Chapter 39, 44, 46, 47, 9, 34, 35, 25, 45 EAQ (Exam 2)
A parent tells the nurse, "My infant who is breastfed passes stools an average of 5 times per day." How does the nurse respond?
"This is a normal finding for the infant."
A patient receives a prescription for an oil-retention enema. When asked about the mechanism of action of this enema, which explanation would the nurse provide? Select all that apply. One, some, or all responses may be correct. 1. It lubricates the rectum and colon. 2. The feces absorb oil and become softer. 3. It exerts osmotic pressure lower than the fluid in the interstitial space. 4. It irritates the intestinal mucosa and stimulates peristalsis. 5. It provides relief from gaseous distention.
1, 2
A patient undergoes surgery on the pharynx and has a small-bore nasogastric tube in place. The nurse understands that the tube is inserted for which purpose? Select all that apply. One, some, or all responses may be correct. 1. Medication administration 2. Enteral feeding 3. Gastric decompression 4. Removal of gastric secretions 5. Preparation for barium enema
1, 2
A patient's breast biopsy results return as positive for cancer. The patient says that there is some mistake and that she cannot have breast cancer. Which action would the nurse take to provide further information to this patient? Select all that apply. One, some, or all responses may be correct. 1. Explain the situation to a relative or significant other. 2. Explain carefully the significance and need for prompt tumor removal. 3. Discuss chemotherapy treatment. 4. Inform the patient about breast implants. 5. Talk to the patient in a firm voice.
1, 2
The nurse is caring for a patient who has a colostomy. When assessing the stoma, which color indicates that the stoma is healthy? Select all that apply. One, some, or all responses may be correct. 1. Pink 2. Red 3. Blue 4. Brown 5. Black
1, 2
The nurse is providing a sex education session to a group of grade-school students. Which aspect of sexual education would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct. 1. Body changes 2. Menstruation 3. Sexually transmitted infections 4. Contraception 5. Sexual relationships
1, 2
A normal saline enema has which effect? Select all that apply. One, some, or all responses may be correct. 1. It lessens the danger of excess fluid absorption. 2. It exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. 3. It stimulates peristalsis. 4. It irritates the colonic mucosa. 5. It lubricates the colonic mucosa.
1, 2, 3
What is a common trouble area for a patient in the supine position? Select all that apply. One, some, or all responses may be correct. 1. Extended elbows 2. Unsupported feet 3. Externally rotated hips 4. Decreased circulation to the feet 5. Increased shearing force on the back of the knees
1, 2, 3
Which quality will enable the patient to perform dressing changes at home? Select all that apply. One, some, or all responses may be correct. 1. Adequate strength 2. Sensory acuity 3. Coordination 4. A caregiver's attitude 5. Self-esteem
1, 2, 3
The nurse provides education for a nursing student about auscultating the abdomen for bowel sounds and includes which information? Select all that apply. One, some, or all responses may be correct. 1. Normal bowel sounds occur every 5 to 15 seconds. 2. Each bowel sound lasts 1 to several seconds. 3. High-pitched sounds occur with small intestine obstruction. 4. Flatulence creates a tympanic note. 5. Hypoactive sounds occur with inflammatory disorders.
1, 2, 3, 4
A new graduate nurse is working in a rehabilitation center that specializes in the care of patients with spinal cord injuries (SCIs). The new graduate knows that sexual issues are common among patients with SCIs. Which action can enhance the nurse's comfort in discussing sexual issues with patients? Select all that apply. One, some, or all responses may be correct. 1. Clarifying personal values related to sexuality 2. Role-playing discussion of sexual concerns with another nurse 3. Attending a conference to enhance knowledge about sexuality 4. Avoiding a discussion of sexual concerns until after completing new nurse orientation 5. Asking a nurse who is experienced in caring for patients with SCIs about common sexual concerns
1, 2, 3, 5
Which age-related issue would the nurse consider when conducting a sexual assessment on an adolescent patient? Select all that apply. One, some, or all responses may be correct. 1. Use simple and understandable language. 2. Check for signs of any physical injuries. 3. Keep assessment findings confidential. 4. Use a closed and positive approach to the patient. 5. Reassure the patient that the questions are normal.
1, 2, 3, 5
The nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patient is at the greatest risk of complications if not repositioned properly? Select all that apply. One, some, or all responses may be correct. 1. A 20-year-old unconscious patient 2. A 90-year-old frail patient 3. 65-year-old patient who is visually impaired 4. A 40-year-old patient who has paraplegia 5. A 30-year old patient who has cholecystitis
1, 2, 4
Which evidence-based factor would the nurse consider when caring for a homosexual patient population? Select all that apply. One, some, or all responses may be correct. 1. This population belongs to a sexual minority. 2. Homosexuals do not readily seek preventive care. 3. These patients are comfortable revealing their sexual orientation. 4. They are concerned about discrimination.5 5. The individuals are more prone to getting sexually transmitted infections (STIs).
1, 2, 4
The nurse reviews the procedure for inserting and maintaining a small-bore nasogastric tube. The nurse identifies that which step is included to increase patient comfort? Select all that apply. One, some, or all responses may be correct. 1. Change the tape on the fixation device. 2. Apply a lubricant to the nares. 3. Provide mouth care once daily. 4. Use gargles with topical Xylocaine jelly. 5. Provide lozenges for the patient to suck.
1, 2, 4, 5
Indispensable amino acids are not synthesized by the body and need to be provided by the diet. Which amino acid should be included in the diet to prevent deficiency? Select all that apply. One, some, or all responses may be correct. 1. Histidine 2. Lysine 3. Alanine 4. Asparagine 5. Phenylalanine
1, 2, 5
The nurse reviews the types of radiological tests performed to assess the abdomen. The nurse identifies that the preparation for which procedure requires a dietary restriction? Select all that apply. One, some, or all responses may be correct. 1. Computed tomography scan with contrast 2. Colonoscopy 3. A plain film of the abdomen 4. Ultrasound imaging 5. Barium swallow
1, 2, 5
Which statement about human immunodeficiency virus (HIV) is appropriate? Select all that apply. One, some, or all responses may be correct. 1. HIV is a bloodborne pathogen. 2. HIV spreads through oral-genital sex. 3. HIV is not found in bodily fluids. 4. HIV causes ectopic pregnancy. 5. The risk of contracting HIV can be reduced by the use of condoms.
1, 2, 5
Which substance is a disaccharide? Select all that apply. One, some, or all responses may be correct. 1. Sucrose 2. Lactose 3. Glucose 4. Maltose 5. Fructose
1, 2, 5
The nurse is caring for a pregnant woman who is in labor. When the nurse asks the woman if she wants her husband to be near when she is delivering, the patient strongly objects. People of which culture are likely to react in this way? Select all that apply. One, some, or all responses may be correct. 1. Hindus 2. Mexicans 3. Muslims 4. Filipinos 5. Roman Catholics
1, 3
When a patient reports passing black and tarry stools, the nurse identifies that the patient should be evaluated for which condition? Select all that apply. One, some, or all responses may be correct. 1. Iron ingestion 2. Ingestion of beets 3. Gastrointestinal (GI) bleeding 4. Spastic constipation 5. Malabsorption of fat
1, 3
Which complication may result from a patient who regularly ingests castor oil to relieve constipation? Select all that apply. One, some, or all responses may be correct. 1. Abdominal cramping 2. Constipation 3. Fluid and electrolyte imbalance 4. Damage to the intestinal mucosa 5. Toxic buildup of magnesium
1, 3
A patient is in the first postoperative day after a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The nurse decides to use the ABCDE approach while assessing and managing pain for this patient. What is the correct component of the ABCDE approach? Select all that apply. One, some, or all responses may be correct. 1. A: Ask regularly about the pain. 2. A: Assess the pain once a week. 3. B: Believe the patient about the pain. 4. C: Choose pain control options appropriate to the patient. 5. D: Deny the use of painkillers and encourage the patient to bear the pain naturally.
