CTS CIS4617 Evolve_nivel_III All Questions/Answers (LATEST)

Health Promotion and Maintenance 1.A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? It stimulates plasma cells directly. A high titer of antibodies is generated. It provides immediate active immunity. A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting. 2.A nurse is determining whether a 5-year-old child is displaying appropriate behaviors for this age. What developmental findings does the nurse expect? Select all that apply. Enjoys imitative play Engages in ritualistic games Makes up rules for a new game Asks for a pacifier when uncomfortable Plays near others quietly but not with them Imitating adults by playing adult roles in society is at its peak in children 5 years of age; activities are strongly identified with same-sex parent. A 5-year-old is able to negotiate and use make-believe to play. These children are able to follow some rules but may cheat to win. Older children in the middle childhood years need conformity and rituals, whether they play games or amass collections. Rules to games are fixed, unvarying, and rigid. Knowing the rules means belonging. The use of a pacifier for oral satisfaction is typical of infants. Parallel play occurs in children ages 2 to 3 years. 3.What is the most appropriate communication strategy for the nurse working with adolescents in a clinic in a large city health center? Relating on a peer level Using typical teenage language Establishing a relationship over time Having discussions in concrete terms Several meetings with an adolescent provide an opportunity to develop trust and establish a relationship. Relating on a peer level is unrealistic because the nurse is not an adolescent’s peer. Using teenage language is not necessary and may even impede the establishment of a relationship. It is not necessary to use concrete terms, because the adolescent is capable of abstract thought. 4.The nurse is examining different statements that represent the stages of psychosexual development, according to Sigmund Freud’s psychoanalytical model of personality development. Which statement indicates that the individual is aged between 6 to 12 years? The individual focuses on educational and social accomplishments. The individual tries to resolve prior sexual conflicts that have resurfaced. The individual realizes that the parent is something separate from the self. The individual fantasizes about the parent of the opposite sex as the first love interest. According to Sigmund Freud’s psychoanalytical model of personality development, an individual reaches the latency stage between 6 to 12 years of age. At this stage, the sexual urges of the oedipal stage are repressed and the individual channels them into socially acceptable productive activities. Therefore, the child focuses on educational and social accomplishments. When an individual reaches the genital stage, prior sexual conflicts resurface. He or she tries to resolve them in order to be able to begin an adult mature relationship. At the oral stage, which begins from birth and continues till 12 to 18 months, the infant is able to realize that the parent is something separate from the self. An individual between 3 to 6 years old is in the phallic or oedipal stage. At this stage, the child fantasizes about the parent of the opposite sex as the first love interest. Which of these features would the nurse state are exhibited by a preschooler? Temper tantrums Attempts to control situations Synchronization of moral skills Eagerness for formal education Learn to function independently Preschoolers refine the mastery of their bodies to function independently and eagerly await the beginning of formal education.When parents try to control the behavior of a toddler, it leads to temper tantrums and negative behavior. Toddlers get to know their abilities to control situations and seem pleased with it. School-aged children and adolescents refine and synchronize physical, psychosocial, cognitive, and moral skills to become accepted members of society. What important teaching strategies should the nurse take into consideration to bring a change in the client’s lifestyle? Select all that apply. Use written resources at an appropriate reading level. Practice active listening, and ask the client how he or she prefers to learn. Refrain from including family member in efforts to bring a change in the client’s lifestyle. Provide timelines for modification of eating and exercise lifestyle habits without consulting with the client. Start with identifying what information the client knows regarding health risks related to poor lifestyle choices. To bring a change in the client’s lifestyle, the nurse should use written resources at an appropriate reading level. The nurse should practice active listening and ask the client how he or she prefers to learn. The nurse should start by identifying what information the client knows regarding health risks related to poor lifestyle choices. The nurse should include family members to help bring changes in the client’s lifestyle. The nurse should provide timelines for modification of eating and exercise lifestyle habits after consulting with the client. 6.A parent expresses concern that the adolescent child is not ingesting enough calcium because of an allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply. Cottage cheese Green leafy vegetables Black or baked beans Yogurt Oranges Salmon and sardines Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated. 9.A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD). What answer should the nurse provide? Perforation of the uterus Spontaneous device expulsion Discomfort associated with coitus Development of vaginal infections The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of the device. Perforation of the uterus is a rare, rather than a common, occurrence. Clients do not report discomfort during coitus when an IUD is in place. Increased incidence of vaginal infections is not reported with the use of an IUD. 10.A couple interested in family planning asks the nurse about the cervical mucus method of family planning. The nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is what? Clear and thick Yellow and thin Cloudy and viscid Clear and stretchable The cervical mucus is clear and stretchable (spinnbarkeit) at ovulation because of maximal estrogen stimulation. Clear, thick cervical mucus occurs after ovulation has occurred. Yellow, thin cervical mucus does not occur at any specific point during the menstrual cycle and may indicate an infection. The parents of a school-age child tell the nurse, "My child seems very hot or red in the face, has abdominal pain, and appears jittery." What does the nurse suggest as the reason for the child’s signs and symptoms? "The child is experiencing stress in some area of life." "The child is growing up and feels the need for autonomy." "The child may be eating mostly junk food out of the house." "The child may be staying up late at night to watch television." Appearing hot or red in the face and jittery, along with abdominal pain, indicates that the child is experiencing stress. The parents need to talk about any stressors that the child is experiencing and should encourage the use of effective problem-solving and coping skills. Staying up late at night and watching television may cause fatigue, but not abdominal pain or jitteriness. The school-age child does not seek autonomy and shares most things with the family. Eating junk food out of the house may result in obesity or unhealthy eating habits. 