ABAC Phone Study 2

Auditory and/or Visual Disorder 1. B 2. B 3. A 4. B 5. A 6. A 7. B 8. B 9. B 10. A 11. A 12. A 13. A 14. B 15. A 16. A 17. B 18. C 19. A 20. C

Auditory and/or Visual Disorder Post-test 1. Which of the following is true regarding preoperative care for the client diagnosed with a cataract? a. Instillation of a miotic to dilate the pupil. b. Use of an anticholinergic to produce paralysis of accommodation. c. Hold the client NPO for 24 hours prior to the procedure to decrease secretions d. Instill corticosteroid eye drops for three days prior to the procedure. 2. Mrs. Jones is experiencing sudden acute pain in and around the eye. She is also experiencing nausea and vomiting, halos around lights and blurred vision. Based on these signs and symptoms, the nurse knows that Mrs. Jones is most likely experiencing: a. Primary open-angle glaucoma b. Acute angle-closure glaucoma c. Secondary glaucoma d. Congenital glaucoma 3. The underlying pathophysiological cause of glaucoma is: a. Elevated IOP b. Retinal Detachment c. Macular Degeneration d. Opacity of the Lens 4. Mr. Jackson is diagnosed with Meniere's disease. Which of the following orders if written by the physician should the nurse question? a. Diet as tolerated with moderate amounts of caffeine allowed. b. High-sodium diet c. Antivert as ordered d. Force fluids to 3000 mL per day 5. Nursing interventions for the client with Meniere's Disease are aimed at: a. Minimizing vertigo and providing safety. b. Decreasing intraocular pressure. c. Promoting the outflow of aqueous humor. d. Preventing sensorineural hearing loss. 6. The type of hearing loss that occurs in the outer and middle ear and impairs the sound being conducted from the outer to the inner ear is known as which type of hearing loss? a. Conductive b. Sensorineural c. Functional d. Mixed 7. Which type of hearing loss is caused by impairment of function in the inner ear or its central connections? a. Conductive b. Sensorineural c. Functional d. Mixed 8. Which of the following communication techniques is appropriate for the client with impaired hearing? a. Talk in a louder voice. b. Draw attention with hand movements. c. Avoid touch. d. Over enunciate your spoken words. 9. The hallmark sign of age-related macular degeneration is: a. Halos around lights b. Drusen c. IOP d. Vertigo 10. Mr. Coarsey has cataracts and is experiencing glare when he visualizes objects. He also states that his glare becomes worse at night. The nurse teaches Mr. Coarsey that the worsened night glare is caused by: a. Light scatter by the lens opacities. b. Decreased IOP due to his horizontal position associated with resting at night. c. Lens constriction. d. Pupil dilation associated with IOP. 11. Legal blindness is defined as: a. Central visual acuity for distance of 20/200 or worse in the better eye with correction. b. Visual acuity for distance of 50/200 or worse in the better eye with correction. c. Visual field no greater than 40 degrees at its widest diameter or in the better eye. d. Visual field no greater than 30 degrees in its widest diameter or in the better eye. 12. Mr. Timmons has glaucoma and is placed on the carbonic anhydrase inhibitor known as Diamox. The nurse knows that Mr. Timmons is receiving this drug to: a. Decrease aqueous humor production. b. Increase extracellular osmolarity. c. Stimulate opening of the trabecular meshwork. d. Inhibit cholinesterase production. 13. The surgical treatment for Otosclerosis is: a. Stapedectomy b. Labrinthectomy c. Endolymphatic shunt d. Vestibular nerve section 14. The nurse should instruct clients with glaucoma that: a. They should see their family practitioner or internist every 2 months. b. Punctual occlusion will lessen systemic absorption of the miotic eye drops. c. If they use their eye drops properly, they can expect full resolution of the glaucoma. d. The frequent pain caused by the IOP can be controlled with pain medications. 15. The nurse would suspect the development of Otosclerosis and loss of hearing in which of the following clients? a. A 26-year-old female with 2 biologic children under 7 years of age. b. A 42-year-old female, African American with a history of otitis media. c. A 65-year-old male who can hear high-pitched sounds more effectively than low pitched sounds. d. A 50-year-old male who is experiencing vertigo and tinnitus. 16. Mrs. Vickers is experiencing sensorineural hearing loss. The nurse expects that Mrs. Vickers will: a. Have difficulty understanding speech. b. Experience a reversal of damage if she continues to use the prescribed medications. c. Hear low pitched sounds better than high pitched sounds. d. Experience better hearing with the use of a hearing aid. 17. Clients who experience permanent visual impairment: a. Need others to speak louder for them so they can communicate properly. b. May feel defensive or threatened when others make eye contact with them during a conversation. c. Feel at ease around other vision impaired persons. d. Experience the grieving process with vision loss like other losses. 18. In addition to visual acuity measurement, the primary diagnostic procedure for AMD is: a. Slit lamp microscopy b. Tonometry c. Ophthalmoscopy d. Gonioscopy 19. Which of the following clients may be developing acute angle closure glaucoma? a. Client with IOP of >50 mmHg. b. Client with IOP of 20 mmHg. c. Client with IOP of 12mmHg. d. Client with IOP of 2-3 mmHg. 20. Which of the following signs and symptoms should the nurse report promptly following cataract surgery? a. Increase in visual acuity. b. Scratchiness in the operative eye. c. Pain. d. Decreased drainage from the operative site.

Auditory and/or Visual Disorder Pretest - Answers 1. True 2. True 3. B 4. C 5. A 6. B 7. Unknown 8. A 9. False 10. B 11. Phenergan, Benadryl, Atropine, Valium 12. True 13. A 14. A 15. True 16. A 17. Use hand movements to draw client's attention Speaker's face should be in good light. Do not cover face or mouth with hands while speaking to client. Do not chew, eat, smoke, or talk while speaking to client. Good eye-to-eye contact. Use touch if appropriate Speak to client on the side of his/her good ear. Avoid light behind the speaker.

