Past health history and current health status

Midterm Study Guide NSG 110

1. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

C. Interpersonal

Rationale: Interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving, expression of feelings, decision-making and personal growth.

Rationale: Obtaining information from the client is a component of the orientation phase.

B. Encourage the client to use self-exploration.

Rationale: Talking with others about the client is a component of the preinteraction phase.

3. A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

B. Asking for an explanation
Rationale: The use of a “why” question requires that the client provide an explanation that he may not have, causing him to become defensive. A better response would be to give a reasonable answer to the question and clarify any additional concerns the client has.

C. Behaving defensively
Rationale: A defensive response occurs in the face of criticism. A better response would be to provide the information the client is requesting.

A. Clarifying
Rationale: Clarifying involves checking the client’s message for accuracy and clarity.

B. Focusing
Rationale: Focusing involves centering on key elements or concepts in a message.

B. Channel
Rationale: A channel is the means of conveying and receiving messages through the use of a sense.

C. Environment
Rationale: The environment is the setting for the interaction between the nurse and client.

B. "Everyone knows there are others who can chair this committee better than me."

Rationale: This statement expresses self-doubt and reluctance, not assertiveness, and it does not clearly express the nurse' s thoughts about declining to chair a committee.

A. Sit in front of the group for the meeting and then stand for the announcement.

Rationale: The weight of a message increases when the sender stands.

D. Lean gently over the back of a chair sitting to one side of the room when making the announcement.

Rationale: Slouching or non-erect posture suggests indifference and changes the impact of the message the nurse is sending.

Rationale: The nurse does not have an understanding of a client' s feelings when first establishing a collaborative relationship.

C. Offer the client personal thoughts and beliefs.

A. Clarification
s message is clear and accurate. Rationale: Clarifying verifies whether the sender'
B. Summarizing
Rationale: Summarizing reviews the important aspects of a communication interchange. Here, the nurse is just beginning a dialogue.

C. Confrontation
Rationale: Confrontation points out inconsistencies in the client' s behavior and feelings.

B. The client' s sociocultural background influences nonverbal communication.

Rationale: Sociocultural background has a major influence on what a client' s nonverbal behavior means.

Rationale: The client should be given complete privacy when conducting an interview. Privacy will allow the nurse to establish trust and rapport with the client, which can lead to open communication. The presence of a family member may cause the client to feel reluctant to express feelings openly.

B. Provide basic wound care for obvious physical injuries.

Rationale: The nurse promotes communication to the client who is quiet and withdrawn by using direct and honest communication. This manner which conveys support fosters trust between the client and nurse to promote communication for the withdrawn client.

15. A nurse is leading a family therapy session for a mother, father, and two adolescent siblings.

Rationale: This communication is an example of blaming. Blaming is when family members blame others to shift focus from their own inadequacies. The nurse should model effective communication for both the client and client' s family members by using communication that is clear, direct, honest, and respectful.

C. "Can you tell me the reason you get upset each time I go to the mall?"

A. Summarizing

Rationale: A statement like "So you want to leave so you can care for your family" would illustrate the therapeutic communication technique of summarizing.

D. Clarifying

Rationale: A statement like "Tell me what you mean by taking care of your family" would illustrate the therapeutic communication technique of clarifying.

C. "You need to calm down before discussing this matter any further."
Rationale: "You" statements are aggressive, rather than assertive, and are therefore nontherapeutic.

D. "Why did you make the choice to behave negatively?"
Rationale: "Why" questions are likely to make the client feel defensive and are therefore nontherapeutic.

D. "Did your symptoms occur before or after you took the medication?"
Rationale: The nursing example of therapeutic communication is a closed-ended question, not reflection.

19. A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

s culture often determines when and where she will seek medical treatment. Rationale: A client'
D. Nurses should expect clients to adapt to the care provided regardless of culture.

Rationale: Nurses should adapt care to meet the client' s needs and demonstrate culturally sensitive care.

C. Set client-centered, measurable and realistic goals.

Rationale: There is another activity the nurse should complete first. D. Determine effectiveness of interventions.

B. Stand directly in front of the client.

Rationale: The nurse should stand directly in front of the client to optimize the client' s ability to hear and comprehend; however, there is another action the nurse should take first.

