NUR 418 Exam 1 | Complete Solutions (Verified)

NUR 418 Exam 1 | Complete Solutions (Verified) A nurse wishes to improve their cultural sensitivity while working with patients. Which action by the nurse would best indicate progress toward this goal? 1. Demonstrate good knowledge of different cultural health beliefs 2. Effectively respond to the needs of people of different cultures 3. Interact respectfully with patients who have differing health beliefs 4. Recognize that they will never be the expert in other cultures A nurse manager is evaluating staff members on their cultural competence. Which action best demonstrates this characteristic? 1. Attends workshops on cultural diversity and health practices 2. Participates in community health events with minority populations 3. Plans care with the family members within their cultural beliefs 4. Uses family members as interpreters to make them feel important The culturally sensitive nurse can understand and respond to the needs of individuals and families from different cultures. This nurse plans interventions with a solid knowledge of the values and practices of the members of the culture. Being open, listening to the family, and involving them in care demonstrates respect, unifies the nurse-patient relationship, and will motivate the patient (and family) to make positive health changes. A patient wishes to use complementary therapy when managing a chronic health condition. Which action by the nurse is most appropriate? 1. Advise the patient that stopping medical treatment may cause it to worsen. 2. Inform the patient that there are no complementary therapies for this condition. 3. Investigate herbs that can be substituted for prescription drugs. 4. Suggest the patient add massage therapy to the medical regimen. A nurse is working with a family that uses multiple complementary and alternative medicine (CAM) modalities. What action by the nurse is best? 1. Allow the family to continue these practices as desired. 2. Assess how these practices reflect religious beliefs. 3. Inform the family that most of these practices do not work. 4. Provide evidence-based information about the therapies. A nurse is caring for a patient from a culture with which the nurse is totally unfamiliar. What action by the nurse will best promote effective communication? 1. Call for a professional interpreter to translate information. 2. Pattern voice tone and eye contact after the patient's behaviors. 3. Talk slowly and deliberately using simple language and cues. 4. Use nonverbal communication as much as possible with the patient. A nurse manager expects all employees to be patient advocates. Which nursing action best demonstrates this nursing role? 1. Arranging a family-physician conference to clarify treatment plans 2. Encouraging treatment options based on personal beliefs and values 3. Giving contact information for governmental assistance agencies 4. Working on a political campaign to reduce poverty in the state A patient and family have the nursing diagnosis of impaired verbal communication secondary to a language barrier. What action by the patient/family would best indicate that short-term goals for this diagnosis have been met? 1. Able to communicate long-term desires for health of the patient 2. Demonstrates comprehension by head nodding and saying "yes" 3. States understanding of condition and treatment via an interpreter 4. Understands how nonverbal communication varies between cultures A nurse is working with family members who have been striving to improve their functioning as a family unit. What behavior would suggest to the nurse that the family is meeting its goals? 1. The children are in multiple activities to develop talents. 2. The desire to be understood guides most communication. 3. Family members gave up some activities to eat dinner together on most nights. 4. The parents have a strong desire for the children to succeed. A nurse works a great deal with refugees and is frustrated because, as a group, they don't seem to want to implement desired health behaviors. What action by the nurse would be most helpful? 1. Conduct a health screening and educational event each month. 2. Provide written information in the group's native language. 3. Teach selected group representatives to be lay health educators. 4. Try to establish relationships within the refugee community. According to family systems theory, each family system contains boundaries that affect how the outside world interacts with the family. Families that have recently immigrated to the United States might have closed boundaries and may only be receptive to health information provided by extended family members or members of their community. Establishing a lay health educator program in which community members can be taught health information with the intent of delivering it to their communities would be a good way to work with these families while respecting their boundaries. A patient is dismissed from the hospital and is receiving nursing care at home to help in the recovery from a serious illness and operation. The visiting nurse notes that the family is in a state of disarray and members are disorganized and not communicating. The patient is trying to direct everyone's actions. The nurse calls a family meeting. What action by the nurse is best? 1. Encourage family members to make "to do" lists and assign chores. 