1, 3, 4
A patient is suffering from spiritual distress. Of which patient feeling would the nurse be aware? Select all that apply. One, some, or all responses may be correct. 1. Doubt 2. Being cheated 3. Loneliness 4. Loss of faith 5. Desire to kill others
1, 3, 4
The nurse is teaching a patient about hygiene practices. During the interaction, the patient expresses feelings and opinions about the teaching provided and hygiene practices. The nurse understands that these expressions are a part of the affective domain of learning. Which behavior is included in affective learning? Select all that apply. One, some, or all responses may be correct. 1. Organizing 2. Perception 3. Responding 4. Characterizing 5. Comprehension
1, 3, 4
A patient is in the first postoperative day after a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. Which teaching would the nurse give the patient? Select all that apply. One, some, or all responses may be correct. 1. Opioids can be used safely in cases of moderate to severe pain. 2. Opioids can be given only after surgery or for postsurgical pain. 3. Slow titration prevents potentially dangerous opioid-induced side effects. 4. The drug is administered carefully because its action cannot be reversed. 5. In cases of any adverse effects, opioid antagonist drugs can be given to reverse the effects.
1, 3, 5
A patient with heart disease asks the nurse if medications for heart disease can cause erectile dysfunction. Which drugs can cause erectile dysfunction? Select all that apply. One, some, or all responses may be correct. 1. Illicit drugs 2. Antidiabetics 3. Diuretic agents 4. Antiplatelet drugs 5. Antihypertensives
1, 3, 5
The nurse is caring for a patient on pain management therapy. Which type of therapy causes a release of endorphins that can block the transmission of painful stimuli? Select all that apply. One, some, or all responses may be correct. 1. Massage 2. Opioid analgesics 3. Cold application 4. Nonsteroidal antiinflammatory drugs (NSAIDs) 5. Transcutaneous electrical nerve stimulation (TENS)
1, 3, 5
The nurse is caring for a patient who is on opioid therapy. For which finding is the nurse carefully observing the patient? Select all that apply. One, some, or all responses may be correct. 1. Decreased pulse rate 2. Increased respiratory rate 3. Decreased blood pressure 4. Pupil dilatation 5. Peripheral edema
1, 3, 5
The nurse is learning about the effects of pain on the sympathetic system. What is a manifestation of sympathetic stimulation in response to pain? Select all that apply. One, some, or all responses may be correct. 1. Increased heart rate 2. Rapid, irregular breathing 3. Increased glucose level 4. Decreased blood pressure 5. Decreased gastrointestinal motility
1, 3, 5
The nurse is teaching a group of caregivers about the concept of pain in older adults. Which information would the nurse include? Select all that apply. One, some, or all responses may be correct. 1. Older patients underreport pain. 2. Sleeping indicates pain relief. 3. Opioids are safe to use in older patients. 4. Older adults tend to perceive more pain. 5. Older adults with cognitive impairment do not experience less pain.
1, 3, 5
Which statement made by the nursing student about effective teaching indicates effective learning? Select all that apply. One, some, or all responses may be correct. 1. "Teaching is most effective when it responds to the learner's needs." 2. "Teaching is a process of both understanding and applying newly acquired concepts." 3. "Teaching is the concept of imparting knowledge through a series of directed activities." 4. "Teaching is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills through an experience or external stimulus." 5. "Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills."
1, 3, 5
During a colonoscopy, the health care provider finds a single polyp in the patient. The nurse anticipates which intervention will be performed? Select all that apply. One, some, or all responses may be correct. 1. Removal of the growth 2. Cauterization of the growth 3. Institution of cryotherapy 4. Sample collection for a biopsy 5. Waiting and watching the single lesion
1, 4
Which complication would the nurse have to monitor for when using the supported Fowler's position? Select all that apply. One, some, or all responses may be correct. 1. Pressure on the posterior aspect of the knees 2. Excessive lateral flexion of the spine 3. Hyperextension of the lumbar spine 4. Increased shearing force on the back 5. Unprotected pressure points at the ileum
1, 4
The human body has a mechanism to reduce pain perception by inhibitory neurotransmitters. Which is an inhibitory neurotransmitter of pain in the brain? Select all that apply. One, some, or all responses may be correct. 1. Serotonin 2. Histamine 3. Substance P 4. Norepinephrine 5. Gamma-aminobutyric acid (GABA)
1, 4, 5
The nurse attends to a group of patients with depression. The nurse conducts a group discussion with the patients to teach them effective learning skills. How will the group discussion help the patients? Select all that apply. One, some, or all responses may be correct. 1. Allow patients to receive support from other patients in the group. 2. Encourage patients to express concerns. 3. Allow patients to discuss personal and sensitive things. 4. Help patients learn from others' experiences. 5. Promote responsiveness, valuing others, and organization.
1, 4, 5
The nurse works in a postsurgical ward. Which statement by the nurse indicates a common misconception about pain? Select all that apply. One, some, or all responses may be correct. 1. Psychogenic pain is not real. 2. Chronic pain is not psychological. 3. Patients who cannot speak can feel pain. 4. Administering analgesics regularly leads to drug addiction. 5. Patients who abuse substances overreact to discomfort.
1, 4, 5
Which statement holds true about sexuality? Select all that apply. One, some, or all responses may be correct. 1. It is influenced by personal beliefs. 2. It is not affected by medications in use. 3. It is influenced by the place where one lives. 4. Pregnancy may affect sexual interest. 5. It may be affected by chronic respiratory disease. 6. Ethnicity plays a role in shaping sexual values.
1, 4, 5, 6
The nurse is caring for a patient with malabsorption syndrome. Which change in bowel elimination is the patient likely to report? Select all that apply. One, some, or all responses may be correct. 1. Pale stools 2. Black, tarry stools 3. Clay-colored stools 4. Increased flatulence 5. Oily stools
1, 5
Which statement about chlamydia is appropriate? Select all that apply. One, some, or all responses may be correct. 1. It affects the genitourinary tract. 2. There is no cure for this disorder. 3. It does not cause ectopic pregnancy. 4. The rectum is resistant to chlamydia infection. 5. It may cause infection of the eyes and lungs in newborns.
1, 5
The registered nurse is evaluating the statements of a student nurse after teaching about cultural assessment models. Which statement by the student nurse needs correction? 1. "Cultural assessment models are used to stereotype a particular group of patients." 2. "Cultural assessment models help focus on the information relevant to a patient's problem." 3. "Cultural assessment models can be used to understand a patient's religious beliefs." 4. "Cultural assessment models help one to understand the complex factors that influence a patient's cultural world view.
1. "Cultural assessment models are used to stereotype a particular group of patients."
The nurse at a community health center is teaching a group of menopausal women about normal changes in the female sexual response that occur with aging. Which statement by one of the women indicates that the information is understood? 1. "It's normal for me to take longer to reach an orgasm." 2. "I might experience chest pain or shortness of breath during intercourse." 3. "It's normal for me to lose interest in sexual relationships." 4. "I won't need to be concerned about contraception or sexually transmitted infections because of my age.
1. "It's normal for me to take longer to reach an orgasm."
After interacting with the wife of a patient who has terminal cancer, the nurse anticipates that the patient is experiencing denial. Which statement by the wife supports the nurse's conclusion? 1. "My husband wants to get another opinion, even after a clear diagnosis." 2. "My husband is blaming the health care provider for his condition." 3. "My husband is not showing any interest in his favorite games and movies." 4. "My husband says he wants to spend as much time as possible with the family."
1. "My husband wants to get another opinion, even after a clear diagnosis."
A registered nurse is teaching a nursing student about using nonsteroidal antiinflammatory drugs (NSAIDs) for pain management. Which statement by the student indicates a need for further teaching? 1. "NSAIDs work by depressing the central nervous system." 2. "NSAIDs act by inhibiting the synthesis of prostaglandins." 3. "Patients allergic to aspirin are more likely to be allergic to other NSAIDs." 4. "Use of NSAIDs in older adults may result in increased risk of adverse events."
1. "NSAIDs work by depressing the central nervous system."
The nursing instructor asks the student nurse to differentiate between A-delta and C peripheral nerve fibers. Which statement by the student nurse indicates effective learning? 1. "The A-delta fibers are myelinated, and the C fibers are unmyelinated." 2. "The A-delta fibers are smaller in diameter, and the C fibers are larger in diameter." 3. "The A-delta fibers transmit signals slowly, and the C fibers transmit signals rapidly." 4. "The A-delta fibers cause diffuse sensation, and the C fibers cause localized sensations."