Auditory and/or Visual Disorder Pretest 1. True or False. Conductive hearing loss is the inability of the sound waves to reach the inner ear. 2. True or False. Sensorineural hearing loss occurs when the inner ear or cochlear portions of the cranial nerve VIII is abnormal or diseased. 3. Janie is admitted with Meniere's disease. The triad of signs and symptoms of this disease are: a. Nausea, vomiting, tinnitus b. Vertigo, tinnitus, unilateral fluctuating hearing loss c. Pain, sweating, meningeal irritation d. Infection, gradual hearing loss, tinnitus 4. Kimberly, age 72, is admitted to the hospital for elective surgery. As the nurse prepares to perform an initial assessment of her, Kimberly tells the nurse that she is functionally blind and is hard of hearing. During the initial assessment of Kimberly, which nursing action is most important? a. Ask Kimberly about her upcoming elective surgery. b. Obtain as much information as possible from family members about her special needs. c. Make eye contact with Kimberly and ask her what assistance she needs d. Perform an evaluation of Kimberly's visual acuity and schedule an ophthalmic examination 5. Mrs. Tyson is ready to be discharged following cataract surgery. To evaluate whether Mrs. Tyson understands the postoperative regimen and procedures, which nursing action is most appropriate? a. Have Mrs. Tyson demonstrate administration of eye drops. b. Ask Mrs. Tyson to rate her pain on a scale of 0-10. c. Determine who will be caring for her at home while she is on bedrest. d. Evaluate how well she can see with the operative eyes. 6. Mrs. Johnson has glaucoma. She asks the nurse what the cause of her open-angle glaucoma is? The nurse explains that: a. The retinal nerve is damaged by an abnormal increase in the production of aqueous humor. b. Aqueous humor produced in the eye cannot drain from the eye, causing pressure damage to the optic nerve. c. The flow of aqueous humor into the anterior chamber is decreased by the lens of the eye blocking the papillary opening. d. Lens enlargement that occurs normally with aging pushes the iris forward, covering the outflow channels of the eye. 7. The cause of otosclerosis is __________________________________. 8. The surgical procedure that is done to correct otosclerosis is: a. Stapedectomy b. Endolymphatic shunt c. Labyrinthectomy d. Vestibular nerve resection 9. True or False. Mydriatic eye medications cause constriction of the pupil 10. A client is admitted with acute angle-closure glaucoma. The nurse anticipates immediate implementation of which medical treatment? a. Administration of analgesics b. Administration of cholinergic agents c. Administration of cycloplegics d. Preparation of a surgical iridectomy 11. During an acute attack of Meniere's disease, three medications that will be ordered include: _________________, _____________________, ___________________. 12. True or False. Ambulatory/home care for the client diagnosed with Meniere's disease includes the use of diuretics, antihistamines, low-salt diet, Valium, Vitamins, and restriction of caffeine, nicotine and alcohol intake. 13. Jim has been diagnosed with acute glaucoma. Upon examination, his tonometry reading is 60 mmHg. This reading is indicative of: a. Increased intraocular pressure b. Normal eye pressure c. Decreased pressure in the eyes d. Anterior chamber leakage of fluids 14. Mr. Jackson has chronic glaucoma. His physician has placed him on a mitotic agent. Which of the following is an example of this type of agent? a. Pilocarpine b. Timoptic c. Mannitol d. Ophthalgan 15. True or False. Beta blockers reduce the production of aqueous humor or facilitate the outflow of aqueous humor. 16. The retinal degenerative process that involves the macula which results in varying degrees of central and near vision loss is known as: a. AMD b. Cataracts c. Glaucoma d. OCP 17. Two nonverbal aids to utilize in communicating with the hearing impaired client are: ____________________________ and ___________________________. 18. Increased ocular pressure (IOP) develops in glaucoma because ___________________ cannot be emptied form the anterior chamber in the eye. 19. Clients diagnosed with acute glaucoma should avoid drugs such as corticosteroids and antihistamines because they: a. Cause the development of IOP. b. Cause severe interactions with other eye medications c. Restrict the action of the enzyme that produces aqueous humor. d. Enhance the effects of diuretics that the client is also taking and can lead to rapid fluid loss 20. The glare that clients with cataracts experience is worse at night because of: a. Pupil dilation b. The muscles of accommodation don't work as well in darkness c. By nighttime, there is an accumulation of water in the pupil. d. There is scattering of light caused by the buildup of aqueous humor

Blood Administration and Central Lines 1. B 2. B 3. False 4. False 5. A

Blood Administration and Central Lines Pretest 1. Which of the following expands blood volume and provides clotting factors? a. Whole blood b. Plasma c. Red blood cells d. Albumin 2. Mr. Johnson is to receive plasma. He currently has an IV infusing D5W into his right arm via a #18g jelco. Which nursing action is appropriate prior to hanging the plasma? a. Piggyback the plasma IV line into the D5W line. b. Discontinue the D5W and hang the Normal Saline. c. Change the IV catheter from a #18g jelco to a #22 jelco. d. Hang LR IV fluids and piggyback it into the D5W line along with the plasma to provide extra fluids for the client. 3. True or False. If the start of the transfusion is delayed for several hours, the plasma may be stored in the refrigerator located on the clinical unit. 4. True or False. Adverse reactions to a transfusion include bradycardia, bradypnea, and nausea. 5. Ms. Grimsley develops a severe allergic reaction to a blood transfusion she is currently receiving. Which signs and symptoms will the nurse expect to see exhibited by her at this time? a. Dyspnea, chest pain, circulatory collapse b. Flushing, itching, urticarial c. Tachycardia, dyspnea, crackles d. Bronchial wheezing, fever, chills

Broad Overview of Nutrition 1. A 11. B 2. B 12. B 3. D 13. B 4. C 14. A 5. A 15. C 6. A 7. B 8. A 9. C 10. A

