Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NRS104Fundamentals > Final Review > Flashcards

Final Review Flashcards

1
Q

You are working in the triage area of the emergency department, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients.

A. An ambulatory, dazed 45-year-old man with a bandaged head wound
B. A restless 60-year-old with fever, severe headache and nuchal rigidity
C. A 25-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
D. A 50-year-old woman with moderate abdominal pain and occasional vomiting

A

B, A, D, C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a client with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply)

A. Auscultate breath sounds
B. Administer medications via metered-dose inhaler (MDI)
C. Complete in-depth admission assessment
D. Check oxygen saturation using pulse oximetry
E. Initiate the nursing care plan
F. Evaluate the client’s technique for using MDI

A

A, B, D

C, E, F are all the RN’s scope of practice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

A client has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant?

A. Assisting the client to sit up on the side of the bed
B. Instructing the client to cough effectively
C. Teaching the client to use incentive spirometry
D. Auscultating breath sounds every 4 hours

A

A

B, C are patient teaching, which belong to the RN

D is assessment, which must be performed by LPN or RN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

You are providing nursing care for a client with a diagnosis of cystitis. Which intervention should you delegate to the nursing assistant?

A. Teaching the client how to secure a clean-catch urine sample
B. Assessing the client’s urine for color, odor, and sediment
C. Reviewing the nursing care plan and add nursing interventions
D. Providing the client with a clean-catch urine sample container

A

D

A-C belong to the nurse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

A client hospitalized reports 5 to 8 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis?

A. Diarrhea
B. Imbalanced nutrition
C. Acute pain
D. Ineffective therapeutic regimen

A

A, b/c the pain is due to the diarrhea. If there is no d/t then the answer would be C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

You are planning a treatment and prevention program for chronic fecal incontinence for an elderly client. Which intervention should you try first?

A. Administer a glycerin suppository 15 minutes before evacuation time
B. Insert a rectal tube at specified intervals each day
C. Assist the client to the bedpan or toilet 30 minutes after meals
D. Use incontinence briefs or adult-sized diapers

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Two weeks ago, a client with heart failure received a new prescription for carvedilol 3.125mg BID orally. When evaluating the client in the clinic, you obtain the following data. Which finding is of most concern?

A. Complaints of increased fatigue and activity intolerance
B. Weight increase of 0.5 kg over a 1-week period
C. Bibasilar crackles audible in the posterior chest
D. Sinus bradycardia at a rate of 48 beats/min

A

D

Carvedilol is a beta-blocker so we need to be concerned about decrease in HR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

As the charge nurse in a long-term care facility that employs RN, LPN and nursing assistant staff members, you have developed a plan for ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to delegate to an LPN team leader?

A. Weigh all resident with heart failure each morning
B. Listen to lung sounds and check for edema weekly
C. Review all heart failure medications with residents every month
D. Update activity plans for residents with heart failure every quarter

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

You are initiating a nursing care plan for a elderly client with a nursing diagnosis Risk for Falls. Which intervention should you delegate to a nursing assistant?

A. Identify environmental factors that increase risk for falls
B. Monitor gait, balance, and fatigue level with ambulation
C. Collaborate with physical therapist to provide the client with a walker
D. Assist the client with ambulation to the bathroom and in the halls

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

The nurse incorporates which priority nursing interventions into the plan of care to promote sleep for a client in the hospital?

A. Turn television on low to late night programming
B. Have client follow hospital routines
C. Avoid awakening client for non-essential tasks
D. Administer prescribed sleeping medications at dinner

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the initiating event that starts the evidence-based practice process?

A. Clinically relevant question
B. Systematic reviews of published research
C. Critiques of research
D. A review of nursing research

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Put the following steps of evidence-based practice in the correct order:

A. Integrate the best evidence with one’s clinical practice.
B. Ask a burning clinical question in PICOT format
C. Disseminate the outcomes of the evidence-based practice decision or change
D. Search for the best evidence to answer the PICOT question
E. Search for and collect the most relevant best evidence
F. Evaluate the outcomes of the practice decision or change based on evidence

A

B, D, E, A, F, C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What does PICOT stand for?

A 
Population
Intervention
Comparison
Outcome
Time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A group of nurses have implemented an evidence-based practice (EBP) change and have evaluated the effectiveness of the change. What is their next step?

A. Conduct a literature review
B. Share the findings with others
C. Review the statistical analysis
D. Create a well-defined PICOT question

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

For clients with systolic heart failure, do exercise program versus without exercise reduce the further risk of hospital admission due to heart failure? What is the best description of O in the PICOT question?

A

Reducing further risk of hospital admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

In clients with chronic wounds, what is the effect of topical negative pressure in promoting healing compared with traditional moisturized gauze dressing? What is the best description of C in the PICOT question?

A

Traditional moisturized gauze dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

The nurse who works in a newborn nursery asks, “I wonder if the moms who breastfeed their babies would be able to breastfeed more successfully if we played peaceful music while they were breastfeeding.” In this example of a PICOT question, which represents “I”?

A. Breastfeeding moms
B. Newborns
C. Peaceful music
D. The nursery

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which part of the research journal article outline the background of the problem being studied and summarizes the existing literature on the subject ?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Which part of the research journal article summarizes the entire article and usually provides the purpose of the study?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Which part of the research journal article describes in detail how the study was conducted, including the type and number of subjects, the research design used, what data were collected and how, and the types of analysis done?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Which part of the research journal article are the findings often presented both in words and in charts, tables, or graphs?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

E

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Which part of the research journal article reports what the results mean in regard to the purpose of the study and the literature review?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which part of the research journal article includes a list of articles and books used by the researcher?