2.What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period? Giving a pacifier to the infant Putting a mobile over the infant's crib Providing the infant with a soft, cuddly toy Warming the infant's formula before feeding Sucking meets oral needs, which are primary during infancy. An infant a few days old is too young to focus well on a mobile; in addition, the newborn will be placed in a side-lying position after surgery and therefore would not be able to see a mobile. A newborn is not developmentally capable of enjoying a soft, cuddly toy. Warming the infant's formula before feeding does not satisfy a developmental need. 3.A nurse is caring for a hospitalized school-aged child. What development-related activity is most important for the nurse to encourage? Family contact Peer interaction Therapeutic play Academic studies School-aged children have a need to be successful in school; this will help ensure that the child keeps up with the work being presented in class. Although contact with family is important, the school-aged child is beginning to move away from the family and into other realms. Although peer and social interactions and play are important, industrious activities and educational success are more important at this age. The school-aged child does not benefit from therapeutic play as much as the preschooler does. At this age the child can understand a simple explanation of treatment, although it is helpful to be shown and to handle the equipment. 5.A student nurse compares the sources of stress in both 7-year-olds and 12-year-olds. Which source of stress is prevalent in children of both these age groups? Idols Health Money Confusion Idols are a source of stress for both 7-year-old and 12-year–old children. The 7-year-old has a desire to be more like an admired idol. The 12-year-old continues hero worshipping. Health is a source of stress for 12 year olds and some may become hypochondriacs during this period of development. Health is not a source of stress for 7 year olds. Money can be a source of stress for the 12 year old. This child is anxious to earn and handle money but often uses poor judgment. Money is not yet a matter of concern for the 7 year old. Too much freedom can create confusion in a 12-year-old and can cause the child to flounder. A 7-year-old does not usually have much freedom and, thereby, does not experience the accompanying stress. 7.A nurse in the women's health clinic is counseling clients about family planning. What should the nurse consider when discussing the effects of a high concentration of estrogen in the blood? It causes ovulation. Lactation is stimulated. It prompts secretion of oxytocin. It inhibits secretion of follicle-stimulating hormone (FSH). A high level of plasma estrogen inhibits anterior pituitary secretion of FSH; this effect appears to be mediated by the hypothalamus and its releasing factors. Luteinizing hormone, not estrogen, causes ovulation. Lactogenic hormone (prolactin) stimulates lactation. Putting the infant to the breast prompts the release of oxytocin, which is secreted by the posterior pituitary gland, resulting in the let-down reflex. 8.Which statements should the nurse include in a teaching session for pregnant couples regarding fetal growth and development? Select all that apply. "All major organs are developed and function prior to birth." "Development occurs in a head-to-toe and central-to-peripheral pattern." "The fetal stage of development is most vulnerable to teratogenic influences." "Pregnancy includes the preembryonic, embryonic, and fetal stages of development." "During pregnancy the embryo grows from a single cell to a complex physiologic being." Information the nurse should include in a teaching session regarding fetal growth and development during pregnancy includes that development occurs in a head-to-toe (cephalocaudal) and central-toperipheral (proximal-distal) pattern; the three stages of pregnancy include the preembryonic, embryonic, and fetal stages of development; and the embryo grows from a single cell to a complex physiologic being. While all major organs do develop during pregnancy not all function prior to birth. The embryonic, not the fetal, stage of development is most vulnerable to teratogenic influences. The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruits and vegetables Nuts and seeds Lean red meats Milk and eggs With diverticular disease, the client should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. For clients with diverticular disease, nuts and seeds are contraindicated, because they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats. 3.A nursing student is listing the steps that need to be followed for applying developmental theory when caring for chronically ill older adults with depression. Which step listed by the nursing student needs correction? "The nurse should understand adult development and its implications for practice." "The nurse should be aware of signs of depression such as general fatigue or insomnia." "The nurse should recognize the need to identify depression so that heart failure can be prevented." "The nurse should understand the older adult’s concept of depression and views on treatment for mental illness." The nurse should recognize the need to identify depression so that appropriate treatment can be provided to the older adults. Congestive heart failure is not caused by depression. The nurse should understand adult development and its implications for practice when applying developmental theory. The nurse should be aware of signs of depression such as general fatigue or insomnia. The nurse should understand the older adult’s concept of depression and views on treatment for mental illness as it helps him or her to get complementary and alternative treatment measures. 5.Because of a measles epidemic, a 6-month-old infant receives measles immunoglobulin. The nurse should help the parents understand that to ensure continuous protection against measles, the infant should be revaccinated around what age? 8 months 10 months 12 months 18 months The optimal age for measles vaccination is between 12 and 15 months; if prophylaxis is given earlier because of exposure to a person with measles, it is not counted as one of the two required doses. Eight months and 10 months are too early; the infant will still have antibodies from the previous vaccination. Eighteen months is not the optimal time; the measles immunization should be given between 12 and 15 months. 7.During a routine physical examination a 10-year-old girl is discovered to have scoliosis. The curve is diagnosed as mild and functional, and a daily exercise program is established. The next month at the follow-up visit, what statement made by the girl helps the nurse determine that the child is complying with the exercise program? "I like doing my exercises with my brother so he can get stronger." "I think my exercises will make me a better softball and soccer player." "I do my exercises every day while my mother stays with me and watches." "I count out loud when I do my exercises so my mother can hear that I'm doing them all." The child is anticipating improvement; this reflects positive internal motivation, which helps maintain the child's interest and willingness to continue with the program. Motivation may diminish if the focus is on the brother rather than on the child's need to do the exercises. Doing the exercises to please the mother, as evidenced by having the mother watch every day or listen to the daughter counting to show that the exercises are being done, is external motivation, which is not as desirable as internal motivation. 