Module 1 Flashcards
Which of the following methods of information exchange can occur without client authorization?
a. walking rounds that involve two nurses discussing an assigned client at the bedside in a private room
b. recording shift report on a device for all oncoming staff to access information about all clients on the unit
c. talking about a client’s information during a staff in service with all levels of unit staff present
d. providing an employer with confirmation that their employee is currently being treated in the facility
a. walking rounds that involve two nurses discussing an assigned client at the bedside in a private room
A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Which of the following agencies should the nurse instruct the client to file the complaint?
a. Occupational Safety and Health Administration
b. The Joint Commission
c. Office for Civil Rights
d. Privacy and Civil Liberties Office
c. Office for Civil Rights
A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client’s spouse is not present at the the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client’s surgery?
a. ask the facility’s privacy officer to witness the informed consent document
b. inform the client’s friends that are present about the surgery and obtain group consent
c. ask the nursing supervisor to provide implied emergency consent
d. inform the provider of the spouse’s contact information so consent can be obtained over the telephone
d. inform the provider of the spouse’s contact information so consent can be obtained over the telephone
a nurse is teaching a newly licensed nurse about using a computer to document in a client’s health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. I should share my computer password with the nurse orienting me
b. I should remain aware of my surroundings when documenting in the computer
c. I can step away from the computer for a short time if i am logged on and no one is around
d. I can review the health records of other clients on the unit not assigned to me
b. I should remain aware of my surroundings when documenting in the computer
which of the following actions should a nurse take after witnessing a breach of a client’s confidentiality in a provider’s office?
a. complete a health information privacy complaint form
b. anonymously notify the proper government agency
c. notify the client and ask them to complete a health information privacy complaint
d. inform the provider that a formal complaint will be submitted if another breech in committed
a. complete a health information privacy complaint form
A nurse in a pediatrician’s office is speaking on the telephone with the guardian of a school age child who will become a new client at the office. The nurse should instruct the guardian to call the child’s previous providers office to request which of the following?
a. the guardian be allowed to take the child’s medical records and make photocopies for the new pediatricians office
b. the child’s original medical records be given to the new pediatricians office
c. a form authorizing release of copies of the child’s medical records to be signed by the guardian
d. a form authorizing of the release of the child’s medical records to be signed by the new pediatrician and sent back to the previous provider
c. a form authorizing release of copies of the child’s medical records to be signed by the guardian
A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurse take to ensure the study complies with the HIPPA Privacy Rule?
a. contact the medical record department to obtain permission to access client’s charts
b. submit their proposal to the institutional review board for review and describe how they will de-identify client information
c. notify the clients who will be induces in the study to submit a written request if they choose not to participate
d. obtain permission from the risk management department to gain access to incident reports that were files due to client falls
b. submit their proposal to the institutional review board for review and describe how they will de-identify client information
keeping promises and commitments to clients
fidelity
providing impartial, fair, and equitable care to all clients
justice
minimizing harm and practicing in a way that benefits the client
beneficence
respecting the client’s right to make decisions about their care
autonomy
providing truthful and accurate information to the client
veracity
a nurse works in a small community hospital emergency department and receives a report from the EMS that they are on route with a pediatric client who has severe burns to the upper body and difficulty breathing. The nearest burn center is 75 miles away. Which of the following actions should the nurse and ED team take to adhere to EMTALA?
a. instruct EMS to reroute to the burn center instead of coming directly to the ED
b. ask EMS to confirm the client’s insurance status to determine if the client can be treated in the ED
c. attempt to stabilize the client in the ED before transport to the burn center
d. determine if a pediatric provider is available before accepting the client in the ED
c. attempt to stabilize the client in the ED before transport to the burn center
in the video the charge nurse is informed that the client’s protected health information is displayed on a computer. which of the following actions should the nurse take first?
a. report the incident to the facilities privacy officer
b. talk with the clients nurse about the concern
c. log out of the client’s nurse from the computer
d. provide HIPPA training to the client’s nurse
c. log out of the client’s nurse from the computer
the six ethical principles of the nursing profession
- autonomy
- beneficence
- nonmaleficence
- veracity
- fidelity
- justice
the five professional values of nursing
- altruism
- human dignity
- integrity
- autonomy
- social justice
the process the nurse mist complete to identity, assess, and develop their own personal value system
value clarification
the two types of unintentional torts
- malpractice
2. negligence
the four types of intentional torts
- invasion of privacy
- defamation
- assault
- battery
the two types of advance directives
- living will
2. durable power of attorney
the physical and mental exhaustion that can cause the nurse to be unable to function safely
nurse fatigue
the process of documentation that is inaccurate, incomplete, or misleading
falsification of health records
a nurse truthfully answers and clients questions about their laboratory results. the nurse is demonstrating which of the following ethical principles?