A.  Abstract
B. Introduction
C. Conclusion
D. Reference
E. Results
F. Methods
A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Which level of evidence includes at least one well-designed Randomized Controlled Trial (RCT) with a control group and an experimental group?

A. Level I
B. Level II
C. Level V
D. Level VI

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Which level of evidence includes an analysis and review of multiple RCTs?

A. Level I
B. Level II
C. Level V
D. Level VI

A

A - Systematic Reviews

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Which level of evidence is an article that includes a group of expert opinions?

A. Level I
B. Level II
C. Level V
D. Level VI

A

D - Expert Opinion(s)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

In reviewing the history of nursing, advances in health care and the role of nurses have been associated with which of the following?

A. Economic expansion periods
B. Women’s liberation movements
C. Military conflicts
D. Weather disasters

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is the type of care management approach that coordinates and links healthcare services to clients and their families while streamlining costs and maintaining quality?

A. Primary nursing
B. Total patient care
C. Case management
D. Functional nursing

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is the type of care management approach that promotes health and prevents the development of diseases or injury?

A. Primary nursing
B. Total patient care
C. Case management
D. Functional nursing

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the type of care management approach where the nurse is assigned to all the needs of 4-6 clients?

A. Primary nursing
B. Total patient care
C. Case management
D. Functional nursing

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is the type of care management approach that allows for the care of a greater number of clients? Where the head nurse assigns tasks?

A. Primary nursing
B. Total patient care
C. Case management
D. Functional nursing

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

The examination for registered nurse licensure is exactly the same in every state in the United States. What should the public understand about this exam?

A. Guarantees safe and quality nursing practice for all clients
B. Ensures standard nursing care for all clients
C. Ensures that honest and ethical care is provided
D. Provides a minimum standard of knowledge for a RN to practice

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

A client is admitted with acute exacerbation of asthma. The client is treated by a clinical nurse specialist with bronchodilators and oxygen therapy. The client is clinically stable and is planned for discharged. The client’s daughter is so inspired by their work that she now wishes to pursue a career in nursing. What is the minimum educational qualifications to become a clinical nurse specialist?

A. Basic nursing education
B. Registered nurse licensure
C. Doctoral degree in nursing
D. Master’s degree in nursing

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

The nurse is caring for a client whose daughter wishes to pursue a career in professional nursing. She wants to enroll in a program that is of short duration and makes her eligible to take the nursing licensure exam. Which educational program should the nurse recommend to this student?

A. Practical Nursing Program
B. Associate Degree in Nursing
C. Baccalaureate Degree in Nursing
D. Nursing Diploma Program

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Which theorist believes that people have a natural ability for self-care, and nursing should focus on affecting that ability?

A. Dorothea Orem
B. Florence Nightingale
C. Hildegard Peplau
D. Callista Roy

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Which theorist believes that nursing is the art of providing nurturing care to patients?

A. Dorothea Orem
B. Florence Nightingale
C. Hildegard Peplau
D. Ernestine Wiedenbach

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Which theorist believed in meeting the personal needs of the patient within the environment?

A. Dorothea Orem
B. Florence Nightingale
C. Hildegard Peplau
D. Callista Roy

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Which theorist believed that nursing is a therapeutic, interpersonal, and goal-oriented process?

A. Dorothea Orem
B. Florence Nightingale
C. Hildegard Peplau
D. Callista Roy

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Which theorist believed that human needs are created within the interrelated adaptive modes of physiologic self-concept, role function, and interdependence?

A. Dorothea Orem
B. Florence Nightingale
C. Hildegard Peplau
D. Callista Roy

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

A client tells the nurse that the pain medication is ineffective and causes too many side effects. Which interprofessional team members should the nurse​ consult? (Select all that​ apply.)

A. Pharmacist
B. Physician
C. Dietitian
D. Social Worker
E. Physical Therapist
A

A, B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

During a health campaign, the nurse is educating a group of older clients about Medicare. Which statement describes part B of this plan?

A. It provides voluntary medical insurance
B. It provides a choice of three insurance plans
C. It provides a voluntary prescription drug improvement
D. It provides protection for medical, surgical, and psychiatric care.

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

During a health campaign, the nurse is educating a group of older clients about Medicare. Which statement describes Medicare Advantage Plus?

A. It provides voluntary medical insurance
B. It provides a choice of three insurance plans
C. It provides a voluntary prescription drug improvement
D. It provides protection for medical, surgical, and psychiatric care.

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

During a health campaign, the nurse is educating a group of older clients about Medicare. Which statement describes part D of this plan?

A. It provides voluntary medical insurance
B. It provides a choice of three insurance plans
C. It provides a voluntary prescription drug improvement
D. It provides protection for medical, surgical, and psychiatric care.

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

During a health campaign, the nurse is educating a group of older clients about Medicare. Which statement describes part A of this plan?

A. It provides voluntary medical insurance
B. It provides a choice of three insurance plans
C. It provides a voluntary prescription drug improvement
D. It provides protection for medical, surgical, and psychiatric care.

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

A caregiver asks a nurse to explain respite care. How would the nurse respond?

A. “A service that allows time away for caregivers.”
B. “A special service for the terminally ill and their family.”
C. “Direct care provided to individuals in their home”
D. “Living units for people without regular shelter.”

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

The nursing assistant reports that the client blood pressure is 178/92 mmHg. Which is the best task delegation?

A. Have the LPN give antihypertensive medication(s) by mouth now
B. Instruct the nursing assistant to get the client back into bed STAT
C. Tell the nursing assistant to remeasure the client blood pressure every 15 minutes
D. Send the LPN to recheck the client’s blood pressure to ensure that the reading is correct

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Which finding should be immediately reported to the provider?

