Bstrandable NCLEX Miscellaneous 5 Questions And Answers Latest 2022

Bstrandable NCLEX Miscellaneous 5 Questions And Answers Latest 2022 How does managed care affect the economics of health care delivery? - ANSDecreases duplicate processes and redundant facilities rationale: The corp ...

Bstrandable NCLEX Miscellaneous 5 Questions And Answers Latest 2022 How does managed care affect the economics of health care delivery? - ANSDecreases duplicate processes and redundant facilities rationale: The corporatization of health care amalgamates the smaller health care operations into the larger organizations to decrease duplicate and redundant health care provisions. For example, one hospital would provide a high level of cardiac care, while another hospital would focus on oncology. What is meant by the term integrated health care delivery system (IHS)? - ANS- A large health care system that can provide all needed services under one corporate umbrella rationale: As part of the corporatization of health care, the individual health care organizations are merging into systems to provide all needed services under one corporate umbrella. These are known as integrated health care delivery systems. Characteristics of clinical pathways include all of the following except: - ANS- Being a nurse-centered orientation rationale: Clinical pathways help reduce expensive variations in care. Clinical pathways are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for clients with a particular diagnosis, procedure, or symptom. Patient-focused care is a recently developed term to describe: - ANS- A nursing care delivery system rationale: Patient-focused care is another type of delivery system. The level of productivity is increased through centralization of functions (phlebotomy, diet instruction, respiratory therapy) on the unit under the direction of the RN and cross-training ancillary workers to do more than one function. The patient comes into contact with fewer people under this organizational framework. What are two tools that support case management? - ANS- Clinical pathways and disease management rationale: Both of these tools support case management by coordination and delivery of highquality care. Clinical pathways are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for clients with a particular diagnosis, procedure, or symptom. A delivery of nursing care organized around tasks is known as: - ANS- Functional nursing rationale: Aides and vocational nurses/licensed practical nurses are allowed to perform functions such as administration of medication and treatments. This functional kind of nursing results in a fragmented, impersonal kind of care. A system in which a nurse plans and directs the care of clients over a 24-hour period is known as: - ANS- Primary nursing rationale: In primary nursing the fragmentation between shifts and nurses is eliminated because one nurse is accountable for planning the care of the client around the clock. Which statement is true about the case management model of nursing care? - ANSIt is based on previously defined client outcomes. rationale: Clinical pathways are a tool used to support case management and to define client outcomes.. These are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for clients with a particular diagnosis, procedure, or symptom to achieve a defined client outcome. What is the primary work environment of nurses who are case managers? - ANS- All types of health care organizations, as well as organizations with health-related functions, hire case managers. rationale: The case managers work in all types of health care institutions. They may also work for insurance or utilization review companies or in health-related areas of various types of large businesses. Which statement is true about client classification systems? - ANS- They provide historical data of the usage of nursing time, which is helpful when developing the department budget. rationale: A client classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet client needs. Which of the following best describes the concept of evidence-based practice? - ANS- It provides for the use of recent research in current nursing practice. rationale: The IOM reported that it took 17 years for research to be reflected into daily practice. Evidence based practice is the use of the current best evidence to provide care and make decisions regarding client care. A client is admitted to the labor and delivery unit where she is assigned a registered nurse who will manage her care for the duration of her hospitalization. What type of nursing care delivery model is represented in this nursing unit? - ANS- Primary care rationale: This is an example of primary care nursing, in which the RN is the principal or primary person to manage and coordinate the client's care around the clock. Patientfocused care is an interdisciplinary approach to client care. Functional care is the provision of care by nursing and nursing ancillary staff rather than by an all-nursing staff as seen in primary care nursing. Case management is a model of care delivery in which an RN case manager coordinates and collaborates with other health services when a client has complicated health care needs, but