10.The nurse instructs the son of an older client about age-related immune system changes and associated care measures. Which statement made by the son during a follow-up visit indicates a need for further instruction? "My parent has a private room at home." "My parent has received the pneumococcal vaccination recently." "My parent comes in for check-ups only whenever he or she has a fever." "My parent has been given a second dose of the pertussis vaccination." Older clients should have regular check-ups even in the absence of fever. Because aging causes reduced neutrophil function, some infections may not show fever symptoms. Older adults should have a private room at home to avoid other adults who may have viral infections. Because older adults have a decreased production of antibodies against new antigens, the caretaker should ensure that the older client has received updated vaccinations against infectious diseases such as pneumococcus and pertussis What is the similarity between the formal operations period and the preoperational period according to Piaget’s theory? Both the periods describe "imaginary audience." Both the periods demonstrate "animism" in a child. Both the periods explain egocentric thought of an individual. Both the periods occur in the beginning of cognitive development. The preoperational period and formal operations period explain the egocentric thought. The preoperational period describes "egocentrism" in a child at the age of 2 to 7 years; the formal operations period explains the egocentric thought from 11 years of age to adulthood. During the formal operations period, an individual believes that his/her actions and appearance are constantly being scrutinized by an "imaginary audience," which is not seen during the preoperational period. The preoperational period, not the formal operations period, tells about "animism" where the child thinks that there is life in every inanimate object. The preoperational period marks the beginning of the cognitive development, whereas formal operations period marks the end of cognitive development. 4.Which fine motor skill lacking in a 6-month-old infant would cause the nurse concern? Lack of a pincer grasp Inability to hold a bottle Lack of a hand preference Inability to pick up small objects The nurse would anticipate that a 6-month-old infant would be able to hold a bottle; therefore, this would cause the nurse concern. Lack of a pincer grasp, lack of hand preference, and the inability to pick up small objects would not cause the nurse concern at this time. 6.What is the similarity between evidence-based practice (EBP) and quality improvement (QI)? Both receive funding from internal sources. Both use data sources from multiple research studies. Both need approval of the institutional review board. Both are conducted by researchers employed for this purpose. Both evidence-based practice (EBP) and quality improvement (QI) are funded by internal sources. EBP uses information from multiple research studies; in contrast, QI collects data from client records. EBP does not require the institutional review board approval; QI sometimes may require institutional review board approval. EBP and QI are carried out by practicing nurses and possibly other members of the healthcare team. Research studies are carried out by researchers. 8.A school nurse is screening children for scoliosis. In what age group is it usually identified? Adolescence Preadolescence Early school years Middle school years Preadolescence is the time when scoliosis is most likely to become evident because of the growth spurt that occurs at this time. Although scoliosis may occur at any age, idiopathic scoliosis, the most common type, tends to become evident during the preadolescent growth spurt. 9.A young child presents with a blood lead level (BLL) of 17 mcg/dL. The nurse is aware that the client’s BLL levels have remained at this level in two samples obtained 4 months apart. Which actions will the nurse take to provide appropriate care for this client? Select all that apply. Refer client to social services. Refer client to a clinical center specializing in lead poisoning. Consider treating with appropriate chelation therapy. Perform follow-up testing within 1 month, then every 3 to 4 months. Immediately provide diagnostic testing and initiate chelation therapy. The Centers for Disease Control and Prevention (CDC) have recommended various actions to be taken depending on the BLL of the client. While a BLL of 17 mcg/dL falls in the range of BLL 15-19 mcg/dL, the nurse needs to follow the guidelines for 20 to 44 mcg/dL if BLL remains 15 mcg/dL or higher on two samples obtained at least 3 months apart. The client in this case has had a BLL of 17 mcg/dL on two samples obtained 4 months apart, so, based on the guidelines for 20 to 44 mcg/dL, the nurse will refer the client to a clinical center specializing in lead poisoning and will also consider treating him or her with appropriate chelation therapy. The nurse would have simply referred the client to social services and performed follow-up testing within 1 month, then every 3 to 4 months, if the guidelines for BLL 15-19 mcg/dL had been followed. The nurse would immediately provide diagnostic testing and initiate chelation therapy if BLL is 70 mcg/dL or higher. 1.An infant born with exstrophy of the bladder is admitted to the pediatric unit for urinary diversion surgery in which the ureters are to be transplanted to a resected section of the small intestines, with one end attached to the abdominal wall. What does the nurse call the procedure when explaining the surgery to the parents? Cystostomy Ileal conduit Ureterosigmoidostomy Cutaneous ureterostomy An ileal conduit is the transplantation of the ureters into a resected portion of the ileum, which is then used to create a stoma on the abdominal wall for drainage of urine. Cystostomy is an opening into the bladder through the abdominal wall that allows urine to flow out. In ureterosigmoidostomy the ureter is transplanted into the colon and urine is excreted through the rectum. In cutaneous ureterostomy the ureter is transplanted through the abdomen and attached to the skin. 4.A nurse manager notices that a previously effective nurse appears to be distracted, at times forgets to document changes in clients’ status, and rarely completes the required workload without help from another nurse. What should the nurse manager say to the nurse? "You seem to be having difficulty completing your assignments. What can I do to help?" "Why are you having trouble fulfilling your assignment? I need to know what’s going on." "Call me to help you organize your day—then you’ll have time to complete your assignment." "I’ve noticed that you always give part of your workload to another nurse. This is unacceptable." An understanding and supportive approach to a colleague helps the individual identify and address the problem. Asking why the nurse is having trouble fulfilling her assignment and what is going on is an accusatory approach. Implying a lack of organizational skills may or may not be accurate; also, it is an accusatory approach. Observing that the nurse always gives part of her workload to another nurse and noting that this is unacceptable states a fact of which the individual is probably aware; it may interfere with self-identification of the problem and is accusatory. What are the similarities between evidence-based practice and quality improvement? Select all that apply. Nurses conduct the activities in both. Funding resources are internal in both. The effects of the practice are measured in both. Expert opinions are the data resources in both. Institutional Review Board approval is needed for both. In both evidence-based practice and quality improvement, practicing nurses conduct the activities. The funding resources in evidence-based practice and quality improvement are internal, that is, from the health care agency itself. The measurement of the effects of practice or any change in practice regarding clients is done in quality improvement only. Data resources in evidence-based practice are based on expert opinions, personal experience and clients. In quality improvement, the data is collected from client records or clients from a specific area such as the intensive care unit. Institutional Review Board approval is only needed for evidence-based practice. 