A. A change in color vision
B. Crusty yellow drainage on the eyelashes
C. Increased lacrimation
D. A curtain like shadow across the visual field

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

A nurse researcher keeps current on the trends to watch in health care delivery. What trends are likely included? (Select all that apply)

A.  Globalization of economy and society
B. Slowdown in technology development
C. Decreasing diversity
D. Increasing complexity of client care
E. Changing demographics
F. Shortages of key health care professionals
A

A, D, E, F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Which level of evidence is a prospective study, meaning you follow the person for years and years, but you only study one variable?

A. Level III
B. Level II
C. Level V
D. Level IV

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Which level of evidence is an article that just reviews the data that is available without taking into account other variables?

A. Level III
B. Level II
C. Level V
D. Level VI

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Which level of evidence is a study that considers outside variables, but still focuses on the one outcome or result and the one person?

A. Level III
B. Level II
C. Level V
D. Level VI

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What is the type of care management approach the includes the nurse going into the patient’s home and providing private care?

A. Primary nursing
B. Case Method
C. Team Nursing
D. Functional nursing

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What is the type of care management approach that includes a charge nurse overseeing teams of different medical personnel?

A. Primary nursing
B. Case Method
C. Team Nursing
D. Functional nursing

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Which of the following terms describes self-determination, or being independent and self-governing?

A. Beneficence
B. Ethical dilemma
C. Autonomy
D. Ethics

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Which of the following terms is the principle of doing good?

A. Beneficence
B. Ethical dilemma
C. Autonomy
D. Ethics

A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Which of the following terms describes a nurse facing a situation where adherence to basic ethical principles results in two conflicting courses of action?

A. Beneficence
B. Ethical dilemma
C. Autonomy
D. Ethics

A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Which of the following terms describes the system dealing with standards of character and behavior related to what is right and wrong?

A. Beneficence
B. Ethical dilemma
C. Autonomy
D. Ethics

A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Which of the following terms describes a type of ethical approach that aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor?

A. Fidelity
B. Nonmaleficence
C. Feminist Ethics
D. Justice
E. Utilitarian
A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Which of the following terms describes keeping promises and commitments made to others?

A. Fidelity
B. Nonmaleficence
C. Feminist Ethics
D. Justice
E. Utilitarian
A

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Which of the following terms describes the process that distributes benefits, risks, and costs fairly?

A. Fidelity
B. Nonmaleficence
C. Feminist Ethics
D. Justice
E. Utilitarian
A

D

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Which of the following terms describes the principle of avoiding evil?

A. Fidelity
B. Nonmaleficence
C. Feminist Ethics
D. Justice
E. Utilitarian
A

B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Which of the following terms describes the action-guiding theory of ethics that states that the rightness or wrongness of an action depends on the consequences of the action?

A. Fidelity
B. Nonmaleficence
C. Feminist Ethics
D. Justice
E. Utilitarian
A

E

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What is the code of ethics in nursing?

A

the principles that reflect the primary goals, values, and obligations of the profession

64
Q

Which of the following terms refers to employees who report their employers’ violation of the law to appropriate law enforcement agencies outside the employers facilities?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

B

65
Q

Which of the following terms refers to legal rules that are designed to protect health care providers when they give aid to people in emergency situations?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

C

66
Q

Which of the following terms refers to an unexpected occurrence involving death or serious physical or psychological injury, or even the risk of death or injury?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

A

67
Q

Which of the following terms refers to performing an act that a reasonably prudent person under similar circumstances would not do, OR failing to perform an act that a reasonably prudent person under similar circumstances would do?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

E

68
Q

Which of the following terms is the act of negligence as applied to a professional person such as a physician, nurse, or dentist?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

F

69
Q

Which of the following terms refers to a document filed in response to any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor?

A. sentinel event
B. Whistle-blowing
C. Good Samaritan Laws
D. Incident Report
E. Negligence
F. Malpractice
A

D

70
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the A stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

E

71
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the B stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

A

72
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the C stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

D

73
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the D stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

B

74
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the E stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

C

75
Q

When deciding which patient to prioritize, the nurse should consider the ABC’s. What does the F stand for?

A. trauma to the chest, COPD, pneumonia, seizure that effects breathing
B. anything that can harm a person with physiological harm as per Maslow’s first consideration; potential suicide, loss of limb or eyesight, CIWA, infections, seizure or fall precautions
C. Inability to void or control voiding; constipation, diarrhea
D. cardiac failure; low Hgb, Hct; fluid overload or deficit; critical electrolyte imbalances especially in renal failure
E. foreign body in the trachea; swelling in trachea, larynx or airways; drowning
F. Assistance with eating food selection

A

F

76
Q

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply.

A. People are born with values.
B. Values act as standards to guide behavior.
C. Values are ranked on a continuum of importance.
D. Values influence beliefs about health and illness.
E. Value systems are not related to personal codes of conduct.
F. Nurses should not let their values influence patient care.

A

B, C, D

A value is a belief about the worth of something, about what matters, which acts as a standard to guide one’s behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person’s values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

77
Q

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission?

A. Modeling
B. Moralizing
C. Laissez-faire
D. Rewarding and punishing

A

D

When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system.

78
Q

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote “prizing” in the process of values clarification? Select all that apply.

A. A patient decides to quit smoking following a diagnosis of lung cancer.
B. A patient shows off a new outfit that she is wearing after losing 20 pounds.
C. A patient chooses to work fewer hours following a stress-related myocardial infarction.
D. A patient incorporates a new low-cholesterol diet into his daily routine.
E. A patient joins a gym and schedules classes throughout the year.
F. A patient proudly displays his certificate for completing a marathon.

A

B, F

Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joining a gym for the year and following a low-cholesterol diet faithfully.

79
Q

A nurse incorporates the “five values that epitomize the caring professional nurse” (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice?

