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Final Exam Exam #3
Terms in this set (50)
The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client?
Refer the client to a support group
A client states that the client is "fed up" with the care that the client has been receiving in the hospital and plans to leave immediately. What procedure is followed with regard to this client?
The client needs to sign a form releasing the physician and agency from responsibility.
A nurse has been appointed to oversee safety measures in an assisted living facility that caters to older adults. The nurse should prioritize measures aimed at reducing residents' risks of:
A 22-year-old woman who recently immigrated to the country has been admitted to the hospital with an ovarian cyst. Both the client and spouse do not speak the dominant language of the new country, and this has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take to communicate with the client?
Organize professional interpretation, either in person or by telephone.
A client tells the nurse, "I don't know what is wrong with me. I just feel so uneasy. It is like something bad is going to happen." What feeling is this client describing?
A client admitted to the health care facility for a surgery has lost his identification bracelet. What is the nurse's responsibility in this case?
arranging for replacement of the bracelet immediately
An individual calls the telehealth nurse and reports that a family member was just found on the floor of an enclosed garage while a car was still running. The family member is unconscious and cherry red in color. What direction will the telehealth nurse provide?
open garage doors and windows, and call 911
An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching?
Put a small nightlight in the hall and stairway.
When administering an injection to a client with hepatitis C in a health care facility, the nurse sustained a needlestick injury. Which ensuing action would be most important?
The nurse needs to file an incident report after the event occurs.
The nurse discovers that a recently admitted client does not speak the same language as the nurse. Which action would the nurse take?
Arrange for a trained language interpreter.
An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take?
Ensure that the client does not eat or drink anything.
What is the leading cause of injury-related deaths in adults 65 and older?
Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting?
"If I make an error, I draw a single line through it and put my initials by it."
Once a client is admitted and all the admission data are collected, the nurse is expected to develop an initial plan for the client's care. By what point after admission should the nurse develop the plan?
no later than 24 hours
A nurse provides care in a hospital in which there are as many as four beds in each room. The nurse is responsible for the care of all four clients in a particular room, one of whom requires the insertion of a Foley (urinary) catheter. How can the nurse best protect this client's privacy?
Ensure that the curtains around the client's bed are secured so that the client cannot be seen by others.
The nurse prepares to give the change-of-shift report. The nurse provides the oncoming nurse with the intake and output record of the client for the shift, pictured above. What is the client's fluid balance in milliliters? Record your answer using a whole number.
The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply.
history of falls
A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?
sympathetic nervous system
The nurse is caring for two clients on the same unit. One client states that cold temperatures and loud noises are stressors. The other client says the temperature is fine and the noises do not bother him. What is the difference between the two clients related to these stressors?
The perception and effects of stressors are highly individualized.
If a nurse assessed the vital signs of a person who was in the initial alarm reaction stage (shock phase) of the general adaptation syndrome, what would be the expected findings?
Which question would be helpful in eliciting data about the effects of stress during a health history?
"How does your body feel when you are upset?"
While conducting the physical assessment of a client, the nurse notes an increase in the blood glucose level. Upon inquiry, the client discloses that lately he has been under a lot of stress at work. Which stage of stress is the client experiencing?
A client who has been working with an organization for several years did not get a promotion. As a result, the client has gone into depression. Which suggestion should the nurse make in order to help the client with his stress?
seek professional help
A client has been brought to the health care facility with accident-related injuries. During the initial interview, the client becomes agitated and upset and is unable to answer any more of the nurse's questions. What does the nurse conclude about the condition of the client?
The client's mind is preparing for a fight-or-flight response as he relates the incident.
The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?
identifies client's full name and date of birth
An adolescent expresses concern that a friend is under "a lot of stress" with home life, classes, clubs, community service, and part-time work. The adolescent asks the nurse what medication the friend should take to "calm down." Which response by the nurse will be supportive of the client?
"Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives."
A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation?
Cross out 86/132 with a single line and place the nurse's initials above it.
The nurse enters a client's room without knocking while the client is bathing. What common response may the client feel at this intrusion?
The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include?
Be alert for signs of peer pressure.
Which statement made by the client indicates a need for further teaching regarding stress management?
"I manage my stress with occasional alcohol and alprazolam."
The nurse is performing an admission intake on a client with dehydration and diarrhea. The client states, "Every time I get stressed, I get diarrhea! Why does this happen?" Which explanation does the nurse share with the client?
"During stress, chemical messengers send signals between the brain and gut causing a variety of gastrointestinal symptoms."
Upon admission, the client noted practicing Orthodox Judaism. Upon receiving the meal tray, the client states, "I cannot eat this. Please remove the tray." Which item on the tray is the client referring to because of kosher dietary laws?
a baked pork chop with gravy
The nurse is admitting a client with uncontrolled hypertension and diabetes. During the initial assessment, the client informs the nurse that he has been seeking assistance and care from the shaman in the community. The nurse recognizes that the client's blood pressure and blood sugar are elevated upon admission. What is the nurse's best response?
"I understand that you value the care provided by the shaman, but we would like you to consider medications and dietary changes that may lower your blood pressure and blood sugar levels."
A nurse will be finishing work for the day at 1900. Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty at 1900?
change of shift reports
The nurse is admitting a client that asks that jewelry and money be taken and locked away safely. When collecting these items for safe keeping, what is the priority action by the nurse?
Make an inventory list and have the nurse, supervisor, and client sign the envelope they are located in.
A 79-year-old client with a history of osteoporosis experienced a fall while attempting to walk independently to the hospital washroom to urinate. How can the nurse best prevent a repeat of this incident?
Encourage the client to ring the call bell when the client has the urge to void.
In the computer, the nurse needs to document the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took his medication at 1530 hours?
The client is a disabled veteran with bilateral above the knee amputations (AKA). The client frequently has tender, erythemic areas along bilateral incision lines. Which type of facility will provide appropriate care for this client?
A new client, whose ability with the dominant language is limited, is being admitted to the hospital . The hospital has multiple interpreters. Which factor should the nurse prioritize when requesting a certified interpreter?
should be same gender and approximate age, if possible
The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?
When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?
take control of the situation
A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform?
heightens arousal and increases energy
A nurse is working with a client whose quality of life is impacted by the presence of numerous comorbid health problems. The nurse is aware that the client's body is attempting to maintain homeostasis, a process that primarily involves:
responding appropriately to internal and external influences.
A client experienced a fight-or-flight response immediately following a car accident. What clinical symptoms would the nurse expect to assess? Select all that apply.
increased heart rate
The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply.
Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy.
No new labs have been ordered after surgery.
The client has a clean and dry abdominal dressing.
Pain level is currently a 3 following administration of intravenous morphine.
The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.
"I will write, print, or type information legibly."
"I will use only agency-approved abbreviations."
"I will draw a straight line through any blank space."
When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting?
Ensure that the client's name appears on all pages.
A nurse is making a visit to a client's home and, during the assessment, the nurse notices some possible hazards. What would the nurse identify as potential hazards? Select all that apply.
clutter on the stairs
electrical outlet with several extension cords
evidence of mice droppings
The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate? Select all that apply.
Flag the chart and room door.
Apply an allergy-alert identification bracelet on the client.
Communicate to the interdisciplinary health care team to use nonlatex equipment.
Teach the client to wear a Medic-Alert bracelet.
A nurse has been commissioned to ensure that the policies and procedures at a large, multisite health care institution comply with the Nursing Home Reform Law. What trend initially prompted the enactment of this legislation?
the widespread use of physical restraints in long-term care facilities
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