WEEK 4 / ALL practice questions from fundamentals + ati

A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. ACCESS model component 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety Nursing approach A. Help patients feel culturally secure and able to maintain their cultural identity. B. Remain aware of verbal and nonverbal responses. C. Be aware of how patients from diverse backgrounds perceive their care needs. D. Become aware of your patient's culture and your own cultural biases. E. Learn about the patient's health beliefs and practices. F. Show respect by creating a caring rapport.

1-E 2-B 3-D 4-F 5-C 6-A

A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time.

1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 4. Provide specific information in frequent, small amounts for older adult patients.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care (Select all that apply) 1. Use antimicrobial toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

1. Use antimicrobial toothpaste. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care.

Which of the following scenarios demonstrate that learning has taken place? (Select all that apply) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.

2. A patient describes how to set up a pill organizer for newly ordered medicines. 4. A patient demonstrates how to take his blood pressure at home.

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

2. Assess skin for redness, abrasions, and open areas daily. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

The nurse delegates needed hygiene care for an alert elderly patient who had a stroke. Which intervention would be appropriate for the assistive personnel to accomplish during the bath? (Select all that apply) 1. Checking distal pulses 2. Providing range-of-motion (ROM) exercises to extremities 3. Determining type of treatment for stage 1 pressure injury 4. Changing the dressing over an intravenous site 5. Providing special skin care

2. Providing range-of-motion (ROM) exercises to extremities 5. Providing special skin care

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue, but avoid stimulating gag reflex.

2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 5. Remove partial plate or dentures if present. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 6. Gently brush tongue, but avoid stimulating gag reflex. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.

A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply) 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic.

2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply) 1. Prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

2. Sims' position 3. Semi-Fowler's position with head to side

A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergency angiogram to remove the clot. Which teaching approach is most appropriate? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

2. Telling approach

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient who prefers a bath in the evening when his wife visits and can help him 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

3. A patient who is experiencing frequent incontinent diarrheal stools and urine

A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

3. Cognitive domain 5. Psychomotor domain

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

3. Radiation therapy 4. Dehydration

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure? (Select all that apply) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

3. Respirations 4. Gag reflex

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test

3. Return demonstration

A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregivers

3. Role-playing

A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.

3. Set mutual goals for the education session.

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive-compulsive behavior. 2. Personal preferences. 3. The patient's cultural norm. 4. Controlling behaviors.

3. The patient's cultural norm.

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female patient who has had removal of a breast lesion and is having her menstrual period 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line 3. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

4. Readiness to learn

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions. E. Wear cotton socks

A. Inspect the feet daily. B. Use moisturizing lotion on the feet. E. Wear cotton socks

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client.

A. Schedule rest periods during morning care.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth.

A. Turn the client's head to the side.

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them.

B. Brush the dentures with a toothbrush and denture cleaner.