A. Altruism
B. Autonomy
C. Human dignity
D. Integrity

A

D

The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

80
Q

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute?

A. Providing honest information to patients and the public
B. Promoting universal access to health care
C. Planning care in partnership with patients
D. Documenting care accurately and honestly

A

B

The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

81
Q

An older nurse asks a younger coworker why the new generation of nurses just aren’t ethical anymore. Which reply reflects the BEST understanding of moral development?

A. “Behaving ethically develops gradually from childhood; maybe my generation doesn’t value this enough to develop an ethical code.”
B. “I don’t agree that nurses were more ethical in the past. It’s a new age and the ethics are new!”
C. “Ethics is genetically determined…it’s like having blue or brown eyes. Maybe we’re evolving out of the ethical sense your generation had.”
D. “I agree! It’s impossible to be ethical when working in a practice setting like this!”

A

A

The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually.

82
Q

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse’s action reflects which principle of bioethics?

A. Autonomy
B. Beneficence
C. Justice
D. Fidelity
E. Nonmaleficence
A

E

Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another’s right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises.

83
Q

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse’s commitment to the principle of autonomy?

A. The nurse helps the patient prepare a durable power of attorney document.
B. The nurse gives the patient undivided attention when listening to concerns.
C. The nurse keeps a promise to provide a counselor for the patient.
D. The nurse competently administers pain medication to the patient.

A

A

The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

84
Q

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient’s doctor threatens the nurse with firing if the nurse raises questions about the patient’s care or calls the consult. What ethical conflict is this nurse experiencing?

A. Ethical uncertainty
B. Ethical distress
C. Ethical dilemma
D. Ethical residue

A

B

Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised.

85
Q

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply.

A. Advocacy is the protection and support of another’s rights.
B. Patient advocacy is primarily performed by nurses.
C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities.
D. Nurse advocates make good health care decisions for patients and residents.
E. Nurse advocates do whatever patients and residents want.
F. Effective advocacy may entail becoming politically active.

A

A, C, F

Advocacy is the protection and support of another’s rights. Among the patients with special advocacy needs are the very young and the older adult, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences.

86
Q

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law?

A. Public law
B. Private law
C. Civil law
D. Criminal law

A

D

Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

87
Q

Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply.

A. Violations that may result in disciplinary action
B. Clinical procedures
C. Medication administration
D. Scope of practice
E. Delegation policies
F. Medicare reimbursement
A

A, D

Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation.

88
Q

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse?

A. Appellates
B. Defendants
C. Plaintiffs
D. Attorneys

A

C

The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant.

89
Q

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient’s vital signs during routine eye surgery, leading to the death of the patient. The nurse’s attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential?

A. Accreditation
B. Licensure
C. Certification
D. Board approval

A

C

Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

90
Q

Review of a patient’s record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed?

A. Assault
B. Battery
C. Invasion of privacy
D. False imprisonment

A

B

Assault is a threat or an attempt to make bodily contact with another person without that person’s consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

91
Q

A veteran nurse pled guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman’s vital signs during the procedure. The surgeon who performed the procedure called the nurse’s action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case?

A. The surgeon who performed the procedure called the nurse’s action pure negligence, saying that the patient could have been saved.

B. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community.

C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery.

D. The nurse had a duty to monitor the patient’s vital signs, and due to the nurse’s failure to perform this duty in this circumstance, the patient died.

A

D

Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse–patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient.

92
Q

An attorney is representing a patient’s family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse’s actions. How should the nurse respond?

A. “I’m sorry, but I can’t talk with you; you will have to contact my attorney.”

B. “I will answer your questions so you’ll understand how the situation occurred.

C. “I hope I won’t be blamed for the death because it was so busy that day.”

D. “First tell me why you are doing this to me. This could ruin my career!”

A

A

The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff’s lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants.

93
Q

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication?

A. The nurse is not responsible, because the nurse was following the doctor’s orders.

B. Only the nurse is responsible, because the nurse actually administered the medication.

C. Only the health care provider is responsible, because the health care provider actually ordered the drug.

D. Both the nurse and the health care provider are responsible for their respective actions.

A

D

Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed.

94
Q

A nurse answers a patient’s call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply.

A. An incident report is used as disciplinary action against staff members.

B. An incident report is used as a means of identifying risks.

C. An incident report is used for quality control.

D. The facility manager completes the incident report.

E. An incident report makes facts available in case litigation occurs.

F. Filing of an incident report should be documented in the patient record.

A

B, C, E

Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

95
Q

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true?

A. Students are not responsible for their acts of negligence resulting in patient injury.

B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.

C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor.

D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

A

B
Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student’s competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

96
Q

A nurse working in a primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply.

A. Health and illness are the same for all people.

B. Health and illness are individually defined by each person.

C. People with acute illnesses are actually healthy.

D. People with chronic illnesses have poor health beliefs.

E. Health is more than the absence of illness.

F. Illness is the response of a person to a disease.

A

B, E, F

Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential. An illness is the response of the person to a disease.

97
Q

A nurse working in a hospital setting cares for patients with acute and chronic conditions. Which disease states are chronic illnesses? Select all that apply.

A. Diabetes mellitus
B. Bronchial pneumonia
C. Rheumatoid arthritis
D. Cystic fibrosis
E. Fractured hip
F. Otitis media
A

A, C, D

Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time.

98
Q

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply.

A. A White male diagnosed with HIV
B. An African American teenager who is 6 months pregnant
C. A Hispanic male who has type II diabetes
D. A low-income family living in rural America
E. A middle-class teacher living in a large city
F. A White baby who was born with cerebral palsy

A

B, C, D, F

National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs.

99
Q

A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?

