not performed
B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed
The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A) The provider's disapproval if the surgery is not performed
B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed
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) A client is receiving care in the hospital for life-threatening injuries sustained in a motor vehicle crash and is taken immediately to surgery. There is no family available to provide consent; however, the client's medical record is available and reviewed by the nurse. Which treatments are inappropriate in this situation? Select all that apply.
A) Emergency surgery
B) Treatment that was previously refused
C) Treatment that violates religious beliefs
D) Medications to treat the injury
E) Experimental medications for a research study
Answer: B, C, E
Explanation: A) In most states, the law assumes an individual's consent to medical treatment when the person is in imminent danger of loss of life or limb and unable to give informed consent. In other words, the emergency doctrine assumes that the individual would reasonably consent to treatment if able to do so. This doctrine serves as a guiding principle that permits healthcare providers to perform potentially life-saving procedures under circumstances that make it impossible or impractical to obtain consent. Treatment that was previously refused or violates the client's documented religious beliefs is not appropriate. Experimental medications that are being initiated in conjunction with a research study are also not appropriate
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A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request?
A) The nurse asks the client's parents if this is okay with them.
B) The nurse agrees but still informs the parents immediately of everything they did not witness.
C) The nurse strongly urges the client to reconsider this request to receive the best possible care.
D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.
Answer: D
Explanation: A) Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.
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Which action demonstrates correct reporting of suspected child abuse?
A) The nurse includes the entirety of the client's medical record.
B) The nurse compiles a report with all pertinent information that is factually true.
C) The nurse recommends that the organization report the abuse to state authorities.
D) The nurse reports only information the client has authorized for release
Answer: B
Explanation: A) Reports should be complete and accurate and should be made according to the policy of the organization for which the nurse works. In addition to reporting the abuse within the organizational framework, the nurse should personally report the abuse to the proper authorities. When abuse is reported, all pertinent information in the client's medical record (not simply the entire record) is required by law to be disclosed to the reporting agency. As such, reporting abuse or suspected abuse represents an exception to client confidentiality rules.
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A client newly diagnosed with diabetes mellitus tells the nurse that the prescribed diet does not provide enough variation of choice. It is against the state's nurse practice act for a nurse to order a diet for the client. Which response by the nurse is most appropriate?
A) "I will bring you a different menu."
B) "I will ask my manager to talk with the dietitian."
C) "Let's look at your diet and see what type of variety we can find."
D) "I will notify the dietary department to change your diet."
Answer: C
Explanation: A) A nurse practice act (NPA) is a series of state statutes that define the scope of practice, standards for education programs, licensure requirements, and grounds for disciplinary actions. The law provides a framework for establishing nursing actions in the care of clients. It is against most states' nurse practice acts for the nurse to order a diet for the client. The nurse is allowed to assist the client to choose appropriate foods as ordered by the physician. The nurse cannot notify the dietary department or enlist the assistance of a manager to change the diet with a healthcare provider prescription. Providing the client with another menu will not help the client choose foods within the prescribed diet.
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) A nurse educator is teaching a group of nursing students about the function of the state board of nursing. Which information will the educator include in the teaching session? Select all that apply.
A) Creating the NCLEX-RN examination
B) Defining professional standards
C) Investigating violations of the nurse practice act
D) Suspending or revoking licenses
E) Finding drug treatment centers for impaired nurses
Answer: B, C, D
Explanation: A) Boards of nursing oversee nursing licensure by defining professional standards, investigating violations of the nurse practice act, sanctioning those who violate the nurse practice act, and suspending or revoking licenses. The National Council for the State Boards of Nursing creates the NCLEX-RN examinations. The state board of nursing is not responsible for finding treatment programs for drug-impaired nurses.
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The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How would this change in the state board of nursing structure influence the nurse's ability to practice nursing? Select all that apply.
A) The nurse can only practice nursing in the residing state.
B) The nurse can practice nursing in other states within the compact.
C) The nurse is accountable to the state in which the nurse and clients reside.
D) The nursing license will become similar to having a driver's license.
E) The nurse has to obtain an additional license.
Answer: B, C, D
Explanation: A) The mutual recognition model of nurse licensure allows a nurse to have a single license that confers the privilege to practice in other states that are part of the Nurse Licensure Compact. The nurse is held accountable for following the laws and rules of the state in which the nurse practices or where the client is located. It is similar to the driver's license model: A single license to drive is issued in the state of primary residency, but this license also allows the privilege to drive in other compact states. Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.
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The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond?
A) It formally recognizes nurses who have achieved a high standard of practice in managed care.
B) It provides a process for recognizing the professional competence of individuals who pass the program.
C) It investigates and adjudicates cases of professional negligence.
D) It lists the state requirements for a nursing professional to achieve licensure.
The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond?
A) It formally recognizes nurses who have achieved a high standard of practice in managed care.
B) It provides a process for recognizing the professional competence of individuals who pass the program.
C) It investigates and adjudicates cases of professional negligence.
D) It lists the state requirements for a nursing professional to achieve licensure.
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Which of the following is a licensure examination developed by the National Council of State Boards of Nursing (NCSBN) for state and territory boards of nursing (BONs) to implement as part of their requirements for licensure?
A) National Council Licensure Examination for Registered Nurses (NCLEX-RN)
B) National Nurse Aide Assessment Program (NNAAP)
C) Medication Aide Certification Examination (MACE)
D) Nursing Workforce Diversity (NWD) program
Answer: A
Explanation: A) The National Council of State Boards of Nursing (NCSBN) has developed two licensure examinations, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and the National Council Licensure Examination for Practical Nurses (NCLEX-PN), for state and territory BONs to implement as part of their requirements for licensure. The NCSBN also offers two additional examinations: the National Nurse Aide Assessment Program (NNAAP) and the Medication Aide Certification Examination (MACE). The Nursing Workforce Diversity (NWD) program is not a licensure examination.
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Which statement exemplifies the ultimate accountability of nursing students for their actions?
A) "State regulatory bodies have the ultimate responsibility for my actions."
B) "The client's perception of the care I give determines the correctness of my actions."
C) "I am responsible for my own actions, correct or incorrect."
D) "No one may judge my actions as correct or incorrect other than me."
Answer: C
Explanation: A) Each nurse practice act (NPA) addresses the duties and responsibilities of nursing students in that state. Typically, this includes language that allows nursing students the privilege to practice nursing without a license while engaged in the clinical practicum of an approved nursing education program under the supervision of qualified faculty. Nursing students have the ultimate responsibility (accountability for their actions that includes the obligation to answer for an act done and to repair any injury one may have caused) for their own actions. This responsibility does not rest ultimately with the state and does not depend solely on client perceptions. Responsibility does not mean that no one else but the nursing student may judge the student's actions.
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A client with terminal cancer has signed an advance directive indicating that no parenteral nutrition or hydration will be implemented. For several days the client has refused food and fluids, pushing the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." Which actions by the nurse are appropriate? Select all that apply.
A) Take the case to the hospital's ethics committee.
B) Honor the client's refusal of parenteral nutrition and hydration.
C) Talk to the healthcare provider so the family's wishes can be acted upon.
D) Help the family come to terms with the situation.
E) Honor the family's wishes and have them sign a consent form.
Answer: B, D
Explanation: A) A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate and through the moral principle of autonomy. Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client's refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.
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Answer: B, D
Explanation: A) A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate and through the moral principle of autonomy. Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client's refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.
Answer: D
Explanation: A) The nurse, recognizing that the client is no longer competent, should follow whatever hospital policy is in place for contacting the agent named in a durable power of attorney for healthcare. The physician is not the appropriate individual to make decisions for the client. Social services may be the department that would contact the agent of a durable power of attorney, but social services would not be that power. In the case of an incompetent client, the spouse would be the agent of the durable power of attorney only if the court appointed the spouse.
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After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are appropriate in this situation? Select all that apply.
A) Telling the client that changes to the advance directive can be made at any time
B) Telling the client that it is not necessary to make decisions about healthcare needs in the future
C) Giving a copy of the advance directives to the client's adult children
D) Educating the client about the purpose and types of life-sustaining measures
E) Having the client name an individual to be responsible for care decisions
Answer: A, C, D
Explanation: A) The nurse should explain that if a decision is made on an advance directive, the decision can be changed. Clients should be instructed to provide a copy of their advance directives to their next of kin. The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures and provide teaching on these measures if necessary. An advance directive does not mean that the client does not need to make any future decisions about healthcare. An individual to be responsible for care decisions is a durable power of attorney for healthcare and may or may not be included when creating an advance directive.
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A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply.
A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities.
D) The surrogate decision maker has the authority to have access to all medical records.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.
A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply.
A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities.
D) The surrogate decision maker has the authority to have access to all medical records.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.
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The nurse on the medical unit is admitting a client. When the nurse asks the client about advance directives, the client states, "I have a living will." Which is the purpose of a living will?
A) Provides specific instructions about type of medications the client requires to sustain life
B) Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves
C) Provides specific instructions about who will make healthcare decisions if the client cannot
D) Provides specific instructions about how decisions are to be made if the client is unable to make the decisions
Answer: B
Explanation: A) There are two types of advanced directives, the living will and the durable power of attorney for healthcare. The living will provides specific instructions about what medical treatment the client chooses to omit or refuse. The durable power of attorney for healthcare identifies who will be making healthcare decisions if the client cannot. Living wills do not dictate medication requirements or how decisions are to be made if the client cannot make them.
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The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, "I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will." When planning care for this client, which intervention is the most appropriate?
A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.
B) Encourage the client to allow for mechanical ventilation.
C) Educate the client on the purpose of mechanical ventilation.
D) Refer the client to a therapist to deal with the death of her mother.
Answer: A
Explanation: A) Although it is appropriate to educate the client on mechanical ventilation, the client asked for information on making out a living will. It would be most appropriate at this time for the nurse to educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. The nurse should not attempt to convince the client to allow for medical treatment. The nurse may educate the client on a medical treatment, but that does not address the client's desire for a living will. There is no indication that this client needs therapy.
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A client on a medical-surgical unit experiences a code blue situation unexpectedly. The emergency situation has ended and the client survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this?
A) Discussing the event outside the hospital
B) Asking management for the use of a private room to debrief
C) Talking while riding in the staff elevator
D) Debriefing about the situation at home
Answer: B
Explanation: A) To comply with HIPAA, nurses cannot discuss events involving clients in any setting where the conversation can be heard by others, so a private room would be the best place to debrief. The nurses must also guard against other health professionals not directly involved with the client overhearing their discussion; consequently, a staff elevator is not acceptable. Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This would also preclude nurses from discussing client care in the home.
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Answer: B
Explanation: A) To comply with HIPAA, nurses cannot discuss events involving clients in any setting where the conversation can be heard by others, so a private room would be the best place to debrief. The nurses must also guard against other health professionals not directly involved with the client overhearing their discussion; consequently, a staff elevator is not acceptable. Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This would also preclude nurses from discussing client care in the home.
Answer: C
Explanation: A) The Privacy Rule protects all "individually identifiable health information" held or transmitted in any form or media, whether electronic, paper, or oral. The rule calls this information protected health information and delineates it further to include information that identifies the individual (e.g., name, address, birth date, and Social Security number) or for which a reasonable basis exists to believe the information can be used to identify the individual. Information in a computer data system may not always be safe, and it would be inappropriate for the nurse to say this. Nurses need to be involved with the design, implementation, and evaluation of electronic medical records to maximize their use and effectiveness, but this does not ensure security. Reminding the client that there is indeed cause for privacy concerns is not as therapeutic as explaining that the system requires a password.
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) Which action protects the client's confidentiality?
A) The nurse discusses details of a client's case with family members she expects will tell no one else.
B) The nurse doesn't reveal outside the healthcare team that he was involved with the treatment of a famous client.
C) The nurse thinks HIPAA procedures for her facility are too restrictive to enable necessary sharing of information.
D) The nurse discusses clients only with other employees of the healthcare facility where he works.
Answer: B
Explanation: A) Confidentiality refers to the assurance the client has that private information will not be disclosed without his or her consent. Confidentiality applies both to the nature of the information the nurse obtains from the client and to how the nurse treats client information once it has been disclosed to the nurse. The nurse who does not reveal he participated in the treatment of a famous client is protecting that client's confidentiality. The nurse discussing the details of a client's case with family members and the nurse discussing clients with any other employees of his facility are violating client confidentiality. The nurse who thinks her facility's HIPAA procedures are too restrictive is neither protecting nor violating confidentiality.
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Answer: B
Explanation: A) Confidentiality refers to the assurance the client has that private information will not be disclosed without his or her consent. Confidentiality applies both to the nature of the information the nurse obtains from the client and to how the nurse treats client information once it has been disclosed to the nurse. The nurse who does not reveal he participated in the treatment of a famous client is protecting that client's confidentiality. The nurse discussing the details of a client's case with family members and the nurse discussing clients with any other employees of his facility are violating client confidentiality. The nurse who thinks her facility's HIPAA procedures are too restrictive is neither protecting nor violating confidentiality.
Answer: A, D, E
Explanation: A) The nurse has the responsibility to keep client information private and confidential. Actions that ensure client confidentiality include only sharing information with staff who are directly involved in care and restricting discussion regarding client care to the report room or other areas that are secure. Client names and diagnoses should only be shared with those who are directly providing care. The nurse is able to review the client's care needs with the designated health insurance agent.
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The Health Insurance Portability and Accountability Act (HIPAA) was created in part to
A) exclude clients with preexisting conditions from healthcare insurance coverage.
B) designate special rights for individuals who lose other health coverage.
C) promote medical underwriting in group plans.
D) relax the rules for disclosure of protected health information.
Answer: B
Explanation: A) The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted by Congress to minimize the exclusion of preexisting conditions as a barrier to healthcare insurance, designate special rights for individuals who lose other health coverage, and eliminate medical underwriting in group plans. The act includes the Privacy Rule, which creates a national standard for the disclosure of private health information. This rule affects all healthcare providers as well as health insurance plan providers, and it defines, not relaxes, the rules for disclosure of protected health information.
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Which of the following should the nurse understand to be health information not protected under the HIPAA Privacy Rule?
A) A client's Social Security number, birthdate, and mailing address
B) A description of the symptoms of an illness the client has that does not reference the client in any way
C) The details of a client's visit to a medical office including the diagnosis rendered
D) How much the client owes for a treatment rendered to the client
Answer: B
Explanation: A) Protected health information includes information that identifies the individual (e.g., name, address, birth date, and Social Security number) or for which a reasonable basis exists to believe the information can be used to identify the individual as it relates to the individual's past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or the past, present, or future payment for the provision of healthcare to the individual. A mere description of the symptoms for an illness that does not reference the client in any way is not protected health information.
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While making rounds on the night shift, a nursing supervisor notes that a 73-year-old client under observation following a myocardial infarction has multiple visible bruises on the arms and legs. The supervisor suspects abuse because nothing in the client's chart suggests this client should have sustained these injuries. This state's good faith immunity applies in cases of suspected abuse not only of children but also of older adults or adults with disabilities. Which action has the highest priority for the nursing supervisor in this situation?
A) Notify authorities regarding the suspected abuse.
B) Do nothing about the situation.
C) Notify the security department.
D) Ask a shift nurse about the source of the injuries
Answer: A
Explanation: A) States also have specific laws pertaining to the mistreatment of adults and older adults. These laws may be similar to those that govern the abuse and neglect of children. For example, many states generally offer good faith immunity to individuals who report suspected abuse or neglect of an older adult or an adult with a disability. This immunity would apply in the case of this client. Security is not the appropriate department to notify unless the injuries were sustained at work. Questioning a shift nurse about the source of the injuries is fine to do but should not replace reporting the injuries to the appropriate authorities, which should be done in this case because the supervisor suspects abuse.
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During an assessment of a child in the urgent care clinic, the nurse notes that the child has a swollen and split lip. When asking the parent how the child's lip injury occurred, the parent responds, "We are here for my child's ear not my child's lip." Which is the rationale for reporting this incident?
A) The child reports that a parent caused the injury.
B) The lip injury is unrelated to the ear infection.
C) The nurse can be sued if there is no abuse.
D) Suspected abuse must be reported.
Answer: D
Explanation: A) Suspected child abuse must be reported by law. Healthcare personnel are protected by good faith immunity because the ultimate goal is the protection of the child. The lip injury being unrelated to the ear infection is not a reason to report the injury. Most children will not accuse an abuser; rather, they generally protect the abuser. The reason for the law is that experts can assess the situation and determine if abuse has occurred. The nurse is protected by good faith immunit
181
An adolescent client with a sexually transmitted infection (STI) says to the nurse, "Promise you won't tell my parents about my condition." The agency policy is that all STIs must be reported in accordance with federal and state law. Which action by the nurse is appropriate?
A) Disclosing information to the parents
B) Reporting the STI to the proper authorities
C) Respecting the client's privacy and confidentiality by not mentioning or reporting the STI
D) Telling other nurses in the clinic that the client has an STI
Answer: B
Explanation: A) In this case, the nurse is required to report information about the client's STI to the state health department. Because of confidentiality issues, the nurse should not report the STI to the parents or to other nurses not involved in the client's care.
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The nurse is in the midst of a complicated client care situation and is not sure what needs to be done with some information. Which healthcare issues must the nurse report to the state? Select all that apply.
A) Amputation of a limb
B) Death of a client
C) Death of a neonate
D) Diagnosis of tuberculosis
E) Kidney transplant
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Explanation: A) The term mandatory reporting refers to a legal requirement to report an act, event, or situation that is designated by state or local law as a reportable event. All states mandate the reporting of certain vital statistics, including deaths. Many states also require healthcare providers to report neonatal deaths. Federal and state laws mandate the reporting of communicable diseases such as tuberculosis. Limb amputations and transplants do not need to comply with mandatory reportable events
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A nurse who reports suspected child abuse, honestly believing it to have occurred, is not subject to civil or criminal liabilities when the subsequent investigation does not make a determination of abuse. This is called
A) good faith immunity.
B) protection of privacy.
C) breach of confidentiality.
D) criminal malfeasance.
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Answer: A
Explanation: A) In every state, healthcare workers are protected from civil or criminal liabilities when they report suspected child abuse in good faith, even if the subsequent investigation does not make a determination of abuse. This is called good faith immunity. This is not protection of privacy, breach of confidentiality, or criminal malfeasance.
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Answer: A
Explanation: A) In every state, healthcare workers are protected from civil or criminal liabilities when they report suspected child abuse in good faith, even if the subsequent investigation does not make a determination of abuse. This is called good faith immunity. This is not protection of privacy, breach of confidentiality, or criminal malfeasance.
Answer: D
Explanation: A) Regardless of the situation, the nurse is not required to conduct any type of investigation or otherwise confirm that the suspected abuse of a pediatric client has, in fact, occurred. The nurse is required only to have a good faith suspicion based on information disclosed by a client, physical symptoms observed in a client, or the nurse's personal observations of behavior on the part of a client, colleague, or third party. The nurse is not required, therefore, to question a parent or guardian about the abuse, personally observe the client being abused, or identify witnesses who will testify to the abuse.
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A nurse educator is planning a class for a group of nursing students regarding risk management. Which information should the educator include in this presentation? Select all that apply.
A) Risk management seeks to prevent harm.
B) Risk management empowers clients.
C) Risk management controls the cost of supplies.
D) Risk management examines past mistakes and identifies potential hazards.
E) Risk management ensures that nurses are truthful.
Answer: A, D
Explanation: A) The major goal of a risk management department is to limit a healthcare agency's financial and legal risk associated with the delivery of care, particularly in terms of lawsuits, ideally before incidents occur. This involves preventing harm to clients and hospital personnel by examining past mistakes and identifying potential hazards. The cost of supplies, truthfulness of nurses, and empowerment of clients are not goals of risk management.
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A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice?
A) Not discussing errors made
B) Questioning every order that the physician writes
C) Urging the nurse's organization to purchase liability insurance
D) Storing unused equipment in the halls of the unit
Answer: C
Explanation: A) Healthcare organizations can use several strategies to minimize risk. One of the most basic strategies is protecting against financial risk by purchasing insurance or by self-insuring. Risk management also entails analyzing errors to determine causes and changing policy to reduce more errors. Nurses should report all errors in an effort to assist in the campaign to reduce medical errors. Storing unused equipment in the hall serves to eliminate risk of contamination but could increase the risk of injury. The nurse does not need to question every order that a physician writes; the nurse is responsible only for questioning orders that may injure clients.
187
The nurse is concerned about the risk involved when implementing healthcare provider prescriptions for a newly admitted client. Which strategies should the nurse consider to reduce this risk? Select all that apply.
A) Question any order written for a postoperative client.
B) Question any order a client questions.
C) Question any order if the client's condition changes.
D) Question any verbal order.
E) Question any order that is incomplete.
Answer: B, C, E
Explanation: A) Nurses can minimize risk by analyzing procedures and medications ordered by the physician. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescribing physician. To protect themselves legally, nurses should question any order a client questions, any order if the client's condition has changed, and any order that is incomplete. Orders written for postoperative clients do not all need to be questioned. Verbal orders should be recorded accurately to avoid miscommunication, but they do not all need to be questioned
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Answer: B, C, E
Explanation: A) Nurses can minimize risk by analyzing procedures and medications ordered by the physician. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescribing physician. To protect themselves legally, nurses should question any order a client questions, any order if the client's condition has changed, and any order that is incomplete. Orders written for postoperative clients do not all need to be questioned. Verbal orders should be recorded accurately to avoid miscommunication, but they do not all need to be questioned
Answer: A, C, E
Explanation: A) Children are at a higher risk for medical error than other clients and also may be more vulnerable to harm from errors due to their immature physiology. Reasons for increased medical error among children include miscalculation of doses and amounts and incorrect placement of the decimal point in calculations. Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective. The nurses should not be refusing to dilute medications because many preparations require dilution to achieve the small dosages required by infants, and they should not expect the pharmacy to prepare the medications in exact doses.
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A medication error occurred and the nurse is preparing to complete an incident report. Which information is required to thoroughly complete this report? Select all that apply.
A) Name of client involved in the incident
B) Location where incident report is completed
C) Date and time of the incident
D) Medication involved in the incident
E) Number of hours the nurse was at work before the incident occurred
Answer: A, C, D
Explanation: A) An incident report is an agency record of an accident or incident occurring within the agency. Incident reports generally include the names and identifying information of any clients and healthcare personnel involved in the incident as well as information on witnesses; the location, time, and date of the incident; and if a medication is involved, the medication's name and dosage. The location of the incident, not where the incident report itself is completed, should be entered. The number of hours the nurse worked before the incident occurred is not a part of the report.
190
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The nurse is assessing a 20-month-old and learns that he is unable to stand alone. Which aspect of development does the nurse identify as altered?
A) Behavior
B) Height
C) Motor
D) Growth
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Answer: C
Explanation: A) Development is an increase in the complexity of function and skill progression, the capacity of an individual to adapt to the environment. It includes changes in a person's cognitive, psychosocial, and gross and fine motor skills. In this case, the child's inability to stand is indicative of a delay in motor development. Growth refers to physical change and increase in size; it does not entail changes in skills and abilities. Height is one indicator of growth. Behavior is a component of each developmental stage and can sometimes indicate that development has taken place, but its absence does not mean that development has not occurred.
191
What activity should the nurse implement for a 6-month-old client with gross motor delays?
A) Pull the child to a sitting position and prop the child in that position.
B) Encourage the child to hold a rattle or play patty-cake.
C) Talk to the child and play music.
D) Encourage the child to pull up to a standing position.
Answer: A
Explanation: A) The infant at 6 months should have head control and is working on sitting without support. Pulling the child to a sitting position allows the neck muscles to support the head. Propping the child in a sitting position helps to develop self-righting behaviors. It is too early to worry about standing. Talking to the child promotes language development, not gross motor development. Handling a rattle is a fine motor behavior, not a gross motor behavior.
192
Which activities should the nurse emphasize when teaching parents about how to foster development in preschool-aged children?
A) Providing time for playing sports, such as basketball, to increase gross motor skills
B) Helping them develop skills needed in the adult world, such as allowance budgeting
C) Allowing "pretend" time, such as dress-up or role-playing activities
D) Presenting diversity in culture and practices as part of home-based study
Answer: C
Explanation: A) Preschool-aged children should be given activities that focus on make-believe and pretend opportunities. Gross motor activities are also important, but children this age prefer activities such as swinging, riding a tricycle, and throwing a ball to organized sports. School-age children are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help them function in the adult world. Understanding diversity, role preference, and performance is the task of the adolescent.
