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Nursing A Concept Based Approach to Learning 1st Edition Volume 1 NCCLEB Test Bank

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Nursing A Concept Based Approach to Learning 1st Edition Volume 1 NCCLEB Test Bank

ISBN-13: 978-0135078068

ISBN-10: 0135078067

 

Description

Nursing A Concept Based Approach to Learning 1st Edition Volume 1 NCCLEB Test Bank

ISBN-13: 978-0135078068

ISBN-10: 0135078067

 

 

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Below you will find some free nursing test bank questions from this test bank:

 

CONCEPT 13: HEALTH, WELLNESS, AND ILLNESS

 

 

About

 

 

  1. When working with clients and defining the term health, the nurse uses examples from a variety of sources such as Nightingale, the World Health Organization, the President’s Commission on Health, and the ANA. Broadly, health is which of the following? (Select all that apply.)

 

  1. A process
  2. A state of well-being
  3. Purely the absence of disease
  4. A dynamic state of being
  5. Affected solely by physiological factors

 

Answer:

  1. A process
  2. A state of well-being
  3. A dynamic state of being

 

Rationale:

Broad definitions of the term health have been developed by various entities, including those mentioned above. It has been described as a process, a state of well-being, and a dynamic state of being. It is not merely the absence of disease. It involves the whole person as well as the environment, not just physiological factors.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Understanding

Learning Outcome: 1. Define health, illness, wellness, and disease.

 

 

  1. A nurse is assessing a client who practices yoga for relaxation, follows a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. This client would exemplify which of the following levels of wellness?

 

  1. Emergent high-level wellness in a favorable environment
  2. Emergent high-level wellness in an unfavorable environment
  3. Protected poor health in a favorable environment
  4. High-level wellness in a favorable environment

 

Answer:

  1. High-level wellness in a favorable environment

 

Rationale:

High-level wellness in a favorable environment involves biopsychosocial, spiritual, and economic resources that support healthy lifestyles. This client meets those criteria. The client is not emerging into high-level wellness; she has already achieved it. Emergent high-level wellness in an unfavorable environment would be exemplified by a client who has the knowledge to implement healthy lifestyles but does not implement them because of family responsibilities, job demands, or other factors. The client does not have any health problems and therefore does not fit the description of protected poor health.

Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 2. Explain the health-illness continuum and the concept of high-level wellness.

 

 

  1. A nurse educator is reviewing internal variables that affect people’s health status with a group of clients who are interested in impacting their health status in a positive way. Which of the following does the educator explain are examples of internal variables? (Select all that apply.)

 

  1. Genetic makeup
  2. Age
  3. Developmental level
  4. Environment
  5. Spiritual and religious beliefs

 

Answer:

  1. Genetic makeup
  2. Age
  3. Developmental level
  4. Spiritual and religious beliefs

 

Rationale:

Internal variables that affect people’s health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include genetic makeup, gender, age, and developmental level. Psychologic dimensions include the mind–body interactions. Cognitive dimensions include lifestyle choices and spiritual and religious beliefs. Environment is an example of an external variable that affects a person’s health.

Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 3. Define health promotion.

 

 

  1. A nurse is teaching classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those with opposing opinions. The nurse is focusing on which component of wellness?

 

  1. Physical
  2. Social
  3. Emotional
  4. Environment

 

Answer:

  1. Social

 

Rationale:

The social component of wellness focuses on the ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with differing opinions and beliefs. The physical component of wellness is the ability to carry out daily tasks, achieve fitness of all body systems, and practice positive lifestyle habits. The emotional component deals with the ability to manage stress and express emotions appropriately. The environmental component focuses on the health measures that improve the standard of living and quality of life in the community.

Nursing Process: Implementation

Client Need: Psychosocial Integrity

Cognitive Level: Applying

Learning Outcome: 4. Describe the nurse’s role in health promotion.

 

 

  1. A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care and live in poverty. The nurse will be working with clients who are at which level of wellness?

