NURSING 201 Saunders Review Test 2; Complete Guide Q&As COMPLETE SOLUTIONS.

The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A. A client with measles. Correct B. A client with C. difficle. C. A client with influenza. Incorrect D. A client with pneumonia. E. A client with tuberculosis. Correct
Rationale: Airborne precautions are used for those clients that are diagnosed with or suspected to have a condition spread through airborne transmission. Measles and tuberculosis are transmitted via airborne transmission. A client with influenza should be placed on droplet precautions. A client with C. difficile should be placed in contact and enteric precautions and a client with pneumonia only requires standard precautions.
Test Taking Strategy:
Focus on the subject of the question, airborne contact precautions. Think about how each disease identified in the options is transmitted in order to help select the correct option. Review: all types of transmission-based precautions
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Fundamentals of Care: Infection Control
Priority Concepts: Care Coordination, Infection
HESI Concepts: Care Coordination, Infection
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th
ed. p. 440). St. Louis, MO: W.B. Saunders Company.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 173). St. Louis: Mosby.
Awarded 1.0 points out of 2.0 possible points.
9.ID: 0
The nurse at an outpatient clinic is performing a health assessment on a 67 year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client’s age? Select all that apply. A. Tetanus vaccine Incorrect B. Shingles vaccine Correct C. Influenza vaccine Correct D. Rotavirus vaccine Incorrect E. Pneumococcal vaccine Correct
Rationale: The Centers for Disease Control (CDC) recommends that a healthy individual over the age of 65 years old should receive the shingles vaccine, an annual influenza vaccine, and a pneumococcal vaccine. Rotavirus is given to infants and the client is not due for a tetanus booster.
Test-Taking Strategy: Focus on the data in the question and recall the recommended immunization schedule. Also focus on the client’s age to assist in answering. Review: immunization schedules
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Content Area: Developmental Stages: Health Assessment/Physical Exam
Priority Concepts: Health Promotion, Immunity
HESI Concepts:
Health Promotion, Immunity
Reference: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th
ed. p. 16). St. Louis, MO: W.B. Saunders Company.
Awarded -1.0 points out of 3.0 possible points.
10.ID: 5
The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. A. Lisinopril 10 mg orally once daily. B. Furosemide 20mg orally once daily. C. Fluoxetine 20 mg orally once daily. Correct D. Metformin 500mg orally twice daily. E. Cyclobenzaprine 5mg every 8 hours as needed. Correct
Rationale: A close review of medications is necessary for safe care of any client client but because the aging process affects physiological functioning, medication prescriptions for the older client need to be carefully monitored. The use of fluoxetine and cyclobenzaprine are considered inappropriate in the older client according to the Beers criteria and should not be used. All other medications listed would be appropriate.
Test-Taking Strategy: Focus on the subject of this question, appropriate medication use in the elderly population. Think about physiological changes that occur with aging when selecting the correct option. Also, specific knowledge of medications in the Beers criteria and the classifications of the medications in the options will assist in answering correctly. Review: Beers criteria
Level of Cognitive Ability: Synthesizing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Analysis
Content Area: Fundamental of Care: Medications and Administration
Priority Concepts: Collaboration, Safety
HESI Concepts:
Collaboration, Safety
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th
ed. p. 20-21). St. Louis, MO: W.B. Saunders Company.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., p. 74). St. Louis: Mosby.
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, The American Geriatrics Society 2012 Beers Criteria Update Expert Panel; ia_JAGS.pdf
Awarded 1.0 points out of 2.0 possible points.