2. Explain that changes in one person require changes in the others. 3. Make a referral to a counselor or mental health nurse practitioner. 4. Tell the family members that, for the patient to recover, they must assume the patient's role. A nurse is working with a blended family of 1 year with five children aged 3, 7, 13 (twins), and 19. The parents seem overly stressed and anxious and do not seem to work well as a unit. What can the nurse conclude about this family? 1. Communication problems are the core of the parents' stress. 2. Economic stressors are impacting the parental dyad. 3. The family is in too many developmental stages to master any of them. 4. There are too many children to give each one adequate attention. A nurse is working with a patient who is newly married and pregnant and says she is distressed because she and her husband seem to be so different, and they argue over petty issues. What action by the nurse using group theory would be best? 1. Ask the patient if she can remember why she and her husband fell in love. 2. Caution her that this level of disagreement will cause stress to the unborn baby. 3. Offer the patient a referral to a community counseling center for couples' therapy. 4. Reassure her that this is normal and help her brainstorm ways to work cooperatively. A clinic nurse is using group theory to assess a family whose youngest child recently moved back home after graduating from college and is unable to find a job. Which statement by a parent would indicate to the nurse that goals for norming have been met? 1. "I'm glad my son stays in his room in the basement all day, so he doesn't bother us." 2. "It's hard to decide how much food to buy because we don't know where he's eating." 3. "My son is gone a lot of the time, so we really don't notice that he moved back in." 4. "We have agreed not to have a curfew as long as we know when he will be home." A student observes as an adult brother and sister lash out at the nurse caring for their hospitalized parent. The parent lives at home but is dependent on the children for care and is obviously neglected. The nurse has informed the children that social work will be involved in their parent's case. How does the nurse explain this interaction? 1. "Don't worry; they will calm down eventually." 2. "Families often get emotional in these situations." 3. "They are focusing attention on me, not the problem." 4. "This family is obviously highly dysfunctional." A nurse working with a married couple notes that both parties seem to try to be dominant in their sessions. According to Bowen's family systems theory, which question asked by the nurse would yield the most useful information? 1. "Are you each a first-born, middle child, or youngest sibling?" 2. "How demonstrative was each of your parents when you were growing up?" 3. "How many children were in each of your families?" 4. "What socioeconomic classes did you both grow up in?" A nurse working with a pregnant patient who is a recent immigrant to the United States notes that her husband rarely accompanies her to prenatal visits, and when he does, he sits in the waiting room. What action by the nurse is best? 1. Ask the patient what role men in her culture play in pregnancy. 2. Ask the patient why her husband doesn't seem involved. 3. Encourage the man to participate to support his wife. 4. Research the couple's cultural background and health beliefs. The family clinic nurse initiates conversation with a 16-year-old adolescent male who is 5 feet 10 inches and weighs 250 pounds (113.6 kg). Which of the following is the most appropriate question for the nurse to ask the adolescent regarding his weight? 1. "Are you willing to talk about your weight gain this year?" 2. "Do you realize your weight puts you into an obese category?" 3. "Do you participate in any activities or exercise?" 4. "What do you think about your weight right now?" A group of student nurses are reviewing the Nurse Practice Act. Which statements indicate that teaching has been effective? Select all that apply. 1. "Nurse Practice Acts are the same across the United States." 2. "Roles and responsibilities are specified by type of license." 3. "Information for initial application." 4. "Criteria for renewal of professional license." 5. "Describes required elements for professional nursing programs." A nurse is reviewing research studies. Based on the concept of evidence-based practice, which type of research designs would be considered to be Level 1? Select all that apply. 1. "Committee report." 2. "Randomized clinical trial (RCT)." 3. "Expert opinion." 4. "Meta-analysis." 5. "Case studies." Which statements are accurate based on common mortality statistics? Select all that apply. 1. "The birth rate is based on data collection obtained every 2 years." 2. "Fetal and neonatal fatalities are included in the perinatal mortality rate." 3. "Neonatal mortality rate includes deaths up to 1 year." 4. "Infant mortality rate includes all deaths under age 1 year per 1,000 births." 5. "Maternal mortality rates include only term gestations." A nurse is assessing a patient in the women's clinic for Chadwick's sign. How does the nurse perform this assessment? 