1. "The A-delta fibers are myelinated, and the C fibers are unmyelinated."
While assessing a patient of a different culture, the nurse wants to know the patient's perception of the etiology of the disease. Which is the most appropriate question asked by the nurse using a patient's explanatory model? 1. "What do you call your problem?" 2. "Why do you think it started when it did?" 3. "What do you think your sickness does to you?" 4. "What are the chief problems your sickness has caused you?"
1. "What do you call your problem?"
Which term describes the suggested intake for individuals based on experimentally determined estimates of nutrient intakes? 1. Adequate intake 2. Tolerable upper intake level 3. Estimated average requirement 4. Recommended dietary allowance
1. Adequate intake
Which domain of learning occurs when a patient is both verbally and nonverbally participating in group activities? 1. Affective 2. Cognitive 3. Attentional 4. Psychomoto
1. Affective
The nurse at an outpatient clinic asks a Chinese American patient with newly diagnosed hypertension if he is limiting sodium intake as directed. The patient nods his head but does not make eye contact with the nurse. Which action would the nurse take next? 1. Ask the patient how much salt he is consuming each day. 2. Discuss the health implications of sodium and hypertension. 3. Remind the patient that many foods such as soy sauce contain hidden sodium. 4. Suggest some low-sodium dietary alternatives
1. Ask the patient how much salt he is consuming each day.
Which drug may provide relief from bone pain? Select all that apply. One, some, or all responses may be correct. 1. Calcitonin 2. Gabapentin 3. Nortriptyline 4. Bisphosphonates 5. Infusional lidocaine
1. Calcitonin 4. Bisphosphonates
Which physical sign often indicates the possibility of sexual abuse in children? 1. Chronic pain 2. Excessive masturbating 3. Vomiting or abdominal tenderness 4. Trauma to the labia, vagina, cervix, or anus
1. Chronic pain
The nurse is teaching a patient how to adjust insulin dosages based on blood glucose results. This is an example of which type of learning? 1. Cognitive 2. Affective 3. Adaptation 4. Psychomotor
1. Cognitive
The nurse is counseling a couple on contraceptive methods. Which nonprescription method would the nurse recommend? 1. Condom 2. Diaphragm 3. Vaginal ring 4. Transdermal skin patch
1. Condom
When the nurse has a prejudice against a particular culture, which type of behavior is likely to result? 1. Discrimination 2. Culturally congruent care 3. Effective intercultural communication 4. Sufficient knowledge of diverse groups
1. Discrimination
Decreased levels of which hormone may result in painful sexual intercourse? 1. Estrogen 2. Testosterone 3. Growth hormone 4. Follicle-stimulating hormone (FSH)
1. Estrogen
A patient recently diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I am perfectly fine, and I don't want to discuss my treatment and condition." After considering the patient's current stage of grief, which action by the nurse would be appropriate? 1. Explain the situation to the patient's family. 2. Focus on skills the patient will require in the coming weeks. 3. Provide necessary information to the family for the patient's discharge. 4. Convince the patient that the treatment for the illness is essential.
1. Explain the situation to the patient's family.
Which concept related to spiritual health is a patient experiencing when she states that she knows her husband loves her even when he cannot be by her side? 1. Faith 2. Hope 3. Transcendence 4. Connectedness
1. Faith
When collecting a guaiac fecal occult blood test (gFOBT), the nurse should take which action? 1. Interpret the color of the guaiac paper after 30 to 60 seconds. 2. Open the flap of the slide and, using a cotton applicator, thinly smear stool in the first box of the guaiac paper. 3. After waiting 10 to 15 minutes, open the cardboard flap and apply two drops of developing solution on each box of guaiac paper. 4. Recognize that a green color indicates it is positive for guaiac or presence of fecal occult blood.
1. Interpret the color of the guaiac paper after 30 to 60 seconds.
What is the correct order of steps involved in the LEARN communication technique for cultural assessment and planning?
1. Listening to the patient's explanation of the present problem 2. Explaining the nurse's perception of the problem to the patient 3. Recognizing the similarities and differences between the patient's and nurse's perceptions 4. Involving the patient and his or her family while providing recommendations 5. Obtaining a mutually agreeable, culturally oriented, patient-centered plan
Which amino acid is indispensable? 1. Lysine 2. Alanine 3. Asparagine 4. Glutamic acid
1. Lysine the body does not synthesize it and it must be part of a healthy diet.
Which concept of intersectionality refers to limited access to certain facets of society? 1. Marginalization 2. Under inclusion 3. Social inequality 4. Matrix of domination
1. Marginalization
A health care provider prescribes medication for a patient in respiratory distress. Shortly after, the patient complains of severe pain. Which medication did the patient likely receive? 1. Naloxone 2. Capsaicin 3. Lidocaine patch 4. Acetaminophen
1. Naloxone
Which aspect of psychomotor learning involves an awareness of qualities through the use of sensory stimulation? 1. Perception 2. Adaptation 3. Origination 4. Mechanism
1. Perception
What is the order of steps to place a patient in Sims (semi-prone) position?
1. Position the patient in the supine position. 2. Move to another side of the bed and turn patient on side. 3. Place a small pillow under patient's head. 4. Place pillow under flexed upper arm. 5. Place pillow under flexed upper leg. 6. Support feet in dorsiflexion with foot support devices
A nursing instructor asks a nursing student, "How can health care providers help reduce health disparities?" Which response indicates a need for further teaching? 1. Providing compartmentalized care 2. Providing culturally competent care 3. Improving the quality of health care 4. Helping patients get access to language services as needed
1. Providing compartmentalized care
Which component in saliva acts on cooked starch to begin converting it to maltose? 1. Ptyalin 2. Gastrin 3. Pepsinogen 4. Hydrochloric acid
1. Ptyalin
What factor is the nurse least likely to associate with health disparities among marginalized groups? 1. Self-care 2. Quality of health care 3. Public and health policy 4. Complex interaction among individual genetics
1. Self-care
Which result can occur from excess manipulation when performing a digital rectal examination to determine the presence of fecal impaction? 1. Slowing heart rate 2. Severe cramping 3. Fluid and electrolyte imbalance 4. Toxic buildup of magnesium
1. Slowing heart rate
A nursing instructor asks a nursing student to list the key concepts of intersectionality. Which answer indicates a need for further teaching? 1. Social equality 2. Marginalization 3. Matrix of domination 4. Overinclusion and under inclusion
1. Social equality
What is the goal of culturally congruent care? 1. To provide care to fit a patient's own values, beliefs, and traditions 2. To help recognize biases, prejudices, and assumptions about other people 3. To assess social, cultural, and biophysical factors that influence patient treatment and care 4. To motivate the nurse to learn from others, accept the role as a learner, and be open to and accepting of cultural differences
1. To provide care to fit a patient's own values, beliefs, and traditions
Arrange the patient's behaviors in order of increasing complexity according to the psychomotor domain of learning.
1. perception and set, the patient's awareness of objects or qualities through the use of sensory stimulation and the readiness of the patient to take a particular action. 2. guided response,the early stage of learning a particular skill under the guidance of an instructor that involves imitation and practice of a demonstrated act. 3. mechanism, the confidence and proficiency of the patient in performing a skill that is more complex or involves several more steps than a guided response. 4. complex overt response; smoothly and accurately performing a motor skill that requires complex movement patterns. 5. adaptation, well-developed motor skills movements of the patient, which can be modified when unexpected problems occur. 6. origination, the use of existing psychomotor skills to create new movement patterns and perform them as needed in response to a particular situation or problem.
Cognitive Domain of Learning
1. remembering; learning new facts or information and being able to recall them. 2. understanding; the ability to understand the meaning of learned material. 3. applying, which involves use of abstract and newly learned ideas in an actual situation. 4. analyzing, which involves the ability to break information into organized parts. 5. evaluating, which involves the ability to judge the value of something for a given purpose. 6. creating which involves the ability to apply knowledge and skills to create something new.
What is the minimum recommended daily intake of macrominerals in the body?
100 mg
A 15-year-old girl states that she is having unprotected intercourse with her boyfriend. She asks for more information about birth control methods. Which information would the nurse include in patient education? Select all that apply. One, some, or all responses may be correct. 1. Condoms or diaphragms are the most effective methods. 2. Hormonal methods are effective but do not protect against sexually transmitted infections (STIs). 3. Barrier methods are less effective than hormonal but offer some protection against STIs. 4. Sterilization is an effective option that the patient should consider. 5. The rhythm method is effective for preventing pregnancy.