A. Tertiary
B. Secondary
C. Primary
D. Promotive

A

C

Giving influenza injections is an example of primary health promotion and illness prevention.

100
Q

A patient in a community health clinic tells the nurse, “I have a high temperature, feel awful, and I am not going to work.” What stage of illness behavior is the patient exhibiting?

A. Stage 1: Experiencing symptoms
B. Stage 2: Assuming the sick role
C. Stage 3: Assuming a dependent role
D. Stage 4: Achieving recovery and rehabilitation

A

B

Stage 2: Assuming the sick role. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: Experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one’s personal definition of health. The stage of assuming a dependent role is characterized by the patient’s decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities.

101
Q

Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms?

A. Jane, whose best friend had a benign breast lump removed
B. Sarah, who lives in a low-income neighborhood
C. Tricia, who has a family history of breast cancer
D. Nancy, whose family encourages regular physical examinations

A

C

The physical dimension includes genetic inheritance, age, developmental level, race, and biological sex. These components strongly influence the person’s health status and health practices. A family history of breast cancer is a major risk factor.

102
Q

Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply.

A. A nurse runs an immunization clinic in the inner city.
B. A nurse teaches a patient with an amputation how to care for the residual limb.
C. A nurse provides range-of-motion exercises for a paralyzed patient.
D. A nurse teaches parents of toddlers how to childproof their homes.
E. A school nurse provides screening for scoliosis for the students.
F. A nurse teaches new parents how to choose and use an infant car seat.

A

B, C

Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity.

103
Q

The nurse uses the agent–host–environment model of health and illness to assess diseases in patients. This model is based on what concept?

A. Risk factors
B. Demographic variables
C. Behaviors to promote health
D. Stages of illness

A

A

The interaction of the agent, host, and environment creates risk factors that increase the probability of disease.

104
Q

A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health–illness continuum and the high-level wellness models?

A. Illness as a fixed point in time
B. The importance of family
C. Wellness as a passive state
D. Health as a constantly changing state

A

D

Both these models view health as a dynamic (constantly changing state).

105
Q

A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility?

A. By being a role model for healthy behaviors
B. By not requiring sick days from work
C. By never exposing others to any type of illness
D. By budgeting time and resources efficiently

A

A

Good personal health enables the nurse to serve as a role model for patients and families.

106
Q

A nurse uses Maslow’s hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful?

A. Making accurate nursing diagnoses

B. Establishing priorities of care

C. Communicating concerns more concisely

D. Integrating science into nursing care

A

B

Maslow’s hierarchy of basic human needs is useful for establishing priorities of care.

107
Q

The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply.

A. Preventing falls in the facility
B. Changing a patient’s oxygen tank
C. Providing materials for a patient who likes to draw
D. Helping a patient eat his dinner
E. Facilitating a visit from a spouse
F. Referring a patient to a cancer support group.

A

B, D

Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs; providing art supplies may help meet self-actualization needs; facilitating visits from loved ones helps meet self-esteem needs; and referring a patient to a support group helps meet love and belonging needs.

108
Q

The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow’s basic human needs is being met by this nurse?

A. Physiologic
B. Safety and security
C. Self-esteem
D. Love and belonging

A

B

By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection. An example of a physiologic need is clearing a patient’s airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient’s family to arrange a visit.

109
Q

A nurse caring for patients in a long-term care facility uses available resources to help patients achieve Maslow’s highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply.

A. Humans are born with a fully developed sense of self-actualization.

B. Self-actualization needs are met by depending on others for help.

C. The self-actualization process continues throughout life.

D. Loneliness and isolation occur when self-actualization needs are unmet.

E. A person achieves self-actualization by focusing on problems outside self.

F. Self-actualization needs may be met by creatively solving problems.

A

C, E, F

Self-actualization, or reaching one’s full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs.

110
Q

A nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family?

A. A father, a mother, and children
B. A group whose members are biologically related
C. A unit that includes aunts, uncles, and cousins
D. A group of people who live together and depend on each other for support

A

D

Although all the responses may be true, the best definition is a group of people who live together and depend on each other for physical, emotional, or financial support.

111
Q

A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply.

A. Who is the person you depend on for emotional support?

B. Who is the breadwinner in your family?

C. Do you plan on having any more children?

D. Who keeps your family together in times of stress?

E. What family traditions do you pass on to your children?

F. Do you live in an environment that you consider safe?

A

A, D

The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function.

112
Q

The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors?

A. The family does not have dental care insurance or resources to pay for it.

B. Both parents work and leave a 12-year-old child to care for his younger brother.

C. Both parents and their children are considerably overweight.

D. The youngest member of the family has cerebral palsy and needs assistance from community services.

A

B

Inadequate childcare resources is a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic risk factor.

113
Q

A nurse working in an “Aging in Place” facility interviews a married couple in their late seventies. Based on Duvall’s Developmental Tasks of Families, which developmental task would the nurse assess for this couple?

A. Maintenance of a supportive home base

B. Strength of the marital relationship

C. Ability to cope with loss of energy and privacy

D. Adjustment to retirement years

A

D

The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children.

114
Q

A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community?

A. It meets all the needs of its inhabitants

B. It has mixed residential and industrial areas

C. It offers access to health care services

D. It consists of modern housing and condominiums

A

C

A healthy community offers access to health care services to treat illness and to promote health. A healthy community does not usually meet all the needs of its residents, but should be able to help with health issues such as nutrition, education, recreation, safety, and zoning regulations to separate residential sections from industrial ones. The age of housing is irrelevant as long as residences are maintained properly according to code.

115
Q

A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care?

