Which model is most useful in examining the cause of disease in an individual, based upon external factors? The Agent-Host-Environment Model What is the definition of wellness? an active state of being healthy When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by his personal expectations in relation to health and illness. The nurse is demonstrating understanding of which health model? What level of prevention is noted when the nurse educates a group of mothers of school-age children on self breast examinations? A nursing instructor is working with a class of first semester nursing students. The instructor explains the interrelatedness of health and wellness. What would be the best definition the nursing instructor could give of health? Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. 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? It focuses on what people believe to be true about their health.
When chronic illnesses and disabilities are present, individuals benefit most from what kind of activities? Those that help them maintain independence. How can the nurse best demonstrate being a role model for health promotion? Avoid smoking and drinking alcohol 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? A nurse is caring for a patient who has breast cancer. The patient tells the nurse: “I don’t know why this happened to me, but I’m ready to move on and do whatever I need to do to get healthy again.” This patient is in which stage of acute illness? What is a dynamic balance among the physical, psychological, social, and spiritual aspects of a person's life? 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 has a gradual onset and lasts for a long time. 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 A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for patients in this developmental stage? Setting up parenting classes A home healthcare nurse is performing a home visit to a 58-year-old man and his 56-year-old wife who receives home chemotherapy as part of her treatment regimen for breast cancer. The nurse will recognize that this family is likely to be engaged in which of the following development tasks? Maintaining ties with older and younger generations Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? The nurse makes a home visit to evaluate a 3-week-old baby. Upon arrival at the family's home, the nurse discovers that the parents of the baby are a lesbian couple. When planning appropriate nursing interventions for this family, which of the following must the nurse do first? Confront personal biases about this type of family structure. The home health nurse is making an initial visit to a client's home. During the visit she observes the mother cooking dinner, the father watching television with a child on his lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following? A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? An 85-year-old man is being transferred from his house to a nursing home by his wife. What is the first action the nurse should take to help reduce the stress of relocation on the client? Assess the client's usual lifestyle and daily activities You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care center. What is the most important factor of community-based nursing for you be knowledgeable about? Community resources available to patients. A community is defined as a social group that may or may not share common geographic boundaries yet interact because of A nurse who is using DuVall's conceptual framework to assess a family with two parents and three children must first determine the Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow’s Hierarchy of Needs? Providing the mother the phone number for the Poison Control Center A 44-year-old female client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which of the following values? Urine output of 1500 ml in 24 hours Priority nursing interventions are geared to meeting the physiologic needs of patients. What are examples of physiologic needs according to Maslow’s hierarchy of needs? (Select all that apply.) • A nurse administers pain
medication to a postoperative patient. A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment? Limited time in learning to be a marital partner The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate? Read the Koran passage to the client. Which step of the nursing process involves reporting or analysis of data to identify and define health problems? A newly diagnosed diabetic has been sent home after in-depth education regarding the diabetic management plan. Because the client is a new diabetic, the nurse included in his plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in this client? The client will: maintain a blood sugar between 70 mg/dL and 110 mg/dL. The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following? A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: complete postoperative assessment. The nurse recognizes that the most appropriate example of the assessment phase of the nursing process is which of the following? Palpating a mass in the right lower quadrant of the abdomen Which statement is true of the nursing process? Scientific problem solving can occur within the nursing process. Which activity is the clearest example of the evaluation step in the nursing process? checking the client's blood pressure 30 minutes after administering captopril. The clinical nurse manager understands that which of the following types of knowledge are required for competent clinical reasoning in nursing? Select all that apply. • Demonstrates basic
mathematical problem solving A nurse has developed a plan of care for an adult client. What is a nursing function that is important when using a nursing diagnosis to guide the care of this client? Prioritize the nursing diagnoses. The student nurse has been assigned to a pediatric hospital floor next week. The student understands that he or she is expected to be able to use the syringe pump with the clinical instructor when giving medications. The student has never used this pump before and is anxious. What is the most appropriate way for the student to lessen the anxiety associated with the clinical rotation? Practice using the pump in the lab setting if it is available and with instructor permission. At 0730, the nurse notes that the client states that his pain is a 7 on a scale of 1 to 10. Based on this assessment the nurse administers pain medication to the client. At 0800, 30 minutes after pain medication was administered, the nurse evaluated the client and found that his pain was a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? 0730: Client’s pain is a 7 on a scale of 0-10, pain medication administered. the nursing student recognizes that the purpose of diagnosis in the nursing process is to:
