When formulating a definition of "health," the nurse should consider that health, within its current definition, is:
The absence of disease
A function of the physiological state
The ability to pursue activities of daily living
A state of well-being involving the whole person
A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic?
"I would like you to perform this exercise once a day."
"Your physician has left orders that you are to follow."
"The laboratory tests reveal the need to reduce your daily percentage of fat intake."
"Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels."
The client states, "Heart disease runs in our family. My blood pressure has always been high." The nurse determines that this is an example of the client's:
Negative health behaviour
A client is discharged following a heart attack. In using the Stages of Health Behaviour Change as a guide, the nurse recognises that the client is most likely to begin to accept information on diet changes and an exercise program during which stage?
When assessing the external variables that influence a client's health beliefs and practices, the nurse must consider his:
Reaction to the heart disease
A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of:
Which of the following nursing activities is an example of tertiary level care-giving?
Teaching a client how to irrigate a new colostomy
Providing a class on hygiene for an elementary school class
Informing a client that her infant can be immunised at the health department
Arranging for a hospice nurse to visit with the family of a client with lung cancer
Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse?
In the Health Belief Model, the nurse recognises that the focus is placed on the:
Basic human needs for survival
Functioning of the individual in all dimensions
Relationship of perceptions and compliance with therapy
Multidimensional nature of clients and their interaction with the environment
The client who recently received a kidney transplant is worried about her husband since he has taken over the physical tasks of running their home. The client is in the process of adapting to a change in:
Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the client's health status, the nurse will specifically look for:
Anxiety level present
Family remedies used
Location and type of occupation
Available health insurance coverage
A nurse understands that illness behavior means:
Each distinct illness will cause the client to behave in a specific manner
Nursing care provides interventions that are behavior oriented
The client's behaviors will have a direct impact on his illness
When ill, a client's perception of illness will result in unique behaviors
A client tells the nurse that his illness is a result of his failure to "live a good life." The nurse recognizes this statement as an example of the client's:
Negative health behavior
Which of the following client statements best relates to the third component of the Health Belief Model?
"My blood cholesterol is only a little high."
"No one in my family is susceptible to the flu."
"I'll just avoid the food that causes the problem."
"By losing weight my blood pressure may come down."
The goal of Pender's Health Promotion theory is best reflected in which of the following nursing interventions?
Suggesting the client experience a variety of exercise routines before settling on the one to adapt
Arranging for a client to attend a support group for individuals who also have severe burn scars
Playing soft, classical music when a client diagnosed with Alzheimer's becomes physically agitated
Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care
The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the client's:
Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu?
Staffing a flu immunization clinic at a senior citizen's center
Providing flu prevention literature for distribution to visitors
Reminding client care personnel of the importance of the flu shot
Getting a drug manufacturer to donate flu vaccine for the homeless
The nurse can best discuss the impact of a known risk factor on a client's health by stating:
"It doesn't mean you'll get the disease just that the odds are greater for you."
"Now you know that the possibility is there, you can take steps to prevent it."
"The risk factor can be managed by making a change in your lifestyle."
"You're lucky because you have the benefit of being able to do something about it."
The nurse is caring for an older adult client who has reported symptoms suggestive of depression. Which of the following questions asked by the nurse is most therapeutic in assessing the client's perception of the impact depression has had on her life?
"What does it mean to be depressed?"
"How does being depressed make you feel?"
"Were you happy before becoming depressed?"
"What makes you think that you are depressed?"
The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piaget's theory of cognitive development suggests that the nurse can help the child cope with the stress of this hospital experience best by:
Arranging for the parents to be with the child until the anesthetic takes affect
Explaining the entire process with the child using age-appropriate language
Using play as a means of familiarizing the child with the events he will experience
Providing the child with a coloring book that shows the events he will be experiencing
Which of the following nursing responses is most therapeutic when made in response to a parent's concern about her 3-year-old child's tendency to "break the rules"?
"Just keep reminding her of the rules."
"Daycare will help her learn to play fair."
"She will begin to understand that concept in a year or so."
"Add an age appropriate punishment for breaking the rules."
To help a comatose client's family make a moral decision regarding the termination of life support, the nurse must first:
Refrain from expressing his/her personal beliefs concerning the life support issue
Provide the family with information regarding the process of terminating life support
Determine whether the client had expressed any written or oral wishes regarding the issue
Facilitate the family's decision-making process by providing them with a quiet, private space for discussion
Which of the following best describes a nurse thinking at stage 5 of Kohlberg's Moral Developmental Theory?
"The client has a right to decide whether or not to proceed with the treatment plan."
"The hospital's policies and procedures are excellent tools for making client oriented decisions."
"It won't be fair to expect to get every weekend and holiday off, so I'll certainly work my share."
"If you don't keep client information confidential you could be terminated immediately."