the case manager may not be involved in the daily care activities of the client. Which type of nursing delivery models would be appropriate in a rural area that would require fewer numbers of registered nurses? Select all that apply. - ANS- - Functional nursing -Team nursing -Patient-focused care rationale: When you have a limited number of RN's, then functional nursing, team nursing, and patient-focused care are useful, because you can deliver quality care by using more ancillary staff. Primary care is usually 24-hour RN coverage, and transition care is where APRNs conduct assessments and—with physicians—design and coordinate patient care and discharge plans. The primary role of The Joint Commission (TJC) is: - ANS- Ensuring medical facilities meet client safety guidelines rationale: The Joint Commission is the primary accrediting body for health care institutions. Its standards directly address client safety issues. Magnet status is approved by the American Nurses Association. TJC does not lobby Medicare/Medicaid issues. The CDC would be the agency that maintains standards regarding infection control for hospital compliance. The Joint Commission publishes a Sentinel event alert every month. Which of the following is the best example of a sentinel event? - ANS- Code Pink is called after a newborn is discovered missing from the nursery. rationale: A sentinel event is an unexpected occurrence involving death or loss of limb or function. Examples of sentinel events include serious medication errors, significant drug reactions, surgery performed on the wrong body site, blood transfusion reactions, and infant abductions. The technique used to identify the factors involved in an error is called: - ANS- A root cause analysis rationale: When an error is analyzed, the primary causes need to be determined so that a workable and effective solution can be developed. A root cause analysis is such a process designed to investigate and categorize the root cause of the event. The person known for emphasizing the Pareto principle (80/20 rule) leading to the idea of total quality management is: - ANS- Joseph Juran rationale: Joseph Juran is one of the forefathers of quality initiatives. He stressed the meaning of the Pareto principle and how it applies to improving quality in all organizations. The Joint Commission mandates the use of continuous quality improvement and measurement of specific quality outcomes, including clients admitted with: - ANSCommunity-acquired pneumonia and congestive heart failure rationale: TJC mandates outcome measures for clients admitted with a diagnosis of acute MI, congestive heart failure, community-acquired pneumonia, surgical infection prophylaxis, pregnancy-related conditions, and deep vein thrombosis. The primary barrier to the implementation of quality improvement processes is: - ANS- Expense rationale: A primary barrier to implementing effective quality improvement programs is the cost. The cost of providing health care has greatly increased over the past few decades. However, through quality improvement measures, overall health care costs can be reduced. The primary goal of the continuous quality improvement process of Six Sigma is to: - ANS- Diminish misuse of processes rationale: The primary goal of Six Sigma is to increase profits by improving standard operating procedures, reducing errors, and decreasing misuse of the system. During the define phase of the define-measure-analyze-improve-control (DMAIC) process, the team members: - ANS- Identify the stakeholders rationale: In the define phase, a charter is developed; goals, team leaders, membership, and team roles and responsibilities are identified; and the stakeholders affected by the process are identified. To become credentialed as a Certified Professional in Healthcare Quality, you must: - ANS- Take an exam rationale: To become a CPHQ, you must take and pass an examination. Only about 75% of those who test actually become certified. Which statement is true about client classification systems? - ANS- The systems provide historical data of the usage of nursing time, which is helpful when developing the department budget. rationale: A client classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet client needs. It is not a formula for unit staffing. The continuous quality improvement (CQI) committee has performed a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are client-centered and written in behavioral terms. The expected standard is 98% compliance. The sample size was 200. Results showed that 180 charts met the standard. What assessment can be made? - ANS- The standard was not met. An action plan should be developed. rationale: A threshold, or cutoff point, is determined for each indicator. This example represents a 90% compliance rate, but the threshold was set at 98%. Which of the following statements are true about continuous quality improvement? Select all that apply. - ANS- -The accountability for quality is vested in the individual nurse -Quality standards must incorporate the expectations of clients and their families.providing direct client care. -Systems within the hospital must be reviewed to determine how care can be enhanced. rationale: This approach