Fundamentals Flashcards
Which nursing process would the nurse undertake when collecting the medical history of a client?
Assessment
- client information is part of an assessment
When conducting a client interview, what response is an example of back channeling?
“All right, go on.”
- active listening prompts
Probing a client
open-ended questions help obtain more information unit; the client says nothing more
Which program is least liekly to focus on medication delivery process modification?
experimental research
Which documentation would the nurse utilize to report that a client’s degree of edema has a depth of 8 mm?
4+
Edema mm and grade + are a ratio of
2mm= 1+
Which of these ethical issues related to the long-term care settings
guardianship
power of attorney
advance directives
responsible party designation
DNR orders
Adherence to pt’s bill of rights
Which activity places a client at risk for hyperthermia?
performing activity in high humidity
What is a great indication of motivation to learn?
readiness or requesting information
Which nursing interventions indicate client care that supports physical functioning?
maintain nutritional status
and regular bowel patterns
In palliative care, the nurse is the
pt advocate
evaluate physical emotional and spiritual needs
Subjective data
what the client says
Objective data
observed
During a routine physical, a 50 y/o client ask why a stool specimen for occult blood testing was prescribed. which response would the nurse utilize?
Starting at your gae, this test is performed routinely as part of an assessment for colon cancer
- describe what you know do not infer information about client
MEDLINE
database to find studies related to allied health science
Medicare is used for
people over 65
Which research design would the nurse researcher utilize when examining subjects’ responses to chlorhexidine and povidone-iodine as antiseptics?
experimental
- researcher is involved with variables
Which nursing practice is associated with self-regulation skill?
reflecting on one’s experience
The nurse tells the client who they are and explains a procedure to be performed. which critical thinking attitude is the nurse applying?
confidence
A client with sickle cell anemia is experiencing a vaso-occlusive crisis and has a PCA pump. 5/10 pain on right elbow, “locked out” for another 10 mins. What action should the nurse implement?
TV diversion
Prescribed prn warm, wet compress on the elbow
Call the HCP
Inform needs to wait until med is available
Prescribed prn warm, wet compress on the elbow
- vasodilation will help reduce the pain of vaso-occulsive pain
Which principle refers to the professional obligation of the nurse to assume responsibility for actions?
accountability
Percussion
tapping the skin with fingertips causes vibrations in the underlying tissues
Internal variable
emotional factors
School health nursing programs have which goal
health promotion
Which variable is an example of an external variable?
socioeconomic factors
Which is the role of a case manager in a healthcare organization?
follow up with a client after discharge
Which purpose describes the Nurse Practice Acts?
describe and define the legal boundaries of nursing practices within each state
Which role is the nurse fulfilling when explaining the reason for IV infusion and kit to the client?
educator
In which sequence of techniques would the nurse assess a client’s abdomen?
inspection
auscultation
percussion
palpation
Percussion is used for
kidney inflammation
Which step in the nursing process would involve promoting a safe environment for the client?
implementation
Planning stage contains
strategies and alternatives to achieve specific outcomes
During diagnostic stage contains
analyze assessment data to determine health care issues
Which function is the role of the nurse administrator in a health care setting?
preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and development
Nurse practitioner provides
comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions
Nurse educators provide
knowledge about current nursing practices, trends, theories, and necessary skills in labs and clinical settings
When informing the health care provider of a client requesting pain med after surgery, which role did the nurse play
advocate
Which theory focuses on developing the interpersonal relationships between the nurse, client, and family?
Peplau
Orem’s theory
client’s self care needs
Leininger’s theory
recognizes the importance of culture and its influence on everything that involves the client and providers of care
Henderson’s theory
assisting the individual in the performance of activities they can perform unaided that will contribute to health, recovery, or a peaceful death
NIC Taxonomy
Behavioral
Psychosocial functioning and lifestyle chnage
NIC Taxonomy
Community
supports the health of the community
NIC Taxonomy
Physiological
supports physical functioning
NIC Taxonomy
Health system
supports the effective use of the hospital resources
- give support services for the delivery of care
The nurse assessed a client’s pulse rate and recorded the score as 3+. which descriptor reflects the strength of the pulse
strong, full
(4+ bounding, 2+ expected, 1+ diminished)
Which physiological changes are expected during the 1st trimester of pregnancy?