22. A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?

A. Establish short-term, realistic goals for the client.

Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows before proceeding with the plan.

D. Evaluate the effectiveness of the client’s admission teaching plan.

C. Assessment

Rationale: The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.

C. Nausea
Rationale: Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

D. Petechiae
25.A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply.)
A. Decreased gastric motility B. Decreased skin elasticity C. Increased pain threshold D.

C. When asking the client how he completes his ADLs
Rationale: The nurse should ask an open-ended question to help evaluate the client' s ability to perform or assist with ADLs.

D. When asking if the client took his medications this morning
Rationale: A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further.

Rationale: This option is a secondary source of information. Although secondary sources provide some information for the nurse, they are not as helpful as information the nurse collects directly from the client.

D. Progress note
Rationale: This option is a secondary source of information. Although secondary sources provide some information for the nurse, they are not as helpful as information the nurse collects directly from the client.

D. Motor impairment
Rationale: The nurse should individualize the client' s instructional period so that the client does not need to use motor skills. For example, the nurse can include a family caregiver to give a return demonstration of any necessary motor skills.

29. A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?

30. A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

A. Sit side-by-side with the client.

Rationale: The nurse should establish intermittent eye contact and maintain it during active listening. It demonstrates interest is what the client is saying.

D. Lean back in the chair.

B. "Would you tell me about all of your medical issues?"

Rationale: This is a closed-ended question. The client might reply, "No." After that, it might be difficult to begin again to build rapport.

32. The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model is the nurse implementing?

A. Functional

C. Case Method

Rationale: The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift.

Rationale: Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians’ offices, clinics, and diagnostic centers.

B. Ambulatory care facility

A. Social worker
Rationale: The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare.

B. Occupational therapist
Rationale: The occupational therapist helps patients regain function and independence in activities of daily living.

Rationale: Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care).

B. Making work assignments for the oncoming shift.

Rationale: Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing).

36. An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, the patient lived at home with her spouse and managed their activities of daily living (ADLs) very well. The hospital is ready to discharge the patient because the recommended length of stay in a hospital has been exceeded.

D. Home health
Rationale: This patient cannot ambulate or perform ADLs, so outpatient therapy and home care would not be appropriate.

37. A high school graduate desires to become a registered nurse in order to work in a community setting. In which type of program should this student enroll?

38. In preparation for relocating to another state the nurse contacts the state board of nursing to obtain the necessary transfer of nursing license. Where will the nurse learn about continuing education requirements for the new state of practice?

A. State board of nursing
Rationale: The state board of nursing notifies nurses about continuing education requirements and will notify nurses of any changes in the requirements.

A. Helping a client develop a plan for a low-fat, low-cholesterol diet.

B. Disinfecting an abraded knee after a child falls off a bicycle.

B. Define the scope of practice for nursing.

C. Develop rules and regulations for nursing practice.

B. Diagnosis
Rationale: The nursing diagnosis is derived from the data gathered during assessment.

C. Plan outcomes
Rationale: Nursing outcomes are derived from the diagnosis.

Rationale: Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

C. Nurses care for clients who have multiple health problems.

A. It was developed from the ANA Standards of Care.

Rationale: The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards.

D. It involves care that only the nurse will give.

Rationale: The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team.

D. Ask the client’s perceptions of her health problem

Rationale: Asking the client about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

Rationale: The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan.

C. Follow up to verify that care for the nursing diagnosis was given.

A. Theoretical knowledge

Rationale: Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena.

D. Use of the nursing process
Rationale: The nurse has not yet met this patient, so she could not have begun the nursing process.

46.The staff development instructor prepares an in-service presentation on full-spectrum nursing for new graduate nurses. Which statement should the instructor emphasize as being the key point about this delivery approach?

C. It focuses on assessment as the cornerstone of care.

Rationale: Full-spectrum nursing does not focus on assessment as the cornerstone of care.

B. Health promotion
Rationale: Peplau did not develop a theory about health promotion.

C. Nurse–patient relationship
Rationale: Hildegard Peplau was a psychiatric nurse who showed that developing a relationship with psychiatric patients made their treatment more effective. From her work, she developed the theory of interpersonal relations, which focuses on the nurse–patient relationship. This theory is in use every day in nursing.