Broad Overview of Nutrition Post test 1. No matter what form of sugar is consumed, the body converts it to which one of the following? a. Glucose b. Sucrose c. Lactose d. Fructose 2. Which one of the following is the major source of carbohydrate in the diet? a. Glycogen b. Starches c. Glucose d. Sugars 3. Which one of the following is considered the body's carbohydrate stores? a. Polymers b. Soluble fiber c. Ketones d. Glycogen 4. You client is supposed to decrease his intake of saturated fats. Which one of the following would you suggest he avoid? a. Corn oil b. Salmon c. Hydrogenated margarine d. Canola oil 5. Mrs. Jones is pregnant. Which one of the following instructions should be included in your client education regarding diet? a. She should increase her intake of protein. b. She should increase her intake of simple carbohydrates c. She should avoid the intake of monounsaturated fatty acids. d. She should consume 0.5 gms of protein per kilogram of body weight each day. 6. Which one of the following causes the level of calcium in the blood to increase? a. Parathyroid hormone b. Calcitonin c. Vitamin C d. Vitamin E 7. Which of the following is the best source of calcium? a. Yellow vegetables b. Dark, green vegetables c. Processed foods d. Baked potatoes 8. Mr. Smith has been placed on a sodium restricted diet. It would be best if he avoided or decreased the intake of which of the following? a. Processed foods b. Bananas c. Dried fruit d. Fresh tuna 9. Which one of the following plays the greatest role in helping to maintain acid-base balance? a. Sodium b. Calcium c. Potassium d. Magnesium 10. Mr. Hill has been complaining of not being able to see at night. An assessment will reveal a deficiency of which one of the following vitamins? a. A b. B c. C d. D 11. A five-year-old child has soft, fragile bones. She has not been exposed to much sunlight. An assessment will reveal the presence of which of the following? a. Osteomalacia b. Rickets c. Beriberi d. Scurvy 12. Which one of the following plays the greatest role in the blood clotting processes? a. Vitamin E b. Vitamin K c. Thiamine d. Potassium 13. Mrs. Smith needs to increase her intake of vitamin C. She should increase her intake of which of the following? a. Organ meats b. Dark, green vegetables c. Enriched grains d. Milk 14. Mrs. Hill has been diagnosed with beriberi. An assessment could reveal which one of the following? a. Indigestion and muscle weakness b. Fragile bones c. Bleeding d. Dermatitis 15. Which of the following groups of foods would be the best sources of carotene? a. Bananas, cantaloupe, and pears b. Broccoli, lettuce, and lima beans c. Collards, spinach, and sweet potatoes d. Lemons, oranges, and strawberries

Broad Overview of Nutrition 1. A 2. C 3. Solid 4. Saturated 5. A 6. B 7. D 8. C 9. D 10. C 11. A 12. D 13. B 14. Urine 15. A

Broad Overview of Nutrition Pretest 1. Which one of the following is the recommended source of energy for the body? a. Carbohydrates b. Fats c. Proteins d. Vitamins 2. Which one of the following is an example of a complex carbohydrate? a. Table sugar b. Maple syrup c. Legumes d. Eggs 3. A saturated fat is _______________________ at room temperature. 4. Hydrogenation results in a _________________ fat. 5. Which one of the following is highest in cholesterol? a. Liver b. Tuna c. Peanuts d. Soybeans 6. Which one of the following is a complete protein food? a. Nuts b. Meat c. Grains d. Vegetables 7. Which one of the following vitamins increases calcium absorption? a. A b. B c. C d. D 8. Which one of the following plays the major role in fluid balance? a. Calcium b. Potassium c. Sodium d. Phosphorus 9. Ordinary dietary cholesterol intake should be less than how many milligrams per day? a. 100 b. 150 c. 250 d. 300 10. How many servings of vegetables should we have each day? a. 1 to 3 b. 2 to 3 c. 3 to 5 d. 6 to 11 11. Which one of the following vitamins is necessary for vision? a. A b. B6 c. B12 d. C 12. A deficiency of vitamin C results in which one of the following? a. Beriberi b. Rickets c. Osteoporosis d. Scurvy 13. Which one of the following vitamins require the intrinsic factor for absorption? a. B6 b. B12 c. C d. Folic Acid 14. Water soluble vitamins are excreted in the _____________________. 15. Which one of the following is a function of vitamin B6? a. Coenzyme in the synthesis of amino acids. b. Functions in the formation of heme. c. Essential for blood clotting. Necessary for formation of DNA.

Care of the Client with a Hematological Dysfunction 1. C 2. C 3. C 4. D 5. A 6. A 7. C 8. C 9. D 10. A

Care of the Client with a Hematological Dysfunction Post Test 1. A client with iron deficiency anemia develops an intolerance to oral iron therapy and is changed to parenteral iron injections. When giving this drug the nurse should: a. Inject it into the client's arm b. Massage the site vigorously afterwards. c. Inject it deeply using the Z-track method. d. Instruct the client to rest in bed afterwards. 2. A client is prescribed ferrous sulfate tablets twice daily. She is a 40-year-old with iron deficiency anemia. The nurse should teach the client which of the following? a. It will discolor the teeth. b. It will change the color of her urine c. It may cause constipation d. Vitamin C intake should be decreased. 3. Discharge client teaching for a client with pernicious anemia should include instructions to take this medication as prescribed: a. 10. Mg of folic acid daily b. 325 mg iron supplement daily c. Vitamin B12 injections monthly d. Supplemental iron injections daily 4. When assessing the client with pernicious anemia, the nurse identifies that the severe vitamin deficiency is often manifested by: a. Jaundice and hyperactivity b. Heartburn and palpitations c. Constipation and weight loss d. Paresthesia's and loss of balance 5. A 59-year-old client is being discharged following removal of two-thirds of the stomach. As part of the discharge planning, the nurse will incorporate plans to prevent the development of: a. Pernicious anemia b. Aplastic anemia c. Iron deficiency anemia d. Hypo proliferative anemia 6. The nurse cares for a client with folic acid deficiency. The nurse recalls that one of the most frequent causes of folic acid deficiency is: a. Poor nutritional intake due to alcoholism b. Lack of absorption of the intrinsic factor c. Diet that consists of vegetables only and no meat d. Chronic blood loss 7. A 65-year-old client is attending hear clinic appointment after a hospitalization with severe iron deficiency anemia. In preparing to evaluate teaching, which of the following food choices by the client indicates the need for further teaching? "My diet will include lots of the following" a. Liver b. Beans c. Fish d. Green leafy vegetables 8. A client has been taking anticonvulsants for five years. He is prone to the development of which type of anemia? a. Iron deficiency b. Pernicious c. Folic acid d. Aplastic 9. Preventing infection and hemorrhage should be given the highest priority in which of the following types of anemia? a. Iron deficiency b. Pernicious c. Folic acid d. Aplastic 10. A client is admitted with severe iron deficiency anemia. An assessment will reveal which one of the following? a. Tachycardia b. Thrombocytopenia c. Paresthesia d. Ataxia

