Funda Ratio 002

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FUNDA – 002 ANSWERS AND RATIONALE

NURSING PROCESS
1. CORRECT ANSWER: C.
In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care of clients; instead
they plan care with clients and families. Assessment (option D), goal setting (option A), and interventions (option B) will be most
accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take,
but they will have less overall effectiveness if the client and family are not part of the plan.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.304
2. CORRECT ANSWER: C.
Assessment involves collecting, organizing, validating , and documenting data about a client. Option A represents the evaluation
phase. Option B represents the implementation phase. Option D represents the planning phase.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.262
3. CORRECT ANSWER: A.
Subjective data is apparent only to the person affected and cannot be measured, seen, felt, or heard by the nurse. The client is
always considered the primary source. Secondary sources of data include the family, other health personel, and the client records.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.262,264
4. CORRECT ANSWER: C.
This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk
factor (malnutrition). Option A and B do not have related factors that are under the control of the nurse (i.e.,type of diet ordered).
The diagnosis in option D does not specify the type of impairment (greater than or less than body requirements) and is therefore
incomplete. It also does not provide direction for development of goals and interventions.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.279
5. CORRECT ANSWER: B.
A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/label the problem. The
second part (related factors) includes the factor either contribute to or are probable etiologies of the human response. Some
formats include a third part to the statement for actual (not risk) diagnosis; this third part consist of the clients signs or symptoms and
is joined to the statement with the label as evidence by. This type of statement is the most complete. Option A is not a nursing
diagnosis but is a medical diagnosis. Option C and D are vague.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.279-281
6. CORRECT ANSWER: C and D.
An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options C and D are SMART goals.
Options A and B have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot
expect a postoperative client to be pain free. Option E is not a client goal.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.303
7. CORRECT ANSWER: B.
Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or
inappropriate for a client, the nurse must act as client advocate and collaborate with the appropriate healthcare team member to
determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions.
Option A, C and D are inappropriate and unsafe.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.62,81
8. CORRECT ANSWER: A. Part of the professional nurse`s role is to delegate responsibility for activities while maintaining accountability. The
nurse must catch the needs of the client with the skills and knowledge of UAP`s. Certain skills and activities, such as those in option B, C ,
and D, are not within the legal scope of practice for a UAP.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.472
9. CORRECT ANSWER: D.
A change-of-shift report should include significant changes (good or bad) in a clients condition. The information should be
accurate, concise, clear, and complete. Options A is vague and options B and C are normal data and are therefore or lesser
importance to convey in the change-of-shift report.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.345
10. CORRECT ANSWER: D.
Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have
been met. Diagnosing identifies health problems, risk, and strengths. Planning is the formulation of client goals and nursing strategies
(interventions) required to prevent, reduce, or eliminate the clients’ health problems. Implementing is carrying out or delegating the
nursing intervention.
Reference: Kozier, B.,Erb, G.,Berman,A.,& Snyder,S.J.(2004).fundamentals of nursing: conception,process and practice (7th ed.).
upper Saddle River, NJ: Pearson Education, p.320
HEALTH ASSESSMENT
11. CORRECT ANSWER: A.
In order to gain as much as insight and information from the client as possible, the nurse should establish a level of trust or rapport
with the client. The client will be best able to relax and answer if he or she is asked in a non threatening manner. Offering the client
food or drink is not appropriate. The nurse should not ask the client about health insurance or finances, as other personnel determine
this. The client does not need to wear an examining gown to answer question.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.268
12. CORRECT ANSWER: D.
During inspection, the nurse scrutinizes and evaluates by sight any clues of pathology that may be present. By first performing the
other assessment techniques (auscultation, percussion, and palpation), the nurse could alter the findings.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.593
13. CORRECT ANSWER: B, D and E.
Four key areas of functioning to be address ed in the mental status exam are appearance, behavior (option B), and cognition and
thought processes (options D and E). Educational level is unrelated to mental status. Gait and balance are assessed as part of the
neurological exam.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,pp. 531,534
14. CORRECT ANSWER: A.
The chief complaint offers the nurse an indication of what the problem is and how health care should proceed. The nurse can
continue to probe during the interview to identify contributing factors to the client’s chief complaint. The client’s statements must be
documented using his or her own phrases and terminology.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.263.
