The nurse who is attempting to practice in a culturally sensitive manner must first realize that recognition of the visible signs of a client’s culture: 1. Is essential to the establishment of a nurse-client relationship 2. Provides the basis for a sense of trust between client and nurse 3. Does not ensure understanding of the […]
Which one of the four linkages of interest in the nursing paradigm refers to factors in the home or school? 1. Person 2. Health 3. Nursing care 4. Environment ANSWER ANS: 4 Environment/situation includes all possible conditions affecting the client and the setting in which health care needs occur, such as the home, school, […]
A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.) 1. Keeps asking when she can go 2. Repeatedly […]
The hospitalized client requests a bedtime snack. Which food should the nurse offer this client? 1. Hot chocolate 2. Tea and crackers 3. Cereal with milk 4. Chips and salsa ANSWER Correct Answer: 3 Rationale 1: Hot chocolate contains caffeine, which can cause wakefulness and nocturia. Rationale 2: Tea contains caffeine, which can cause […]
The nurse is delegating the feeding of an older adult client to ancillary personnel. Which of the following should the nurse include in the instructions as possible warning signs of dysphagia (difficulty swallowing)? (Select all that apply.) 1. Delay in swallowing food 2. Easily triggered gag reflex 3. Absence of a gag reflex 4. Uncoordinated […]
A nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for indi-viduals in this age-group. An expected finding for this client is: 1. Increased tactile responsiveness 2. Increased sensitivity to visual glare 3. Increased hearing acuity […]
To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client: 1. “Have you ever been married?” 2. “Where do you currently work?” 3. “Has anyone ever taught you about contraception?” 4. “Who do you have for support […]
The nurse is planning to assess a client’s pulse. What characteristics should the nurse include in this assessment? 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity ANSWER Correct Answer: 1, 2, 3 Rationale 1: When assessing the pulse, the nurse collects data about the rate. Rationale 2: When assessing the pulse, the […]
During a home safety assessment, the nurse identifies that there are a number of hazards present. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this client with diabetic peripheral neuropathy? 1. Improper water heater settings 2. Absence of smoke detectors 3. Cluttered walkways 4. Lack of […]
Nursing interventions may be categorized based upon the degree of nursing autonomy. An ex-ample of a nurse-initiated intervention is: 1. Providing client teaching 2. Administering medication 3. Ordering a liver CAT scan 4. Referring a client to physical therapy ANSWER ANS: 1 Health teaching is an example of a nurse-initiated intervention. Administering medication is […]
