NEW UPDATE QUESTIONS AND ANSWERS FOR CRITICAL CARE HESI PRACTICE EXAM 2022

NEW UPDATE QUESTIONS AND ANSWERS FOR CRITICAL CARE HESI PRACTICE EXAM 2022 NEW UPDATE QUESTIONS AND ANSWERS FOR CRITICAL CARE HESI PRACTICE EXAM 2022 a - IS the selected answer: The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently b - IS the selected answer: A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver d - IS the selected answer: A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation c - IS the selected answer: A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? a. Loss of skin integrity caused by the burns b. Potential infection as a result of the burn injury c. Inadequate gas exchange caused by smoke inhalation d. Decreased fluid volume because of the depth of the burns b - IS the selected answer: During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? a. Hypokalemia and hyponatremia b. Hyperkalemia and hyponatremia c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia a - IS the selected answer: A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? a. Normal sinus rhythm b. Sinus tachycardia c. Sinus bradycardia d. Sinus arrhythmia b - IS the selected answer: The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity c. Physical mobility d. Urinary elimination c - IS the selected answer: A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer c - IS the selected answer: A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. Decreased rate of glomerular filtration b. Excessive blood loss through the burned tissues c. Plasma proteins moving out of the intravascular compartment d. Sodium retention occurring as a result of the aldosterone mechanism a - IS the selected answer: The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? a. Azotemia b. Hypokalemia c. Metabolic alkalosis d. Respiratory alkalosis d - IS the selected answer: A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. Equal b. Unrelated c. Inversely related d. Directly proportional c - IS the selected answer: A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted. b. Dressings will be changed daily. c. Personal protective equipment will be worn by staff. d. Room temperature will be kept below 72° F (22.2° C). a - IS the selected answer: A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities b - IS the selected answer: A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice a - IS the selected answer: A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? a. "Do you have chest pain?" b. "Are you feeling anxious?" c. "Do you have any palpitations?" d. "Are you feeling short of breath?" b - IS the selected answer: During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? a. Stimulating crying b. Suctioning the airway c. Using an Ambu bag with oxygen support d. Placing the infant in the reverse Trendelenburg position c - IS the selected answer: While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin and aspirin b. Slow the rate and monitor the vital signs c. Stop the transfusion and administer normal saline through new IV tubing d. Ask the client to further describe the feeling and rate the pain d - IS the selected answer: A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future d. Beginning realization of implications for the future b - IS the selected answer: A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b. Numbness c. Skin desquamation d. Generalized discomfort b - IS the selected answer: Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown d. Colorless c - IS the selected answer: A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? a. Level of consciousness and pupil size b. Characteristics of pain and blood pressure c. Quality of respirations and presence of pulses d. Observation of abdominal contusions and other wounds b - IS the selected answer: Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? a. Red b. Black c. Green d. Yellow a - IS the selected answer: A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? a. Use a consistent approach to care and encourage participation. b. Prepare equipment while doing the procedure and explain the treatment to the client. c. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. d. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. b - IS the selected answer: Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia b - IS the selected answer: A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? a. Provide low-sodium milk. b. Provide high-protein drinks. c. Provide foods that are low in potassium. d. Provide 10% more calories in the form of fats. d - IS the selected answer: A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? a. 20 b. 25 c. 30 d. 36 d - IS the selected answer: A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels a - IS the selected answer: Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS) b - IS the selected answer: The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag b - IS the selected answer: On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? a. Prepare for blood transfusions. b. Notify the surgeon immediately. c. Make the client nothing by mouth (NPO). d. Administer the prescribed preoperative sedative. a - IS the selected answer: A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? a. Become aware of their personal values b. Gain information related to their needs c. Make correct decisions related to their health d. Alter their value systems to make them more socially acceptable b - IS the selected answer: An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? a. Shyness b. Cultural variation c. Symptom of depression d. Shame regarding treatment d - IS the selected answer: Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? a. Get the client's full name and address. b. Call for assistance from the psychiatrist. c. Know some myths and facts about sexual assault. d. Be aware of any personal bias about sexual assault. c - IS the selected answer: Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans a - IS the selected answer: The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? a. The child is developing a conscience. b. The child is learning about gender roles. c. The child is developing a sense of security. d. The child is learning about the political process. c - IS the selected answer: A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion. b. Discuss the case with coworkers. c. Notify the primary healthcare provider of the client's refusal of blood products. d. Explain to the client that they will die without the blood transfusion. b - IS the selected answer: Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? a. Enjoyment of specific foods is inherited. b. There are familial influences on childhood eating habits. c. Childhood obesity is usually not a predictor of adult obesity. d. Children with obese parents are destined to become obese themselves. d - IS the selected answer: After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? a. Increased cultural sensitivity b. Decreased cultural imposition c. Decreased cultural dissonance d. Increased cultural competence a - IS the selected answer: A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? a. Contact an interpreter provided by the hospital. b. Contact the client's family member to translate for the client. c. Communicate with the client using Spanish phrases the nurse learned in a college course. d. Communicate with the client with the use of a hospital-approved Spanish dictionary. b - IS the selected answer: During a routine checkup a patient reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the patient's weight and BMI at a healthy range, but the patient states, "I wish I were as thin as my co-workers." The patient is at risk for what culturally-bound condition? a. Neurasthenia b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a - IS the selected answer: The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain b. Check the pressure dressing for bleeding c. Assist the client to ambulate around his room d. Irrigate the client's nasogastric tube with sterile water a - IS the selected answer: A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? a. Culture shock b. Social immaturity c. Experience of discrimination d. Lack of interest in school activities d - IS the selected answer: A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? a. Assign articles about various cultures so that they can become more knowledgeable. b. Relocate the nurses to units where they will not have to care for clients from a variety of cultures. c. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. d. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work. a - IS the selected answer: A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? a. Coin in the umbilicus b. Tight diaper over the umbilicus c. Binder that encircles the umbilicus d. Adhesive tape across the umbilicus c - IS the selected answer: What should a nurse consider about the past experiences of clients who have immigrated to this country? a. It affects all of their inherited traits. b. There will be little impact on their lives today. c. It is important that their values be assessed first. d. How they will interact is permanently established. a - IS the selected answer: Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler? a. Children have no concept of right or wrong to guide their behaviors. b. Children imitate the religious behaviors without comprehending any meaning. c. Children reason and question some of the established parental religious standards. d. Children have a reverence for religious matters and are able to articulate their faith. c - IS the selected answer: A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative impact on people's health." a - IS the selected answer: A resident in a nursing home recently immigrated to the United States (Canada) from Italy. How does the nurse plan to provide emotional support? a. By offering choices consistent with the client's heritage b. By assisting the client in adjusting to American culture c. By ensuring that the client understands American beliefs d. By correcting the client's misconceptions about appropriate health practices b - IS the selected answer: A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? a. Ask the nursing supervisor to discuss this with the healthcare provider. b. Encourage the family to bring in special foods preferred in their culture. c. Order a high-protein milkshake as a between-meal snack to stimulate her appetite. d. Explain to the family that the dietitian plans nutritious meals that the client should eat. d - IS the selected answer: Which internal variable influences health beliefs and practices? a. Family practices b. Cultural background c. Socioeconomic factors d. Intellectual background c - IS the selected answer: A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? a. The patient is of Asian culture. b. The patient is of African culture. c. The patient is of North American culture. d. The patient is of Latin American culture. c - IS the selected answer: As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? a. Setting of care b. Anxiety disorder c. Attitudes and beliefs d. Cultural and ethnic disparities d - IS the selected answer: The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family c - IS the selected answer: How can the lines of communication be improved in a healthcare organization during the process of delegation? a. By considering all aspects of client care b. By selecting experienced nursing assistants as delegatees c. By appreciating and valuing each other's cultural perspectives d. By selecting a delegatee having similar strengths as that of the delegator b - IS the selected answer: During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a. Spiritual belief b. Family practices c. Emotional factors d. Cultural background d - IS the selected answer: The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? a. Yin/Yang balance b. Biomedical belief c. Determinism belief d. Magicoreligious belief a - IS the selected answer: A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? a. Cultural desire b. Cultural awareness c. Cultural knowledge d. Cultural encounters a - IS the selected answer: A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver? a. The nurse provides therapeutic treatment to the client. b. The nurse teaches the client about signs of spiritual distress. c. The nurse communicates the wishes of the client to family members. d. The nurse collaborates with the agency chaplain to pursue the best treatment plan. a,b,c - IS the selected answer: Which nursing interventions are examples of the nurse as a caregiver? (Select all that apply) a. Encouraging the client to exercise daily b. Setting goals for the client to reduce weight c. Arranging for the client to meet a spiritual advisor d. Evaluating the client's understanding of prescribed diet e. Demonstrating the procedure to self-administer insulin injection b - IS the selected answer: An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? a. "The prevalence of hypertension is about equal for women of all races." b. "The higher-risk population is composed of African-American men and women." c. "The highest-risk population consists of older Caucasian-American men and women." d. "The prevalence of hypertension is greater for African-American men than for African-American women." c - IS the selected answer: A nurse understands that when a client is a member of a different ethnic community it is important to do what? a. Ensure that the nurse's biases are understood by the family. b. Make plans to counteract the client's misconceptions about therapies. c. Offer a therapeutic regimen compatible with the lifestyle of the family. d. Recognize that the client's responses will be similar to other clients' responses. d - IS the selected answer: Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson's Transpersonal Caring? a. Promoting transpersonal teaching-learning b. Promoting and expressing positive and negative feelings c. Developing a helping, trusting, human caring relationship d. Providing for a supportive, protective, and/or spiritual environment d - IS the selected answer: The nurse leader states, "The people in rural America dress and act differently from those in urban centers." What concept describes this statement? a. Acculturation b. Ethnocentrism c. Cultural imposition d. Cultural marginality c - IS the selected answer: A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism d - IS the selected answer: The nurse is assessing a Latino-Caribbean patient who was brought to the hospital by family members. The family reports the patient started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? a. Bulimia nervosa b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a - IS the selected answer: A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? a. Seek the help of an official interpreter. b. Seek the help of the primary healthcare provider to assist the client. c. Seek help from the client's family friend who speaks the client's language. d. Seek help from the client's caregiver who speaks the same language as the client. c - IS the selected answer: A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? a. Cohesiveness b. Educational level c. Cultural background d. Socioeconomic status c - IS the selected answer: A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? a. They affect their inherited traits. b. They have little effect on their lives today. c. They are important in assessment of their values. d. They establish personal interactions throughout life. a - IS the selected answer: When caring for a client who adheres to a kosher diet, which important thing should the nurse make sure to exclude from the client's meals? a. Pork and shellfish b. Blood-containing food c. All meat, fish, and poultry d. Animal and dairy products during Lent d - IS the selected answer: A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? a. "Do you like living in this country?" b. "When did you come to this country?" c. "Is there a family member who can translate for you?" d. "Which family member do you prefer to receive information?" a - IS the selected answer: A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario? a. Spiritual factors b. Emotional factors c. Developmental stage factors d. Intellectual background factor b - IS the selected answer: A pregnant client states, "Abortion is banned in our community because it interferes with God's creative work." According to the nurse, which variable influences the client's health belief? a. Emotional factors b. Cultural background c. Socioeconomic factors d. Perception of functioning d - IS the selected answer: A school nurse works with adolescents who recently immigrated to the U.S. and are adjusting to life in the public schools. What characteristics help the nurse differentiate students who are assimilating from students who are acculturating? a. Students who acculturate shun all aspects of their new culture. b. Students who assimilate are generally unhappy in their new culture. c. Students who acculturate tend to be more social in their new culture. d. Students who assimilate abandon all aspects of their original culture. c - IS the selected answer: A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? a. Eating beef and veal is prohibited. b. Consumption of fish with scales is forbidden. c. Meat and milk at the same meal are forbidden. d. Consuming alcohol, coffee, and tea are prohibited. c - IS the selected answer: The nurse starts a new job and recognizes that the patient population is very diverse. What action will help the nurse to provide culturally competent care? a. Read about all of the cultural groups in the local population. b. Treat all of the patients the same, regardless of their cultural background. c. Increase self-awareness of cultural identity, cultural knowledge, and potential biases. d. Attempt to remain culturally neutral while treating patients of a different culture. c - IS the selected answer: Among which group of women are breast cancer death rates the lowest? a. Hawaiian b. Puerto Rican c. Asian American d. African American a,b,c,d - IS the selected answer: When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities Hispanic older adults face? (Select all that apply). a. Value differences b. Language barrier c. Lack of health care facility d. Inadequate health insurance e. Poor diet and nutrition a,b,e - IS the selected answer: What statements about culturally congruent care by the student nurse are correct? (Select all that apply). a. "It is the main goal of transcultural nursing." b. "It is provided through cultural competence." c. "It is provided in accordance with set criteria." d. "It is bound to the professional health care system." e. "It depends on the patterns and needs of an individual." b - IS the selected answer: A patient with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the patient's behavior and attitude is most consistent with which cultural group? a. German culture b. Somalian culture c. Ukrainian culture d. More secular culture d - IS the selected answer: A patient who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? a. The student expects the interpreter to act as the patient's advocate. b. The student expects the interpreter to have a health care background. c. The student maintains steady eye contact with the patient. d. The student talks only to the interpreter about the patient. b - IS the selected answer: While talking with a 60-year-old patient, the nurse learns that the patient emigrated 15 years ago from China and likes to live independently away from the patient's grown children. The patient eats only Chinese foods at home. What should the nurse infer from these findings? a. The patient has undergone assimilation. b. The patient has undergone biculturalism. c. The patient has undergone acculturation. d. The patient has undergone enculturation. b - IS the selected answer: Which instruction would be most beneficial for an aging African-American client with hypertension? a. "Check the pulse daily." b. "Have an annual urinalysis." c. "Record blood pressure weekly." d. "Visit an ophthalmologist monthly." c - IS the selected answer: An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client. b. The nurse should proceed with the transfusion in order to save the client's life. c. The nurse should inform the primary healthcare provider and not give blood to the client. d. The nurse should explain to the family member that the client needs this transfusion. a,b,c - IS the selected answer: What points should a nurse keep in mind when caring for a client who belongs to a different culture? (Select all that apply). a. The nurse should be aware of his or her own cultural values and behavior patterns. b. The nurse should focus on understanding the client's traditions, values, and beliefs. c. The nurse should understand that unique cultural perceptions exist regarding health practices. d. The nurse should know that every client strictly adheres to his or her cultural beliefs and traditions. e. The nurse should know that a client's cultural background does not influence the nurse-client relationship. a - IS the selected answer: An elderly client states, "Disease occurs when supernatural elements enter the body." Which variable influences the client's health beliefs in this scenario? a. Spiritual factors b. Emotional factors c. Intellectual background d. Perception of functioning c - IS the selected answer: In order to provide ideal therapeutic communication to patients, a health care facility provides interpreter services. Which statement regarding an interpreter is correct? a. Interpreters can be relatives or friends of the patient as well. b. The interpreter should be able to make literal, word-for-word translations. c. The interpreter should be able to interpret not only the language but also the culture. d. The interpreter should be available as long as the health care provider is caring for the patient. c - IS the selected answer: What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness? a. Referring the husband to a psychotherapist for help in dealing with his anger b. Placing the couple in a couples' therapy group that addresses terminal illness c. Helping the couple express to each other their feelings about his terminal illness d. Encouraging the wife to verbalize her feelings to a therapist during individual therapy sessions a - IS the selected answer: A patient who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? a. Immediately involve pastoral services while caring for the patient. b. Involve the family member in the patient's care instead of pastoral support. c. Listen to the patient's request for support then carry on with the clinical work. d. Falsely promise that pastoral services has been contacted and plan to see the patient. c - IS the selected answer: A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? a. Restore the client's health. b. Promote the client's recovery. c. Relieve the client's discomfort. d. Support the client's significant others. a - IS the selected answer: A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox and did not want to go to school but she insisted that the child go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? a. Grow in intensity and duration b. Progress to a psychiatric illness c. Be easier to understand and to accept d. Cause the mourner to experience a pathological grief reaction a,d,e - IS the selected answer: A patient who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? (Select all that apply). a. Chemotherapy b. Repositioning c. Regular oral care d. Blood transfusion e. Radiation therapy c - IS the selected answer: A patient with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the patient is terminally ill. What is the best nursing intervention in this situation? a. Suggest that the family members get a second opinion. b. Suggest that the family members continue to try different treatments. c. Encourage the family members to provide pallative care to the patient. d. Inform the family members that the disease is no longer curable and the patient will die shortly. b,d,e - IS the selected answer: After reviewing a patient's reports, the primary healthcare provider suggests palliative care for the patient. Which conditions would qualify the patient for this type of care? (Select all that apply). a. Peptic ulcer b. Chronic renal failure c. Cognitive impairment d. Congestive heart failure e. Chronic obstructive lung disease c - IS the selected answer: A terminally ill patient has died in the hospital and it is time to inform the patient's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family? a. Primary health care provider b. Pharmacist c. Social worker d. Occupational therapist c - IS the selected answer: A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? a. Add a placebo to the morphine to appease the spouse. b. Discuss with the spouse the risk for morphine addiction. c. Assess the client's pain before increasing the dose of morphine. d. Check the client's heart rate before increasing the morphine to the next level. c,e - IS the selected answer: What interventions should the nurse perform while caring for an actively dying patient? (Select all that apply). a. Admit the patient in hospice care. b. Perform aggressive laboratory tests. c. Provide patient and family reassurance. d. Keep the patient undisturbed for long time. e. Perform symptom management in the patient. a - IS the selected answer: A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? a. Enhances the quality of the client's life b. Reduces the likelihood of a respiratory infection c. Prevents the malabsorption syndrome from occurring d. Cures the cachexia that results from bone cancer and chemotherapy 0.2 - IS the selected answer: A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. mL c - IS the selected answer: The primary healthcare provider instructs the nurse to manage fluid replacement therapy in a patient with cancer. What type of care is the patient receiving? a. Palliative care b. Comfort care c. Supportive care d. End-of-life care d - IS the selected answer: What should a nurse recommend to best help a client during the period immediately after a spouse's death? a. Crisis counseling b. Family counseling c. Marital counseling d. Bereavement counseling d - IS the selected answer: A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? a. "What makes you think he doesn't love you?" b. "Avoidance is a defense. He needs your help to cope." c. "Do you think he's having difficulty dealing with your illness?" d. "You seem very upset. Tell me how your husband is avoiding you." a,b,e - IS the selected answer: Which nursing interventions enhance comfort in an imminently dying patient in the hospital? (Select all that apply). a. Frequently repositioning the patient b. Maintaining oral hygiene in the patient c. Limiting frequent visits of the family members d. Measuring the vital signs of patient frequently e. Applying body lotion to the patient's skin daily c - IS the selected answer: The grieving wife of a client who has just died says to the nurse, "We should've spent more time together. I always felt that the children's needs came first." The nurse recognizes that the wife is experiencing what? a. Displaced anger b. Shame for past behaviors c. Expected feelings of guilt d. Ambivalent feelings about her husband a - IS the selected answer: A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse best support the client's spouse? a. Assist the couple to maintain open communication. b. Offer the couple a description of the disease process. c. Instruct the spouse about the action of the medications. d. Meet privately with the spouse to explore personal feelings. d - IS the selected answer: A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision? a. The newborn has no rights. b. It is the same as euthanasia. c. It is illegal professional practice. d. The newborn is being allowed to die. d - IS the selected answer: A 76-year-old widower is terminally ill. He is very quiet and is unwilling to have visitors. During the initial contact with this client, what should the nurse do? a. Assess what the client knows about death and the dying process. b. Avoid talking about his condition unless he initiates the discussion. c. Encourage him to accept phone calls from those who wish to visit with him. d. Explore the extent to which he understands his situation and what the information means to him. a - IS the selected answer: A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? a. Bargaining b. Frustration c. Depression d. Rationalization b - IS the selected answer: According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? a. Anger b. Denial c. Bargaining d. Depression a - IS the selected answer: What childhood problem has legal as well as emotional aspects and cannot be ignored? a. School phobia b. Fear of animals c. Fear of monsters d. Sleep disturbances a - IS the selected answer: A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? a. "A nurse should provide a personal point of view." b. "Negotiations should be held in formal settings only." c. "Negotiation takes place immediately after gathering information." d. "The group agrees to a statement of the problem during the negotiation process." b - IS the selected answer: A nurse who promotes freedom of choice for clients in decision-making best supports which principle? a. Justice b. Autonomy c. Beneficence d. Paternalism d - IS the selected answer: Which nursing action indicates that the nurse is actively listening to the client? a. The nurse states his or her own opinions when the client is speaking. b. The nurse refrains from telling his or her own story to the client. c. The nurse reads the client's health record during the conversation. d. The nurse interprets what the client is saying and reiterates in his or her own words. a, b - IS the selected answer: What is true about psychosocial changes observed in adolescents? Select all that apply. a. "They search for personal identity." b. "They develop their own ethical systems." c. "They consider themselves invincible." d. "They think of their parents as materialistic." e. "They get emotionally dependent on their parents." c - IS the selected answer: A nurse administers intravenous (IV) therapy to the wrong client. What possible legal complications might the nurse face in such situation? a. Assault b. Battery c. Malpractice d. False imprisonment b - IS the selected answer: What is the professional nurse's legal responsibility regarding child abuse? a. Honor the request of the parents not to report the suspected abuse. b. Report any suspected abuse to local law enforcement authorities. c. Return the child to the legal parent even if he or she is suspected of abuse. d. Provide the parents with a copy of the child's medical record. a - IS the selected answer: A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? a. Battery b. Invasion of privacy c. False imprisonment d. Defamation of character d - IS the selected answer: What legal complications might a nurse face for using a restraint without a legal warrant on a client? a. The nurse may be charged with libel. b. The nurse may be charged with negligence. c. The nurse may be charged with malpractice. d. The nurse may be charged with false imprisonment. c - IS the selected answer: A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what? a. Libel b. Negligence c. Breach of confidentiality d. Defamation of character a - IS the selected answer: A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? a. Demonstration of a personal bias b. Problem solving based on assessment c. Determination of client acuity to set priorities d. Consideration of the complexity of client care d - IS the selected answer: What stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? a. Social contract orientation b. Society-maintaining orientation c. Instrumental relativist orientation d. Universal ethical principle orientation c - IS the selected answer: The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation? a. Educator b. Manager c. Advocate d. Administrator b - IS the selected answer: Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? a. Confront her friend with her suspicions. b. Talk to the school nurse about her concerns. c. Inform the girl's mother about her daughter's behavior. d. Watch a while longer before doing anything that might ruin the friendship. c - IS the selected answer: A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? a. Justice b. Veracity c. Autonomy d. Beneficence a - IS the selected answer: The professional obligation of a nurse to assume responsibility for actions is referred to as what? a. Accountability b. Individuality c. Responsibility d. Bioethics d - IS the selected answer: A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. What role does the nurse play here? a. Educator b. Manager c. Caregiver d. Advocate a - IS the selected answer: A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do? a. Honor the client's decision and document the behavior and all interventions. b. Use an authoritarian approach to induce the client to take the prescribed medication. c. Call the primary healthcare provider and request that the client be discharged against medical advice. d. Start proceedings to have the client declared incompetent and seek a court order permitting medication. d - IS the selected answer: Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? a. Right task b. Right person c. Right supervision d. Right communication d - IS the selected answer: Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? a. Restraints can be used when less restrictive interventions are not successful. b. Restraints can be used when all other alternatives have been tried and exhausted. c. Restraints can be used only to ensure the physical safety of the resident or other residents. d. Restraints can be used anytime without a written order from the healthcare provider. d - IS the selected answer: Which of the following legal defenses are the most important for a nurse to develop? a. Dedication b. Certification c. Assertiveness d. Accountability b, c, e - IS the selected answer: A nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. a. When consent has been obtained from the spouse b. When consent has been given specifically by a court c. When self-consent has been granted by a court order d. When consent has been given by a grandparent e. When consent has been obtained from at least one parent of the minor c - IS the selected answer: What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare? a. A proxy is a legal document that prohibits the purchase or sale of organs. b. A proxy is a legal document that ensures the client has the right to refuse medical treatment. c. A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client. d. A proxy is a legal document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition. b - IS the selected answer: The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? a. Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. b. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. c. Maintain immobilization of a client's leg to prevent dislodging a skin graft. d. Keep an older adult client from falling out of bed following a surgical procedure. a - IS the selected answer: The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility c - IS the selected answer: How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? a. It is a willful act violating a client's rights. b. It is a civil wrong made against a person or property. c. It is an act that lacks intent but involves volitional action. d. It is an unintentional act that includes negligence and malpractice. c - IS the selected answer: Which ethical principles govern a nurse's behavior when making difficult decisions about a patient's care at the point of care? a. Bioethics b. Metaethics c. Clinical ethics d. Research ethics b - IS the selected answer: Which ethical principle is violated when the nurse forgets to give a painkiller to a patient as promised? a. Justice b. Fidelity c. Veracity d. Nonmaleficence b - IS the selected answer: A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? a. Treat all patients equitably and fairly. b. Act in ways to prevent harm to patients. c. Tell the patient the truth about their health. d. Help the patients to make informed choices. a - IS the selected answer: What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? a. The nurse should focus on doing no harm. b. The nurse should keep promises made to clients. c. The nurse should respect the autonomy of clients. d. The nurse should keep the best interests of the client in mind. c - IS the selected answer: A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement? a. Adequate, because the preparations are routine and need no explanation b. Effective, because the client's anxieties would increase if she knew the danger involved c. Questionable, because the client has the right to know what treatment is being given and why d. Incorrect, because only the primary healthcare provider should offer assurances about management of care a - IS the selected answer: What is the duty of a nurse while caring for a client? a. The nurse should determine the client's care preferences. b. The nurse should hide serious information from the family. c. The nurse should inform the family after taking the required steps. d. The nurse should instruct the family to keep the client from doing things himself or herself. c - IS the selected answer: A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction? a. An ethical issue occurs if it is perplexing and if it is not easy to think logically or make a decision. b. An ethical issue occurs if it is not possible to resolve solely through a review of scientific data. c. An ethical issue occurs if the problem aims at the greatest good for the greatest number of people. d. An ethical issue occurs if the answer to the problem has a profound relevance for areas of human concern. d - IS the selected answer: On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, and barely has basic needs attended. The client is the primary caregiver for the infant. What should the nurse do? a. Advise the purchase of appropriate toys designed for this age level. b. Inform the client that the child will be cognitively impaired if he is not stimulated. c. Explain the need for the family to hire a mother's helper for the home. d. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference. d - IS the selected answer: A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? a. Libel b. Slander c. Negligence d. Invasion of privacy c - IS the selected answer: The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to do what? a. Call the security guard. b. Tell the nurse manager to go home. c. Have the supervisor validate the observation. d. Offer the nurse manager a large cup of coffee. Offer the nurse manager a large cup of coffee. b - IS the selected answer: A nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond? a. Answer the questions softly so other people will not hear. b. Decline to discuss the friend's medical condition. c. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead. d. To provide reassurance, tell the coworker of the friend's test results that are within normal limits. a - IS the selected answer: An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? a. Interview the client without the presence of family members. b. Report the abuse to the appropriate state agency for investigation. c. Accept the adult child's explanation until more data can be collected. d. Refer the client's clinical record to the hospital ethics committee for review. c - IS the selected answer: A nurse assisting in a research study calculates the risk-benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? a. Human dignity b. Human rights c. Beneficence d. Utilitarianism c - IS the selected answer: A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? a. Allow the visitor to review the record; sponsors have access to privileged information. b. Ask the primary healthcare provider about granting permission to the sponsor. c. Do not allow the sponsor to review the record. d. Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors. b - IS the selected answer: A registered nurse is teaching a nursing student about malpractice insurance. Which statement by the nursing student requires correction? a. "Malpractice insurance provides for a defense when a nurse is alleged to have committed professional negligence or medical malpractice." b. "Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted." c. "If both the employing institution and the nurse are sued, the nurse needs to notify his or her private insurance carrier of the lawsuit, even though the nurse has insurance through the hospital." d. "If both the hospital policy and the private policy are considered primary and the hospital loses as a result of the nurse's act, the hospital may sue the nurse's private insurer to recover its losses." c - IS the selected answer: It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse's addiction should be taken as an initial intervention? a. Counseled by the staff psychiatrist b. Dismissed from the job immediately c. Referred to the employee assistance program d. Forced to promise to abstain from drugs in the future c - IS the selected answer: A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? a. Counsel the nurse about the problem. b. Ignore the problem until it happens again. c.Notify the nurse manager about the problem. d. Resolve the problem by sending the nurse home. d - IS the selected answer: A child admitted to the hospital is in need of a life-saving heart transplant surgery. However, the parents refuse to allow the surgery stating that such surgeries are against their belief system. The nurse in charge of the cl