emphasizes continually looking for opportunities to improve. CQI looks not only at what the nurse does in the pursuit of quality but also at how the systems of the units in the hospital can be improved to provide better care at lower cost. What is the definition of nursing informatics? - ANS- It is the activities focused on collecting, processing, and analyzing nursing data electronically to support nursing practice and knowledge. rationale: The ANA has defined informatics as "the activities involved in identifying, naming, organizing, grouping, collecting, processing, analyzing, storing, retrieving or managing data and information." The nurse understands that a collection of various information technology applications that provides a centralized repository of information related to client care across distributed locations is called: - ANS- A clinical information system (CIS) rationale: A clinical information system (CIS) is a repository that also encodes the status of decisions, actions underway for those decisions, and relevant information that can help in performing those actions. The database could also hold other information about the client, including genetic, environmental, and social contexts. Essentially, the CIS uses the computer to provide and store information and data about a client from departments that are client-focused or departmental-focused. What are examples of regulatory agencies that will affect health care policy with regard to informatics? - ANS- Health Insurance Portability and Accountability Act (HIPAA) rationale: The Joint Commission (TJC) and the Health Insurance Portability and Accountability Act (HIPAA) are two regulatory and governmental agencies instituting health care policy. What is the importance of using classification systems for nursing nomenclature to describe nursing practice? - ANS- To assist the quality control team to survey and gather data that will reflect the acuity classification of clients rationale: Nursing nomenclatures offer a recognized systematic classification and consistent method of describing nursing practice. Without a common language, data cannot be aggregated into a useful language. With regard to nursing informatics, what is meant by general systems theory? - ANSIt organizes interdependent parts that, when working together, can produce a product that none used alone could produce. rationale: Nursing informatics uses a theoretical foundation. This theory organizes interdependent parts that, when working together, can produce a product that none of the interdependent parts used alone could produce. The nurse understands that the computer-based patient record (CPR) was developed to: - ANS- Provide an instrument with which to obtain clinical information, transcribe data, and track the care of the client in a variety of settings rationale: The CPR basically refers to the same thing as the electronic medical record (EMR), the electronic patient record (EPR), and the electronic health record (EHR). It is important to note that the CPR is not the clinical information system (CIS), but instead is a complex computer system that captures, records, processes, and communicates client data. The CPR includes all information about an individual's lifetime health status and health care and is maintained electronically. The nurse needs basic computer skills to work with the CPR. The nurse understands that computer monitoring on a telemetry unit: - ANSProvides streamlining of data that allows nurses to respond to client changes quickly rationale: The continuous flow of data from a computer allows nurses to respond to client changes very quickly. Timely nursing responses and actions are crucial in leading to positive outcomes when caring for critically ill clients. Computer monitoring is not a substitute for client observation. The number of nurses required to care for clients is not reduced because of computer monitoring, nor does it improve documentation, but rather provides a means to document data. When evaluating an Internet site, the nurse understands that: - ANS- Credibility, accuracy, and reasonableness of the information should be considered rationale: The credibility of the information that you obtain from Internet searches should be challenged. It is important to be skeptical, because not all information that is posted is accurate. Information should be evaluated and reevaluated on a regular basis. It is important to remember that Internet information is dynamic and fluid in nature, as compared with printed information. The American Hospital Association and Congress have identified which of the following as major barriers to the full integration health information technology? Select all that apply. - ANS- -Lack of standardization across point-of-care areas -Funding issues -No single set of privacy laws -Lack of a unique client identifier number rationale: Research data support that the use of the computerized physician order system (CPOE), computerized decision support systems, medication administration record (MAR), and bar-codes on client identification bands can limit errors and improve care. Both organizations identify barriers as: Lack of standardization across point-of-care areas—Laboratory data