1. Auscultates the patient's abdomen for fetal heart tones 2. Inspects the vulva and vagina for a bluish tint 3. Palpates the patient's abdomen for a fluid wave 4. Percusses the patient's abdomen for uterine margins Chadwick's sign is one of the earliest signs of pregnancy and consists of a bluish discoloration of the cervix, vulva, and vagina. The nurse would inspect the patient for this discoloration. A nurse is teaching a patient who is in her first trimester of pregnancy about physical changes she can expect. Which information should the nurse provide? 1. Diminishing sexual interest occurs. 2. Harmful agents can invade the uterus. 3. Leukorrhea is an abnormal condition. 4. Pregnant people are more susceptible to yeast infections. Glycogen levels are increased in vaginal cells during pregnancy, and this change creates an environment more hospitable to Candida albicans. Thus, pregnant people are more susceptible to yeast infections. A pregnant patient in the perinatal clinic complains of a diffuse, reddish discoloration of her palms. What action by the nurse is most appropriate? 1. Ask if she has been exposed to measles. 2. Assess her for Raynaud's phenomenon. 3. Explain that this is a normal finding. 4. Take the patient's vital signs. Palmar erythema is a reddish discoloration of the palms and occurs in about 60% of Caucasian women and in about 35% of African American women during pregnancy. Which of the following are presumptive signs of pregnancy? (Select all that apply) 1. Amenorrhea 2. Nausea and vomiting 3. Hegar's sign 4. Urinary frequency 5. Fatigue 6. Positive pregnancy test 7. Quickening Which of the following are probable signs of pregnancy? (Select all that apply). 1. Chadwick's sign 2. Breast tenderness 3. Hegar's sign 4. Ballottement 5. STIs 6. Ultrasound 7. Pigmentation of skin 8. Positive pregnancy test Which of the following are positive signs of pregnancy? (Select all that apply). 1. Ultrasound 2. Braxton Hicks contractions 3. Fetal movement felt by Dr. 4. Fetal heart tones heard 5. Increased vascular congestion Which of the following statements best describes presumptive signs of pregnancy? 1. Objective indicators resulting from physical changes in the reproductive system that are observed by the examiner. 2. Subjective signs of pregnancy; the symptoms that the patient experiences and reports. 3. Indicators of pregnancy that are attributable only to the presence of a fetus. 1. is the definition of PROBABLE signs of pregnancy 3. is the definition of POSITIVE signs of pregnancy A woman who is 40 weeks pregnant calls the clinic to report that she noted a small amount of blood-tinged mucus on her toilet tissue this morning. What response by the nurse is most appropriate? 1. "Come to the clinic today for an examination." 2. "Labor will probably start within 48 hours." 3. "Lie on your left side and count fetal kicks." 4. "Stay on bed rest until your labor begins." During pregnancy, the cervix is plugged with mucus. When effacement begins, small capillaries can rupture, leading to an expulsion of the blood-tinged mucus plug, called bloody show. Its presence often indicates that labor will begin in 24 to 48 hours. No action is needed at this time. A woman arrives at the birthing unit complaining of frequent strong contractions that begin in her back and cannot be relieved by walking or changing positions. What action by the nurse is most appropriate? 1. Assess the woman for rupture of membranes. 2. Immediately notify the woman's primary care provider. 3. Reassure the woman and send her home. 4. Review the signs of true labor with the woman. Distinguishing true labor from false labor can be difficult. True labor contractions occur with regularity, increased in frequency and duration, and usually begin in the woman's lower back and radiate to the abdomen. Based on the woman's description, the contractions likely are indicative of true labor, so she should be assessed further, including assessment for rupture of membranes. A woman in the perinatal clinic reports a gush of vaginal fluid after sneezing. The nurse performs a Nitrazine tape test and documents that the tape is beige in color. What action should the nurse take? 1. Ask the woman about recent sexual intercourse. 2. Assess the woman for urinary incontinence. 3. Arrange for the woman to be admitted to the birthing unit. 4. Inquire if the woman has symptoms of a vaginal infection. Amniotic fluid is alkaline with a pH between 6.5 and 7.5. When the alkaline amniotic fluid is exposed to Nitrazine tape, the tape turns blue-green, gray, or deep blue. Urine and vaginal secretions are usually acidic, which would leave the Nitrazine tape beige. Because the gush of fluid occurred after sneezing, the nurse should assess the woman for urinary incontinence (especially stress incontinence). A woman's birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come into the birthing unit? 1. After 10 hours of mild contractions 2. When contractions are 3 to 5 minutes apart 3. When contractions are experienced in the back 4. When strong contractions occur 2 to 3 minutes apart During the latent phase of labor, contractions are typically 5 minutes apart, last 30 to 45 seconds, and are considered mild. When contractions become more frequent (every 3 to 5 minutes) and are of moderate to strong intensity, the woman has entered the active phase of labor; this is when the patient should come into the birthing unit. A woman with a history of two stillbirths is in the active phase of the first stage of labor in the high-risk OB unit. How often should the nurse anticipate monitoring fetal heart tones (FHTs) 1. Continuously 2. Every 5 minutes 3. Every 15 minutes 4. Every30minutes Women with certain complications, including a history of stillbirth, a high-risk pregnancy (pre-eclampsia-eclampsia, placenta previa, abruptio placentae, multiple gestations, prolonged or premature rupture of the membranes), induction with oxytocin, or a problem with FHT, should have FHT monitored continuously A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best? 1. Gather equipment for internal FHT monitoring. 