 

  1. Emergent high-level wellness in an unfavorable environment
  2. Protected poor health in a favorable environment
  3. Poor health in an unfavorable environment
  4. Protected poor health in an unfavorable environment

 

Answer:

  1. Poor health in an unfavorable environment

 

Rationale:

The health axis extends from peak wellness to death, and the environmental axis extends from very favorable to very unfavorable. A health mission to an environment such as rural Haiti would involve clients who are not being treated for problems because of poor access and who also live in poor environmental conditions such as poverty and below standard sanitation. Emergent high-level wellness in an unfavorable environment would include clients who have the knowledge to implement healthy lifestyle practices, but cannot implement them because of other factors or demands. Protected poor health in a favorable environment is where clients have an illness but their needs are met by the health care system. These clients have adequate access to appropriate medications, diet, and health care instruction. Protected poor health in an unfavorable environment is not one of Dunn’s quadrants.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 5. Identify characteristics of health, disease, and illness.

 

 

  1. The nurse is caring for a client who has been diagnosed with type 2 diabetes. The nurse determines that the client understands teaching when the client states which of the following?

 

  1. “I will have to take medications for this disease.”
  2. “Chronic illnesses require lifestyle changes.”
  3. “I will take medication for a week for this acute illness.”
  4. “This chronic disease will become worse and lead to death.”

 

Answer:

  1. “Chronic illnesses require lifestyle changes.”

 

Rationale:

Chronic illness is the client’s response to the disease and, in this case, requires lifestyle changes so that the client does not succumb to the disease. Not all diabetics require medication to manage the illness. Diabetes is chronic, not acute. Depending on the client’s response to the disease, the outcome may not become worse or lead to death.

Nursing Process: Evaluation

Client Need: Physiological Integrity

Cognitive Level: Evaluating

Learning Outcome: 6. Differentiate illness from disease and acute illness from chronic illness.

 

 

  1. The industrial nurse is planning programs to address health problems identified in the Healthy People 2010 report. The nurse should include which of the following programs with company employees at the worksite?

 

  1. Stress management
  2. Depression screening
  3. Abuse screening
  4. Substance abuse education

 

Answer:

  1. Stress management

 

Rationale:

Healthy People 2010 identifies the specific problem of worksites that fail to provide programs to prevent or reduce employee stress. While depression and abuse screening and substance abuse education are worthy of attention, they are not as prevalent a problem of the worksite as stress management is.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 7. Develop and evaluate plans for health promotion across the life span.

 

 

 

Exemplar 13.1: Health Beliefs

 

 

  1. During the nursing assessment of the adult client, the nurse finds the client’s beliefs and actions related to common health practices to be “bizarre.” The most appropriate action for the nurse to take at this time would be to:

 

  1. Repeat the assessment later in the day.
  2. Communicate the findings to the health care team.
  3. Inquire as to the culture with which the client identifies.
  4. Write a nursing diagnosis to address the “bizarre” beliefs and actions.

 

Answer:

  1. Inquire as to the culture with which the client identifies.

 

Rationale:

A thorough assessment is needed before proceeding with other steps of the nursing process. Behavior that is considered bizarre in one cultural context may be considered desirable in another. While findings will be communicated and used for nursing diagnosis formulation, these steps are built upon a thorough assessment. Repeating the assessment will most likely result in the same incomplete data. Writing a nursing diagnosis before investigating the client’s culture would be premature.

Nursing Process: Assessment

Client Need: Psychosocial Integrity

Cognitive Level: Applying

Learning Outcome: 1. Describe health belief.

 

 

  1. The Great American Smokeout may motivate many individuals to stop smoking by promoting self-efficacy. Which of the following statements leads the nurse to expect a positive outcome for this client?
  2. “I know that this time I will quit smoking permanently.”
    2. “I am going to do the best that I can, so that I won’t get lung cancer.”
    3. “I am afraid of getting lung cancer like my father.”
    4. “I think this time will be different.”

Answer:

  1. “I know that this time I will quit smoking permanently.”

Rationale:

Self-efficacy refers to the level of confidence an individual has about the ability to perform the activity. The client’s intention to make a permanent change shows the highest level of determination and motivation. Stating that one will do the best one can or thinking that this attempt at quitting smoking will be different are not highly positive indicators of motivation. Stating fear of getting lung cancer does not address a positive activity.

