Freshman Nursing Cumulative Review

43.) Which of the following describes a client who may be experiencing acute hypoxia? a.) Respiratory rate of 40 with heavy abdominal muscle use during respiration b.) Respiratory rate of 12 with normal chest rise and fall during respiration c.) Pulse rate of 112 and flushing of the skin d.) Pulse rate of 60 with a respiratory rate of 14

(a) Hypoxia is caused by insufficient amount of oxygen that reaches the tissues. A normal respiratory rate is typically 12-20 with normal rise and fall of the chest during inspiration and expiration. A patient with a respiratory rate of 40 and using abdominal muscles to breath could be compensating for lack of ability to expand the lungs properly and may be experiencing hypoxia. Though a pulse rate of 112 is out of the normal range and the patient's face was flushing, this has nothing to do with a patient experiencing hypoxia.

42.) Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is: a.) High b.) Low c.) At the high end of normal range d.) At the low end of normal range

(C) 37.9 converts to approximately 100.2, which is considered the high end of a normal range.

41.) Among the following statements, which should be given the HIGHEST priority? a.) The client is in extreme pain b.) The client's blood pressure is 84/40 c.) The client's temperature is 40.6 degrees celsius d.) The client's hands and feet are cyanotic (blue) and cold to touch

(C) A temperature of 40.6 is converted to 105.0 fahrenheit and must be treated as a priority to the other statements. Fevers this high can cause seizures due to a rapid increase in body temperature as well as dehydration. A blood pressure of 84/40 is not life threatening but must be addressed as well as the client in pain, as soon as possible. Cyanotic hands and feet can be a result of Raynaud's Phenomenon, vascular disease with poor circulation, or room temperature and does not require immediate attention as an isolated symptom.

44.) A 50 year old female client was sent to the emergency room from her employee health department at work after complaining of a headache and having a blood pressure reading of 150/100. Patient has no family history of high blood pressure and no previously documented high blood pressure of her own. The most appropriate measure for this patient is which of the following? a.) Give the patient a prescription for blood pressure medication and instruct her to take one tablet daily and return to her primary care doctor in 6 months for a check up. b.) Take the patient to cat scan to rule out a brain tumor c.) Instruct the patient to see the ophthalmologist because her headache could be caused by poor vision d.) Obtain a 24 hour diet recall and offer the patient healthy lifestyle modifications including diet changes and to increase her daily exercise. Instruct the patient to follow up with her primary care doctor within a week.

(D) The most appropriate action to take is review a 24 hour diet recall with the patient and offer healthy lifestyle modifications. It is rarely appropriate to start a patient on blood pressure medications after only one blood pressure reading. Typically 3 high blood pressures in a row should be documented before beginning medication and a patient should be seen in the primary care clinic prior to six months to confirm this. Though ophthalmology wouldn't be a bad recommendation, typically headaches due to eye strain aren't associated with high blood pressure. A cat scan isn't a standard of care for someone with a blood pressure of 150/100 and complaints of a headache.

2.) The maternity nurse is providing instructions to a new mother regarding the psychological development of the newborn infant. Using Erikson's psychological development theory, the nurse instructs the mother to take which measure? a.) Allow the newborn infant to signal a need b.) Anticipate all the needs of the newborn infant c.) Attend to the newborn infant immediately when crying d.) Avoid the newborn infant during the first 10 minutes of crying

(a) According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.

25.) Which of the following is the FIRST priority in preventing infections when providing care for a client? a.) Handwashing b.) Wearing gloves c.) Using a barrier between client's furniture and nurse's bag d.) Wearing gowns and goggles

(a) Handwashing remains the most important factor in preventing infections.

26.) A student nurse is out with her friends on a friday night at a local dinner. She notices a man in apparent distress, standing up, holding his neck, unable to talk, or cough. The man is awake and has a pounding pulse. She rushes over to help him. Which of the following should she perform: a.) Heimlich Maneuver b.) CPR c.) Chest compressions only d.) Mouth-to-mouth breathing

(a)The man appears to be choking on food. The best action is to perform a Heimlich Maneuver

3.) A parent of a 3-year old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instruction should the nurse provide to the parent? (Select all that apply) a.) Set limits on the child's behavior b.) Ignore the child when this behavior occurs c.) Allow the behavior, because this is normal at this age period d.) Provide a simple explanation of why the behavior is unacceptable e) Punish the child every time the child says "no" to change the behavior

(a, d) According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options b and c do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

10.) Vitamin D deficiency can cause which of the following? Select all that apply a.) Osteoporosis b.) Xerophthalmia c.) Osteopenia d.) Rickets e.) Osteomalacia

(a,c,d,e) Xerophthalmia is caused by Vitamin A deficiency, which causes a thickening and dryness of the epithelial covering of the eye. It is also the leading cause of blindness in developing countries.