a. justice
b. nonmaleficence
c. fidelity
d. veracity
d. veracity
a nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. which of the following is the provider violating?
a. the emergency medical treatment and labor act
b. the health insurance portability and accountability act
c. tort law
d. good Samaritan law
a. the emergency medical treatment and labor act
a nurse is caring for a client who asks why they chose the nursing profession. the nurse states that it was because they wanted to heal others. the nurse is referring to which of the following professional values?
a. integrity
b. human dignity
c. altruism
d. social justice
c. altruism
a nurse is teaching a newly licensed nurse about the professional values. the nurse should include that which of the following is an example of autonomy?
a. a nurse provides the same quality of care for every client
b. a nurse maintains client confidentiality
c. a nurse admits they forgot to change a client’s dressing
d. a nurse respects a client’s wish to discontinue a treatment
d. a nurse respects a client’s wish to discontinue a treatment
a nurse is providing privacy for a client who has incontinence. the nurse is demonstrating which of the following professional values?
a. human dignity
b. altruism
c. social justice
d. autonomy
a. human dignity
a nurse is teaching a newly licensed nurse about ethical principles. the nurse should include that which of the following situations is an example of fidelity?
a. a nurse involves a client in making decisions about their care
b. a nurse implements fall precautions for a client who is at risk for falling
c. a nurse tells the truth about forgetting to perform a procedure for a client
d. a nurse keeps a promise to a client to not tell their family about their diagnosis
d. a nurse keeps a promise to a client to not tell their family about their diagnosis
a nurse notifies their supervisor that they accidentally administered the wrong medication to a client. the nurse is demonstrating which of the following professional values?
a. integrity
b. human dignity
c. altruism
d. social justice
a. integrity
a nurse is caring for a client who is alone and just received a serious diagnosis. the client asks the nurse is they can pray together and the nurse agrees. the nurse is demonstrating which of the following ethical principles?
a. autonomy
b. beneficence
c. nonmaleficence
d. justice
b. beneficence
a nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. which of the following actions should the nurse take to provide the expected standard of care
a. document the medication was not administered
b. document that the client is not experiencing pain
c. contact the provider to change the PRN prescription
a. document the medication was not administered
a nurse suspects their coworker might be under the influence of a chemical substance. which of the following actions should the nurse take?
a. counsel the coworker about the substance abuse
b. report the coworker to the ethical committee at the facility
c. ask the coworker how long they have been using substances
d. tell the charge nurse that the coworker might be impaired
d. tell the charge nurse that the coworker might be impaired
a nurse who has been working 12-hour shifts on a busy unit is experiencing nurse fatigue. which of the following effects can result from the nurse fatigue?
a. increase in communication skills
b. increase in effective clinical judgment
c. increase in medication errors
d. increase in productivity
c. increase in medication errors
a nurse is caring for a client who is scheduled for surgery. before the client has signed the informed consent form, the client states, “I don’t really understand what that doctor said. “which of the following actions should the nurse take?
a. explain the procedure in detail to the client
b. ask the provider to discuss the procedure with the client
c. encourage the client to reread the consent form before signing
d. tell the client that the surgeon will explain it to them in the operating room
b. ask the provider to discuss the procedure with the client
a nurse is teaching a group of newly licensed nurse about the professional values. which of the following statements by a newly licensed nurse demonstrates understanding of social justice?
a. health care should be a right for everyone
b. all clients should have a private room in a health care facility
c. i plan to volunteer at the local homeless shelter on my days off
a. health care should be a right for everyone
a nurse is an emergency department is caring for four clients. which of the following clients requires mandatory reporting?
a. an adolescent client who has a fractured tibia following a football game
b. a young adult client who is positive for tuberculosis
c. an older adult client who has dementia, a history of falls, and bruising on their knees
d. a preschooler who has a frequent enuresis
b. a young adult client who is positive for tuberculosis
a nurse is teaching a client about advance directives. which of the following client statements indicates an understanding of the teaching?