Nursing Process: Evaluation

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 2. Identify factors that modify health beliefs.

 

 

 

Exemplar 13.2: Physical Fitness and Exercise

 

 

  1. The nurse planning care for a client who has been hospitalized for two weeks selects the nursing diagnosis Risk for Disuse Syndrome. While assisting the client with a bath, the nurse plans full range of motion in all the client’s joints. The activity that would best support range of motion in the hand and arm is to:

 

  1. Give the client a washcloth to wash her face.
  2. Move the wash basin farther toward the foot of the bed so the client must reach.
  3. Have the client brush her own hair and teeth.
  4. Move each of the client’s hand and arm joints through passive range of motion.

 

Answer:

  1. Have the client brush her own hair and teeth.

 

Rationale:

The best range of motion is the natural movement of the client’s joints in normal activity. Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. The wash basin should be close to the client to prevent overreaching and possible falls. Passive range of motion is a second best choice after normal use of the joints.

Nursing Process: Diagnosis

Client Need: Physiologic Integrity

Cognitive Level: Applying

Learning Outcome: 1. Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise.

 

 

  1. A client is interested in beginning an exercise program and asks the nurse what health risks can be reduced by regular exercise. The nurse determines that the client understands the teaching when the client selects which of the following? (Select all that apply)
  2. Risk of cardiovascular disease
    2. Risk of skin cancer
    3. Risk of colon cancer
    4. Risk of hypertension
    5. Risk of renal disease

Answer:

  1. Risk of cardiovascular disease
  2. Risk of colon cancer
  3. Risk of hypertension

 

Rationale:

Regular physical activity results in a decreased risk of cardiovascular disease, colon cancer, and hypertension. It does not decrease the risk of skin cancer or renal disease.

Nursing Process: Assessment

Client Need:  Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 2. Describe the effects of exercise on body systems.

 

 

  1. The nurse is caring for an elderly client of another race who was medically diagnosed with early osteoporosis. Which intervention is most applicable for this client?

 

  1. Institute an exercise plan that includes weight-bearing activities
  2. Increase the amount of calcium in the client’s diet
  3. Protect the client’s bones with strict bed rest
  4. Provide the client with assisted range of motion exercising twice daily

 

Answer:

  1. Institute an exercise plan that includes weight-bearing activities

 

Rationale:

Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bone, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities. Additional calcium in the diet after osteoporosis has begun is not thought to be effective. Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity. Assisted range of motion exercises are not weight bearing and do not help delay or reverse osteoporosis.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 3. Assess activity-exercise pattern and activity tolerance.

 

 

  1. A group of students is meeting with the school nurse to be evaluated after a class on recommendations for physical activity. Which student has met the outcome for physical activity set by the Centers for Disease Control?
  2. A 16-year-old who runs at a fast pace for 20 minutes 2 times per week
    2. A 15-year-old who lifts moderately heavy weights 15 minutes 3 times per week
    3. A 17-year-old who jogs for 30 minutes 5 times per week
    4. A 13-year-old who speed walks 60 minutes once per week

Answer:

  1. A 17-year-old who jogs for 30 minutes 5 times per week

 

Rationale:

The recommendations for physical activity for adolescents are moderate activity for 30 minutes on 5 or more days per week or vigorous exercise for 20 or more minutes on 3 or more days per week. Only the answer that the adolescent who jogs for 30 minutes 5 days per week fits the referenced criteria.

Nursing Process:  Evaluation

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 4. Develop nursing diagnoses and outcomes related to activity and exercise.

 

 

 

Exemplar 13.3: Oral Health

 

 

  1. A 6-year-old child is being seen by the nurse for a well-child checkup. The parent tells the nurse that they live on a farm and their water supply is from a well. Which of the following does the nurse plan to teach the family?