and pharmacy systems need to be integrated with the client's health record. Funding—Information technology is costly, and often the major costs are borne by hospitals rather than shared by other providers, payers, and employers. Privacy laws—A single set of privacy laws is needed to simplify the task of communicating across agencies and local, state, and federal governments, which can make compliance difficult and interfere with client care. Lack of a uniform approach (identifier number) to match the client to his or her record—A single authentication number is needed to reduce safety risks and provide a uniform access to a client's data. Which of the following are considered nursing practice classification systems? Select all that apply. - ANS- -North American Nursing Diagnosis Association International (NANDA-I) Approved List of Diagnostic Labels -Nursing Interventions Classification (NIC) System -Nursing Outcomes Classification (NOC) System -Nursing Management Minimum Data Set (NMMDS) rationale: The ANA approved the establishment of the Nursing Information and Data Set Evaluation Center (NIDSEC) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers that support documentation of nursing care within automated nursing information systems (NIS) or within computer-based patient record systems (CPR). They recognized the following 13 nursing practice classification systems: North American Nursing Diagnosis Association International (NANDA-I) Approved List of Diagnostic Labels Nursing Interventions Classification System (NIC) Nursing Outcomes Classification System (NOC) Nursing Management Minimum Data Set (NMMDS) Clinical Care Classification (CCC, formerly Home Health Care Classification [HHCC]) Omaha System Patient Care Data Set (PCDS) PeriOperative Nursing Dataset (PNDS) SNOMED CT Nursing Minimum Data Set (NMDS) International Classification of Nursing Practice (ICNP) ABC codes Logical Observation Identifier Names & Codes (LOINC) A nurse assesses an oral temperature for a pateint as 38.5 C (101.3 F) what term would the nurse use to report this temperature? a. fever b. hypothermia c. hypertension d. afebrile - ANS- a. Fever is an elevation in body temperature A nurse is assessing viatl signs on several hospitalized children. The nurse would plan to use the oral route to assess temperature for which patient? a. 6 month old infant b. patient receiving oxygen therapy by mask c. 15 year old healthy adolescent d. unconcious patient - ANS- c. A healthy adolescent would be an appropriate patient for assessing temperature by the oral route. When assessing a temperature rectally, the nurse would use exterme care when inserting the thermometer to preevnt which of the following? a. an incrase in heart rate b. a decrase in heart rate c. a decrease in blood pressure d. an increase in respirations - ANS- b. Insertion of a rectal thermometer may stimulate the vagus nerve, which, inturn, would decrease heart rate. The may potentially be harmful for patients with cardiac problems. While taking an adult patients pulse, a nurse finds the rate to be 140 bpm. What should the urse do next? a. check the pulse again in 2 hours b. check the blood pressure c. record the information d. report the rate - ANS- d. A rate of 140 bpm in an adult is abnormal pulse and should be reported to the isntructor of the nurse in charge or the patient. A pateint complains of sever abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessment? a. an increase in the pulse rate b. a decrease in body temperature c. a decrease in blood pressure d. an increase in repiratory depth - ANS- a. The pulse often increases when an individual is experiencing pain. Pain does not affect body temperature and may increase blood pressure. The nurse is taking an apical pulse. What equipment will he take into the patients room? a. sphyogmomanometer b. electronic thermometer c. stethoscope d. doppler apparatus - ANS- c. The apical pulse can only be assessed by listening with a stehosocope Two nurses are taking an apical-radial pulse and note two differences in the pulse rate of 8 bpm. The nurse would document this difference as which of the following? a. pulse deficit b. pulse amplitude c. ventricual rythm d. hearth arrhythmia - ANS- a. The difference between the apical and raidal pusle rate is called the pulse deficit Before assessing respirations, the nurse reviews normal rates for adults. Which rate would the nurse identify as normal? a. 1-6 breaths/min b. 12 to 20 breaths/min c. 60-80 breaths/min d. 100-120 breaths/min - ANS- b. The normal repiratory rate for adults is 12-20 breaths per minute A patient is having dyspnea. What would the nurse do first? a. remove pillows from under the head b. elevate the head of the bed c. elevate the foot of the bed d. take the blood pressure - ANS- b. Elavating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion A student nurse is learning to assess blood pressure. What does the blood pressure measure? a. flow of blod through the circulation b. force of blood against arterial walls c. force of blood against venous walls d. flow of blood through the heart - ANS- b. blood pressuer is the measurement of the force of blood against arterial walls. A nurse knows that the blood pressure