a. i need to choose a family member as my health care surrogate
b. once i sign my advance directive, i cannot change my decision
c. my health care surrogate will make health care decisions for me if i am unstable
d. i need to have an attorney present to complete my advance directives
c. my health care surrogate will make health care decisions for me if i am unstable
a nurse is providing equal care to a group of clients who have varing economic statuses. which of the following ethical principles is the nurse demonstrating?
a. fidelity
b. autonomy
c. justice
d. veracity
c. justice
a nurse is reviewing standards of care with a group of newly hired nurses. the nurse should include which of the following incidents as an example of a breach of standards of care?
a. a nurse did not read back a verbal medication prescription to a provider
b. a nurse did not return to a client’s room with a promised blanket
c. a nurse documents client care as soon as it is completed
d. a nurse forgot to call a clients family after performing a procedure
a. a nurse did not read back a verbal medication prescription to a provider
a nurse is teaching a newly licensed nurse about ethical principles. the nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles?
a. veracity
b. beneficence
c. autonomy
d. fidelity
c. autonomy
which of the following is responsible for authorizing the practice of nursing?
a. state board of nursing
b. NCLEX
c. American nurses association
a. state board of nursing
which of the following is one of the foundations of the nursing profession?
a. personal morals
b. professional identity
c. professional values
c. professional values
which of the following resources provides guidance on the legal responsibilities of nurses to clients and society?
a. nursing social policy statement
b. code of ethics for nurses
c. scope and standards of practice
b. code of ethics for nurses
a nurse who displays a selfless concern for others is exhibiting which of the following?
a. accountability
b. altruism
c. responsibility
b. altruism
which of the following professional organizations provides specific guidance to licensed practical nurses?
a. IPNRC - international parish nurse resource center
b. NAPNES - national association for practical nurses education and services
c. AACN - American association of critical care nurses
b. NAPNES - national association for practical nurses education and services
which of the following professional associations advances the nursing profession by creating high standards for nursing practice?
a. american nurses association
b. national league for nursing
c. american association of colleges of nursing
a. american nurses association
a nurse is acting as a preceptor for a student studying the concept of autonomy. the nurse confirms the student’s confirms the student’s clear understanding o autonomy when the student describes it as which of the following?
a. critical thinking
b. team collaboration
c. individual choice
c. individual choice
which of the following actions demonstrates the professional concept of assertiveness?
a. boldly sharing conflicting ideas
b. using a team based approach
c. feeling of strong self esteem
a. boldly sharing conflicting ideas
which of the following situations is an example of horizontal violence?
a. a nurse blames a peer for her error
b. a provider openly scorns a charge nurse
c. an assertiveness personnel is belittles by a nurse manager
a. a nurse blames a peer for her error
a nurse educator is describing positive peer to peer interactions during a staff meeting. which of the following should he use to accurately describe coaching?
a. helps overall care delivery
b. has a defined time frame
c. outlines clear initial goals
a. helps overall care delivery
a nurse manager is developing an evaluation form for employees. which of the following description should be used to measure integrity?
a. utilizes good decision making
b. performs wound care successfully
c. follows standard protocols
c. follows standard protocols
which of the following relates to the concept of caring in professional nursing?
a. straying from current values
b. promoting role excellence
c. reflecting historical evidence
b. promoting role excellence
a nurse is compiling an orientation handout related to accountability and responsibility. which of the following should the nurse use to describe responsibilities?
a. an internal obligation to others
b. duty to report quality of work
c. basic care needs of clients
c. basic care needs of clients
a nurse is reviewing information related to balancing autonomy with boundaries. which of the following phrases should the nurse expect to find related to the concept of boundaries?
a. allow for increased flexibility in caregiving
b. impede design and delivery of safe care
c. guided by state nurse practice act
c. guided by state nurse practice act
nurses “five rights”
- right task
- right circumstance
- right person
- right direction and communication
- right supervision
which of the following professional association established the code of ethics, social policy statement, and scope and standards of practice?
a. american association of colleges of nursing
b. american nurses association
c. national league for nursing
b. american nurses association
which of the following defines nurses scope of practice in each state?
a. nurse practice acts
b. american nursing association
c. department of health and human services
a. nurse practice acts
a nurse acting to accomplish goals in an effective manner with other people is fulfilling which of the following roles?