2. Have the nurse document FHT rate as 140/158 on the chart. 3. Instruct the nurse to assess FHT between contractions. 4. Tell the nurse to count only for 30 seconds. Baseline fetal heart tones can only be assessed during the absence of uterine activity. The preceptor should instruct the new nurse to listen for FHTs between contractions. A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first? 1. Assess the maternal temperature and call the primary care provider. 2. Document the findings in the patient's chart. 3. Have the woman get up and walk or change position. 4. Perform a vaginal exam to assess for cord compression. Causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal medications (such as parasympathetic drugs and tocolytic drugs), infection, fetal anemia, and maternal hyperthyroidism. The nurse should quickly assess the maternal temperature and call the provider, as the tocolytic medication may need to be slowed or stopped. The OB nurse assesses moderate baseline variability on the fetal heart monitor. What action by the nurse is best? 1. Administer a bolus of IV fluids. 2. Discontinue oxytocin if it is being delivered. 3. Document the findings in the woman's chart. 4. Perform fetal scalp or vibroacoustic stimulation. Baseline variability is the most important predictor of adequate fetal oxygenation during labor. It can be described as absent, minimal, moderate, or marked. Adequate variability is described as moderate. This is a normal and reassuring finding and should be documented in the patient's chart. No further action is needed. A nurse assessing a fetal heart monitor notes minimal baseline variability not associated with a fetal sleep cycle. There is no change after fetal scalp stimulation. What action by the nurse is most important? 1. Administer a bolus of IV fluids. 2. Administer oxygen at 8-10 L/min per mask. 3. Offer support to the patient and her partner. 4. Prepare to assist with internal fetal monitoring. All the options are correct actions for the nurse to take in this situation. However actions should be prioritized using the A (airway), B (breathing), C (circulation method. The breathing action (administering oxygen) should occur first. A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents contractions occurring every 1 to 2 minutes. Oxytocin (Pitocin) is being infused IV, and oxygen is being delivered at 8 L/min per mask. The woman is positioned on her left side. What action by the nurse takes priority? 1. Discontinue the oxygen. 2. Increase the oxytocin rate. 3. Assist the woman to a supine position. 4. Stop the oxytocin infusion. Late decelerations are a sign of uteroplacental insufficiency and are often indicative of hypoxia and metabolic acidemia. Contractions that occur this frequently signify uterine hyperstimulation. Both circumstances indicate that the oxytocin should be stopped immediately. A nurse is taking care of a woman who has just been admitted in early labor. Based on this monitor tracing, what priority action should the nurse take? 1. Prepare for an emergent delivery. 2. Perform a vagina exam to denote patient's progress. 3. Administer Narcan. 4. Continue to monitor and reposition the patient to left lateral side. This monitor tracing indicates prolonged late decelerations that indicate fetal hypoxia. Regardless of the patient's vaginal exam status, the priority action is to prepare for delivery of the fetus. A nursing manager is concerned about frequent errors on the pediatric unit and wants to decrease them. What action by the manager is best? 1. Have two nurses verify all new orders when they are written. 2. Use barcode authentication. 3. Provide remedial education to nurses who make errors. 4. Require charge nurses to verify care plans with staff nurses. Use of improved technology with barcode authentication will help to limit the amount of medication errors. A 66-lb. child complains of mild pain after a procedure. What action by the nurse is best? 1. Administer 0.3 mg of naloxone (Narcan) every 4 hours orally if needed. 2. Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie to watch. 3. Administer 450 mg of acetaminophen (Tylenol) orally every 3 hours as requested. 4. Administer morphine sulfate (Astromorph) 9 mg orally every 4 hours if needed. For mild pain, acetaminophen and other mild analgesics work well along with a distraction or other comfort measures. The most appropriate choice is 300 mg of acetaminophen (within the dose range of 10-15 mg/kg every 4-6 hours) and a movie to distract the child. A nurse needs to administer medication to a toddler. What action by the nurse is most likely to gain cooperation from the child? 1. Allow the child to negotiate a "reward." 2. Allow the parent to give the medication. 3. Explain that medicine is not a punishment. 