Which of the following client statements made by an older adult best reflects an understanding of the decrease in physical strength and stamina in this developmental stage?
"I know I'm not as young as I use to be."
"I just hire help with jobs I can't do myself."
"You get older you can't do as much, that's life."
"I have to ask my son for help with the yard work."
Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy?
Detection of fetal movement
Observation that the uterus is below the pubis
Confirmation of the desire to breast- or bottle-feed
Determination of the presence of morning sickness
Standard precautions are precautions taken each time an episode of care or task is undertaken (e.g. hand washing, use of personal protective equipment, cleaning of equipment) that will reduce the transmission of infections.
Aprons and gloves should not be worn in common use areas such as corridors, staff room, office or linen room.
Masks and goggles must be worn for care activities such as care of residents who have a cough.
The use of gloves is an effective substitute for hand washing.
You must wash your hands after removing your gloves.
In a care home, standard precautions are the responsibility of nurses and carers only.
The objective of standard precautions is to prevent the spread of infection within the care home:
From resident to resident.
From resident to staff.
From staff to resident.
From staff to staff.
All answers are correct.
The most important procedure for the prevention of infection from microorganisms is:
properly bagging used linen.
Effective hand washing.
Wearing protective eyewear.
Bacteria and viruses can spread by way of:
Water, food, drinks, and eating utensils.
Direct contact with people and/or body substances.
Coughing, sneezing, or vomiting.
All answers are correct
Which of the following statements are true about effective hand washing?
Keep elbows lower than hand when washing and rinsing.
Use friction to clean between fingers, palms, nail beds, back of hands and wrists
Wash for 30 seconds or longer using an alcohol-based hand rinse.
Use a paper towel to turn off the light switch.
You should wash your hands:
After taking off a gloves and/or apron
Before going into a resident’s room and after coming out.
At the beginning and end of my shift.
Alcohol-based hand gel SHOULD NOT be used:
Prior to contact with resident.
If fingernails are chipped.
If the resident has a respiratory infection.
If hands are visibly dirty.
Which of the following are allowed when you are bare below the elbows?
Wedding rings with stones
Long finger nails / nail extensions / false nails
No answer is correct
Who is responsible for cleanliness within the care home?
The manager, The housekeeper/domestic staff
Cohort isolation means:
Different patients with same infection
Different infections in same age group
Only old age people
Only young age people
Standard precautions include:
Making the bed
Air borne precautions includes?
N-95 Mask positive pressure room
N-95 Mask.Negative pressure room
Contact precautions not include: N-95 Mask and Negative pressure room
When are additional transmission based precautions required?
When standard precautions are not useful
When standard precautions alone are not sufficient to prevent the transmission of disease or infectious
When patients have hepatitis C
Mrs fatima is admitted to Hospital A with a leg wound which is infected with methicillin resistant Staphylococcus aureus (MRSA). The wound has moderate purulent ooze. Mr Jones is admitted to hospital A and because he was in the hospital with an MRSA infected surgical wound one month ago. He has his nose and groin swabbed for MRSA and is found to be colonised with MRSA. Mrs Smith is placed in contact precautions. Should Mr Jones also be placed in contact precautions?
Both conditions will be OK
No,there is no need
Yes, because colonization may be a form of carriage and is a potential source of transmission
Three patients present to a small rural hospital on Monday morning. Six year old Will is covered in a florid rash with a high temperature and a cough. His mother does not believe in vaccinating her children. They recently returned from a trip to India. Two month old Jade has been admitted with bronchiolitis probably caused by respiratory syncitial virus (RSV). Ten year old Blake has a nasty infected cut on his hand. His brother was recently discharged from the hospital following treatment for community acquired MRSA infection of his leg.
The hospital only has one single room available. Which of the three patients should be placed in the single room?
No one need to be isolated.
Will because he probably has measles and since this is spread by the airborne route he needs a single room with negative pressure air conditioning. If that is not available he must be put in a single room.
Blake's brother should be isolated
Everyone needs to be isolated.
Five moments have been identified as critical times when hand hygiene should be performed. These are:
Before and after patient contact; before a procedure; after a procedure or contact with blood or body fluids; after contact with the patient's environment
After a procedure or contact with blood or body fluids; after contact with the patient's environment ,before using toilet
Hand should be washed only when you received the patients
Only when you remember
What three elements are needed for a healthcare associated infection to occur?
An infectious agent, a source and a susceptible host
An infectious agent; carrier; pathogen
Source,carrier and contact
Standard precautions are work practices required for the basic level of infection control. Which of the following do they apply to?
All Hep B patients
All patients regardless of suspected or confirmed infection status.
Only TB patients.
The term sterile is absolute; an item is either sterile or not sterile.
Only sterile items can be placed on the sterile field.