9.) The nurse educates the client about foods that are high in calcium. The nurse evaluates that teaching has been effective when the client selects which foods? a.) 1 cup of whole milk, 1 cup spinach, and 3 oz. sardines b.) 1 cup low-fat yogurt, 1 cup broccoli, and 3 oz. sardines c.) ½ cup 2% cottage cheese, 1 cup spinach, and 3 oz frozen tofu d.) 1 medium baked potato with 1 tbsp fat-free sour cream, 1 cup spinach, and 3 oz tofu

(b) 1 cup low-fat yogurt (448 mg calcium), 1 cup broccoli (60 mg calcium), and 3 oz. sardines (324 mg calcium)=total of 832 mg calcium. The other options ranged from 398 mg calcium to 654 mg calcium

8.) A client recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? a.) Milk b.) Oranges c.) Bananas d.) Chicken

(b) Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

21.) A nursing student is attending a post-clinical conference. Her clinical supervisor is discussing the three levels of prevention. The nursing student is know that screening women in their 40s for breast cancer is an example of what type of prevention? a.) Primary Prevention b.) Secondary Prevention c.) Tertiary Prevention d.) General level of prevention

(b) Secondary prevention: screening women for breast, blood pressure screening event, screening men for colorectal cancer in their 50s are all examples of secondary prevention.

4.) The mother of an 8-year old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? a.) "You need to be concerned" b.) "You need to monitor the child's behavior closely" c.) "At this age, the child is developing his own personality" d.) "You need to provide more praise to the child to stop this behavior"

(c) According to Erikson, during school-age years (6-12 years of age), the child begins to move toward peers and friends and away from parents for support. The child also begins to develop social interests that reflect his or her own developing personality instead of the parents. Therefore the other options are incorrect.

22.) A patient with heart disease is seeing his cardiologist for his follow up appointment. Along with ACEI and Beta Blockers, the cardiologist prescribes cardiac-rehabilitation. The nurse in the office is aware that protective qualities of the medications and the effects of the cardiac rehabilitation are examples: a.) Primary Prevention b.) Secondary Prevention c.) Tertiary Prevention d.) Cardiac strengthening program

(c) Tertiary Prevention softens the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.) support groups that allow members to share strategies for living well vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.

6.) The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? a.) "I swim three times a week" b.) "I have stopped smoking cigars" c.) "I have hot chocolate before I go to bed" d.) "I read for 40 minutes before bedtime"

(c) The client should avoid caffeinated beverages and stimulants before bedtime including coffee, tea, soda, and chocolate. Exercising regularly three times a week is beneficial. Smoking and alcohol should be avoided.

7.) The nurse hears a patient calling out for help, hurries down the hall and finds the patient lying on the floor next to the bed. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident and completes an incident report. Which statement should the nurse document on the incident report? a.) The client fell out of bed b.) The client climbed over the side rails c.) The client was found lying on the floor d.) The client became restless and tried to get out of bed

(c) The incident report should contain the patient's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 3 are interpretations of the situation ad are not factual information observed by the nurse.

11.) The nurse enters a client's room and finds the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? a.) Call for help b.) Extinguish the fire c.) Activate the fire alarm d.) Confine the fire by closing the room door

(c) The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing the doors, and finally the fire is extinguished. A good way to remember this is using the RACE pneumonic (Rescue, Alarm, Confine, Extinguish or Evacuate).

13.) The RN asks the student nurse to obtain vital signs on one of her patients. The student nurse enters the room and finds the patient lying in bed stating, "I just woke up with chest pain". The student nurse returns to the primary RN with the vital signs. Which set of vital signs would be most important to notify the physician about immediately? a.) Temperature-99.5, Pulse-84 and regular, Respirations-14, Blood Pressure-124/84 b.) Temperature-96.9, Pulse-68 and irregular, Respirations-16, Blood Pressure-116/70 c.) Temperature-100.0, Pulse-120 and irregular, Respirations-28, Blood Pressure-150/94 d.) Temperature-98.9, Pulse-100 and regular, Respirations-20, 140/90

(c) The temperature is slightly elevated at 100, while the pulse rate is tachycardic at 120 and irregular and respirations are tachypneic at 28, blood pressure is also elevated at 150/94. The patient is having chest pain which could be contributing to his elevated heart rate, elevated respiratory rate and elevated blood pressure. It is important to notify the physician right away regarding the vital signs even if chest pain was not mentioned by the patient.

5.) The nurse is caring for an older adult in a long-term care facility. Which action contributes to encouraging autonomy? a.) Planning meals b.) Decorating the room c.) Scheduling hair-cut appointments d.) Allowing the client to choose social activities

(d) Autonomy is the freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the one that allows the client to be the decision maker.