Care of the Surgical Client 1. B 2. C 3. A 4. A 5. A 6. C 7. D 8. B 9. D 10. B

Care of the Surgical Client Post test 1. It is important for the nurse to determine the client's current use of medications during the preoperative assessment because: a. Anesthetics alter renal and hepatic function, causing toxicity by other drugs. b. Other medications may cause interactions with anesthetics, increasing or decreasing the potency and effect of all drugs the client receives c. These medications cannot be given the day of surgery, requiring dosage and schedule adjustments. d. These medications may alter the client's perceptions of surgery. 2. Ten minutes after a client has received his preoperative medication by IM injection, he asks to get to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Allow him to go to the bathroom since the onset of the effect of the preoperative medication takes more than 10 minutes. b. Assist him to the bathroom and stay with him to protect him from falling. c. Offer him a urinal and position him in bed to promote voiding. d. Tell him to try to hold the urine since he will be catheterized at the beginning of the surgical procedure. 3. The nurse visits the client who is scheduled for surgery in the AM. The client tells the nurse that the physician hasn't really told him what is involved in the surgical procedure. The client also states he has not signed the operative permit. Which response by the nurse is most appropriate? a. Notify the physician that the client has questions about his upcoming surgery and has not signed the consent form yet. b. Tell the client that the physician will be by later to explain the surgical procedure. Go ahead and get the client to sign the operative permit at this time. c. Ask family members if they have discussed the surgical procedure with the physician. d. Explain the surgical procedure and have the client sign the operative permit. 4. Mr. Williford has been NPO since midnight prior to his surgery. The nurse notes that there are no preoperative orders concerning Mr. Williford's daily insulin dose. Which action by the nurse is most appropriate? a. Call the physician to clarify whether insulin should be given and at what dosage. b. Give Mr. Williford his usual daily insulin dose since the stress of the surgery will increase his blood glucose. c. Give Mr. Williford half his usual daily insulin dose since he won't be eating in the morning. d. Withhold any insulin dose since none is ordered and the client is NPO. 5. Which of the following is an activity specific to the circulating nursing in the intraoperative setting? a. Identifies and assesses the client. b. Prepares the instrument table and organizes sterile equipment. c. Scrubs, gowns, and gloves self. d. Passes instruments to the surgeon and assistants. 6. Mr. Triplett, age 68, is brought to the perioperative holding area accompanied by his wife. He is scheduled for a colon resection under general anesthesia. Which data obtained during the perioperative nurse's assessment would indicate the need for special protection techniques for Mr. Triplett during surgery? a. Verbalization by Mr. Triplett that he is very anxious about his surgery. b. Mr. Triplett asking about the details of the surgical procedure. c. A history of arthritis in his back and hips. d. An 8 mmHg increase in his systolic blood pressure from the time of hospital admission. 7. On admission to the post-anesthesia care unit (PACU) from surgery, the nurse places the highest priority on assessing: a. The client's level of consciousness. b. The condition of the surgical site. c. The status of fluid and electrolyte balance. d. The adequacy of respiratory function. 8. Mrs. Jackson is transferred from the PACU to the clinical surgical unit. Which action by the nurse on the surgical unit is most appropriate initially? a. Check the physician's postoperative orders. b. Take Mrs. Jackson's vital signs. c. Assess Mrs. Jackson's pain. d. Check the rate of her IV infusion. 9. Mr. James, age 83, had a surgical repair of a hip fracture and has restrictions on his ambulation. Which potential problem is appropriate for the nurse to identify for Mr. James? a. Risk for altered tissue perfusion b. Impaired physical mobility. c. Activity intolerance. d. Thromboembolism. 10. While caring for Mrs. Newton the first postoperative day, the nurse notices bright red drainage on her abdominal dressing about 3 cm's in diameter. Which action by the nurse is most appropriate in response to this finding? a. Remove the dressing and assess the surgical incision b. Circle the drainage with a pen, noting the date and time. c. Notify the surgeon of a potential for hemorrhage d. Recheck the dressing in 30 minutes to see whether the amount of drainage is increasing.

Care of the Surgical Client 1. True 2. A 3. D 4. A 5. Nitrous Oxide 6. B 7. False 8. D 9. B 10.False

Care of the Surgical Client Pretest 1. True or False. It is the responsibility of the circulating nurse to count sponges, needles, and instruments in surgery. 2. Which of the following medications is classified as a barbiturate and is given IV during surgery? a. Pentothal b. Demerol c. Morphine d. Valium 3. The type of anesthesia whereby the client has a depressed level of consciousness following intravenous administration of a benzodiazepine usually in combination with a narcotic is known as: a. General b. Local c. Regional d. Conscious sedation 4. Mr. Johnson is scheduled for hernia surgery. His physician orders that he receive Zantac IVPB prior to surgery. The nurse knows that the purpose of H2-receptor antagonists such as Zantac is to: a. Increase gastric pH b. Decrease nausea and vomiting c. Increase gastric volume d. Increase gastric emptying 5. The most widely used gaseous inhalation agent is ____________________. 6. The nursing measure that should be performed last on the morning of surgery is to: a. Remove all jewelry, dentures, and hair pins. b. Administer preoperative medications. c. Check the chart to be sure the client has signed for the surgery. d. Have the client to void. 7. True or False. Signs of thromboembolism include distended jugular neck veins, rales, dyspnea and orthopnea. 8. Mrs. Green has just returned to her room following colostomy surgery. The nurse's priority assessment at this time is: a. Urinary output b. ECG monitoring c. Level of consciousness d. Airway patency and respiratory status 9. Mr. Harrell is one day postop following gallbladder surgery. Which of the following nursing interventions if not contraindicated would be appropriate for him? a. Assess his vital signs once every shift. b. Serve a 200-calorie diet and ensure that he drinks 2500 mL of fluid per day. c. Have him to turn, cough, and deep breathe twice per shift. d. Remove his anti-embolism hose every 4 hours to observe for skin changes. 10. True or False. Versed is classified as a muscle relaxant.