11.ID: 3
The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child’s home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. A. Smiling during the exam. B. Blaming the abuser for the injury. C. A need to find and protect a sibling. Correct D. Feeling guilty for causing the abuse to occur. Correct E. Aggressive behavior towards the nurse and health care provider. Correct
Rationale: In homes where intimate partner violence (IPV) occurs, children are exposed to that violence at the very least and often become additional recipients of that violence. IPV usually predates abuse of the child. Younger children seem to have more behavioral problems when exposed to intra-family violence. For instance, they often have problems with anxiety, depression, and aggression. They often experience many fears and worries that are developmentally inappropriate. Expressing the need to find and protect a sibling is an example of worry that is developmentally inappropriate for a five year old child. Guilt is another aspect that abused children frequently struggle with, as children often blame themselves for abuse. The nurse would expect the child to portray aggressive behaviors out of fear. Due to the history of violence that this child has been subjected to, the nurse would not expect the child to smile and be receptive to the exam, or blame the abuser for the injury. Another issue of concern that the nurse should be aware of is post-traumatic stress disorder (PTSD). Associated features of PTSD may be more detrimental than the violence itself.
Test-Taking Strategy: Focus on the subject, “behaviors of an abused child”. Determine which behaviors an abused child would show during interaction with the nurse. Eliminate options 1 and 2, because the child is likely to be afraid and unsure of the nurse and exam. Review: Behaviors of the abused child.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity.
Integrated Process: Nursing Process/Assessment
Content Area: Leadership/Management
Giddens Concepts: Caregiving, Interpersonal Violence
HESI Concepts:
Developmental/Family Dynamics, Violence
References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
12.ID: 9
The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A. A burn mark on the child’s finger. B. Circular burn marks on the infant’s buttocks. Correct C. A bright pink coloring on the infant’s cheeks. D. A dark brown marking on the infant’s lower back. Incorrect E. A stocking pattern of burn marks on the infant’s feet and legs. Correct
Rationale: Examination findings for interpersonal violence range from subtle to obvious. Some may manifest as old or new injuries that may seem mild to more significant and may not raise concern. For this reason, it is critical to consider the history in relation to injuries seen. The nurse should also maintain a high degree of awareness for injuries that are not typically seen in the context of dayto-day living—such as unusual patterns of bruising or burn marks. Findings during the physical assessment that would raise suspicion for the nurse are circular burns or burns that occur in a stocking pattern. A burn mark to the finger should be questioned, but is not highly suspicious for child abuse. Bright pink coloring to the checks is typically normal in infants. Dark brown markings located on the lower back or buttocks are known as Mongolian spots.
Test-Taking Strategy: Focus on the subject, “highly suspicious signs of child abuse”. Note the word “highly” nad determine which signs are indicative of abuse. Eliminate options 1, 3 and 4 because these findings do not necessarily indicate that child abuse has occurred.. Review: Child Abuse
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Interpersonal Violence.
HESI Concepts:
Clinical Decision-Making/Clinical Judgment, Violence
Reference: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 354). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 562). St Louis: Mosby.
Awarded 1.0 points out of 2.0 possible points.
13.ID: 1
The nurse is volunteering at a local health fair to educate the public on primary prevention of stress. Which interventions would be the most appropriate for the nurse to recommend to the public, in order to reduce stress levels? Select all that apply. A. Finding a source of pleasure. Correct B. Developing a positive attitude. Correct C. Counseling for chronic anxiety. Correct D. Engaging in stressful situations. E. Learning relaxation and deep breathing exercises. Correct
Rationale: Primary prevention refers to activities that prevent or decrease the probability of occurrence of an injury, physical or mental illness, or healththreatening situation in an individual or family, or an event or illness in the population by combating harmful forces and by strengthening the capacity of individuals to withstand these forces. It would be most appropriate for the nurse to suggest finding a source of pleasure, whether it is spending time with family or talking a walk each day. Developing a positive attitude, seeking counseling for chronic anxiety and utilizing relaxation and deep breathing exercises are also ways to combat stress. The nurse should recommend that individuals stay away from stressful situations, in order to decrease their overall levels of stress.
Test-Taking Strategy: Focus on the strategic words, “most appropriate”. In this scenario, the most appropriate action is to assist the public in reducing stress levels. Eliminate option 4, because this would lead to an increase in stress levels. Review: Stress reduction.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Giddens Concepts: Health Promotion, Stress
HESI Concepts:
Teaching and Learning/Patient Education, Stress and Coping
Reference: Giddens, J. (2013). Concepts for nNursing Practice. (1st ed., p 354). St. Louis: Mosby.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 92-94). St. Louis: Mosby.