 

  1. Use of fluoride
  2. Effect of sugary foods
  3. Use of teeth whitener
  4. Use of mouthwash

 

Answer:

  1. Use of fluoride

 

Rationale:

Many changes occur in the mouth during school-age years, necessitating periodic examination. Inquire about use of fluoride if the water supply is not fluoridated. Well water does not contain fluoride. While the nurse may teach about the effect of sugary foods on teeth, the priority would be to teach about fluoride, since this family’s water supply does not provide it.  Teeth whitener is not mentioned in the scenario, and while the nurse would be concerned if a 6-year-old was using it, fluoride use is more important. Mouthwash use in a 6-year-old is not as important as asking about fluoride use.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 1. Identify factors influencing oral health.

 

 

  1. Several older adult clients in the nurse’s care report growing concerns about their dental health. They state they need to have dental work done despite continuing the same hygiene habits they have employed for years. They inquire about the underlying cause for these changes. What information should be given to these clients?

 

  1. Dental health begins to decline with aging.
  2. The loss of bone density with aging will result in tooth decay and breakage.
  3. Increases in saliva production increase exposure of the tooth’s enamel to corrosive agents.
  4. Metabolism changes in aging contribute to dental destruction.

 

Answer:

  1. The loss of bone density with aging will result in tooth decay and breakage.

 

Rationale:

The changes in bone health from aging will impact dental health. Simply stating that aging causes problems does not meet the client’s request for information on an underlying cause. Saliva production decreases with aging. Metabolic changes have not led to the changes.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 2. Identify normal and abnormal assessment findings across the

life span.

 

 

  1. The nurse working with a family has observed that the older children have a large number of dental caries, and so plans to provide the mother with information to prevent the development of dental caries in her new infant. Which of these interventions prevents the development of dental caries in infants? (Select all that apply.)

 

  1. Wiping the infant’s gums with soft moist gauze once or twice daily
  2. Avoiding nursing or giving the infant a bottle at bedtime
  3. Giving foods high in sugar only at breakfast time
  4. Using a toothbrush as soon as the first tooth erupts
  5. Using a topical anesthetic daily, beginning as soon as the first tooth begins to erupt

 

Answer:

  1. Wiping the infant’s gums with soft moist gauze once or twice daily
  2. Avoiding nursing or giving the infant a bottle at bedtime

 

Rationale:

The only options given that will assist in the prevention of dental caries are wiping the gums with a soft moist gauze and avoiding putting the infant to bed with a bottle.  Foods high in sugar should be avoided in the infant at all times.  A toothbrush should not be used during infancy.  Topical anesthetic should not be applied daily.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 3. Describe the significance of oral hygiene across the life span.

 

 

  1. Which of the following expected outcomes is correct for a client with the nursing diagnosis self-care deficit related to cognitive impairment?

 

  1. The client will be able to name the staff that works on the day shift.
  2. The client will eliminate safety hazards in her environment.
  3. The client, with supervision, will brush her teeth.
  4. The nurse will stress the importance of adequate fluid intake.

 

Answer:

  1. The client, with supervision, will brush her teeth.

 

Rationale:

A client with cognitive impairment would be able to brush her teeth but only with supervision. She would not voluntarily brush her teeth without prompting from the staff. Cognitive impairment limits the client’s ability to understand and comprehend; therefore, stressing adequate fluid intake, naming the staff, and eliminating safety hazards are not within her realm of understanding.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 4. Develop nursing diagnoses and outcomes related to oral health.

 

 

 

Exemplar 13.4: Nutrition Screening

 

 

  1. The nursing diagnosis readiness for enhanced nutrition related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. An appropriate outcome for this client would be which of the following?

 

  1. Client will understand the importance of eating healthy.
  2. Client will be able to lose weight.
  3. Client will list foods that are nutritionally sound, low fat, and high fiber.
  4. Client will appreciate the value of using the food guide pyramid.

 

Answer:

  1. Client will list foods that are nutritionally sound, low fat, and high fiber.

 

Rationale:

Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like “understand” or “appreciate” are not measurable and are not observable. “Be able to lose weight” is not specific enough, and with the information given, it is not known if that is really what the client wants to attain.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 1. Define nutritional health.

 

 

  1. The client reports that her teenager has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this teenager does not become iron deficient? (Select all that apply.)