Gastrointestinal Dysfunction 1. A 2. A 3. C 4. B 5. C 6. C 7. A 8. C 9. B 10. B 11. D 12. C 13. A 14. D 15. A

Gastrointestinal Dysfunction Post Test 1. The nurse is teaching a client with a history of upper gastrointestinal bleeding to check his stools for blood. Which information provided by the nurse is most accurate? a. Stools that are black and tarry occur with prolonged bleeding from the stomach or small intestine. b. If a client is vomiting blood, stools will not be black and tarry. c. Acute bleeding in the upper GI tract will result in bright red blood in the stools. d. Blood is never obvious in the stools and must be detected by guaiac testing. 2. Mr. Jackson, age 50, is admitted to the ER with severe abdominal pain, anorexia, and chills. His vital signs are temperature 101 degrees Fahrenheit, pulse 130, respirations 34, and blood pressure 82/48. His pain is more intense in the LLQ but radiates throughout the entire abdomen with rebound tenderness and abdominal rigidity. The nurse plans to care for Mr. Jackson based on the knowledge that management of his condition initially involves: a. Treatment for shock. b. Diagnostic testing with barium studies and endoscopy. c. Administration of antibiotics. d. Exploratory laparotomy. 3. Janie, a 23-year-old college student is admitted to the ER for evaluation of abdominal pain with nausea and vomiting. She has leukocytosis and an increased ESR. Appendicitis is suspected when physical examination reveals localized pain at McBurney's point. At which location does the nurse assess McBurney's point? a. Periumbilical area. b. Right abdomen lateral to the umbilicus. c. Halfway between the umbilicus and the right iliac crest. d. In the right lower abdomen when the left lower abdomen is palpated. 4. The registered nurse identifies the potential complication of hypovolemic shock related to loss of circulatory volume for a client with bacterial peritonitis resulting from a ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs as a result of: a. Nasogastric suctioning. b. Extracellular fluid shift into the peritoneal cavity. c. Increased production of stress hormones. d. Drainage of purulent and excessive fluids form the appendix into the peritoneal cavity. 5. Mrs. Grimsley undergoes a total proctocolectomy with a continent ileostomy. Postoperatively a catheter is in place in the stoma and irrigations are performed every four hours. Mrs. Grimsley is very upset, telling the nurse that the stoma is ugly, and she just doesn't think she can live with all the alterations in her body. Which of the following is the nurse's best approach to Mrs. Grimsley's remarks? a. Develop a detailed written plan for Mrs. Grimsley that includes all the information she will need to care for her ileostomy. b. Reassure Mrs. Grimsley that the stoma will shrink, and she will get used to caring for the ileostomy. c. Consult with Mrs. Grimsley and the surgeon to arrange a visitor form a local ostomy support group. d. Recognize that this is a difficult period for Mrs. Grimsley and do not intervene until she has had time to adjust to her situation. 6. Mr. Townsend has a colostomy with abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. During the early postoperative period, which goal should be given the highest nursing priority? a. Providing him with a low residue diet. b. Teaching colostomy irrigation technique. c. Facilitating perineal drainage and healing. d. Encouraging observation and acceptance of the colostomy site. 7. Shawn, age 33, has a transverse colostomy. During the initial postoperative assessment of the stoma, the nurse finds it to be brick red with moderate edema and a small amount of bleeding. Which interpretation of this finding by the nurse is most appropriate at this time? a. The stoma is normal in color and amount of drainage. b. Obstruction of the stoma with venous congestion. c. Inadequate blood supply to the stoma caused by edema. d. An abnormal stromal condition that should be reported to the surgeon. 8. Mrs. Moore has a newly formed ileostomy. Which instruction is appropriate for Mrs. Moore concerning the care of her ileostomy? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Change the pouch every day to prevent leakage of contents onto the skin. c. Maintain a diet that is as near normal as possible, avoiding foods that cause gas or diarrhea. d. Irrigations should be done daily or every other day to avoid having to wear a drainage appliance. 9. Which instruction does the nurse include while teaching a client to irrigate a new colostomy? a. Fill the irrigating container with 1000-2000 mL of lukewarm water. b. Hang the irrigating container about two feet above the stoma, or at shoulder height. c. Stop the irrigation and remove the irrigating cone if cramping occurs. d. It will take an hour for the colon to empty the irrigating solution and feces. 10. The nurse identifies a nursing diagnosis of impaired skin integrity related to diarrhea for Mrs. Smith. The nurse recognizes that teaching regarding perianal care has been effective when Mrs. Smith carries out which action? a. She asks for antidiarrheal medication after each diarrheal stool. b. She cleans her perianal area with soap and water after each diarrheal stool. c. She takes a sitz bath for 40 minutes following each stool. d. Following each bowel movement, she uses a heal lamp to her perianal area for 10 minutes. 11. Mr. Edgewater, age 52, has a herniorrhaphy performed for an incarcerated inguinal hernia. Postoperatively the nurse identifies a nursing diagnosis of pain related to edema and surgical incision. Which nursing intervention is appropriate for this problem? a. Apply moist heat to the abdomen. b. Provide warm sitz baths several times a day. c. Administer stool softeners as ordered. d. Elevate the scrotum with a small pillow. 12. Janice, age 32, is admitted to the emergency department for acute lower abdominal pain with diarrhea and vomiting. Which question asked during the nursing history is the most helpful in eliciting information regarding Janice's pain? a. "Can you describe your usual diet?" b. "What is your usual elimination pattern?" c. "Can you describe your pain?" d. "Do you have a history of fat intolerance?" 13. In teaching a client about nutritional management associated with peptic ulcer disease, which dietary modification does the nurse recognize is most important? a. Avoidance of foods that cause discomfort for the client. b. Elimination of milk and milk products from the diet. c. Avoidance of raw fruits and vegetables. d. Maintenance of six small meals a day with bland foods. 14. Phil, age 41, undergoes surgery for a perforated ulcer. Postoperative orders include morphine with a PCA device and NPO with low, intermittent nasogastric suction in addition to IV fluids and antibiotics. Eight hours after Phil returns to the surgical unit, where he complains of increasing abdominal pain. The nursing assessment reveals absence of bowel sounds and 200 mL of bright red nasogastric drainage. Which action by the nurse is most appropriate? a. Assess Phil's use of the PCA. b. Irrigate the NG tube. c. Apply an abdominal binder. d. Notify the physician. 15. Mr. Jones has been diagnosed with peritonitis. Which of the following nursing interventions will be appropriate for him in the immediate period following admission? a. NPO status b. Force fluids to 2000-3000 mL per day c. Serve a clear liquid diet for the first 48 hours d. Give pain medications each time he requests them

