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During early adolescence (12 to 13 years), primary and
secondary sex characteristics continue to develop,
necessitating more information about _____________.
Body changes
Which of the following is the best guarantee that the patient's priority needs are met
Preparing a nursing care plan in collaboration with the patient
A ____________ self concept is essential to a person's metal and physical health.
Postive
Sally is 5'7", weighs 105lb, and believes that she is fat. Which of the following most represents this perception?
Altered Body Image
The nurse who has little experience in caring for clients with altered self-concept may wish to __________ with a more experience nurse to develop effective plans.
Consult
Which of the following nursing diagnoses contains the proper components?
Risk for Caregiver Role Strain related to unpredictable illness course
The nurse begins the plan when the client is admitted to the agency and updates it throughout these client's stay in response to changes in the client's condition and
Evaluation of goal
Self-concept may vary according to a variety of conditions affecting the individual. The nurse recognizes that even appropriate nursing intervetions are at least likely to alter which of the following:?
Social Self
You are caring for a client who has a nursing diagnosis of Chronic Low Self-Esteem. Which behaviors are consistent with this diagnosis? Select all that apply
- Sets unrealistically high goals
- Has difficulty making positive observations about self
- Verbalizes own weaknesses
- Is unable to perform consistent with his/her family role (mother, father)
A complete plan of care integrates ________ into a
meaningful whole and provides a central source of client information
Dependent and Independent Nursing Functions
Standardized care plan is a formal plan that specifies the nursing care for groups of clients with _____________________.
Common needs
Within our ________ we develop our gender identify, body image, sexual self-concept, and capacity for intimacy
families
The determining factor in the revision of a nursing care plan is
Effectiveness of the interventions
It is important for the nurse to determine the client's cultural background first in order to not ________ specific behaviors
misinterpret
During adolescence, cancers related to _________ are of paramount concern.
body image
Advise parents to discuss _________________ about sexual intercourse, menstruation, and reproduction with children at about 10 years of age.
basic information
The end product of the planning phase is a
client care plan
Which interventions are appropriate for a client with low/ poor self-concept?
- suggest the client say positive things about self
- suggest the client not say negative things about self
____________ as the client's responses, problems, and therapies change.
Priorities change
Effective discharge planning begins at first client contact and involves comprehensive and ___________________ to obtain information about the client's ongoing needs.
ongoing assessment
It is the nurse's responsibly to use _______________ and to remain sensitive to the effect that cultural influences have on a client's behaviors and needs.
Therapeutic communication
An actual diagnosis is based on the presence of associated:
Signs and symptoms
Nursing interventions to promote or enhance a positive self-concept include helping a client to identify areas of
Strength
Adults _______ at anytime of their lives may experience overwhelming anxiety when faced with the decision to engage in sex.
Sexually abused
The ability of a person to handle stressors will largely depend on personal
resources
Three major concerns are related to client's use of nutritional supplements:
- Consistency
- Safety
- Efficacy
He raised the issue of giving priority to patient needs. Which of the following offers the best way for setting priority.
Assessing nursing needs and problems
________ require information about contraceptive measures and precautions to take with regard to STIs
Teenagers
For most people, sexual health is not a concern until its absence or impairment is noticed. A person's degree of sexual health is best determined by that individual, sometimes with the assistance of a ______________.
qualified professional.
In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)", the ETIOLOGY of the problem
Decreased venous return
___________ is required to understand partner's sexual needs and to work through problems and stresses.
regular communication
Inadequate in amount, quality, or degree; not sufficient; incomplete
Deficient
Made worse, weakened, damaged, reduced, detonated
Impaired
lesser in size, amount, or degree
decreased
Not producing the desired effect
Ineffective
to make vulnerable to threat
Compromised
To utilize the nursing process, the nurse must FIRST
Obtain information about the client
One of the primary advantage of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following?
Standardizes organization of client
Care plans include the _________ to address the client's nursing diagnoses and produce the desired outcomes
Actions nurses must take
The ______________ demonstrates accountability to the client and to the nursing profession, since the effectiveness of nursing action
Nurse's signature
While taking a nursing history from a client the nurse promotes communication by:
a. Using broad, open-ended statements
b. Reassuring the client that there is no cause for alarm
c. Asking questions that can be answered by a "yes" or "no"
d. Asking "why" and "how' questions
Using broad, open-ended statements
A nursing diagnosis represents the
Client
As the nurse is about to start her assessment of her plan of
care, she observes her client wringing her hands and looking frightened.