 

  1. Tofu
  2. Soybean milk
  3. Brewer’s yeast
  4. Orange juice
  5. Okra

 

Answer:

  1. Tofu
  2. Soybean milk
  3. Orange juice

 

Rationale:

While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency are tofu, soybean milk, and orange juice. Tofu and soybean milk are good sources of protein and iron. Orange juice supports iron absorption from foods since it is high in vitamin C. Brewer’s yeast is a good source of vitamin B12, which is often low in vegan diets.

Nursing Process: Implementation

Client Need: Physiological Integrity

Cognitive Level: Applying

Learning Outcome: 2. Outline risk factors that affect nutritional health status.

 

 

  1. The client’s lab studies reveal a normal serum albumin with a prealbumin of 10. How does the nurse interpret the significance of these readings?

 

  1. The client has had recent protein malnutrition.
  2. The client is now relatively well nourished with malnutrition 6 to 8 months ago.
  3. The client is at risk for development of malabsorption syndromes.
  4. Carbohydrate malnutrition has occurred over the last 6 months.

 

Answer:

  1. The client has had recent protein malnutrition.

 

Rationale:

Prealbumin is the most responsive serum protein to rapid changes in nutritional status. A level below 11 indicates that aggressive nutritional intervention is necessary. Serum albumin is the slowest of the serum proteins to reflect changes, so abnormalities indicate prolonged protein malnutrition. There is no specific link to malabsorption syndromes. These tests are indicators of protein malnutrition, not carbohydrate malnutrition.

Nursing Process: Evaluation

Client Need: Physiological Integrity

Cognitive Level:  Analyzing

Learning Outcome:   3. Identify physical and laboratory parameters utilized in a nutrition assessment.

 

 

  1. An African American male is discussing his dietary intake with the nurse. The nurse encourages the client to keep sodium intake below 1,500 mg per day. The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive. How should the nurse respond?

 

  1. “African Americans typically have higher sodium levels than their Caucasian counterparts.”
  2. “This is the amount of sodium intake recommended for everyone.”
  3. “This is what will be best for you.”
  4. “Do you eat a great deal of salt?”

 

Answer:

  1. “African Americans typically have higher sodium levels than their Caucasian counterparts.”

 

Rationale:

After generations of conditioning, African Americans frequently have higher sodium levels. The recommended sodium intake for African Americans is slightly lower than are the levels for their Caucasian peers. Simply telling the client the recommendation is “best” does not provide an adequate level of information. The amount of salt ingested by the client should be recorded, but this is not the best response.

Nursing Process: Implementation

Client Needs: Physiological Integrity

Cognitive Level: Applying

Learning Outcome: 4. Identify components of a diet history and techniques for gathering diet history data.

 

 

  1. The nurse in an outpatient setting determines that the teen client is overweight by calculating the client’s body mass index. The teen tells the nurse that cutting all fat from the diet is the way to lose weight. What initial action by the nurse is indicated?

 

  1. Contact the physician
  2. Notify the client’s parents
  3. Refer the client to a dietitian
  4. Discuss the role of fat in daily intake

 

Answer:

  1. Discuss the role of fat in daily intake

 

Rationale:

All individuals require some fat in the diet. It is important for the nurse to discuss this with the client. A discussion with the parents and physician is likely warranted but can wait until after discussion with the client. The interaction will provide additional information concerning the client’s knowledge of the needed dietary elements. A referral from the physician is needed to contact the dietitian.

Nursing Process: Assessment

Client Need: Physiological Integrity

Cognitive Level: Applying

Learning Outcome: 5. Describe existing validated nutritional assessment tools.

 

 

  1. The client is planning to begin trying to conceive a child. What foods should the nurse recommend be included in the client’s daily intake?