3.The nurse manager found that the nursing assistant (NA) shows unwillingness and is not motivated to go beyond the job description to take care of a client during the night. Which strategy by the nurse leader would motivate the NA and create job satisfaction? Ask the authorities to recruit more staff. Ask the authorities to increase the security needs at night. Ask the nursing assistant (NA) to participate in decision making. Ask the authorities to increase the salary of the nursing assistant (NA). According to the two-factor theory of leadership, motivating factors such as recognition and satisfaction of work promote job enrichment and create job satisfaction. Hygiene factors such as recruiting more staff to balance the work for nursing assistants (NAs), increasing the NA’s salary, and increasing the security needs at night only avoid job dissatisfaction; these factors do not necessarily motivate the NA. 5.The nurse leader working in a 30-bed intensive care unit accrued 792 client days in January. What is the percentage of occupancy calculated by the leader nurse? Record your answer using a whole number. _85____% The formula is average daily census (ADC) (rounded) divided by the number of beds in the unit multiplied by 100. ADC equals the client days in a given time period divided by the number of days in the time period. Therefore 792/30 = 25.5. Therefore the percentage of occupancy is 25.5/30 x 100 = 85% Which statements indicate that the nurse leader is adapting to changes in leadership practices to adjust to complex changes in healthcare systems? Select all that apply. "I will stop tracking progress." "I will be clear about purpose and process." "I will involve stakeholders and listen to them." "I will stop utilizing and providing older resources." "I will align systems and processes to support the change." The nurse leader should be clear about the purpose and processes in order to adjust to complex changes. This clarity will help the nurse leader implement the desired changes efficiently and effectively. Listening to the stakeholders and involving them helps the nurse leader understand the changes properly. Aligning systems and processes to support the change is an effective way to implement the change. Tracking progress helps the nurse analyze whether the change is being implemented properly. Utilization of both new and older resources is required to implement the changes effectively. 3.A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? Check the IV access for a blood return Apply warm compresses to the affected extremity Slow the IV infusion until the burning sensation is gone Request an oral supplement from the primary healthcare provider Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return. That finding determines the nurse's next intervention(s). If blood return is present, then it is appropriate to apply warm compresses. If there is not a blood return, the infusion needs to be stopped via that IV site, not slowed. If the potassium infusion cannot be administered, the primary healthcare provider must be notified so that other means of potassium replacement can be instituted. 5.A disturbed client starts to repeat phrases that others have just said. How should the nurse document this speech? Alogia Echolalia Neologism Echopraxia Echolalia is repetition of another person’s remarks, words, or statements. It occurs when individuals are fearful of saying their own words and therefore echo the words of others. Alogia is limited speech. Neologism is when new words are coined or old words take on private symbolic meanings. Echopraxia involves reflecting observed movements rather than speech. 7.Which assessments should the nurse perform while assisting an older adult with housing needs? Select all that apply. Assessing financial status Assessing meaningful activities and interest Assessing environmental hazards and support systems Assessing long range plans such as wills and advance directives Assessing access to public transportation and community activities When assisting an older adult with his or her housing needs, the nurse should assess the client’s financial status, environmental hazards, support systems, and access to public transportation and community activities. When an older adult is planning for retirement, the nurse should assess the client’s meaningful activities and interest and long range plans including wills and advanced directives. 8.Which aspects of organizations does the nurse consider during the decision-making process? Select all that apply. Laws Policies Standards Environment Relationships The decision-making process occurs in view of the organizational laws, policies, and standards. These views are important for the delegator to know when delegating tasks. Environmental considerations may not come under the organizational views. Relationships should be known and considered while delegating tasks to the delegatee. 9.A nurse caring for a client tries to prioritize nursing actions on the basis of Maslow’s hierarchy of needs. Which statement of the client would the nurse pay attention to last? "I feel that I have failed to be a worthy child of my parents." "My aim is to be a famous writer, and I will do anything to achieve my dream." "I do not like to speak to the people in my neighborhood as they are all snobs." "My house is being reconstructed, and chunks of the ceiling are quite often falling off." According to the Maslow’s hierarchy of needs, higher level needs should be addressed after fulfilling all the basic level needs of the client. The client displays the need for self-actualization by conveying to the nurse that he/she intends to do anything in order to become a writer. Self-actualization is the highest level of need, therefore, it should be addressed last. Since the client feels worthless, he/she shows a lack of self-esteem. Self-esteem needs should be addressed before self-actualization needs. The client in the given situation shows a lack of social interaction. Love and belonging needs should be met before addressing higher level needs such as self-esteem need and self-actualization need. In the given situation, the client lacks physical safety as he/she may be hurt by the chunks of the ceiling falling off. Therefore, the need for safety and security should be addressed by the nurse first before turning to the other needs. A registered nurse is teaching a nursing student about managing a pandemic disaster. Which statements by the nursing student indicate the need for further teaching? Select all that apply. "The swine flu outbreak in is a classic example of pandemic." "A pandemic is an infectious disease that occurs in populations worldwide." "A ‘worried well’ population will help