is often higher in oder adults based on the understanding that which of the folowing occurs with age? a. loss of muscle mass b. changes in exercise level c. decreased peripheral resistance d. decreased elasticity in arterail walls - ANS- d. With aging, elasticity in arterial walls is decreased, contributing to an elevated blood pressure reading. A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recomment to the patient? a. floow-up measurements of blood pressuer b. immediate treatement by a physician c. nothing, becuase the nurse considers this reading is due to anxiety d. a change in dietary intake - ANS- a. A single blood pressure reading that is mildly elevated is not significant, but the measurment should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck. A nurse is documenting a blood pressuer of 120/80 mm Hg. The nurse itermprets the 120 to represent which of the following? a. pulse rate b. diastolic pressure c. systolic pressure d. pulse deficit - ANS- c. the systolic pressure is 120 mm Hg. The diastolic pressure is 80 mm Hg It is important to have the appropriate cuff size when taking the blood pressure. WHat error may result from a cuff that is too large or too small? a. an incorrect reading b. injury to the patient c. prolonged pressure on the arm d. loss of Korotkoff sounds - ANS- a. A blood pressure cuff that is not the right size may cuase an incorrect reading. A patient has intravenous fluids infusing int he right arm. When taking a blood pressure on this patient, what would the nurse do in this situation? a. take the blood pressure in the right arm b. Take the blood pressure in the left arm c. Use the smalles possible cuff d. Report the inability to take the blood pressure - ANS- b. The blood pressure should be taken in the arm opposite the one with the infusion. What are the smallest infectious agents capable of causing an infection? a. bacteria b. viruses c. molds d. yeast - ANS- b. a virus is the smallest of all microorganisms and can be seen only with a special microscope. Your patient has developed a low-grade fever and states that she has felt very tired lately. You interpret these findings as indicating which stage of infections? a. incubation period b. prodromal stage c. full stage of illness d. convalescent period - ANS- b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. Efforts by healthcare facilities to reduce the incidence of HAI's include an awareness of which of the following? a. The CDC requires all states to report HAIrates from - ANS- c. According to the Joint Commission, death or serious injury casued by an infection-related event is considered a sentinel event and must be reported. ... A patient develops a urinary tract infection after an indwelling urinary catheter has been inserted. This would most accurately be termed as which type of infection? a. a viral infection b. a chronic infection c. an iatrongenic infection d. an oppotunistic infection - ANS- c. An iatrogenic infection develops as a result of the insertion of an indwelling catheter. Because this infection just developed, it is not chronic, nor did it occur becuase of any altered physiology that may give an opportunistic organism a chance to cause infection. Urinary infections are bacterial, not viral. The nurse has opened the sterile supplies and donned two sterile gloves to complete a sterile dressing change, a procedure that requires surgiacal asepsis. The nurse must do which of the following? a. keep splashes on the sterile field to a minimum b. cover the nose and mouth with gloved hands if a sneeze is imminent c. Use forceps soaked in a disinfectant d. consider the outer 1 inch of the field as contaminated - ANS- d. considering the outter inch of a sterile field as contaminated is a principle of surgical asepis. The CDC standard precaution recommendations apply to which of the following? a. only patients with diagnosed infections b. only blood and body fluids with visible blood c. all body fluids including sweat d. all pateints receiving care in hospitals - ANS- d. standard precautions apply to all patients receiving care in hospitals, regardless of their diganosis or possible infection status In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions? a. droplet precautions b. airborne precautions c. Contact precautions d. universal precautions - ANS- a. rubella is an illness transmitted by large-particle droplets and requires droplet precautions in addition to standard precautions. when caring for a patient with latex allergy, the nurse creates a latex-safe environment by doing which of the following? a. carefully cleaning the wall-mounted blood pressure device before using it. b. donning latex gloves outside the room to limit powder dispersal c. Using a latex-free pharmacy protocol d. placing the patient in a semiprivate room - ANS- c. a latex-free pharmacy protocol is a vital component when creating a safe environement for this patient. Which organizations initially developed the guidelines for minimum protection standards for infection prevention and control? a. OSHA b. Individual healthcare facilities C. the state governing body d. the CDC - ANS- d. the CDC established the initial minimum requirements for infection prevention and