 

  1. Potatoes, tomatoes, and sweet potatoes
  2. Dark green vegetables, lean beef, and eggs
  3. Liver, legumes, and citrus fruits
  4. Whole grains, yeast breads, and milk

 

Answer:

  1. Dark green vegetables, lean beef, and eggs

 

Rationale:

To promote a healthy pregnancy, women planning to attempt conception are encouraged to increase their daily intake of folic acid. This will reduce the incidence of neural tube defects. Milk, potatoes, and tomatoes are sources of vitamin B6. Liver and legumes provide a source of biotin. Citrus fruits provide vitamin C, while whole grains are a source of folic acid, yeast bread is a source of panotothenic acid, and milk is a source of calcium and vitamin D.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 6. Identify specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

 

 

  1. The nurse is caring for a teen who is hospitalized with a diagnosis of anorexia nervosa. When developing the plan of care for the client and family, the nurse includes:

 

  1. Serve the client three balanced meals per day.
  2. Observe the client’s activities for 15 minutes after eating.
  3. Discuss weight-gain needs with the client.
  4. Provide a variety of cold or room-temperature foods.

 

Answer:

  1. Provide a variety of cold or room-temperature foods.

 

Rationale:

Cold or room-temperature foods are often more appealing to clients with anorexia nervosa. Three meals daily could be overwhelming in size to the client. Smaller, more frequent offerings will be better received by the client. The client with bulimia is the client who needs to be observed for vomiting after meals. A focus on gaining weight will promote fixation on pounds instead of health with this population.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 7. Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

 

 

 

Exemplar 13.5: Normal Sleep/Rest Patterns

 

 

  1. The nurse in the hospital is obtaining ordered vital signs on the client who has been diagnosed with pneumonia. The client is on a monitor, and vital signs are recorded from the monitor in order to leave the client undisturbed during the night. The nurse observes that blood pressure, heart rate, and respirations are below baseline for this client. The nurse concludes which of the following about the client?

 

  1. The client is about to have a cardiac arrest.
  2. The client is in stage II of NREM sleep.
  3. The client’s metabolic rate has increased.
  4. The client is in stage IV of NREM sleep.

 

Answer:

  1. The client is in stage IV of NREM sleep.

 

Rationale:

During stage IV sleep, the client is relaxed, and vital signs decrease from baseline by 20-30%. Stage II sleep is characterized by light sleeping with vital signs decreasing slightly. The client’s metabolic rate is decreased in stage IV. A decrease in vital signs is normal during stage IV sleep, and the client is not necessarily at risk for cardiac arrest.

Nursing Process: Assessment

Client Need: Physiologic Integrity

Cognitive Level: Analyzing

Learning Outcome: 1. Explain the functions and the physiology of sleep.

 

 

  1. The mother of a newborn calls the pediatric clinic and states, “I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesn’t breathe regularly, and she sometimes twitches.” What advice should the nurse give this mother?

 

  1. “Please bring your baby in immediately for a checkup.”
  2. “These are common behaviors in newborns and are normal.”
  3. “You should ask the physician about these symptoms at your next checkup.”
  4. “If your baby does this again, take her to the emergency department.”

 

Answer:

  1. “These are common behaviors in newborns and are normal.”

 

Rationale:

These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal. Having the mother wait until the next checkup unnecessarily delays this reassurance. There is no need for an immediate trip to the clinic or to the emergency department.

Nursing Process: Implementation

Client Need: Physiologic Integrity

Cognitive Level: Analyzing

Learning Outcome:  2. Identify the characteristics of the sleep states.

 

 

  1. This is the first hospitalization for an adult client who, after being admitted 3 days ago, is now having trouble sleeping. The nurse also notes some confusion during waking hours. Which of the following would be the most appropriate nursing diagnosis for this client?

 

  1. Ineffective Health Maintenance
  2. Ineffective Coping
  3. Disturbed Sensory Perception
  4. Disturbed Sleep Pattern

 

Answer:

  1. Disturbed Sleep Pattern

 

Rationale: The client is in a new environment. Changes in environment bring about uncertainty, and the client may be unable to sleep or may sleep less well than at home. Although the client is confused, there is no other data presented that could be the cause, making Disturbed Sleep Pattern a more appropriate selection than Disturbed Sensory Perception. In addition, Disturbed s\Sensory Perception relates to one of the five senses. Ineffective Health Maintenance and Ineffective Coping are more global and not applicable to this client’s situation.

Nursing Process: Diagnosis

Client Need: Physiological Integrity

Cognitive Level: Analyzing

Learning Outcome: 3. Describe variations in sleep patterns throughout the life span.

