Health Promotion and maintenance
The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective?
1. "Exercising regularly will decrease my insulin need."
2. "I will need to decrease my insulin dose when I develop an infection."
3. "I need to lose weight since obesity decreases insulin resistance."
4. "Increased stress levels will cause the glucose level in my blood to go down."
1. "Exercising regularly will decrease my insulin need."
(1. Correct: Regular exercise decreases the need for insulin. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose.
2. Incorrect: When an infection occurs, blood sugar increases. The normal response to infection is to increase available glucose to assist in combating the infection. This will increase the requirement for insulin, not decrease it.
3. Incorrect: Obesity increases not decreases insulin resistance, so the cells do not respond normally (are resistant) to insulin. Maintaining a healthy weight with exercise and diet can result in less need for insulin (less resistance to insulin) and less problems in individuals with type 2 diabetes.
4. Incorrect: Emotional upset and undue stress results in increased circulating catecholamines. This will increase the blood glucose levels and increase the requirement for insulin.)
A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?
a) "Would you like me to help you tell them?"
b) "The information you confide in me is confidential."
c) "I must share this information with your employer."
d) "I must share this information with your family."
"The information you confide in me is confidential."
what are the 9 rights of medication administration?
right patient
right drug
right dose
right route
right reason
right to know
right to refuse
right time
right documentation
In assessing a client's history of cardiac work-up, which of the following is the most important parameter to question?
A. Amount of weight loss
B. Character of pain experienced
C. Respiratory rate and depth
D. Amount of coughing
B. Character of pain experienced
The character of pain, including its location, duration, and intensity, is the most important for accurate diagnosis. Answers (C) and (D) should be included in the client's history, but are not as critical. Weight loss (A) is not relevant.
A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication?
A "You have everything to live for."
B "Why do you see yourself as a failure?"
C "Feeling like this is all part of being depressed."
D. "You've been feeling like a failure for a while?"
D
Responding to the feelings expressed by a patient is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the patient's experience and do not facilitate exploration of the patient's expressed feelings. In addition, use of the word "why" is nontherapeutic.
The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents?
Select all that apply.
1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training.
2. Tell the parents about the importance of letting the child do tasks alone.
3. Provide finger foods for the child to eat.
4. Your child will want you to provide emotional support when needed.
5. Assist your child with all tasks to promote independence.
2. Tell the parents about the importance of letting the child do tasks alone.
3. Provide finger foods for the child to eat.
4. Your child will want you to provide emotional support when needed.
(2., 3. & 4. Correct: Letting the child do things on their own will promote a sense of self control and independence during this stage of autonomy versus shame and doubt. Finger foods allow for independence with eating and builds a sense of autonomy. At this age, the child becomes increasingly aware of separateness from the parent. The need is for the parent to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the parent rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment may develop in adulthood. The support provided by the parent can lessen feelings of anxiety for the child when the emotional presence is needed.
1. Incorrect: Strict toilet training can result in retention of feces and constipation. In addition, strict toilet training practices before the child is ready can result in frustration and shame.
5. Incorrect: Assisting with all tasks will promote dependence. This does not give the child opportunities to perform age-appropriate tasks independently and gain a sense of autonomy. Notice the word "all"? This conveys a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions.)
Which activity would be most appropriate to include in a playroom that will be used by children aged 13 months to 6 years?
a) a group sing-along
b) viewing cartoon videos
c) free play with adult supervision
d) drawing and painting project
free play with supervision
What are the six RIGHTs of delegation?
- right task
- right person
- right time
- right information
- right supervision
- right follow up
The nurse is completing the initial morning assessment on the client. While physical examination technique would be used first when assessing the abdomen?
A. Inspection
B. Light palpation
C. Auscultation
D. Percussion
A. Inspection
Visual an inspection is the first step in assessing the abdomen. Auscultation (C) is next because palpation (B) can alter bowl motility, thereby producing inaccurate findings.
Which therapeutic communication technique is being used in this nurse-client interaction?
Client: "When I get angry, I get into a fistfight with my wife or I take it out on the kids."
Nurse: "I notice that you are smiling as you talk about this physical violence."
A. Encouraging comparison
B. Exploring
C. Formulating a plan of action
D. Making observations
ANS: D
The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.
A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women?
Select all that apply.
1. Limit alkaline foods.
2. Avoid caffeine.
3. Maintain a healthy weight.
4. Eat less fiber.
5. Perform high-impact exercise.
2. Avoid caffeine.
3. Maintain a healthy weight.
(2., & 3. Correct: Fluids containing caffeine, carbonation, alcohol or artificial sweeteners act as irritants to the bladder wall and should be avoided. Acidic foods, such as citrus fruits, are also irritants. Obesity can cause increased pressure on the bladder, leading to incontinence.
1. Incorrect: Acidic foods, not alkaline, are bladder irritants and should be avoided.
4. Incorrect: The client should eat more fiber (not less) to prevent constipation, which can put pressure on the bladder and be a cause of urinary incontinence.
5. Incorrect: High-impact exercise puts pressure on the pelvic floor muscles and can increase leakage. Try Pilates, a gentle method of stretching and strengthening core muscles, which has become a more popular treatment for stress incontinence.)
What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness?
a) What is the best way your family resolves crisis situations?
b) Does your family have the strength to deal with the changes and still support you through this difficult time?
c) Has your family been able to handle chronic illness management before?
d) How is your condition affecting your family members and their usual roles?
How is your condition affecting your family members and their usual roles?
A client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for a chest radiograph. The nurse would take which action when preparing to transport the client?