2, 3
A Japanese patient is admitted to the hospital after a fall. The patient does not understand English. Which should the nurse do to promote communication? Select all that apply. One, some, or all responses may be correct. 1. Use sign language. 2. Provide language assistance to the patient. 3. Ask a nurse who speaks Japanese to take over. 4. Check the patient physically and start treatment. 5. Try to learn Japanese.
2, 3
The nurse is administering psyllium to a patient who has constipation. How does psyllium act to help relieve the condition? Select all that apply. One, some, or all responses may be correct. 1. Lubricates the feces 2. Absorbs water into the stools 3. Stretches the intestinal wall 4. Irritates the intestinal mucosa 5. Lowers the surface tension of the stools
2, 3
The nurse is advising a young couple about healthy sexual practices. Which statement about unprotected sex is appropriate? Select all that apply. One, some, or all responses may be correct. 1. Unprotected sex reduces the risk of breast cancer. 2. This practice might result in pregnancy. 3. It carries the risk of infection. 4. Unprotected sex reduces the pleasure of intercourse. 5. This practice initiates premature ejaculation
2, 3
The nurse uses a trochanter roll or a sandbag when performing which intervention? Select all that apply. One, some, or all responses may be correct. 1. Placing the patient in the prone position 2. Placing the patient in the supported supine position 3. Placing the patient in the supported Fowler's position 4. Assisting the patient to sleep in the 30-degree lateral position 5. Assisting the patient in moving up in bed using a friction-reducing device
2, 3
Which statement demonstrates that the older adult understands the correct use of condoms? Select all that apply. One, some, or all responses may be correct. 1. "I can use any kind of lubricant such as lotions or baby oil." 2. "Before using the condom, I should check the package for damage or expiration." 3. "I need to use a condom to help reduce the risk of sexually transmitted infections." 4. "A good place to store condoms is in the bathroom so they don't dry out." 5. "I should not use a condom because I have a latex allergy."
2, 3
While taking a patient's medical history, a nurse records that the patient has asthma. Which medication for pain management might the physician avoid prescribing? Select all that apply. One, some, or all responses may be correct. 1. Tramadol 2. Naproxen 3. Ibuprofen 4. Oxycodone 5. Hydromorphone
2, 3
A group of nursing students is learning about nociceptive and neuropathic pain. What is an example of neuropathic pain? Select all that apply. One, some, or all responses may be correct. 1. Aching muscles 2. Diabetic neuropathy 3. Trigeminal neuralgia 4. Nerve root compression 5. Throbbing pain at knee joint
2, 3, 4
A patient presents with decreased libido, depression, and ineffective coping. Which nursing intervention would be helpful for the patient? Select all that apply. One, some, or all responses may be correct. 1. Assess for influence of cultural beliefs. 2. Assess the causes of ineffective coping. 3. Help the patient to set realistic goals. 4. Encourage the patient to express feelings. 5. Explain to the patient about the use of condoms.
2, 3, 4
The nurse is assessing a patient with acute pain. Which statement is true about acute pain? Select all that apply. One, some, or all responses may be correct. 1. Acute pain is not protective. 2. Acute pain has an identifiable cause. 3. Acute pain causes limited tissue damage. 4. Acute pain results in prolonged hospitalization. 5. Patients with acute pain seek numerous health care providers.
2, 3, 4
The nurse is learning about the effect of different cultures on nursing. Which is a benefit of culturally congruent care? Select all that apply. One, some, or all responses may be correct. 1. It will help the nurse interact with different people in their language. 2. It will help the nurse interpret the needs of the patient who belongs to a different culture. 3. It will help the nurse identify the similarities and differences of various patients across different cultures. 4. It will help the nurse deliver the specific kind of health care that is expected from patients who belong to a different culture. 5. It will help the nurse deliver different remedies for an illness as practiced in the patient's culture.
2, 3, 4
Which sexual disease is caused by bacteria? Select all that apply. One, some, or all responses may be correct. 1. Herpes 2. Syphilis 3. Chlamydia 4. Gonorrhea 5. Genital warts
2, 3, 4
Which substance comprises the referenced daily intakes (RDIs) that the US Food and Drug Administration (FDA) has established? Select all that apply. One, some, or all responses may be correct. 1. Fiber 2. Proteins 3. Vitamins 4. Minerals 5. Total fat 6. Carbohydrates
2, 3, 4
When providing massage for pain relief in a patient recovering from spinal surgery, which area of the body would the nurse avoid? Select all that apply. One, some, or all responses may be correct. 1. Hands 2. Legs 3. Neck 4. Back 5. Reddened skin
2, 3, 4, 5
A patient presents with a 5-day history of diarrhea. The patient states, "I initially experienced nausea and vomiting that lasted 24 hours." For which additional symptom does the nurse assess to determine the plan of care? Select all that apply. One, some, or all responses correct. 1. Bradycardia 2. Dizziness 3. Dry skin 4. Peripheral edema 5. Dark-colored urine
2, 3, 5
A patient presents with ineffective sexual functioning. Which strategy would the nurse suggest to enhance sexual functioning in the patient? Select all that apply. One, some, or all responses may be correct. 1. Discourage the use of pain medications. 2. Discourage the use of alcohol and tobacco. 3. Encourage touching and kissing. 4. Discourage the use of pillows during sex. 5. Communicate concerns and fears with the partner.
2, 3, 5
Which sign manifests in infants and young children who are dehydrated? Select all that apply. One, some, or all responses may be correct. 1. Dizziness 2. High fever 3. Sunken eyes 4. Light-headedness 5. Dry eyes when crying 6. Listlessness or irritability
2, 3, 5, 6
In the context of teaching a mother about her infant's developmental capacity, which statement by the nurse would be appropriate? Select all that apply. One, some, or all responses may be correct. 1. "Encourage learning through the use of pictures." 2. "Keep consistent routines of feeding and bathing." 3. "Use role play and imitation to make learning fun." 4. "Speak softly to convey a sense of trust to the baby." 5. "Use simple words to promote the infant's understanding."
2, 4
The nurse is teaching a group of nursing students about concepts of pain in infants. Which information would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct. 1. Infants cannot express pain. 2. Absorption of drugs is faster than expected. 3. Infants are less sensitive to pain than adults are. 4. Preterm neonates have greater sensitivity to pain than older children do. 5. Assessment of pain involves behavioral cues and physiological indicators.
2, 4, 5
The registered nurse is teaching a nursing student about applying transcutaneous electrical nerve stimulation (TENS) to a patient. Which statement by the student indicates a need for further teaching? Select all that apply. One, some, or all responses may be correct. 1. "I should set the frequency to no more than 50 Hz." 2. "I should use TENS on patients who have chronic cancer pain." 3. "I should place TENS electrodes directly over or near the site of pain." 4. "I should apply hair or skin preparations before placing TENS electrodes." 5. "I should remove TENS electrodes if the patient feels a buzzing or tingling sensation."
2, 4, 5
The registered nurse is teaching a nursing student the steps of planning for moving and positioning patients. Which statement by the nursing student indicates the need for further learning? Select all that apply. One, some, or all responses may be correct. 1."I should perform hand hygiene." 2 ."I should place all pillows on the bed." 3. "I should collect appropriate equipment." 4. "I should explain the procedure to the patient." 5. "I should keep the level of the bed in a low position." 6. "I should close the room door and bedside curtains."
2, 5
When treating a patient who is Muslim, which factor would the nurse keep in mind? Select all that apply. One, some, or all responses may be correct. 1. Muslims consume alcohol in moderation. 2. Muslims do not eat pork. 3. Muslims do not pray 5 times a day. 4. Muslims do not eat meat on Fridays. 5. During Ramadan, Muslims eat only after sunset.