develop a prioritized list of current and possible health problems. Many significant changes have been made to the health care delivery system in recent years. Earlier hospital discharges is one of them. What is one result of earlier hospital discharges? Clients with high home care needs are being discharged into the community. A 16-year-old girl has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. She states, “I don't know why I survived and not my best friend.” It is most important to: communicate her feelings to family and friends. The nurse completes the admission assessment. As part of the admission database, the nurse would determine and record functional abilities, which include: • if the patient wears eyeglasses. A woman living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for her to bathe herself, and her blood pressure is unstable. What type of care would this client benefit from most? Which of the following is the largest single source of reimbursement for home health care services? A client is having an increasing amount of difficulty caring for herself in her home alone. She states to the nurse, “I need more help. What am I going to do?” What would be important for the nurse to do? The nurse should have the social worker visit to discuss care options. When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided? A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately? Which of the following activities does the nurse engage in during the entry phase of the home visit? Select all that apply. • Establish rapport with client and family. The nurse is assigned to care for a client who will be transferred to the rehabilitation unit in the hospital following his postoperative recovery from hip surgery. What is the priority nursing responsibility when transferring a client from one unit in the hospital to another? Provide a verbal report of the client’s status to the admitting nurse. The nurse is caring for a patient whom will benefit from home healthcare services. In preparing for discharge, the nurse is aware that home healthcare can only be initiated if: The physician writes an order for home care. Public health nursing is the branch of nursing that: provides health care for the community. A home health care nurse develops a client's individualized plan of care during the: When preparing to transfer an older adult client back to the long-term-care facility where he has been for several years, it is the primary responsibility of the nurse to: provide for the coordination and continuity of care by the health care providers.Correct A client has severe pain related to degenerative joint disease. On which aspect of care will the nurse need to focus first ability to perform daily activities Client education is a major nursing responsibility. The education that the nurse must accomplish prior to discharge includes what? • A review of appointment schedule for follow-up care. An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client? A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse’s best source of information? consult nursing and medical literature A nurse practitioner has a private practice in conjunction with a
physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing? How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation? "Client states, 'I don't see the point in trying anymore.'" A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment? Adds depth to existing information While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first? validate questionable data A new graduate nurse states that it does not make sense to have to perform such an extensive assessment on clients when they are not feeling well. Which response by the nurse preceptor is an appropriate explanation for conducting a comprehensive physical assessment on clients? Select all that apply. • To appraise the client's health status During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? Ask the client if it is okay to interview her husband for the answers to the interview questions. The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next? The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment The nurse's physical assessment will focus on the client's functional abilities. The nurse, while admitting an older adult client, charts, "The client
does not respond when I speak while standing on the client's right side". This statement is an example of which of the following? A nurse is interviewing an older adult client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this
evidence, what would be the most appropriate nursing diagnosis? Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food Nurses use approved NANDA-I nursing Diagnoses when writing diagnoses for clients. Which diagnoses represent "Domain 1: Health Promotion" as established by NANDA-I? Ineffective Self-Health Management A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Reversed the health problem and the etiology A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge deficit: Medications related to new medical diagnosis A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? Consult reference materials to determine the normal vital signs for 1-month old infants. A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? Ineffective Health Maintenance related to client's denial of illness A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address? Risk for Allergy Response related to latex allergy A client with advanced Alzheimer's disease has a nursing diagnosis of "Risk for Aspiration." What would the nurse select as an appropriate etiology for this diagnosis? Decreased level of consciousness A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Risk for Community Contamination related to possible environmental pollution When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? The nurse should determine the client's normal bowel elimination pattern. A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate? A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Ineffective Airway Clearance A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge deficit: Medications related to new medical diagnosis Which example of client care is not the responsibility of the nurse? confirming a medical diagnosis A female client undergoing chemotherapy for breast cancer has lost all her hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? Disturbed Body Image related to loss of hair The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from: the problem statement of the nursing diagnosis. The nurse recognizes that identifying outcomes/goals must include: involvement of the client and family. The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? “I will test my glucose level before meals and use sliding scale insulin.” The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next? Write a client plan of care When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: Identifies factors causing undesirable response and preventing desired change A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care? Include the client and the client's power of attorney in the discussion. An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome? The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's: The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly? Mr. Conner will demonstrate proper care of stoma by 3/29/15. A nurse is writing outcomes for clients in a rehabilitation facility. Which guidelines should the nurse consider? Select all that apply. • At least one of the outcomes the nurse writes should show a direct