15. CORRECT ANSWER: B:
The cremasteric reflex is tested in men only. The nurse uses a cotton-tipped applicator or other smooth object to stimulate the thigh.
The normal reaction is contraction of the cremaster muscle and elevation of the testicle on the side stimulated.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.620
16. CORRECT ANSWER: A.
To assess for jugular venous distention (which indicate fluid volume overload), the client should be lying supine with the head
elevated to 30 degrees (low Fowler`s). the nurse assesses the highest point of distention of the internal jugular vein in centimeters in
relation to the sterna angle, the point at which the clavicles meet. The other positions listed would not aid in this physical assessment
technique.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.585
17. CORRECT ANSWER: D.
During physical assessment, the nurse inspects the client`s leg for hair distribution. The most common reason for skiny skin and a
complete absence of hair is poor circulation related to peripheral vascular disease (PVD). Thus the nursing diagnosis of impaired
peripheral tissue perfusion applies. The other nursing diagnoses do not relate to or affect hair distribution.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.587
18. CORRECT ANSWER: A.
The apical pulse should be auscultated for one full minute with the stethoscope at the 5th intercostals space in the midclavicular line
(apex of the heart). While ausculting the apical pulse, the radial pulse should be palpated simultaneously to detect discrepancies
caused by dysrhythmias. One radial pulse should be felt for each apical beat heard, but with some dysrhythmias, the radial
pulsation is absent with early beats because of reduce stroke volume. Options B and D would not allow for simultaneous assessment
of the apical and radial pulses. Option C is an incorrect location for cardiac auscultation.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.503
19. CORRECT ANSWER: C.
The Bartholin glands are part of the female anatomy located on the posterior aspect of the vaginal orifice. Therefore, if the medical
condition allows, having client in a lithotomy position (in her back, knees flexed, legs apart ,with feet supported on a surface or
stirrups) will provide the best opportunity for examination. The other responses do no allow for assessment of the female genitalia.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.615
20. CORRECT ANSWER: B.
In order to facilitate visualization of the ear canal and tympanic membrane, the pinna should be pulled up and back for an adult
client. If the earrings are attached to the lobe, there should not be a safety issue; however, they may remove if they are large in size
or are causing the client discomfort during the examination. The nurse should not remove cerumen with an applicator because of
the risk of pushing it further into the canal or rupturing the tympanic membrane. Generally, the ear and eye physical assessment are
performed with the client sitting upright.
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts,process and practice (7th ed.).
upper Saddle River,NJ: Pearson Education,p.557
COMMUNICATION
21. CORRECT ANSWER: B.
The nurse should validate his or her perceptions with the client to ensure the correct interpretation of the client’s nonverbal behavior.
The nurse does not need to verify this observation with another nurse (option C). The nurse should not make false assumptions
(option A) and should not ignore the client’s behavior (option D).
Reference: Kozier, b., Erb, G., Berman,A.,& Snyder,S.J. (2004). Fundamentals of Nursing: Concepts, process and practice (7th ed.).
Upper Saddle River,NJ: Pearson Education,p.274
22. CORRECT ANSWER: C. and E.
Exploring the client’s feelings are important to the nurse. Checking on the client’s frequently conveys that the nurse is concerned
with the client’s status. Providing re-assurance about the surgeon competency (option A) may dismiss the client’s feelings as
unimportant. Providing teaching to a client at this time (option B) is inappropriate because of anxiety. Relating personal experience
focuses the attention on the nurse, rather than the client (option D)
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 431
23. CORRECT ANSWER: C
For a client who is hearing impaired, speaking slowly in a low- pitched voice and facing the client will promote understanding of the
message sent. Option D will not provide enough information to effectively care for the client. Option A and B may be appropriate if
the client cannot hear at all.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 559.
24. CORRECT ANSWER: D
Documentation needs to be accurate and complete and should not express the opinion or judgment of the nurse. The incorrect
options are unclear, judgmental, and/or represent the nurse’s interpretation of data.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 264.
