Hesi Fundamentals

Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems?

Counselor As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client’s community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client’s well-being along a continuum of care.

The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client’s request for pain medication. What is the role of the nurse in this situation?

Advocate The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

Which definition is involved in the caring process called knowing according to Swanson’s theory of caring?

Striving to understand an event as it has meaning in the life of the other In Swanson’s theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other’s capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other’s passage through life transitions and unfamiliar events is related to the caring process called enabling.

A nursing student is examining the health services pyramid. Keeping in mind that care services begin at the bottom of this pyramid, in which order should care services be arranged?

1. Population based services 2.Clinical preventative services 3.Primary health care 4.Secondary health care 5.Tertiary health care According to the health services pyramid, population-based health care services come first. Clinical preventive services form the next level of the pyramid. A nurse should then address the primary health care needs of clients; these needs include prenatal and baby care and nutrition counseling. The next level of health care is secondary health care services, which include emergency care and acute medical-surgical care. Tertiary health care forms the highest level of health care; these needs include intensive care and subacute care.

A nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?

Advocacy The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client’s needs are met and by protecting the client’s rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.

A nurse is assessing a client’s nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?

Normal Finding The client’s nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base that is larger than 180 degrees. Paronychia is the inflammation of the skin at the base of nail. Koilonychia is the concave curves on the nail.

When assessing a client’s fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

Which intervention reflects the nurse’s approach of "family as a context"?

Trying to meet the client’s comfort In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client’s comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family’s needs as a whole to determine their coping skills. This approach also includes assessment of the family’s energy level to determine if the family would be able to meet the client’s needs. In addition, the approach "family as a client" involves assessment of the family’s nutritional needs.

A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?

"A nurse should provide a personal point of view." During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client’s bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.

Which statement regarding Roy’s theory of nursing needs correction?

All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.

Emotional Status and Growth and Development Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply.

Using Pincer Grasp well Picking up small objects Showing hand preference The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

Macule While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

Which nursing action indicates that the nurse is actively listening to the client?

The nurse interprets what the client is saying and reiterates in his or her own words. The nurse is listening actively if he or she is able to take in what the client says. A nurse who is listens attentively interprets and reiterates what the client is saying in his or her own words. A nurse who states his or her own opinions when the client is speaking is being judgmental. A good listener should be able to reach out by exchanging his or her own stories with the client. If a nurse reads the client’s health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

registered nurse is educating a nursing student about the stages of changes in a client’s health behavior. Which statement describes the stage of contemplation?

The client considers a change within the next 6 months. In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse’s accountability regarding this incident?

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply.

Fingers and Earlobes Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

Which intrinsic factor is associated with the fall of an older adult?

Deconditioning Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies?

Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage?

The nurse is able to identify the basic principles of nursing care through careful observation. According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

Which theory details nursing interventions for a specific phenomenon and the expected outcome of care?

Prescriptive Theories Prescriptive theories detail nursing interventions for a specific phenomenon and the expected outcome of the care. Grand theories provide the structural framework for broad, abstract ideas about nursing. Predictive theories identify conditions or factors that predict a phenomenon. Descriptive theories help to explain client assessments.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?

Contact Dermatitis A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions?

You will need to apply them in the morning before you lower your legs from the bed to the floor. Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client?

Acknowledge that the client’s withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client’s response to attempts at intervention.

How can a nurse best evaluate the effectiveness of communication with a client?

Client Feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members’ evaluations of a client’s status. Nurse-client communication should be evaluated by the client’s verbal and behavioral responses.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

Which caring process is defined as "facilitating the other’s passage through life transitions and unfamiliar events" according to Swanson’s theory of caring?

Enabling The enabling process facilitates another’s passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client?

Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Select all that apply.

1.Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response 2.Middle-range theories include Mishel’s theory of uncertainty in illness, which focuses on a client’s experiences with cancer while living with continual uncertainty. 3.Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel’s theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client’s experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.

Which of the following is a description of the percussion technique?

Tapping the skin with the fingertips to vibrate underlying tissues Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.

Which characteristic indicates that nursing is a profession?

The nurse is required to follow a code of ethics. Nursing is a profession because it follows a code of ethics, which are the philosophical ideals of right and wrong that define the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

he client’s pain is 7 on a scale of 1 to 10. Subjective data is information conveyed to the nurse by the client, such as the client’s feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client’s health status. The client’s weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction?

The nurse adjusts the bed and asks if the client is comfortable The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse’s willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse should close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary healthcare provider’s imminent visit.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal disease One of the kidneys’ functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do?

Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

The nurse at a community healthcare center focuses on providing primary preventive care. What is the focus of primary preventive care?

Promoting health in healthy individuals Primary prevention precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.

A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction?

concepts consist of interrelated theories. A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply.