a. change agent
b. manager
c. educator
b. manager
participation in health policy development and the political process is a significant part of which of the following nursing roles?
a. manager
b. collaborator
c. advocate
c. advocate
a nurse is telling the truth, keeping promises, and doing no harm while caring for a client who is experiencing conflict with his family. which of the following is the nurse demonstrating?
a. human client autonomy
b. primary commitment to the client
c. accountability for professional practice
b. primary commitment to the client
which of the following makes it acceptable to report confidential client information if abuse, neglect, or exploitation is suspected?
a. patient self determination act
b. health insurance portability and accountability act
c. Americans with disability act
b. health insurance portability and accountability act
which of the following actions represents the professional value of altruism?
a. a nurse mentoring a colleague in professional growth
b. a nurse respecting a client’s decision to refuse treatment
c. a nurse encouraging a clinic to treat a homeless man who is unable to pay for his care
a. a nurse mentoring a colleague in professional growth
which of the following is a characteristic of a mentor?
a. formally assigned by the nurse manager
b. assists protege in professional development
c. orients new graduates to a specific work environment
b. assists protege in professional development
a nurse is working as a member of an interprofessional team. which of the following actions should the nurse take?
a. plan client care based on the nursing perspective
b. separate client goals by discipline
c. use assertive communication
c. use assertive communication
according to patricia benner, a novice nurse demonstrates which of the following behaviors?
a. intuition
b. improved decision making
c. inflexibility
c. inflexibility
which of the following is a component of bioculturism?
a. following a single value system
b. evaluation of personal values
c. development of professional identity
b. evaluation of personal values
which of the following is a characteristic associated with kramer’s honeymoon phase of reality?
a. complacency
b. excitement
c. fear
b. excitement
which of the following will assist the new graduate nurse with the development of knowledge and skills necessary for the nursing role?
a. mentor
b. collaborator
c. preceptor
c. preceptor
a mentor is assisting a new graduate nurse develop strategies to transition successfully from student to professional nurse. the mentor should intervene if the new nurse incorporates which of the following strategies?
a. evaluates growth by comparing progress with peers
b. actively participates in professional nursing association activities
c. utilizes resources available through the employing facility
a. evaluates growth by comparing progress with peers
a nurse is planning care for a client who is having difficulty swallowing food at a medium. which of the following interventions should the nurse include in the plan of care?
a. place client in semi fowlers position while eating
b. allow the client to rest for 15 min before eating
c. tolt the clients head backwards when he swallows
d. provide oral hygiene before a meal
d. provide oral hygiene before a meal
a nurse is caring for a client who has crohns disease and is on a low residue diet. which of the following foods should the nurse provide the client as a snack?
a. 1 cup of pasta
b. 1 medium apple
c. 1 cup steamed vegetables
d. 1 cup of bran flakes
a. 1 cup of pasta
a nurse is promoting independence at mealtime for a client who has vision impairment. which of the following interventions should the nurse implement?
a. hand the client a fork with a piece of food placed on it
b. place the client’s napkin in his lap
c. reference the face of a clock to indicate where the food is placed on the plate
d. move the water jug before placing the food tray on the bedside table
c. reference the face of a clock to indicate where the food is placed on the plate
a nurse is caring for a client who has been placed on a full liquid diet. which of the following foods should the nurse offer the client?
a. cream of chicken soup
b. scrambled eggs
c. cottage cheese
d. mashed potatoes and gravy
a. cream of chicken soup
a nurse is assisting a client who is at risk for aspiration following a stroke with eating. which of the following actions should the nurse take?
a. lay the client down flat on the bed 20 min after meals
b. place 1 tbsp of food on the unaffected side of the clients mouth
c. elevate the head of the clients bed to a 45 degree angle during meals
d. palpate the clients throat while she is swallowing food
d. palpate the clients throat while she is swallowing food
a nurse is reviewing a client’s medication administration record. the nurse should identify that which of the following medications places the client at risk for dry mouth?
a. digoxin
b. gabapentin
c. isosorbide dinitrate
d. ranitidine
b. gabapentin
a nurse is assessing a client’s oral cavity and observes an accumulation of foul matter. which of the following findings should the nurse document?
a. tartar
b. sordes
c. periodontal disease
d. xerostomia
b. sordes
a nurse is teaching a family member of a client who is unconscientious how to provide oral care for the client. the nurse should identify which of the following statements as an indication that the family member understands the teaching?