Gastrointestinal Dysfunction 1. Bowel resection 2. Rovsing's sign 3. True 4. Bleeding, nausea and vomiting, pain 5. A 6. Crohn's disease 7. B 8. True 9. Peritonitis 10. False 11. A 12. A 13. True 14. One-half (1/2)

Gastrointestinal Dysfunction Pretest 1. The nurse is caring for a client with a strangulated hernia. The nurse expects the client will have which type of surgical procedure? ___________________________________ 2. Mr. Jackson has been diagnosed with appendicitis. He experiences pain in the right lower quadrant when the nurse palpates the left lower quadrant. This is known as __________________________________________. 3. True or False. Peptic ulcer disease usually occurs between 45-70 years of age. 4. Three clinical manifestations of peptic ulcer disease are ______________________, __________________________, and ________________________. 5. Anticholinergic medications such as Pro-Banthine are given to the client diagnosed with Diverticulitis because it: a. Reduces colonic contractions and hypermotility. b. Increases gastric output and absorption. c. Softens the stool and assists with bowel passage of stool. d. Decreases colonic pain associated with the disease process. 6. The intestinal disease that develops "skip lesions" is known as ____________________. 7. Mr. Jackson is being taught how to irrigate his colostomy. The nurse instructs him that he needs to use how much warm tap water to irrigate the colostomy? a. 250 - 500 mL b. 500 - 1000 mL c. 1000 - 2000 mL d. 2000 - 3000 mL 8. True or False. McBurney's point is located halfway between the umbilicus and the right iliac crest. 9. The complication associated with appendicitis when the appendix ruptures and fecal content spills into the abdominal cavity is known as __________________. 10. True or False. Peptic ulcer disease is an ulceration of the mucosa of the stomach only. 11. The diagnostic test that is considered first choice for diagnosis of peptic ulcer disease is: a. Esophagogastroduodenoscopy b. Upper GI series c. Barium enema d. Sigmoidoscopy 12. Signs and symptoms of irritable bowel syndrome include: a. Episodic abdominal pain, cramping, bloating b. Constipation, tachycardia, tachypnea c. Weakness, anemia, rectal bleeding d. Visible pus in diarrhea, weight loss, nausea 13. True or False. The loop colostomy is a type of temporary colostomy that is made when immediate relief is needed for the bowel, often because of obstruction. 14. The nurse is teaching the client about colostomy care. The nurse instructs the client to empty his/her colostomy bag when it is ___________ full.

Hematological Dysfunction 1. Decreased oxygen carrying capacity of the blood resulting in hypoxia 2. B 3. A 4. D 5. B 6. TURE 7. FALSE 8. FALSE 9. A 10. A

Hematological Dysfunction Pretest 1. The overall problem in anemia is _______________________________. 2. The RBCs in iron deficiency anemia are which one of the following? a. Macrocytic and normochromic. b. Microcytic and hypochromic c. Normocytic and normochromic 3. Which one of the following is characteristic of pernicious anemia? a. Absence of the intrinsic factor b. Decreased platelet count c. Dietary deficiency d. Excessive use of anticonvulsants 4. Paresthesia may be evident in a client who has which type of anemia? a. Iron deficiency b. Aplastic c. Folic acid deficiency d. Pernicious 5. An assessment of a client with aplastic anemia could reveal the evidence of which one of the following? a. Leukocytosis b. Thrombocytopenia c. Increased hematocrit d. Erythrocytosis 6. True or False. Anticonvulsants can lead to the development of folic acid deficiency. 7. True or False. Vitamin D enhances the absorption of iron. 8. True or False. Yellow vegetables are high in iron. 9. Which one of the following is an appropriate treatment for aplastic anemia? a. Bone marrow transplantation b. Monthly injections of vitamin B12 c. Oral vitamin B12 supplements d. Increase intake of foods high in vitamin C 10. Which one of the following is an appropriate intervention for a client with iron deficiency anemia? a. Instruct him that the stools will become dark black after taking iron. b. Avoid any IM or SC injections. c. Instruct the client to use an electric razor only. d. Encourage him to avoid intake of organ meats.

Hygiene Post-Test 1. B 2. B 3. C 4. B 5. C

Hygiene Post-Test 1. The nurse is caring for a client who has right-sided paralysis following a stroke. Which of the following factors would be most likely to result in decubitus ulcer formation for this client? a. Poor nutrition b. Immobility c. Reduced hydration d. Skin secretions 2. A 61-year-old client with diabetes mellitus has physician's orders for meticulous foot care. Which of the following is the best rationale for the order? a. The aging process causes increased skin breakdown b. There is increased neuropathy with this pathology that places the client at risk. c. The client probably has a history of poor hygienic care. d. The lower extremities are difficult to see and therefore hard to maintain with good hygiene. 3. To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions? a. Reverse Trendelenburg b. High Fowler's with the head to the side c. Side-lying with the head turned toward the nurse d. Supine with the neck slightly forward 4. A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: a. Powerlessness b. Self-care deficit c. Tissue integrity impairment d. Knowledge deficit of hygiene practices 5. Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process? a. "I work with my ancillary staff to be able to determine what is abnormal." b. "The skin is easy to observe for abnormalities when you are giving the bath." c. "I use the time to really look at my clients and determine what's normal and what's not." d. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."