fatigue
morning sickness
breast enlargement
2nd=increased libido/3rd Braxton Hicks
Which skill in critical thinking requires the nurse to be orderly in data collection?
interpretation
Analysis
info about a client is collected with an open mind
Inference
data collected about the client helps solving an existing problem
Evaluation
results of nursing actions
What standards are important for critical thinking
specific
relevant
What attitudes are required for critical thinking?
fairness
confidence
independence
WHO defines health as
state of complete physical, mental, and social well being
While assessing a client after surgery, which finding would the nurse obtain from the primary source?
primary source = pt
severity of pain
Which statement describes a client in the stage of contemplation in the stages of change?
considers chnage within the next 6 months
Stages of Change
Precontemplation - not intend to chnage
Contemplation - considers change
Action - actively engaged in change
Sustained - beginning 6 months after the action started and continues indefinitely
Maintenance stage
Which point would the nurse not associate with grand theories of nursing?
Mishel’s theory of uncertainty in illness (middle theory)
The nurse speaking in support of the best interest of vulnerable client reflects which nursing duty?
advocacy
A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. which is the correct therapeutic nursing intervention?
sitting quietly with the client
A client engages in angry outbursts and places excessive demands on the staff. a UAP tells the nurse, “I’ve had it. I am not putting up with that behavior. I’m not going in there again.” Which is the correct response by the nurse?
“The client is frightened an taking it out on the staff. Let’s think if approaches we can take.”
Which key factor would the nurse consider when assessing how a client will cope with body image changes?
perception of the change
The nurse teaches a client about wearing thigh-high anti-embolic elastic stockings. which instruction would be correct to include?
“You will need to apply them in the morning before you lower your legs from the bed to the floor.”
- prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity
The nurse provides crutch-walking instructions to a client who has a left-leg cast. Where would the nurse teach the client to place their weight?
on the hands
Which critical thinking skill refers to the use of knowledge and experience to choose effective strategies for client care?
explanation
Evaluation
using criteria to determine the results of nursing actions
Interpretation
orderly collection of data
Self-regulation
nurse identifies ways to improve own performance
When developing a nursing dx for a client after surgery, the nurse documents the “related to” factor as first time surgery. Which assessment activity enabled the nurse to draw this conclusion?
nurse asks the client to explain the surgery
Which statement correctly describes middle-range theories?
these theories are systematic and broad in scope and complexity.
middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response.
these theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching.
middle-range theories include mishel’s theory of uncertainty in illness, which focuses on a client’s experiences with cancer while living with continual uncertainty.
these theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.
middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response.
middle-range theories include mishel’s theory of uncertainty in illness, which focuses on a client’s experiences with cancer while living with continual uncertainty.
these theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.
What statement is not true of concepts
concepts consist of interrelated theories (definition of theory)
Which characteristic would the nurse associate with collaborative problems experienced by a client?
they are identified by the nurse during the nursing dx stage
requires tx by other therapies
Under which type of health care services would the nursing student include subacute care
tertiary
definition of a tort
illegality committed by one person against the property or person of another
Which fine motor skills may be observed in an 8-10 month old infant?
using pincer grasp well
picking up small objects
showing hand preference
What is considered gross motor skills
crawling on hands and knees
pulling oneself to a standing or sitting position
Which statement is not true of descriptive theories?
help direct specific nursing activities
(but help explain client assessments)
Descriptive theories
1st level of theory development
explain, relate, and predict nursing phenomena
speculate why they occur and describe consequences
Nursing Model of Team Nursing
hierarchical communication exists from chnage to charge
charge to team leader
team leader to members
While assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?