1. Apply a mask to the client.
2. Apply a mask and gown to the client.
3. Apply a mask, gown, and gloves to the client.
4. Notify the radiology department so that the personnel can be sure to wear masks when the client arrives.
1. Apply a mask to the client.
This question addresses content related to airborne precautions. Focus on the subject, transporting a client with TB. Institution policies and procedures for airborne precautions are always followed; however, clients known or suspected of having TB need to wear a mask when out of the hospital room to prevent the spread of the infection to others. Gown and gloves are not necessary. Others are not protected unless the infected client wears the mask.
Monitoring the client's skin condition involved several specific nursing actions. Which action would be the least important?
A. Check the skin color
B. Assess the skin temperature
C. Observe skin turgor
D. Examine the skin for dryness
D. Examine the skin for dryness
Dryness of the skin is the least important because the other parameters give more information about the client's over all condition. Color (A) helps identify poor circulation or oxygen exchange, skin temperature (B) may indicate increased temperature, and turgor (C) may indicate dehydration.
A client diagnosed with dependant personality disorder states, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate?
A. "It would be best to do that in order to increase independence."
B. "Why would you want to leave a secure home?"
C. "Let's discuss and explore all of your options."
D. "I'm afraid you would feel very guilty leaving your parents."
ANS: C
The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority?
1. Check blood glucose level.
2. Assess for proper shoe size.
3. Examine the client's feet for signs of injury.
4. Test sensory perception in the client's feet.
3. Examine the client's feet for signs of injury.
(3. Correct: Clients with decreased peripheral sensation are at risk for injury to the extremity. They may sustain an injury and be unaware the injury has occurred. In addition to this, diabetics are at risk for poor wound healing (related to impaired circulation) and infection (related to elevated glucose levels). This is the assessment that should be performed first and takes priority.
1. Incorrect: Checking a fasting blood glucose level is important, but it is not the first action to be taken. Checking the blood glucose level does not fix the problem. The problem is potential risk for injury. Assessing for injury is the priority answer.
2. Incorrect: Diabetics need well-fitting shoes, but this is not the priority answer. Check the client first.
4. Incorrect: Checking the sensation in the feet is not fixing the problem. It will be done later but risk for injury is the priority because the client has numbness of the feet.
How should a nurse assist a patient struggling with daily stress management?
A) Ignore until the patient explicitly asks for help.
B) Recommend relaxation and stress management techniques.
C) Prescribe anti-anxiety medications without consulting a physician.
D) Limit the patient’s social interactions.
Answer: B
Explanation: Teaching relaxation and stress management techniques helps patients better handle daily stress, improving their overall well-being.
The nurse makes rounds on the medical unit to assess the care given by the UAP. Which observation requires an intervention by the nurse?
1. The UAP places the fingers of one hand on the wrist of a client in order to evaluate the respirations.
2. The UAP prepares to take a blood pressure in the left arm of a client recovering from a right mastectomy.
3. The UAP weighs a client on a standing scale while the client is balanced on crutches.
4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.
4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.
Rhinoplasty compromises the ability of the client to breathe through the nose due to the packing in both nostrils. If the clients has to keep the mouth closed for an oral temperature measurement, the client cannot breathe.
Furosemide inhibits reabsorption of sodium, water, and K leading to diuresis. ** The most common electrolyte disturbance associated with furosemde admin is hypokalemia
Nurse inserts a nasogastric tube, and it immediately drains 1000 mL of fluid. Which of the follwoing electrolyte level is of greatest concern at this time?
a. Na
b. K
c. Cl
d. CO2
b. K
A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique?
A. The therapeutic technique of "giving advice"
B. The therapeutic technique of "defending"
C. The nontherapeutic technique of "presenting reality"
D. The nontherapeutic technique of "giving false reassurance"
ANS: D
The nurse's statement, "Things will look better tomorrow after a good night's sleep." is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.
A client is admitted to the hospital with a platelet count of 132,000 mm³ and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement?
Select all that apply.
1. Monitor stools for occult blood.
2. Place on fall prevention.
3. Place client in protective isolation.
4. Restrict venipunctures.
5. Limit visitors
1. Monitor stools for occult blood.
2. Place on fall prevention.
4. Restrict venipunctures.
What is the best approach for a nurse assisting a patient who has difficulty sleeping?
A) Encourage the use of sleep-inducing medications regularly.
B) Recommend establishing a routine bedtime schedule.
C) Advise the patient to watch TV until they fall asleep.
D) Increase caffeine intake to regulate sleep cycles.
Answer: B
Explanation: Establishing a routine bedtime schedule helps regulate the patient's sleep cycle naturally, enhancing sleep quality without medication.
The nurse provides care for clients in the emergency department. Which client does the nurse see first?
1. A preschool age client with a temperature of 101 degrees F.
2. A young adult client with asthma and a productive cough.
3. An adult client with nausea and vomiting for several hours.
4. An older adult client with one episode of fainting.
4. An older adult client with one episode of fainting.
The fainting episode may be the result of an irregular cardiac rhythm or rate change, and this requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest.
A client with a history of cardiac disease is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. The nurse expects to evaluate which laboratory values?
A. Albumin and protein levels
B. Sodium and chloride levels
C. Potassium and blood glucose levels
D. Hemoglobin level and hematocrit
C. Potassium and blood glucose levels
A client's younger daughter is ignoring curfew. The client states, "I'm afraid she will get pregnant." The nurse responds, "Hang in there. Don't you think she has a lot to learn about life?" This is an example of which communication block?
A. Requesting an explanation
B. Belittling the client
C. Making stereotyped comments
D. Probing
ANS: C
This is an example of the nontherapeutic communication block of making stereotyped comments. Clichés and trite expressions are meaningless in a therapeutic nurse-client relationship.