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Answer: C
Explanation: A) Preschool-aged children should be given activities that focus on make-believe and pretend opportunities. Gross motor activities are also important, but children this age prefer activities such as swinging, riding a tricycle, and throwing a ball to organized sports. School-age children are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help them function in the adult world. Understanding diversity, role preference, and performance is the task of the adolescent.
Answer: D
Explanation: A) According to Gould, the seventh stage of adult development is experienced by individuals ages 50-60 and is a period of transformation. Gould's theory states that personalities are set at ages 43-50, in stage 6. Adjusting to decreasing physical capacities is a part of Peck's theory, and self-reflection occurs in stage 5 of Gould's theory, during the ages 35-43.
194
The nurse is conducting a psychoeducation group with male and female clients. The nurse observes what appear to be differences in moral perspectives between the men and women. Which observation is most consistent with Gilligan's theory of moral development?
A) The men are focused on human-made rules governing morality.
B) The women have difficulty looking at moral issues objectively.
C) The men believe that morality is tied to relationships and caring.
D) The women believe that it is most important not to inflict harm.
Answer: D
Explanation: A) According to Gilligan, men tend to consider what is right to be what is just, whereas for women what is right is taking responsibility for others as a self-chosen decision. The ethic of justice, or fairness, is based on the idea of equality: Everyone should receive the same treatment. This is the development path usually followed by men and widely accepted by moral theorists. By contrast, the ethic of care is based on the premise of nonviolence: No one should be harmed. This is the path typically followed by women.
195
According to Bandura's social learning theory, which of the following should the nurse advise the parent of a preschool-aged child to do in order to help the child become independent in activities of daily living?
A) Punish the child if he does not complete the personal care tasks independently.
B) Refuse to help the child with the tasks and insist he do them on his own.
C) Model the tasks and positively reinforce the child for completing the tasks independently.
D) Wait until the child reaches the concrete operational phase before asking him to complete the tasks.
Answer: C
Explanation: A) According to Bandura, children imitate the behavior they see; if the behavior is positively reinforced they tend to repeat it. Negative reinforcement like punishment is not part of Bandura's theory; it is more closely aligned with Skinner's behaviorist theory. Refusing assistance to the child does not align with Bandura's belief in the need for modeling. The concrete operational phase is part of Piaget's theory and not Bandura's.
196
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The nurse is assessing a child who was last seen in the clinic 2 years earlier. Which of the following should the nurse anticipate as having remained relatively stable over time?
A) The child's behavior
B) The child's physical characteristics
C) The child's temperament
D) The child's home environment
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Answer: C
Explanation: A) Temperament refers to innate characteristics that do not change over time. Each individual brings these characteristics to the events of daily life, and they set the stage for the interactive dynamics of growth and development. Physical characteristics include eye color and height; although some physical characteristics remain constant as a child grows, others do not. A person's temperament shapes his or her behaviors; however, regardless of temperament, a child's behaviors should be expected to change over time as a normal part of development. Finally, a child's home environment may change at any time due to any number of factors.
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Answer: C
Explanation: A) Temperament refers to innate characteristics that do not change over time. Each individual brings these characteristics to the events of daily life, and they set the stage for the interactive dynamics of growth and development. Physical characteristics include eye color and height; although some physical characteristics remain constant as a child grows, others do not. A person's temperament shapes his or her behaviors; however, regardless of temperament, a child's behaviors should be expected to change over time as a normal part of development. Finally, a child's home environment may change at any time due to any number of factors.
Answer: C, D, E
Explanation: A) A 5-year-old should be able to button his shirt. A 6-year-old should be able to sit still for a short story; this is a task that children between 3 and 5 years old are typically able to do. A child who cannot cut with scissors by kindergarten age is considered developmentally delayed, but a 2-year-old is not expected to be able to do this. A 2-year-old is not expected to be able to recite a phone number. A 3-year-old is usually able to speak in sentences.
198
The nurse is caring for an adolescent with a chronic illness who suddenly becomes noncompliant with the medication regimen. Which intervention should the nurse choose to help improve medication compliance for this client?
A) Give the client a computer-animated game that presents information on the management of the condition.
B) Recommend to the client's parents that certain privileges should be taken away, such as cell phone use and texting, if compliance fails to improve.
C) Arrange for the physician to discuss the risks related to noncompliance with medications to the client.
D) Set up a meeting with some older teens with the same condition who have been managing their disease effectively.
Answer: D
Explanation: A) Providing the adolescent with positive role models from his or her peer group is the intervention most likely to improve compliance. Interest in games might begin to wane at this age. Adult opinions, even from a physician, could be viewed negatively and challenged. Threatening punishment could further incite rebellion.
199
10) The nurse is teaching a school-aged client how to use a peak flow meter to monitor asthma. Which approach by the nurse is most likely to result in the desired outcome?
A) Providing positive reinforcement after every attempt
B) Explaining that asthma can be fatal if not monitored and treated
C) Telling the client he cannot play until he learns to use the meter correctly
D) Using colloquialisms and slang when describing how to use the meter
Answer: A
Explanation: A) A sense of achievement is very important to school-aged children, and rewarding and reinforcing behavior is most effective. Scare tactics and negative reinforcement are not appropriate. Nurses should use clear, concrete language to enhance understanding.
200
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The nurse notes that an infant does not seem to respond to noises in the environment and has difficulty following the movement of toys. Which diagnostic tools does the nurse anticipate will be used to further assess this client? Select all that apply.
A) CT scan of the brain
B) Vision test
C) Abdominal x-rays
D) Nerve conduction studies
E) Audiology testing
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Answer: B, E
Explanation: A) The child is not responding to environmental noise and is having difficulty tracking the movement of toys. The two tests that should be considered for this child are vision and hearing testing. There is not enough evidence to support that the child would need a CT scan of the brain, abdominal x-rays, or nerve conduction studies.
201
The school nurse cares for students with physical challenges and suspects that the needs for physical safety are not being adequately met for several students in the home environment. Which of the following assessment findings support the nurse's concern? Select all that apply.
A) Wearing the same clothes to school several days of the week
B) Limited arm range of motion
C) Scrapes on knees caused by falling from a bicycle
D) Hand burn from touching a hot stove
E) Lunch contains leftovers from previous evening dinner
Answer: B, C, D
Explanation: A) Wearing the same clothes to school several days of the week and eating leftovers for lunch could be an indication of the family's financial status. Evidence that physical safety needs are not being adequately met would include the formation of contractures, which limits arm range of motion; scrapes on knees after falling from a bicycle, indicating the lack of safety or protective equipment for the head and extremities; and hand burns obtained from touching a hot stove, which could mean the child was not attended in the kitchen at home.
202
A 6-month-old is in the clinic for a well-child visit. As part of the visit, the nurse will assess his development using the Ages and Stages Questionnaire (ASQ). Which will the nurse rely on to make her assessment?
A) Observation of the child's skills in a variety of areas
B) Parent reports of communication and motor skills, social skills, and problem-solving ability
C) Parental reports and observation of the child's skills in a variety of areas
D) Childcare provider reports of communication and motor skills, social skills, and problem-solving ability
Answer: B
Explanation: A) The ASQ relies on parental reports to assess the child's communication and motor skills, social skills, and problem-solving ability. The Battelle Developmental Inventory Screening Test (BTDIST) uses both observation and parental reports to assess a variety of areas. Tests specifically described in this chapter do not include those based solely on observation or childcare provider reports.
203
A nurse is caring for a 76-year-old client. The nurse suspects that the client may be minimizing her pain. Which should the nurse recognize as a common reason for this behavior in older adults?
A) Older adults see pain as a natural progression of aging, causing them to downplay the extent of their pain.
B) Older adults fear that admitting the extent of pain will result in administration of potentially addictive pain killers.
C) Older adults think that admitting the extent of their pain increases the likelihood they will be sent to a rehabilitation hospital prior to returning home.
D) Older adults have usually lost some degree of sensation in their appendages which makes it difficult for them to sense the full extent of their pain.
Answer: A
Explanation: A) Older adults see pain as a natural progression of aging. As such, many elderly patients tend to downplay the extent of their pain, which leads to undertreatment of pain. The nurse should be aware when assessing for pain that the older adult may not rate his or her pain realistically. Fear of addictive pain killers, admission to a rehabilitation hospital, and loss of sensation are unlikely to contribute to the older adult downplaying pain.
204
The school nurse is talking to a child with attention-deficit/hyperactivity disorder (ADHD) who wants to play soccer. Which action is most appropriate for the school nurse to take?
A) Recommend that the child become active in an individual sport, rather than a team sport.
B) Encourage the child to play soccer.
C) Discourage the child from playing a sport.
D) Ask the child's mother to get permission from the child's physician to play soccer.
Answer: B
Explanation: A) The child should be encouraged to play soccer. Participation in a team sport will assist the child with ADHD to expend some energy while cooperating with others and following game rules. Participating in a team sport can help promote self-esteem in the child with ADHD and encourage connectedness with other children. There is no reason for a child with ADHD not to play sports. The mother would not need physician approval for her son to play soccer. Vigorous physical activity is encouraged for all children with ADHD. Some of the benefits of participating in a team sport would not be available with individual sports.
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Answer: B
Explanation: A) The child should be encouraged to play soccer. Participation in a team sport will assist the child with ADHD to expend some energy while cooperating with others and following game rules. Participating in a team sport can help promote self-esteem in the child with ADHD and encourage connectedness with other children. There is no reason for a child with ADHD not to play sports. The mother would not need physician approval for her son to play soccer. Vigorous physical activity is encouraged for all children with ADHD. Some of the benefits of participating in a team sport would not be available with individual sports.
Answer: D
Explanation: A) Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD. Immune response can be associated with autism spectrum disorders but not ADHD. Young parental age has not been associated with ADHD. The measles, mumps, and rubella vaccine was once thought to be associated with autism spectrum disorder, not ADHD, but multiple studies have found no link between immunizations and autism.
206
The nurse is caring for a family with four children whose third child has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement made by the mother suggests that the family may have difficulty coping with this diagnosis?
A) "I don't know how to tell the rest of the family, and I'm not sure how we will manage the other children."
B) "We need to alert the teachers at school as soon as possible so they can work with us to develop a plan that meets my son's needs."
C) "What does this mean for my son's health in the future?"
D) "Given this diagnosis, I'm not sure if we should let our son act in the school play."
Answer: A
Explanation: A) The mother's comments about how to tell the family and manage the other children suggest that the family may have difficulty adjusting to the child's diagnosis. This family will likely need assistance with coping with the child and continuing on with life. Alerting the teachers at school is a positive action and a way to protect the child. Decisions about participating in the school play should be discussed with the child's teachers, but the mother's statement does not suggest poor coping. Asking about the child's health in the future is reasonable at this time.
207
A nurse is caring for a school-age client who is scheduled to have a tonsillectomy the next day. The nurse has planned a preoperative teaching session for the child, who has a history of attention-deficit/hyperactivity disorder (ADHD). Which teaching technique is most appropriate for this client?
A) Play a video describing the procedure to the child.
B) Ask other children who have had this procedure to talk to the child.
C) Allow the child to lead the teaching session to gain a sense of control.
D) Give instructions verbally and use a picture pamphlet, repeating points more than once.
A nurse is caring for a school-age client who is scheduled to have a tonsillectomy the next day. The nurse has planned a preoperative teaching session for the child, who has a history of attention-deficit/hyperactivity disorder (ADHD). Which teaching technique is most appropriate for this client?
A) Play a video describing the procedure to the child.
B) Ask other children who have had this procedure to talk to the child.
C) Allow the child to lead the teaching session to gain a sense of control.
D) Give instructions verbally and use a picture pamphlet, repeating points more than once.
208
The nurse is caring for a young school-age child who was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement by the child's mother requires follow up teaching?
A) "I will let my child do homework while watching a favorite television show."
B) "I will give my child ADHD medication with meals."
C) "I will take my child to the doctor every 3 months for a weight and height check."
D) "I will stick to the same routine each day after school."
Answer: A
Explanation: A) This child should do homework in a quiet environment, away from distractions. Giving ADHD medication with meals will help counteract the anorexia associated with this medication. Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia. Children with ADHD should be screened regularly for height and weight to monitor growth.
209
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The nurse is teaching the family of a child who is prescribed amphetamine mixed salts sustained release (Adderall XR) for attention-deficit/hyperactivity disorder (ADHD). Which of the following should the nurse teach the family is the best time to administer the medication?
A) Just before lunch
B) At bedtime
C) With the evening meal
D) Early in the morning
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Answer: D
Explanation: A) Administering the medication early in the day can help alleviate the effect of insomnia. Before lunch might be difficult and cause embarrassment to the child if the child is in school. Evening and bedtime are incorrect as this medicine can cause insomnia.
210
A community health nurse is teaching a group of women about the dangers of smoking. Which of the following child health problems should the nurse mention as associated with smoking during pregnancy?
A) Benzodiazepine withdrawal
B) Attention-deficit/hyperactivity disorder (ADHD)
C) Vision impairment
D) Personality disorders
Answer: B
Explanation: A) Maternal smoking during pregnancy is associated with an increased risk for ADHD in children. Smoking during pregnancy is not related to vision impairment, personality disorders, or benzodiazepine withdrawal.
211
A nurse is caring for a child who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The client's healthcare provider has prescribed amphetamine-dextroamphetamine (Adderall) to treat the child's disorder. Which of the following statements regarding the use of this medication is appropriate for the nurse to include in the medication teaching?
A) "Your child's liver function should be monitored with this medication."
B) "Your child's growth will need to be monitored on this medication."
C) "This medication may increase the risk of psychosis."
D) "This medication has less abuse tendency because it is not a stimulant."
Explanation: A) Amphetamine-dextroamphetamine (Adderall), a psychostimulant, may delay the child's growth, and height should be monitored frequently. Liver function should be monitored with nonstimulant medications, not stimulants. Nonstimulants, not stimulants, may increase the risk of psychosis. Stimulant medications have a higher–not a lower–tendency to be abused.
212
A community health nurse is educating pregnant clients about the risk factors associated with the development of attention-deficit/hyperactivity disorder (ADHD). Which statement will the nurse include in the educational session?
A) "ADHD has not been linked to prenatal exposure or disease."
B) "ADHD has been linked to a specific gene, and genetic testing may help to diagnose this."
C) "ADHD has been linked to prenatal exposure to cigarette smoke."
D) "ADHD has been linked to childhood exposure to folate."
Answer: C
Explanation: A) Although ADHD has not been linked to a specific gene, the disorder has been linked to prenatal exposure or disease. Prenatal exposure to cigarette smoke increases the risk for the child to develop ADHD. ADHD has been linked to childhood exposure to lead, not folate.
213
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) Assuming approximately the same birth weight, level of prenatal care, and level of genetic predisposition, which of the following infants is least likely to develop ADHD during childhood?
A) An infant born at 35 weeks' gestation
B) An infant born at 36 weeks' gestation
C) An infant born at 38 weeks' gestation
D) An infant born at 34 weeks' gestation
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Answer: C
Explanation: A) Preterm birth is a risk factor for ADHD. The infant born at 38 weeks is considered a term infant; all the others are considered preterm. Thus, the infant born at 38 weeks is at lowest risk.
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Answer: C
Explanation: A) Preterm birth is a risk factor for ADHD. The infant born at 38 weeks is considered a term infant; all the others are considered preterm. Thus, the infant born at 38 weeks is at lowest risk.
Answer: B
Explanation: A) Typically, girls with ADHD show far more anxiety, mood swings, social withdrawal, rejection, and cognitive and language problems than boys, but less aggression and impulsiveness. Sleep disturbances are common in ADHD clients of both genders.
215
A nurse is completing a psychosocial assessment of an adult client. Which finding is most consistent with an adult who has ADHD?
A) "The client stated that he has many friends and an active social life, and he thrives in fast-paced environments."
B) "The client stated that at times he feels tired and listless, struggling to get out of bed and complete basic self-care tasks."
C) "The client stated that he feels confident when completing job tasks and is punctual and effective at work, even though he has difficulty getting along with coworkers."
D) "The client stated that he struggles with alcohol use and often engages in unprotected sex and recreational drug use."
Answer: D
Explanation: A) Chemical dependence and participation in risky behaviors are common in adults with ADHD. Personal and social relationships tend to be difficult for adults with ADHD, so it is unlikely he would enjoy socializing with others. In addition, adults with ADHD tend to struggle in the workplace. Finally, tiredness, listlessness, and inability to complete care tasks would be indicative of depression, not ADHD
216
A pediatric nurse is performing an assessment on a toddler who is suspected of having autism spectrum disorder (ASD). Which of the following questions to the parents would be least useful in gathering the information necessary to appropriately assess the toddler for this disorder?
A) "Does your child have manic or depressed episodes?"
B) "Tell me about your child's social interactions."
C) "Does your child perform ritualistic behaviors when performing activities?"
D) "Is your child able to name objects?"
Answer: A
Explanation: A) Manic or depressed episodes are characteristics of bipolar disorder, not autism. Autism is characterized by social isolation, communication impairment, and strange repetitive behaviors.
217
Which should the nurse identify as risk factors for a pregnant client having a baby with autism? Select all that apply.
A) Employed as a computer programmer
B) Smokes one pack per day of cigarettes
C) Drinks two glasses of wine on the weekends
D) Age 40
E) Rides a stationary bicycle four times a week for 30 minutes
Which should the nurse identify as risk factors for a pregnant client having a baby with autism? Select all that apply.
A) Employed as a computer programmer
B) Smokes one pack per day of cigarettes
C) Drinks two glasses of wine on the weekends
D) Age 40
E) Rides a stationary bicycle four times a week for 30 minutes
Answer: B, C, D
218
A nurse is providing education to the caregiver of a child with autism spectrum disorder (ASD). Which commonly associated behavioral problem should be identified in this teaching?
A) Depression in relation to feelings of inadequacy
B) Episodes of self-injury
C) Strong tendency toward hypoactivity
D) Hostility when faced with structured environments or repetitive activities
Answer: B
Explanation: A) Many children with a spectrum disorder have associated behavioral problems such as hyperactivity, aggressiveness, temper tantrums, and self-injurious behaviors like head banging. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. These children typically have a restricted, repetitive repertoire of interests or behaviors, and therefore usually will not become depressed due to perceiving themselves as inadequate (although some children with high-functioning ASD may experience feelings of inadequacy). Many children with ASD will have difficulty adapting to change, so they will prefer structured environments and consistent schedules. These children also tend toward hyperactivity rather than hypoactivity, although this is not always the case.
219
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The parents of a child with autism spectrum disorder (ASD) observe that the child has difficulty making friends and are concerned about social expectations for their child. Which of the following is the priority diagnosis for this child based on the parents' concern?
A) Ineffective Coping
B) Deficient Diversional Activity
C) Social Isolation
D) Impaired Social Interaction
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The parents of a child with autism spectrum disorder (ASD) observe that the child has difficulty making friends and are concerned about social expectations for their child. Which of the following is the priority diagnosis for this child based on the parents' concern?
A) Ineffective Coping
B) Deficient Diversional Activity
C) Social Isolation
D) Impaired Social Interaction
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220
The parent of a child with autism spectrum disorder (ASD) asks why family therapy has been prescribed. Which response by the nurse is most appropriate?
A) "Family therapy will help you learn how to assess your child's potential."
B) "Family therapy will provide your child with an opportunity to learn problem-solving skills."
C) "Family therapy will help you interact with your child."
D) "Family therapy will help you learn how to cope with your child's diagnosis."
Answer: D
Explanation: A) Parents of children with autism report more family problems, more marital problems, more depression, and more social isolation than parents of typically developing children or parents of children who are severely and persistently mentally ill. Family therapy will help them cope with the diagnosis through the problem-solving process. The other responses are important interventions for the child but are not the goal of family therapy.
221
The nurse is caring for a child newly diagnosed with autism spectrum disorder (ASD). Which of the following is the most appropriate overall outcome for this child?
A) To function more effectively in social and emotional interactions
B) To stay on task
C) To acknowledge the effects of personal behavior on others
D) To acknowledge personal strengths
Answer: A
Explanation: A) Autism spectrum disorders involve difficulties in the quality of both the social interaction and the communication of the child. In social interaction, the child may have problems making eye contact, fail to develop appropriate peer relationships, fail to spontaneously seek out shared enjoyment with other people, or show no social or emotional reciprocity. Children with spectrum disorders may or may not be able to acknowledge the effects of their behavior on others, stay on task, or acknowledge personal strengths.
222
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The nurse is providing education to the parents of a child diagnosed with ASD. Which of the following healthcare professionals should the nurse tell the parents will take part in their child's care? Select all that apply.
A) Social services
B) Laboratory
C) Speech therapy
D) Play therapy
E) Public health agency
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Answer: A, C, D
Explanation: A) The goals of therapy are to facilitate communication, reduce rigidity, and treat maladaptive behaviors. To reach these goals, the child will be treated by a speech therapist, a play therapist, and social services. Laboratory technicians do not treat clients. A public health agency does not treat clients, although individuals who work there might.
223
The nurse is caring for a child diagnosed with autism spectrum disorder (ASD) who is being admitted to the hospital with dehydration. Which action by the nurse is appropriate when the child arrives to the care area?
A) Take the child on a tour of the pediatric unit.
B) Take the child to the playroom for arts and crafts.
C) Quietly orient the child to a single-bed hospital room.
D) Orient the child to a four-bed unit.
Answer: C
Explanation: A) Orienting a child with autism to a new environment is important, although this must be done in a quiet, controlled environment. A single room is the best place for an autistic child if the child must be hospitalized. Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. Arts and crafts might be appropriate for an autistic child if done in the child's room, but going to the playroom would be too much stimulation for this child. An autistic child should be in a single room, if possible, away from distractions.
224
The nurse is caring for an adult client with ASD. He indicates that he struggles with finding and maintaining employment. Which action by the nurse best addresses the client's needs?
A) Give the client information about state subsidies that will help him get by without a job.
B) Suggest the client work for a business owned by a family member or family friend.
C) Ask the client what his strengths are and identify types of jobs based on those strengths.
D) Encourage the client to seek opportunities that do not require communication with others.
Answer: C
Explanation: A) Adults with ASD are most successful when they seek employment opportunities that play to their strengths. Many adults with ASD are financially subsidized by the state, but if the client wishes to work, the nurse should encourage him and help him with that goal. Working for a family member or friend's business might help the client find a job, but does not address the issues that make it difficult for him to keep a job. Communication is a struggle with clients with ASD, but discouraging communication with others would not be appropriate, nor is it realistic in the workplace.
225
A parent of a high school student with high-functioning ASD asks whether the child will ever be able to work. Which response by the nurse is best?
A) "There are job training programs that assist adults with ASD."
B) "Most adults with high-functioning ASD need to be supported by the state."
C) "You should plan to provide care for your child for the rest of your life."
D) "Individuals with high-functioning ASD usually grow out of the disorder."
A parent of a high school student with high-functioning ASD asks whether the child will ever be able to work. Which response by the nurse is best?
A) "There are job training programs that assist adults with ASD."
B) "Most adults with high-functioning ASD need to be supported by the state."
C) "You should plan to provide care for your child for the rest of your life."
D) "Individuals with high-functioning ASD usually grow out of the disorder."
226
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An individual with ASD who demonstrates marked distress on switching activities (such as responding with loud verbalizations and behaviors that could result in self-harm) is demonstrating which level of clinical manifestations of the disorder?
A) Level I clinical manifestation
B) Level II clinical manifestation
C) Level III clinical manifestation
D) Level IV clinical manifestation
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Answer: C
Explanation: A) Marked distress on switching activities is a level III manifestation of ASD. Level I manifestations typically include inflexible behavior and organizational problems, and level II manifestations typically involve difficult switching activities but not distress. There is no level IV categorization for clinical manifestations.
227
A nurse is assessing a child who shows marked abnormalities in speech patterns. These includes using you in place of I, parroting words and phrases, and repeating questions rather than answering them. The nurse should recognize that these are characteristic of which condition?
A) Cerebral palsy
B) Autism spectrum disorder
C) Attention-deficit/hyperactivity disorder (ADHD)
D) Failure to thrive
Answer: B
Explanation: A) Using you in place of I, engaging in echolalia (compulsive parroting of a word of phrase just spoken by another), and repeating questions rather than answering them are speech patterns typically indicative of autism spectrum disorder. Speech abnormalities are generally not seen in cerebral palsy, ADHD, or failure to thrive.
228
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The nurse is caring for a 9-month-old client diagnosed with ataxic cerebral palsy (CP). Which of the following clinical manifestations does the nurse anticipate when assessing this client? Select all that apply.
A) Muscle instability
B) Hypotonia
C) Hemiplegia
D) Hypertonia
E) Tremors
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Answer: A, B
Explanation: A) Hypotonia in infancy and muscle instability are seen in ataxic CP. Hemiplegia and hypertonia are seen in spastic CP. Tremors and exaggerated posturing are seen in dyskinetic CP. Hypertonia and persistent primitive reflexes are seen in spastic CP.