2, 5
Which adjuvant drug is preferred for treating neuropathic pain? Select all that apply. One, some, or all responses may be correct. 1. Corticosteroids 2. Anticonvulsants 3. Opioid analgesics 4. Nonopioid analgesics 5. Tricyclic antidepressants
2, 5
Which teaching intervention would facilitate learning when teaching handwashing to a group of preschoolers? Select all that apply. One, some, or all responses may be correct. 1. Teach psychomotor skills needed to maintain health. 2. Use role playing, imitation, and play to make learning fun. 3. Provide information regarding the health problem to the child. 4. Allow the preschooler to make decisions about health and health promotion. 5. Encourage learning together through pictures and short stories about how to perform hygiene.
2, 5
What does the nurse teach the student nurse about quality health care to prevent health disparities? 1. "Quality health care should be variable." 2. "Quality health care should be effective." 3. "Quality health care should be slow and thorough." 4. "Quality health care should be health care organization-centered."
2. "Quality health care should be effective."
Which nursing student statement regarding a nurse's role with victims of sexual abuse indicates a need for further teaching? 1. "Nurses should educate individuals regarding all available community services." 2. "They do not have the authority to report suspected abuse to the authorities." 3. "Nurses are in an ideal position to assess different occurrences of sexual violence." 4. "They should ask the victim about abusive behaviors in the absence of the suspected abuser."
2. "They do not have the authority to report suspected abuse to the authorities."
The nurse determines that after teaching first grade children about healthy nutrition, the students will be able to name three examples of foods that are fruits. Which phrase does this describe? 1. A teaching plan 2. A learning objective 3. Reinforcement of content 4. Enhancing the children's self-efficacy
2. A learning objective
After reviewing a patient's laboratory reports, the nurse suspects that the patient has pancreatitis based on increased levels of which component? 1. Bilirubin 2. Amylase 3. Alkaline phosphatase 4. Carcinoembryonic antigen
2. Amylase
To digest starch, which enzyme does the pancreas secrete? 1. Lipase 2. Amylase 3. Elastase 4. Carboxypeptidas
2. Amylase
Which term describes both selenium and betacarotene? 1. Vitamins 2. Antioxidants 3. Trace elements 4. Inorganic substances
2. Antioxidants
An Arab woman is admitted to the hospital. A male nurse is assigned to examine this patient. The patient is uncomfortable and expresses displeasure at being assigned a male nurse. What should the nurse manager do? 1. Ask the male nurse to go ahead with the examination. 2. Assign a female nurse to carry out the examination. 3. Remain in the room when the male nurse is examining the patient. 4. Explain to the patient that the hospital is short on staff and that she has to cooperate.
2. Assign a female nurse to carry out the examination.
What is the similarity between patient-centered care and cultural competence? 1. Both involve individualized care. 2. Both improve health care quality. 3. Both emphasize personal relationships. 4. Both concentrate on the qualities of disadvantaged groups
2. Both improve health care quality
Which term refers to the process in which biochemical substances break down into simpler substances during physiological states of negative nitrogen balance? 1. Anabolism 2. Catabolism 3. Absorption 4. Metabolism
2. Catabolism
During their clinical postconference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that a patient was homeless. Which difference was being described between the student and the patient? 1. Ethnicity 2. Culture 3. Heritage 4. Religion
2. Culture
The registered nurse is providing instructions to a nursing student about the interventions performed while moving the patient. Which instruction given by the registered nurse should be prioritized? 1. "Determine the comfort level of the patient." 2. "Determine the effects of illness on exertion." 3. "Determine whether the patient understands what is expected." 4. "Determine whether it would be difficult to move the patient alone."
2. Determine the effects of illness on exertion.
A 50-year-old man reports he is experiencing issues related to his sexual performance. His blood levels are normal except for a high glucose level. His semen analysis is within normal limits. Which disorder is likely responsible for his condition? 1. Hypoactive sexual desire 2. Erectile dysfunction 3. Dyspareunia 4. Infertility
2. Erectile dysfunction
During a preoperative assessment, a patient reports a history of a heart attack and use of anticoagulant medications. If epidural anesthesia is administered to the patient for the surgery, which possible complication would the nurse look for? 1. Synergistic effects 2. Hematoma 3. Allergic reaction 4. Respiratory depression
2. Hematoma
A patient is diagnosed with a diabetic ulcer with gangrene to his foot. The health care provider advises surgery, but the patient refuses because removal of a body part is not permitted according to his or her religion. Which concept justifies this scenario? 1. Marginalization 2. Iceberg analogy 3. Intersectionality 4. Health disparity
2. Iceberg analogy
When mucus is noted in a patient's feces, the nurse suspects which cause? 1. Constipation 2. Intestinal infection 3. Increased peristalsis 4. Malabsorption of fat
2. Intestinal Infection
What is the definition of cultural awareness in Campinha-Bacote's model of cultural competency? 1. It is the ability to assess social, cultural, and biophysical factors that influence patient treatment and care. 2. It is the in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people. 3. It is the cross-cultural interaction that provides opportunities to learn about other cultures and develop effective intercultural communication. 4. It is the sufficient comparative knowledge of diverse groups, including the values, health beliefs, care practices, world views, and bicultural ecologies commonly found within each group.
2. It is the in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people.
The nurse is incorporating the patient's religious dietary preferences into the care plan. Which step of the LEARN mnemonic is the nurse applying? 1. Explain 2. Negotiate 3. Recommend 4. Acknowledge
2. Negotiate
Which statement is true regarding nonpharmacological pain interventions? 1. Nonpharmacological interventions should only be used alone. 2. Nonpharmacological interventions are useful for patients who cannot tolerate pain medications. 3. Nonpharmacological interventions have a clear set of guidelines regarding intensity and duration. 4. Nonpharmacological interventions should be used in place of pharmacological therapies for acute pain.
2. Nonpharmacological interventions are useful for patients who cannot tolerate pain medications.
An older Chinese woman is admitted to the hospital after a hip fracture. Once the fracture has healed, the nurse encourages the patient to walk around the room. The patient refuses to walk without her son. What should the nurse do in this scenario? 1. Leave the patient alone but understand that the patient has no self-confidence. 2. Respect the patient's wish and ask her to walk when her son is present. 3. Explain to the patient calmly that she cannot be dependent on her son. 4. Tell the patient that she needs to walk now, and that it is inappropriate to be dependent on her son.
2. Respect the patient's wish and ask her to walk when her son is present.
Which part of the PLISSIT model would the nurse use when he or she is clear about the victim's problem? 1. Intensive therapy 2. Specific suggestions 3. Permission to discuss sexuality issues 4. Limited information related to sexual health problems
2. Specific suggestions
A 25-year-old patient in the emergency department states that she has had a cough and fever for the past 3 days. While performing a physical assessment, the nurse finds several bruises that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. Which action would the nurse perform first? 1. Refer the patient to a sexual counselor. 2. Tell the patient about a safe house for women. 3. Ask the patient to describe how she got the bruises. 4. Report the abuse immediately to the proper authorities.
2. Tell the patient about a safe house for women.
The nurse finds that a patient has not understood the health education provided on personal hygiene. How does the nurse ensure that the patient understands the teachings? 1. The nurse provides reading material on personal hygiene. 2. The nurse clarifies the information and requests a teach-back. 3. The nurse provides a video demonstration of personal hygiene. 4. The nurse requests that a family member help the patient understand.
2. The nurse clarifies the information and requests a teach-back.
Which statement is true regarding the goal of core measures? 1. They help recognize prejudices and assumptions about other people. 2. They help reduce mortality, complications, and inpatient readmissions. 3. They help provide care that fits with the patient's own values, beliefs, and traditions. 4. They help assess social, cultural, and biophysical factors that influence patient treatment and care.
2. They help reduce mortality, complications, and inpatient readmissions.
A male patient approaches the nurse for advice on permanent methods of contraception. Which option would the nurse suggest to the patient? 1. Tubal ligation 2. Vasectomy 3. Subdermal implants 4. Transdermal skin patches
2. Vasectomy
A patient in pain mentions a history of allergy to aspirin. Which drug might the health care team avoid in this patient? Select all that apply. One, some, or all responses may be correct. 1. Fentanyl 2. Morphine 3. Naproxen 4. Ibuprofen 5. Oxycodone
3, 4
A patient with cancer is irritated with the side effects of chemotherapy and blames the nurse for his or her condition. Taking into consideration the patient's current stage of grief, which nursing action is appropriate? Select all that apply. One, some, or all responses may be correct. 1. Provide teaching on present occurrences. 2. Convince the patient to undergo treatment. 3. Listen quietly to the patient's concerns. 4. Tell the patient's family that this behavior is normal. 5. Focus on knowledge that the patient will require in the upcoming weeks.