25. CORRECT ANSWER: C
A prerequisite to learning a new psychomotor skill is that the client is able to physically perform the skill in this case the client doesn’t
have the dexterity to palpate a pulse or ability to see a clock’s second hand, the client will need assistant with the skill. Options A
and B are unnecessary for the nurse to assess prior to implementing the teaching plan. Motivation to attain better health is also
important, but the nurse must first evaluate the client’s ability to perform the skill.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 451
26. CORRECT ANSWER: D
Having the client actively demonstrates the procedure is the best way for the nurse to evaluate the client’s level of skill.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 451
27. CORRECT ANSWER: A
Learning is the cognitive domain involves the acquisition and the use of knowledge mentally or intellectually. Option C involves
learning in the affective domain, which involves changing feelings and values toward a positive health behavior. Option B and D
involve learning in the psychomotor domain.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 458.
28. CORRECT ANSWER: C
Critical pathways are documents that identify outcome criteria that a group of patients are expected to achieve on each day of
hospitalization. Option C would be outcome critierion. Option A is a medical order. Option B is a nursing intervention (not necessarily
appropriate one) and option D is also a nursing intervention.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 336
29. CORRECT ANSWER: A
Physical assessment data and client response to care are pieces of information that are most important in ensuring that client’s
healthcare needs are being met. The other options are useful to a nurse assuming care of a client but are more limited in the scope
of information they provide (options C and D) or are not as relevant to client’s status in real time (option B)
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 345.
30. CORRECT ANSWER: D
Charting by exception is a form of documentation in which notations are made if there was an exception to the standard of care or
the client’s response to care. All other options are normal and are therefore not necessary to include in documentation using this
format.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p. 335.
PROFESSIONAL STANDARDS
31. CORRECT ANSWER: B
Negligence is defined as the failure to act as a reasonably prudent person would act in the same situation, or doing something that a
reasonably prudent person would not do. Giving a medication without an order is an example of option A. Option C is incorrect
because it relates to criminal statues that may not have been violated in this case. Option D does not relate to hospital-based care.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p. 57.
32. CORRECT ANSWER: B
Malpractice occurs when any form of negligence causes injury to the client. It is the failure to act as a reasonably prudent person with
the same knowledge and experience would act in the same or similar situation. A tort is a wrong or injury that a person has suffered from
another’s action. Fraud is deliberate deception, and assault is an injury inflicted on one person by another.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p. 57.
33. CORRECT ANSWER: C
Informed consents must always meet three requirements; it must be voluntary, the individual must have the capacity to consent, and
the individual must understand the treatment and associated information in the consent document. Because of the language barrier,
the client may not understand what he was consenting to , and if so, the document is not valid. It is not necessary for witnesses to be
licensed personnel and the document is not required to be notarized. The client immigration status is not related to the consent.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p. 53.
34. CORRECT ANSWER: A, B, D
Practice within the provisions of the Nurse Practice Act is essential to legal nursing practice. Treating all clients with kindness and respect
and seeking assistance when confronted with new situations will reduce the nurse‘s risks of liability in lawsuits, seeking help when ensure in
new situation also help reduce risk of error by providing more expert opinions. Observing and reporting suspicious behavior (option E) is
unprofessional and at times could increase the risk of harm to clients if the unit were understaffed.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.476.
35. CORRECT ANSWER: D
Any country has its own Nurse Practice Act that provides parameter in which Nurses practice. Each state has a different interpretation of
the individual acts; the Nurse Practice Acts delineates the scope of practice. The agency’s policy and procedures would be modified if
new nursing responsibilities are assigned; however, agency policy must be consistent with the nursing practice act. Liability insurance
coverage determines under what conditions the insurance company will pay a claim. The Good Samaritan Principle covers emergency
aid rendered outside employment.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.54.
36. CORRECT ANSWER: A
Advance directive offer guidance to the healthcare team when the client cannot make a decision regarding treatment. Advance
directive are written while the client is competent. A durable power of attorney allows a competent person the power to act on behalf
of the client in the event that the client loses decision making capacity. Informed consent is a crucial component of health care and
seeks to alert the client to all avenues of care and treatment.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.1043-1044.