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The nurse is providing teaching to a client who is concerned about giving birth to a child with cerebral palsy. Which would the nurse include as risk factors for the condition? Select all that apply.
A) Cesarean delivery
B) Severe jaundice following birth
C) Infection and fever during pregnancy
D) Preterm labor
E) Birth weight of 9 pounds or above
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The nurse is providing teaching to a client who is concerned about giving birth to a child with cerebral palsy. Which would the nurse include as risk factors for the condition? Select all that apply.
A) Cesarean delivery
B) Severe jaundice following birth
C) Infection and fever during pregnancy
D) Preterm labor
E) Birth weight of 9 pounds or above
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) The nurse is planning care for a child who is diagnosed with cerebral palsy (CP). Which of the following are appropriate nursing diagnoses for this child? Select all that apply.
A) Impaired Mobility
B) Risk for Injury
C) Anxiety
D) Caregiver Role Strain
E) Deficient Diversional Activity
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Answer: A, B, E
Explanation: A) The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
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Answer: A, B, E
Explanation: A) The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
Answer: D
Explanation: A) The family members will need breaks from caring for the child in order to provide time for themselves and the other children. Meals-on-Wheels is a service intended for those who are shut-ins. There is no evidence that the family is financially challenged and needs food stamps. Counseling is an option if and when the family shows signs of ineffective coping, which respite care is designed to help prevent.
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The nurse caring for a child recently diagnosed with cerebral palsy (CP) is discussing the plan of care with the parents. Which should the nurse identify as a major goal of therapy for this child?
A) Promoting optimal global development
B) Increasing the child's IQ level
C) Reversing the degenerative processes that have occurred
D) Curing the underlying defect
Explanation: A) Promoting optimal development in all areas is the goal of therapy with children with CP. CP is caused by a probable brain insult and cannot be cured. Most children with CP have normal IQs, but they might have behavior or perceptual problems. CP is caused by an irreversible brain insult.
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A child with cerebral palsy (CP) is scheduled for casting of the lower extremities. When instructing the parents about the purpose of the casts, which of the following will the nurse include in the teaching session? Select all that apply.
A) Promote skeletal alignment
B) Maintain stability
C) Improve muscle tone
D) Improve muscle function
E) Control involuntary movements
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Answer: A, B, E
Explanation: A) Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.
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Which statement made by a parent would cause the nurse to suspect that the infant may have a developmental condition like cerebral palsy (CP)?
A) "My 6-month-old baby is rolling from back to prone now."
B) "My 8-month-old cannot sit without support."
C) "My 10-month-old is not walking."
D) "My 3-month-old smiles at me all the time."
Answer: B
Explanation: A) Children with cerebral palsy are delayed in meeting developmental milestones. The infant who fails to sit unassisted at 8 months of age is showing a delay. A baby rolls over from back to prone at 6 months, smiles socially at 6 weeks, and walks at 12 months.
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Answer: B
Explanation: A) Children with cerebral palsy are delayed in meeting developmental milestones. The infant who fails to sit unassisted at 8 months of age is showing a delay. A baby rolls over from back to prone at 6 months, smiles socially at 6 weeks, and walks at 12 months.
Answer: C
Explanation: A) As individuals with CP age, they are more prone to both urinary and bowel incontinence. CP does not increase the risk of bladder infection. Incontinence is often a cause of depression in CP patients, not the other way around. Urinary incontinence in adults with CP is usually not due to neurologic problems. In addition, the doctor—not the nurse—would refer the client to a neurologist.
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The nurse sees several adult clients between the ages of 30 and 40 for annual checkups, one of whom has CP. Which of the following client statements represents a common consequence of the stress state caused by CP?
A) "My muscles seem to always hurt all over, and my joints are sore a lot, too."
B) "I have a really hard time socializing and understanding nonverbal communication.
C) "There are times when I just cannot control my anger and I hurt other people."
D) "I just have no appetite lately, and I seem to get dehydrated a lot."
Answer: A
Explanation: A) The majority of adults with CP will have signs of premature aging by their early 40s. These include chronic pain due to the contractions of the muscles, arthritis due to the wear and tear on the joints, and persistent fatigue due to the extended energy needed to work against contracted muscles. Difficulty socializing and understanding nonverbal cues are characteristic of adult ASD. Aggression problems are characteristic of ADHD. Lack of appetite and dehydration are typical of geriatric failure to thrive.
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10) An infant is diagnosed with congenital CP caused by a meningitis infection. Based on this diagnosis, the nurse understands that the pathway for cellular damage is
A) genetic mutation to the brain cells prompted by infection with the causative agent.
B) accumulation of causative agents in the blood stream that gradually build up in the brain.
C) stretching and shearing of the neural pathways and brain tissue.
D) consumption of brain tissue and production of lactic acid by the causative pathogen.
Answer: D
Explanation: A) Streptococcus pneumonia is the pathogen that causes meningitis in infants, and it causes cellular damage through consumption of the brain's tissue and production of the byproduct lactic acid. Genetic mutations are not caused by infections. Neurotoxins like bilirubin accumulate in the bloodstream and eventually damage nerve cells in the brain. Trauma stretches and shears neural pathways and brain tissue.
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Which of the following sets of symptoms would the nurse identify in an infant exhibiting hypotonia?
A) Tense muscles and uncoordinated, awkward, stiff movements
B) Increased range of motion of joints, diminished reflex response, floppiness
C) Constant involuntary writhing motions that are more severe distally.
D) Paralysis of one side of the body, with greater upper extremity dysfunction
Answer: B
Explanation: A) Floppiness, increased range of motion of joints, and diminished reflex response are all hallmarks of hypotonia. Tense or tight muscles and uncoordinated, awkward, stiff movements are typical of hypertonia. Constant involuntary writing motions that are more severe distally are signs of athetosis. Paralysis of one side of the body, with the upper extremities being more dysfunctional than the lower extremities, is indicative of hemiplegia.
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While conducting a well-child assessment, the nurse suspects that a 2-month-old has failure to thrive (FTT). Which of the following height and weight measurement parameters should the nurse use to help diagnose this health problem?
A) Height and weight below the 50th percentile
B) Height and weight below the 15th percentile
C) Height and weight below the 5th percentile
D) Height and weight below the 10th percentile
Answer: C
Explanation: A) A child whose weight and height fall below the 5th percentile is diagnosed with failure to thrive. The other percentiles—10th, 15th, and 50th—are higher than that used to diagnose FTT.
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During a home visit, the nurse suspects that a newborn is at risk for failure to thrive (FTT). Which statement by the child's mother supports this assessment?
A) "I do not like to cook."
B) "I needed help at first learning to breastfeed my baby."
C) "I have a glass of wine with dinner once a week."
D) "I have been feeling depressed for the past several weeks."
Answer: D
Explanation: A) The mother who is depressed and anxious may not be interacting appropriately with her infant and puts the child at risk for failure to thrive. A glass of wine once a week is appropriate. The mother's aversion to cooking will not affect the infant. Needing help with breastfeeding is normal for a first-time mother.
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The nurse is caring for a child with intellectual deficits who has been diagnosed with failure to thrive (FTT). The family is expressing difficulty with managing the child's care needs. Which nursing diagnosis would be appropriate for this situation?
A) Impaired Parenting related to poor parenting skills
B) Dysfunctional Family Processes related to a child with intellectual disability
C) Hopelessness related to terminal condition of the child
D) Compromised Family Coping related to the child's developmental variations
Answer: D
Explanation: A) The family's ability to cope is compromised by the child's developmental variations, but the family is not dysfunctional. Hopelessness and Impaired Parenting are not appropriate in the given situation.
242
The parents of an infant report that the baby is often withdrawn and lethargic and does not eat or sleep well. The nurse notes that the child is underweight and small for its age. Which action by the nurse is most appropriate?
A) Giving the baby medicine for colic
B) Drawing blood for laboratory work
C) Feeding the baby
D) Observing interactions between the parents and the infant
Answer: D
Explanation: A) Because the parents' concerns and nurse's observations are possibly related to failure to thrive, the nurse would assess the relationship and interactions between the infant and the parents. Assessment is the priority, not feeding the baby. The physician—not the nurse—orders labs and medications.
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The nurse suggests that the mother of an infant with failure to thrive (FTT) see a lactation specialist to assist with breastfeeding. Which goal is appropriate when planning care for this family?
A) Increase the number of well-child checkups for the child.
B) Convince the mother to use formula instead of continuing with breastfeeding.
C) Improve the parent-child relationship.
D) Prevent complications associated with poor nutrition.
Answer: D
Explanation: A) The goal is to prevent complications associated with poor nutrition. There is no evidence that the mother is not relating well to the child. Increasing the amount of checkups will not improve nutrition. If the mother wishes to continue breastfeeding and help can be obtained, it may be harmful to her self-esteem to insist she bottle feed the infant, although supplementation with formula is an option.
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A nurse is teaching a mother of an infant who has been diagnosed with failure to thrive (FTT) about the treatment for the condition. Which statement by the nurse is appropriate?
A) "Appetite stimulant medications will be prescribed to help your child gain weight."
B) "If your child is breastfeeding, you must stop and feed your child formula."
C) "A home care nurse will be visiting to see how your child eats."
D) "A home care nurse will be visiting to insert a nasogastric feeding tube in your child."
Answer: C
Explanation: A) Teaching the child's parent is paramount in the treatment for a child with FTT. A home care nurse may visit the child's home to observe how the child eats in order to teach the child's parent about any barriers or techniques to improve nutrition. No specific pharmacologic therapy is indicated with FTT. A woman who is breastfeeding a child with FTT does not need to stop breastfeeding. The mother should be provided teaching about proper breastfeeding techniques and additional information as needed. A child with FTT does not automatically require a nasogastric tube for enteral feedings.
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Answer: C
Explanation: A) Teaching the child's parent is paramount in the treatment for a child with FTT. A home care nurse may visit the child's home to observe how the child eats in order to teach the child's parent about any barriers or techniques to improve nutrition. No specific pharmacologic therapy is indicated with FTT. A woman who is breastfeeding a child with FTT does not need to stop breastfeeding. The mother should be provided teaching about proper breastfeeding techniques and additional information as needed. A child with FTT does not automatically require a nasogastric tube for enteral feedings.
Answer: A
Explanation: A) Age-related changes impact food intake and digestion and can lead to GFTT, including decreased sense of taste, decreased secretion of digestive enzymes, and decreased salivation. GI motility also slows with age, decreasing metabolism. Neurologic diseases or conditions can lead to either FTT or GFTT, as can excessive caloric expenditure. Congenital errors of metabolism often cause FTT, not GFTT.
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Which of the following best describes the relationship of nutrition, immunity, and geriatric failure to thrive (GFTT)?
A) Illness leads to decreased appetite, which leads to decreased nutrition. This leads to decreased ability to recover from illness. Illness increases susceptibility to GFTT.
B) Decreased nutrition leads to increased appetite. If appetite is so great that it cannot be satiated, GFTT develops. Once GFTT develops, risk of illness and infection increases.
C) Decreased appetite leads to decreased in nutrition. This leads to decreased ability to recover from infection, which increases susceptibility to illness. Illness increases susceptibility to GFTT.
D) GFTT leads to decreased appetite. This leads to imbalanced nutrition and increased susceptibility to illness. This increases the likelihood that GFTT will become chronic.
Which of the following best describes the relationship of nutrition, immunity, and geriatric failure to thrive (GFTT)?
A) Illness leads to decreased appetite, which leads to decreased nutrition. This leads to decreased ability to recover from illness. Illness increases susceptibility to GFTT.
B) Decreased nutrition leads to increased appetite. If appetite is so great that it cannot be satiated, GFTT develops. Once GFTT develops, risk of illness and infection increases.
C) Decreased appetite leads to decreased in nutrition. This leads to decreased ability to recover from infection, which increases susceptibility to illness. Illness increases susceptibility to GFTT.
D) GFTT leads to decreased appetite. This leads to imbalanced nutrition and increased susceptibility to illness. This increases the likelihood that GFTT will become chronic.
Answer: C
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) What does a nonorganic cause of failure to thrive (FTT) mean?
A) The FTT is not the result of a disease process or medical condition.
B) The FTT is the result of inborn errors in metabolism.
C) The FTT is the result of congenital disease.
D) The FTT is the result of a congenital anomaly such as cleft palate.
Answer: A
Explanation: A) Most cases of FTT are nonorganic in origin, meaning they are not the result of a disease process or medical condition. FTT resulting from nonorganic causes is called feeding disorder of infancy or early childhood. Organic causes of FTT include congenital diseases,
248
A nurse is caring for a pregnant client who has a history of depression. When including information to decrease the client's risk for having an infant diagnosed with failure to thrive (FTT), which of the following rationales is appropriate?
A) Women with mental illness have a decreased breast-milk supply, increasing the risk of FTT.
B) Women with mental illness may be socially isolated, increasing the risk of FTT.
C) Women with mental illness take medications that pass through the breast milk, increasing the risk of FTT.
D) Women with mental illness lack the knowledge required to provide adequate nutrition, increasing the risk of FTT.
Answer: B
Explanation: A) Women with mental illness may be socially isolated, increasing the risk of FTT. The other statements are false generalizations and are not culturally competent statements.
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The nurse is caring for a client who sustained multiple injuries in an automobile accident. As a part of secondary prevention for this client, which does the nurse include in the plan of care?
A) Promote wellness.
B) Detect early disease.
C) Restore the client to previous functioning.
D) Prevent the progression of more symptoms.
Answer: D
Explanation: A) Rehabilitation is tertiary prevention and is aimed at restoring the client to the previous level of functioning. Prevention of the progression of symptoms and early detection of disease are secondary preventions. Promoting wellness is considered primary prevention.
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Answer: D
Explanation: A) Rehabilitation is tertiary prevention and is aimed at restoring the client to the previous level of functioning. Prevention of the progression of symptoms and early detection of disease are secondary preventions. Promoting wellness is considered primary prevention.
Answer: C, D, E
Explanation: A) Managed care describes a healthcare system that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Managed care clinics will emphasize cost-effective care by offering preventive services and health promotion activities. Case management describes a range of models for integrating and delivering healthcare services from multiple providers to the client. Client-focused care is a delivery model that organizes healthcare services around the stated needs of the client.
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A nurse working on a medical-surgical unit has opted to return to school to earn a Bachelor of Science in Nursing (BSN) degree. After considering projected changes in healthcare and the population cared for in the community, which includes an expanding minority population composed largely of immigrants arriving from Central and South America as well as older adults as the fastest-growing demographic, the student might consider selecting which elective course?
A) A course on medical Spanish
B) A psychology course on young adults
C) A personal finance class
D) A class on the effect of illness on a young child
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Answer: A
Explanation: A) Minorities in the United States will likely be the majority by the year 2042. By becoming proficient at other languages, such as Spanish, the nurse will be better able to meet the needs of the clients who seek care within the community. The largest group of clients will be age 65 or older in the near future, so an extra class about an aging population would be more helpful than a class about children or young adults. The student might consider a class on the effects of finance and cost in the delivery of healthcare rather than personal finance.
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252
The manager of a small clinic has cross-trained the nurses to perform electrocardiogram (ECG) testing, phlebotomy, and some respiratory therapy interventions. This clinic is providing client-focused care. Which of the following actions shows this delivery model in action?
A) Many disciplines collaborate to provide client care.
B) Client care is carefully managed to control costs.
C) If a client complains of breathing difficulty, nurses concentrate on respiratory therapy for that client.
D) Client progress is efficiently tracked
Answer: C
Explanation: A) In client-focused care, the needs of the client, physical or emotional, as expressed by the client drive care decisions. Interdisciplinary collaboration, careful cost management, or efficient tracking of client progress are not distinguishing features of this model.
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A nurse is planning a community health fair at a local community center. Which goals regarding health promotion does the nurse plan to highlight at the event? Select all that apply.
A) The ability to change and modify goals as health needs change
B) The ability for clients to be able to assess and evaluate their health needs
C) The ability for the client to promote health in other individuals
D) The ability to promote cost-saving techniques to healthcare providers
E) The ability to prevent disease by imitating nursing techniques
A nurse is planning a community health fair at a local community center. Which goals regarding health promotion does the nurse plan to highlight at the event? Select all that apply.
A) The ability to change and modify goals as health needs change
B) The ability for clients to be able to assess and evaluate their health needs
C) The ability for the client to promote health in other individuals
D) The ability to promote cost-saving techniques to healthcare providers
E) The ability to prevent disease by imitating nursing techniques
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The nurse knows that communication among healthcare team members is essential during mass casualty events (MCEs). Which is essential when communicating under these circumstances?
A) Providing concise, accurate, and timely information
B) Preparing for ethical challenges
C) Documenting to prevent legal issues
D) Coordinating care between management and clinicians
Answer: A
Explanation: A) Communication among the various emergency team members must be concise, accurate, and timely during an MCE. Nurses must use their knowledge to foster better communication. Nurses face ethical and legal issues associated with the provision of care in MCEs, and they are also challenged as they decide what care to provide to patients; however, these issues do not directly affect communication even though they are affected by communication.
255
Why should job seekers in the healthcare sector pay attention to advances in healthcare technology?
A) Advances in technology require specialized personnel.
B) Advances in technology involve policies and strategies at the organizational level.
C) Changing demographics increase the need for new jobs.
D) Technology plays a role in health literacy.
Answer: A
Explanation: A) Many advances in technology require specialized personnel, creating new opportunities for individuals seeking employment in the healthcare sector. These advances may involve politics and strategies at the organizational level, but that is not of primary interest to job seekers. Changing demographics do not necessarily involve technology. Technology does play a role in health literacy, but this is not of primary interest to job seekers.
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The nurse is taking care of a client who is being discharged but will need home nursing care, physical therapy, and speech therapy. Which framework helps the client who has multiple care needs?
A) Case management
B) Client-focused care
C) Managed care
D) A health maintenance organization
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Answer: A
Explanation: A) Multidisciplinary teams led by a case manager are at the heart of successful case management. Case management is essential when a client has multiple care needs and requires the services of multiple providers. The goal of case management is to reach and then maintain the individual's optimum level of health, quality of life, and activities of daily living by ensuring that the individual's healthcare needs are met. Client-focused care is focused on the client's expressed needs but not specifically on providing the services of multiple providers, managed care provides high-quality care at a lower cost but is not specifically focused on providing the services of multiple providers, and HMOs are a kind of managed care.
257
If more older adults live in Mississippi than elsewhere in the United States and clients in Massachusetts have much greater access to health services than clients elsewhere in the United States, then what does this imply about access of older adults to healthcare in Mississippi?
A) The likelihood is that more specialists serving older populations will work in Mississippi than in Massachusetts.
B) Their access to healthcare should be roughly equal to that of older adults living in Massachusetts but with a different mix of providers.
C) The need for services will be much greater for older adults in Mississippi than in Massachusetts due to a decreasing number of healthcare providers.
D) There will be much more robust rural services for older adults in Mississippi than in Massachusetts.
Answer: C
Explanation: A) No states have enough primary care providers to meet their needs. Aggravating this problem is the growing number of healthcare providers who specialize. If Massachusetts is a state with a much greater than average access for clients to health services, it is likely that states such as Mississippi offer less access to these services and fewer primary care physicians, and Mississippi's greater population of older adults will lack access to the care they need. Nothing here implies that there will be fewer specialists working in Massachusetts, and the trend is for more specialists everywhere. Nothing here indicates anything about the mix of providers in either state, and rural services tend to be lacking.
258
The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. Which of the following is the best example of this problem for the educator to share with the students?
A) "Delays of diagnoses lead to higher mortality and morbidity rates."
B) "Delays in health coverage for children put the health provider at risk for litigation."
C) "Immunizations are free for children at public health clinics."
D) "Older adults are less likely to be treated for falls."
Answer: A
Explanation: A) Those who are not insured, or are underinsured, often do not seek treatment in a timely manner due to finances. As a result, diagnosis is made in the later stages of the disease, resulting in decreased chance of survival and an increased cost of treatment. The exposure of healthcare providers to litigation is not an aspect of this issue. Children with healthcare coverage receive preventive care such as immunizations and are more likely to stay healthy and do well in school. Adults age 65 and older are eligible for Medicare and have access to healthcare for falls and other medical problems.
259
The nurse in an urgent care center is assessing an adult client who is diagnosed with the flu. The nurse discusses the need for flu shots with the client, who states, "I cannot afford the shots. I do not have health insurance." Which suggestion by the nurse is most appropriate?
A) Seek preventive care at the local health department.
B) Find a primary care physician who will give free care.
C) Obtain the flu shot at a local pharmacy.
D) Get the shot every year in the emergency department.
Answer: A
Explanation: A) Public health organizations, such as local health departments, are available for those who are uninsured or underinsured. This provides the client with health promotion and preventive measures as well as treatment when the client is ill. Using the emergency department for preventive care is part of the increased cost of healthcare. The nurse should not give the client a vague message that he or she needs need to find a care provider who gives free care. Rather, the nurse would refer the client to a specific place that can meet the client's needs. Flu shots at pharmacies require payment by the client and are not the solution for those with a low income and no insurance.
260
A client asks the nurse, "How am I going to pay for a surgery? I'm broke, but I've been so sick." Which statement regarding the Affordable Care Act (ACA) may be applicable to this client's situation?
A) "The ACA extends coverage to people who do not qualify for public assistance and whose employers do not offer health insurance."
B) "Unfortunately, you will probably be denied coverage because of your existing condition."
C) "Most insurance premiums will be more and some less; you will have to shop around."
D) "Because the rate of inflation is slowing, the ACA will also help curb medical costs
Answer: A
Explanation: A) The ACA was created to ensure that all U.S. citizens have access to affordable, quality care and to curb the growth of healthcare costs. Under the ACA, a client cannot be denied coverage because of an existing condition. Insurance premiums should remain the same. The ability of the ACA to curb medical costs is irrelevant to this client's needs.
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A nurse on the pediatric unit contemplates the changes in healthcare insurance for 2014 when speaking with other colleagues. Which aspects of the Affordable Care Act (ACA) affect children favorably? Select all that apply.
A) Insurance companies cannot deny coverage based on preexisting conditions.
B) Insurance companies cannot drop children who have serious illnesses.
C) Benefits are paid through private benefactors.
D) All children are covered regardless of whether the parents are covered.
E) The government must make appropriate arrangements for children based on need.
Answer: A, B
Explanation: A) Children with healthcare coverage receive preventive care and are more likely to attend school regularly and have better focus. The ACA will affect children favorably because insurance companies will no longer be able to deny coverage to children based on preexisting conditions or drop insured individuals and/or their dependents who experience serious illness. Under the ACA, benefits are not paid through private benefactors. Coverage is intended for all U.S. citizens, not just children and not only based on an assessment of need.
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The nurse knows that Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 to prevent which action by emergency services?
A) Refusing to treat uninsured clients
B) Servicing suburban clients only
C) Stopping the poor from using emergency services as primary care
D) Providing free examinations to the poor
Answer: A
Explanation: A) In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Prior to the enactment of this law, providers of emergency services often refused to treat clients who were uninsured and who could not afford to pay for services. EMTALA does not have to do with provisions for nonsuburban clients, ensuring the poor use emergency services as primary care, or preventing free examinations to the poor.
263
The nurse taking care of a client in the clinic notes that the client comes in twice per week, but never seems to have anything majorly wrong. Which is a benefit of providing education about self-care to this client?
A) The client's perception of need will change, promoting appropriate and timely healthcare.
B) The client will continue to come to the clinic seeking help until someone helps the client.
C) The client will seek affordable insurance by which to gain appropriate healthcare.
D) The client will learn to seek healthcare services from legitimate sources.
Answer: A
Explanation: A) A client's perceived need for healthcare services can be a barrier to access. It may cause clients to seek care that is unnecessary or care that is necessary but provided at an inappropriate and often more expensive place of service than needed. The nurse can change clients' perception of need (thereby promoting appropriate and timely healthcare) by managing client care, teaching adults about self-care and the care of their children, and teaching clients when and how to access appropriate care. An educated client will not continue to come to the clinic when there is no need. The issue here is not the need for affordable insurance or the inability to recognize legitimate sources of care.
264
At a local seminar discussing healthcare resources, the nurse discusses the phenomenon that healthcare resources are declining while costs for healthcare are increasing. An older adult in attendance asks the speaker why it has become so difficult to obtain needed care and services. Which response by the nurse is the most appropriate?
A) "There is increased cost due to the increased incidence of malpractice lawsuits."
B) "There is a decrease in the number of adults needing care."
C) "There are not enough medications produced for those who need them."