1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 3. Interventions to provide care before, during, and immediately after surgery Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy [1] [2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.

A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman’s systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply.

1. Factors that change the environment also affect an open system. 2.The components are interrelated and share a common purpose to form a whole. 3.An open system interacts with the environment, with an exchange of information between the system and the environment. Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman’s systems theory defines a total-person model of holism and an open-systems approach

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client’s health history?

Attention Span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client’s health history data. Physical and developmental subdimensions would include activities and coordination

What is a stressor?

A stressor is any stimuli that can produce tension and cause instability within the system A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

Which physical assessment technique involves listening to the sounds of the body?

Auscultation Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what?

Hand-washing Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

How does the World Health Organization (WHO) define "health"?

A state of complete physical, mental, and social well-being The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

Which basic human needs belongs to the fourth level as per Maslow’s hierarchy of needs? Select all that apply.

Worth and Achievement Fourth level of Maslow’s hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

Which assessment is expected when a client is placed in the lithotomy position during physical examination?

Assessment of female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

Which of these programs is least likely to focus on medication delivery process modification?

Experimentation Research Experimental research is least likely to focus on medication delivery process modification. Quality improvement, evaluation research, and performance improvement are all likely to focus on medication delivery process modification in order to make the process better for the client.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client’s urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

Which age is considered the phallic stage according to Sigmund Freud’s developmental theory?

3-6 years old According to Sigmund Freud’s developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage a. Six to 12 years of age is the latent stage. Eighteen months to 3 years of age is the anal stage.

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply.

Assault, Battery, False imprisonment Intentional torts include battery, assault, and false imprisonment. Unintentional torts include negligence and malpractice.

Which integumentary finding is related to skin texture?

Assessing for texture refers to the character of the surface of the skin. Assessing for elasticity determines the turgor of the skin. Assessing for vascularity determines skin circulation. Fluid buildup in the tissues indicates edema.

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client’s health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client’s response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client’s care. The nurse selects interventions (nursing and collaborative) individualized to each of the client’s nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client’s response and whether the interventions were effective. The nursing process is dynamic and continuous.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Relieve the client’s discomfort Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client’s discomfort

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client’s spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?

To client from outside resources Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client’s own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.

What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare?

A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client. Healthcare proxies enable another person or persons to make healthcare decisions on the client’s behalf when the client is no longer able to make decisions on his or her own. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. This act is not related to healthcare proxies. The ethical doctrine of autonomy ensures the client’s right to refuse medical treatment. A living will is a written document that directs treatment in accordance with the client’s wishes in case of a terminal illness or condition.

Which statement defines "information" gathered by the nurse?

It is the organization and interpretation of data Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission?

Primary Nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master’s degree level of education. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?

Descriptive theories help direct specific nursing activities. Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

A home health nurse on a first visit checks the client’s vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse’s most appropriate response?

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client’s bed is an appropriate intervention. The nurse’s comfort needs should not take precedence over the client’s needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse’s job description. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn’t work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses’ responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?

"Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people’s health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client’s room and finds her crying. Which is the most appropriate intervention by the nurse?

sit down next to bed and allow her to cry Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client’s behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

Assessment The documentation of the client’s information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the doctor understand the client’s history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client’s problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client’s problems and then the plan is implemented. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A nursing student is listing the points that need to be remembered about the loss of a client’s medical records. Which point listed by the nursing student is accurate?

"There is an assumption that the care provided to the client was negligent." In case a client’s medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary healthcare providers need to demonstrate why the medical records were lost. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

According to Erikson’s theory of psychosocial development, which opposing conflicts is an older adult likely to face?

Integrity vs. despair According to Erikson’s theory of psychosocial development, an older adult is likely to face the opposing conflict of Integrity versus Despair. An infant in the age group between birth and one year old is likely to face the opposing conflicts Trust versus Mistrust. A young adult is likely to face the opposing conflicts Intimacy versus Isolation. School-aged children between the ages of 6 and 11 years are likely to face the opposing conflicts Industry versus Inferiority.

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education?

"I should monitor weight and food intake once in a month." The nurse should monitor an older client’s weight and food intake at least once a day because of the client’s dementia. The nurse should serve food that is easy to eat provide assistance with eating. The nurse should also offer food supplements that are tasty and easy to swallow.

What critical thinking skill is applicable when knowledge and experience is used to care for clients?

Explanation When the nurse is using his or her experience to care for clients, the skill called explanation is involved. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments?

King According to King’s theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau’s theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale’s theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client’s environment. According to Benner and Wrubel, the goal of nursing is to focus on a client’s need for caring as a means of coping with stressors of illness.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what?

