Online Practice Test 25

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 25 > NCLEX® Review Date/Time Submitted: July 15, 2012 at 2:15 PM (UTC/GMT)

Summary of Results 80% Correct of 10 Scored items: 8 Correct:  80% 2 Incorrect:  20% More information about scoring

1.		The nurse notes that a client appears very worried and upset about an upcoming procedure. After acknowledging the client's discomfort and providing information and support, the nurse evaluates that comfort care provided has been successful by: Your Answer: Asking if the client is now more comfortable about having the procedure performed than previously
		Objective: Describe how nurses demonstrate caring in practice. Rationale: The goal of comfort care is enhanced comfort; therefore, the nurse should compare comfort levels before and after the intervention. Enhanced client comfort entails more than simply understanding the procedure. While blood pressure may indicate tension or stress, asking if the client is less stressed is a more reliable indicator of psychological comfort. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The nurse is preparing an 83-year-old, English-speaking client of Hispanic descent for a pacemaker insertion. The client has a religious medal pinned to her hospital gown. The nurse knows that the gown will be removed in surgery for the procedure. What is the best way to care for this client? Your Answer: Send the medal to the OR with a note explaining the significance of it to the client
		Objective: Identify nursing theories focusing on caring. Rationale: When nursing care fails to be reasonably congruent with the client's beliefs, lifeways, and values, there may be signs of conflict, noncompliance, and stress. Culturally congruent care is provided in three major ways: (a) by preserving the client's familiar lifeways, (b) by making accommodations in care that are satisfying to clients, and (c) by repatterning nursing care to help the client move toward wellness Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		A fifty five year old client has been admitted to the hospital with a diagnosis of possible myocardial infarction. The client complains of chest pain and has a hypotensive episode. While the client is in the trendelenburg position, the nurse discovers the client has been grieving over the sudden loss of her adult child. The nurse's best response would be: Your Answer: Say to the client, "You look worried. Do you want to talk about the loss of your child?"
		Objective: Analyze the importance of different types of knowledge in nursing. Rationale: Personal knowledge of the client is a key in the caring relationship between nurse and client. The nurse aims to know who the client is, in his or her uniqueness. This knowledge is gained by observing and talking with the client and family, using listening and communication skills. The nurse cannot remain detached, but is actively engaged with the client. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
4.		The nurse learns from a report that a client has suffered severe, disfiguring injuries in an accident. What is the best way for the nurse to prepare for the first encounter with this client? Your Answer: Reviewing all medications and treatment procedures prior to meeting the client Correct Answer: Learning more about the specifics of the disfigurement to better control first reactions by the nurse
		Objective: Describe how nurses demonstrate caring in practice. Rationale: Clients who have disfiguring injuries will watch the nurse's facial expressions for signs of acceptance or disgust. Facial expressions will be easier to control if the nurse is adequately prepared for the encounter beforehand. Being prepared for care and knowing about the client's support systems are important, but control of facial expression so that the nurse conveys acceptance of the client is the top priority in establishing trust. By being emotionally present to the client, the nurse conveys that they and their existence matters. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		The nurse has been working with an elderly client and his wife preparing the husband for discharge. The wife wants to care for the client at home despite repeated requests by the family to admit him to a long term facility. What should the role of the nurse be in family disagreements? Your Answer: Be an advocate for the husband and wife.
		Objective: Describe how nurses demonstrate caring in practice. Rationale: Nurses both advocate for and are advocates for clients and families. Through advocacy, nurses are champions for their clients. They empower clients and families through activities that enhance well-being, understanding, and self-care. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		A client is crying. The nurse is very busy, but recognizes the client's need for interaction. The best way for the nurse to convey a willingness to be with the client for support is to: Your Answer: Pull up a chair, sit down, and state: "I see that something is bothering you. Do you want to talk?"
		Objective: Describe how nurses demonstrate caring in practice. Rationale: The client is in need of support by the nurse now. Despite the nurse's schedule, a willingness to spend time with the client must be communicated both verbally and nonverbally through body language (congruence) for the client to trust the nurse's words. Attentive listening requires full attention of the nurse, which cannot happen when the nurse is attending to other tasks. Compassion is a gift from the heart, rather than a skills or technique. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		The nurse has been asked to work a third double shift during one week. The head nurse begs the nurse to stay until midnight. The exhausted nurse should: Your Answer: Say no, but tell her that you can stay until the next shift begins their rounds
		Objective: Evaluate the importance of self care for the professional nurse. Rationale: It is imperative that nurses attend to their own needs, because caring for self is central to caring for others. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		An ICU nurse has been complaining of lethargy, fatigue and burn out. The best response to this individual would be: Your Answer: "Perhaps you need to take care of yourself by getting more rest and eating a healthy diet."
		Objective: Evaluate the importance of self care for the professional nurse. Rationale: Everyone needs to pay attention to nutrition and exercise and avoid unhealthy lifestyle practices. By attending to personal needs, the nurse could improve stamina and resilience. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A client with cancer asks a nurse about complementary therapies. A nurse's best response to the question would be: Your Answer: "Be very careful about choosing complementary therapies." Correct Answer: "Meditation can assist a person to release gears, worries and doubts."
		Objective: Identify the value of reflective practice in nursing. Rationale: The interconnectedness of the mind and body is the basis for the complementary therapies. Imagery, meditation, storytelling, music therapy, and yoga are complementary therapies that bring balance to thoughts and emotions. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		The nurse received shift report on a client with end stage cancer. The departing nurse reports, "He is not doing well and his vital signs have been dropping all day." Upon entering the client's room, the nurse sees that his face is unshaven, bed linens are dirty, and hair is tousled. The nurse's plan should include: Your Answer: Ask him what he needs to be more comfortable.
		Objective: Discuss the meaning of caring. Rationale: Caring practice involves connection, mutual recognition, and involvement. A nurse and client should mutually develop the plan of care. The goal is compassion and care for each individual. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Decide what is the best action for client and situation.