D) "There are plenty of nurses but not enough doctors."
Answer: A
Explanation: A) Services are reduced because of increasing costs and needs. One reason for increased costs is the practice of defensive medicine because of the risks of malpractice litigation. There is an increasing shortage of nurses and physicians. Over the next decade, there will be an increasing number of older adults needing medical care. The cost of supplies and medication, not the amount available, is the reason for decreased services.
265
The nurse is assessing an older adult client in the free clinic. The nurse notes that the client's cholesterol level is higher than the target and has increased since the client's last visit. The nurse assesses the client for possible causes for this increase. After determining that the client has not changed dietary and exercise habits, which conclusion by the nurse is the most appropriate?
A) The client has increased egg consumption.
B) The client may not be taking medications as prescribed.
C) The client needs more aerobic activity.
D) The client may be experiencing high triglyceride levels.
Answer: B
Explanation: A) Rationing is a method used by individuals, insurance companies, and the government to prevent increases in the cost of healthcare or to reduce the cost of healthcare. Individuals ration when they decide to provide self-care for an illness or injury rather than seeking care from a healthcare provider. In the case of this client, rationing of prescribed medications is likely the issue because dietary and exercise habits have not changed, which rules out increased egg consumption or the need for more aerobic activity. Concluding that the client may be experiencing high triglyceride levels does not identify a reason for the increased cholesterol level.
266
A young mother brings her children to the health department for routine immunizations. The mother is crying because she lost her job and fears that her asthmatic daughter may be denied appropriate healthcare because she is unable to pay for it. The nurse realizes that many clients are experiencing these fears. Which action by the nurse would have the greatest impact for all clients who experience this fear?
A) Reminding the client that everything will be fine
B) Becoming involved in the American Nurses Association (ANA)
C) Moving to an area that needs healthcare workers
D) Giving the client medications and supplies from the clinic at no charge
Answer: B
Explanation: A) Because nurses are in a position to be closely associated with the needs of clients, nurses need to be involved in professional organizations that participate in educating legislators at the local and national levels. An example of such an organization is the American Nurses Association (ANA). For nurses to move to areas needing healthcare workers would not help with the rising cost of healthcare. Telling a worried parent that everything will be fine is giving the client potentially false hope. Giving clients supplies and medications from the clinic increases costs and will not help solve the overall problem with healthcare today.
267
A client in the clinic asks the nurse about a medication seen on television. When the nurse suggests a generic, cheaper version of the medication, the client is resistant to this recommendation. This is an example of which of the following?
A) Healthcare treatment choices that drive up costs
B) Factually misleading advertisements by pharmaceutical manufacturers
C) Client-focused care
D) The need for stricter Food and Drug Administration (FDA) safeguards for consumers
Answer: A
Explanation: A) Inappropriate healthcare treatment choices by consumers have also contributed to increases in healthcare costs. Mass advertising by pharmaceutical manufacturers and specialty treatment centers directed at consumers have contributed to these inappropriate treatment choices. However, this does not mean the advertisements are necessarily factually misleading. A client being guided in healthcare decisions by an advertisement is not an example of client-focused care or necessarily an argument for stricter FDA safeguards.
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) The local clinic staff has noticed an increase in the flu this season and requested more vaccine from the Centers for Disease Control and Prevention (CDC). The nurse knows that the CDC will control the vaccine distribution by considering which factors? Select all that apply.
A) The amount of vaccine being requested by local health departments
B) The speed at which the vaccine becomes available
C) Who gets the available vaccine
D) Ensuring that only medical personnel can receive the vaccine
E) Ensuring that only babies and military personnel receive the vaccine
) The local clinic staff has noticed an increase in the flu this season and requested more vaccine from the Centers for Disease Control and Prevention (CDC). The nurse knows that the CDC will control the vaccine distribution by considering which factors? Select all that apply.
A) The amount of vaccine being requested by local health departments
B) The speed at which the vaccine becomes available
C) Who gets the available vaccine
D) Ensuring that only medical personnel can receive the vaccine
E) Ensuring that only babies and military personnel receive the vaccine
269
The nurse educator is teaching a group of nursing students about the methods that are used by insurance companies to ration healthcare resources. Which method does the educator include in the teaching session regarding this topic?
A) Denying coverage for services not supported by research
B) Covering clients for preexisting conditions only
C) Providing health savings accounts for covered individuals
D) Covering organ donations
Answer: A
Explanation: A) Rationing is one means of allocating healthcare resources. Rationing is a method used by individuals, insurance companies, and the government to prevent increases in the cost of healthcare or to reduce the cost of healthcare. Methods used by insurance companies to ration healthcare resources include noncoverage (e.g., noncoverage of preexisting conditions for up to a year after enrollment) and denial of coverage for services (e.g., services deemed to be experimental or those that are not supported by scientific evidence that proves their efficacy). Covering clients for preexisting conditions only, providing health savings accounts, and organ donation are not methods of rationing used by insurance companies.
270
As a working professional concerned with proper resource allocation, the nurse knows that one reason to join the American Nurses Association (ANA) is for which opportunity?
A) To participate in national discussions about resources
B) To draw attention to the nurse's credentials
C) To determine how to fight for resources locally
D) To advocate for resources through different business sources
Answer: A
Explanation: A) Nurses must be aware of and participate in discussions that affect the allocation of healthcare resources in the workplace, in their communities, and at the federal level. Nurses are uniquely placed to advocate on behalf of clients when allocation of resources is being considered in their communities. They may advocate by talking with local legislators, writing to politicians, and engaging in discussions in their neighborhoods and social groups. As working professionals, nurses have the opportunity to participate in national discussions about resources through a number of professional organizations, such as the American Nurses Association. ANA membership as regards resource allocation is not a means of building the nurse's credentials, fighting for local resources, or enlisting business sources in the provision of resources.
271
The nurse is participating on a local council as an advisor regarding community needs during an emergency. Which recommendation regarding community needs during an emergency that the nurse might include when advising the council would be involved in the emergency response phase?
A) A coordinated emergency preparedness plan
B) Assembling disaster kits
C) Programs to restore the community
D) The identification of potential hazards to the community
Answer: A
Explanation: A) A coordinated response to emergencies occurs during the emergency response phase. Although a comprehensive disaster plan is developed in the preparedness phase, it is enacted in the emergency response phase. During the mitigation phase of the emergency response, the community identifies the potential hazards and takes measures to prevent or minimize the emergency. Assembling disaster kits is part of the preparedness phase. Programs to restore the community are part of the recovery phase.
272
A hospital in the community has been notified of a multi-car crash on the interstate that will result in the transfer of many injured clients to the hospital. As part of the emergency response, the charge nurses in the emergency department (ED) and intensive care unit (ICU) are responsible for which tasks? Select all that apply.
A) Assigning care for the clients as they are admitted to the unit
B) Exceeding their scope of practice when and if required
C) Assessing the priority of the current clients for the ED or ICU
D) Delegating staff nurses to gather needed supplies for the arriving clients
E) Providing any care that any patient needs
Answer: A, C, D
Explanation: A) Nurses must observe both the physical and mental status of victims and ensure appropriate triage and treatment. They should not use their time to provide care that will be of minimal or questionable benefit. During the crisis, nurses should be constantly aware of their defined scope of practice and must not exceed it even when circumstances would seem to dictate otherwise. The charge nurses in each unit are responsible for assessing the current clients and recommending to the physicians those clients who can be moved to make room for clients needing more immediate care. The charge nurse would delegate the gathering of supplies to the staff nurses. The charge nurse would also assign care for the clients who are admitted to the unit.
273
The charge nurse assesses clients during a mass casualty incident (MCI) and transfers some to other units but discharges others to home. In planning for the admission of critically ill clients from the emergency department, to which nurses will the charge nurse assign the new clients when admitted to the unit?
A) Nurses with risk-reduction knowledge
B) Nurses with advanced assessment skills
C) Nurses with impeccable ethics
D) Nurses with exceptional self-care methods
Answer: B
Explanation: A) During the admission of injured clients, the charge nurse would assign the new clients to those nurses with advanced assessment, technical, and communication skills. Advanced practice nurses who have received training in emergency and trauma care will have significantly greater responsibilities than nurses with less training. Nurses do need to have good ethics, sufficient risk-reduction knowledge, and appropriate self-care knowledge during emergency responses. However, during the admission of victims, the charge nurse would want the highly competent nurses caring for the new clients.
274
) A group of nurses attend an in-service regarding emergency preparedness for the hospital. One of the nurses has three small children and lives in a two-story house in the suburbs. After the class, the nurse plans to initiate which action to enhance family safety?
A) Training her family in performing nursing interventions to take part in an emergency response
B) Obtaining a fire escape ladder for the second floor of the home
C) Developing a plan for her family to join her in the event of an emergency
D) Ensuring she and her family move to a safe area unlikely to be involved in a disaster
Answer: B
Explanation: A) During the preparedness phase, nurses must also develop an emergency plan for themselves and their immediate families. When this plan is complete, nurses can be confident that their families are prepared to weather an emergency in relative safety. With this assurance, nurses who choose to assist in a disaster or who are required to remain at the hospital during a disaster will be able to leave their families without delay and remain available until no longer needed. Part of this plan should include means of escape such as fire escape ladders. The nurse's family is not qualified to perform nursing interventions and should go to a safe place in an emergency, not join the nurse where she is. No place is completely safe from all potential disasters.
275
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A nurse recently attended a seminar that discussed the many threats to homeland security. As nurse manager of the emergency department, the nurse is responsible for planning for emergencies from bioterrorism. Which agents does the nurse include when planning for bioterrorism? Select all that apply.
A) Anthrax
B) Tuberculosis
C) Cancer
D) Flu
E) Smallpox
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Answer: A, E
Explanation: A) Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern in regard to bioterrorism. Cancer, flu, and tuberculosis have not been developed into biological threats and would not kill the number of people that smallpox would.
276
A nurse is performing START triage for clients injured in a terrorist attack. Which client would the nurse classify as expectant?
A) Client is breathing but has an absent radial pulse.
B) Client has a respiratory rate below 30.
C) Client is apneic after positioning of an airway.
D) Client is breathing adequately with a radial pulse but does not obey commands
Answer: C
Explanation: A) A client who is apneic after the positioning of an airway would be tagged as black, expectant, meaning the client is not expected to survive. The other clients would all be classified as requiring immediate intervention.
277
The nurse is working with an emergency response team following massive flooding caused by a hurricane. What will working with the Clinical Outreach Communication Activity (COCA) team enable the nurse to do?
A) Have two-way communication with the Centers for Disease Control and Prevention (CDC) concerning infection risks.
B) Facilitate communication between doctors in the field during a disaster and their healthcare team.
C) Provide resources to the community during times of disaster.
D) Provide expert advice to other nurses during natural disasters.
Answer: A
Explanation: A) The CDC manages the COCA to ensure that clinicians have up-to-date information. The COCA is designed to provide two-way communication between clinicians and the CDC about emerging health threats such as pandemics, natural disasters, and terrorism. The COCA keeps a list of emergency preparedness and training resources offered by federal agencies and COCA partners. COCA does not enable communication between doctors and their teams in the field, provide resources to communities during disasters, or enable communication between nurses during disasters.
278
The nurse manager is discussing the preparedness phase of a revised emergency management plan for the emergency department. The American Nurses Association (ANA) is a resource the nurse manager can use to help nurses understand which of the following during an emergency response?
A) The ethics of emergency response
B) The procedure for working in a hot zone during a hazardous material incident
C) The role of the incident commander in a disaster response
D) The best means of communicating with agencies such as the Centers for Disease Control and Prevention (CDC) during a crisis
Answer: A
Explanation: A) During the preparedness phase, individual nurses must gain an understanding of their expected roles in an emergency and prepare for them. Because nurses will be required to allocate scarce resources and supplies and make unbelievably difficult client care decisions, they must understand the ethics associated with such choices. The ANA is a good source of information to guide nurses' understanding of their roles and possible consequences. Nurses must be aware of their employer's response plans and have a sense of how their state and local community will operate during an emergency. The ANA is not a primary source of information for working in hot zones, the role of the incident commander, or the best means of communicating with agencies such as the CDC.
279
A nurse is responding in the aftermath of a hurricane. Hundreds of clients demand attention. The nurse will implement which of the following in assessing the priority of these clients?
A) Reverse triage
B) Standard emergency department triage
C) A disaster response plan
D) American Nurses Association (ANA) ethics rules
Answer: A
Explanation: A) Nurses perform triage every day in emergency departments. During a mass casualty event (more than 100 victims), the demand on nurses' knowledge and skills will be even greater. Mass casualty events call for the implementation of reverse triage, in which the most severely injured or ill victims who require the greatest resources are treated last to allow the greatest number of victims to receive medical attention. A disaster response plan involves the general response to an emergency. The American Nurses Association (ANA) guides nurses in making ethical decisions but does not specifically address the means of prioritizing client needs in a disaster.
280
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A railway accident causes the release of a dangerous chemical compound into the atmosphere. The nurse providing rapid triage and emergency treatment for clients in an effort to stabilize them knows that which is the primary purpose of the warm zone in this incident?
A) Decontamination
B) Rapid triage
C) Reverse triage
D) Emergency medical treatment
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Answer: A
Explanation: A) The warm zone (also referred to as the yellow, contamination, or contamination reduction zone) is located at least 300 feet from the outer edge of the hot zone. Although the primary purpose is decontamination, rapid triage and emergency treatment to stabilize victims may also take place in the warm zone. Individuals who have the highest levels of contamination are treated with the highest priority. Personal protective equipment (PPE) is required in this zone.
281
Terrorists have detonated a bomb in the downtown area of a major city, destroying part of a hotel, damaging nearby buildings, and killing or injuring an unknown number of people. A nurse in an emergency department handling many clients injured in the explosion receives a phone call from the babysitter for her children aged 5, 6, and 9, who says she's been watching the event unfold on TV since it happened. The nurse's family lives in a suburb more than 20 miles from the downtown. What should the nurse say?
A) "Explain to the children that the people who did this are sick and will be punished for what they've done."
B) "Please continue to watch the TV coverage with my kids in the room to ensure that you know what's going on at all times."
C) "Please tell my children I'm alright but turn off the television and play a game with them to get them thinking about something else."
D) "If you plan to continue to watch the TV coverage, please do it on the TV in my bedroom away from the kids."
Answer: C
Explanation: A) Limit the amount of media and news coverage children are exposed to, as this can be frightening to younger children. In this case, it would be best for the babysitter to engage the children in play that does not involve obsessively watching the news. Continuing to watch the news nonstop, trying to explain the tragedy in terms of crime and punishment, or watching the TV away from the children is not appropriate.
282
The detonation of several incendiary devices in a suburban area has caused widespread fires. A nursing home nearest one of the largest fires needs to be evacuated. What is the concern a nurse working in the home will have for his clients in this situation?
A) Socioeconomic limitations
B) Diminished sensory awareness
C) Inadequate thermoregulation mechanisms
D) Limited mobility
Answer: D
Explanation: A) Although diminished sensory awareness, inadequate thermoregulation mechanisms, and socioeconomic limitations all must be considered for older adults in an emergency, the primary issue that should concern the nurse in this situation is his clients' limited mobility. They need to evacuate, and doing so quickly could be difficult for many of his clients.
283
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The nurse is providing teaching to a client who is scheduled to undergo surgery in 2 weeks. Which topics should the nurse include that will prepare the client to help reduce complications during the postoperative phase? Select all that apply.
A) Maintaining a patent airway
B) Deep breathing and coughing
C) Caring for the surgical incision
D) Managing constipation
E) Managing pain
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Answer: B, C, D, E
Explanation: A) Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.
284
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The nurse is providing teaching to a client who is about to undergo surgery. When discussing whom the client can expect to see in the operating room suite, which individuals should the nurse include? Select all that apply.
A) Surgeon
B) Postoperative nurse
C) Circulating nurse
D) Anesthesiologist
E) Social worker
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Answer: A, C, D
Explanation: A) The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.
285
The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs? Select all that apply.
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
C) Deficient Knowledge
D) Risk for Imbalanced Nutrition: Less than Body Requirements
E) Risk for Imbalanced Fluid Volume
The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs? Select all that apply.
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
C) Deficient Knowledge
D) Risk for Imbalanced Nutrition: Less than Body Requirements
E) Risk for Imbalanced Fluid Volume
286
The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to phase 2 of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________.
The Aldrete score:
Respiration
2 = Able to take deep breath and cough
1 = Dyspnea/shallow breathing
0 = Apnea
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O2 Saturation
2 = Maintains >92% on room air
1 = Needs O2 inhalation to maintain O2 saturation >90%
0 = Saturation <90% even with supplemental oxygen
Consciousness
2 = Fully awake
1 = Arousable on calling
0 = Not responding
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Circulation
2 = BP 20% preop
1 = BP 20–49% preop
0 = BP 50% preop
Activity
2 = Able to move 4 extremities
1 = Able to move 2 extremities
0 = Able to move 0 extremities
Answer: 8
Explanation: The Aldrete system is designed to assess a client's transition from phase 1 recovery to phase 2 recovery, from discontinuation of anesthesia until return of protective reflexes and motor function. The criteria of respirations, oxygen saturation, consciousness, circulation, and activity are scored. The maximum score is 10. This client scores a 2 for respiration, a 1 for oxygen saturation, a 2 for consciousness, a 1 for circulation (roughly a 25% increase in blood pressure over preop BP, and a 2 for activity for a total of 8. Clients who score ≥8 are considered fit for transition to phase 2 recovery.
287
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The postoperative care nurse is reviewing the documentation from the intraoperative phase of a client's surgical procedure. Which information should the nurse anticipate finding on the intraoperative documentation? Select all that apply.
A) Pain assessment
B) Start and stop times of anesthesia
C) Medication review
D) Antibiotic infusion times
E) Start and stop times of the procedure
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Answer: B, D, E
Explanation: A) Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
288
The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the client's care? Select all that apply.
A) An organ is going to be removed.
B) This is an emergency surgery.
C) The client will be hospitalized longer.
D) The client is at risk for blood loss.
E) The client is at risk for hypothermia.
The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the client's care? Select all that apply.
A) An organ is going to be removed.
B) This is an emergency surgery.
C) The client will be hospitalized longer.
D) The client is at risk for blood loss.
E) The client is at risk for hypothermia.
289
While receiving report from the operating room, the nurse learns that a client's surgical wound after gallbladder removal is classified as III. What does this classification tell the nurse? Select all that apply.
A) The alimentary tract was not entered.
B) The wound is necrotic and infected.
C) Gallbladder contents spilled into the surgical site.
D) A break in sterility occurred during the surgery.
E) The alimentary, respiratory, genital, or urinary tract was entered.
Answer: C, D
Explanation: A) An incision is classified as III—contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I—clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV—dirty, infected if the wound is necrotic and infected. An incision is classified as II—lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
290
The nurse is preparing an older adult client for surgery. On which topics should the nurse focus when preparing this client's preoperative teaching? Select all that apply.
A) Level of hearing
B) Amount of anesthesia needed during surgery
C) Teaching on deep breathing and coughing
D) Plans for discharge care
E) Actions to prevent pressure ulcers
Answer: A, C, D, E
Explanation: A) Clients do not need teaching related to intraoperative anesthesia amounts. For the older client, make sure the client can hear the information to be presented or provide information through alternative means. Deep breathing and coughing assist in the prevention of pneumonia and other respiratory conditions related to surgery, and deep breathing and coughing education should start in the preoperative phase. The older client is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. The older client could be at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or a history of steroid use.
291
A prothrombin time (PT) test measures which of the following?
A) Time required for the client's blood to clot
B) Time required for the client's plasma to clot
C) Time required for platelets to effectively stop bleeding
D) Time required for a surgical procedure
A prothrombin time (PT) test measures which of the following?
A) Time required for the client's blood to clot
B) Time required for the client's plasma to clot
C) Time required for platelets to effectively stop bleeding
D) Time required for a surgical procedure
292
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) What drug may be used to treat nausea and vomiting associated with operative procedures?
A) Metoclopramide
B) Acetaminophen
C) Midazolam
D) Fentanyl
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Explanation: A) An antiemetic such as metoclopramide may be used to treat nausea and vomiting associated with operative procedures. A nonopioid analgesic such as acetaminophen provides temporary analgesia for mild to moderate pain. An anxiolytic such as midazolam is a relaxant. An opioid analgesic such as fentanyl controls moderate to severe pain but does not alter the pain threshold.
293
Explanation: A) An antiemetic such as metoclopramide may be used to treat nausea and vomiting associated with operative procedures. A nonopioid analgesic such as acetaminophen provides temporary analgesia for mild to moderate pain. An anxiolytic such as midazolam is a relaxant. An opioid analgesic such as fentanyl controls moderate to severe pain but does not alter the pain threshold.
Answer: D
Explanation: A) Assessment is the most significant concept during the perioperative process and encompasses most of the other concepts. In addition to monitoring the client's vital signs and taking into account the spiritual, cultural, and emotional aspects of a client's care, assessment may include a nurse's communication with the healthcare and surgical team. Assessing what other team members gather from a nurse's communication is vital to a client's safety.
294
) Which of the following statements best describes the vital signs the nurse collects during the preoperative phase?
A) They are the only vital signs collected during the perioperative period.
B) When later vital signs are taken, they are compared against the preoperative set.
C) Generally preoperative vital signs are only relevant during the intraoperative process.
D) These are not essential and may be omitted for emergency surgeries.
) Which of the following statements best describes the vital signs the nurse collects during the preoperative phase?
A) They are the only vital signs collected during the perioperative period.
B) When later vital signs are taken, they are compared against the preoperative set.
C) Generally preoperative vital signs are only relevant during the intraoperative process.
D) These are not essential and may be omitted for emergency surgeries.
295
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How often should a client be monitored during the intraoperative phase?
A) Every 5 minutes
B) Every 30 minutes
C) Constantly
D) Occasionally
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Answer: C
Explanation: A) Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.
296
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A client with terminal cancer is undergoing surgery to partially remove a tumor that is pressing on a nerve and causing pain. This is classified as what type of surgery?
A) Reconstructive
B) Diagnostic
C) Palliative
D) Emergency
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Answer: C
Explanation: A) Palliative surgery may be performed to alleviate pain or symptoms associated with a disease, and so this client's surgery, because it involves partially removing a tumor causing severe pain, is most illustrative of palliative surgery. Reconstructive surgery is to restore lost or reduced appearance or function. A diagnostic procedure would be conducted to determine or confirm a diagnosis. Emergency surgery is to save life or limb.
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) Which of the following situations demands that all perioperative staff cover their bodies with lead shields?
A) The surgical team uses a bipolar handpiece to cauterize a client's tissue.
B) The surgical team uses a class 3 laser to cut a client's kidney stone.
C) The surgical team uses a pneumatic tourniquet to cut off circulation to a client's hand.
D) The surgical team uses radiology to take intraoperative photos.
Answer: D
Explanation: A) When radiology is used, perioperative staff must make sure lead shields cover their bodies, including women's ovaries and men's testicles, because radiation can cause sterility. Staff should also wear a neck shield to protect the thyroid gland. The other procedures do not involve radiation and don't require lead shields.
298
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A client presents with decreased blood volume, hypotension, tachycardia, and tachypnea during surgery. Which of the following intraoperative complications is most likely?
A) Hypovolemia
B) Hypervolemia
C) Hypokalemia
D) Hypernatremia
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A client presents with decreased blood volume, hypotension, tachycardia, and tachypnea during surgery. Which of the following intraoperative complications is most likely?
A) Hypovolemia
B) Hypervolemia
C) Hypokalemia
D) Hypernatremia
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299
A nurse was involved in the perioperative care of a preterm infant requiring cardiothoracic surgery. The infant has now been moved to the NICU. How should the nurse change the focus of her assessment in the postoperative phase?
A) The nurse should assess the client as preterm.
B) The nurse should assess the client's respiratory status.
C) The nurse should assess the client's glucose levels.
D) The nurse should assess the parents' coping mechanisms.
Answer: D
Explanation: A) The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU) at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.
300
The nurse must start an IV for a toddler in the emergency department. The toddler is accompanied by a parent. The parent asks the nurse, "Can I stay with my child and comfort him?" Which response by the nurse is best?
A) "Yes, it would be helpful for you to stay and comfort your child."
B) "We do this all the time, so don't worry. I will come get you when we are done starting the IV."
C) "Be ready to hold your child down when I tell you to."
D) "It doesn't take long to start an IV, so there's no need for you to stay for the procedure."