a. i will use mineral oil to keep her lips moist
b. i will cleanse her guns with a lemon glycerin swab
c. i will use my fingers to keep her mouth open
d. i will rinse her mouth with an alcohol free mouth wash
d. i will rinse her mouth with an alcohol free mouth wash
a nurse is assessing a client who is receiving chemotherapy and reports pain and burning in his mouth. the nurse notes red and inflamed oral mucosa. which of the following should the nurse document?
a. stomatitis
b. halitosis
c. gingivitis
d. glossitis
a. stomatitis
a nurse is caring for a client who is unconscious and requires oral hygiene. the nurse should place the client in which of the following positions?
a. dorsal recumbent
b. lateral
c. prone
d. Trendelenburg
b. lateral
a nurse is preparing an educational program for a group of staff nurses about transmission precautions. which of the following instructions should the nurse include?
a. a nurse should use airborne precautions when caring for a client who has tuberculosis
b. a nurse should use contact precautions when caring for a client following stem cell transplant
c. a nurse should use a protective environment when caring for a client who has streptococcal pharyngitis
a. a nurse should use airborne precautions when caring for a client who has tuberculosis
a nurse is preparing to exit the isolation room of a client who has disseminated varicella zoster virus which requires airborne precautions. which of the following actions should the nurse take?
a. keep the client’s door open to prevent a feeling of loneliness
b. remove the first glove b grasping the lower portion of the glove with the opposite hand and pulling it off inside out
c. remove the mask by holding the front of the mask with one hand while trying to untie the top and bottom ties with the other hand
d. fold the contaminated side outward when removing the gown
b. remove the first glove b grasping the lower portion of the glove with the opposite hand and pulling it off inside out
a nurse is evaluating an assistive personnel’s understanding of isolation precautions. which of the following actions by the AP indicates an understanding of isolation precautions?
a. covering her uniform with a client hospital gown when emptying the bed pan for a client who has clostridium difficile infection
b. wearing cleaning gloves when providing a back massage for a client who is post operative following an appendectomy
c. using separate urinary measuring container to empty a clients urinary catheter drainage bag
d. holding her hands higher than her elbows when performing hand hygiene at the beginning of the shift
c. using separate urinary measuring container to empty a clients urinary catheter drainage bag
a nurse in full PPE is preparing to leave the room of a client who is in isolation. which of the following PPE should the nurse remove first?
a. face shield
b. gloves
c. gown
d. mask
b. gloves
a nurse is contributing to the plan of care for a client who has a wound infection and requires contact precautions. which of the following actions should the nurse include in the plan of care?
a. remove the isolation gown before leaving the clients room after providing direct care to the client
b. place the client in a room with a negative airflow pressure of at least six exchanges pre hour
c. limit the visitation of family members to 30 min per day
d. instruct the client to remain in bed
a. remove the isolation gown before leaving the clients room after providing direct care to the client
a nurse is caring for a client who has a health care associated infection. which of the following describes an exogenous HAI?
a. a salmonella infection that occurs after eating contaminated food
b. an infection that occurs during a therapeutic procedure
c. a yeast infection that occurs while receiving broad spectrum antibiotics
d. a urinary tract infection that occurs after a sterile catheter insertions
a. a salmonella infection that occurs after eating contaminated food
what should the nurse do to maintain standard precautions?
a. rinse gloves that become visibly soiled during use
b. use an antimicrobial soap for routine handwashing
c. disinfect hands immediately after washing hands
d. keep gloves on when touching environmental surfaces
c. disinfect hands immediately after washing hands
a nurse is caring for a client who has mycoplasma pneumoniae. the client has been placed on droplet precautions. which of the following actions should the nurse take when caring for the client?
a. wear a respirator
b. protect the eyes
c. put on clean gloves
d. wear shoe covers
b. protect the eyes
a nurse is about to irrigate a clients open wound. besides gloves which of the following PPE should the nurse wear?
a. a sterile gown
b. goggles
c. a face shield
d. an N95 respirator
c. a face shield
which of the following products can affect the permeability of latex gloves?
a. antimicrobial soap and water
b. alcohol based antiseptic gel
c. petroleum based hand lotion
d. water based hand lotion
c. petroleum based hand lotion
a nurse is washing their hands with soap and water prior to repositioning a client in bed. during the handwashing procedure, it is important to take which of the following actions?