3, 4
Which nonpharmacological technique poses a risk of injury to the patient if the patient has a history of diabetic neuropathy? Select all that apply. One, some, or all responses may be correct. 1. Yoga 2. Massage 3. Hot bath 4. Cold application 5. Relaxation exercises
3, 4
A patient has opted for a diaphragm as a mode of contraception. Which advice would the nurse provide to the patient? Select all that apply. One, some, or all responses may be correct. 1. The diaphragm should be used along with an intrauterine device (IUD). 2. This device should be used along with condoms. 3. It should be refitted after pregnancy. 4. It should be refitted after a significant change in weight. 5. The diaphragm should be used with a contraceptive cream.
3, 4, 5
How is cultural competence different from patient-centered care? Select all that apply. One, some, or all responses may be correct. 1. Cultural competence involves individualized care. 2. Cultural competence improves health care quality. 3. Cultural competence aims to increase health equity. 4. Cultural competence emphasizes reducing disparities. 5. Cultural competence concentrates on disadvantaged groups.
3, 4, 5
When caring for a patient who is suffering from a serious illness, the nurse encourages the patient to follow his or her spiritual practices. How does spirituality help in healing? Select all that apply. One, some, or all responses may be correct. 1. Decreases the risk of infection in the patient. 2. Helps treat without any medication. 3. Increases the pain threshold of the patient. 4. Decreases stress and increases the immune response. 5. Reduces perception of pain and anxiety.
3, 4, 5
As per the Culturally and Linguistically Appropriate Standards (CLAS), what point is covered under communication and language assistance? Select all that apply. One, some, or all responses may be correct. 1. Communicate the organization's progress. 2. Offer language assistance to individuals at a low cost. 3. Provide easy-to-understand print and multimedia materials. 4. Ensure the competence of individuals providing language assistance. 5. Inform patients of language assistance services verbally and in writing. 6. Offer language assistance to individuals who have limited English proficiency.
3, 4, 5, 6
Which information would the registered nurse (RN) include regarding learning in the nursing plan? Select all that apply. One, some, or all responses may be correct. 1. Learning involves setting an appropriate pace. 2. It requires the educator to be knowledgeable about subject matter. 3. Learning includes both understanding and applying newly acquired concepts. 4. Learning involves imparting knowledge through a series of directed activities. 5. It is the acquisition of new knowledge, behaviors, and skills through an experience.
3, 5
The registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient? 1. "What are your dietary preferences?" 2. "What time do you typically go to bed?" 3. "Do you bathe and use deodorant more than 1 time a week?" 4. "Do you have any health issues that we should know about?"
3. "Do you bathe and use deodorant more than 1 time a week?"
If the nurse suspects a patient is a victim of interpersonal violence, which question is most appropriate? 1. "What in your life troubles you?" 2. "How would you describe your life?" 3. "Does anyone force you to have sex against your will?" 4. "What happens when you and your spouse debate issues?"
3. "Does anyone force you to have sex against your will?"
A registered nurse is teaching a nursing student about various nonpharmacological pain-management interventions. Which statement by the student indicates a need for further teaching? 1. "Biofeedback can help change a patient's perception of pain." 2. "Music therapy can be used in combination with pharmacological measures." 3. "Guided imagery provides effective pain relief for a patient who has acute appendicitis." 4. "Therapeutic touch is a complementary and alternative medicine pain relief method."
3. "Guided imagery provides effective pain relief for a patient who has acute appendicitis."
The registered nurse is teaching a nursing student about positioning techniques. Which statement by the nursing student indicates effective learning? 1. "I can use a thick pillow, because it decreases cervical flexion." 2. "I can use pillows of any size to position the patient." 3. "I can use folded sheets when additional pillows are unavailable." 4. "I can use a thin pillow to protect the skin from pressure ulcers."
3. "I can use folded sheets when additional pillows are unavailable."
Which question does the nurse ask a patient to assess the beliefs and practices of the patient? 1. "What caused your problem?" 2. "What is your main source of income?" 3. "What do you do to keep yourself well?" 4. "How should we address you or what should we call you?"
3. "What do you do to keep yourself well?"
The nurse has to examine a patient and administer an intravenous medication that is not a lifesaving drug. The patient is a devout Muslim. When the nurse goes to administer the medication, the nurse finds that patient is getting ready for namaz (prayers). The nurse understands that the patient prays at certain times, as specified in his culture. What should the nurse do in this scenario? 1. Administer the drug while the patient prays. 2. Ask the patient to pray after the medication is administered. 3. Allow the patient to pray and come back later to administer the medication. 4. Tell the patient that the nurse has other patients to look after and cannot come later
3. Allow the patient to pray and come back later to administer the medication.
How can a nurse develop cultural knowledge? 1. Become self-aware of personal biases. 2. Understand the forces that influence one's own world view. 3. Avoid unwarranted generalizations about any particular group. 4. Engage in an in-depth self-examination of one's own background.
3. Avoid unwarranted generalizations about any particular group.
The nurse provides education for a group of community members about colorectal cancer and includes which warning sign of cancer? Select all that apply. One, some, or all responses may be correct. 1. Rectal bleeding 2. Obesity and inactivity 3. Change in bowel habits 4. Older than 50 years of age
3. Change in bowel habits
Which bowel elimination problem is most likely the result of improper diet, reduced fluid intake, and lack of exercise? 1. Diarrhea 2. Flatulence 3. Constipation 4. Incontinence
3. Constipation
The nurse, while caring for a patient of a different cultural background, learns about the patient's cultural practices that affect health. The nurse uses these facts to plan the patient's care. Which component of Campinha-Bacote's model of cultural competency is reflected in this scenario? 1. Cultural skill 2. Cultural desire 3. Cultural encounter 4. Cultural knowledge
3. Cultural encounter
The school nurse is about to teach a freshman-level high-school health class about nutrition. Which instructional approach ensures that the students meet the learning outcomes? 1. Provide information using a lecture. 2. Use simple words to promote understanding. 3. Develop topics for discussion that require problem solving. 4. Complete an extensive literature search focusing on eating disorders.
3. Develop topics for discussion that require problem solving.
Which substance is a monosaccharide? 1. Fiber 2. Starch 3. Dextrose 4. Glycogen
3. Dextrose
Which type of pain-management therapy is preferred for relieving chronic cancer pain? 1. Local anesthesia 2. Topical analgesic 3. Epidural analgesia 4. Perineural local anesthetic infusion
3. Epidural analgesia
A patient presents with abdominal discomfort, and the nurse auscultates 40 bowel sounds in 1 minute. Which pattern of bowel sounds does the nurse document? 1. Normal 2. Hypoactive 3. Hyperactive 4. Tympanic note
3. Hyperactive
Which complication from untreated sexually transmitted infections (STIs) is most serious in women? 1. Genital discharge and dyspareunia 2. Painful menstrual cycles 3. Infertility and pelvic inflammatory disease 4. Genital warts
3. Infertility and pelvic inflammatory disease
A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department and detects disparities in health outcomes between rich and poor. What does this example illustrate? 1. Illness attributed to natural and biological forces 2. Creation of the student's interpretation and descriptions of the data 3. Influence of socioeconomic factors on morbidity and mortality 4. Combination of naturalistic, religious, and supernatural modalities
3. Influence of socioeconomic factors on morbidity and mortality
A Haitian patient is admitted to the hospital for arthritic pain. During the nursing assessment, the nurse learns that the patient is using a therapy called cupping for palliation of pain along with traditional Western medicine. Cupping involves placing heated cups on the skin. Which is the most appropriate action by the nurse? 1. Ask the patient to stop this therapy immediately. 2. Ignore this information and continue with Western medicine. 3. Learn about this therapy and avoid imposing own beliefs. 4. Ask the patient to select either Western medicine or cupping therapy.