enhance the available health care resources." "Collaboration with other health care personnel is required to handle the affected clients." "Conducting public information campaigns is a relatively inefficient method of managing a pandemic." The "worried well" are the members of a population who are not affected by a disease, but who seek evaluation, preventive treatment, and reassurance from the health care provider. In pandemics, when the existing health care resources may be stretched, these populations further deplete the resources. Conducting public information campaigns creates awareness of a disease among the public. This is an effective means of managing the pandemic on a basic level. The swine flu outbreak that occurred in was a pandemic. A pandemic is an infection or disease that occurs throughout populations in a vast portion of the world, which leads many people to seek medical care. 4.The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Select all that apply. Keep the client's head of bed elevated at least 10 degrees. Connect tube feeding bag to client and feeding pump. Flush with warm water before beginning feeding. Check prescription for correct client formula. Set correct rate and initiate pump. Check for diarrhea. Connect the feeding bag to the client and pump and check for any residual feeding before initiating the feeding. Always check the most recent tube feeding prescription before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should be assessed. The client's head of bed needs to be elevated at least 30 degrees. 6.A nursing student is learning about Henderson’s theory. Which of these statements by the student indicates effective learning? Select all that apply. "Henderson’s theory focuses on assisting an individual." "Henderson’s theory addresses a client’s self-care needs." "Henderson’s theory defines the role of a nurse in helping a client achieve a peaceful death." "Henderson’s theory discusses the 13 basic needs of an individual." "Henderson’s theory describes the spiritual domain of an individual." A client’s self-care needs are best described under Orem’s theory for maintaining health and well-being. As per Henderson’s theory, there are 14 basic needs of an individual which should be fulfilled. Henderson’s theory focuses on the nurse assisting an individual to carry out any daily activities that will contribute to an individual’s health. The nurse should also help the client have a peaceful death in case of severe morbid conditions. Henderson’s theory describes different domains of an individual’s life such as the physiological, psychological, sociocultural, spiritual, and developmental domains. 10.Which statements accurately explain the deontology system of ethics? Select all that apply. Deontology examines a situation for the presence of essential right or wrong. Deontology emphasizes the commitment to respect the "rightness" of autonomy. Deontology deals specifically with the consequences of an action to determine right and wrong. Deontology determines that actions are right or wrong based on their "right-making characteristics." Deontology believes in the concept of using the greatest good for the greatest number of people principle to decide the right action. The system of deontology examines a situation for the presence of an essential right or wrong. The principle that guides the system of deontology is the commitment to respect the "rightness" of autonomy. According to deontology, an action is considered to be right or wrong based on its "rightmaking characteristics." Utilitarianism deals specifically with the consequences of an action to determine right and wrong. According to this system, the right action is based on whatever creates the greatest good for the greatest number of people. o Chart/Exhibit 1 The nurse is caring for a group of clients who survived a bus accident. Which group does the nurse assess first? 1 Group 1 2 Group 2 3 Group 3 Correct4 Group 4 Chest pain with diaphoresis is a condition that is included in the emergent triage category. The emergent or life-threatening tier level indicates that the existing condition poses an immediate threat to life and that the client should be treated first. Displaced or multiple fractures and complex soft tissue injuries are included in the urgent triage category, which indicates the client should be treated immediately, but there is no threat to life. Strains and sprains are conditions included in the nonurgent triage category, which indicates the client can wait several hours. 92%of students nationwide answered this question correctly. View Topics 1 3 Confidence: Pretty sure Stats Issue with this question? 3. A nurse identifies that a client with dementia seems anxious, frequently paces about, and exhibits deteriorating hygiene. How can the nurse address these behaviors? Correct1 By directing staff members to reinforce reality with each client contact 2 By providing a restrictive environment, including restraints, to prevent self-injury 3 By ignoring instances when confabulation is used to substitute for memory lapses 4 By having the client identify positive coping skills to prevent feelings of inadequacy Having staff members reinforce reality compensates for impaired cognition and helps provide a consistent approach, which may decrease the client’s anxiety. Once anxiety is decreased, activities of daily living may be addressed. Restraints may increase confusion and agitation; they should be used only when absolutely necessary to prevent injury to self or others. Confabulation should be accepted, but it does not address the behaviors being exhibited. Having the client identify positive coping skills is not realistic; it will not help the client address activities of daily living. 41%of students nationwide answered this question correctly. View Topics 1 8 Confidence: Pretty sure Stats Issue with this question? 4. A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client’s infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply. Correct1 Using informatics 2 Applying quality improvement Correct3 Using evidence-based practice Correct4 Providing patient-centered care 5 Working in an interdisciplinary team According to the Institute of Medicine (IOM) competencies of the twenty-first century, the nurse should use informatics to provide better client care. This involves using information technology to communicate, manage knowledge, reduce errors, and support decisionmaking. The nurse in the given situation uses informatics to keep track of the client’s recovery. A nurse should also use evidence-based practice to improve client care. This includes activities such as conducting research and integrating the best research with clinical practice and client values. The nurse in the given situation displays this competency by conducting extensive research about the client’s condition to prepare the care plan. A nurse is required to provide patient-centered care. Relieving pain and suffering, coordinating continuous care, advocating for disease prevention and health promotion, and educating clients are examples of nursing activities related to patient-centered care. The nurse in the given situation performs this task by educating the client about hygiene maintenance. 43%of students nationwide answered this question correctly. View Topics 1 2 Confidence: Pretty sure Stats Issue with this question? 5. For which situations would total client care be an appropriate delivery system? Select all that apply. 