a. make sure the water is hot
b. wash for at least 20 seconds
c. use a liquid soap preparation
d. remove rings and watches first
b. wash for at least 20 seconds
contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
a. hepatitis B
b. measles
c. meningitis
d. infectious diarrhea
d. infectious diarrhea
a nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include?
a. lean on the crutches to support your body weight when standing
b. fully extend your arms when holding onto the hand grips
c. hold the crutches on your unaffected side when preparing to sit in a chair
d. hold the crutches 9 in in front of and to the side of each foot
c. hold the crutches on your unaffected side when preparing to sit in a chair
a nurse stands facing a client to demonstrate active range of motion exercises. which of the following actions should the nurse take to demonstrate hyperextension of the hip?
a. move their leg behind their body
b. move their leg forward and up
c. move their leg medially toward their other leg
d. turn their foot and leg away from their other leg
a. move their leg behind their body
a nurse is assisting with the ambulation of a client who becomes light headed and begins to fall. which of the following actions should the nurse take?
a. wrap both arms around the clients arms and shoulders
b. move both feel together when the client begins to fall
c. protect the client’s extremities while lowering them to the ground
d. extend one leg and allow the client to slide down the leg to the floor
d. extend one leg and allow the client to slide down the leg to the floor
a nurse is caring for a client who has a prescription for knee length antembolic stockings. which of the following actions should the nurse take?
a. place the stocking on the client after the client ambulates to the restroom
b. ensure the client’s toes are visible after placing the stockings on the client
c. after applying the stockings, place two fingers between the clients leg and stocking to check the fit
d. measure the clients calf circumference and leg length from heel to toe
d. measure the clients calf circumference and leg length from heel to toe
a nurse is caring for a client who has been hospitalized and is performing active range of motion exercises. which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?
a. abducting the arm so that it lies next to the clients side
b. flexing the shoulder by raising the arm from a side position to a 180 degree angle
c. abducting the arm to a 90 degree angle from the side of the body
d. circumduction the shoulder in a 180 degree half circle
b. flexing the shoulder by raising the arm from a side position to a 180 degree angle
a nurse is preparing to transfer a client who has left sided weakness from the bed to the chair. which of the following actions by the nurse demonstrates correct transfer technique?
a. positioning the chair slightly behind the nurse so that the seat faces the clients bed
b. placing the clients left leg in front of the right leg just prior to the transfer
c. aligning the nurses knees with the clients knees just before the transfer
d. grasping the client under the axillae to assist them to their feet
c. aligning the nurses knees with the clients knees just before the transfer
a nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a client from the bed to the chair. for which of the following actions by the AP should the nurse intervene?
a. places a removable cover over the sling
b. leaves the beg in the lowest position throughout the procedure
c. locks the hydraulic valve before attaching the sling to the lift
d. raises the head of the bed to a sitting position just before the transfer
b. leaves the beg in the lowest position throughout the procedure
a nurse is a long term care facility is caring for a client who is on bed rest and requires frequent linen changes. which of the following should the nurse identify as the priority rationale for frequent linen changes?
a. moisture from excessive diaphoresis can cause skin breakdown
b. moisture of the sheets can cause discomfort to the client
c. it provides an opportunity to frequently evaluate the skin on the clients back
d. it provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs
a. moisture from excessive diaphoresis can cause skin breakdown
a nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. which of the following statements by the newly licensed nurse indicated an understanding of the teaching?
a. ill swab the clients mouth with lemon glycerin swabs
b. ill swab the clients mouth with mouthwash
c. ill swab the clients mouth with chlorhexidine
d. ill swab the clients lips with a very small amount of mineral oil
c. ill swab the clients mouth with chlorhexidine
a nurse is planning morning hygiene care for postoperative client. which of the following actions should the nurse take?
a. inform the client when morning hygiene care is provided at the hospital
b. schedule the clients morning hygiene care at the same time as their roommate
c. ask the client in what order they typically perform their morning routine
d. plan to provide care before the next scheduled dose of pain medication
c. ask the client in what order they typically perform their morning routine
a nurse is preparing to provide oral care for a client who is NPO. the client tells the nurse i don’t need oral care because i haven’t eaten anything. which of the following responses should the nurse take?