control. Which of the following lists the recommended sequence for removing soiled personal protective equipment when the nurse prepares to leave the patient's room? a. gown, goggles, mask, gloves, and exit the room b. gloves, wash hands, remove gown, mask, and goggles c. gloves, goggles, gown, mask, and wash hands d. goggles, mask, gloves, gown, and wash hands - ANS- c. gloves are always removed first becuase they are most liekly to be contaminated, and hands should be washed thoroughly after the equipment has been removed and before leaving the room. For a nurse under with unsoiled hands, effective hand hygiene between patients requires which of the following? a. at least a 15 second scrub with plain soap and water b. at least a 23 minute scrub with an antimicrobial soap c. use of an alcohol-based antiseptic handrub d. that a mask be worn when scrubbing - ANS- c. hands that are not visibly soiled can be effeftively cleaned with an alchohol-based hand rub Which hospitalized patient is most at risk for developing a helthcare-associated infection? a. Mr. Y, a 60 year old patient who smokes two packs of cigarettes daily b. Mrs. J, a 40 year old patient who has a white blood cell count of 6,000/mm3 c. Mr. L, a 65 year old patient who has indwelling urinary catheter in place d. Mrs. M, a 60 yaer old patient who is a vegetarian and slightly underweight - ANSc. indwelling urinary catheters have been implicated in most health care associated infections. A patient develops food poisoing from conaminated potato salad. what is the means of transmission for the infection organism? a. direct contact b. vector c. vehicle d. airborne - ANS- c. contaminated food is a vehicle for transmitting an infection. A nurse is caring for and obese 62 year old patient with arthritis who has developed an open reddened area over his sacrum. which of the following is a priority nursing diagnosis? a. imbalanced nutrition: more than body requirements related to immobility b. impaired physical mobility related to pain and discomfort c. Chronic Pain related to immobility d. risk for infection related to altered skin integrity - ANS- d. The priority diagnosis in this situation is the possibility of an infection developing in the open skin area. the nurse teaches a patient at home to use clean technique when changing a wound dressing. This is which of the following? a. The nurse's preference b. Safe for the home setting c. Unethical behavior d. grossly negligent - ANS- b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended. A patient complains of abdominal pain that is difficult to localize. The nurse categorically interprets this as which type of pain? a. causalgia b. visceral c. superficial d. pyschogenic - ANS- b. Teh patient's pain would be categrozied as visceral pain, which is poorly loclized and can originate in body organs in the abdomen. It is not complex regional pain syndrome (causalgia), which is pain that occurs in the area of injured peripheral nerves, cutaneous pain, which is superfical and usually involves the skin or subcutanteous tissue, or phychogenic pain, in which a physical cuase for the pain cannot be identified. A patient complains of pain in a site that is different from where it originates. The nurse documents this as what type of pain? a. Transient pain b. superficial pain c. phantom pain d. referred pain - ANS- d. Referred pain is perceived in an area distant from its point of origin, where as transient pain is brief but passes quickly. A patient who has fallen and injured his wrist carefully cradles it with the other hand. The patient is demonstrating which of the following responses to pain? a. behavioral b. affective c. pysiologic d. involuntary - ANS- a. Protecting or guarding a painful area is a behavioral response. Affective responses are psychological ones, and examples of physiologic or invuluntary response would be increased blood pressure or dialation of the pupils. To help relive her pain, Ann concentrates on a favorite vacation setting. The nurse interprets this technique as which of the following? a. distraction b. relaxation c. Recall d. Imagery - ANS- d. Imagery is a mind-body interaction that decreases pain sensation by focusing on pleasurable images. Which of the following descriptions does the nurse use to best describe intractable pain? a. intermittent in nature b. Resistant to treatment c. Excruciating d. Widespread - ANS- b. intractable pain is sever pain that is resistant to relief measures. The other terms do not describe this resistance to treatment. Applying the gate control theory of pain, which of the following would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication - ANS- b. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices involve attempts to stimulate nerve fibers that interfere with pain transmission as explained by the gate control theory. Which of the following would the nurse expect to assess as a physiologic response to moderate pain? a. pupil dialation b. Restlessness c. Decreased pulse rate d. Protection of the painful area - ANS- a. dilation of pupils is a physiologic or involuntary response to moderate pain, whereas decreased pulse rate, also a physiologic or involuntary response, occurs when pain is severe and deep. Restlessness and protection of the painful area are behavioral responses. Mrs. Young is receiving ATC medication for treatment of terminal cancer. She has recently reported several episodes of breakthrough pain. What treatment is most effective to manage these sudden flare-ups of pain? a. Increasing the dose of her ATC medication for treatment of terminal cancer. b. Restricting her physical activity c. Doing nothing more since her cancer is terminal d. Supplementing with doses of a short-acting opioid - ANS- d. breakthrough pain is best addressed by administering a short-acting opioid similar to her ATC medication. Increasing the dose of her ATC medication also increases her risk for developing side effects. All pain can be treated effectively, and limiting physical activity will not affect her breakthrough pain but may negatively affect her current lifestyle and self esteem. When assessing pain in a child, the nurse needs to be aware of which of the following considerations: a. Immature neurologic development results in reduced sensation of pain. b. Inadequate or inconsistent relief of pain is widespread. c. Reliable assessment tools are currently unavailable. d. Narcotic analgesic use should be avoided - ANS- b. healthcare personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored. Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pail. She is aware that he has consistently refused his pain medication. Which of the following would be a priority nursing diagnosis? a. Acute pain related to fear of taking prescribed post operative medication b. Impaired physical mobility related to surgical procedure c. anxiety related to outcome of surgery d. Risk for infection related to surgical incision - ANS- a. Mr. Wrights immediate problem is pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible but not a priority in this situation. When planning strategies for pain control in older patients, the nurse should be aware of which of the following? a. pain is a natural outcome of the aging process. b. Sensitivity to pain increases with age c. Narcotic use should be avoided d. Denial of pain may occur - ANS- d. older people frequently deny pain because they view it as an ominous sign that may interfere with their independence. Pain sensitivity may decrease with age, but even this assumption is unsafe. Pain is not a natural outcome of the again process. Opioid medications can be used if the older patients response is carefully monitored ad evaluated. When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. on a p.r.n. basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly - ANS- c. the prn protocol is totally inadequate for patients experiencing chronic pain. ATC doses of analgesics are more effective, wheras conservative pain management for whatever reason may also prove ineffective. Which of the following descriptions is true os using a placebo for pain control without the patients consent? a. widespread practice b. consistently effective c. deceptive d. justified to determine whether the pain is real - ANS- c. using a placebo to control pain creates distrust in the nurse-patient relationship and is considered unethical The nurse provides vigilant monitoring of a patient receiving epidural analgesia to prevent the occurrence of which of the following? a. pruritus b. urinary retention c. vomiting d. respiratory depression - ANS- d. too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has which of the following findings? a. a respiratory rate of 10/min with normal deapth b. a sedation level of 4 c. Mild confusion d. Reported constipation - ANS- b. sedation level is more indicative or respiratory depression because it usually precedes it. A sedation level of 4 calls for immediate action because that patient has minimal or no response to stimuli. During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation - ANS- A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview. The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?" - ANS- A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having." The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?" - ANS- B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning. The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday. - ANS- C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement. Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated - ANS- D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm. A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition - ANS- D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process. The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician - ANS- B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience - ANS- A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented. The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit - ANS- A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours - ANS- B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement. Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes - ANS- B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed. The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals - ANS- D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings. CONTINUES...