3. Learn about this therapy and avoid imposing own beliefs.
What concept of intersectionality addresses the fact that some groups have limited access to certain facets of society such as the labor market? 1. Overinclusion 2. Social location 3. Marginalization 4. Social inequality
3. Marginalization
Which element do proteins contain that make them different from carbohydrates? 1. Carbon 2. Oxygen 3. Nitrogen 4. Hydrogen
3. Nitrogen
The nursing student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? 1. Performing ROM exercises when the pain score is 2 2. Performing ROM exercises 5 times during a session 3. Performing ROM exercises from smaller joints to larger joints 4. Performing ROM exercises by extending the joint as much as possible
3. Performing ROM exercises from smaller joints to larger joints
A patient experiences chronic constipation but has no other symptoms. The nurse anticipates the health care provider will prescribe which medication to provide relief for the condition? 1. Castor oil 2. Mineral oil 3. Polycarbophil 4.Docusate sodium
3. Polycarbophil
A patient who was hospitalized for a smoking-related illness tells the nurse, "I am ready to accept responsibility for learning, and I need your help." Which stage of psychosocial grief is reflected in this statement? 1. Anger 2. Disbelief 3. Resolution 4. Bargaining
3. Resolution
The nurse is caring for a Korean woman who has just delivered her first baby. Which soup would the nurse anticipate the family to provide as the first meal to the woman? 1. Tomato soup 2. Sweet corn soup 3. Seaweed soup 4. Hot garlic soup
3. Seaweed soup
A 50-year-old male patient comes for a follow-up visit a few months after a myocardial infarction. The nurse plans to interview the patient to assess his sexual health. During assessment, the patient expresses that he is not able to perform well sexually. Which explanation would the nurse give to the patient?
3. Sexuality can be affected by ailments such as myocardial infarction, but the patient should return to normal soon.
Which concept of intersectionality involves unequal access to resources and services? 1. Overinclusion 2. Marginalization 3. Social inequality 4. Matrix of domination
3. Social inequality
The nurse is caring for different patients. Which patient's condition may benefit from logrolling? 1. Head injury 2. Hand fracture 3. Spinal cord injury 4. Abdominal surgery
3. Spinal cord injury
A 45-year-old patient has been put on a low-residue diet postoperatively. Which food should be avoided in the patient's diet? 1. Pastas 2. Casseroles 3. Steamed vegetables 4. Canned cooked vegetables
3. Steamed vegetables
What is the primary goal of patient-centered care? 1. To provide care that fits a patient's own values, beliefs, and traditions 2. To help recognize biases, prejudices, and assumptions about other people 3. To provide individualized care and restore an emphasis on personal relationships 4. To assess social, cultural, and biophysical factors that influence patient treatment and care
3. To provide individualized care and restore an emphasis on personal relationships
The nurse is attempting to teach a below-the-knee amputee patient to walk with the help of crutches. The patient is doubtful about doing it, but the nurse strongly believes in the patient's ability to walk. Which source of self-efficacy does the nurse use to convince the patient? 1. Enactive mastery 2. Vicarious experience 3. Verbal persuasion 4. Physiological and affective states
3. Verbal persuasion
How much energy does 1 g of carbohydrate produce?
4 kcal
The nurse is teaching pain management to a group of caregivers. Which information would be included? Select all that apply. One, some, or all responses may be correct. 1. Chronic pain is often psychological. 2. Only hospitalized patients experience severe pain. 3. Psychogenic pain is not real. 4. Regular administration of analgesics will not lead to addiction. 5. Patients with minor illnesses may also experience severe pain.
4, 5
Which student nurse statement regarding cultural competence indicates a need for further teaching? 1. "Culturally competent organizations adapt to diversity." 2. "Culturally competent organizations conduct cultural self-assessment." 3. "Culturally competent organizations institutionalize cultural knowledge." 4. "Culturally competent organizations manage the dynamics of homogeny."
4. "Culturally competent organizations manage the dynamics of homogeny."
While measuring the vital signs of a Muslim patient, the nurse observes that the patient is anxious. Which statement by the nurse indicates a good understanding of transcultural nursing? 1. "I know modesty is very important for you, but you'll have to adjust this time." 2. "I know modesty is very important for you, but it should not interrupt the assessment." 3. "I know modesty is very important for you. However, we have to adhere to hospital rules." 4. "I know modesty is very important for you. Is there any way I can make you comfortable?"
4. "I know modesty is very important for you. Is there any way I can make you comfortable?"
After teaching a group of young adults about contraception, the nurse concludes that there is a need for further teaching. Which statement made by a young adult supports the nurse's conclusion? 1. "A vasectomy is a contraceptive method that is permanent." 2. "A condom is the most effective barrier method for contraception." 3. "I consult a health care provider before starting hormonal contraceptive therapy." 4. "I prefer to use a combined method of birth control to reduce the risk of sexually transmitted infections (STIs)."
4. "I prefer to use a combined method of birth control to reduce the risk of sexually transmitted infections (STIs)."
The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? 1. "I should raise the side rail on the opposite side of the bed from where I'm standing." 2. "I should evaluate the patient for correct body alignment." 3. "I should determine the type of assistance required for safe positioning." 4. "I should arrange the positioning equipment as close as possible to the patient's bed."
4. "I should arrange the positioning equipment as close as possible to the patient's bed."
The nurse is assessing a patient who complains of back pain. After taking the patient's history, the nurse does not expect the physician to recommend acetaminophen. Which patient statement led the nurse to this conclusion? 1. "I drink alcohol occasionally." 2. "I have been constipated for 3 days." 3. "I am allergic to penicillin." 4. "I was diagnosed with hepatitis B 2 months ago."
4. "I was diagnosed with hepatitis B 2 months ago."
A patient with epigastric and abdominal pain is scheduled for a barium swallow. Which statement by the patient indicates a correct understanding of the required preparation for the test? 1. "I will eat only soft foods the day before the test." 2. "There is no need for special preparation before the test." 3. "I will not eat or drink anything for 24 hours before the test." 4. "I will take a laxative to clear my bowels the day before the test."
4. "I will take a laxative to clear my bowels the day before the test."
The nurse is teaching a patient about diabetes. Which statement made by the patient indicates the affective domain of learning? 1. "Diabetes may cause cataracts and glaucoma." 2. "Insulin injections will help lower my blood glucose level." 3. "I will regularly check my blood glucose level with the glucometer." 4. "I would like to participate in the discussion about the treatment plan."
4. "I would like to participate in the discussion about the treatment plan."
The nurse is performing a cultural assessment of a patient. Which question by the nurse reflects a focused question? 1. "Who lives with you?" 2. "What do you do to keep yourself well?" 3. "What do you think caused your illness?" 4. "Is there someone with whom you want us to talk about your care?"
4. "Is there someone with whom you want us to talk about your care?"
Which statement by the nurse would make the patient pay more attention to the care being provided? 1. "You should learn about the medical tests." 2."You should ask questions if you do not understand something." 3. "You should ask a trusted family member to be your advocate." 4. "You should make sure that you are getting the right treatment from the right health care professional."
4. "You should make sure that you are getting the right treatment from the right health care professional."