 

 

  1. The client who is about to be discharged asks the nurse for suggestions on how to improve the quality of her sleep so that she can wake feeling refreshed in the morning. The nurse reviews the client’s history and suggests: (Select all that apply.)

 

  1. Adjust the temperature in the room to a comfortable level.
  2. Change the time of aerobic exercise to one hour prior to sleep.
  3. A cup of tea before bed is relaxing.
  4. Limit the use of alcohol to early in the evening.
  5. Do not smoke before bedtime.

 

Answers:

  1. Adjust the temperature in the room to a comfortable level.
  2. Limit the use of alcohol to early in the evening.
  3. Do not smoke before bedtime.

 

Rationale: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and its consumption should be limited to well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise close to bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

Nursing Process: Implementation

Client Need: Physiologic Integrity

Cognitive Level: Applying

Learning Outcome: 4. Describe interventions that promote normal sleep.

 

 

 

Exemplar 13.6: Consumer Education

 

 

  1. A nurse is working with a family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should:

 

  1. Provide written instructions before discharge.
  2. Address any healing beliefs the family has.
  3. Make sure the child comes back for the follow-up appointment.
  4. Make sure the parents can set up the treatments for their child.

 

Answer:

  1. Address any healing beliefs the family has.

 

Rationale:

The client who does not understand will learn little, and providing an interpreter to assist with communication is extremely important in this situation. However, if the prescribed treatment conflicts with the client/family’s cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client’s parents. It is also important to provide written material and assess the psychomotor skills of the child, but the first priority is ascertaining any belief conflicts that may interfere with the treatment.

Nursing Process: Assessment

Client Need: Safe and Effective Care Environment

Cognitive Level: Analyzing

Learning Outcome: 1. Explain the importance of the teaching role of the nurse in consumer education.

 

 

  1. A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client says, “I already know what you are attempting to teach because I looked everything up on the Internet.” The best action for the nurse to take is to:

 

  1. Document that the client understands teaching.
  2. Give the client printed learning materials.
  3. Teach the client’s support system how to perform the procedure.
  4. Require the client to perform a return demonstration.

 

Answer:

  1. Require the client to perform a return demonstration.

 

Rationale:

The nurse is responsible for documenting that the client can perform the skill that has been taught. Giving the client written directions or teaching the support person does not meet the requirement that the client will perform the skill. The nurse cannot document that the client understands teaching until a return demonstration by the client is correctly performed.

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

Cognitive Level: Analyzing

Learning Outcome: 2. Explain the implications of using the Internet as a source of health information.

Source: Kozier/Cheryl Gardner

 

 

  1. The nurse has completed client teaching regarding medication administration to a client whose goal is compliance with therapy. Which of the following statements by the client best illustrates compliance?

 

  1. “I’m glad to know about my medications. It makes taking them a lot easier.”
  2. “I already knew most of what you told me.”
  3. “I think you should have waited until I was ready to go home. Maybe I’d remember better.”
  4. “If I take my medications as prescribed, I’ll feel better.”

 

Answer:

  1. “I’m glad to know about my medications. It makes taking them a lot easier.”

 

Rationale:

Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they are prescribed and improves the possibility for following the prescribed regimen. Statements of prior knowledge do not necessarily lead to compliance, and neither does merely following the advice of the health care prescriber.

Nursing Process: Evaluation

Client Need: Physiological Integrity

Cognitive Level: Analyzing

Learning Outcome: 3. Identify methods to evaluate learning.

 

 

  1. A home health nurse is working with a client who has pulmonary fibrosis. The nurse at the time of discharge established which of the following teaching priorities for follow-up care?

 

  1. The client will be able to set up and administer a nebulizer treatment by the end of the day.
  2. The client will have increased activity level by the end of the week.
  3. The client will be able to do ADLs (activities of daily living) without shortness of breath in 3 days.
  4. The client will have a positive attitude about the diagnosis by the end of the month.

 

Answer:

  1. The client will be able to set up and administer a nebulizer treatment by the end of the day.

 

Rationale:

Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslow’s hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs.

Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive Level: Applying

Learning Outcome: 4. Demonstrate effective documentation of teaching–learning activities.