Perception of change It is not the reality of the change, but the client’s feeling about the change, that is most important in determining a client’s ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client’s perception of the change.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?

nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host’s resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

Which factor is used to assess the quality of health care provided to a client?

Functional health status of client after discharge Health care providers determine the quality of care provided to the client by measuring outcomes that show how a client’s health status has changed. One method of measuring the quality of health care provided to the client is the functional health status of the client after discharge. The nursing staff should take necessary fall prevention measures for the client; however, this is not a measurable outcome. All health care personnel should practice hand hygiene to prevent infection, which is a quality measure, not an outcome of health care. Teamwork and coordination among health care personnel is important to provide efficient health care to the client. It is not an outcome of health care.

Which statement is true for collaborative problems in a client receiving healthcare?

They are identified by the nurse during the nursing diagnosis stage. The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client’s health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

An African man presents to the emergency department to obtain pain medication. The nurse behaves judgmentally and labels the client a drug abuser. What is the nurse demonstrating?

Ethnocentrism Ethnocentrism is the tendency of a person to hold his or her own beliefs superior to those of other people. It causes biases and prejudices in regard to people from other groups. This practice is transmitted by cultural groups from one generation to another. In multiculturalism, two cultures coexist and are accepted by the individual. In a cultural encounter, part of cultural competence, a nurse engages in cross-cultural interactions for effective communication. Cultural imposition occurs when a nurse or health care provider ignores the differences between his or her own culture and others and imposes his or her beliefs on people of other cultures. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly and see whether it completely covers the material asked by the question; and (3) narrow the choices by immediately eliminating answers that you know are incorrect.

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan?

Administering general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client’s skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which component of decision-making refers to the duties and activities an individual is employed to perform?

Responsibility Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer." The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A registered nurse is explaining the term "just culture" to the student nurse. Which explanation provided by the registered nurse is accurate?

"It refers to promoting open discussion whenever error occurs without fear of recrimination." The term "just culture" refers to the promotion of open discussion whenever errors occur without fear of recrimination. Fidelity refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Accountability refers to the ability to answer for one’s actions.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

What are the steps of evidence-based practice (EBP) in order?

The first step in EBP is to ask the relevant clinical question. The second is to collect the most relevant and best evidence. After the collection, critically appraise the evidence gathered. Then integrate all the evidence into one’s clinical expertise and client preferences and values to make a practice decision or change. Then evaluate the practice decision or change. The last step is to share the outcomes of EBP changes with others.

Which site is best used to inspect a client who is suspected to have jaundice?

Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain?

Phenomenon A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don’t worry. I’m sure everything will come out all right." What does the nurse conclude about the nursing assistant’s answer?

False reassurance A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client’s concerns. This response is not a form of distraction; it minimizes the client’s concern and shuts off communication. This response does not contain any value statements.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an n95 mask when entering room A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

What legal complications might a nurse face for using a restraint without a legal warrant on a client?

false imprisonment If a nurse uses restraints without a legal warrant on a client, he/she may be charged with false imprisonment. Libel is the written defamation of character. Negligence is any conduct that falls below the standard of care. Malpractice is a type of negligence that is regarded as professional negligence.

Which assessment finding is associated with depression?

The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

Which type of theory is the Neuman systems model?

Grand Theory Neuman systems model is an example of a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research. Theories related to growth and development are descriptive theories. Prescriptive theories address nursing interventions for a phenomenon, describe the condition under which the prescription occurs, and predict the consequences. Mishel’s theory of uncertainty is a prescriptive theory. Middle-range theories tend to focus on a specific field of nursing. Mishel’s theory of uncertainty in illness is a middle-range theory.

Arrange the order of steps involved in the evidence-based practice process.

Evidence-based practice is a problem-solving approach that integrates the conscientious use of best evidence in combination with a clinician’s expertise, client preferences, and client values to make decisions about client care. First, the nurse should ask a clinical question and collect the most relevant and best evidence. Then, the nurse critically appraises the gathered evidence and integrates the evidence with his or her clinical expertise along with the client’s preferences and values to make a decision or change. Then the nurse evaluates the practice decision or change and shares the outcomes of the evidence-based practice changes with his or her team.

A nursing student is recalling the order of priority for giving consent to perform an autopsy in cases where a medical examiner review is not needed. Which person receives the highest priority for giving consent?

The client in writing before death If a medical examiner’s review is not necessary, the highest priority is given to the client. The client may provide the consent in writing before death. If the client or the surviving spouse is unable to give consent for the autopsy, a surviving child may be requested to give consent. The surviving parent may give consent for an autopsy if the client, the surviving spouse, and the surviving child are unable to do so. In case the client has not provided written consent before death, the nurse may obtain consent from the surviving spouse.

What should the community nurse teach about the risk of adolescent pregnancy?

Risk for premature birth The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.