The client reports to the nurse that "she feels out of control". Which
approach by the nurse is MOST APPROPRIATE to maintain a safe
environment?
Observe the client in a ongoing manner but odd not intervene.
Decide which of the client's problems need __________________ and which problems can be addressed by standardized plans and routine care.
individualized plans
Sending messages
Communicating
Assigning relative worth
Valuing
Activity
Moving
Establishing bonds
Relating
Subjective awareness of information
Feeling
Before conducting a psychosocial assessment, the must establish trust and a ____________ relationship with the client.
working
People who have a poor _______ may respond negatively to sexual arousal
Body image
The effectiveness of nurse-client communication is best validated by:
Client feedback
Nurse have a responsibility to ________ clients for a negative self-concept to identify the possible causes in order to help them develop a more positive view of themselves
Assess
This is a crucial part of comprehensive health care plan and should be addressed in each client's care plan
Discharge Planning
Nursing process can be define as the
steps the nurse employs provide nursing care
Because sexuality and sexual function are aspects of health ad well-being, they are part of nursing care and need to be
Assessed
An 89-year-old client states, "I'm a lost cause. I can't even stand long enough to cook my own meals anymore". Which is the most appropriate response
That must be difficult. What things are you still able to do?"
An informal nursing care plan is a strategy for action that exist in the
Nurses's mind
________ should be initiated as soon as possible after the
initial assessment
Planning
________ often requires information about measures to
prevent unwanted pregnancies (abstinence or contraceptive devices)
Young Adults
After meals
pc
Before meals
ac
Nothing by mouth
NPO
As desired
ad lib
Twice daily
BID or bid
complains
c/o
Diet as tolerated
DAT
Discontinue
D/C; DC
Right eye, overdose
OD
left eye
OS
By or through:
Per
By mouth:
po
When necessary
prn
Four times a day:
did
At once, immediately:
stat
Three times a da
tid
Physical examination
PE (px)
Main Blood Group System
ABO
Bathroom Privileges
BRP
Admitted
ADM
The overall goal of the client advocate is to protect the client's ___________.
rights
The advocate must be careful to remain ________ and not convey approval or disapproval of the client's choices.
objective
Advocacy requires accepting and respecting the client's right to decide, even if the nurse believes
the decision to be ______.
wrong
A code of ethics is best defined as
Formal guidelines and standards for professional actions
Standards of nursing practice serve as a guide for:
Safe nursing care and management
Health care issues often become an ethical dilemma because of which of the following?
Choices involved do not appear to be clearly right or wrong.
With regard to ethical situations in client care, the most important nursing responsibility is to: A. Remain neutral and fair in ethical decisions
Be accountable for the morality of one's own action
Maintaining confidentiality of patient information is part of nurse's
Ethical and legal obligation
An aler, oriented adult Jehovah Witness client is refusing blood even though he realizes he could die. The wife, whose is not believer, asks that blood be give. How should the situation be handled?
Do not give blood, respecting the client's right to refuse
Nurse advocates often are conflicted about respecting a patient's right to be self-determining, while at the same time wanting to do everything in their power to promote the patient's best interests. Which is the best general guideline for situations like these?
When in conflict, weight the benefits and risks of each option and choose wisely.
A situation in which the best of course of action is often not clear, and strong ethical reasons exists to support each position:
Ethical Dilemma
An 85 year old is refusing dialysis for his kidney failure. The primary ethical principle involved is:
Autonomy
One of your chronically ill patients is always irritable that she shouts at anybody who enters the ward. One of these responses is indicative of your knowledge about the rights of patients in the health care system:
The hospital has the right to place a patient in isolation or physical restraint
A patient was informed by his attending physician about the need for a major surgery. Which by doing so violates the rights of a patient?
The risk of treatment and facts relating to it should not be told to the patient or else he might refuse the surgery
Mrs. Green rides the elevator to the third floor where her husband is a client. While on the elevator, Mrs. Green hears two nurses talking about Mr. Green. They are discussing the physical assessment result and the potential prognosis and whether he should be told. The nurses are violating which of the following ethical principles?
Confidentiality
The nurse is administering medication, and the client states, " I've never seen this pill before." What should the nurse do next?
Check the medication orders
The client does not want chemotherapy, but the family says he should take it. What is the best response by the nurse?
Share with the client what the nurse would do in that situation.
Which of the following situations is most clearly violation of the underlying principles associated with professional nursing ethics?
When asked about the purpose of a
medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed."
The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.
Nurses and Profession
In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.
Nurses and People
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