10717142
Descripción
Test por Kathleen Jackson, actualizado hace más de 1 año
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Creado por Kathleen Jackson
hace casi 7 años
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Pregunta 1
Pregunta
When formulating a definition of "health," the nurse should consider that health, within its current definition, is:
Respuesta
-
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
Pregunta 2
Pregunta
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?
Respuesta
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"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."
Pregunta 3
Pregunta
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:
Respuesta
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Risk factors
-
Active strategy
-
Health beliefs
-
Negative health behaviour
Pregunta 4
Pregunta
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?
Respuesta
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Action
-
Preparation
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Maintenance
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Contemplation
Pregunta 5
Pregunta
When assessing the external variables that influence a client's health beliefs and practices, the nurse must consider his:
Respuesta
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Income status
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Religious practices
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Educational background
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Reaction to the heart disease
Pregunta 6
Pregunta
A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of:
Respuesta
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Health promotion
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Primary prevention
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Tertiary prevention
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Secondary prevention
Pregunta 7
Pregunta
Which of the following nursing activities is an example of tertiary level care-giving?
Respuesta
-
Teaching a client how to irrigate a new colostomy
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Providing a class on hygiene for an elementary school class
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Informing a client that her infant can be immunised at the health department
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Arranging for a hospice nurse to visit with the family of a client with lung cancer
Pregunta 8
Pregunta
Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse?
Respuesta
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Obesity
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Sunbathing
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Overcrowded housing
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Industrial-based occupation
Pregunta 9
Pregunta
In the Health Belief Model, the nurse recognises that the focus is placed on the:
Respuesta
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Basic human needs for survival
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Functioning of the individual in all dimensions
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Relationship of perceptions and compliance with therapy
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Multidimensional nature of clients and their interaction with the environment
Pregunta 10
Pregunta
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:
Respuesta
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Body image
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Self-concept
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Illness behavior
-
Family dynamics
Pregunta 11
Pregunta
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:
Respuesta
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Anxiety level present
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Family remedies used
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Location and type of occupation
-
Available health insurance coverage
Pregunta 12
Pregunta
A nurse understands that illness behavior means:
Respuesta
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Each distinct illness will cause the client to behave in a specific manner
-
Nursing care provides interventions that are behavior oriented
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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
Pregunta 13
Pregunta
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:
Respuesta
-
Risk factor
-
Health belief
-
Illness behavior
-
Negative health behavior
Pregunta 14
Pregunta
Which of the following client statements best relates to the third component of the Health Belief Model?
Respuesta
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"My blood cholesterol is only a little high."
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"No one in my family is susceptible to the flu."
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"I'll just avoid the food that causes the problem."
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"By losing weight my blood pressure may come down."
Pregunta 15
Pregunta
The goal of Pender's Health Promotion theory is best reflected in which of the following nursing interventions?
Respuesta
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Suggesting the client experience a variety of exercise routines before settling on the one to adapt
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Arranging for a client to attend a support group for individuals who also have severe burn scars
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Playing soft, classical music when a client diagnosed with Alzheimer's becomes physically agitated
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Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care
Pregunta 16
Pregunta
The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the client's:
Respuesta
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Emotional wellness
-
Developmental stage
-
Professed spirituality
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Intellectual background
Pregunta 17
Pregunta
Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu?
Respuesta
-
Staffing a flu immunization clinic at a senior citizen's center
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Providing flu prevention literature for distribution to visitors
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Reminding client care personnel of the importance of the flu shot
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Getting a drug manufacturer to donate flu vaccine for the homeless
Pregunta 18
Pregunta
The nurse can best discuss the impact of a known risk factor on a client's health by stating:
Respuesta
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"It doesn't mean you'll get the disease just that the odds are greater for you."
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"Now you know that the possibility is there, you can take steps to prevent it."
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"The risk factor can be managed by making a change in your lifestyle."
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"You're lucky because you have the benefit of being able to do something about it."
Pregunta 19
Pregunta
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?
Respuesta
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"What does it mean to be depressed?"
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"How does being depressed make you feel?"
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"Were you happy before becoming depressed?"
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"What makes you think that you are depressed?"
Pregunta 20
Pregunta
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:
Respuesta
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Arranging for the parents to be with the child until the anesthetic takes affect
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Explaining the entire process with the child using age-appropriate language
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Using play as a means of familiarizing the child with the events he will experience
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Providing the child with a coloring book that shows the events he will be experiencing
Pregunta 21
Pregunta
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"?
Respuesta
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"Just keep reminding her of the rules."
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"Daycare will help her learn to play fair."
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"She will begin to understand that concept in a year or so."
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"Add an age appropriate punishment for breaking the rules."
Pregunta 22
Pregunta
To help a comatose client's family make a moral decision regarding the termination of life support, the nurse must first:
Respuesta
-
Refrain from expressing his/her personal beliefs concerning the life support issue
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Provide the family with information regarding the process of terminating life support
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Determine whether the client had expressed any written or oral wishes regarding the issue
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Facilitate the family's decision-making process by providing them with a quiet, private space for discussion
Pregunta 23
Pregunta
Which of the following best describes a nurse thinking at stage 5 of Kohlberg's Moral Developmental Theory?