A. Individual and family health care needs
B. Populations within the community
C. Local health care facilities
D. Families in crisis

A

A

In contrast to community health nursing, which focuses on populations within a community, community-based nursing is centered on individual and family health care needs. Community-based nurses may help families in crisis and work in health care facilities, but these are not the focus of community-based nursing.

116
Q

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply.

A. The United States has become less inclusive of same-sex couples.

B. Cultural diversity is limited to people of varying cultures and races.

C. Cultural diversity is separate and distinct from health and illness.

D. People may be members of multiple cultural groups at one time.

E. Culture guides what is acceptable behavior for people in a specific group.

F. Cultural practices may evolve over time but mainly remain constant.

A

D, E, F

A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group’s needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

117
Q

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply.

A. A hospital nurse tells a nurse’s aide that patients should not be given a choice whether or not to shower or bathe daily.

B. A nurse treats all patients the same whether or not they come from a different culture.

C. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods.

D. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence.

E. A nurse directs interview questions to an older adult’s daughter even though the patient is capable of answering them.

F. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

A

A, D

Cultural imposition occurs when a hospital nurse tells a nurse’s aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult’s ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient’s sexual orientation, the nurse is engaging in stereotyping.

118
Q

A nurse caring for culturally diverse patients in a health care provider’s office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient’s race? Select all that apply.

A. A Native American patient
B. An African-American patient
C. An Alaska Native
D. An Asian patient
E. A White patient
F. A Hispanic patient
A

A, C, E, F

Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

119
Q

A nurse is using the ESFT model to understand a patient’s conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness?

A. How do you get your medications?
B. How does having COPD affect your lifestyle?
C. Are you concerned about the side effects of your medications?
D. Can you describe how you will take your medications?

A

B

The ESFT model guides providers in understanding a patient’s explanatory model (a patient’s conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: “How does having COPD affect your lifestyle?” explores the explanatory model, “How do you get your medications?” refers to the social and environmental factor, “Are you concerned about the side effects of your medications?” addresses fears and concerns, and “Can you describe how you will take your medications?” involves therapeutic contracting.

120
Q

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process?

A. Cultural assimilation
B. Cultural imposition
C. Culture shock
D. Ethnocentrism

A

A

When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one’s own cultural group are best, superior, or most preferred to those of other groups.

121
Q

A nurse states, “That patient is 78 years old—too old to learn how to change a dressing.” What is the nurse demonstrating?

A. Cultural imposition
B. Clustering
C. Cultural competency
D. Stereotyping

A

D

Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.

122
Q

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention?

A. Use short words and talk more loudly.
B. Ask an interpreter for help.
C. Explain why care can’t be provided.
D. Provide instructions in writing.

A

B

The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can’t be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn’t speak English, she won’t understand what the nurse is saying.

123
Q

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive?

A. “Do you think you will be able to eat the food we have here?”
B. “Do you understand that we can’t prepare special meals?”
C. “What types of food do you eat for meals?”
D. “Why can’t you just eat our food while you are here?”

A

C

Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

124
Q

A nurse is telling a new mother from Africa that she shouldn’t carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias?

A. Cultural imposition
B. Clustering
C. Cultural competency
D. Stereotyping

A

A

The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

125
Q

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care?

A. Learning the predominant language of the community
B. Obtaining significant information about the community
C. Treating each patient at the clinic as an individual
D. Recognizing the importance of the patient’s family

A

C

In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient’s culture, and recognizing the influence of family on the patient’s life.

126
Q

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply.

A. Actual
B. Perceived
C. Psychological
D. Anticipatory
E. Physical
F. Maturational
A

A, B, C

The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is loss that is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

127
Q

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply.

A. The family arranges for a funeral for their loved one.

B. The family arranges for a memorial scholarship for their loved one.

C. The coroner pronounces the patient’s death.

D. The family arranges for hospice for their loved one.

E. The patient is diagnosed with terminal cancer.

F. The patient’s daughter writes a poem expressing her sorrow.

A

A, B, F

Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life), that make up the outward expressions of grief. A diagnosis of cancer and the coroner’s pronouncing the patient’s death are not behaviors of the family during a period of mourning. Arranging for hospice care would not be an expression of mourning.

128
Q

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing?

A. Somatic grief
B. Anticipatory grief
C. Unresolved grief
D. Inhibited grief

A

C

Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Somatic grief is not a classification of grief, rather somatic symptoms are the expression of grief that may occur with inhibited grief. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place.

129
Q

A home health care nurse has been visiting a patient with AIDS who says, “I’m no longer afraid of dying. I think I’ve made my peace with everyone, and I’m actually ready to move on.” This reflects the patient’s progress to which stage of death and dying?

A. Acceptance
B. Anger
C. Bargaining
D. Denial

A

A

The patient’s statement reflects the acceptance stage of death and dying defined by Kübler-Ross.

130
Q

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he’s finally made peace with his family. Which response by the nurse would be most appropriate?

A. “You can’t be feeling this way. You know you are going to die.”

B. “It does seem unfair. Tell me more about how you are feeling.”

C. “You’ll be all right; who knows how much time any of us has.”

D. “Tell me about your pain. Did it keep you awake last night?”

A

B

This response by the nurse validates that what the patient is saying has been heard and invites him to share more of his feelings, concerns, and fears. The other responses either deny the patient’s feelings or change the subject.

131
Q

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, “I just can’t sleep. I keep thinking about what my family will do when I am gone.” What response by the nurse would be most appropriate?

A. “Oh, don’t worry about that now. You need to sleep.”

B. “What seems to be concerning you the most?”

C. “I have talked to your wife and she told me she will be fine.”

D. “I’m not qualified to advise you, I suggest you discuss this with your wife.”

A

B

Using an open-ended question allows the patient to continue talking. An open-ended question, such as, “What seems to be concerning you the most?” provides a means of encouraging communication. False reassurances are not helpful. Also, the patient’s feelings and restlessness should be addressed as soon as possible.