Legal, Ethical, and Cultural 1)A 2)C 3)A 4)C 5)B 6)C 7)A 8)D 9)D 10)A 11)A 12)C 13)D 14)D 15)A

Legal, Ethical, and Cultural Post Test 1. The admitting nurse explains the process of signing forms to allow for the client's insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. This is an example of which of the following? a. Contract law b. Tort law c. Statutory law d. Administrative law 2. Before the nurse can apply for licensure renewal, the state board of nursing requires 30 hours of continuing education in nursing in-service or education. This practice exemplifies which of the following? a. Licensure b. Competency c. Credentialing d. Certification 3. A high school graduate wants to attend nursing school that is highly regarded for its program. Which of the following entities must accredit or approve nursing programs? a. State Board of Nursing b. NLNAC c. CCNE d. ANA 4. The client presents her hand when the nurse makes this statement: "I need to start an IV so you can get your antibiotics." This is an example of which of the following a. Informed consent b. Express consent c. Implied consent d. Compliance 5. A nurse is caring for a client in the emergency department who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the client's back and arms. When questioned, the client is distracted and ambiguous with her answers. The nurse should: a. Report the situation to law enforcement. b. Report the situation to social services. c. Question the adult child who brought the client to the ED. d. File a written report in the client's chart. 6. A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. This nurse is demonstrating which of the following professional values? a. Human dignity b. Altruism c. Social justice d. Integrity 7. A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. The nurse who uses the theory of principles-based reasoning would make which of the following statements? a. "This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make." b. "I need to try and help the family understand the client's decision so they can work through this situation together." c. "This client's health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death." d. "The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die." 8. A nurse is having difficulty with the decision for aggressive cancer therapy in an elderly client, wondering if the therapy will be more harmful than the disease and knowing that the client will be subjected to harmful chemicals. This nurse is struggling with which of the following principles? a. Autonomy b. Justice c. Beneficence d. Nonmaleficence 9. A student nurse accidentally left the call light outside the reach of an elderly client. Luckily another nurse found the situation and was able to rectify the matter before something happened. The student responded, "I know better. I should've double checked where the light was before I left the room." This student tis demonstrating which of the following? a. Justice b. Fidelity c. Responsibility d. Accountability 10. A home health client has been prescribed nutritional supplements three times a day. The formula is expensive, and the client tells the home health nurse that she is taking them three times a day, but diluting them so she can use only one can, not three, per day. As a client advocate, the nurse should: a. Help the client look for available community resources that may be of assistance. b. Tell the client that she needs to take the prescribed amount. c. Report the situation to the physician. d. Weigh the client on a weekly basis to monitor weight gain or loss. 11. A new graduate nurse is working in a busy emergency department of a hospital, situated in a culturally diverse area of the city. In striving to be culturally sensitive, the nurse will: a. Try to learn about the attitudes toward health care and traditions of the different cultures in that area. b. Understand and attend to the total context of the client's situation, suing knowledge, attitudes, and skills. c. Possess the underlying background knowledge that will provide these clients with the best possible health care. d. Strive to be culturally sensitive, culturally appropriate, and culturally competent. 12. The nurse is working with clients form different cultural backgrounds than the nurse's own. Which of the following situations would illustrate prejudice on the nurse's part? a. Assuming that all members of each culture are alike b. Understanding that all culture members will have the same beliefs c. Bringing previous negative information and experiences into this situation d. Taking general knowledge from literature and applying it to the situation 13. A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work in a county hospital. The nurse has had limited prior experience with the various cultural groups that are served by the hospital. This nurse is at risk for which of the following? a. Prejudice b. Stereotyping c. Discrimination d. Culture shock 14. A Chinese client is hospitalized with a fever of unknown origin and follows a very traditional, cultural view of illness. Which of the following foods will the client prefer? a. Hot tea b. Soup and coffee c. Spicy meat d. Cold liquids 15. A community health nurse works with a variety of cultures providing health care services that include preventive care, acute treatment, and education. Of the following clients, which is most likely to use folk medicine? a. The client who speaks little English and does not have a job b. A family who has numerous relatives in a Spanish-American sector of the city c. A female client whose culture is one of male dominance d. A Chinese client who has a small, family run business in the area.

Prevention of Infection, Safety, Sleep, Skin integrity and Wound Care, Activity and Exercise 1. 10 2. NREM and REM 3. True 4. C 5. True 6. Sanguineous or hemorrhagic 7. True 8. Vector borne 9. True 10. D

Prevention of Infection, Safety, Sleep, Skin integrity and Wound Care, Activity and Exercise PRE-TEST 1. The Centers for Disease Control recommends that health care personnel vigorously wash their hands under a stream of water for at least _______ seconds. 2. The two types of sleep are __________ and ____________. 3. True or False. During NREM sleep, the peripheral blood vessels dilate. 4. Toddlers require how many hours of sleep per 24-hour period? a. 16-18 b. 12-14 c. 10-12 d. 6-8 5. True or False. In Stage III of pressure ulcer formation, there is full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia. 6. __________________ Exudate consists of large amounts of red blood cells indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. 7. True or False. Isokinetic exercise involves muscle contraction or tension against resistance. 8. The type of indirect transmission that occurs when a flying insect injects salivary fluid during biting is known as: a. Vector borne b. Vehicle borne c. Airborne d. Droplet 9. True or False. In active immunity, the host produces its own antibodies in response to natural antigens or artificial antigens. 10. During sleep, which of the following physiologic changes occurs during NREM sleep? a. Activity of the GI tract decreases. b. Skeletal muscles become tense. c. Basal metabolic rate decreases by 50% d. Pulse rate decreases.

Prevention of Infection, Safety, Sleep, Skin integrity and Wound Care, Activity and Exercise 1. B 2. B 3. C 4. A 5. A 6. B 7. A 8. C 9. D 10. D