Respuesta
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"The client has a right to decide whether or not to proceed with the treatment plan."
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"The hospital's policies and procedures are excellent tools for making client oriented decisions."
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"It won't be fair to expect to get every weekend and holiday off, so I'll certainly work my share."
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"If you don't keep client information confidential you could be terminated immediately."
Pregunta 24
Pregunta
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?
Respuesta
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"I know I'm not as young as I use to be."
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"I just hire help with jobs I can't do myself."
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"You get older you can't do as much, that's life."
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"I have to ask my son for help with the yard work."
Pregunta 25
Pregunta
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?
Respuesta
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Detection of fetal movement
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Observation that the uterus is below the pubis
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Confirmation of the desire to breast- or bottle-feed
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Determination of the presence of morning sickness
Pregunta 26
Pregunta
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.
Respuesta
- True
- False
Pregunta 27
Pregunta
Aprons and gloves should not be worn in common use areas such as corridors, staff room, office or linen room.
Respuesta
- True
- False
Pregunta 28
Pregunta
Masks and goggles must be worn for care activities such as care of residents who have a cough.
Respuesta
- True
- False
Pregunta 29
Pregunta
The use of gloves is an effective substitute for hand washing.
Respuesta
- True
- False
Pregunta 30
Pregunta
You must wash your hands after removing your gloves.
Respuesta
- True
- False
Pregunta 31
Pregunta
In a care home, standard precautions are the responsibility of nurses and carers only.
Respuesta
- True
- False
Pregunta 32
Pregunta
The objective of standard precautions is to prevent the spread of infection within the care home:
Respuesta
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From resident to resident.
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From resident to staff.
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From staff to resident.
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From staff to staff.
-
All answers are correct.
Pregunta 33
Pregunta
The most important procedure for the prevention of infection from microorganisms is:
Respuesta
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Wearing gloves
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properly bagging used linen.
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Effective hand washing.
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Wearing protective eyewear.
Pregunta 34
Pregunta
Bacteria and viruses can spread by way of:
Respuesta
-
Water, food, drinks, and eating utensils.
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Direct contact with people and/or body substances.
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Coughing, sneezing, or vomiting.
-
All answers are correct
Pregunta 35
Pregunta
Which of the following statements are true about effective hand washing?
Respuesta
-
Keep elbows lower than hand when washing and rinsing.
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Use friction to clean between fingers, palms, nail beds, back of hands and wrists
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Wash for 30 seconds or longer using an alcohol-based hand rinse.
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Use a paper towel to turn off the light switch.
Pregunta 36
Pregunta
You should wash your hands:
Respuesta
-
After taking off a gloves and/or apron
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Before going into a resident’s room and after coming out.
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At the beginning and end of my shift.
-
All answers are correct
Pregunta 37
Pregunta
Alcohol-based hand gel SHOULD NOT be used:
Respuesta
-
Prior to contact with resident.
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If fingernails are chipped.
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If the resident has a respiratory infection.
-
If hands are visibly dirty.
Pregunta 38
Pregunta
Which of the following are allowed when you are bare below the elbows?
Respuesta
-
Wedding rings with stones
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Wrist watches
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Long finger nails / nail extensions / false nails
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No answer is correct
Pregunta 39
Pregunta
Who is responsible for cleanliness within the care home?
Respuesta
-
The manager, The housekeeper/domestic staff
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The nurses
-
The carers
-
All answers are correct
Pregunta 40
Pregunta
Cohort isolation means:
Respuesta
-
Different patients with same infection
-
Different infections in same age group
-
Only old age people
-
Only young age people
Pregunta 41
Pregunta
Standard precautions include:
Respuesta
-
Hand hygiene
-
PPE
-
Making the bed
-
All answers are correct
Pregunta 42
Pregunta
Air borne precautions includes?
Respuesta
-
N-95 Mask positive pressure room
-
N-95 Mask.Negative pressure room
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Hand Hygiene
-
Gloves
Pregunta 43
Pregunta
Contact precautions not include: N-95 Mask and Negative pressure room
Respuesta
- True
- False
Pregunta 44
Pregunta
When are additional transmission based precautions required?
Respuesta
-
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
-
All answers are correct
Pregunta 45
Pregunta
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?
Respuesta
-
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
-
Maybe
Pregunta 46
Pregunta
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?
Respuesta
-
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
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Everyone needs to be isolated.
Pregunta 47
Pregunta
Five moments have been identified as critical times when hand hygiene should be performed. These are:
Respuesta
-
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
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Hand should be washed only when you received the patients
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Only when you remember
Pregunta 48
Pregunta
What three elements are needed for a healthcare associated infection to occur?