Answer: A
Explanation: A) An important part of nurse competency is knowing what procedures to follow when performing skills. For example, when initiating an IV on a pediatric client, procedure dictates that the nurse should always seek assistance from the client's parent if the parent is willing and capable of offering assistance. If the parent agrees to offer assistance, the nurse can then provide appropriate teaching. Instructing the parents to hold down the child without giving them a choice is inappropriate; many parents do not want to participate in activities that cause pain to their child. Telling the parent not to worry is both pointless and dismissive of the parent's concerns. It is also inappropriate for the nurse to say that the procedure won't take long, because the nurse does not know how much time the procedure will actually require.
301
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A nurse forgets to return a client's bed to the low position after performing a bed bath. When a colleague points this out, the nurse states, "I should have returned the bed to the low position. Thank you for pointing out my error." With which characteristic is the nurse's response most consistent?
A) Compassion
B) Integrity
C) Fidelity
D) Justice
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Answer: B
Explanation: A) Integrity involves adherence to a strict moral or ethical code. Nurses demonstrate integrity in various ways, such as by accepting feedback as a tool for improving their delivery of client care and by maintaining accountability for their actions and freely admitting when they make mistakes. By admitting to an error, this nurse is demonstrating integrity. Justice has to do with being fair. Fidelity means to be faithful to agreements and promises. Compassion is an awareness of and concern for the suffering of others.
302
The nurse is caring for a critically ill infant in the neonatal intensive care unit (NICU). The infant's parents ask whether the child's 3-year-old sibling can visit. Small children are not permitted to visit the NICU because of the risk of infection to the infants on the unit. Which action by the nurse best demonstrates a compassionate response?
A) Seek permission from unit management and the neonatologist to allow the sibling to visit
B) Offer to make counseling available to the sibling
C) Tell the parents that visiting is not permitted and offer to take pictures of the client
D) Tell the parents to bring the sibling in to visit in the middle of the night
Answer: A
Explanation: A) Compassion, or awareness of and concern about other individuals' suffering, is an important component of professionalism. Nurses demonstrate compassion when they recognize a client's need and respond appropriately to meet that need. In this situation, although the nurse would realize that certain rules are in place for the protection of clients, the nurse would also recognize the need for compassion. Of the options provided, the most appropriate way to demonstrate compassion would be to seek permission to allow the sibling to visit and see that the infant is alive and being cared for. The nurse would not make the decision without the permission of the management team. Telling the parents what the rules of the unit are will only increase the family's frustration when they are looking to the nurse for assistance. Offering counseling may or may not be an effective means of assisting the family.
303
A nurse overhears two colleagues disparaging a client on a public elevator. Which action by the nurse is most appropriate?
A) Immediately ask the nurses to stop talking about clients in public.
B) Report the nurses' behavior to the unit manager.
C) Wait and speak to the nurses about their behavior in a private place.
D) Report the nurses' behavior to the hospital's risk manager.
Answer: C
Explanation: A) Nursing integrity ensures that patients' rights are respected in the healthcare setting. If the first nurse were to confront the two colleagues in the elevator, this conversation could be overheard by others. Thus, the first nurse should wait and speak to the other nurses privately about the breach of confidentiality. The nurse could report the incident to the unit manager, but it would be better for the nurse to personally confront the two colleagues in a professional way. If this isn't possible, then notifying the nurse manager would be the next step. The risk manager is only involved in situations in which there is an injury to a staff member or client.
304
A hospital's nursing staff is deciding whether to unionize. The hospital CFO tells a nurse supervisor to make sure all leaders of the unionization effort are scheduled for client care during union meetings. Which actions by the nurse supervisor are appropriate? Select all that apply.
A) Schedule the organizers for client care during union meeting times.
B) Schedule the organizers for client care according to clinical staffing needs.
C) Reprimand the staff nurses for their attempts to unionize.
D) Continue to implement the usual staffing procedures.
E) Discuss the need for professional nursing integrity with the CFO.
Answer: B, D, E
Explanation: A) In some cases, administrators may serve their careers and no longer the priorities of client-centered care. This can lead to potential abuses of power, such as the one described in this situation. Nurses who are in positions of authority have a duty to address such abuses, thereby maintaining their integrity and that of their profession. They can do this by taking steps to emphasize principles over personality and by focusing on client needs over political ends. In this situation, examples of such behavior would include following regular staffing procedures that reflect client care needs, as well as discussing the need for professional nursing integrity with the CFO.
305
A nurse has just received the shift report for a 12-hour shift. As the nurse is preparing to enter a client's room, the nurse overhears a coworker telling an offensive joke with a sexual undertone to the client. Which action by the nurse is appropriate?
A) Tell the coworker, in private, that such conduct is offensive and not professional.
B) Ignore the coworker and walk away.
C) Report the incident to the unit manager.
D) Ask to be scheduled on a different shift than this coworker.
Answer: A
Explanation: A) Nurses must develop assertiveness skills to deter sexual harassment in the workplace. Privately telling the coworker to stop, and explaining why, is the first step in putting an end to the situation. Ignoring the coworker's behavior or asking to be scheduled opposite this individual does not address the situation in an assertive manner. Reporting the incident to the nurse manager would be an appropriate second step if the behavior doesn't stop after the nurse's initial discussion with the coworker.
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In which of the following situations would the nurse's actions most likely be classified as intimidation?
A) When addressing a client, the nurse states, "I can't overemphasize how important it is that you stick with the treatment plan."
B) When addressing a coworker, the nurse states, "Your behavior is a violation of hospital policy. If you keep it up, I'll be forced to notify your supervisor."
C) When addressing a client, the nurse states, "It's essential that you take this medication at the same time each day. If you don't, your symptoms will likely intensify."
D) When addressing a coworker, the nurse states, "You'd best think twice about doing that again, or you might be sorry."
Answer: D
Explanation: A) Intimidation is bullying, threatening, or forcing someone who is physically or emotionally weaker to do something (or refrain from doing something) in order to avoid retribution. Telling a coworker that he or she will "be sorry" for carrying out a particular action is a clear example of intimidation. A more suitable, less intimidating approach would be to tell the coworker why the behavior is unacceptable and ask him or her to stop; if the coworker refuses to do so, approaching the supervisor would be an appropriate next step. Telling a client that you can't overstate the importance of treatment is not intimidation because it does not involve the threat of retribution. Explaining that failure to take a medication as prescribed may result in a worsening of symptoms is not intimidation; here, rather than threatening retribution, the nurse is providing education about the chosen pharmacological therapy
307
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The process of ________ involves the acquisition of lifelong learning, experience, technical expertise, and interdependent collaboration required to become a professional nurse.
A) maturation
B) formation
C) transformation
D) socialization
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Answer: B
Explanation: A) In recent years, nursing scholars have developed the concept of formation, a process that facilitates the transformation of an individual from a layperson to a professional nurse. Formation is an evolutionary process that requires the acquisition of lifelong learning, experience, technical expertise, and interdependent professional collaboration. It marks a departure from the prior model of socialization, in which nurses were said to become part of the profession through internalization of nursing's long history of subservient female roles, the acceptance of dominant behaviors for males, and a hierarchical structure in healthcare organizations.
308
Which action by the novice nurse demonstrates commitment to a new job on a busy cardiac care unit?
A) Joining the American Nurses Association (ANA)
B) Questioning the preceptor during all procedures
C) Arriving at every shift on time
D) Exhibiting clinical competence
Answer: C
Explanation: A) The new nurse can demonstrate commitment by showing up for all shifts in a timely fashion. It should not be necessary for the new nurse to question every procedure, given that the new nurse has some prior clinical experience. Joining the ANA is a commitment, but it is not relevant to this question. Clinical competence develops over time, and the new nurse is not likely to exhibit complete competence yet; thus, showing up on time is a better predictor of the nurse's commitment.
309
A novice nurse is caring for an older adult client with dementia. The nurse leaves for a break and forgets to put the call light within the client's reach. When checking on the nurse's clients, a colleague discovers the nurse's negligence. Which conclusion by the colleague is appropriate?
A) The novice nurse is appropriately taking care of self.
B) The novice nurse's workload is too difficult.
C) The novice nurse is demonstrating inappropriate safety measures for the client.
D) The novice nurse is demonstrating appropriate comfort measures for the client.
Answer: C
Explanation: A) The novice nurse is demonstrating inappropriate safety measures by not leaving the call light within the client's reach. There is no evidence that the nurse's workload is too difficult, and the scenario does not provide any information about comfort measures. It is appropriate for nurses to take breaks; however, client safety should be the nurse's first commitment.
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) Which action by a student nurse is most consistent with commitment to the nursing profession?
A) The student calls in sick for clinicals in order to study for a class exam.
B) The student declines to observe a new procedure for giving a necessary bath.
C) The student misses class to attend a political rally.
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Answer: D
Explanation: A) Whereas calling in sick for a frivolous reason demonstrates a lack of commitment, calling in sick with a bona fide illness demonstrates protection of clients who are already compromised. Attending a political rally may be important, but for the student, attending class demonstrates greater commitment to the profession of nursing. Studying for a class exam is also important, but not more important than learning clinical skills. Indeed, a student who demonstrates commitment seeks out as many new learning experiences as possible.
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311
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A new nurse decides to join a professional organization that represents his practice specialty. Which type of commitment does this action exemplify?
A) Affective
B) Normative
C) Subjective
D) Continuance
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Answer: A
Explanation: A) There are three types of professional commitment: affective, normative, and continuance. Affective commitment is an attachment to a profession and includes identification with and involvement in the profession. This type of commitment develops when involvement in a profession produces a satisfying experience. The nurse manager described in this scenario is demonstrating affective commitment. In comparison, normative commitment is a feeling of obligation to continue in the profession, and continuance commitment is awareness of the costs associated with leaving the profession.
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Answer: A
Explanation: A) There are three types of professional commitment: affective, normative, and continuance. Affective commitment is an attachment to a profession and includes identification with and involvement in the profession. This type of commitment develops when involvement in a profession produces a satisfying experience. The nurse manager described in this scenario is demonstrating affective commitment. In comparison, normative commitment is a feeling of obligation to continue in the profession, and continuance commitment is awareness of the costs associated with leaving the profession.
Answer: A, B, C
Explanation: A) Nurses can prevent burnout by using healthy techniques to manage stress. Suggestions include planning daily relaxation activities, establishing a regular exercise program, learning to say no, accepting errors and failures as learning experiences, accepting change and limitations, developing collegial support groups, participating in professional organizations, and seeking counseling if needed.
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Answer: A, B, C
Explanation: A) Nurses can prevent burnout by using healthy techniques to manage stress. Suggestions include planning daily relaxation activities, establishing a regular exercise program, learning to say no, accepting errors and failures as learning experiences, accepting change and limitations, developing collegial support groups, participating in professional organizations, and seeking counseling if needed.
Answer: A
Explanation: A) Factors associated with professional commitment include a strong belief in and acceptance of the profession's code, role, goals, values, and morals; a willingness to exert considerable personal effort on behalf of the profession; a strong desire to maintain membership in the profession; and a pattern of behaviors congruent with the nurses' professional code of ethics.
314
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A student nurse says, "I'm nervous about taking the NCLEX, and I'm a little worried about all the responsibility that comes with being a registered nurse. At the same time, I'm eager to pass the test so I can start working. I think the rewards of nursing are well worth the hard work and sacrifice." This statement suggests that the student nurse is in which stage of commitment?
A) The integrated stage
B) The testing stage
C) The passionate stage
D) The exploratory stage
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Answer: A
Explanation: A) Commitment to a profession develops in five stages: exploratory, testing, passionate, quiet and bored, and integrated. The integrated stage is the final stage of commitment development. Individuals who reach this stage have integrated both positive and negative elements of the profession into a more flexible, complex, and enduring form of commitment. They act out their commitment as a matter of habit. These students are in the final stages of their nursing program and are beginning to see themselves as nurses, eager to take the NCLEX-RN and begin employment.
MNL LO: Analyze the concept of professional behaviors and its application to nursing care.
315
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Which type of commitment involves a feeling of obligation to continue in a profession, usually as a result of having received benefits or having had positive experiences through engagement in the profession?
A) Continuance commitment
B) Affective commitment
C) Reciprocal commitment
D) Normative commitment
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Answer: D
Explanation: A) There are three types of professional commitment: affective, normative, and continuance. Affective commitment is an attachment to a profession and includes identification with and involvement in the profession. Normative commitment is a feeling of obligation to continue in a profession that develops as a result of having received benefits or having had positive experiences through engagement in that profession. Continuance commitment is awareness of the costs associated with leaving a profession; it develops when negative consequences of leaving, such as loss of income, are seen as reasons to remain.
316
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) During which stage of commitment do nursing students tend to focus on the negative elements of nursing and weigh their ability to handle those elements?
A) Passionate stage
B) Testing stage
C) Exploratory stage
D) Quiet-and-bored stage
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Answer: B
Explanation: A) Commitment to a profession develops in five stages: exploratory, testing, passionate, quiet and bored, and integrated. The testing stage is the period in which individuals discover negative elements of the profession. During this stage, individuals start to assess their willingness and ability to deal with those negative elements.
317
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After accidentally providing food to a client who is NPO for surgery, the nurse reports the error to the healthcare provider and follows hospital policy for managing the error. Which characteristic is demonstrated by the actions of this nurse?
A) Social justice
B) Human dignity
C) Reliability
D) Accountability
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After accidentally providing food to a client who is NPO for surgery, the nurse reports the error to the healthcare provider and follows hospital policy for managing the error. Which characteristic is demonstrated by the actions of this nurse?
A) Social justice
B) Human dignity
C) Reliability
D) Accountability
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318
2) During a staff meeting, the new nurse manager informs the staff that each nurse will be getting an email account that needs to be checked daily for information from the manager. Which responses to this policy would be expected of a "Generation X" nurse? Select all that apply.
A) "Can we access the email account from home?"
B) "That sounds like a great idea."
C) "I would rather get the information directly from you."
D) "I would rather receive the information in a unit newsletter."
E) "Can we use this account to email one another?"
Answer: A, B, E
Explanation: A) Both Generation X and Generation Y/Millennial nurses would likely support the new email policy. Given their high level of comfort with technology, nurses in these age groups would also likely ask whether the new email accounts could be accessed from home or used to communicate with other staff members. In contrast, older nurses would likely prefer communication that is personal and/or not attached to technology.
319
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A charge nurse is making assignments for the shift and notes that a client from a different culture was recently admitted and will require a thorough admission assessment during the upcoming shift. Which generation of nurse is likely to be the most culturally sensitive and thus the best choice for this client assignment?
A) The Millennial nurse
B) The Generation X nurse
C) The veteran nurse
D) The baby boomer nurse
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Answer: A
Explanation: A) A nurse from the Millennial generation would most likely exhibit the highest level of cultural sensitivity and would thus be the best choice for this assignment. Broadly speaking, Millennial generation nurses have received the most education regarding culturally sensitive care and can be a good resource for the older nurses on the unit.
320
A nurse is reprimanded for being habitually late. What action by the nurse would best address this performance issue?
A) The nurse must take responsibility and accept any corrective action.
B) The nurse must provide proof that all instances of tardiness were unavoidable.
C) The nurse must have a positive attitude.
D) The nurse must trade shifts in order to be on time.
Answer: A
Explanation: A) Reliability and accountability are key factors in professionalism. From a systems perspective, each nurse is responsible for completing the duties of the job appropriately so that others can complete their work, too. Almost everyone misses work or arrives late on occasion. However, when poor attendance or lack of punctuality becomes a habit, it also becomes a performance issue and possible grounds for corrective action or termination of employment.
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Answer: A
Explanation: A) Reliability and accountability are key factors in professionalism. From a systems perspective, each nurse is responsible for completing the duties of the job appropriately so that others can complete their work, too. Almost everyone misses work or arrives late on occasion. However, when poor attendance or lack of punctuality becomes a habit, it also becomes a performance issue and possible grounds for corrective action or termination of employment.
Answer: A
Explanation: A) Arrogance, or excessive pride and a feeling of superiority, can be an extremely dangerous characteristic in the nurse, as it can lead to a false belief that the nurse is always right and does not need input from others. Accurate self-assessment of strengths and weaknesses and acceptance of feedback from others promote both safety and growth and are therefore essential abilities for the nurse.
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) The charge nurse, who is a member of Generation X, is training a new nurse, who is a member of the Millennial generation. Which aspects of the two nurses' work ethics may be in conflict? Select all that apply.
A) Preference for self-directed activity versus a need for feedback
B) Loyalty to profession versus desire for new challenges and opportunities
C) Workaholic orientation versus need for work-life balance
D) Respect for authority versus questioning of authority
E) Preference for personal forms of communication versus preference for communication via cell phone
Answer: A, B
Explanation: A) Nurses from Generation X tend to seek challenges; are self-directed; are comfortable with technology; expect instant access to information; desire employment in which they can balance work and personal life; prefer managers who function as mentors and coaches; have limited motivation to stay with the same employer but are loyal to their profession; desire more control over their own schedule; and have a pragmatic focus on outcomes rather than process. Nurses from the Millennial generation tend to be social, confident, optimistic, talented, well-educated, collaborative, open minded, and achievement oriented; expect daily feedback; be high maintenance; thrive on the adrenaline rush of new challenges and opportunities; and view personal cell phones as a necessity for daily life and interpersonal communication.
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How can a healthcare facility's management best take advantage of the multigenerational nursing staff?
A) By emphasizing the unique strengths each generation brings to the workplace
B) By encouraging the hardworking, loyal veterans to serve as mentors for the younger nurses
C) By highlighting the adaptability of the techno-savvy Generation X nurses
D) By encouraging the older nurses to adopt the optimistic viewpoint of the Millennial nurses
Answer: A
Explanation: A) Celebrating the unique strengths of each generation of nurse can decrease interpersonal tension and facilitate personal growth. Nurses who learn to acknowledge and appreciate their colleagues from different backgrounds, including generational backgrounds, have a distinct advantage. The best teams use the contributions of each generation's skill set and strengths. The hardworking, loyal veterans; the idealist, passionate baby boomers; the technoliterate, adaptable Generation Xers; and the young, optimistic Millennials can come together in a powerful network with a remarkable ability to support each other and maximize client care.
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) An individual's work ethic reflects his or her
A) belief in the importance and moral worth of work.
B) desire to advance in a chosen profession.
C) level of affective commitment to a profession.
D) degree of optimism with regard to the work environment.
Answer: A
Explanation: A) A person's work ethic reflects his or her belief in the importance and moral worth of work. An individual does not need to be part of a specific profession in order to have a strong work ethic. Although an optimistic attitude is often associated with a strong work ethic, optimism itself does not determine an individual's work ethic.
325
) Which of the following situations would be considered an example of insubordination?
A) A staff nurse informs the unit supervisor that she can't complete an assigned care task because it is outside her scope of practice.
B) A staff nurse informs the unit supervisor that he cannot complete an assigned care task because it requires a piece of equipment that is not currently available.
C) A staff nurse informs the unit supervisor that she won't complete an assigned care task because it's beneath her level and more appropriate for unlicensed assistive personnel.
D) A staff nurse informs the unit supervisor that he cannot complete an assigned care task because another nurse has already performed the task.
Answer: C
Explanation: A) Professional nurses should refuse work assignments only when they are not qualified or not prepared to perform the assignment—as would be the case when a task is outside the nurse's scope of practice or a needed piece of equipment is unavailable. Refusal to perform a task would also be appropriate if completing the task would result in duplication of services. In all such cases, the nurse should discuss the situation immediately with the supervisor. Otherwise, the nurse should be ready to complete all assigned tasks, because refusal to do so may be regarded as insubordination and grounds for dismissal. Here, the nurse who refuses a task simply because she feels it is "beneath her level" would be engaging in insubordinate behavior.
326
An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse's first priority?
A) Implementing a low-level exercise program for the client
B) Assessing the client's pain management
C) Teaching the client relaxation techniques
D) Referring the client to a dietitian
Answer: B
Explanation: A) When caring for a client with a degenerative bone disease that is impairing mobility, the nurse should assess pain management prior to implementing an exercise program, teaching relaxation exercises, or referring to a dietitian.
327
A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the nurse is appropriate?
A) Referring the client to physical therapy
B) Placing an ice pack on the client's ankle
C) Planning for a corticosteroid injection
D) Ordering an x-ray of the ankle
Answer: B
Explanation: A) An appropriate intervention for a client who experiences an ankle injury is placing ice on the ankle to limit swelling. If physical therapy is needed, the referral would be given after the ankle has had time to heal. A corticosteroid injection would be more appropriate for a client with osteoarthritis, not an acute ankle injury. Ordering an x-ray of the ankle is outside the nurse's scope of practice.
328
The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment?
A) Assessing the client's muscle mass and strength
B) Measuring the length and circumference of the client's extremities
C) Inspecting the client's spine for curvature
D) Palpating the client for tenderness and pain
Answer: C
Explanation: A) When assessing a client's gait and posture, the nurse should be sure to inspect the client's spine for curvature. Assessing muscle mass and strength, measuring the length and circumference of the extremities, and palpating for tenderness and pain are part of the physical assessment performed by the nurse for clients who are experiencing mobility issues.
329
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The nurse is caring for a client who is experiencing limited mobility related to a musculoskeletal alteration. Which laboratory tests would be useful to diagnose the client appropriately? Select all that apply.
A) Magnetic resonance imaging (MRI)
B) Alkaline phosphatase (ALP)
C) Human leukocyte antigen-B27 (HLA-B27)
D) Rheumatoid factor (RF)
E) Electromyography (EMG)
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Answer: B, C, D
Explanation: A) ALP, HLA-B27, and RF are all laboratory tests that are used to diagnose clients with musculoskeletal disorders that can cause alterations in mobility. ALP is produced by bone and other organs. Increased ALP may indicate bone disease, bone fracture, bone tumors, osteomalacia, Paget disease, or rickets. Decreased ALP may indicate Wilson disease. The presence of HLA-B27 indicates an increased risk for ankylosing spondylitis and arthritis. Elevated levels of RF may indicate rheumatoid arthritis, scleroderma, lupus erythematosus, and adult Still disease. MRI and EMG are both diagnostic, not laboratory, tests use to diagnose the cause of alterations in mobility
330
The nurse is caring for a client who is 28 weeks pregnant. The client says she has recently begun to experience frequent lower back pain and asks the nurse what can be done to control this pain. What is the nurse's best response?
A) "Back pain is common during pregnancy and can usually be managed by taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
B) "Let's talk about some postural adjustments that might help alleviate your pain."
C) "Back pain during pregnancy is often related to kidney infection. Have you experienced any recent urinary problems, including pain when voiding?"
D) "The physician will likely order an x-ray to investigate potential causes of your pain."
Answer: B
Explanation: A) Back pain is common during pregnancy due to strain on the back from the growing uterus and fetus; abdominal weakness from stretched abdominal muscles; and hormonal changes that loosen the ligaments in the joints of the pelvis. Kidney infection is not a leading cause of back pain in pregnant women. Pregnancy-related back pain is usually managed conservatively. Postural changes or other adaptations can help increase mobility and decrease discomfort. The recommended pain medication is acetaminophen, because NSAIDs are contraindicated during pregnancy. Although diagnostic imaging may be useful, x-rays should be avoided because they deliver ionizing radiation to the fetus.
331
The nurse is caring for a preadolescent male client who is accompanied by his mother. Which statement by the mother would be consistent with the client experiencing growing pains?
A) "My son often complains that his arms and legs feel sore."
B) "My son seems to get injured very easily, especially broken bones."
C) "My son often doesn't want to walk because his knees hurt."
D) "My son occasionally complains of pain in his lower back."
Answer: A
Explanation: A) Long bones of children contain an epiphyseal plate that serves as a location for bone growth. Rapid bone growth in these long bones may produce growing pains as the lengthening bones pull on the muscles. Because this only occurs in the long bones, growing pains are most likely to be felt in the arms and legs. Growing pains would not cause joint pain or lower back pain. Growing pains are also not associated specifically with fractured bones.
332
The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention?
A) Instructing on the importance of proper nutrition and an active lifestyle
B) Administering a prescribed nonsteroidal anti-inflammatory drug (NSAID)
C) Identifying necessary modifications to the home environment
D) Prescribing a skeletal muscle relaxant
Answer: A
Explanation: A) An appropriate independent nursing intervention for a client who is experiencing an alteration in mobility is providing instruction on the importance of proper nutrition and an active lifestyle. Administering a prescribed NSAID is an example of a collaborative intervention that the nurse can implement. Identifying necessary modifications for the home environment is a collaborative intervention often implemented by the occupational therapist. Although it is appropriate for the nurse to administer a skeletal muscle relaxant, it is outside the scope of nursing practice to prescribe this medication.
333
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The nurse is providing care for a client who is experiencing subjective symptoms of carpal tunnel syndrome. Which test should the nurse anticipate being performed by a provider during the physical assessment of this client?