132
Q

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare?

A. POLST form
B. Durable power of attorney for health care
C. Living will
D. Allow Natural Death (AND) form

A

B

A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A Physician Order for Life-Sustaining Treatment form, or POLST form, is a medical order indicating a patient’s wishes regarding treatments commonly used in a medical crisis. The living will is a document whose precise purpose is to allow people to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. Allow natural death on the medical record of a patient indicates the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient.

133
Q

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: “Please help me end my suffering.” Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide?

A. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient’s death.

B. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses.

C. After exhausting every intervention to keep a dying patient comfortable, the nurse says, “I think you are now at a point where I’m prepared to do what you’ve been asking me. Let’s talk about when and how you want to die.”

D. The nurse responds: “I’m personally opposed to assisted suicide, but I’ll find you a colleague who can help you.”

A

A

The ANA Code of Ethics states that the nurse “should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life” (2015, p. 3). Yet, nurses may be confronted by patients who seek assistance in ending their lives and must be prepared to respond to the request: “Nurse, please help me die….”

134
Q

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife’s health care provider about which type of order?

A. Comfort Measures Only
B. Do Not Hospitalize
C. Do Not Resuscitate
D. Slow Code Only

A

A

The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order. The wife would want all aggressive treatment to be stopped at this point, and all care to be directed to a comfortable, dignified death. A Do Not Hospitalize order is often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive treatment. A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. A Slow Code means that calling a code and resuscitating the patient are to be delayed until these measures will be ineffectual. Many health care institutions have policies forbidding this, and a nurse could be charged with negligence in the event of a Slow Code and resulting patient death.

135
Q

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply.

A. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support.

B. Explain to the family what will happen at each phase of the weaning and offer support.

C. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.

D. Tell the family that death will occur almost immediately after the patient is removed from the ventilator.

E. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider.

F. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

A

A, B, C

A nurse’s role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient’s family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on his or her own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision.

136
Q

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant’s parents also have a 22-month-old son at home. The nurse’s assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document?

A. Grieving
B. Ineffective Coping
C. Caregiver Role Strain
D. Powerlessness

A

C

The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided. The other diagnoses do not fit the assessment data.

137
Q

A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care?

A. To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient.

B. The nurse sits on the side of the bed of a dying patient, holding the patient’s hand, and crying with the patient.

C. The nurse refers to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father.

D. The nurse tells a dying patient to sit back and relax and performs patient hygiene for the patient because it is easier than having the patient help.

A

B

The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body, and many patients retain a sense of hearing almost to the moment of death; therefore, nurses should explain to the comatose patient the nursing care being given. The nurse should address caregiver role endurance by actively listening to family members. Because it is good to encourage dying patients to be as active as possible for as long as possible, it is generally not good practice to perform basic self-care measures the patient can perform simply because it is “easier” to do it this way.

138
Q

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy?

A. The nurse leaves the patient in a sitting position while the family visits.

B. The nurse places identification tags on both the shroud and the ankle.

C. The nurse removes soiled dressings and tubes.

D. The nurse makes sure a death certificate is issued and signed.

A

A

Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

139
Q

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate?

A. Inform the family that there is no need for them to wash the body since the mortician typically does this.

B. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel.

C. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens.

D. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

A

D

The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

140
Q

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker?

A. The patient
B. The patient’s daughter
C. The patient’s health care provider
D. The ethics consult team

A

A

Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilities unless she asks them to do this. The ethics consult team is not a decision-making body; it can make recommendations but has no authority to order anything.

141
Q

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse “I feel no connection to God” and “I’m worried that I find no real meaning in life.” What would be the nurse’s best response to this patient?

A. Give the patient a hug and tell him that his life still has meaning.

B. Arrange for a spiritual adviser to visit the patient.

C. Ask if the patient would like to talk about his feelings.

D. Call in a close friend or relative to talk to the patient.

A

C

When caring for a patient who is in spiritual distress, the nurse should listen to the patient first and then ask whether the patient would like to visit with a spiritual adviser. To arrange for a spiritual adviser first may not respect the wishes of the patient. A hug and false reassurances do not address the diagnosis of spiritual distress. Talking to friends or relatives may be helpful, but only if the patient desires their visits.

142
Q

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn’t assist patients with their spiritual distress because she recognizes only a “field power” in each person. She said, “My parents and I hardly talk because I’ve deserted my faith. Sometimes I feel real isolated from them and also from God—if there is a God.” Analysis of these data reveals which unmet spiritual need?

A. Need for meaning and purpose

B. Need for forgiveness

C. Need for love and relatedness

D. Need for strength for everyday living

A

C

The data point to an unmet spiritual need to experience love and belonging, given the nurse’s estrangement from her family and God after leaving the church. The other options may represent other needs this nurse has, but the data provided do not support them.

143
Q

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs?

A. Can you describe your usual spiritual practices and how you maintain them daily?

B. Are your spiritual beliefs causing you any concern?

C. How can I and the other nurses help you maintain your spiritual practices?

D. How do your religious beliefs help you to feel at peace?

A

C

Questioning how the staff can meet patients’ spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices assesses spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at peace assesses the need for forgiveness.

144
Q

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: “I want to eat what everyone else does—and give me decent dishes.” Analysis of these data reveals what finding?

A. The nurse should have ordered kosher dishes also.

B. The staff must have behaved condescendingly or critically.

C. Mr. Goldstein is a problem patient and difficult to satisfy.

D. Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

A

D

On the basis of his name alone, the nurse jumped to the premature and false conclusion that this patient would want a kosher diet.