bruit
Ectropion
eyelid is tuned outward away from the eye
Entropion
malposition resulting in an inversion of a eyelid margin
Borborygmi
rumbling or gurgling noises made by the movement of fluid and gas in the intestines
Watson’s theory of transpersonal caring carative factor
providing for a supportive, protective, and/or spiritual environment
promotes health, restoring the client to health, and prevent illness
Orem’s self-care theory
client’s self-care needs
Roy’s theory
goal of nursing is to help a client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness
Which principal componenets are associated with the nurse;s time management skills
goal setting
priority
interruption control
Ptosis
client with drooping of the eyelid over the pupil
Nystagmus
involuntary oscillation of the eyes, and usually occurs after an injury
Benner and Wrubel’s theory
primacy of caring is the base for the development as means to cope with stressors
Neuman’s theory
stress and the client’s reaction to the stressors
Roy adaptation model views the _________ as an adaptative system
client
The nurse finds the client’s fever spikes and falls without a return to a normal level. What pattern of fever is this characteristic?
remittent
Intermittent
fever spikes and interspersed with normal temps
Which example in nursing practice would demonstrate Watson’s creative factor called forming a human-altruistic value system?
using self-disclosure to promote a therapeutic alliance with the client
While examining a client, the nurse finds an elevated 0.6 mmfilled with serous fluid on the cheek. What is the term?
Vesicle
Phenomenon
set of theoretical components such as concepts, definitions, assumptions, or propositions
Domain
perspective of a profession
Paradigm
pattern of thought that is useful in describing the domain of a discipline
Environment
all possible conditions affecting clients and the settings in which their healthcare needs occur
Integrity
to be able to recognize personal opinions that may conflict with a client’s opinions
Extrinsic factors include
environmental hazards outside and within the home
Gordon’s self perceptiona nd tolerance pattern
describes client’s self worth, emotional patterns and body images
Structural Empowerment in 14 Forces of magnetism
personnel policies and programs
Clubbing
nail base is larger than 180 degrees
Paronychia
inflammation of the skin at the base of nail
Koilonychia
concave curves on the nail
Upon assessing a client who underwent abd surgery 10 days ago, client reports pain. What type of pain is it?
visceral
Somatic pain
aching or throbbing in qaulity and well localized in bone
Referred pain
tumors pain is in other body parts than actual source
Intractable pain
neuropathic severe constant not curable
Which legal complication might the nurse face for using a restraint without a legal warrant on a client?
false imprisonment
While measuring the rectal temp, inserted 2.5-3.5 into anus in the direction of umbilicus rationale
ensure adequate exposure to blood vessels
Preauricular lymph node
swelling in front of the left ear of client reporting ear pain
Mastoid
behind the ear
Submental
below chin
Fine motor skills in ascending order as the infant develops
reflexive grasp (1 month)
look and play with fingers (2-4 months)
bring objects to mouth (4-6)
bang objects together (6-8)
crawl with pincer grasp (8-10)
pick up and place in containers (10-12)
Nurse’s participation in assisted suicide violates the
code of ethics
A client who had MI discharged, when to resume sex. Response?
“Have you discussed with HCP”
Antipyretic med may cause Reye syndrome in children
aspirin
Research-based practice uses
knowledge based only on research studies
Labelling error means
failur to validate the data
Which behavior by the client exhibits denial after a recent dx?
attempts to minimize the illness
(not acknowledging the problem)
What are the 3 levels of critical thinking in a nursing judgment?
Basic - expert has right answer
Complex - examines and analyzes information
Commitment - make choices without help
Benner’s proficient nurse level
focuses on managing care rather than skills
Nursing Process
assessment
diagnosis
planning
implementation
evaluation
Which characteristic indicates that nursing is a profession
required to follow a code of ethics
King suggests
goal of nursing is to use communication to help client’s reestablisb a positive adaptation to their environments
Which is the most therapeutic response by the nurse to a client who is joking about dying?
Does it help to joke about your illness?
S/S of decrease in body temp
shivering
contraction of blood vessels
Concrete operations stage of Piaget’s theory of cognitive development?
child is able to describe a process without actually doing it
neutropenic precautions
prevent the spread of infection to the client from outside sources
Maslow’s hierarchy of needs
lowest physiological needs
4th safety and security
3rd love and belonging
2nd self esteem
1st self actualization
What are the 5 rights of nursing delegation
right task
circumstances
person
communication
supervision
Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self-catheterization?