A) Bulge test
B) Ballottement test
C) Phalen test
D) McMurray test
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Answer: C
Explanation: A) Phalen test is a special assessment to determine whether the client is experiencing carpal tunnel syndrome. With this test, the wrists are held in acute flexion for 60 seconds. Numbness, tingling, or pain may indicate carpal tunnel syndrome. All of the other tests listed here are used to assess the knee.
334
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The nurse is caring for an adult client who sustained a right distal radial fracture and a left tibia fracture. Which mobility aid does the nurse anticipate being used for this client?
A) Lofstrand crutches
B) Platform crutches
C) Walker
D) Axillary crutches
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Answer: B
Explanation: A) This client has fractures in both the leg and wrist. Platform crutches are used for clients who are unable to bear weight on their wrists. A walker, axillary crutches, and Lofstrand crutches all require use of the wrists.
335
) The nurse is providing care for several clients. For which client should the nurse anticipate an order for administering 1000 mg of aspirin?
A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain
B) A 5-year-old client who is experiencing ankle pain after a fall from a horse
C) A 38-year-old client who is experiencing headache pain after a skiing accident
D) A 70-year-old client who is experiencing back pain after laminectomy
Answer: A
Explanation: A) Aspirin is appropriate for the client with rheumatoid arthritis who is experiencing hand pain, assuming there are no other contraindications. This medication is not appropriate for the other clients, however. Aspirin therapy is not recommended for children because it is associated with an increased risk of Reye syndrome, and it may contribute to bleeding in adult clients who have sustained physical injury.
336
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The cells that produce the matrix for bone formation are known as
A) osteoclasts.
B) sarcomeres.
C) osteoblasts.
D) epiphyseal plates.
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Answer: C
Explanation: A) Osteoblasts are the cells that produce the matrix for bone formation, whereas osteoclasts are cells that break down bone tissue. Sarcomeres are filaments made of actin or myosin that are found within muscle. Epiphyseal plates are areas of cartilage located between the epiphysis and diaphysis of a child's long bones.
337
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Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint?
A) 0
B) 5
C) 8
D) 10
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Answer: B
Explanation: A) The muscle function grading scale ranges from 0 to 5. A score of 0 indicates paralysis, meaning that the client cannot contract the muscles associated with a given joint. In contrast, a score of 5 indicates that the client can move a joint through the full range of motion under full resistance.
338
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Within the human body, which type of connective tissue connects bones to other bones to form a joint?
A) Tendon
B) Ligament
C) Cartilage
D) Myelin
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Answer: B
Explanation: A) Ligaments, tendons, and cartilage are all connective tissues. Ligaments connect bones to other bones to form a joint. Tendons connect bones to muscles and carry the contractile forces from the muscle to the bone to cause movement. Cartilage is a type of flexible connective tissue found in many locations throughout the body. Myelin is not a type of connective tissue but rather a fatty substance that insulates neuronal axons and promotes faster signal transmission.
339
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A client presents with an alteration in mobility. Which finding would suggest damage to the muscle?
A) Increased PTH levels
B) Decreased PTH levels
C) Decreased CK levels
D) Increased CK levels
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Answer: D
Explanation: A) Creatine kinase (CK) is used to detect muscle damage, muscle inflammation, rhabdomyolysis, polymyositis, and muscular dystrophy. Thus, increased CK levels are suggestive of increased muscle inflammation. Parathyroid hormone (PTH) levels are not linked to muscle inflammation but rather to osteoporosis, kidney disease, parathyroid gland tumors, lack of calcium, and vitamin D disorders.
340
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The nurse is providing care to a client who is experiencing back pain. Which of the following items in the client's history is a known risk factor for disc herniation?
A) 49 years of age
B) Female gender
C) Short stature
D) Anorexia
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Answer: A
Explanation: A) The client's age is a known risk factor; herniated discs are most common between the ages of 30 and 50, because discs naturally degenerate with age. Other risk factors include male gender, tall height, and excess weight (which is extremely uncommon in clients with anorexia).
341
Which of the clients described below are at increased risk for back problems? Select all that apply.
A) A 45-year-old man who has played golf three times a week for the past 20 years
B) An 18-year-old woman who has been a distance runner since middle school
C) A 62-year-old man who is a heavy truck mechanic and has a body mass index (BMI) of 30
D) A 12-year-old boy who has a history of cerebral palsy and a current BMI of 21
E) A 78-year-old man with a 40 pack-year smoking history who was recently widowed
Answer: C, D, E
Explanation: A) Factors that increase the risk of herniated intervertebral discs include male gender, age (clients over 30 are at higher risk), obesity, history of smoking, and regularly engaging in heavy lifting. This means both the 62-year-old client and the 78-year-old client have multiple traits that put them at elevated risk of disc herniation. Risk factors for scoliosis include age of between 9 and 15 and history of cerebral palsy; thus, the 12-year-old client is at elevated risk for this condition. Neither playing golf nor running track causes a high risk of back problems.
342
A preadolescent client is recovering from spinal fusion surgery for scoliosis. Which nursing interventions should the nurse carry out to address comfort and mobility? Select all that apply.
A) Reposition every 2 hours.
B) Monitor intake and output.
C) Encourage and assist with range of motion (ROM) exercises every 4 hours while awake.
D) Administer pain medication around the clock.
E) Encourage incentive spirometer use every 4 hours while awake.
Answer: A, C, D
Explanation: A) Interventions that address movement restrictions and/or pain in a preadolescent client recovering from spinal fusion include repositioning every 2 hours, encouraging and assisting with ROM exercises every 4 hours while awake, and administering pain medication around the clock. All of these interventions relate to a diagnosis of Impaired Physical Mobility. The use of an incentive spirometer may be appropriate after surgery, but it would relate to a diagnosis of Impaired Tissue Perfusion and not a diagnosis involving pain or restricted movement. Monitoring intake and output would be applicable for a diagnosis of Fluid Volume Excess or Fluid Volume Deficit.
343
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The nurse is providing care to a client who returns to the medical-surgical unit after herniated disc surgery. The client's vitals are as follows: HR 100, RR 22, BP 130/86 mmHg, T 98.8°F, and pain rating of 7 on a scale of 0 to 10. Which nursing diagnosis is the highest priority for this client based on these assessment data?
A) Impaired Physical Mobility
B) Acute Pain
C) Activity Intolerance
D) Chronic Pain
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Answer: B
Explanation: A) The client is currently experiencing acute pain as evidenced by elevated vital signs and a pain rating of 7 on a 0-to-10 scale. Thus, the priority nursing diagnosis is Acute Pain. Impaired Physical Mobility and Activity Intolerance are appropriate diagnoses in light of the client's surgical procedure, but they are not the highest priority. The client was likely experiencing chronic pain prior to the surgery, and it probably contributed to the need for the procedure.
344
The nurse is planning care for a client with acute back pain who is a single mother of two small children and works part-time as a receptionist. Based on this information, which nursing intervention is the highest priority?
A) Instructing the client in appropriate body mechanics for lifting and ways to modify her work environment
B) Suggesting that the client take time off from work until her back is healed
C) Obtaining an order for nonsteroidal anti-inflammatory drugs (NSAIDs) from the client's healthcare provider
D) Suggesting that the client's children be taken care of by an extended family member until the client's back is healed
Answer: A
Explanation: A) The client is at risk for Ineffective Health Management, given that she has two small children who need care and a part-time job that is sedentary. To help the client better manage her health, the nurse should provide instruction on appropriate body mechanics for lifting and ways to modify her work environment. The client may or may not be prescribed NSAIDs. Suggesting that the client take time off from work or have extended family members care for her children may or may not be appropriate and should not be included in the plan of care.
345
The nurse is planning care for a client who is 1 day postoperative after spinal fusion surgery. Which of the following is an appropriate outcome for this client?
A) The client will remain in prone position.
B) The client will maintain urine output at 20 mL per hour.
C) The client will use the incentive spirometer every 2 hours.
D) The client will void 12 hours after surgery
Answer: C
Explanation: A) An appropriate outcome for this client is the use of an incentive spirometer every 2 hours. The client is not expected to remain in a prone position, urine output should be at least 30 mL per hour, and the client should void within 8 hours of surgery.
346
The nurse is documenting the interdisciplinary team report on an adolescent client who has a 35-degree Cobb angle confirmed by x-ray. What interventions should the nurse anticipate being included in the collaborative plan of care for this client? Select all that apply.
A) Obtaining a physical therapy consult prior to surgical intervention
B) Maintaining the existing curvature with no increase
C) Bracing for 12-23 hours per day and providing a support group referral
D) Administering nonopioid analgesics and a TLSO or Milwaukee brace
E) Instructing the client on exercises and appropriate support groups
Answer: C, D, E
Explanation: A) Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for 12-23 hours per day with a TLSO or Milwaukee brace, mild pain medication, counseling or support group referral, and exercise to improve posture and maintain or increase spine flexibility. Mild scoliosis requires observation every 3-6 months. Severe scoliosis requires surgical intervention and subsequent physical therapy.
347
The nurse is planning care for the client with chronic pain from herniated intervertebral discs who is also experiencing constipation. Which intervention should the nurse carry out to address constipation?
A) Restrict foods high in fiber.
B) Avoid the use of stool softeners.
C) Encourage fluid intake of 2500-3000 mL each day.
D) Medicate for pain around the clock.
Answer: C
Explanation: A) A client with a herniated intervertebral disc could have problems with constipation because of reduced mobility. Interventions to alleviate and prevent constipation include encouraging fluid intake of 2500-3000 mL each day, encouraging foods high in fiber, and administering stool softeners to clients who cannot tolerate a high-fiber diet. Medicating for pain around the clock should be avoided if possible, because most pain medications have constipation as a side effect.
348
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) Which region of the spine is the most common location of herniated discs?
A) Cervical region
B) Thoracic region
C) Lumbar region
D) Sacral region
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Answer: C
Explanation: A) The most common location of herniated discs is the lumbar region (L4-L5 and L5-S1), followed by the cervical region (C5-C6 and C6-C7).
10) On the first postoperative day after spinal fusion, the nurse assesses a client and notes the following vital signs: T 39.2°C, BP 100/50 mmHg, HR 118, and RR 23. Drainage at the client's incision site is clear and tests positive for glucose. Which assessment parameter indicates the highest risk for surgical wound infection?
349
On the first postoperative day after spinal fusion, the nurse assesses a client and notes the following vital signs: T 39.2°C, BP 100/50 mmHg, HR 118, and RR 23. Drainage at the client's incision site is clear and tests positive for glucose. Which assessment parameter indicates the highest risk for surgical wound infection?
A) Temperature
B) Incisional drainage positive for glucose
C) Heart rate 118 bpm
D) Presence of incisional drainage
Answer: B
Explanation: A) Incisional drainage isn't necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Similarly, the client's heart rate could be elevated for numerous reasons.
350
The mother of a preadolescent client meets with the school nurse to discuss the client's recent diagnosis of scoliosis. Which interventions would be appropriate for the nursing diagnosis of Disturbed Body Image related to deformity and brace? Select all that apply.
A) Including the student and family in a meeting to elicit her feelings about scoliosis and wearing a brace
B) Offering to arrange a meeting for the student with an 8th grader who has scoliosis
C) Encouraging the student and family to register for home schooling to minimize the risk of ridicule
D) Teaching the student and family about clothing that will hide the brace
E) Suggesting that the pediatrician prescribe an anti-anxiety agent for the student
Answer: A, B, D
Explanation: A) In this scenario, important interventions related to a diagnosis of Disturbed Body Image include attentive listening, offering a support group or person, and teaching the student and family about clothes that will hide the brace. Avoiding other children and community encounters will increase the client's risk of social isolation. There is not enough information to indicate a problem that requires pharmacologic management
351
During a home care visit, an older adult client begins to cry softly when asked about coping with back pain. The client states, "My back hurts bad all the time. I am so confused about all these tests and scared that the doctor wants me to have surgery." In this scenario, which of the following nursing interventions is the highest priority?
A) Asking the client to rate the pain on a scale of 0 to 10
B) Explaining potential procedures in a way the client will understand
C) Administering all pain medication as ordered
D) Attentively listening to the client's thoughts and fears
Answer: D
Explanation: A) The priority nursing intervention for a client who is ready to disclose emotions is to attentively listen to the client's thoughts and fears. If the nurse is asking about coping, a general back pain assessment and medication administration has already likely been completed. Explaining potential procedures will be done after the assessment is complete and the plan of care is set in place.
352
An adolescent client with scoliosis has a Cobb angle of 32 degrees. Given this information, what treatment will the nurse likely need to prepare the client for?
A) This client will not need specific treatment.
B) The nurse will prepare the client for physical therapy.
C) The nurse will prepare the client for wearing a brace.
D) The nurse will prepare the client for undergoing spinal fusion surgery.
Answer: C
Explanation: A) Typically, clients with Cobb angles less than 15 degrees do not require treatment. Clients with Cobb angles of 15 to 25 degrees are treated conservatively with physical therapy, whereas clients with Cobb angles between 25 and 40 degrees are advised to wear a corrective brace. For clients with Cobb angles in excess of 40 degrees, spinal fusion surgery is the most effective option.
353
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Which condition or symptom is most common in clients with a herniated cervical disc?
A) Sciatica
B) Stiff neck and shoulder pain
C) Changes in knee and ankle reflexes
D) Cauda equina syndrome
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Answer: B
Explanation: A) Sciatica, cauda equina syndrome, and changes in knee and ankle reflexes are all symptoms associated with lumbar disc herniation. Herniation of the cervical discs is more commonly associated with numbness, tingling, muscle spasms, and weakness in the upper body, as well as stiff neck and shoulder pain that radiates to the arms and fingers.
354
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A client sustained multiple fractures in a motor vehicle crash. Of the various fracture types sustained by the client, which places the client at highest risk for osteomyelitis?
A) Avulsion fracture
B) Open fracture
C) Comminuted fracture
D) Depression fracture
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Answer: B
Explanation: A) The risk for osteomyelitis, or bone infection, is highest with an open fracture, in which the bone breaks through the skin. Comminuted, avulsion, and depression fractures are closed from the environment and present a lower risk of infection.
355
The nurse is caring for clients in an assisted living facility. Which resident would the nurse identify as being at the highest risk for the development of fractures from a fall?
A) A resident who participates in resistance training exercises three times a week and takes a calcium supplement
B) A resident who hikes in the woods once a week and smokes 14 cigarettes per day
C) A resident who line dances twice per week and has a glass of wine with dinner
D) A resident who teaches yoga four times per week and is lactose intolerant
Answer: B
Explanation: A) Among older adult clients, smoking is the highest-risk behavior. Although exercise helps prevent fractures, hiking on an uneven surface can be a risk. Resistance training, line dancing, yoga, and taking a calcium supplement all decrease the risk of fracture with a fall. Consuming one glass of wine each day is not a risk factor for fractures from a fall. Lactose intolerance can lower calcium intake, although there are other sources of dietary or supplemental calcium that lactose-intolerant clients can use to reduce their fracture risk.
356
The nurse is teaching an older adult client and caregiver about appropriate ways to decrease the client's risk for falls. Which interventions are appropriate for the nurse to include in this teaching session? Select all that apply.
A) Start walking for exercise several times per week.
B) Wear sensible shoes with good support when shopping.
C) Wear socks when walking in the kitchen.
D) Encourage the use of throw rugs throughout the home.
E) Make sure hallways and stairways have adequate lighting, even at night
Answer: A, B, E
Explanation: A) Interventions that are appropriate to decrease this client's risk for falls include wearing sensible shoes with good support when shopping and making sure hallways and stairways have adequate lighting, even at night. A mild to moderate exercise program is also beneficial, as it helps improve balance and strength, thus reducing the likelihood of falls. Nonslip footwear should be encouraged. Throw rugs should be discouraged
357
A nurse is teaching a mother warning signs and symptoms to watch for in her child, who will be discharged with a full leg cast. Which statements by the mother indicate the need for further instruction? Select all that apply.
A) "If her foot turns white and cold, I should call the physical therapist."
B) "I can expect that my child will have some pain, but the medicine should help."
C) "We can use a blow dryer on warm to help with the itching that my child will experience."
D) "We can cut a hole in the cast if my child's foot swells until we get to the doctor's office."
E) "It is okay if the plaster cast gets damp as long as I blow dry it."
Answer: A, C, D, E
Explanation: A) The only option that indicates appropriate understanding of cast care is the mother's statement that her child may have pain that will be relieved by medication. All of the other statements indicate a need for further instruction. If the child's foot turns white and cold, the family should contact the physician. Itching may be helped by use of a blow dryer on the cool setting. Holes should not be cut in the cast, and the plaster should stay dry at all times.
358
A client is admitted to your inpatient rehabilitation unit. This client is currently in halo traction. (See exhibit.) Based on this information, which of the following should be the priority nursing diagnosis for the client?
A) Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights
B) Risk for Infection related to surgical incision and insertion of hardware
C) Risk for Disuse Syndrome related to use of traction to stabilize fracture
D) Acute Pain related to bone and soft tissue damage
Answer: B
Explanation: A) Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.
359
The x-ray of a client 14 weeks post-ulnar fracture exhibits no callus formation. Based on this
data, which collaborative intervention should the nurse anticipate?
A) The physical therapist will set up Buck traction.
B) The surgeon will schedule a consultation with the client.
C) The pharmacist will educate the client on antibiotics.
D) The nurse will counsel the client on starting range-of-motion exercise
Answer: B
Explanation: A) An ulnar fracture that does not show callus formation after 14 weeks would be classified as experiencing nonunion. Nonunions frequently require surgical correction. Buck traction, antibiotics, and exercise are not indicated for nonunion of a fracture.
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) The nurse is providing care for a client who experienced a fracture requiring a plaster cast. Which nursing intervention is appropriate for this client?
A) Prescribing opioid pain medication
B) Assessing the client's neurovascular status
C) Discouraging client ambulation
D) Encouraging the client to keep the cast damp
Answer: B
Explanation: A) It is appropriate for the nurse to assess the client's neurovascular status to monitor for compartment syndrome related to the fracture. The nurse can administer an opioid pain medication but cannot prescribe one. The nurse should encourage the client to ambulate and to keep the plaster cast dry
361
The nurse in an orthopedic outpatient clinic expects to see several clients with fractures for follow-up. Based on the information provided below, which of the nurse's clients is at highest risk for a delayed union?
A) A 20-year-old college student with type I diabetes mellitus who sustained a fractured tibia in a bicycle accident. The nutrition recall tool completed during the client's last visit was consistent with American Diabetic Association (ADA) guidelines.
B) A 62-year-old bartender with a history of peptic ulcer disease who sustained a fractured clavicle breaking up a fight at work. During his prior visit, the client stated he was upset that his injury required him to abstain from upper body resistance training.
C) A 49-year-old teacher with osteoporosis who sustained an open ulnar fracture in a motor vehicle crash. At her last visit, the client reported that she had cut down smoking to 10 cigarettes per day.
D) A 55-year-old accountant who sustained fractures to the 4th and 5th right metatarsals. The client has a history of hypertension that is well controlled with medication
Answer: C
Explanation: A) Evaluating the risk of delayed union requires knowledge of the factors that impact bone healing. The client at greatest risk of delayed union has two factors that decrease the likelihood of proper healing: an open fracture and osteoporosis. This client also uses tobacco, which decreases blood supply to the healing bone. Although diabetes does increase the risk of delayed union, this client is young and exercised on a bicycle prior to the crash. If the client is following an ADA diet, there is adequate intake of vitamin D and calcium, which fosters bone healing. Neither peptic ulcer disease nor controlled hypertension are risks for delayed bone healing.
362
A client hospitalized with an open reduction and internal fixation of a fractured femur reports right calf pain. The nurse notes that the client's right calf is 3.5 cm larger than the left calf with generalized posterior erythema. The right calf is tender to touch, and the dorsalis pedis pulse is 3/4+ bilaterally. Which of the following is the priority action by the nurse?
A) Use a Doppler stethoscope to confirm pedal pulses.
B) Notify the healthcare provider of the findings.
C) Prepare to apply a cast to the right leg.
D) Prepare to administer intravenous heparin.
Answer: B
Explanation: A) These findings indicate possible deep vein thrombosis (DVT). The nurse's first action upon assessing these signs and symptoms should be to notify the healthcare provider immediately. If a pedal pulse can be palpated, then a Doppler stethoscope is not needed; however, a Doppler ultrasound test may be ordered by the provider. A cast is not indicated with internal fixation. Intravenous heparin will likely be ordered after the condition is confirmed by the provider.
363
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During which phase of the fracture healing process is woven bone replaced by lamellar bone?
A) Reactive phase
B) Reparative phase
C) Remodeling phase
D) Inflammatory phase
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Answer: C
Explanation: A) In the reactive or inflammatory phase of fracture healing, a hematoma forms around the injury. Inflammatory cells then enter the wound and degrade debris and bacteria in the area. Next, in the reparative phase, fibroblasts, osteoblasts, and chondroblasts begin to secrete collagen to form fibrocartilage, which develops into a soft callus that joins the fractured bone. Once the soft callus is formed, it is replaced by woven bone through endochondral ossification, which forms a hard callus. Finally, during the remodeling phase, woven bone is replaced by highly organized lamellar bone.
364
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Which of the following fractures presents the greatest risk for development of fat embolism syndrome?
A) Open fracture of the fibula
B) Closed fracture of the femur
C) Open fracture of the humerus
D) Closed fracture of the clavicle
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Answer: B
Explanation: A) Fat embolism syndrome may occur in conjunction with closed fractures of the long bones or pelvis. Of the closed fractures listed here, only the fracture of the femur involves a long bone, so this is the injury that presents the greatest risk for development of fat embolism syndrome.
365
) The nurse is presenting a program at a senior center on how to survive a fall. Which statement by a program participant indicates that this person needs clarification about what emergency actions to take after a fall?
A) "I should crawl to a phone on the affected side to keep it stable against a hard surface."
B) "I should try to cover myself with a blanket while I wait for help to arrive."
C) "To call for help, I can scoot on my bottom to a low wall-mounted phone."
D) "If possible, I can crawl to a stairway and use the stairs to lift up to a standing position."
Explanation: A) Clients at risk for falls and hip fractures should be taught how to notify emergency services in the event of a fall and injury. These clients should be instructed to turn onto the stomach and crawl to the phone, or to scoot to the phone using the buttocks on the uninjured side. And another option is to crawl to a stairway and use the stairs to gradually lift the body to a standing position. While waiting for help to arrive, clients should cover themselves with a blanket if possible to help prevent shock.
366
The nurse is assessing an older adult client in a long-term care facility after a fall. Which finding requires priority action?
A) The injured leg is shortened and externally rotated.
B) Redness and severe swelling are found at the hip joint.
C) Pain is relieved by moving the affected extremity.
D) The client is repeatedly flexing the injured leg at the hip.
Answer: A
Explanation: A) The client with a fractured hip is often in extreme pain and assumes a position with the leg on the affected side shortened and externally rotated because of gravity and the pull of the muscles. Any movement of the leg on the side of the affected hip is likely to cause severe muscle spasms and further pain. Redness and swelling are the classic signs of inflammation not immediately present after hip fracture. Extreme pain associated with hip fracture prevents any voluntary movement in the leg.
367
A postmenopausal client asks the nurse what she can do to prevent fracturing her hips, as her mother and grandmother both experienced this health problem. Which response by the nurse is most appropriate?
A) "You should avoid all types of exercise."
B) "You should consider a smoking cessation program."
C) "You should limit your exposure to the sun."
D) "You should use throw rugs throughout your home."
Answer: B
Explanation: A) One modifiable risk factor for hip fractures is smoking. Women who smoke have a greater risk of fracture because smoking reduces bone density in menopausal and postmenopausal women. The client should not be instructed to avoid exercise; exercise will enhance the client's gait, balance, and musculoskeletal strength. Limiting sun exposure will not impact the client's risk of experiencing a hip fracture. The nurse should not instruct the client to use throw rugs throughout the home because this could cause tripping, leading to a fall.
368
The first day after surgery to repair a fractured hip sustained from a fall, an older adult client refuses to ambulate but states, "I will consider it tomorrow." In this situation, which is the priority action by the nurse?
A) Coordinate personnel to assist with ambulation
B) Document the client's refusal
C) Assess why the client is refusing to ambulate
D) Notify the healthcare provider
Answer: C
Explanation: A) The first thing the nurse should do is assess why the client is refusing to ambulate. The client might be fearful of falling, given that a prior fall resulted in a fractured hip. Following this assessment, the nurse could plan interventions that would facilitate ambulation, such as controlling pain and reducing the fear of falling. It is premature to notify the healthcare provider. The nurse should not force the client to get out of bed. Documenting the client's refusal is appropriate, but after determining the reason for the refusal.