37. CORRECT ANSWER: D
A client advocate is one who expresses and defends the cause of the client. It is the nurse’s responsibility to ensure the client has access
to healthcare services that meets health needs. A direct care provider administers nursing care. A case manager provides for continuity
of care, and a client educator provides instruction.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.81
38. CORRECT ANSWER: D
Delegation is the transference of responsibility for the performance of an activity from one person to the next. The delegator, however,
retains accountability for the outcome of the activity that has been delegated. An obligation to complete a task is responsibility.
Empowerment is conferring power in a situation to another. Supervision involves directly or indirectly observing the care provided.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.470
39. CORRECT ANSWER: A
Over delegation occurs when too much authority and accountability is transferred to the delegate. Reverse delegation occurs when
authority is transferred to an individual of higher rank (option B). Option C is an example of failure to delegate, and option D is an
example of appropriate delegation.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.471
40. CORRECT ANSWER: A
In primary nursing, one nurse is responsible for total care of number of clients 24 hours a day, 7 days a week. Team nursing provides
individual nursing team led by a professional nurse. The case manager may not provide direct client care but coordinates health care
among numerous health care workers. Functional nursing is task-based and assigns different team members to complete various nursing
activities, auch as taking vital signs, changing dressings or administering medications.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.). Upper
Saddle River, NJ: Pearson Education, p.100
HEALTH PROMOTION
41. CORRECT ANSWER: A
To assess body image, the nurse must gather the client’s perception of his body. Option c is not related to body image. Options B
and D are objective data.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.959
42. CORRECT ANSWER: A, B, C, E
A cultural as assessment should include information of the person’s health believes and practices, the healthcare practitioners the
person usually consults, and the person’s belief regarding the origin of illnesses. The person’s reason for dressing in a particular
manner is not relevant to this situation and the question may be viewed as rude or intrusive.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.217
43. CORRECT ANSWER: B, E
Anti-hypertensives, narcotics, diuretics, antipsychotics, antidepressants, antihistamines, and others decrease sexual desire.
Propanolol is an anti-hypertensive while sertraline is an anti-depressant. Azithromycin is an antibiotic. Ascorbic acid is a water-soluble
vitamin. Warfarin is an anti-coagulant.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.980
44. CORRECT ANSWER: C
Option C indicates that the clients is not alone, which enhance communication by affirming the clients feelings. Adolescents will feel
more willing to discuss private issues if parents are not present (option B) and if they understand that their concers are common with
other teens. Questions should be sensitively worded rather than intrusive (option D). Written instructions should supplement teaching
rather than being the primary vehicle for teaching.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.387
45. CORRECT ANSWER: A
Development readiness for toilet training is demonstrated by standing and walking well, dressing self, recognizing the need for
elimination, and having the physical ability to delay elimination. Lack of these abilities can indicate that the toddler needs
additional time before attempting toilet training.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.1228
46. CORRECT ANSWER: B
The extended family is considered as source of strength, support, and emotional stability for the Mexican American family.
Alternative healers and specific foods also may be important to the state of health, so these should not be banned or limited.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.212
47. CORRECT ANSWER: A
Non verbal behavior may have varied meaning among different cultures; therefore, the nurse must validate meaning. There is
insufficient information to determine the need for a translator (option B). Option C is unnecessary and option D is premature
because the nurse has insufficient data.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.214
48. CORRECT ANSWER: B
Assessment of religious practice that the client would find comforting should be accomplished first in order to assist the client with
spiritual distress. Option a would be done if indicated as an answer to Option B. Option C may or may not be appropriate; there is
insufficient data in the stem of question to support it. Option D may be needed if other options are unsuccessful.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.214
49. CORRECT ANSWER: A
The nurse should offer self to the client by being physically present, attentive, and listening to the clients feeling’s and concerned. In
option B the nurse should always analyze the reason for sharing personal beliefs. Option C is not therapeutic. In times of distress
clients may not be able to pray. Option D is not appropriate because the client is displaying depression, not anxiety.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.1002
50. CORRECT ANSWER: C
Nurses have normal and legal responsibility to report all suspected child abuse to the authorities failure to report suspected child
abuse can result liability for the nurse. The mother’s feelings about the child are of little relevance since she may not be the abuser.
Referring the child to another center may be indicated, but only after the case has been investigated. Noting suspicions on the
chart will not protect the child from harm.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.374

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