1 Client scheduled for lithotripsy for renal calculi Correct2 Client with an endotracheal tube for pulmonary sepsis Correct3 Client recovering from cardiovascular bypass graft surgery Correct4 Client recovering from the placement of a cerebrospinal fluid shunt 5 Client transferring to a rehabilitation unit after total hip replacement surgery Total client care is used in critical care settings where one nurse provides total care to one or two critically ill clients. The client with an endotracheal tube for pulmonary sepsis and the client recovering from cardiovascular bypass graft surgery are considered acutely ill and will be receiving care in a critical care area. The client recovering from cranial surgery to place a cerebrospinal fluid shunt would be appropriate for total client care. Total client care would not be an ideal care approach for the client scheduled for lithotripsy or the client being transferred to a rehabilitation unit. At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 pm tonight?" What is the nurse's best response? "I will give one capsule tonight before bedtime." "I will get a prescription so that the medicine can be taken." "Does your healthcare provider know about your child's allergy?" "Did you ask your healthcare provider if your child should have this tonight?" Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current healthcare provider's prescription; this is a dependent function of the nurse. The nurse should not ask if the healthcare provider is aware of the problem; it is the nurse's responsibility to document the client's health history. It is the nurse's responsibility to review the healthcare provider's prescriptions and question them when appropriate. Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner? 1 to 2 L via nasal cannula to keep SaO2 above 90%. 1 to 2 L via nasal cannula to maintain SaO2 at or above 95%. 3 L via mask to maintain SaO2 at 95%. Do not give oxygen because it may suppress hypoxic drive in client. Oxygen therapy usually is delayed until stage 4, which is very severe COPD. Usually it is administered at 1 to 2 L per minute to maintain SaO2 at or above 90%. One to 2 L to maintain the SaO2 above 95% is not necessary. Oxygen administration may not be necessary. Three liters of oxygen via a mask is unnecessary, and a level of 95% may suppress the hypoxic drive in clients who are chronic CO2 retainers. Oxygen should not be given unless the chronic saturation level is less than 88%. 2.A client who was sexually assaulted and is aware of the possible legal implications decides to seek prosecution of the rapist. The nurse carefully listens and documents all assessments. This is done because with a charge of rape the burden of proof has which implication? The burden of proof rests with the health team. It is on the defendant to prove innocence. Burden of proof must be established before the case will be heard. The burden of proof rests with the criminal justice system in collaboration with the victim. When the person who has been sexually assaulted chooses to seek prosecution of the rapist, the prosecutor must prove that rape occurred; the accused is innocent until proven guilty. The medical team may be asked to provide evidence at the trial, but the state, with the victim’s help, must prove that the rapist is guilty. The defendant tries to establish innocence in a rape case. Guilt or innocence will be established by a jury, with the burden of proof placed on the victim. 4.As a part of the nursing curriculum, the nursing faculty is teaching nursing students about high-quality clinical delegation experiences and has also chosen to engage the students with nursing mentors. Which skill does the nursing faculty expect the nursing students to develop via this approach? Proficiency in delegation Application of theory to delegation Professional self-confidence in delegation Development of clinical judgment in delegation Because of the ever-changing health care system, the faculty in nursing schools should teach and mentor the nursing students regarding advances in the health care system. Teaching and exposing the students to high-quality clinical delegation experiences and engaging the student nurses with nursing mentors is helpful for fostering students’ professional self-confidence. These experiences advance the nurse’s ability to become a successful delegator. The student’s proficiency in delegation is improved with the study and practical application of teaching and learning. The nursing practicum develops the student’s ability to apply theoretical knowledge to the process of delegation and also develops the student’s clinical judgment skills related to delegation. 7.The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? Multipara in active labor Middle-aged woman with substernal chest pain Older adult male with a partially amputated finger Adolescent boy with an oxygen saturation of 91% Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening, and the client can wait for care. A woman in active labor should be assessed immediately, because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a lifethreatening illness and should be assessed immediately. 8.It is lunchtime at a mental health facility, and a client is unable to open her door because she has run out of the paper towels she uses to avoid touching the doorknob. What is the priority intervention by the nurse? Exploring the feelings that triggered her use of the ritual for opening doors Encouraging her to open the door if she expects to leave for the dining room Opening the door for her and telling her that the staff will try to find more towels Giving her a supply of paper towels and then sending her to the dining room for lunch Providing paper towels takes into consideration the fact that the client’s anxiety will increase if the ritual is interrupted; this allows the client to complete the ritual and encourages her to go to the dining room for lunch. Exploring feelings at this time is inappropriate, because it will increase anxiety and result in the client missing a meal. Having the client open the door without performing the ritual denies the ritual, which will result in an increase in anxiety. Opening the door for the client will precipitate a conflict between completing the ritual and going to the dining room; this conflict will increase anxiety. 9.A nurse in the pediatric clinic is evaluating a 6-year-old child with sickle cell anemia whose spleen autoinfarcted by age 4. What is the priority nursing care at this time? Monitoring for signs of jaundice Assessing the abdomen frequently Monitoring serial hematocrit readings Determining parental knowledge about infection The spleen plays a role in immunity. Initially the spleen enlarges and becomes congested with accumulated sickled red blood cells; in time, fibrous material replaces the tissue in the spleen, and by age 5 the spleen is obliterated. Without a spleen the child is prone to infection, which can precipitate a sickle cell crisis. Assessing the child for jaundice is not a priority, because jaundice is an expected adaptation that is not life threatening. Abdominal assessments are important but not required frequently in this situation. Serial hematocrit readings are necessary only if the child is in sickle cell crisis. 10.How would the nurse arrange the healthcare members in the ranking order based on their profession? Nurse Director Nurse Manager Registered nurse. Licensed vocational nurse The nurse director has the ability to transfer selected nursing activities in a given situation to competent individuals. The nurse manager is the designated individual to whom all the nursing professionals should answer regarding a given task. The registered nurse is the healthcare professional who is mainly involved in the task of delegation while caring for different clients. The licensed vocational nurse performs the activities delegated by the registered nurse. 