A) “Wear sterile gloves when doing the procedure.”
B) “Wash hands before performing the procedure”
C) “Perform the self-catheterization every 12 hours.”
D) Dispose of the catheter after you have catharized yourself.”
B) “Wash hands before performing the procedure”
Which statement mischaracterizes the term paradigm?
The perspective of a profession is known as its paradigm.
The paradigm of nursing includes four links: the person, health, environment and situation, and nursing.
The knowledge of science, philosophy, and theories accepted and applied by a discipline are linked by a paradigm.
The elements of the nursing paradigm direct the activity of the nursing profession including knowledge development, philosophy, theory, educational experience, research, and practice.
The perspective of a profession is known as its paradigm.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia?
Red blood cell count
Sputum culture
Arterial blood gas
Hemoglobin
Arterial blood gas
Which step would the nurse take first when preparing a concept map for as assigned client?
Assess the client and gather information.
Arrange cues into clusters that form patterns.
Identify patterns reflecting the client’s problem.
Identify specific nursing diagnoses for the client.
Arrange cues into clusters that form patterns
The client has a visual impairment. Which technique would the nurse use to communicate?
Face the caregiver while speaking.
Provide bright, diffuse lighting that produces glare.
Stand or sit far away from the client while remaining in the client’s full
view.
Encourage the client to use assistive devices such as eyeglasses
Encourage the client to use assistive devices such as eyeglasses
An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client?
Touch
Reminiscence
Reality orientation
Validation therapy
Reality orientation
When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease?
Pulse rate
Tissue turgor
Specific gravity
Body temp
Tissue turgor
The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client?
Care that supports physical functioning
Care that supports homeostatic regulation
Care that supports psychosocial functioning
Care that provides immediate short-term help in physiological crises
Care that supports homeostatic regulation
Which statement correctly describes the domain of nursing? Select all that apply. One, some, or all responses may be correct.
The domain is the perspective of nursing only and not all professions.
The domain of nursing provides both a practical and theoretical aspect of the discipline.
The domain provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a paradigm.
The domain is the knowledge of nursing practice as well as the knowledge of nursing history, nursing theory, education, and research.
The domain of nursing gives nurses a comprehensive perspective that allows them to identify and treat a client’s health care needs at all levels and in all health care settings.
The domain of nursing provides both a practical and theoretical aspect of the discipline.
The domain is the knowledge of nursing practice as well as the knowledge of nursing history, nursing theory, education, and research.
The domain of nursing gives nurses a comprehensive perspective that allows them to identify and treat a client’s health care needs at all levels and in all health care settings.
Which nursing behavior is an intentional tort?
• Miscounting gauze pads during a client’s surgery
Causing a burn when applying a wet dressing to a client’s extremity
Divulging private information about a client’s health status to the med
Failing to monitor a client’s blood pressure before administering an antihypertensive
Divulging private information about a client’s health status to the med
Which feature is most likely related to entry-level nurse competencies?
Motivating others on the unit
Setting objectives and guiding the staff
Using a participatory approach in decision-making
Working and collaborating with other team members
Working and collaborating with other team members
tow would the nurse respond to an alcohol recovery program ponsor requesting to read the client’s progress record?
• By allowing the visitor to review the record; sponsors have access to privileged information
By asking the primary health care provider about granting permission to the sponsor
By not allowing the sponsor to review the record
By allowing the visitor to review the record; clients with alcoholism need reassurance from sponsors
By not allowing the sponsor to review the record
For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?
Skeletal and nervous
Circulatory and urinary
Respiratory and urinary
Muscular and endocrine
Respiratory and urinary
Which information is appropriate to include in education about sentinel events?
Causes moderate harm to the client
Undesirable and largely avoidable
Effect is mitigated by interventions
Very common in hospital settings
Undesirable and largely avoidable
The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurse’s care?
Meet the clients’ family.
Read the clients’ medical reports.
Participate in the bedside rounds.
Visit the clients and introduce self.
Participate in the bedside rounds