a. since you are not eating we can wait and do it before bedtime
b. oral care is still important even though you are not eating
c. ill give you a sip of water to swish around in your mouth then you can spit it out
d. we will wait until your family gets here to help
b. oral care is still important even though you are not eating
a nurse is observing an assistive personnel make a clients bed while the client is out of the room. which of the following actions indicates an understanding of the procedure?
a. the AP records the tasks when it is completed
b. the AP wears sterile gloves while making the bed
c. the AP changes the clients pillowcase
d. the AP reuses the clients clean blanket and spread
d. the AP reuses the clients clean blanket and spread
a nurse is performing a complete bed bath for a client. which of the following actions should the nurse take?
a. raise the room temperature
b. completely remove the linens
c. add soap to the water in the basin before beginning the bath
d. . bathe one side of the body at a time
a. raise the room temperature
a nurse is assisting a client with personal hygiene care. which of the following actions should the nurse take to reduce the risk of infection?
a. massage the reddened areas of the clients skin
b. wash eyes from the outer canthus to the inner canthus
c. wash the client from the shoulder down to the fingertips with smoothed, short strokes
d. clean the least soiled areas prior to cleaning the most soiled areas
d. clean the least soiled areas prior to cleaning the most soiled areas
a nurse is caring for a client who has refused to have a biopsy. the client states, “I don’t need the biopsy. I wouldn’t do anything about it anyways if it is cancer.” the nurse replies “you don’t want the biopsy because you would not seek treatment if it as cancer. is that correct?” which of the following therapeutic communication techniques is the nurse using?
a. affirmation
b. open ended question
c. reflection
d. restating
d. restating
A nurse asks a client how he learns best. The client states, “ I think I learn the best when I can discuss the information with a group of people. “This indicates that the client has a preference for which of the following learning styles?
Auditory
A nurse is preparing to a teach a client how to ambulate with crutches and is determining the client’s readiness to learn. Which of the following factors should the nurse include in this assessment?
The client’s cognitive ability, the client’s physical needs, the client’s level of motivation, the client’s developmental stage
A nurse is teaching a client who has a new diagnosis of diabetes mellitus type 1. Which of the following questions by the nurse addresses the client’s affective domain?
“How do you feel diabetes will affect your lifestyle?” One of the focuses of the affective domain is the client’s feelings.
A nurse is preparing an educational lecture for bariatric client. Which of the following should the nurse take into consideration when developing the lecture?
Audiovisuals are an important component of the lecture format in order to engage the audience, the content should apply to all lecture participants
A nurse is preparing an adult client’s teaching plan and gathering information about the client’s culture. Which of the following client statements helps the nurse understand the client’s social organization?
“My mother needs to be present for any teaching.” The client’s comment, indication a matriarchal family structure, is a component of cultural social organization.
A nurse is evaluating a client’s ability to self-administer insulin. Which of the following behaviors is reflective of the mechanism level of psychomotor domain?
The client demonstrates confidence in a performing an insulin injection. The psychomotor domain consists of seven levels of behavior. The mechanism level refers to the client’s ability to perform a skill with confidence.
A nurse is caring for a client who has a new prescription for digoxin (Lanoxin). Which of the following should the nurse first teach the client?
“Your provider is prescribing medication to strengthen your heart’s contraction.” Knowledge is the first level of cognitive behavior. Identifying the purpose of the medication is an example of providing basic knowledge information is the first thing the nurse should teach.
Which of the following should the nurse take into consideration when selecting an environment to provide client education?
Noise level, size of space, lighting, and temperature.
A nurse is preparing a toddler for surgery. Which of the following s appropriate for the nurse to take into consideration when developed the teaching plan?
Toddlers depend on their senses to learn. Toddlers are in the sensorimotor cognitive stage, which means that they learn from their senses.
A client with Alzheimer disease in a nursing home is more compliant in following directions for dressing and feeding with one nurse than with other staff members. This phenomenon is best explained by
- the Therapeutic Model of Interaction.
- aggression.
- empathy.
- the Health Belief Model.
the Therapeutic Model of Inteaction
Chronic illness may be characterized by periods of remission. Remission is best defined as:
- the presence of a disease with the absence of symptoms.
- a pathologic change in the structure of function of the body or mind.
- the reappearance of symptoms of a disease.
- the response of a person to a disease.
the presence of disease with the absence of symptoms
A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon?