1 1 Confidence: Pretty sure Stats Issue with this question? 3. o Chart/Exhibit 1 A large group of clients who are injured in a fire are admitted to a healthcare facility. Which group of clients does the nurse think are receiving appropriate medical care? 1 Group 1 2 Group 2 Correct3 Group 3 Incorrect4 Group 4 The Emergency Severity Index (ESI) is a five-level triage system that incorporates concepts of illness severity and resource utilization. Group 3 are classified as ESI-3, in which mediumhigh resource intensity is required. Group 1, with simple lacerations, comes under ESI-4, in which and low resource intensity is required. Group 2, with multiple trauma unless responsive comes under ESI-3, and may require high resource intensity with multiple or often complex diagnostic studies. Group 4, with closed extremity traumas, comes under ESI4 and may require low resource intensity and one simple medical procedure. What is the correct order of phases that a disaster management team should follow in a region commonly affected by hurricanes? Correct 1. Assess risks in the region where a hurricane is more likely to occur, and evaluate the probable damage. Correct 2. Attempt to limit disaster impact, such as evacuating population to safer regions. Correct 3. Implement the disaster management plan. Incorrect 4. Evaluate the implementation strategies, to prepare for any disaster in future. Incorrect 5. Stabilize the community and return it to the previous status. Disaster management is a five-phase process. The first phase is preparedness, which is the protective plan designed before the occurrence of an event to assess the risk and evaluate the potential damage. Mitigation is the attempt to limit disaster’s impact on human health and community functions. This includes evacuating people to safer places. Then the actual implementation of disaster care should be planned. After the acute phase of a disaster is over, the community should be stabilized and the evaluation of the strategy should be performed. A registered nurse is educating a nursing student about the utilitarian system of ethics. What information should the nurse provide? Select all that apply. Correct1 "The value of something is decided by its usefulness." Correct2 "The main emphasis is on the outcome or consequence of the action." 3 "The system examines a situation for the presence of essential right or wrong." Correct4 "The greatest good for the greatest number of people determines the right action." Incorrect5 "The actions can be determined whether right or wrong based on their ‘right-making characteristics.’" According to utilitarianism, the value of something is decided by its usefulness. This system is also called consequentialism since the primary emphasis is on the outcome or consequence of the action. According to utilitarianism, the right action is based on the greatest good for the greatest number of people. Deontology examines a situation for the presence of essential right or wrong. According to deontology, actions can be decided as right or wrong based on their "right-making characteristics." Reduction of Risk Potential How should the nurse screen the newborn of a diabetic mother for hypoglycemia? 1 Testing for glucose tolerance 2 Drawing blood for a serum glucose determination 3 Arranging for a fasting blood glucose determination Correct4 Testing heel blood with the use of a glucose-oxidase strip Glucose-oxidase strips are used by nurses to screen infants for hypoglycemia. The glucose tolerance test and serum glucose determination are not used to screen newborns for hypoglycemia. Fasting blood glucose levels are not used routinely to screen newborns for hypoglycemia. A nurse in the cardiovascular clinic reviews a client’s ECG. What should the nurse do? 1 Recommend the Valsalva maneuver. Correct2 Document that the rhythm is normal. 3 Prepare to defibrillate the client at 200 joules. 4 Advise the client to reduce the intake of caffeine. The client is experiencing a regular sinus rhythm. The P-QRST is one to one, the R-R interval is consistent, the PR interval is 0.16 second, and the QRS complex is 0.08 second. Recommending the Valsalva maneuver is beneficial if a client is experiencing paroxysmal supraventricular tachycardia. Preparing to defibrillate the client at 200 joules is appropriate if a client is experiencing ventricular fibrillation. Caffeine is a stimulant; decreasing caffeine is appropriate if a client has premature contractions or atrial flutter/fibrillation caused by myocardial irritability. 83%of students nationwide answered this question correctly. View Topics 1 2 Confidence: Pretty sure Stats Issue with this question? 5. The nurse observes the following pattern on a client’s electrocardiogram (ECG) strip. What dysrhythmia does the nurse identify? 1 Asystole 2 Atrial flutter 3 Ventricular fibrillation Correct4 Premature ventricular complex Beats 2 and 4 are premature ventricular complexes or beats. The impulse originates in the ventricles, and it occurs before the next expected ventricular beat. Asystole is characterized by an absence of electrical and mechanical cardiac activity, with no countable heartbeat. Atrial flutter is characterized by an atrial rate of 250 to 350 regular beats per minute, more than 100 irregular ventricular beats per minute, a sawtooth P wave, variable PR intervals, and normal QRS complexes. Ventricular fibrillation is characterized by lack of organization in electrical impulses, conduction of impulses, and ventricular contractions. 77%of students nationwide answered this question correctly. View Topics 1 6 Confidence: Pretty sure Stats Issue with this question? 6. A nurse is caring for a client with end-stage kidney disease who is about to receive a transplant. When the client returns from the postanesthesia care unit after a kidney transplant, how often should the nurse measure the client’s urinary output? Correct1 1 hour 2 2 hours 3 15 minutes 4 30 minutes Hourly output is critical in assessing kidney function; decreasing urinary output is a sign of rejection. Every 2 hours is too infrequent for monitoring output immediately after a kidney transplant; it is essential to monitor output more frequently to evaluate whether the new kidney is working or being rejected. It is not necessary to monitor every 15 or 30 minutes. 63%of students nationwide answered this question correctly. View Topics 1 5 Confidence: Pretty sure Stats Issue with this question? 9. During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? Correct1 Turn and reposition the client every 2 hours. 2 Cover the ulcer with an occlusive transparent dressing. 3 Clean the ulcer with hydrogen peroxide and leave it open to the air. 4 Provide the client with a diet high in vitamin C, zinc, and protein. Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing. Covering the area with an occlusive transparent dressing and cleansing the area with hydrogen peroxide are not recommended for this situation. Providing a diet high in vitamin C, zinc, and protein will also aid in tissue healing and help prevent further breakdown, but this is not the priority action. 79%of students nationwide answered this question correctly. View Topics 1 4 Confidence: Pretty sure Stats Issue with this question? 10. A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? Correct1 Continue to monitor the client. 