C. Promoting oxygenation in the critically ill patient
Rationale: According to Maslow’s hierarchy of needs, basic physiological needs should be met first. They include the need for rest, food, air, water, temperature regulation, elimination, sex, and physical activity. Therefore, the nurse should address the critically ill patient’s need for rest first.

D. Promoting self-esteem after a body image change
Rationale: Self-esteem needs are addressed after physiological, safety, and love/belonging needs are met.

D. TENS
Rationale: ENS is the intervention (I) in the PICO system.

49.The nurse wonders whether a dry dressing would be more beneficial for a particular type of wound instead of using the wet-to-damp approach. Which part of the PICOT process is the nurse defining?

50.The nurse plans to explain the difference between qualitative and quantitative research to a group of staff who will be participating in a research study. Which statement should the nurse include during this discussion? Select all that apply.

A. Qualitative data are reported as numbers.

51. A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

A. Providing a community program on stress reduction

Rationale: Tertiary preventive care focuses on creating a better quality of life and decreasing physical deterioration.

D. Referring a client who has had a mastectomy to a support group

B. Meals on Wheels

Rationale: Meals on Wheels is a service that delivers meals daily to older adults who need them, either at senior centers or directly to their homes. It is appropriate for the nurse to recommend this service for this client.

53.An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

A. Teach plant workers about proper lifting techniques.

Rationale: The nurse uses secondary prevention to screen for problems. This strategy is appropriate to include.

D. Collaborate with physical therapists to develop programs for injured employees to return to work. Rationale: The nurse should promote recovery from existing conditions as part of tertiary prevention.

C. Administering influenza immunizations at a local health fair Rationale: Immunizations are an example of primary prevention.

D. Testing new nurses for exposure to tuberculosis.

C. Community recreational center
Rationale: A community recreational center offers tertiary public health prevention.

D. Crisis center

B. Toddler/Preschooler

Rationale: The nurse should include screening of motor development and screenings for fine and gross motor development, language development, and oral health for the toddler age group.

57.A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don' t understand why my child is so upset. I' ve never seen my child act this way around others before." Which of the following statements should the nurse make?

A. "This is a normal, expected reaction for a child of this age."

58. A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group?

A. Congenital anomalies
Rationale: Congenital anomalies are the leading cause of infant mortality in the U.S.

A. "Our baby will sleep in our bed because I am breastfeeding."

Rationale: Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib or bassinet after breastfeeding.

D. "We will remove blankets and toys from the crib."

Rationale: The infant should lie on a firm mattress without soft materials such as pillows, quilts, pillows, blankets, and stuffed animals that can cause suffocation.

Rationale: Hospice care provides holistic support and care for clients who are terminally ill and their families.

C. “Respite care helps relieve pain and promote comfort.”
Rationale: Palliative care or hospice care helps relieve pain and promote comfort.

B. This service focuses on teaching the primary caregiver to meet the client’s needs.

Rationale: The rehabilitation process focuses on the client’s physical, mental, social, spiritual, and economic abilities.

A. Autonomy vs. shame and doubt
Rationale: This is the developmental stage of early childhood. Its characteristics are the ability to cooperate with others and to express oneself.

B. Generativity vs. stagnation
Rationale: This is the developmental stage of middle adulthood. Its characteristics are creativity, productivity, and concern for others.

B. 6 months
Rationale: Birth weight typically doubles by 6 months of age.

C. 9 months

B. Ask the child about his favorite toy

Rationale: Toddlers have a fear of strangers, so it would be important to establish rapport before examining the child.

Rationale: Potty training is typically accomplished between 18 months and 3 years of age but is not a safety concern.

B. How the child acts when you enter the room
Rationale: It would be normal for a child at this age to be afraid of strangers.

A. Accept the fact that she is getting older.

Rationale: During the middle years, many adults are realistic and insightful about age-related physical and emotional changes. Others experience difficulty coping with passing youth and advancing age.

D. Have had a meaningful and intimate relationship.

Rationale: Developing meaningful relationships is a task most influential for the young adult.