145
Q

A nurse working in an emergency department assesses how patients’ religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery?

A. A patient of the Adventist faith

B. A patient who practices Buddhism

C. A patient who is a Jehovah’s Witness

D. A patient who is an Orthodox Jew

A

C

Patients who practice the Jehovah’s Witness faith believe blood transfusions violate God’s laws and do not allow them. The other religious groups do not restrict modern lifesaving treatment for their members.

146
Q

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed?

A. Baptism frequently postpones or prevents death or suffering.

B. It is legally required that nurses provide for this care when the family makes this request.

C. It is a nursing function to assure the salvation of the baby.

D. Not having a Baptism for the baby when desired may increase the family’s sorrow and suffering.

A

D

Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family’s sorrow and suffering, which is an appropriate nursing concern. Whether baptism postpones or prevents death and suffering is a religious belief that is insufficient to bind all nurses. There is no legal requirement regarding baptism, and although some nurses may believe part of their role is to ensure the salvation of the baby, this function would understandably be rejected by many.

147
Q

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply.

A. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days.

B. A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures.

C. A nurse administering medications to a Muslim patient avoids touching the patient’s lips

D. A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday.

E. The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient.

F. The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

A

A, B, D, F

The nurse dietitian should ask a Buddhist if he has any diet restrictions related to the observance of holy days. Since Catholic Scientists avoid the use of pain medications, the nurse should ask a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. A nurse administering medications to a Hindu woman avoids touching the patient’s lips. A nurse should ask a Roman Catholic woman if she would like to attend the local Mass on Sunday. The nurse is careful not to schedule treatment and procedures on Saturday for a Jewish patient due to observance of the Sabbath. The nurse would appropriately consult with the medicine man of a Native American patient and incorporates his or her suggestions into the care plan.

148
Q

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child’s own spirituality?

A. The child’s church or religious organization
B. What parents say about God and religion
C. How parents behave in relationship to one another, their children, others, and to God
D. The spiritual adviser for the family

A

C

Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family’s spiritual advisor, and the child’s church or religious organization are less important sources of learning.

149
Q

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation?

A. Patients usually want to conceal information about their spiritual needs.

B. Patients are not concerned about spiritual needs until after their spiritual adviser visits.

C. Family members and close friends often initiate spiritual concerns.

D. Illness increases spiritual concerns, which may be difficult for patients to express in words.

A

D

Illness may increase spiritual concerns, which many patients find difficult to express. The other options do not correspond to actual experience.

150
Q

A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients?

A. Calling the patient’s own spiritual adviser first

B. Asking whether the patient has a spiritual adviser the patient wishes to consult

C. Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser

D. Advising the patient and spiritual adviser concerning health options and the best choices for the patient

A

B

Even when a nurse feels comfortable discussing spiritual concerns, the nurse should always check first with patients to determine whether they have a spiritual adviser they would like to consult. Calling the patient’s own spiritual adviser may be premature if it is a matter the nurse can handle. The other two options deny patients the right to speak privately with their spiritual adviser from the outset, if this is what they prefer.

151
Q

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing?

A. Spiritual Alienation
B. Spiritual Despair
C. Spiritual Anxiety
D. Spiritual Pain

A

A

Spiritual Alienation occurs when there is a “separation from the faith community.” Spiritual Despair occurs when the patient is feeling that no one (not even God) cares. Spiritual Anxiety is manifested by a challenged belief and value system, and Spiritual Pain may occur when a patient is unable to accept the death of a loved one.

152
Q

A patient states she feels so isolated from her family and church, and even from God, “in this huge medical center so far from home.” A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress?

A. The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living.

B. The patient will identify spiritual beliefs that meet her need for meaning and purpose.

C. The patient will express peaceful acceptance of limitations and failings.

D. The patient will identify spiritual supports available to her in this medical center.

A

D

Each of the four options represents an appropriate spiritual goal, but identifying spiritual supports available to this patient in the medical center demonstrates a goal to decrease her sense of isolation.

153
Q

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan?

A. Ask the patient which spiritual adviser he would like you to call.

B. Recommend that the patient read spiritual biographies or religious books.

C. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past.

D. Introduce the belief that God is a loving and personal God.

A

C

The nursing intervention of exploring with the patient what, in addition to his family, has given his life meaning and purpose in the past is more likely to correct the etiology of his problem, Spiritual Pain, than any of the other nursing interventions listed.

154
Q

After having an abortion, a patient tells the visiting nurse, “I shouldn’t have had that abortion because I’m Catholic, but what else could I do? I’m afraid I’ll never get close to my mother or back in the Church again.” She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem?

A. Patient states, “I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands.”

B. Patient has slept from 10 PM to 6 AM for three consecutive nights without medication.

C. Patient has developed mutually caring relationships with two women and one man.

D. Patient has identified several spiritual beliefs that give purpose to her life.

A

A

Because this patient’s nursing diagnosis is Spiritual Distress: Guilt, an evaluative statement that demonstrates diminished guilt is necessary. Only answer a directly deals with guilt.

155
Q

Mr. Brown’s teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: “I just will not tolerate a thief.” Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness?

A. Assure Mr. Brown that many parents feel the same way.

B. Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass.

C. Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive.

D. Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

A

C

Helping Mr. Brown identify how his unforgiving feelings may be harmful to him is the only nursing intervention that directly addresses his unmet spiritual need concerning forgiveness. Assuring Mr. Brown that many parents would feel the same way or that many teenagers shoplift out of rebelliousness may make him feel better initially, but neither option addresses his need to forgive. Suggesting that Mr. Brown may not have spent enough time with his daughter is likely to make him feel guilty.

NRS104Fundamentals (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions