NR 226 ACTUAL FINAL Exam

NR 226 ACTUAL FINAL Exam "Which patient statement indicates that the patient is experiencing bruxism? 1. "I walk around in my sleep almost every night, but I don't remember it." 2. "I annoy the whole family with the loud snoring noises I make at night." 3. "I occasionally urinate in bed when I am sleeping, and it's embarrassing." 4. "I am told by my wife that I make a lot of noise grinding my teeth when I sleep." - CORRECT ANSWER 4. "I am told by my wife that I make a lot of noise grinding my teeth when I sleep." "Which are most important for a nurse to consider when a patient reports the presence of pain? Select all that apply. 1. The extent of pain is directly related to the amount of tissue damage. 2. Fatigue increases the intensity of pain experienced by the patient. 3. Behavioral adaptations are congruent with statements about pain. 4. Giving opioids to a patient in pain will lead to an addiction. 5. The person feeling the pain is the authority on the pain. - CORRECT ANSWER 2. Fatigue increases the intensity of pain experienced by the patient. Fatigue decreases a person's coping abilities which increases the intensity of pain. 5. The person feeling the pain is the authority on the pain. Pain is a personal experience. Margo McCaffery, a pain researcher, has indicated that pain is whatever the person in pain says it is and exists whenever the person in pain says it exists." "Which statements by a patient indicate a precipitating factor associated with pain? Select all that apply. 1. "I usually feel a little dizzy and think I'm going to vomit when I have pain." 2. "My pain usually comes and goes throughout the night." 3. "I usually have pain after I get dressed in the morning." 4. "My pain feels like a knife cutting right through me." 5. "My incision hurts when I cough." - CORRECT ANSWER 3. "I usually have pain after I get dressed in the morning." Anything that induces or aggravates pain is considered a precipitating factor of pain. For example, precipitating factors may be physical (e.g., exertion associated with activities of daily living, Valsalva maneuver), environmental (e.g., extremes in temperature, noise), or emotional (anxiety, fear). 5. "My incision hurts when I cough." Anything that induces or aggravates pain is considered a precipitating factor of pain. Coughing raises intra-abdominal pressure, which can aggravate the pain of a surgical incision. Patients are taught to support the operative site with the hands or a pillow when coughing to limit the extent of pain." "A nurse administers a back rub to a patient after first providing for privacy and maintaining standard precautions. Place the following steps in the order in which they should be implemented. 1. Apply warmed lotion to your hands. 2. Position the patient in the side-lying position. 3. Assess the skin for color, turgor, and skin breakdown. 4. Arrange the gown and top linens so that the patient's back is exposed. 5. Use a variety of strokes to massage the muscles of the back and sacral area. - CORRECT ANSWER Answer: 2 4 3 1 5 The first step is to position the patient in the side-lying position because this provides for a comfortable, supported position during the procedure. The second step is to arrange the gown and linens so that the patient's back is exposed because this provides access to the patient's back. The third step is to assess the skin to ensure that there are no indications of a problem that is a contraindication for having a back rub. The fourth step is to warm the lotion in your hands because warm lotion is more comfortable and supports muscle relaxation. A variety of strokes (e.g., effleurage, pétrissage, tamponage, small circular movements, and feathering) relieves muscle tension, promotes physical and emotional relaxation, and increases circulation to the area." "When assessing patients who have difficulty sleeping, the nurse assesses for which common physiological responses to insomnia? Select all that apply. 1. Vertigo 2. Fatigue 3. Irritability 4. Headache 5. Frustration - CORRECT ANSWER 1. Vertigo Shortened non-rapid-eye-movement (NREM) sleep can result in vertigo, which is a physiological response to sleep deprivation. 2. Fatigue Interrupted NREM sleep can result in fatigue, which is a physiological response to sleep deprivation. 4. Headache Shortened NREM sleep can result in headache, which is a physiological response to sleep deprivation." "A nurse is assessing a patient experiencing chronic pain. Which characteristics are more common with chronic pain than with acute pain? Select all that apply. 1. Gradual onset 2. Long duration 3. Anticipated end 4. Psychologically depleting 5. Responds to conventional interventions - CORRECT ANSWER 1. Gradual onset Chronic pain has a gradual progressive onset because it usually is related to a long-term problem (e.g., diabetic neuropathy). Acute pain has a rapid onset because it usually is related to abrupt trauma to the body (e.g., surgical incision, damage from an automobile collision). 2. Long duration Chronic pain is categorized as pain longer than 6 months' duration. Acute pain is categorized as pain shorter than 6 months' duration. 4. Psychologically depleting Chronic pain is psychologically depleting because it drains both physical and emotional resources; this is related to the unrelenting nature of the pain and that it usually continues for life." "autonomy - CORRECT ANSWER the right to make one's own decisions, even when those decisions might not be in the person's own best interest." "Benefience - CORRECT ANSWER actions that promotes good for others, without any self-interest." "Nonmaleficence - CORRECT ANSWER duty to do no harm" "Justice - CORRECT ANSWER fairness in care of delivery and use of resources" "fidelity - CORRECT ANSWER fulfillment of promises" "veracity - CORRECT ANSWER a commitment to tell the truth." "When caring for a terminally ill patient, a family member says, "I need your help to hasten my mother's death so that she is no longer suffering." What should the nurse do based on the position of the American Nurse association in relation to assisted suicide? 1) Not participate in active euthanasia. 2) Participate based on personal values and beliefs. 3) Participate when the patient is experiencing severe pain. 4) Not participate unless two practitioners are consulted and the patient has had counseling. - CORRECT ANSWER Correct Answer: 1 (Withholding the medication and docu- menting the patient's refusal are the appropriate interventions. Patient's have a right to refuse care.) 2. Notifying the practitioner eventually should be done, but it is not the priority at this time. 3. Discussing the situation with a family member without the patient's consent is a violation of confidentiality. 4. The patient has been taught about the medication and adamantly refuses the medication. Further teaching at this time may be viewed by the patient as badgering." "Which organization is responsible for ensuring that Registered Nurses are minimally qualified to practice nursing? 1) Sigma Theta Tau 2) State Boards of Nursing 3) American Nurses Association 4) Constituent leagues of the National League for Nursing. - CORRECT ANSWER Correct Answer: 2. (The National Council of State Boards of Nursing is responsible for the NCLEX examinations; however, the licensing authority in the jurisdiction in which the graduate takes the examination verifies the acceptable score on the examination.) 1. Sigma Theta Tau, the international honor society of nursing, recognizes academic achievement and leadership qualities, encourages high professional standards, fosters creative endeavors, and supports excellence in the profession of nursing. This organization does not grant licensure. 3. The American Nurses Association (ANA) is the national professional organization for nursing in the United States. It fosters high standards of nursing practice; it does not grant licensure. 4. The National League for Nursing (NLN) is committed to promoting and improving nursing service and nursing education; it does not grant licensure" "A nurse expert is called to testify in a lawsuit regarding professional nursing malpractice primarily to testify: 1. About standards of nursing care as they apply to the facts in the case 2. With regard to laws governing the practice of nursing 3. For the prosecution 4. For the defense - CORRECT ANSWER Correct Answer: 1 (The American Nurses Association Standards of Clinical Nursing Practice are authoritative statements by which the national organization for nursing describes the responsibilities for which its practitioners are accountable. An expert nurse is capable of explaining these standards as they apply to the situation under litigation. These professional standards are one criterion that helps a judge or jury determine if a nurse committed malpractice or negligence.) 2. An expert nurse is not an expert in the law. The expert nurse's role is not to make judgments about the laws as they apply to the practice of nursing. 3. A nurse expert can testify for either the prosecution or the defense. 4. A nurse expert can testify for either the defense or the prosecution." "The nurse initiates a visit from a member of the clergy for a patient. How is the nurse functioning when initiating this visit? 1. Interdependently 2. Independently 3. Dependently 4. Collegially - CORRECT ANSWER Correct Answer: 2 (The nurse is initiating the referral to the member of the clergy and is therefore working independently. Nurses are legally permitted to diagnose and treat human responses to actual or potential health problems.) 1. The nurse does not need a practitioner's order to make a referral to a member of the clergy. An interdependent intervention requires a practitioner's order associated with a parameter. 3. This action is within the scope of nursing practice. The nurse does not need a practitioner's order to make a referral to a member of the clergy. 4. The nurse can make a referral to a mem- ber of the clergy without collaborating with another professional health-care team member." "A patient is asked to participate in a medical research study. The nurse describes to the patient and family members how the patient is protected by the: 1. Code of Ethics 2. Informed Consent 3. Nurse Practice Act 4. Constitution of the United States - CORRECT ANSWER Correct Answer: 2 (Informed consent is an agreement by a client to accept a course of treatment or a procedure after receiving complete information necessary to make a knowledgeable decision.) 1. A code of ethics is the official statement of a group's ideals and values. It includes broad statements that provide a basis for professional actions. 3. Nurse Practice Acts define the scope of nursing practice; they are unrelated to informed consent. 4. The Constitution of the United States addresses broad individual rights and responsibilities. The rights related to nursing practice and patients include therights of privacy, freedom of speech, and due process." "The nurse is implementing an ordered bowel preparation for a patient who is scheduled for a colonoscopy. Which is the most serious consequence that is prevented by an effective bowel preparation? 1. Discomfort 2. Misdiagnosis 3. Wasted expense 4. Psychological stress - CORRECT ANSWER Correct Answer: 2 (Fecal material in the intestines can interfere with the visualization, collection, and analysis of data obtained through a colonoscopy, resulting in diagnostic errors.) 1. Although this may occur, it is not the most serious outcome of an inappropriate preparation for a colonoscopy. 3. A test may have to be cancelled or per- formed a second time if the patient has an ineffective bowel preparation. Although this is a serious consequence, it is not life threatening. 4. Although this is a serious consequence, it is not life threatening." A practitioner asks the nurse to witness an informed consent. Which patient does the nurse identify is unable to give an informed consent for surgery? 1) 16 year old boy who is married 2) 35 year old woman who is depressed 3) 50 year old woman who does not speak English 4) 65 year old man who has received a narcotic for pain. - CORRECT ANSWER Correct Answer: 4 (Narcotics depress the CNS, including decision-making abilities. 1 - Because legally anyone under 18 who is married can make the decision. 2 - wrong because a depressed person can make these decisions until proven mentally incompetent. 3 - Wrong because this person can provide informed consent after translations." "When the nurse is administering a medication to a confused patient, the patient says, "this pill looks different from the one I had before." What should the nurse do? 1) Ask what the other pill looked like. 2) Explain the purpose of the medication. 3) Check the original medication prescription. 4) Encourage the patient to take the medication. - CORRECT ANSWER Correct answer: 3 (This is the safest intervention because it goes to the original source of the prescription.) 1 - Wrong because This action by itself is unsafe because the patient is confused and the information obtained may be innacurate. 2 - This intervention ignores the patient's concern. 4 - This action ignores the patient's statement and is unsafe without obtaining additional information." "The nurse administers an incorrect dose of a medication to a patient. What is the primary purpose of documenting this event in an Incident Report? 1) Record the event for future litigation. 2) Provide a basis for designing new policies. 3) Prevent similar situations from happening again. 4) Ensure accountability for the cause of the accident. - CORRECT ANSWER Correct answer: 3 (Risk-management committees use stats about accidents & incidents to identify patterns of risk and prevent future accidents/incidents.) 1 - Wrong because although documentation of an incident may be used in a court of law, it is not the primary reason for an incident report. 2- This is not the primary reason. New policies may or may not have to be written and implemented. 4 - Although nurses are always accountable for their actions, accountability for the cause of an incidence is the role of the courts." "A practitioner writes a prescription for a medication that is larger than the standard dose. What should the nurse do? 1) Inform the supervisor 2) Give the drug as prescribed. 3) Give the average dose of the medication. 4) Discuss the prescription with the practitioner. - CORRECT ANSWER Correct Answer: 4 (Nurses have a prof. resonsibility to know/investigate the standard dose for medications being administered. In addition, nurses are responsible for their own actions regardless of whether there is a written prescription) 1 - It is unnecessary to call the supervisor. 2 - This is unsafe for the patient and may result in malpractice. 3 - Changing a medication prescription is not within the scope of nursing practice." "When the nurse attempts to administer a medication to a patient, the patient refuses to take the medication because it causes diarrhea. The nurse provides teaching about the medication, but the patient continues to adamantly refuse the medication. What should the nurse do first? 1) Document the patient's refusal to take the medication. 2) Notify the practitioner of the patient's refusal to take the medication. 3) Discuss with a family member the need for the patient to take the medication. 4) Explain again to the patient the consequences of refusing to take the medication. - CORRECT ANSWER Correct Answer: 1 (The patient has the right to refuse) 2. Notifying the practitioner eventually should be done, but it is not the priority at this time. 3. Discussing the situation with a family member without the patient's consent is a violation of confidentiality. 4. The patient has been taught about the medication and adamantly refuses the medication. Further teaching at this time may be viewed by the patient as badgering." "The practitioner orders OOB for a patient. How is the nurse functioning when moving this patient out of bed to a chair? 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently - CORRECT ANSWER Correct Answer: 1 (Determining the extent of activity desirable for a patient is within the practitioner's, not a nurse's, scope of practice. Following activity orders is a dependent function of the nurse.) 2. The responsibility to determine a patient's activity level is not within the legal scope of nursing practice. 3. A practitioner works independently when determining a patient's desired activity level. 4. The nurse is following the practitioner's order to get the patient OOB. There are no restrictions or parameters in relation to the order. However, the nurse must use judgment before, during, and after a transfer if a patient's condition changes." "A Registered Nurse witnesses an accident and assists the victim who has a life-threatening injury. What should the nurse do to meet the most important standard when acting as a Good Samaritan at the scene of an accident? 1. Seek consent from the injured party before rendering assistance 2. Implement every critical-care intervention necessary to sustain life 3. Stay at the scene until another qualified person takes over responsibility 4. Insist on helping because a nurse is the best-qualified person to provide care - CORRECT ANSWER Correct Answer: 3. When a nurse renders emergency care, the nurse has an ethical responsibility not to abandon the injured person. The nurse should not leave the scene until the injured person leaves or another qualified person assumes responsibility. 1. Depending on the injured person's physi- cal and emotional status, the person may or may not be able to consent to care. 2. When a nurse helps in an emergency, the nurse is required to render care that is consistent with care that any reasonably prudent nurse would provide under simi- lar circumstances. The nurse should not attempt interventions that are beyond the scope of nursing practice. 4. A nurse should offer assistance, not insist on assisting, at the scene of an emergency." "A faculty member of a nursing program is conducting an informational session for potential nursing students. The faculty member includes the information that at the completion of the program licensure to practice is: 1. A responsibility of the American Nurses Association 2. Granted on graduation from a nursing program 3. Approved by the National League for Nursing 4. Required by state law - CORRECT ANSWER Correct Answer: 4. The Nurse Practice Act in a state stipulates the requirements for licensure within the state. 1. The ANA Standards of Clinical Nursing Practice do not address licensure. 2. When a person graduates from a school of nursing, the individual receives a diploma that indicates completion of a course of study; the diploma is not a license to practice nursing. 3. The National League for Nursing (NLN) promotes nursing service and nursing education; it is not involved with licensure." "When considering legal issues the word contract is to liable as standard is to: 1. Rights 2. Negligence 3. Malpractice 4. Accountability - CORRECT ANSWER Correct Answer: 4. Liable means a person is responsible (accountable) for fulfilling a contract that is enforceable by law. Accountable means a person is responsible (liable) for meeting standards, which are expectations established for making judgments or comparisons. 1. Although patients have a right to receive care that meets appropriate standards, the word right does not have the same relationship to the word standard as the relationship between the words contract and liable. 2. The words standards and negligence do not have the same relationship as contract and liable. Negligence involves an act of commission or omission that a reasonably prudent person would not do. 3. The words standards and malpractice do not have the same relationship as contract and liable. Malpractice is negligence by a professional person." "An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, "If you keep ringing, there will come a time I won't answer your bell." What legal term is related to this statement? 1. Slander 2. Battery 3. Assault 4. Libel - CORRECT ANSWER Correct Answer: 3. This is an example of assault. Assault is a verbal attack or unlawful threat causing a fear of harm. No actual contact is necessary for a threat to be an assault. 1. This is not an example of slander, which is a false spoken statement resulting in damage to a person's character or reputation. 2. This is not an example of battery, which is the unlawful touching of a person's body without consent. 4. This is not an example of libel, which is a false printed statement resulting in damage to a person's character or reputation." "The nurse is informed that a credentialing team has arrived and is in the process of assessing quality of care delivered at the hospital. What is the organization associated with the credentialing of hospitals? 1. Joint Commission 2. National League for Nursing 3. American Nurses Association 4. National Council Licensure Examination - CORRECT ANSWER Correct Answer: 1. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) evaluates health-care organizations' compliance with Joint Commission standards. Accreditation indicates that the organization has the capabilities to provide quality care. In addition, federal and state regulatory agencies and insurance companies require Joint Commission accreditation. 2. The National League for Nursing (NLN) fosters the development and improvement of nursing education and nursing service. 3. The American Nurses Association (ANA) is the national professional organization for nursing in the United States. Its purposes are to promote high standards of nursing practice and to support the educational and professional advancement of nurses. 4. In the United States, graduates of educa- tional programs that prepare students to be- come Licensed Practical Nurses or Registered Professional Nurses must successfully complete the National Council Licensure Examination-PN (NCLEX-PN) and the National Council Licensure Examination-RN (NCLEX-RN), respectively, as part of the criteria for licensure." "A student nurse is about to graduate from an accredited nursing program. The student nurse understands that an action unrelated to a state Nurse Practice Act is: 1. Setting guidelines for nurses' salaries in the state 2. Establishing reciprocity for licensure between states 3. Determining minimum requirements for nursing education 4. Maintaining a list of nurses who can legally practice in the state - CORRECT ANSWER Correct Answer: 1. State Nurse Practice Acts define and regulate the practice of nursing within the state. The salary of nurses is determined through negotiations between nurses or their representatives, such as a union or a professional nursing organization, and the representatives of the agency for which they work. 2. A state's Nurse Practice Act determines the criteria for reciprocity for licensure. 3. A state's Nurse Practice Act stipulates minimum requirements for nursing education. 4. A state's Nurse Practice Act defines the criteria for licensure within the state. The actual functions, such as maintaining a list of nurses who can legally practice in the state, may be delegated to another official body such as a State Board of Nursing or State Education Department." "Nursing practice is influenced by the doctrine of respondeat superior. What is the basic concept related to this theory of liability? 1. Nurses must respond to the Supreme Court when they commit acts of malpractice 2. Health-care facilities are responsible for the negligent actions of the nurses whom they employ 3. Nurses are responsible for their actions when they have contractual relationships with patients 4. The laws absolve nurses from being sued for negligence if they provide inappropriate care at the scene of an accident - CORRECT ANSWER Correct Answer: 2. The ancient legal doctrine respondeat superior means "let the master answer." By virtue of the employer-employee relationship, the employer is responsible for the conduct of its employees. 1. This is unrelated to respondeat superior. Negligence and malpractice, which are unintentional torts, are litigated in local courts by civil actions between individuals. 3. Individual responsibility is unrelated to respondeat superior. A nurse can have an independent contractual relationship with a patient. When a nurse works for an agency, the contract between the nurse and patient is implied. In both instances the nurse is responsible for the care provided. 4. This is unrelated to respondeat superior. Good Samaritan laws do not provide absolute immunity." "When attempting to administer a 10:00 PM sleeping medication, the nurse assesses that the patient appears to be asleep. What should the nurse do? 1. Withhold the drug 2. Notify the practitioner 3. Awaken the patient to administer the drug 4. Administer it later if the patient awakens during the night - CORRECT ANSWER Correct Answer: 3. Administering a medication is a dependent function of the nurse. The prescription should be followed as written if the prescription is reasonable and prudent. This medication was not a PRN medication but rather a standing order. 1. This is a violation of the practitioner's or- der. Drug administration is a dependent nursing function. 2. This is unnecessary. 4. The drug should be administered as prescribed not at a later time." "What is the primary purpose of the American Nurses Association Standards of Clinical Nursing Practice? 1. Establish criteria for quality practice 2. Define the philosophy of nursing practice 3. Identify the legal definition of nursing practice 4. Determine educational standards for nursing practice - CORRECT ANSWER Correct Answer: 1. The ANA Standards of Clinical Nursing Practice describe the nature and scope of nursing practice and the responsibilities for which nurses are accountable. 2. A philosophy incorporates the values and beliefs about the phenomena of concern to a discipline. The ANA Standards of Clinical Nursing Practice reflect, not define, a philosophy of nursing. Each nurse and nursing organization should define its own philosophy of nursing. 3. The laws of each state define the practice of nursing within the state. 4. Educational standards are established by accrediting bodies, such as the National League for Nursing Accrediting Commission, the Commission on Collegiate Nursing Education, and state education departments." "The client who requires a co-signature for a valid consent for surgery is a: 1. 15-year-old mother whose infant requires exploratory surgery 2. 40-year-old resident in a home for developmentally disabled adults 3. 90-year-old adult who wants more information about the risks of surgery 4. 50-year-old unconscious trauma victim who needs insertion of a chest tube - CORRECT ANSWER Correct Answer: 2. A client living in a protected environment such as a home for developmen- tally disabled adults may not have the mental capacity to make medical decisions and requires the signature of a court-appointed legal representative. This person could be a parent, sibling, relative, or unrelated individual. 1. A mother may legally make medical deci- sions for her children even if the mother is younger than 18 years of age. 3. Older adults can make decisions for them- selves as long as they understand the risks and benefits of the surgery and are not receiving medication that may interfere with cognitive ability. 4. The insertion of a chest tube to inflate a lung is an emergency intervention to facilitate respiration and oxygenation. This emergency procedure is implemented to sustain life and does not require a signed consent if the client is incapacitated." "A patient is scheduled to have surgery, and informed consent is to be obtained. Place these steps in the order in which they should performed. 1. The patient is willing to sign the consent voluntarily 2. The patient signs the consent in the presence of the nurse 3. The nurse determines that the patient is alert and competent to give consent 4. The practitioner informs the patient of the risks and benefits of the procedure - CORRECT ANSWER Correct Answer: 4, 3, 1, 2 4. It is the responsibility of the practitioner to provide all the information necessary to make a knowledgeable decision. Patients have a legal right to have adequate and accurate information to make informed decisions. 3. Patients must be competent to sign a consent form. The patient must be alert, competent, and in touch with reality. Confused, sedated, unconscious, or minor patients may not give con- sent. Minor patients who are married, parents, emancipated, or serving in the United States military can provide a legal consent. 1. Patients must give their consent voluntarily and without coercion. 2. The health-care provider witnessing the signing of the consent must ensure that the signature is genuine." "Identify the actions that are examples of slander. Select all that apply. 1. _____ Volunteer telling another volunteer a patient's age 2. _____ Nurse explaining to a patient that another nurse is incompetent 3. _____ Personal care assistant sharing information about a patient with another patient 4. _____ Unit manager documenting a nurse's medication error in a performance appraisal 5. _____ Housekeeper who is angry at a nurse erroneously telling another staff member that the nurse uses cocaine - CORRECT ANSWER Correct Answer: 2, 5 2. This is an example of slander. Slander is a false spoken statement resulting in damage to a person's character or reputation. 5. This is an example of slander. It is a malicious, false statement that may damage the nurse's reputation. 1. This is a violation of the patient's right to confidentiality, not slander. 3. This is a violation of the patient's right to confidentiality, not slander. 4. This is not slander because it is a written, not spoken, statement and it documents true, not false, information." "A nurse is caring for a patient who is experiencing pain. For which common psychological response to pain should the nurse assess the patient? 1. Experiencing fear related to loss of independence 2. Withdrawing from social interactions with others 3. Asking for pain medication to relieve the pain 4. Verbalizing the presence of nausea - CORRECT ANSWER 1. Experiencing fear related to loss of independence Psychological or affective responses to pain relate to feelings and emotional distress. Fear of being dependent on others and loss of self-control are psychological responses to pain." "Which is the appropriate patient outcome for an adult who has disturbed sleep because of nocturia? 1. Report fewer early morning awakenings because of a wet bed. 2. Demonstrate a reduction in nighttime bathroom visits. 3. Resume sleeping immediately after voiding. 4. Use an incontinence device at night. - CORRECT ANSWER 2. Demonstrate a reduction in nighttime bathroom visits. Demonstrating a reduction in night- time bathroom visits is an appropriate outcome for nocturia, which is voluntary urination during the night." "A patient who had a total abdominal hysterectomy two days ago reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first? 1. Reposition the patient. 2. Offer a relaxing back rub. 3. Use distraction techniques. 4. Administer the prescribed analgesic. - CORRECT ANSWER 4. Administer the prescribed analgesic. Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision that require adequate pharmacological intervention to provide relief from pain." "A nurse is caring for a patient who is diagnosed with narcolepsy. Which is the most serious consequence of this disorder? 1. Inability to provide self-care 2. Impaired thought processes 3. Potential for injury 4. Excessive fatigue - CORRECT ANSWER 3. Potential for injury Narcolepsy is excessive sleepiness in the daytime that can cause a person to fall asleep uncontrollably at inappropriate times (sleep attack) and result in physical harm to self or others." "A patient is experiencing discomfort associated with gastroesophageal reflux. In which position should the nurse teach the patient to sleep? 1. Right lateral 2. Semi-Fowler 3. Prone 4. Sims - CORRECT ANSWER 2. Semi-Fowler Gastric secretions increase during rapid-eye-movement (REM) sleep. The semi-Fowler position limits gastroesophageal reflux because gravity allows the abdominal organs to drop, which reduces pressure on the stomach and results in less stomach contents flowing upward into the esophagus." "A patient is experiencing anxiety. Which aspect of sleep should the nurse expect primarily will be affected as a result of the anxiety? 1. Onset 2. Depth 3. Stage II 4. Duration - CORRECT ANSWER 1. Onset Anxiety increases norepinephrine blood levels through stimulation of the sympathetic nervous system, which results in prolonged sleep onset." "A patient requests pain medication for severe pain. Which should the nurse do first when responding to this patient's request? 1. Use distraction to minimize the patient's perception of pain. 2. Place the patient in the most comfortable position possible. 3. Administer pain medication to the patient quickly. 4. Assess the various aspects of the patient's pain. - CORRECT ANSWER 4. Assess the various aspects of the patient's pain. All the factors that affect the pain experience should be assessed, including location, intensity, quality, duration, pattern, aggravating and alleviating factors, and physical, behavioral, and attitudinal responses. Assessment must precede intervention." "A nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which should the nurse plan to discuss with this patient? 1. Using the ordered device that supports airway patency 2. Placing two pillows under the head when sleeping 3. Requesting a sedative to promote sleep 4. Sleeping in the supine position - CORRECT ANSWER 4. Sleeping in the supine position A continuous positive airway pressure (CPAP) device worn when sleeping keeps the upper airway patent by maintaining an open pathway that facilitates gas exchange." "Which is the most important nursing intervention that supports a patient's ability to sleep in the hospital setting? 1. Providing an extra blanket 2. Limiting unnecessary noise on the unit 3. Shutting off lights in the patient's room 4. Pulling curtains around the patient's bed at night - CORRECT ANSWER 2. Limiting unnecessary noise on the unit Noise is a serious deterrent to sleep in a hospital. The nurse should limit environmental noise (e.g., distributing fluids, providing treatments, rolling drug and linen carts) and staff communication noise." "A patient has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this patient? 1. Asking what is an acceptable level of pain 2. Providing interventions that do not precipitate pain 3. Focusing on pain management intervention before pain is excessive 4. Determining the level of function that can be performed without pain - CORRECT ANSWER 3. Focusing on pain management intervention before pain is excessive Administration of analgesics around the clock (ATC administration) at regularly scheduled intervals or by long-acting controlled-release transdermal patches maintains therapeutic blood levels of analgesics, which limit pain at levels of comfort acceptable to patients." "Which concept should the nurse consider when assessing a patient's pain? 1. The expression of pain is not always congruent with the pain experienced. 2. Pain medication can significantly increase a patient's pain tolerance. 3. The majority of cultures value the concept of suffering in silence. 4. Most people experience approximately the same pain tolerance. - CORRECT ANSWER 1. The expression of pain is not always congruent with the pain experienced. An obvious response to pain is not always apparent because psychosociocultural factors may dictate behavior. Fear of the treatment for pain, lack of validation, acceptance of pain as punishment for previous behavior, and the need to be strong, courageous, or uncomplaining are factors that influence behavioral responses to pain." "Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care? 1. Fragmented sleep 2. Early awakening 3. Restless legs 4. Sleep apnea - CORRECT ANSWER 1. Fragmented sleep Sleep deprivation occurs with frequent interruptions of sleep because the sleeper returns to stage I rather than to the stage that was interrupted. There is a greater loss of stage III and IV non-rapid-eye-movement (NREM) sleep, which is essential for restorative sleep." "A nurse is performing an admitting interview. Which patient statement about pain should cause the most concern for the nurse? 1. "I try to pretend that it is not part of me, but it takes a lot of effort." 2. "My pain medication works, but I'm afraid of becoming addicted." 3. "At home I take something for the pain before it gets too bad." 4. "They say my pain may get worse, and I can't stand it now." - CORRECT ANSWER 4. "They say my pain may get worse, and I can't stand it now." The level of pain tolerance is exceeded. The present pain must be relieved and the patient assured that future pain also will be controlled." "A patient has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the patient? 1. Hypoxia 2. Delirium 3. Lethargy 4. Dementia - CORRECT ANSWER 2. Delirium Melatonin regulates the circadian phases of sleep. Environmental triggers called synchronizers adjust the sleep- wake cycle to a 24-hour solar day. Intensive care units have bright lights and increased sensory input that cause disorientation to day and night and interrupt sleep. Interrupted sleep results in lability of mood, irritability, excitability, suspiciousness, confusion, and delirium." "Which concept associated with sleep should the nurse consider to plan nursing care for a hospitalized patient? 1. People require eight hours of uninterrupted sleep to meet energy needs. 2. Frequency of nighttime awakenings decreases with age. 3. Fear can contribute to the need to stay awake. 4. Bedrest decreases the need for sleep. - CORRECT ANSWER 3. Fear can contribute to the need to stay awake. Fear of loss of control, the unknown, and potential death results in the struggle to stay awake, which interferes with the ability to relax sufficiently to fall asleep." "A nurse is assessing a patient in pain. Which word might the nurse use when documenting the pattern of a patient's pain? 1. Tenderness 2. Moderate 3. Episodic 4. Phantom - CORRECT ANSWER 3. Episodic The word episode refers to an incident, occurrence, or time period; therefore, the word episode refers to a pattern of pain and is concerned with time of onset, duration, recurrence, and remissions." "A nurse is obtaining a health history from a newly admitted patient. Which patient statement about alcohol intake is based on a common physiological response? 1. "After I go drinking, I have to urinate during the night." 2. "When I drink, I get hungry in the middle of the night." 3. "Falling asleep is hard, but once asleep I sleep great." 4. "If I drink too much, I oversleep in the morning." - CORRECT ANSWER 1. "After I go drinking, I have to urinate during the night." Alcoholic beverages are fluids that have a mild diuretic effect. Frequent nighttime awakening to empty a full bladder is called nocturia." "A nurse is assessing a patient experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? 1. Self-focusing 2. Sleep disturbances 3. Guarding behaviors 4. Variations in vital signs - CORRECT ANSWER 4. Variations in vital signs Acute pain stimulates the sympathetic nervous system, which responds by increasing pulse, respirations, and blood pressure. Chronic pain stimulates the parasympathetic nervous system, which results in lowered pulse and blood pressure." "At which time does a nurse medicate a patient for pain for it to be considered preemptive analgesia? 1. Before a patient goes to sleep 2. At equally distant times around the clock 3. As soon as a patient reports the occurrence of pain 4. Before doing a dressing change that has been painful in the past - CORRECT ANSWER 4. Before doing a dressing change that has been painful in the past The word preemptive means preventive, anticipatory, and defensive. Therefore, preemptive analgesia is administered before an activity or intervention that may precipitate pain in an attempt to limit the anticipated pain." "A patient is diagnosed with chronic fatigue syndrome. Which is most important for the nurse to explore in relation to the patient's status? 1. Ability to provide self-care 2. Physical mobility 3. Social isolation 4. Gas exchange - CORRECT ANSWER 1. Ability to provide self-care Chronic fatigue syndrome is a condition characterized by the onset of disabling fatigue." "The fatigue is so overwhelming and consuming that it interferes with the activities of daily living. Which is most important for nurses to understand when caring for patients in pain? 1. Patients who are in pain will request pain medication. 2. Patients usually are able to describe the characteristics of their pain. 3. Patients need to know that the nurse believes what they say about their pain. 4. Patients will demonstrate vital signs that are congruent with the intensity of their pain. - CORRECT ANSWER 3. Patients need to know that the nurse believes what they say about their pain. Pain is a personal experience, and the nurse must validate its presence and severity as perceived by the patient. This conveys acceptance and respect and promotes the development of trust." "A patient is experiencing lack of sleep because of pain. Which is the most appropriate goal for this patient? 1. The patient will be provided with a back massage every evening before bedtime. 2. The patient will report feeling rested after awakening in the morning. 3. The patient will request less pain medication during the night. 4. The patient will experience four hours of uninterrupted sleep. - CORRECT ANSWER 2. The patient will report feeling rested after awakening in the morning. Sleep is a sensory experience that restores cerebral and physical functioning. Evaluations related to sleep are based on patient reports because effectiveness of sleep is a subjective assessment." "A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain? 1. Assisting with relaxing imagery 2. Obtaining a prescription for an opioid 3. Encouraging the patient to take a warm shower 4. Recommending that the patient be more active during the day - CORRECT ANSWER 1. Assisting with relaxing imagery Imagery, the internal experience of memories, dreams, fantasies, or visions, uses positive images to distract, which reduces stress, limits mild pain, and promotes relaxation and sleep." "During which time frame do people tend to be the sleepiest? 1. 12 noon and 2 p.m. 2. 6 a.m. and 8 a.m. 3. 2 a.m. and 4 a.m. 4. 6 p.m. and 8 p.m. - CORRECT ANSWER 3. 2 a.m. and 4 a.m. Research demonstrates that most people experience sleep-vulnerable periods between 2 a.m. and 6 a.m. and between 2 p.m. and 5 p.m." Bruxism, clenching and grinding of the teeth, is a parasomnia that occurs during stage II NREM sleep. Usually, it does not interfere with sleep for the affected individual but rather the sleeper's partner." "A nurse is caring for patients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action? 1. Patient-controlled analgesia 2. Intramuscular sedatives 3. Intravenous narcotics 4. Regional anesthesia - CORRECT ANSWER 3. Intravenous narcotics Intravenous analgesics act within 1 to 2 minutes but drug inactivation (biotransformation) also is fast, so there is a short duration of action." "A nurse is teaching a community health education class about rest and sleep. Which concept related to sleep should the nurse include? 1. Total time in bed gradually decreases as one ages. 2. Sleep needs remain consistent throughout the life span. 3. Alcohol intake interferes with one's ability to fall asleep. 4. Bedtime routines are associated with an expectation of sleep. - CORRECT ANSWER 4. Bedtime routines are associated with an expectation of sleep. An expectation of an outcome of behavior usually becomes a self- fulfilling prophecy. Bedtime rituals include activities that promote comfort and relaxation (e.g., music, reading, and praying) and hygienic practices that meet basic physiological needs (e.g., bathing, brushing the teeth, and toileting)." "A nurse is teaching a patient various techniques to promote sleep. Which internal stimulus that most commonly interferes with sleep should the nurse include in the teaching? 1. Ringing in the ears 2. Bladder fullness 3. Hunger 4. Thirst - CORRECT ANSWER 2. Bladder fullness Bladder fullness causes pressure in the pelvic area that interrupts sleep. Awakening to void during the night is a common occurrence, particularly in older adult men." "A nurse is giving a back rub. Which stroke is most effective in inducing relaxation at the end of the procedure? 1. Percussion 2. Effleurage 3. Kneading 4. Circular - CORRECT ANSWER 2. Effleurage Effleurage involves long, smooth strokes sliding over the skin. When performed slowly with light pressure at the end of a back rub it has a relaxing, sedative effect." "A patient states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement? 1. Pattern 2. Duration 3. Location 4. Constancy - CORRECT ANSWER 3. Location This is referred pain, which is pain felt in a part of the body that is at a distance from the tissues causing the pain. Referred pain is related to location of pain." "A nurse is providing health teaching for a patient with the diagnosis of obstructive sleep apnea. Which aspect of sleep should the nurse explain is most often affected? 1. Amount 2. Quality 3. Depth 4. Onset - CORRECT ANSWER 2. Quality Sleep apnea is the periodic cessation of breathing during sleep. Episodes occur during rapid-eye-movement (REM) sleep (interfering with dreaming) and non-rapid-eye- movement (NREM) sleep (interfering with restorative sleep), both of which reduce the quality of sleep." "A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic question the nurse can ask about the quality of the patient's sleep? 1. "How would you describe your sleep?" 2. "Do you consider your sleep to be restless or restful?" 3. "Is the number of hours you sleep at night good for you?" 4. "Does your bed partner complain about your sleep behaviors?" - CORRECT ANSWER 1. "How would you describe your sleep?" This open-ended question requires patients to explore the topic of sleep as it relates specifically to their own experiences." "A nurse strains a back muscle when moving a patient up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort? 1. Use guided imagery. 2. Perform progressive muscle relaxation. 3. Apply a cold compress to the site for 20 minutes. 4. Take a nonsteroidal anti-inflammatory medication every 6 hours. - CORRECT ANSWER 3. Apply a cold compress to the site for 20 minutes. Thermal therapy (e.g., application of heat or cold) stimulates the large A-delta fibers that close the gate that allows the transmission of pain impulses to the central nervous system." "A patient is having difficulty sleeping and may be experiencing shortened non-rapid- eye movement (NREM) sleep. Which patient assessments support this conclusion? Select all that apply. 1. Decreased pain tolerance 2. Inability to concentrate 3. Excessive sleepiness 4. Irritability 5. Confusion - CORRECT ANSWER 1. Decreased pain tolerance An increased sensitivity to pain is associated with disturbed non-rapid- eye-movement (NREM) sleep. During NREM sleep the body is engaged in restoring physiological properties of the body. 3. Excessive sleepiness During NREM sleep the parasympathetic nervous system dominates and the vital signs and metabolic rate are low; also, growth hormone is consistently secreted, which provides for anabolism. Shortened NREM sleep decreases these restorative processes, resulting in fatigue, lethargy, and excessive sleepiness." "A primary health-care provider prescribes oxycodone oral solution 15 mg every 6 hours. The drug is supplied in a 500-mL bottle that indicates 5 mg/5 mL. How much oral solution should the nurse administer? Record your answer using a whole number. - CORRECT ANSWER Answer: 15 mL" "A 12-year-old boy is experiencing nocturnal enuresis. Which strategies should the nurse explore with the boy and his parents? Select all that apply. 1. Limiting fluid intake after dinner 2. Voiding immediately before going to bed 3. Eliminating caffeinated beverages from the diet 4. Thinking about waking up dry when going to bed at night 5. Having the boy change his own bed linens when he wets the bed - CORRECT ANSWER 1. Limiting fluid intake after dinner Limiting fluid intake after dinner reduces the amount of urine production while asleep. 2. Voiding immediately before going to bed Voiding empties the bladder and makes room for urine produced during the night. 3. Eliminating caffeinated beverages from the diet Caffeine irritates the mucous membranes of the urinary system and stimulates the need to void. 4. Thinking about waking up dry when going to bed at night Positive imagery supports self-esteem and may become a self-fulfilling prophesy." "A nurse is using the FLACC behavioral scale to assess an 8-month-old child's level of pain. The nurse identified that the patient's legs were drawn up to the abdomen and the patient was whimpering. The patient was squirming and shifting back and forth and had a constant frown and the chin was quivering. The infant was reassured when cuddled by the nurse. On a scale of 0 to 10, which is the child's level of pain? 1. 3 2. 5 3. 7 4. 9 - CORRECT ANSWER 3. 7 According to the FLACC behavioral scale to assess pain, the child's level of pain is 7. A constant frown with a quivering chin receives a score of 2. Legs drawn up to the abdomen receives a score of 2. Squirming and shifting back and forth receives a score of 1. Moaning and whimpering receives a score 1. Reassured by hugging receives a score of 1." "Which concepts associated with rest and sleep must the nurse consider when planning nursing care? Select all that apply. 1. Energy demands increase with age. 2. Metabolic rate increases during rest. 3. Sleep requirements increase during stress. 4. Catabolic hormones increase during sleep. 5. Lack of awareness of the environment increases with sleep. - CORRECT ANSWER 3. Sleep requirements increase during stress. Stress precipitates the sympathetic nervous system, increasing cortisone, norepinephrine, and epinephrine, which increase the metabolic rate. Physical and psychic energy expended is restored through rest and sleep. 5. Lack of awareness of the environment increases with sleep. Individuals experience varied levels of consciousness when asleep. There is a progressive lack of awareness of the environment as one passes from stages 1 through 4." "A nurse is caring for a patient who is having difficulty sleeping. Which patient responses indicate to the nurse that the patient is not obtaining adequate rapid-eye- movement (REM) sleep? Select all that apply. 1. Hyporesponsiveness 2. Immunosuppression 3. Irritability 4. Confusion 5. Vertigo - CORRECT ANSWER 3. Irritability Rapid-eye-movement (REM) sleep is essential for maintaining mental and emotional equilibrium and, when interrupted, results in irritability and excitability. 4. Confusion REM sleep is essential for maintaining mental and emotional equilibrium and, when interrupted, results in confusion and suspiciousness." "An older female adult explains to the nurse that she has insomnia. The nurse interviews the patient and her husband and reviews the patient's medication reconciliation form. Which factors does the nurse conclude are associated with the patient's insomnia? Select all that apply. 1. Metformin 2. Older adult 3. Female gender 4. Alcohol intake 5. Diphenhydramine 6. Catnaps during the day - CORRECT ANSWER 2. Older adult Sleep patterns tend to change as one ages. Older people become sleepy earlier and wake up earlier (alteration in circadian rhythms), wake up more frequently (lower levels of growth hormone and melatonin), and experience less deep sleep (more rapid sleep cycles). 3. Female gender Hormonal shifts in women occur throughout life: monthly related to ovulation, during pregnancy, and during and after menopause. Hormonal changes can precipitate nausea, anxiety, weight gain, generalized discomfort, restless legs syndrome, acid reflux, and frequent urination. All of these physiological responses can precipitate insomnia. 