resolution of the problem statement in the nursing diagnosis. The nurse recognizes that an example of a cognitive outcome is: The client identifies three foods high in potassium by August 8. When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate? The outcome is not observable or measurable. The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include? Risk factors and prevention of diabetes mellitus A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. How should the nurse respond to the client’s statement? Consult with the physician to treat the client’s nausea. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? bed bath for the newly-admitted client who has multiple skin lesions Nurses implement care for clients in various health care settings. Which activities would typically be carried out during the implementation step of the nursing process? Select all that apply. • Collecting additional client data Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? Collaborate with other disciplines to revise the discharge plans. Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action? Helping to allay a patient’s fears about surgery As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important? It enables the nurse to revise the care plan appropriately. During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's most . appropriate first action? Go to the client and assess the client's pain. A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? The nurse should inform the charge nurse that she does not have the experience to properly care for this client A student nurse is performing a sterile dressing change on a client's abdominal incision. While establishing her sterile field, the nurse drops her forceps on the floor. She is unable to continue with the dressing change because she has no extra supplies in the room, and no one is present to bring new forceps. The student has failed to organize ... The nurse is collecting data on a client presenting to the medical short-stay unit for a colonoscopy. A client reports to the nurse that he quit smoking six months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? The nurse is collecting data on a client presenting to the medical short-stay unit for a colonoscopy. A client reports to the nurse that he quit smoking six months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? A nurse identifies an area where client care has been compromised. Which of the following steps should the nurse take to improve performance? Select all that apply. • Plan a strategy using indicators
A client has returned to the clinic for a postoperative visit. The nurse reviews the plan of care and could choose to take which action based on the client's previous responses to the current plan of care? Select all that apply. • Terminate the plan of care if outcomes have been achieved. The nurse manager observes one of the unit nurses failing to was her hands upon entering a client room. Hospital protocol is washing hands before and after entering a client room. The nurse manager knows that this is an example of: Which of the following is the most important indicator of quality nursing care? The nurse considers the individual needs of clients. A nurse manager attempts to achieve performance improvement in the emergency department of a busy inner-city hospital. Which nursing actions follow Haase and Miller’s recommended steps in performance improvement? Select all that apply. • The
nurse discovers that there is a problem with the triage system that is in place in the emergency department. Which statement related to the evaluation of outcome attainment for a client is correct? Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. A group of nurses of the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. The nurses know that this program is termed which of the following? Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called which of the following? Which action is appropriate when evaluating a client’s responses to a plan of care? Continue the plan of care if more time is needed to achieve the goals/outcomes. A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Calling the client information desk to find out the room number of the family member Which documentation tool will the nurse use to record the client's vital signs every 4 hours? What is the primary purpose of the client record? When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? It provides quick access to abnormal findings. The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate? Ask the client if information can be given to the parent. The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. What action by the nurse is most appropriate? Assess the triggers from the data. A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? A nurse takes a patient’s pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results? Graphic sheets (specific patient values such as rr, hr, bp, t What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply. • Time A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format? A nurse recognizes an error in documentation regarding the site of a wound. What actions by the nurse are appropriate? (Select all that apply.) • Put a single line through the incorrect entry. When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting? Ensure that the client's name appears on all pages A nurse helps a patient who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information? “You can fill in information from your own records and store it on your computer or the Internet.” |
A nurse is caring for a client who is in an acute care facility. the nurse should recognize
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