Awarded 2.0 points out of 4.0 possible points.
14.ID: 4
The nurse is assisting a family with end-of-life care for their child. Which actions by the nurse would be the most appropriate? Select all that apply. A. Acknowledging the emotions of the family members. Correct B. Taking time to listen to the family talk about their child. Correct C. Limiting communication with the family, to allow grieving. D. Reminding the family that their feelings and emotions are normal. Correct E. Gently reminding the family that they must focus on their remaining children.
Rationale: Chronic and terminal conditions involve the loss of health and result in grief. Grief is a normal psychophysiological process that occurs in response to a specific loss. As adjustment to the condition progresses, many parents experience chronic sorrow related to the unending nature of the child's condition and the ongoing feelings of loss. It is important that the nurse take the time to listen to the family as they talk about their child. The nurse should also acknowledge the emotions of the family members and remind them that their feelings and emotions are normal. Not acknowledging the family members feelings are often triggers for grief. It would be inappropriate, or even hurtful, to the family if the nurse limited communications or suggested that the family focus on the remaining children. During this time, family members need therapeutic and caring support from the nurse.
Test-Taking Strategy: Focus on the strategic words, “most appropriate”. Determine which nursing actions would be the most beneficial to the family in their time of need. Eliminate options 3 and 5, because these actions may be upsetting to the family and may not provide the support that the family needs. Review: End-of-life Care.
Priority Nursing Tip: The grief experience is unique to each person. Be supportive to the client and family at all times. Prepare by practicing therapeutic communication.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Giddens Concepts:
Communication, Palliation.
HESI Concepts:
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 807-809). St Louis: Mosby.
Awarded 2.0 points out of 3.0 possible points.
15.ID: 1
A pregnant client has a history of depression and has been noncompliant with treatment in the past. What actions by the nurse would be the most appropriate? Select all that apply. A. Respect the client's decisions. Correct B. Maintain a hopeful, caring relationship with the client. Correct C. Discuss the noncompliance with the client, if the client brings it up. D. Provide education to the client about depression and treatment options. Correct E. Ask the client what methods of managing the depression have worked in the past. Correct
Rationale: Women are at risk for developing a psychiatric disorder between the ages of 18 and 45 years—the childbearing years. Women who have serious mental disorders may be engaging in sexual activities that can result in pregnancy. The pregnant woman may have a history of disorder in mood, anxiety, substance use, schizophrenia, personality, or development and may be noncompliant with treatment for the disorder. Assessment throughout pregnancy and the postpartum period is critical to the mother's and the baby's health. The nurse should strive to maintain respect for the client's decisions at all times, even though the nurse may not agree with the client's decisions. Maintaining a hopeful and caring relationship with the client, allows for the establishment of trust. The nurse should provide education when the client is open to learning, and utilize teachable moments whenever possible. In order to create a plan of care that works, the nurse should ask the client what methods of depression management have been successful in the past. It would not be effective for the nurse to avoid discussion of depression unless the client's brings up the topic. The nurse should recognize the need for education and begin assessing the client's readiness to learn.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.”Think about the components of a therapeutic relationship and methods to deal with noncompliance. Determine which actions by the nurse would be the most appropriate to maintain a therapeutic relationship with the client. Eliminate option 3, because this action would not be beneficial to the client. Review: Depression.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Adherence, Caregiving,
HESI Concepts:
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 748-749). St. Louis: Elsevier.
Awarded 2.0 points out of 4.0 possible points.
16.ID: 0
The nurse is caring for a client who is in labor and preparing for birth. The nurse has been advised that the pregnancy is the result of a rape. Which statements by the nurse would be the most appropriate? Select all that apply. A. "You are safe here." Correct B. "We have done this many times before." Incorrect C. "Just relax; we know what we are doing." D. "You are in labor and preparing to give birth to your baby." Correct E. "You do not need to be concerned about anything because your baby is ok." Correct