2 Notify the primary healthcare provider. 3 Ensure that a defibrillator is close by. 4 Administer lidocaine intravenously as per protocol. Premature atrial contractions usually are benign if they occur at a rate of fewer than 10 per minute. Their presence indicates atrial irritability, and the client should be monitored closely. Notifying the primary healthcare provider is premature; more data are needed. Defibrillation is used for ventricular, not atrial, fibrillation. Lidocaine is specific for ventricular, not atrial, irritability. During an examination of a client with kidney dysfunction, the nurse finds the presence of glucose in the urine. Which nursing intervention is beneficial for this client? Administering oral fluids Noting the finding down as normal Administering hypoglycemic medication Reporting this finding to the primary healthcare provider The presence of glucose in the urine is an abnormal finding that requires further assessment. Therefore, the nurse should report this finding to the primary healthcare provider. The nurse should not administer oral fluids or hypoglycemic medication without instructions from the primary healthcare provider. 4.What does the nurse find in the laboratory report of a client who is suspected of having a urinary disorder and is on steroid therapy? Increased red blood cells count Increased sodium count Increased serum creatinine levels Increased blood urea nitrogen levels Steroid therapy may be used to treat urinary disorders; however, it may cause the blood urea nitrogen (BUN) levels to elevate. Increased red blood cell count occurs in polycythemia. Increased sodium does not occur with steroid use. An increase in serum creatinine levels indicates kidney impairment. 7.Which diagnostic study is used to determine a client’s bone density? Diskogram Standard X-ray Computed tomography scan Magnetic resonance imaging A standard X-ray is used to determine bone density. A diskogram is used to visualize abnormalities of the intervertebral disc. A computed tomography scan is used to identify soft tissues, bony abnormalities, and various types of musculoskeletal trauma. Magnetic resonance imaging is used to diagnose avascular necrosis, disc disease, tumors, osteomyelitis, ligament tears, and cartilage tears. 8.The registered nurse observes the student nurse caring for the skin of the client who recently underwent radiation therapy. Which actions made by the student nurse should the nurse correct? Select all that apply. Using a washcloth for cleaning the radiated site Rinsing soap thoroughly from the skin of the client Drying the irradiated area with rubbing motions Wearing loose clothing over the skin at the radiation site Removing the ink marks that identify the location of the focused beam of radiation The nurse should use a hand rather than a washcloth when cleansing the radiated site. This is to provide gentle care to the site. The irradiated area should be dried using patting motions rather than rubbing motions. The ink marks present on the site exactly identify where the location of beam radiation is to be focused. The nurse should take care not to remove these. The skin of the client should be thoroughly rinsed using a mild soap as prescribed by the radiation oncology department. The client’s clothing should be loose over the radiation site. A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma asks the nurse what will happen if surgery is not performed. On what information should the nurse base a response? The tumor must be removed to prevent heart and kidney damage. Surgery will prevent the tumor from metastasizing to other organs. Radiation therapy can be just as effective as surgery if the tumor is small. Chemotherapy is as reliable as surgery for the treatment of adenomas of this type in some people. Renal and cardiac complications will occur if hypertension caused by the tumor is not arrested. Aldosteronomas are benign tumors; metastasis is not possible. Radiation is not used to treat this type of adenoma. Chemotherapy is not recommended treatment for this particular adenoma. 3.A nurse is preparing a teaching plan for a client who is to undergo electroconvulsive therapy. What instructions should the nurse include? Void just before the procedure. Wear cotton clothing during the procedure. Sleep for several hours after the procedure. Eat a light breakfast 1 hour before the procedure. During the expected seizure the client may become incontinent. The client will awaken 20 to 30 minutes after the procedure. Although the client will be groggy and confused, there is no requirement that the client sleep for several hours. The client should be supervised until oriented and capable of self-care. There are no restrictions concerning the type of fabrics that should be worn; however, the clothing should be comfortable and metal hair accessories should not be worn. Food or fluid should not be consumed for at least 4 hours before therapy as a means of preventing vomiting and aspiration. 4.A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client? Sleep will be induced and the treatment will not cause pain. The treatment is totally safe with the new methods of administration. The client may ask any question, but it is better not to talk about the therapy. The client may experience some unrecoverable short-term and long-term memory loss. Clients fear ECT because they think it will be painful. If they are reassured that they will be asleep and will feel no pain, there will be less anxiety. No treatment requiring anesthesia is totally safe. Clients may not realize their own fears and therefore may not know what questions to ask; also, this response cuts off further communication. Temporary, not permanent, memory loss occurs. 5.The nurse is providing immediate postoperative care to a client who had a thyroidectomy. The nurse should monitor the client for which clinical manifestation? Urinary retention Signs of restlessness Decreased blood pressure Signs of respiratory obstruction The first and most important observation should be for signs of respiratory obstruction. Tracheal compression can occur because of edema in the surgical area. Tracheal compression is exhibited by decreased inspiratory/expiratory pressure, decreased ventilation, dyspnea, shortness of breath, tachypnea, tachycardia, nasal flaring, use of accessory muscles to breathe, cyanosis, reduced oxygen saturation, and altered arterial blood gases. Although urinary retention is a concern after anesthesia, it is not life threatening. Signs of restlessness may be a result of the anesthesia; however, if it is because of a lack of oxygenation, assessing for respiratory obstruction is a more direct and objective assessment associated with this surgery. The blood pressure is not significantly affected by this type of surgery unless thyroid storm occurs; when assessing for thyroid storm, all the vital signs will increase. 6.After a gastrectomy, a client has a nasogastric tube to low continuous suction. The client begins to hyperventilate. How does the nurse anticipate that this breathing pattern will alter the client's arterial blood gases? Increase the PO2 level Decrease the pH level Increase the HCO3 level Decrease the Pco2 level Hyperventilation results in the increased elimination of carbon dioxide from the blood. The PO2 level is not affected. The pH level will increase. The carbonic acid level will decrease. 8.After a transurethral resection of the prostate, the retention catheter is pulled taut and secured to the client's leg. The cl