Even if there is no visible sign of a tear, if a glove is thought to have been punctured, it should be changed.
The edges of a wrapper are considered sterile.
An open-gloving technique would be used when performing urinary catheterization.
Living tissue cannot be sterilized but can be rendered surgically clean.
Hand washing is not necessary if gloves are worn.
The amount of space that should be left between sterile and nonsterile surfaces is 2 to 4 centimeters
Culture may be defined as “common values, beliefs, traits, traditions and/or language
that are learned and shared by members of a group.”
It is OK to use gestures since each one has the same meaning universally.
A client’s cultural background will often determine how they would like to be
approached and their communication style.
Which of the following statements is correct?
People all have the same basic needs when they are sick.
Although pain is experienced by all, culture is an important consideration in how you observe clients and provide care
Regardless of their culture, clients will follow the service plan or plan of care as long as they understand it
Two clients from Spain can be treated alike because of their common culture.
Different cultures have varying ideas about family involvement in client care therefore:
Consult the head of the family regarding who should be included in decision making.
Research the patient’s culture so that appropriate care decisions may be made.
Consult the agency’s policy and procedures regarding client involvement in care.
Ask the client to whom information should be given and who to consult for decision making.
Which of the following is not a reason to assist residents with grooming?
Being well groomed can enhance the resident's medication use
Being well groomed can enhance the resident's self esteem
Being well groomed can enhance the resident's feelings of self worth
Being well groomed can enhance the resident's desire to participate in activities
Which of the following encourages independence with activities of daily living?
Putting items within easy reach
Praising the resident
ADL's an acronym for:
Advancing Daily Living
Activities of Daily Living
Activity of Declining Life
Activities Don't Last
A resident who needs the grooming items set out and partial performance of the task by the caregiver is considered:
Stand by assist
No answers are correct
How should the water for the shower be checked?
First by the caregiver, then pointed at the resident so he can feel it on his legs
By the resident, since he is the one taking the shower
By the caregiver, then pointed away from the resident allowing him to feel it with his hand
By the caregiver only
Medications can be left in the room with the resident because they said they will take them.
When a resident refuses a medication, put it in an envelope with name, date, and reason for refusal.
When documenting a wound near the ankle, it would be correct for the nurse to write that the wound is distal to a wound located on the thigh.
A pressure ulcer can be defined as a lesion caused by unrelieved pressure resulting in damage of underlying tissues.
Partial thickness tissue loss is when subcutaneous fat may be visible as well as tendon or muscle but no bone exposure?
A stage 4 pressure ulcer always has undermining and/or tunneling.
Wound edges that are detached means that the oase of the wound is deeper than the edges.
Which pain scale is the most sensitive to gender and ethnic differences?
An entry must be made in the nurse's notes each time you give pain meds with the reason why, time given and effectiveness
Care Plans must reflect what interventions work for the patient and which ones don't.
A patient is hospitalized with severe depression after her divorce is finalized. Which type of loss is the patient experiencing?
The nurse is caring for a patient who is terminally ill with lung cancer. Recently, the patient's blood pressure has been decreasing and heart rate increasing. He is experiencing temperature fluctuations and perspires profusely with limited movement. Based on these findings, the patient will most likely die within which time period?
1 to 3 months
1 to 2 weeks
Days to hours
A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care:
Is appropriate when the patient desires to intentionally end his life
Focuses on minimizing the disease process as rapidly as possible
Focuses on symptom management for patients not responding to treatment
Is holistic care for patients dying or debilitated and not expected to improve
After a patient dies of ovarian cancer, her daughter says to the nurse, "You'll probably think I'm terrible, but I'm glad she can finally rest peacefully." Which response by the nurse is best?
"Your feelings are a normal response to watching your loved one suffer."
"It's unusual for family members to be grateful that a loved one has died."
"Your mother's death has been very hard on you; you should seek counseling."
"I don't understand what you mean by this comment."
A nurse is caring for a dying patient who is non-responsive. Which of the following is it important for the nurse to do?
Be alert to the patient's nonverbal cues.
Direct explanations about care to family members.
Tell the patient when the nurse is about to leave the room.
Sit by the head of the bed when speaking to the patient.
A patient has been in the dying process for about 10 days. His wife has left his side only for very short periods during that time, and she looks pale and exhausted. The nurse, realizing the wife has not eaten much, suggests that she take a break to eat and rest. The woman refuses, saying, "I don't want to leave him. I won't have him much longer, and I don't want him to go when I'm gone." What should the nurse do?
Explain that she will be of more help to her husband if she is rested and well.
Tell the wife that it is safe to leave her husband for an hour or two because he won't die that soon.
Call the primary care provider to come and try to persuade her to take physical care of herself.
Arrange for a cot for her at the bedside and arrange to have food brought to her.