- Morbidity
- Risk factor
- Exacerbation
- Infection
exacerbation
An older adult patient has been recently diagnosed with vascular dementia. Because the client lives alone and has poorly controlled hypertension, the client has begun to receive home healthcare. This new aspect of the client’s care is characteristic of which stage of illness?
- Assuming a dependent role
- Experiencing the symptoms
- Assuming the sick role
- Achieving recovery and rehabilitation
Assuming a dependent role
The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?
- Factors that predispose a person to infectious diseases
- How people interact with their environments
- What people believe to be true about their health
- How health is a constantly changing state
What people interact with their environment
The nurse is caring for a client admitted to the hospital with pneumonia and associated pleuritic chest pain. Which would be a priority when creating the nursing care plan?
- Monitoring fluid intake and output.
- Effective infection control measures.
- Effective pain management.
- Monitoring airway clearance.
-Monitoring airway clearance.
Which model is most useful in examining the cause of disease in an individual, based upon external factors?
- The Agent-Host-Environment Model
- The High-Level Wellness Model
- The Health Belief Model
- The Health-Illness Continuum
-The Agent-Host-Environment Model
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?
- It takes a long time to cure.
- It is a sequela of acute illness.
- It has a gradual onset and lasts for a long time.
- It persists for a long time.
-It has a gradual onset and lasts for a long time.
A community health nurse arranges for a dental checkup camp for the local children in the school district. Which of the following would most likely be the nurse’s goal for this health camp?
- Reversal of self-care deficit
- Illness prevention
- Health promotion
- High-level wellness
Health promotion
When providing care to a client, the nurse integrates knowledge that a client’s beliefs and actions are related and influenced by the client’s personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?
- Health belief model
- Clinical model
- Holistic health model
- High-level wellness model
-Health belief model
The nurse’s community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?
- Tertiary
- Medical
- Primary
- Secondary
-Primary
Which is an example of tertiary health promotion?
- Water treatment
- Pap tests
- Family counseling
- Rehabilitation
-Rehabilitation
What have the models of health promotion and illness prevention been used for?
- To define a medical framework for the care of the disabled.
- To create a forum for improving rehabilitative care.
- To help health care providers understand health-related behaviors.
- To formulate care plans for the disabled population.
-To help health care providers understand health-related behaviors.
When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept?
- Focus on what can no longer be.
- Focus on why the client has the illness.
- Focus on what is possible.
- Focus on the altered functioning.
-Focus on what is possible.
A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client’s circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions?
- Sociocultural and intellectual
- Physical and emotional
- Environmental and spiritual
- Emotional and environmental
-Sociocultural and intellectual
A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?
- Secondary prevention
- Residual prevention
- Tertiary prevention
- Primary prevention
-Tertiary prevention
A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness?
- New symptoms occur at this time.
- Symptoms are not experienced.
- The disease is no longer present.
- The symptoms of the illness reappear.
Symptoms are not experienced
The recognition of health as an ongoing process toward a person’s highest potential of functioning is defined as:
- health belief model.
- agent-host-environment.
- illness.
- high-level wellness.
High-level Wellness
What level of prevention is represented by educating a group of clients on breast self-examination?
- Secondary prevention
- Primary prevention
- Educational prevention
- Tertiary prevention
Primary prevention
The client is admitted with a gastrointestinal bleed. The physician ordered a colonoscopy. Which level of care encompasses this procedure?
-Quanternary
-Primary
-Secondary
-Tertiary
Secondary
Secondary
To be an effective change agent for wellness, the nurse must:
-lead a sedentary lifestyle.
-consume a diet low in fat.
-skip breakfast to reduce calories.
-drink caffeinated beverages.
Consume a diet low in fat
Consume a diet low in fat
A client enjoys eating high-calorie carbohydrate meals, but understands her blood sugar can increase sharply, ultimately causing the feeling of butterflies in her stomach as her blood sugar decreases. This is considered:
- health promotion.
- illness prevention.
- self-concept.
- a holistic approach.
Self-concept
Why are health promotion and illness prevention a key responsibility of nurses?
- Chronic illnesses are the leading health problem in the world.
- Chronic illnesses can cause pain and suffering.
- People do not like to be sick and feel bad.
- Treatment of chronic illnesses is very expensive.
Chronic illnesses are the leading health problem in the world