4. Let the toddler self-administer the medicine. A toddler may consider medicine to be a punishment and may resist taking it. Because the parent is a comforting figure for them, allowing the parent to administer the medication is a good option for the uncooperative child. A preschool-age child is going to have a potentially painful procedure. What action by the nurse is best to prepare the child for this event? 1. Allow the child to decide if the parents stay or not. 2. Let the child touch and explore the equipment first. 3. Talk about it briefly for several days before hand. 4. Use play to demonstrate the procedure to the child. The nurse should use play to demonstrate the procedure and allow the child to "perform" the procedure on a doll or stuffed toy. A nurse is assisting the physician during a lumbar puncture (LP) for a pediatric patient. What priority actions should be included in the plan of care? Select all that apply. 1. "Distraction is used in place of local/regional anesthesia." 2. "Positioning of the patient is based on developmental age." 3. "Vital signs are taken postprocedure." 4. "Patient should remain flat for at least 1 hour." 5. "Fluids are restricted postprocedure." A nursing instructor is evaluating a nursing student on the placement of a nasogastric tube on a pediatric patient. Which findings indicate correct procedure? Select all that apply. 1. "Gloves are applied following hand hygiene." 2. "Verify tube length from mouth to the earlobe." 3. "Auscultate stomach following insertion of air." 4. "Use dominant hand to insert." 5. "Lubricate tip with petrolatum jelly." A pediatric patient has to be restrained for a surgical procedure. Which priority actions should the nurse perform to maintain safety? Select all that apply. 1. "Check the restraint initially every hour once applied." 2. "Assess and document condition of skin surface by restraints." 3. "Monitor vital signs per protocol." 4. "Reapply restraints once a shift." 5. "Monitor for level of pain postprocedure." Prioritize the following steps for the administration of pain medication to a preschool-aged child post-appendectomy. (Example: 1234) 1. Administer within 30 minutes of scheduled time 2. Confirm rights of medication administration 3. Assess for drug allergies 4. Verify using two unique identifiers 3, 2, 4, 1 A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate? 1. Assure the parents that this is temporary. 2. Document the findings in the infant's chart. 3. Have the mother switch to bottle feeding. 4. Review the chart for history of a traumatic birth. Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth. A nurse is observing a mother who has just had a spontaneous vaginal delivery. Which observation would alert the nurse to a potential concern related to maternal-infant bonding? 1. The new mother states that she is very tired. 2. The new mother avoids looking at the baby when placed on her abdomen. 3. The placenta has yet to be delivered. 4. The new mother states that she is hungry. Facilitation of bonding experiences between mother and newborn focus on maintaining eye contact. The fact that the mother's gaze is averted is a potential concern that can impact maternal-infant bonding. The perinatal nurse and student nurse are conducting an assessment on a postpartal woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding sound. How should the nurse document this information? 1. A bladder containing about 500 cc of urine 2. A full bladder 3. An empty bladder 4. A hard bladder To percuss the bladder, the nurse places one finger flat on the patient's abdomen over the bladder and taps it with the finger of the other hand. An empty bladder has a dull, thudding sound. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping when she breastfeeds her infant. The perinatal nurse should document this condition as which of the following? 1. After pains 2. Bladder hypotonia 3. Diastasis recti abdominis 4. Uterine hemorrhage Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced afterpains because both cause powerful uterine contractions. Patients often describe the sensation as a discomfort like menstrual cramps. A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best? 1. Encourage the woman to drink plenty of fluids. 2. Document the findings and notify the provider. 3. Have the woman cough and deep breathe. 4. Prepare to administer acetaminophen (Tylenol). Dehydration and exertion often cause a transient increase in body temperature up to 100.4°F (38°C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. A nurse assessing a postpartum woman 12 hours after uncomplicated vaginal birth finds her pulse to be 110 beats/minute. What action by the nurse is best? 1. Assess the patient for causes of tachycardia. 2. Document the findings and notify the provider. 3. Facilitate a blood draw for laboratory studies. 4. Place the patient on a 1,000-mL fluid restriction. Postpartum tachycardia can result from several causes, including complications, blood loss, prolonged labor, temperature elevation, and infection. The nurse should assess the patient thoroughly to determine the cause of the tachycardia. The nurse is assessing a woman in the immediate postpartum period. The patient's respiratory rate is 22 breaths/minute. The most important aspects of nursing care would be to do which of the following? Select all that apply. 1. "Assess and provide pain management." 2. "Assess the patient's blood pressure and pulse." 3. "Increase the patient's fluid intake." 4. "Notify the provider for continued tachypnea." 5. "Provide ongoing assessment."