The nurse identifies that the use of a fracture pan for a bowel movement would be beneficial for which patient? 1. A patient who is obese 2. A patient experiencing confusion 3. A patient on bed rest 4. A patient recovering from a total hip replacement
4. A patient recovering from a total hip replacement
Which intervention would the nurse perform first if a patient on morphine 10 mg/mL infusion therapy experiences severe respiratory depression? 1. Administer acetylcysteine. 2. Change morphine infusion to oral oxycodone. 3. Decrease the rate of infusion. 4. Administer 0.4 mg of naloxone
4. Administer 0.4 mg of naloxone
The nurse is using an interpreter to communicate with a patient who does not speak English. Which action by the nurse may hamper the communication between the nurse and the patient? 1. Introducing the interpreter to the patient 2. Determining the interpreter's qualifications 3. Looking at the patient instead of the interpreter 4. Asking the patient's family members to serve as interpreters
4. Asking the patient's family members to serve as interpreters
Which type of laxative acts by causing the stool to absorb water and swell? 1. Emollient 2. Stimulant 3. Lubricant 4. Bulk-forming
4. Bulk-forming
A nurse lists cultural biases and prejudices with which he or she was raised. Of what component of cultural competency is this most a part? 1. Valuing diversity 2. Institutionalizing cultural knowledge 3. Managing the dynamics of difference 4. Conducting a cultural self-assessment
4. Conducting a cultural self-assessment
A patient with diabetes has a new prosthetic leg and states, "I am looking forward to resuming my swimming exercises next week." This statement reflects which stage of psychosocial adaptation? 1. Resolution 2. Bargaining 3. Acceptance 4. Denial or disbelief
4. Denial or disbelief
A patient follows an ovolactovegetarian diet. Which food item is consumed in this diet? 1. Poultry 2. Fish 3. Meat 4. Eggs
4. Eggs
Which is least appropriate when communicating with a non-English-speaking patient who has complete hearing loss? 1. Ensuring that interpreters are competent in medical terminology 2. Providing the patient with auxiliary aids, services, and written materials 3. Notifying the patient about the right to receive language assistance services 4. Informing the patient that language assistance services are provided at a low cost
4. Informing the patient that language assistance services are provided at a low cost
A patient is admitted to the emergency department after the ingestion of a poison. The nurse anticipates a prescription for which type of cathartic? 1. Bisacodyl 2. Castor oil 3. Docusate calcium 4. Magnesium citrate
4. Magnesium citrate
Which substance may cause complications for a patient who has kidney dysfunction? 1. Castor oil 2. Mineral oil 3. Docusate sodium 4. Magnesium hydroxide
4. Magnesium hydroxide
Why would a health care provider prescribe acetylcysteine to a patient who is on pharmacological pain management therapy? 1. Overdose of aspirin 2. Overdose of fentanyl 3. Overdose of morphine 4. Overdose of acetaminophen
4. Overdose of acetaminophen
Which drug is unsafe for the central nervous system as a supplement to epidural anesthesia? 1. Aspirin 2. Naproxen 3. Ibuprofen 4. Oxycodone
4. Oxycodone
Which domain is required for learning to use a walker? 1. Affective domain 2. Cognitive domain 3. Attentional domain 4. Psychomotor domain
4. Psychomotor domain
The nurse teaches a patient with diabetes how to use a glucometer and then asks the patient to use the glucometer to measure his or her blood sugar. The nurse is using which teaching method? 1. Practice 2. Demonstration 3. Independent projects 4. Return demonstration
4. Return demonstration
Which dimension of spirituality includes "a sense of authentically connecting to one's inner self?" 1. Faith 2. Hope 3. Connectedness 4. Self-transcendence
4. Self-transcendence
Which tube is appropriate as an intervention for bleeding esophageal varices? 1. Ewald 2. Dobhoff 3. Miller-Abbott 4. Sengstaken-Blakemore
4. Sengstaken-Blakemore
A health care provider prescribes 10 mg of codeine every 4 hours to a patient who has chronic pain from cancer. However, after taking a second dose of the prescribed drug, the nurse notices that the patient is very drowsy and nauseous. Which dose alteration may provide effective pain relief while improving the drowsiness and nausea?
5 mg codeine every 4 hours
A patient took more than the prescribed amount of acetaminophen and is experiencing hepatotoxicity. Which drug might the nurse anticipate the health care provider to use to treat this patient?
Acetylcysteine
The nurse cares for a patient with a nasogastric tube for gastric decompression in place. Which action does the nurse include in the plan of care to prevent adverse effects related to the tube? Select all that apply. One, some, or all responses correct. 1. Irrigate the tube with saline. 2. Administer frequent oral hygiene. 3. Measure the length of the exposed tube. 4. Measure the pH of the aspirated tube contents. 5. Frequently lubricate the nares to minimize discomfort.
All of the above are correct
When comparing nasogastric tubes used for gastric decompression, the nurse recognizes which specific purpose of the Salem Sump?
Allow for stomach decompression and provide an air vent.
Which intervention does the nurse include in the bowel-training program for a patient with chronic constipation secondary to cognitive impairment?
Allowing ample time for evacuation
The nurse has placed a patient in the Sims' position. Which areas would bear the maximum weight of the body?
Clavicle
A patient with rheumatoid arthritis reports acute joint pain in the hand. Which intervention is inappropriate for providing pain relief?
Collaborating with an occupational therapist to provide assistive devices for grooming
The nurse is positioning a patient with hemiplegia in the supine position. The nurse places a folded towel under the hip of the patient. Which rationale explains this intervention?
Control Hip Position
The nurse suspects that a patient has a bowel obstruction based on which assessment finding?
Cramping; absence of bowel movements
The nurse is assessing a patient who has sustained severe injuries in a motor vehicle accident. The patient is in severe pain and is diaphoretic. On assessment, the patient's heart rate is increased, pupils are dilated, and blood pressure is decreased. Which finding is caused by the stimulation of the parasympathetic nervous system?
Decrease in blood pressure
What assessment would the nurse make a priority before moving a patient?
Determine whether the patient's illness contradicts exertion.
List the steps in the correct order in which to apply an ostomy pouch. 1.Remove the used pouch and skin barrier. 2.Apply clean gloves. 3.Measure the stoma. 4.Gently cleanse the peristomal skin with warm tap water. 5.Close the end of pouch with clip or integrated closure. 6.Cut an opening on the pouch. 7.Press the adhesive backing of the pouch smoothly against the skin.
Hand hygiene prevents transmission of microorganisms. Removing the pouch allows for visualization of the skin and stoma. Cleansing the stoma removes microorganisms and allows for proper visualization. Measuring the stoma ensures the selection of the correct size of pouch. Cutting an opening allows for customization of the pouch to provide an appropriate fit over the stoma. Gently applying the pouch smoothly ensures adherence. Closing the end of the pouch with a clip or integrated closure prevents leakage of the contents of the pouch.
Which condition is observed by placing the patient in the Sims' position?
Lateral Flexion of the neck
L. E. A. R. N.
Listen, Explain, Acknowledge, Recommend, and Negotiate
Which amino acid does the body not synthesize?
Lysine
While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. Which rationale explains this intervention?
Maintain correct allignment
A patient is scheduled for a plain film x-ray of the kidney, ureter, and bladder. Which preparation will be included on the patient's treatment plan?
No preparation required
A health care provider administers epidural anesthesia to a patient in the terminal stages of cancer for pain relief. Which nursing intervention is then necessary?
Notifying the health care provider if the patient develops pain at the epidural insertion site
What are soluble fibers?
Oats, barley, and cornmeal are soluble fibers, which can be dissolved in water.
How many nurses would be required to place a patient in the semi-prone position?
One Nurse
Which class of pain management drugs may interfere with bowel or bladder function?
Opioid analgesics
Which positioning aid increases cervical flexion?
Pillows
Which aspect of positioning a patient in the supported Fowler's position has a goal of decreasing flexion of vertebrae?
Place a small pillow at the lower back
While positioning a patient with hemiplegia in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. Which rationale explains this nursing action?
Prevent flexion contractures
Which position would be beneficial for a patient who is suspected to have lung injury?
Prone
The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition?
Prone Position
The nurse is positioning a postoperative patient to place the major portion of the body weight on the hip and shoulder. In which position does the nurse place the patient?
Side-Lying
Upon auscultating the abdomen of a patient with a stethoscope, the nurse hears high-pitched and hyperactive bowel sounds. The nurse identifies that the assessment findings correspond with which condition?
Small intestine obstruction
While administering an enema to a patient, the nurse notes blood in the return fluid and rectal bleeding. Which action does the nurse take?
Stop the instillation and obtain vital signs
Which substances are disaccharides?
Sucrose, lactose, and maltose
Increased cervical flexion is observed when the patient is placed in which position?
Supported Fowlers position
The nurse administers 250 mg of acetaminophen along with 5 mg of hydrocodone to a patient in pain. Why is acetaminophen part of this protocol?
To decrease the dose of opioid required for pain control
While helping a patient move up in bed, the nurse turns the patient from side to side to place the drawsheet under the patient. What rationale explains this nursing action?
To reduce friction during the movement
Which site is at risk of skin breakdown when the patient is in the side-lying position?
Trochanter
The nurse places the patient in the prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae?
Turning the patient's head to one side and supporting it with a small pillow
A 65-year-old patient is experiencing mild musculoskeletal pain. Which drug is the health care provider most likely to prescribe?
acetaminophen
Which pain management drug is considered the best-tolerated and safest analgesic?
acetaminophen
Daily recommended fluid intake (L)
men: 3.7 L women: 2.7 L