Respuesta
-
An infectious agent, a source and a susceptible host
-
An infectious agent; carrier; pathogen
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Source,carrier and contact
-
All answers are correct
Pregunta 49
Pregunta
Standard precautions are work practices required for the basic level of infection control. Which of the following do they apply to?
Respuesta
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All Hep B patients
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All patients regardless of suspected or confirmed infection status.
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Only TB patients.
-
No answer is correct
Pregunta 50
Pregunta
The term sterile is absolute; an item is either sterile or not sterile.
Respuesta
- True
- False
Pregunta 51
Pregunta
Only sterile items can be placed on the sterile field.
Respuesta
- True
- False
Pregunta 52
Pregunta
Even if there is no visible sign of a tear, if a glove is thought to have been punctured, it should be changed.
Respuesta
- True
- False
Pregunta 53
Pregunta
The edges of a wrapper are considered sterile.
Respuesta
- True
- False
Pregunta 54
Pregunta
An open-gloving technique would be used when performing urinary catheterization.
Respuesta
- True
- False
Pregunta 55
Pregunta
Living tissue cannot be sterilized but can be rendered surgically clean.
Respuesta
- True
- False
Pregunta 56
Pregunta
Hand washing is not necessary if gloves are worn.
Respuesta
- True
- False
Pregunta 57
Pregunta
The amount of space that should be left between sterile and nonsterile surfaces is 2 to 4 centimeters
Respuesta
- True
- False
Pregunta 58
Pregunta
Culture may be defined as “common values, beliefs, traits, traditions and/or language
that are learned and shared by members of a group.”
Respuesta
- True
- False
Pregunta 59
Pregunta
It is OK to use gestures since each one has the same meaning universally.
Respuesta
- True
- False
Pregunta 60
Pregunta
A client’s cultural background will often determine how they would like to be
approached and their communication style.
Respuesta
- True
- False
Pregunta 61
Pregunta
Which of the following statements is correct?
Respuesta
-
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.
Pregunta 62
Pregunta
Different cultures have varying ideas about family involvement in client care therefore:
Respuesta
-
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.
Pregunta 63
Pregunta
Which of the following is not a reason to assist residents with grooming?
Respuesta
-
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
Pregunta 64
Pregunta
Which of the following encourages independence with activities of daily living?
Respuesta
-
Adequate lighting
-
Putting items within easy reach
-
Praising the resident
-
All answers are correct
Pregunta 65
Pregunta
ADL's an acronym for:
Respuesta
-
Advancing Daily Living
-
Activities of Daily Living
-
Activity of Declining Life
-
Activities Don't Last
Pregunta 66
Pregunta
A resident who needs the grooming items set out and partial performance of the task by the caregiver is considered:
Respuesta
-
Independent
-
Stand by assist
-
Total assist
-
No answers are correct
Pregunta 67
Pregunta
How should the water for the shower be checked?
Respuesta
-
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
Pregunta 68
Pregunta
Medications can be left in the room with the resident because they said they will take them.
Respuesta
- True
- False
Pregunta 69
Pregunta
When a resident refuses a medication, put it in an envelope with name, date, and reason for refusal.
Respuesta
- True
- False
Pregunta 70
Pregunta
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.
Respuesta
- True
- False
Pregunta 71
Pregunta
A pressure ulcer can be defined as a lesion caused by unrelieved pressure resulting in damage of underlying tissues.
Respuesta
- True
- False
Pregunta 72
Pregunta
Partial thickness tissue loss is when subcutaneous fat may be visible as well as tendon or muscle but no bone exposure?
Respuesta
- True
- False
Pregunta 73
Pregunta
A stage 4 pressure ulcer always has undermining and/or tunneling.
Respuesta
- True
- False
Pregunta 74
Pregunta
Wound edges that are detached means that the oase of the wound is deeper than the edges.
Respuesta
- True
- False
Pregunta 75
Pregunta
Which pain scale is the most sensitive to gender and ethnic differences?
Respuesta
-
Visual
-
Verbal
-
Numerical
-
Flacc
Pregunta 76
Pregunta
An entry must be made in the nurse's notes each time you give pain meds with the reason why, time given and effectiveness
Respuesta
- True
- False
Pregunta 77
Pregunta
Care Plans must reflect what interventions work for the patient and which ones don't.
Respuesta
- True
- False
Pregunta 78
Pregunta
A patient is hospitalized with severe depression after her divorce is finalized. Which type of loss is the patient experiencing?
Respuesta
-
Actual
-
Perceived
-
Physical
-
External
Pregunta 79
Pregunta
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?
Respuesta
-
1 to 3 months
-
1 to 2 weeks
-
Days to hours
-
Moments
Pregunta 80
Pregunta
A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care:
Respuesta
-
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
Pregunta 81
Pregunta
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?
Respuesta
-
"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."
Pregunta 82
Pregunta
A nurse is caring for a dying patient who is non-responsive. Which of the following is it important for the nurse to do?
Respuesta
-
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.
Pregunta 83
Pregunta
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?
Respuesta
-
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.
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