369
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A client with a BMI of 35 is recovering from total hip replacement surgery and experiencing pain that is exacerbated with movement. The client says to the nurse, "I live alone. How will I ever be able to return to my home?" Based on this information, which is the priority nursing diagnosis for this client?
A) Overweight
B) Acute Pain
C) Impaired Physical Mobility
D) Ineffective Coping
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Answer: B
Explanation: A) The priority nursing diagnosis is Acute Pain. Unless this pain is controlled, the client will not be able to participate in interventions to address the nursing diagnosis of Impaired Physical Mobility. The diagnoses of Ineffective Coping and Overweight can be addressed after Acute Pain and Impaired Physical Mobility have been addressed
370
The nurse is providing discharge instructions to an older adult client who is recovering from a fractured hip. The client is planning to stay with an adult child, who is included in the discharge teaching. Which statements on the part of the client indicate appropriate understanding of the information presented by the nurse? Select all that apply.
A) "I have signed a contract with Lifeline."
B) "We are removing the area rugs in the hallway."
C) "I've borrowed a toilet seat riser from the equipment closet."
D) "I will be sure to take oxycodone before I go downstairs in the morning."
E) "I can help with housework while I'm staying at my child's house."
Answer: A, B, C
Explanation: A) Statements regarding the use of an emergency alert service and a toilet seat riser indicate appropriate understanding of the information presented. Picking up loose area rugs can help decrease the risk of falls. Pain medication should not be taken when there is a risk of a fall, particularly prior to going down a set of stairs. The nurse should assess the housework that the client wants to help with while living with the adult child. Many housework tasks will be inappropriate.
371
The nurse is evaluating care provided to a client recovering from hip replacement surgery. Which piece of documentation in the medical record indicates that the client has achieved the expected outcome for pain management?
A) The client states pain is a 6 on a numeric pain scale of 0 to 10 prior to evening care.
B) The client is crying and requesting pain medication prior to morning care.
C) The client is using a PCA pump around the clock and rates pain as a 2 on a numeric pain scale of 0 to 10.
D) The client refuses pain medication prior to physical therapy. Pain is rated as a 7 on a numeric pain scale of 0 to 10.
Answer: C
Explanation: A) Expected outcomes for pain management following hip replacement surgery are to minimize pain to a client rating of 3 or lower via medication administration, including use of patient-controlled analgesia (PCA) as appropriate. Completely eliminating pain is an unrealistic goal. Thus, only the client who is using the PCA pump and has a pain rating of 2 on a 0-to-10 scale has achieved an expected outcome for pain management.
372
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An older adult client experiences a hip fracture. Prior to the injury, the client had an active lifestyle. Based on this information, which surgical procedure should the nurse anticipate?
A) Total hip replacement
B) Open reduction and external fixation
C) Arthroplasty
D) Open reduction and internal fixation
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Answer: D
Explanation: A) Open reduction and internal fixation is the preferred surgical procedure to repair a fractured hip for older adult clients who are active and will be able to use crutches with partial weight bearing following surgery. A total hip replacement, also called arthroplasty, is generally performed only when severe arthritis or an underlying bone condition is present, which does not appear to be the case given this client's activity level prior to the injury. Open reduction and external fixation is not a surgical option for a fractured hip.
373
A client is recovering from surgery to repair a fractured hip. Which actions by the nurse may reduce this client's risk for osteomyelitis in the postoperative period? Select all that apply.
A) Assess for pain every 1-2 hours.
B) Use sterile technique for dressing changes.
C) Assess wound for size, color, and drainage.
D) Administer antibiotics as prescribed.
E) Administer anticoagulants as prescribed.
Answer: B, C, D
Explanation: A) Interventions that can reduce the client's risk for infection include using sterile technique for dressing changes; assessing the wound for size, color, and drainage; and administering antibiotics as prescribed. Assessing for pain every 1-2 hours is appropriate for the nursing diagnosis of Acute Pain, but it does not help reduce the risk of osteomyelitis. Administering anticoagulants per order is appropriate for the client who is at risk for deep vein thrombosis (DVT), but again, it does not help reduce the risk of osteomyelitis.
374
A client is undergoing surgery for a fractured hip. The surgeon has stated that careful attention will be paid to preserving the epiphyseal plate. Which client will require this precaution during surgery?
A) A postmenopausal woman with paraplegia
B) A 32-year-old man who is a competitive body builder
C) A prepubescent girl who is a vegetarian
D) An 85-year-old woman with osteoporosis
Answer: C
Explanation: A) Epiphyseal plates are unique joints that produce growth of bone length in children. There is an epiphyseal plate that lies between the head and neck of the femur that must be preserved during hip surgery in pediatric clients to prevent obstruction of bone growth. Of the clients listed here, only the prepubescent girl is young enough to have an epiphyseal plate. All of the other clients are older than 18-25 years of age, when the epiphyseal plate closes.
375
The nurse gives discharge instructions to an adult client who sustained a bicycle fall and underwent open reduction and internal fixation of a fractured hip. After the teaching is complete, which statements by the client indicate appropriate understanding of the information presented? Select all that apply.
A) "I will use my abduction pillow while sleeping to maintain proper hip alignment."
B) "I will use a high toilet seat to prevent excess flexion of my hip."
C) "I only need to use my walker during physical therapy appointments."
D) "I will take my prescribed ibuprofen to decrease the risk for deep vein thrombosis."
E) "I might experience bruising because of the warfarin I've been prescribed."
Answer: A, B, E
Explanation: A) Statements regarding use of an abduction pillow to maintain proper hip alignment; use of a high toilet seat to prevent excess flexion of the hip; and awareness that warfarin presents an increased risk for bruising all indicate client adequate understanding. The nurse should remind the client to use the walker at all times until told otherwise. The nurse should also explain that warfarin, not ibuprofen, is prescribed to decrease the risk for deep vein thrombosis.
376
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) A hip fracture that occurs in the trochanter region would be classified as a(n)
A) intracapsular fracture.
B) intercapsular fracture.
C) extracapsular fracture.
D) subcapsular fracture.
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Answer: C
Explanation: A) Hip fractures are broadly classified as either intracapsular or extracapsular. Intracapsular hip fractures occur at the head or neck of the femur within the capsule of the hip joint. Extracapsular hip fractures occur within the trochanter region, which is between the neck and diaphysis of the femur. Extracapsular fractures can be further divided into intertrochanteric or subtrochanteric. The terms intercapsular and subcapsular are not used to describe fractures of the hip.
377
For non-elderly adult clients who fracture a hip, why is internal fixation or casting of the fracture generally preferred over hip replacement?
A) Internal fixation or casting is preferred because it does not disturb the client's epiphyseal plate.
B) Internal fixation or casting is preferred because of the lower risk of deep vein thrombosis.
C) Internal fixation or casting is preferred because of the shorter recovery time.
D) Internal fixation or casting is preferred because of the limited longevity of hip prostheses
Answer: D
Explanation: A) Non-elderly adults are likely to live beyond the decade or so anticipated lifespan of a replacement hip. Internal fixation and casting are the preferred treatment methods for these clients because hip replacement may eventually necessitate revision surgery, which carries a greater level of risk than the initial hip replacement surgery. Protection of the epiphyseal plate is not a concern in adult clients, because they no longer have epiphyseal plates.
378
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A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client states that the last time this happened, she recovered in a few weeks. Which classification of multiple sclerosis is the client experiencing?
A) Progressive-relapsing
B) Secondary-progressive
C) Relapsing-remitting
D) Primary-progressive
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Answer: C
Explanation: A) There are four classifications of multiple sclerosis (MS). This client is affected by relapsing-remitting MS, which is characterized by clearly defined flare-ups with worsening neurological function followed by periods of partial or complete remission with few or no symptoms. In comparison, primary-progressive MS involves slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions; secondary-progressive MS begins as relapsing-remitting but becomes worse between exacerbations; and progressive-relapsing MS involves a steady worsening of disease with acute relapses.
379
A young adult client complains of blurred vision and muscle spasms that have come and gone over the past several months. The physician suspects that the client has multiple sclerosis. What in the client's history would the nurse recognize as a risk factor for MS?
A) The client is a male.
B) The client is of Native American descent.
C) The client is of European descent.
D) The client takes a vitamin D supplement daily.
Answer: C
Explanation: A) Risk factors for MS include being female, having a European ancestry, and being between the ages of 20 and 40. Smoking also increases the risk for MS, but taking a vitamin D supplement may decrease the risk.
380
A client with a history of relapsing-remitting multiple sclerosis (MS) is expecting her first child. Which of the following nursing interventions would be indicated for this client?
A) Suggest the client seek reproductive counseling.
B) Tell the client to expect a period of remission after delivery.
C) Instruct the client to expect an exacerbation of symptoms while pregnant.
D) Discuss the client's options for pain control during labor, as her contractions will be especially severe.
Answer: A
Explanation: A) A definite genetic cause of MS has not been established; however, studies suggest that genetic factors make some individuals more susceptible to the disorder than others. Also, some medications used in the treatment of MS can be harmful to a fetus. Thus, reproductive counseling would be recommended for this client. Pregnancy often brings about remission (not exacerbation) of MS, and there is a slightly increased relapse rate postpartum. The strength of uterine contractions in a client with MS is not severe, and because clients often have lessened sensation, labor may be almost painless.
381
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A client with relapsing-remitting multiple sclerosis (MS) tells the nurse that even though her primary symptoms of exacerbation are leg spasms and blurred vision, her greatest struggle is getting through the day because she is always tired. Which diagnosis should the nurse identify as a priority for this client?
A) Fatigue
B) Disturbed Sensory Perception
C) Impaired Physical Mobility
D) Self-Care Deficit
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Answer: A
Explanation: A) The client states that the worst part of her disease exacerbations is being tired, even though leg spasms and blurred vision are present. Therefore, the nurse should identify the diagnosis of Fatigue as a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.
382
) The nurse is caring for a client admitted with an exacerbation of multiple sclerosis (MS). The client is demonstrating frustration with eating because he is experiencing hand and arm spasms that prevent the proper use of utensils. Which intervention should the nurse implement to best assist this client?
A) Consult with the occupational therapist regarding assistive devices for meals.
B) Counsel the client to select finger foods for meals.
C) Plan time to feed the client.
D) Consult with the physical therapist regarding hand and arm exercises.
Answer: A
Explanation: A) Because the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with the occupational therapist regarding devices the client can use to maintain independence at mealtimes. The nurse should not counsel the client to select finger foods for meals, nor should the nurse feed the client. Neither of these actions would support the client's self-concept and self-esteem needs. The nurse might consult the physical therapist regarding hand splints, but hand and arm exercises might not be beneficial for this client.
383
A client with multiple sclerosis (MS) is observed transferring from the bed to a motorized wheelchair and applying splints to the lower extremities before entering the bathroom to perform morning self-care. What could the nurse conclude regarding this observation?
A) The client uses assistive devices to optimize autonomy.
B) The client should be instructed to conduct morning care before applying splints to the lower extremities.
C) The client is dependent on assistive devices.
D) The client should be advised to avoid use of a motorized wheelchair when possible
Answer: A
Explanation: A) The nurse observed the client independently transfer from the bed to a motorized wheelchair, apply splints, and enter the bathroom to perform morning self-care. This is evidence that the client uses assistive devices to optimize autonomy. The nurse should not conclude that the client is dependent on assistive devices, because this conclusion suggests that the client is not autonomous. Similarly, the nurse should not conclude that the client requires instruction regarding wheelchair avoidance or when to apply splints, because this conclusion does not take the client's preferences into consideration
384
A client with multiple sclerosis is prescribed diazepam (Valium). What assessment finding indicates that this medication is effective for the client?
A) Muscle spasticity is reduced.
B) Blood glucose level is within normal limits.
C) The client states that muscles are weak.
D) Ophthalmologic examination shows no evidence of cataracts.
Answer: A
Explanation: A) Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis. It does not cause muscle weakness. Evidence of medication effectiveness would be an observed reduction in muscle spasticity. Glucose intolerance would be assessed if the client were prescribed an adrenal corticosteroid. Cataract development is also a side effect of adrenal corticosteroids.
385
The nurse is planning care for a client with multiple sclerosis. Which intervention would address the nursing diagnosis of Fatigue?
A) Encourage increased activity.
B) Schedule physical therapy three times a day.
C) Plan activities with sufficient rest periods between them.
D) Group activities together so care will not be interrupted.
Answer: C
Explanation: A) Interventions to address the diagnosis of Fatigue include assessing the client's level of fatigue, arranging activities to include rest periods between them, and assisting the client in setting priorities regarding activities. Activities should not be grouped together. Increased activity will not help the client with fatigue. Physical therapy three times a day may be too aggressive for this client
386
The nurse is caring for several clients from various cultural backgrounds. Which client would the nurse assess as having the highest risk for multiple sclerosis?
A) A Brazilian woman with chronic parasitic infestation
B) A Hispanic man with colonized methicillin-resistant Staphylococcus aureus (MRSA)
C) A Northern Canadian woman who has smoked for 25 years
D) An African man in his 20s who has a vitamin D deficiency
Answer: C
Explanation: A) The Northern Canadian woman who smokes has three risk factors for MS: female gender, living farthest from the equator, and smoking. Factors that lower the risk of MS include living closer to the equator (as is the case for the Brazilian and Hispanic clients), having a lowered immune response (as is the case for the client with chronic parasitic infestation), and being male.
387
) An adult client recently diagnosed with multiple sclerosis (MS) reports engaging in vigorous exercise on a regular basis. Which statements contain the correct information to give this client when answering specific questions about lifestyle? Select all that apply.
A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise."
B) "You will tolerate exercise better in an air-conditioned room."
C) "Acupuncture may benefit some of your symptoms."
D) "Drinking cold water is recommended during exercise."
E) "You will be able to maintain your current exercise schedule."
) An adult client recently diagnosed with multiple sclerosis (MS) reports engaging in vigorous exercise on a regular basis. Which statements contain the correct information to give this client when answering specific questions about lifestyle? Select all that apply.
A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise."
B) "You will tolerate exercise better in an air-conditioned room."
C) "Acupuncture may benefit some of your symptoms."
D) "Drinking cold water is recommended during exercise."
E) "You will be able to maintain your current exercise schedule."
Answer: B, C, D
Explanation: A) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room and drinking cold beverages help keep body temperature down. Acupuncture has low risk and may be beneficial for some symptoms of MS. Hyperbaric oxygen therapy carries more risk than benefit. Also, it is unlikely that a newly diagnosed client with MS will be able to tolerate regular vigorous exercise.
388
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During an outpatient clinic follow-up appointment, a client with multiple sclerosis (MS) has lab tests completed. The results show elevated levels of aspartate aminotransferase (AST), serum glutamic-oxaloacetic transaminase (SGOT), alanine aminotransferase (ALT), serum glutamic-pyruvic transaminase (SGPT), and alkaline phosphatase (ALP). The nurse recognizes that these elevated enzyme levels are a potential adverse effect of which medications? Select all that apply.
A) Interferon beta-1a (Avonex)
B) Teriflunomide (Aubagio)
C) Glatiramer acetate (Copaxone)
D) Mitoxantrone (Novantrone)
E) Fingolimod (Gilenya)
```
Answer: A, B
Explanation: A) AST, SGOT, ALT, SGPT, and ALP are liver enzymes that are monitored to detect adverse responses to the medications interferon beta-1a (Avonex) and teriflunomide (Aubagio). Glatiramer acetate (Copaxone), mitoxantrone (Novantrone), and fingolimod (Gilenya) are used to treat MS but do not typically cause liver damage.
389
A nurse is teaching the parents of a client who was recently diagnosed with multiple sclerosis (MS) about what to expect as their child's condition progresses. Which statement by the parents indicates the need for further instruction?
A) "My child is at increased risk for seizures because of the MS diagnosis."
B) "It's not unusual for kids with MS to have problems with their schoolwork."
C) "MS usually progresses faster in children than in adults."
D) "Making friends may be more difficult for our child because of the MS."
Answer: C
Explanation: A) Children with MS often experience seizures related to their diagnosis, and they may suffer from reduced academic performance and difficulty in family and peer relationships. However, MS usually progresses more slowly in children than in adults. Thus, the parents' statement about the speed of disease progression indicates the need for further instruction.
390
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Which category of multiple sclerosis (MS) is characterized by a slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions?
A) Relapsing-remitting
B) Progressive-relapsing
C) Primary-progressive
D) Secondary-progressive
```
Answer: C
Explanation: A) There are four classifications of multiple sclerosis (MS). Relapsing-remitting MS is characterized by clearly defined flare-ups with worsening neurological function followed by periods of partial or complete remission with few or no symptoms. Primary-progressive MS involves slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions. Secondary-progressive MS begins as relapsing-remitting but becomes worse between exacerbations. Progressive-relapsing MS involves a steady worsening of disease with acute relapses.
391
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Which of the following would be classified as a secondary symptom of multiple sclerosis (MS)?
A) Pressure sores
B) Urinary retention
C) Depression
D) Unsteady gait
```
Answer: A
Explanation: A) Secondary symptoms of MS result from chronic primary symptoms of the disease. Because pressure sores result from primary symptoms such as muscle weakness and inability to ambulate, they would be considered a secondary symptom. In comparison, both urinary retention and unsteady gait are primary symptoms of MS, whereas depression is a tertiary symptom (because it involves a psychosocial problem).
392
A client with multiple sclerosis (MS) is said to be experiencing an exacerbation when he or she experiences symptoms that:
A) last at least 1 week and are separated from a previous attack by at least 30 days.
B) last at least 24 hours and are separated from a previous attack by at least 30 days.
C) last at least 2 weeks and are separated from a previous attack by at least 2 months.
D) last at least 30 days and are separated from a previous attack by at least 2 months.
Answer: B
Explanation: A) Clients with MS who are suffering from an exacerbation may experience one or more symptoms that last from days to months, and symptoms can be different during distinct exacerbations. A true exacerbation must last at least 24 hours and must be separated from the previous attack by at least 30 days.
393
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Which of the following medications is used to treat tertiary symptoms of multiple sclerosis (MS)?
A) Bupropion
B) Ciprofloxacin
C) Magnesium hydroxide
D) Glatiramer acetate
```
Answer: A
Explanation: A) Tertiary symptoms of MS relate to psychosocial problems, such as relationship difficulties, loss of a job because of decreased performance, or hopelessness. Of the medications listed here, only bupropion (an antidepressant) would be used to treat a tertiary symptom (depression). Copaxone would be used to treat the primary symptoms of MS, whereas ciprofloxacin (an antibiotic) and magnesium hydroxide (a laxative) would be used to treat the secondary symptoms of infection and constipation, respectively.
394
The nurse is providing teaching to the client recently diagnosed with osteoarthritis. Which statement by the nurse is correct?
A) "Osteoarthritis is most commonly seen in thin, small-built female clients."
B) "Osteoarthritis is a result of joint inflammation."
C) "Osteoarthritis occurs due to erosion of cartilage in the joints."
D) "Osteoarthritis is a metabolic bone disease."
Answer: C
Explanation: A) Osteoarthritis is characterized by progressive erosion of the cartilage within joints. It is not a metabolic bone disease; examples of such diseases include osteoporosis, osteomalacia, and Paget disease. Thin, small-built female clients are at increased risk for osteoporosis, not osteoarthritis. In fact, osteoarthritis is more commonly associated with obesity than with slight build. Finally, joint inflammation is a characteristic of rheumatoid arthritis, not osteoarthritis.
395
The nurse is caring for a client with osteoarthritis. Which factor in the client's history and physical assessment would the nurse recognize as a risk factor for developing this condition?
A) Body mass index of 36.5
B) History of esophageal reflux disease
C) Client plays tennis three times each week
D) Blood pressure of 136/78 mmHg
Answer: A
Explanation: A) Obesity increases the risk of developing osteoarthritis (OA), because the added weight increases stress on weight-bearing joints, causing the joints to wear down more quickly. This client has a body mass index of 36.5, which is considered obese. Moderate recreational exercise (such as tennis three times per week) has been shown to decrease the chance of developing OA and slow the progression of manifestations when OA is present. Esophageal reflux is not associated with OA. Blood pressure is not a known risk factor for the development of OA.
396
An older adult client with bilateral osteoarthritis of the knees tells the nurse, "I know I need to lose weight, but exercising makes my knees ache." What instruction should the nurse provide to this client?
A) "You should discuss knee replacement surgery with your physician."
B) "Exercising the muscles in your legs might be hard now, but over time, it will help protect your knees."
C) "Try eating a reduced-calorie diet for several months before attempting exercise."
D) "You need to stretch your muscles, because stretching is the only form of exercise that improves osteoarthritis."
Answer: B
Explanation: A) Encouraging exercise is an important aspect of nursing care for clients with osteoarthritis (OA). Exercise can increase flexibility, improve blood flow, and help clients lose weight. Over time, these factors can help protect the joints against further deterioration and pain. The nurse should not counsel the client to follow a reduced-calorie eating plan for several months before attempting exercise. The client may or may not want to have knee replacement surgery. Stretching is just one type of exercise that will benefit clients with OA. The other components, strengthening and aerobic exercise, can be obtained through walking, swimming, and isometric, isotonic, and resistive exercises.
397
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) The nurse is planning care for a client with osteoarthritis. Which nursing diagnosis would have the highest priority?
A) Fatigue
B) Chronic Pain
C) Ineffective Coping
D) Disturbed Body Image
```
Answer: B
Explanation: A) When providing care to a client diagnosed with osteoarthritis, priority diagnoses would include Chronic Pain, Impaired Physical Mobility, and Self-Care Deficit. Thus, of the diagnoses identified for this client, Chronic Pain would be the highest priority. Once this diagnosis has been addressed, the nurse and client can focus on the lower priority diagnoses of Fatigue, Ineffective Coping, and Disturbed Body Image
398
The nurse is planning care for a client with osteoarthritis of the hip. Which intervention would be appropriate for this client?
A) Provide moist heat packs to the affected joint 3 times each day.
B) Instruct the client on the importance of strict bedrest.
C) Provide nonsteroidal anti-inflammatory drugs (NSAIDs) when pain becomes severe.
D) Provide opioid pain medication as prescribed
Answer: A
Explanation: A) Interventions appropriate for a client with osteoarthritis (OA) include NSAIDs, moist heat, active range-of-motion exercises, proper posture and body mechanics, and assistive devices to safely maintain independence with activities of daily living. Opioid medication is not typically prescribed for the treatment of OA. NSAIDs are most effective if taken before the pain is severe. The client should be encouraged to be mobile, not on strict bedrest
399
The nurse is evaluating care provided to a client with osteoarthritis (OA). Which client statement indicates to the nurse that interventions for OA have been successful?
A) "I had to take early retirement and now stay at home all day and rest my legs."
B) "I am sleeping throughout the night and have not missed any work because of knee pain."
C) "I am moving from my two-story house into the first floor of my daughter's home so I won't have to walk steps anymore."
D) "I changed my work hours so now I work part time and have a nursing assistant who helps me bathe twice a week at home."
Answer: B
Explanation: A) Expected outcomes for the care of a client with OA include independence with activities of daily living, minimal lifestyle impact because of OA, and controlled pain that allows for rest and sleep. Of the client statements provided, only the one about improved sleep and pain not interfering with work indicates achievement of these outcomes. A client who changes work hours and has a nursing assistant for bathing is experiencing a reduction in activities of daily living and a significant impact in lifestyle. A client who is moving in with a daughter is experiencing significant lifestyle impact. A client who retires early and stays at home all day is also experiencing a significant impact in lifestyle.
400
A client with osteoarthritis tells the nurse she has difficulty walking to the bathroom first thing in the morning. Which nursing action would assist this client?
A) Suggesting a family member provide the client with a bedpan
B) Discussing the option of residing in an assisted-living facility
C) Consulting with physical therapy for an assistive walking device such as a walker or cane
D) Suggesting the client use a bedside commode at home
Answer: C
Explanation: A) Assistive devices are items used to maintain, increase, or improve function. The client describes difficulty walking to the bathroom in the morning. The best intervention to help this client would be to consult with physical therapy for an assistive walking device such as a walker or cane. The use of a bedside commode or bedpan may help with the immediate need to use the bathroom, but the client will still have difficulty ambulating in the morning. The option of residing in an assisted-living facility might be premature for this client
401
A client with chronic hip pain is diagnosed with osteoarthritis. Which instruction regarding home safety is most appropriate for the nurse to provide to this client?
A) Walk up and down the steps at home as much as possible.
B) Rest in a recliner.
C) Place scatter rugs in high-traffic areas.
D) Install grab bars in the bathroom near the commode and in the shower.
