What example of patient confidentiality
A principle in the American Nurses Association code for nurse
Which one of the following nursing action is performed in the intervention phase of the nursing process
Administration medication
A nursing assistant report that a client is complaing of pain which nursing action does the nurse perform first
Assess the client to determine the location, quality and intensity of the pain
A client presents with the following nursing diagnoses According to Maslow's hierarcy of needs which one has the highest priority choices are acitivity intolerance, anxiety, fluid volume excess, self-care deficit feeding
fluid volume excess
What is example of correct written patient goal/expected outcome
The patient will maintain a serum sodium level between 135-145 mEq/L
While admitting a patient to the hospital,you notice the respiratory rate is 28/minute. This observation is an activity associated with which step in the nursing process
Assessment
Which of the following client statements indicates that a focused assessment is needed
I having trouble breathing
A client is admitted with anascara (generalized edema) and is placed on IV diuretic therapy. Which one of the following outcomes is a therapeutic outcome
Client will lose weight during the first twenty-four hours of therapy
A tweleve year old is admitted with a diagnosis of acute appendicitis and is being prepared for surgeLy. Which one of the following laboratorly values would you expect to find in your assessment of the client
Leukocytes 13,200/mm (elevated leukocytes)
The nursing assistant just told you that Mrs. Jones is having trouble swallowing after having received her iron injection. What would you assess Mrs. Jones for first?
Anaphylaxis
nursing assistant reports that a previously stable patient now has a blood pressure 78/44. Which action should the nurse first carry out?
Call physician immediately
Which one of the following is an appropriate intervention in a patient with a diagnosis of ineffective breathing pattern?
Keep the head of the bed elevated
Which one of the following interventions is specific for nursing diagnosis at risk of falling related to a disturbance in balance in an alert but relativelly frail eighty year old hospitalized client
Assist patient when walking in the room or corridor
Patient goal and expected outcomes are identified in which step of the nursing process
Planning
Which one of the following childhood behaviors does the nurse assess as most indicative of normal cognitive development?
Pretend play in a toddler
Which one of the following statement best fits with Travis's concept of wellneww
I jog every day because I enjoy being well and jogging keeps me well
According to the epidemiologic model of health and illness which one of the following is the disease host?
A college student with a streptococcal throat infection
Which of the following assessment finding is most indicative of stress
Tachycardia, elevated blood pressure, and increased resp. rate
Which one of the following nursing history questions indicates that the nurse is sensitive to Lazarus's transaction-based model of stress?
Some people find moving to another city stressful, nWas it stressful for you?
An A student salys she is always anxious before a test Which of the following statement best explains this student's experience
Mild anxietlyl increase alertness
A fifty six year old man is recovering in rehabilitation center He fractured his hip and femur in a car accident three weeks ago Although he realizes his wife works full time and lives thitry-five miles away he expressess anger and hurt when his wife does
The patient will expess his anger in a constructive way
Which one of the following concepts is the most likely nursing diagnosis for an eighty one year old alert client who is recovering well from a fractured hip but who insists that two people accompany her each time she gets out of bed or walks in the corrid
Fear related to recent fall
A nurse is preparing to discharge a client whose annual income is less than ten thousand a year which client response most indicates that her safetly in the community is at risk
I doubt if I will be able to let you know how I am doing My phone isnt connected
A client with cancer pain requests a book of cartoons from the New York Times which is the most appropriate response on the part of the nurse
Many people find laughter relieves pain and hepls them feel better
A client reports that he is no longer able to phone people because he cannot see the number nor is he able to write checks due to his poor vision This is example of a decreased ability to perform
Instrumental activities of daily living
A fifteen year old high school football player admitted with a severe case of infectious mononucleosis tells a nurse all he wants to do is die. The nurse know that
Sucidial depression is a serious health problem among adolesecents
A client is admidmitted with congestive heart failure and receives furosemide IV (Lasix) Which of the following is the best indicators that the therapeutic goal of Lasix has been achieved?
Decrease in rales
The nurse correctly assess that a twenty two year old young man with a body mass index of fifteen is
Malnourished
At the change of shift report the informs you that a client has normal breath sounds This meas the client has
short inspiration and longer expiration at the bronchial level
At the change of shift report the nurse informs you that a patient admitted with head injury has a glasgow coma scale score of fifteen This means the patient is
Alert
A monthly self breast examination in women and self testicular examination in men are examples of which one of the following concepts
secondary prevention
Which one of the following is an example of a health change that occurs with age
Diminished sense of touch
In caring for culturally diverse population the nurse knows that disproportionate burden of chronic disease and infant mortality is borne by which groups
minorities
A LPN ask What is Healthy People 2000
An outline of disease prevention health goal for United States
A sixty six year old neighbor with no history of heart disease says her physician told her to walk at least a mile a day She asks what does he think IM going to gain by walking Your respond is
Physical activity maintains functional ability and quality of life
A thirty eight year old female jogger expleains that she jogs to attain her full potential which is how she also describes health This is an example of which definition of health
Eudamonistic
During a neurological assessment a nurse will ask a client to point tour nose one of the purposes of this directive is to assess for
speech and language ability
Population based goals/desired outcomes are built into
A public health nurse starts a self-help group to discuss neighborhood safety issues
A neighbor is knocking frantically on your front door when you open the door the neighbor says her toddler has just ingested poison Your best response is
Call the regional poison control center
Shearing friction and pressure are considered to be causes of which one of following
Pressure ulcers
A toddler is most at risk of aspiration when engaging in which one of the following activities
Playing with cuddly stuffed animals that have eyes and noses capable of being detached
Which one of the following nursing diagnoses is most likely to be associated with an increase risk of environmental injury
Acute or chronic confusion
Which patient statement is a cue to the nurse that the patients needs additional instruction with regard to safety
I wear sunscreen only when i go to the beach
The first intervention a nurse performs in the event of a fire is to
rescue and remove clients in danger
Jane Doe normally develops a sunburn within twelve minutes of sun exposure How much time will Jane be able to stay in the sun if she applied a sunscreen with an SPE of 15?
3 Hours
Darkly pigmented individuals are
Not as suceptible to sunburn as lightly pigmented individuals, but may burn and may develop cancer of the skin
A nurse uses alarms and sensor devices to
detect unassisted movements likely to place the patients at risk
Which one of the following interverntion is the only appropriate restraint avoidance strategy in a client with a urinary catheter
Assess the spatient to determines if a urinary catheter is still needed