4. Alcohol intake Alcohol is a sedative that can help one fall asleep but it prevents deeper stages of sleep and causes one to awaken frequently during the night and earlier in the morning." "ANA Professional Nursing Code of Ethics - CORRECT ANSWER Serves as an ethical framework for a nurses practice. Provides a nurse with direction in respect to their ethical relationships, nursing responsibilities, appropriate behaviors and in making day to day choices in their practice. The code is grounded in the principles of: Advocacy Responsibility Accountability Confidentiality" "ethical dilemmas in nursing - CORRECT ANSWER are situations that challenge one's ability to choose the most ethical course of action. Nurses are charged with using ethical concepts in their delivery of patient care. Ethical concepts include providing care which is good, correct, and rational." "A health care issue often becomes an ethical dilemma because. A. A clients legal rights coexist with a health professionals obligation B. Decisions must be made quickly, often under stressful conditions C. Decisions must be made based on value systems D. The choices involved do not appear to be clearly right or wrong. - CORRECT ANSWER D. The choices involved do not appear to be clearly right or wrong" "Resolving An Ethical Conflict - CORRECT ANSWER Identify whether or not the issue is indeed an ethical dilemma. Gather as much relevant information as possible about the dilemma. Reflect on your own values as they relate to the dilemma. State the ethical dilemma, including all surrounding issues and the individuals it involves. List and analyze all possible options for resolving the dilemma, and review the implications for each option. Select the option that is in concert with the ethical principle that applies to this situation, the decision maker's values and beliefs, and the profession's values for the client care. Apply this decision to the dilemma, and evaluate the outcomes." "Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A. American Nurses Association's (ANA's) Code of Ethics B. Nurse Practice Act (NPA) written by state legislation C. Standards of care from experts in the practice field D. Good Samaritan laws for civil guidelines - CORRECT ANSWER A. American Nurses Association's (ANA's) Code of Ethics" "The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parent resolve this ethical conflict, the nurse knows the first step is: A. Exploring reasonable courses of action B. Collecting all available information about the situation C. Clarifying values related to the cause of the dilemma. D. Identifying people who can solve the difficulty - CORRECT ANSWER B. Collecting all available information about the situation" "Standards of care - CORRECT ANSWER or standards of practice in nursing are policies and guidelines that provide a foundation as to how a nurse should act and what he or she should and should not do in his or her professional capacity." "The scope of nursing practice is legally defined by: A.State Nurse Practice Acts B.Professional nursing organizations C.Hospital policy and procedure manuals D.Healthcare providers in the employing institutions - CORRECT ANSWER A.State Nurse Practice Acts" "neglicence - CORRECT ANSWER is conduct which falls below the generally accepted standard of care of a reasonably prudent person." "Malpractice - CORRECT ANSWER refers to professional negligence; when nursing care falls below the standard of care dictated by the profession malpractice results." "A confused patient who fell out of bed because the side rails were not used as ordered is an example of which type of liability? A.Felony B. Battery C. Assault D. Negligence - CORRECT ANSWER D" "Informed Consent - CORRECT ANSWER is a patient's agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives and consequences of refusal." "witness the consent - CORRECT ANSWER The nurses primary role in the informed consent process is to _____?" "obtaining informed consent - CORRECT ANSWER The healthcare provider performing the procedure is responsible for ___??" "The Nurse is required to do these to ensure informed consent - CORRECT ANSWER •Ensure the client has received all the necessary information. •Ensure the client fully understands all of the information. •Ensure the client has signed the informed consent. •Notify the provider if the client has specific questions and requires clarification. The provider is required to provide clarification. •Ensure the consent process and any clarification issues are appropriately documented." ""The nurse changes a patient's dry sterile dressing. How is the nurse functioning when performing this task? 1. Interdependently 2. Collaboratively 3. Independently 4. Dependently - CORRECT ANSWER Correct Answer: 4. A nurse is not permitted legally to prescribe wound care. The nurse needs a practitioner's order to provide wound care. 1. The changing of a dry sterile dressing is an interdependent action by the nurse when the practitioner's order for wound care states: Dry Sterile Dressing PRN. 2. In this situation, the nurse is not working with other health-care professionals to implement a practitioner's order. 3. This intervention is not within the scope of nursing practice without a practitioner's order." "The nurse must administer a medication. What should the nurse do first? 1. Check the patient's identification armband 2. Ensure the medication is in the medication cart 3. Verify the practitioner's prescription for accuracy 4. Determine the appropriateness of the prescribed medication - CORRECT ANSWER Correct Answer: 3. The administration of medications is a dependent function of the nurse. The practitioner's prescription should be verified for accuracy. The prescription must include the name of the patient, the name of the drug, the size of the dose, the route of administration, the number of times per day to be administered, and any related parameters. 1. Although this action is essential for the safe administration of a medication to a patient, it is not the first step of this procedure. 2. Although this may be done as a time- management practice, it is not the first step when preparing to administer a medication to a patient. 4. A nurse is legally responsible for the safe administration of medications; therefore, the nurse should assess if a medication prescription is reasonable. However, this is not the first step when preparing to administer a medication to a patient." "When choosing a nursing school in the United States that awards an associate degree, a future student nurse should consider schools that have met the standards of nursing education established by which organization? 1. National League for Nursing Accrediting Commission 2. North American Nursing Diagnosis Association 3. American Nurses Association 4. Sigma Theta Tau - CORRECT ANSWER Correct Answer: 1. The National League for Nursing Accrediting Commission (NLNAC) is an organization that appraises and grants accreditation status to nursing programs that meet predetermined structure, process, and outcome criteria. 2. The North American Nursing Diagnosis Association (NANDA) developed a constantly evolving taxonomy of nursing diagnoses to provide a standardized language that focuses on the patient and related nursing care. 3. The American Nurses Association (ANA) is the national professional organization for nursing in the United States. It does not accredit schools of nursing. 4. Sigma Theta Tau, the international honor society of nursing, recognizes academic achievement. It does not accredit schools of nursing." "The patient's diet order is "clear liquids to regular as tolerated." How is the nurse functioning when progressing the patient's diet to full liquid? 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently - CORRECT ANSWER Correct Answer: 4. The practitioner's order implies a progression in the diet as tolerated. The nurse uses judgment to determine the time of this progression, which is an interdependent action. 1. This dietary order has par