Answer: D
Explanation: A) The client should be encouraged to install grab bars in the bathroom near the commode and in the shower. The client should be instructed not to overuse the affected joints with excessive stair climbing. Scatter rugs are a hazard to mobility and should be avoided. The client should also be instructed to sit in a straight-back chair, avoid slumping, and avoid use of a recliner.
402
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A client seeking treatment for severe knee pain has worked in a factory for 30 years in a position requiring repetitive lifting and carrying of 20- to 40-pound boxes. Based on the client's history, the nurse should anticipate which initial recommendation from the multidisciplinary healthcare team?
A) Joint replacement surgery
B) Pharmacologic therapy
C) Referral for a disability application
D) Intermittent use of a cane
```
Answer: B
Explanation: A) Of these options, pharmacologic therapy would be the most likely initial intervention. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and joint injections are all possible options. Joint replacement should be delayed as long as possible because artificial joints often require replacement within 15-20 years. There is not enough information to determine whether applying for disability is appropriate at this time. A cane is not indicated at this time.
403
) Lab results are back for a client who has limiting joint pain. Synovial fluid analysis shows no uric acid crystals or bacteria. The client asks what the test results mean. How should the nurse respond?
A) "These test results mean that your joint pain is likely not caused by gout or septic arthritis."
B) "These test results mean that your joint pain is likely not related to any form of arthritis."
C) "These test results mean that your joint pain is likely caused by either rheumatoid arthritis or septic arthritis."
D) "These test results mean that your joint pain is likely caused by either cancer of the joint or gout."
Answer: A
Explanation: A) Gout is caused by the collection of uric acid crystals in a joint. The absence of uric acid crystals in the synovial fluid (joint fluid) makes gout unlikely. Septic arthritis is caused by infection, so the absence of bacteria makes sepsis unlikely. However, this test does not rule out osteoarthritis or rheumatoid arthritis, so these are still possible diagnoses. Although the nurse may provide information related to which conditions have been ruled out, providing a medical diagnosis is outside the nurse's scope of practice
404
A client with osteoarthritis (OA) of the knees and hips returns for a 3-month follow-up visit with the provider. The nurse calculates that the client's body mass index (BMI) is now 22. The client reports starting a water aerobics and running program three times per week. The client is also using hot packs for edema for 20 minutes and cold packs for pain for 40 minutes daily. After evaluating the client's actions, which follow-up interventions should the nurse plan? Select all that apply.
A) Reinforce the correct use of hot packs.
B) Suggest the client replace running with a lower impact exercise.
C) Explain the risk of injury associated with use of cold packs.
D) Advise the client to continue weight loss.
E) Congratulate the client on starting water aerobics.
Answer: A, B, C, E
Explanation: A) The nurse should congratulate the client on starting water aerobics because it is a low-impact exercise mode. The nurse should also congratulate the client on the weight loss. Note, however, that a BMI of 22 is ideal, so continued weight loss should not be encouraged. The client should be informed that using cold packs for more than 30 minutes may cause skin injury. The nurse should also reinforce that hot packs are used to decrease pain and ice packs are used for edema (swelling). Finally, the nurse should suggest that the client replace the high impact exercise of running with a lower impact exercise such as walking or biking.
405
A nurse is teaching the parents of a client who was recently diagnosed with osteoarthritis (OA) about their child's condition. Which statement by the parents indicates the need for further instruction?
A) "Our daughter's OA is likely related to a joint injury she sustained last year."
B) "Most kids with OA usually have only one or two affected joints."
C) "Because our daughter developed OA as a child, she is more likely to become disabled as a result of this condition."
D) "Our daughter may outgrow her OA as she ages."
Answer: C
Explanation: A) Juvenile OA is usually secondary to a congenital abnormality, genetic condition, or joint injury. It typically occurs only in the one or two joints affected by the abnormality or injury. Children with OA are less likely to become disabled and may outgrow the condition as they age. Thus, the parents' statement about an increased likelihood of disability indicates the need for further instruction.
406
Which of the following treatment options would least likely be considered for a 71-year-old client with osteoarthritis (OA)?
A) Physical therapy
B) Administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Weekly tai chi sessions
D) Administration of narcotics
Answer: B
Explanation: A) Acetaminophen is a first-line medication for older adults due to its efficacy and safety. Narcotics are a second-line choice, because they are safer than NSAIDs for older adults. Mindfulness exercises and complementary health approaches such as yoga or tai chi may assist older adults in increasing mobility and reducing pain levels. Physical therapy is especially important in older adults to maintain or improve mobility of joint(s).
407
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Which of the following procedures used in the treatment of osteoarthritis (OA) involves removing a small amount of bone at the articulating surface of the joint and fitting a metal replacement over the end of the bone?
A) Osteotomy
B) Arthroplasty
C) Arthroscopy
D) Joint resurfacing
```
Answer: D
Explanation: A) In joint resurfacing, a small amount of bone is removed at the articulating surface of the joint and a metal replacement is fitted over the end of the bone. Osteotomy involves surgical removal of a wedge of bone above or below the joint to realign the joint and shift the weight away from the damaged portion of the joint. Arthroscopy entails insertion of a small fiber optic light source, magnifying lens, and camera into the joint to visualize the joint structures. Arthroplasty is total joint replacement, in which a surgeon removes the damaged joint surfaces and replaces them with plastic, metal, or ceramic prostheses.
408
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Which of the following terms is used to describe osteoarthritis (OA) that is caused by an underlying condition, such as injury, congenital malformation, or metabolic disease?
A) Idiopathic
B) Secondary
C) Localized
D) Generalized
```
Answer: B
Explanation: A) OA can be classified as either idiopathic or secondary. Idiopathic OA has no identifiable cause. Idiopathic OA can be further divided into localized or generalized, with localized OA affecting one or two joints and generalized OA affecting three or more joints. Secondary OA is caused by an underlying condition, such as injury; congenital malformation; metabolic, endocrine, or neuropathic disease; or other medical cause.
16) Which of the following procedures would be most appropriate to repair a finger joint that is affected by severe osteoarthritis (OA)?
409
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Which of the following procedures would be most appropriate to repair a finger joint that is affected by severe osteoarthritis (OA)?
A) Osteotomy
B) Joint resurfacing
C) Joint fusion
D) Internal fixation
```
Answer: C
Explanation: A) Joint fusion is used to permanently fuse two or more bones together at a joint using pins, plates, screws, and rods. It is often recommended for badly damaged smaller joints, such as the spine, wrist, ankle, finger, or toe. Osteotomy is usually performed on the knee and hip and entails surgical removal of a wedge of bone above or below the joint to realign the joint and shift the weight away from the damaged portion of the joint. Joint resurfacing, which involves removing a small amount of bone at the articulating surface of the joint and fitting a metal replacement over the end of the bone, is often performed for hip and shoulder joints. Internal fixation is used to fix fractures, not to address osteoarthritis.
410
Clients with osteoarthritis (OA) can reduce their risk of further joint damage by doing which of the following?
A) Applying topical analgesic creams as prescribed
B) Avoiding movement of affected joints
C) Taking acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) before joint pain becomes severe
D) Receiving cortisone injections in affected joints no more than three times per year
Answer: D
Explanation: A) Because frequent use of corticosteroids can cause joint damage, clients should receive cortisone injections in affected weight-bearing joints no more than three or four times per year. Avoiding movement of affected joints does not reduce the risk of joint damage; rather, it worsens the effects of OA. Applying topical analgesics and taking acetaminophen and NSAIDs reduces the pain of OA but does not reduce the risk of further joint damage.
411
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) A client complains of a right-hand tremor, increasing weakness, and muscles that feel tight. The nurse notes that the client has poor voice volume and facial muscles that do not move easily. The nurse recognizes that these symptoms are consistent with which condition?
A) Parkinson disease
B) Spinal cord injury
C) Cerebrovascular accident
D) Multiple sclerosis
```
Answer: A
Explanation: A) Manifestations of Parkinson disease include unintentional tremor, slowed movements, low amplitude of speech, expressionless face, and muscle rigidity. The client is complaining of or exhibiting all these symptoms, suggesting a diagnosis of Parkinson disease. These symptoms are not manifestations of multiple sclerosis, spinal cord injury, or a cerebrovascular accident
412
) A middle-aged female client states to the nurse, "I have noticed a slight tremor in my left hand when it's at rest. I think I might have Parkinson disease because my mother had it." Which response by the nurse is the most appropriate?
A) "Having a close relative with Parkinson disease can increase your chance of developing it as well."
B) "You shouldn't worry too much, because Parkinson disease has a higher prevalence in males."
C) "It is unlikely that you have the same illness as your mother."
D) "You probably don't have Parkinson disease. Your mother was probably exposed to a toxin that caused her illness."
Answer: A
Explanation: A) In some individuals, Parkinson disease (PD) is inherited; approximately 15% to 25% of individuals with PD have a relative with PD. The nurse should not tell the client it is unlikely she has the same illness as her mother. Exposure to toxins is one theory for the development of the illness; however, the nurse has no way of knowing whether the client's mother was exposed to toxins or if that was the cause for her disease. Men are at higher risk for PD, with 50% more men than women developing the disease, but this does not eliminate the client's risk of having the disease, especially given her mother's diagnosis.
413
A client with Parkinson disease (PD) ambulates with a shuffling gait and leans slightly forward. When seated, the client conducts a conversation, reads, and is able to self-feed without assistance. Which nursing diagnosis is a priority for this client?
A) Ineffective Coping
B) Impaired Physical Mobility
C) Imbalanced Nutrition: More than Body Requirements
D) Anxiety
Answer: B
Explanation: A) The client demonstrates a shuffled gait with forward leaning when ambulating. When seated, the client is able to converse, read, and self-feed. Of the diagnoses listed, the one with the highest priority would be Impaired Physical Mobility. Imbalanced Nutrition would not be a priority, as the client can feed himself. There is no evidence to support the diagnoses of Ineffective Coping or Anxiety at this time.
414
The nurse is planning care for a client with Parkinson disease (PD). Which of the following nursing interventions aimed at the client's spouse would best support the client's continued mobility?
A) Suggesting that the spouse use a blender to make foods easier for the client to swallow
B) Reviewing the client's medication administration schedule with the spouse
C) Instructing the spouse to ambulate the client at least four times a day
D) Instructing the spouse on proper turning and repositioning techniques
Answer: C
Explanation: A) Because exercise fosters not just mobility but also independence and self-esteem, the intervention that would be most appropriate is for the nurse to instruct the spouse to ambulate the client at least four times a day. Instructing on turning and repositioning techniques would not support physical mobility. Blending foods to aid with swallowing would not support physical mobility. Reviewing the medication administration schedule would not support physical mobility.
415
The nurse is evaluating the care of a client with Parkinson disease (PD). Which finding indicates an improvement in the client's nutritional status?
A) The client filled out the menu card for each meal.
B) The client coughs frequently when drinking fluids.
C) The client was able to feed himself and had no weight change in 1 week.
D) The client had a 4-pound weight loss in 1 week.
Answer: C
Explanation: A) The finding that the client was able to feed himself and had no weight change in 1 week is indicative of an improvement in nutritional status. The client filling out the menu card does not indicate that the client actually consumed any of the meal. If the client coughs frequently when drinking fluids, it could indicate that interventions to address nutritional status have not been effective. The client's losing 4 pounds in 1 week would not support an improvement in nutritional status
416
The wife of a client with Parkinson disease (PD) expresses frustration about trying to communicate with her husband. What can the nurse do to facilitate communication between the client and spouse?
A) Recommend that the client and spouse learn sign language.
B) Suggest that the spouse obtain a hearing aid.
C) Consult with speech therapy for exercises to aid the client with speech and language.
D) Suggest the client and spouse communicating by writing.
Answer: C
Explanation: A) The spouse is frustrated with the client's impaired verbal communication. The best intervention would be to consult with speech therapy for exercises to aid the client with speech and language. The spouse does not need a hearing aid. The spouse and client do not need to learn sign language in order to communicate. The client may or may not be able to write because of hand tremors, so it may not be appropriate for the nurse to suggest that the client and spouse communicate via writing.
417
The nurse instructs a client with Parkinson disease (PD) about levodopa/carbidopa. Which client statement indicates that this teaching has been effective?
A) "I should eat a high-protein diet when taking this medication."
B) "When taking this medication, I should sit up for several minutes before going from lying down to standing up."
C) "This medication will not affect my blood pressure medications."
D) "Given enough time, this medication will cure my Parkinson disease."
Answer: B
Explanation: A) Levodopa/carbidopa is a medication that boosts dopamine levels in clients with PD. This medication commonly causes orthostatic hypotension, so clients must take care when changing positions from lying to standing. Clients should also avoid eating protein-rich meals when taking this medication, as a high-protein diet may interfere with levodopa absorption from the GI tract. There is no medication that is known to cure Parkinson disease. Care must be taken if clients are also taking medications to lower their blood pressure because a cumulative effect may occur, leading to hypotension and increased risk for falling.
418
The nurse completes a teaching session for a young adult client who was recently diagnosed with Parkinson disease (PD). Which client statement indicates this teaching has been effective?
A) "I could have prevented PD with diet and exercise."
B) "I probably have a genetic mutation that caused my PD."
C) "My brain contains too much of a chemical called dopamine."
D) "Most people with PD first experience symptoms when they are about my age
Answer: B
Explanation: A) Early-onset PD is likely due to a genetic mutation. Increasing age is a risk factor for the disease, and diagnosis as a young adult is uncommon. PD is associated with decreased dopamine levels in the brain, not an excess of dopamine. Although consuming a healthy, pesticide-free diet is recommended, dietary intake has not been definitively linked to development of PD.
419
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) A client is being evaluated for Parkinson disease (PD). Which findings on the Unified Parkinson Disease Rating Scale (UPDRS) would be considered positive for PD? Select all that apply.
A) Diarrhea
B) Dystonia
C) Retropulsion
D) Hyperphonia
E) Festination
```
Answer: B, C, E
Explanation: A) The UPDRS rates clients in 42 different areas of function. Positive findings for PD include retropulsion (the tendency to fall backward), festination (rapid walking as if trying to run), and dystonia (twisting and repetitive movements). Diarrhea and hyperphonia (loud voice) are not symptoms of PD. Constipation and hypophonia (soft voice) are symptoms of PD.
420
The interdisciplinary treatment team proposes interventions to improve and maintain physical function for an adult client with Parkinson disease (PD). Which of the following interventions are supported by research? Select all that apply.
A) Low-intensity treadmill training
B) Walking barefoot indoors
C) Use of resistance bands
D) Active and passive range-of-motion exercises
E) High-intensity treadmill training
Answer: A, C, D, E
Explanation: A) Research studies have shown improvements on the 6-minute walk test of individuals with PD after participation in low-intensity and high-intensity treadmill training, strength training (such as with resistance bands), and range-of-motion exercises. Use of shoes with non-slip soles is advised.
421
The nurse is caring for a 30-year-old female client who was recently diagnosed with Parkinson disease (PD). Which of the following statements should the nurse include in the teaching for this client?
A) "Having the early-onset form of PD puts you at greater risk for dementia."
B) "If you get pregnant, it is highly unlikely that you will be able to carry the baby to term."
C) "Given your age, your PD is likely to progress more slowly than it does for people who develop the condition later in life."
D) "You can continue using birth control pills, because PD medications do not have an impact on their efficacy."
Answer: C
Explanation: A) Clients with early-onset PD generally have a slower disease progression and a lower rate of dementia than clients who develop the disease later in life. The effect of PD medication on the efficacy of birth control pills is not known, so clients should be urged to consider other forms of contraception. Many women with PD have successfully carried healthy babies to full term.
422
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Which of the following is not a common clinical manifestation of Parkinson disease (PD)?
A) Restless leg syndrome
B) Cogwheel rigidity
C) Malignant hypertension
D) Pill-rolling
```
Answer: C
Explanation: A) Malignant hypertension is not a clinical manifestation of PD; orthostatic hypotension is more commonly associated with this disease. All of the other conditions listed here (restless leg syndrome, cogwheel rigidity, and pill-rolling) are frequently observed in clients with PD.
423
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) In clients with Parkinson disease, increasing doses of and long-term exposure to levodopa can cause which of the following conditions?
A) Dyskinesia
B) Insomnia
C) Hypertension
D) Compulsive behavior
```
Answer: A
Explanation: A) With increasing doses and long-term exposure, levodopa usually causes dyskinesia, which may become less tolerable for the client than the symptoms of PD. Insomnia and hypertension are not side effects of levodopa. Compulsive behavior is a side effect of dopamine antagonists, not levodopa
424
Why do clients with Parkinson disease (PD) nearly always take carbidopa in combination with levodopa?
A) Carbidopa minimizes the conversion of levodopa to dopamine within the brain, thus minimizing levodopa's unwanted side effects.
B) Carbidopa enhances levodopa's conversion to dopamine throughout the body, thus intensifying levodopa's effectiveness.
C) Carbidopa prevents levodopa from converting to dopamine until it reaches the brain, thus minimizing levodopa's unwanted side effects.
D) Carbidopa prevents levodopa's conversion to dopamine in the brain, thus intensifying levodopa's effectiveness.
Answer: C
Explanation: A) Levodopa is a natural chemical that can cross the blood—brain barrier and be converted directly to dopamine in the brain. Levodopa can also be converted to dopamine outside the brain, which leads to the most common side effects of nausea and orthostatic hypotension. Therefore, levodopa is almost always given in combination with carbidopa, which prevents levodopa from converting to dopamine until it reaches the brain.
425
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) A client in the initial stages of Parkinson disease (PD) would most likely exhibit which of the following symptoms?
A) Bilateral rigidity
B) Unilateral tremors
C) Bilateral tremors
D) Unilateral rigidity
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Answer: B
Explanation: A) Motor symptoms associated with PD usually begin unilaterally, not bilaterally. For most clients, the earliest motor symptom is tremors; rigidity usually develops later in the course of the disease.
426
An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What is a priority while providing nursing care for this client?
A) Adequate urine output
B) Stable blood pressure
C) Continued stabilization of the neck and spinal cord
D) Insertion of an intravenous access line
Answer: C
Explanation: A) The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the emergency department. An intravenous access line is necessary, but stabilization of the neck and spinal cord is of first priority.
427
A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconscious. After calling the ambulance, which is the priority action by the nurse?
A) Open the airway using the head tilt maneuver.
B) Try to rouse the client by gently shaking the shoulders.
C) Protect the client's neck and head from any movement.
D) Place the client on the side to prevent aspiration.
Answer: C
Explanation: A) Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring the client from the stretcher to the hospital bed with backboard in place. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should use the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. This client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.
428
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A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis?
A) Impaired Physical Mobility
B) Autonomic Dysreflexia
C) Ineffective Breathing Pattern
D) Impaired Gas Exchange
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Answer: C
Explanation: A) Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.
429
The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Ineffective Peripheral Tissue Perfusion? Select all that apply.
A) Discuss future care needs when the client is discharged.
B) Increase fluids to 3000 mL per day.
C) Turn and reposition the client every 2 hours.
D) Assess for a full bladder.
E) Assess blood pressure every 2-3 minutes.
Answer: D, E
Explanation: A) Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.
430
The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that these interventions have been successful?
A) The client had two episodes of impacted stool over the last week.
B) The client is improving in ability to perform self-urinary catheterization.
C) The client is limiting fluids to reduce need to void.
D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.
Answer: B
Explanation: A) An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. A client with an indwelling urinary catheter who is receiving stool softeners every morning is not progressing toward appropriate bowel and bladder elimination habits. A client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. A client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.
431
The nurse in the emergency department is preparing to administer methylprednisone to a client with a spinal cord injury. What does the nurse recognize as the intended therapeutic effect of the medication?
A) To increase blood glucose level
B) To improve the client's level of consciousness
C) To prevent cord damage from ischemia and edema
D) To improve the client's ability to be adequately ventilated
Answer: C
Explanation: A) High-dose steroid protocol using methylprednisone must be implemented within 8 hours of spinal cord injury to improve neurologic recovery. Clinical research indicates that use of this medication is effective in preventing secondary spinal cord damage from edema and ischemia. Methylprednisone may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.
432
The nurse is evaluating the success of a bowel and bladder retraining program with a client who is recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? Select all that apply.
A) One episode of bladder incontinence in 8 hours
B) Client performs self-urinary catheterization every 4 hours while awake
C) Client transfers to use bedside commode after breakfast to evacuate bowels
D) Two episodes of impacted stool in 1 week
E) Client maintains a high-fluid, high-fiber diet
Answer: B, C, E
Explanation: A) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes the client performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to have impacted stool removed twice in 1 week.
433
The nurse is caring for a client who sustained a gunshot wound below the level of T12, resulting in ipsilateral motor paralysis, ipsilateral loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. When planning care for this client, which interpretations of this data by the nurse are likely to be correct? Select all that apply.
A) The client's American Spinal Injury Association Impairment Scale score is A.
B) The spinal cord injury is incomplete.
C) These findings are consistent with Brown-Sequard syndrome.
D) Hemisection of the spinal cord is likely.
E) Some recovery of sensory function is likely.
Answer: B, C, D, E
Explanation: A) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. An American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5.
434
The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement on the part of the attendees indicates that they understand the risk factors and prevention methods associated with spinal cord injury?
A) "There isn't much I can do to prevent a head injury when another vehicle hits my car."
B) "As long as my grandson wears a helmet, he will be safe on his motorcycle."
C) "I'm going to spend extra time discussing this talk with my college-age son because of his higher risk for spinal cord injury."
D) "Due to their elevated risk, I'd like you to present this talk to members of the local Native American population."
Answer: C
Explanation: A) The highest-risk population for spinal cord injuries is young adult males, including college-age men. Riding motorcycles increases the risk of spinal cord injuries, even when helmets are used. Native Americans are the ethnic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for individuals who are involved in motor vehicle crashes
435
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The nurse assesses a young adult client who was involved in a swimming accident that resulted in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this statement, which nursing diagnosis is most appropriate for this client?
A) Risk for Post-Trauma Syndrome
B) Impaired Physical Mobility
C) Self-Care Deficit
D) Noncompliance
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Answer: A
Explanation: A) The client's statement is unrealistic and evidence of Risk for Post-Trauma Syndrome. Although the diagnoses of Impaired Physical Mobility and Self-Care Deficit are appropriate for a client with tetraplegia, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.
436
A female client who sustained a spinal cord injury (SCI) several years ago tells the nurse she is interested in becoming pregnant. She asks the nurse for more information about how her SCI might impact a potential pregnancy. Which of the following statements should the nurse include in her response to the client?
A) "Women with SCI should avoid pregnancy, because it puts too much stress on their bodies and can exacerbate their injuries."
B) "If you become pregnant, your risk for autonomic dysreflexia will likely decrease."
C) "The good news is that none of the medications used in the treatment of SCI are known to have detrimental effects on the fetus."
D) "Should you have a baby and opt to breastfeed, you may experience an increase in muscle spasticity."
Answer: D
Explanation: A) Women with SCI are considered to be "high risk" during pregnancy, but that does not mean pregnancy should be avoided. Instead, the woman will need to work closely with a team of healthcare professionals to prevent complications and prepare for pregnancy, labor, and delivery. Pregnant women are at higher risk for autonomic dysreflexia, especially during labor and delivery. Many women are unable to continue taking prescribed medications during pregnancy due to the potential harm they pose to the fetus. New mothers must also consider the effects of their SCI on breastfeeding; muscle spasticity may increase during breastfeeding, and women with limited sensation in their breasts may have reduced milk production.
437
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Which of the following clients is at highest risk for autonomic dysreflexia?
A) A client with an injury to T9
B) A client with an injury to C7
C) A client with an injury to L2
D) A client with an injury to S1
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Answer: B
Explanation: A) Autonomic dysreflexia is the abrupt onset of excessively high blood pressure as the result of an overactive autonomic nervous system; it usually occurs in clients who have injuries above T5. Of the spinal segments listed here, only C7 is located above T5.
438
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A client with permanent paralysis of the trunk, arms, and legs would be said to be experiencing which of the following conditions?
A) Tetraplegia
B) Paraplegia
C) Spinal shock
D) Complete spinal cord injury (SCI)
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Answer: A
Explanation: A) Tetraplegia (also called quadriplegia) is paralysis of the upper and lower limbs and trunk. Paraplegia is paralysis of all or part of the trunk, legs, and pelvic organs. Spinal shock is a temporary condition characterized by spinal cord swelling; decreased blood flow and blood pressure; and complete loss of motor function, spinal reflexes, and autonomic function below the level of injury. Complete SCIs involve a total loss of all sensory and motor function below the level of the injury. Depending on its location, a complete SCI could results in either tetraplegia or paraplegia.