Prevention of Infection, Safety, Sleep, Skin integrity and Wound Care, Activity and Exercise Post-Test 1. Vaccination provides which type of immunity? a. Humoral b. Acquired c. Antibody d. Lymphokine 2. Fomites are an example of which type of transmission? a. Contact b. Vehicle c. Airborne d. Vector borne 3. The first phase of sleep is called: a. REM sleep b. Deep sleep c. NREM sleep d. Light sleep 4. The older adult: a. Needs less sleep. b. Often takes a nap. c. Experiences less REM sleep. d. Experiences good quality sleep. 5. Which hospitalized client is most at risk for developing a pressure ulcer? a. A 70-year-old client with a fractured hip. b. A 45-year-old woman recovering from gallbladder surgery. c. A 16-year-old male paraplegic who suffered a spinal cord injury. d. A 50-year-old client who suffered a mild stroke. 6. After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer is classified as: a. Stage I b. Stage II c. Stage III d. Stage IV 7. Mrs. Sanchez, age 70, is being cared for at home by her family. She is obese and has a Stage III sacral ulcer. The priority nursing diagnosis is: a. Impaired tissue integrity b. Caregiver role strain c. Altered nutrition: less than body requirements d. Bathing/Hygiene Self Care Deficit 8. A client develops food poisoning from contaminated potato salad. The means of transmission for the infectious organism is: a. Direct contact b. Vectors c. Vehicle d. Airborne 9. The leading cause of accidental death for people 79 years and older is: a. Fires b. Exposure to temperature extremes c. Drug overdose d. Falls 10. When completing an incident report, the nurse should: a. Include suggestions to prevent the accident from recurring. b. Provide minimal information about the incident. c. Discuss the details with the client before documenting them. d. Objectively describe the incident in detail.

Respiratory Dysfunction 1. A 2. B 3. B 4. D 5. A 6. D 7. C 8. A 9. A 10. C 11. A 12. D 13. A 14. A 15. C 16. A 17. D

Respiratory Dysfunction Post Test 1. Which one of the following is a pathophysiological change associated with chronic bronchitis? a. There is impaired ciliary function that reduces clearance of mucus. b. The number of goblet cells decreases in number. c. The elasticity of the lungs is lost. d. Blebs develop as more alveoli are destroyed. 2. An assessment of a client with chronic bronchitis will reveal which one of the following early manifestations? a. Dyspnea upon exertion b. Productive coughing c. Underweight body frame d. Hypocapnia 3. Which one of the following is a pathophysiological change associated with emphysema? a. Increased production of mucous b. Hyperinflation of the alveoli c. Increase in the number of mucous secreting glands d. Increased ciliary function 4. Which one of the following is an early sign of emphysema? a. Hypoxia b. Clubbing of the nail beds c. Hypercapnia d. Dyspnea upon exertion 5. Which one of the following is an appropriate intervention for a client with COPD? a. Position in a semi-Fowler's position. b. Administer oxygen at 4 to 5 liters per nasal cannula. c. Encourage intake of a low calorie and high protein diet. d. Discourage purse-lip breathing during mealtimes. 6. Mr. Smith has been prescribed Vanceril, an MDI. He should be instructed to report which one of the following side effects of Vanceril? a. Increased blood pressure b. Nervousness c. Dizziness d. Oral thrush infections 7. Which one of the following instructions should be given if a client is taking prednisone? a. Instruct to take on an empty stomach. b. May be given vitamin C if on long term therapy. c. It should never be abruptly discontinued. d. It may cause you blood sugar to decrease. 8. Which one of the following is the major underlying pathology of asthma? a. Reversible inflammation of the airways b. Decrease release of chemical mediators c. Destruction of the distal alveoli d. Hyperinflation of the alveoli 9. Which one of the following is characteristic of pneumonia? a. Release of endotoxins b. Massive constriction of the pulmonary capillaries c. Blockage of chemical mediators d. Loss of elastic recoil 10. Mr. Jones has just been admitted with pneumonia. Which one of the following diagnoses should be given priority? a. Altered nutrition: less than body requirements b. Pain c. Ineffective airway clearance d. Fatigue 11. Which one of the following is an appropriate intervention for a client with pneumonia? a. Encourage bed rest during the acute stage. b. Avoid splinting the chest. c. Decrease fluid intake d. Assess pulse prior to administering aminophylline. 12. You are talking to a group of individuals about tuberculosis. Which one of the following would be appropriate to include in your presentation? a. You will acquire a TB infection if you are exposed to someone with active TB. b. A negative TB skin test result always means that you will not develop TB. c. A positive TB skin test means that you are infectious. d. You may never acquire TB disease even though you are exposed to TB. 13. Which one of the following is a pathophysiological characteristic of TB? a. The acid-fast bacilli may remain dormant for years. b. The acid-fast bacilli will multiply when deprived of oxygen. c. Once caseous necrosis occurs, active TB will never develop. d. When the Ghon tubercle ulcerates, a wall is formed around it. 14. Mr. Smith is a resident of a residential facility. He had a TB skin test. Which one of the following would indicate a positive result? a. An induration of 10 mm. b. Erythema of 8 mm c. An induration of 30 mm d. Erythema of 15 mm 15. Mr. Hill has been admitted with productive coughing, fever, night sweats, anorexia, and weight loss. He has been exposed to TB. Which one of the following should be done first? a. Obtain a sputum specimen. b. Obtain blood cultures c. Set up AFB precautions d. Complete a detailed health history. 16. Which one of the following is an appropriate intervention associated with the administration of isoniazid (INH)? a. Administer pyridoxine to prevent neuropathy. b. Assess for the development of optic neuritis c. Assess for bruising and bleeding d. Administer vitamin D to increase absorption 17. A client is taking pyrazinamide (PZA) for TB. He should be assessed for which of the following side effects? a. Hepatitis b. Peripheral neuropathy c. Discoloration of body fluids d. Elevated uric acid levels

Teaching-Learning 1. B 2. B 3. D 4. C 5. A

Teaching-Learning Post-Test 1. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, "I will look at the wound four times a day and tell my surgeon if it looks red or swollen." Her statement is an example of: a. Attitudes b. Application c. Analysis d. Evaluation 2. There are many factors assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the; a. Previous knowledge level of the client b. Willingness of the client to want to learn the injection sites c. Financial resources available to the client for the equipment d. Intelligence and developmental level of the individual client 3. Clients give various responses to teaching sessions, for the nurse, an example of an evaluation of a psychomotor skill is: a. Client states side effects of a medication b. Client responds appropriately to eye contact c. Client independently plans an exercise program d. Client demonstrates the proper use of a walking cane 4. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on: a. Use of assistive devices, such as canes b. Self-help devices for post-CVA clients c. Stress management techniques for working parents d. Environmental alterations for clients in wheelchairs 5. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? a. Activity intolerance related to pain b. Ineffective management of treatment regimen c. Noncompliance with prescribed exercise plan d. Knowledge deficit regarding impending surgery