12.) As a nurse employing healthy nutrition education to a patient, you tell them that the functions of carbohydrates include all but which of the following? a.) Provide the body with energy b.) Spare body protein c.) Helps prevent ketoacidosis d.) Preferred fuel for the heart

(d) Carbohydrates are preferred fuel for the brain not the heart

14.) The student nurse is walking into a room, for the first time in the morning, of an alert and oriented patient. Upon walking into the room, the student nurse knows to introduce him or herself, perform hand hygiene, perform a safety/environmental check of the room, and obtain what two identifiers from the patient, while verifying it with the patient's name band? a.) Name, medical record number b.) Name, height c.) Name, age d.) Name, date of birth

(d) Name and date of birth are two identifiers a patient can communicate to the nurse to verify their identity.

30.) What is the hormone that promotes sleep? a.) Melatonin b.) L-tryptophan c.) Progesterone d.) Oxytocin

Answer: a.) Melatonin Rationale: The levels of melatonin, which is the natural hormone that promotes sleep, decline in the latter decades of life. It is produced at night by the pineal gland in the brain.

37.) A nurse is teaching a patient about the importance of balancing protein, carbohydrates, and fats in the diet. The nurse identifies that the teaching about carbohydrates is understood when the patient states, "Carbohydrates are best known for providing? a.) Electrolytes b.) vitamins c.) Energy d.) Minerals

Answer/Rational: C Energy, athletes may have a diet 70% of CHO in order to load CHO before race.

40.) A patient complains of constipation. What should the nurse encourage the patient to eat? a.) Applesauce b.) Bananas c.) Cheese d.) Beans

Answer/Rational: D Applesauce, Bananas, and cheese all thicken the stool. Bean have a lot of fiber in them. They retain water in the stool-softens it and also adds a bulk to stimulates the lower GI/large bowels to move.

39.) When teaching an athletic teenager about nutritional intake, the nurse should explain that the carbohydrate food that would provide the quickest source of energy is a: a.) Glass of milk b.) Slice of bread c.) Snickers d.) Glass of orange juice

Answer/Rational: D OJ has a higher proportion of simple sugars, which are readily available for conversion to energy.

24.) A nursing student is attending a Thanksgiving dinner at his cousin's house. He observes that many of the attendants are drinking heavily. The nursing student is aware that men can have up: a.) 4 alcoholic drinks per day (e.g. 12 oZ, 5%, beer) b.) 2 alcoholic drinks per day (e.g. 12 oZ, 5%, beer) c.) 1 alcoholic drinks per day (e.g. 12 oZ, 5%, beer) d.) 5 alcoholic drinks per day (e.g. 12 oZ, 5%, beer)

Answer: 2 Rational: Men can have up to 2 drinks a day while women can have one drink a day. Although some agencies my argue that even 2 drinks is still too many (add them up?).... Examples of 1 drink: 12oz 5% beer, 5oZ of wine, 1.5oZ of spirit

23.) A nurse is conducting a health screening among females at the mall to assess those who are at risk for developing osteoporosis. Which of the following are important in preventing osteoporosis? a) Calcium, Vitamin D, weight bearing exercise b) Calcium, Vitamin C, weight bearing exercise c) Calcium, Vitamin A, weight bearing exercise d) Calcium, Vitamin D, and Corticosteroids

Answer: A Rational: Calcium, Vitamin D, Good Nutrition, Weight Bearing Exercises, Weight Training, Cardiovascular Training are all importnat ways to prevent or delay the progression of osteoporosis.

35.) A nurse is involved in preparing a poster presentation for a nutrition health fair. The nurse is aware that her clients understood the presentation if they say which of the following? a.) Carbohydrates have 4, proteins have 4, lipids have 9, and alcohol has 7 kilocalories per gram. b.) Carbohydrates have 4, proteins have 6, lipids have 9, and alcohol has 7 kilocalories per gram. c.) Carbohydrates have 9, proteins have 4, lipids have 9, and alcohol has 7 kilocalories per gram. d.) Carbohydrates have 4, proteins have 4, lipids have 6, and alcohol has 7 kilocalories per gram.

Answer: A Rational: Carbohydrates have 4, proteins have 4, lipids have 9, and alcohol has 7 kilocalories per gram.

43.) A nurse measures a blood pressure for a 39 years old male at a blood pressure screening event, his blood pressure is 132/90. The nurse is aware that the client should a.) Follow up with his primary care provider b.) Go to the nearest emergency room c.) Drink more water and get 8 hours of sleep/night d.) Tell the patient that he has Hypertension

Answer: A Rational: HTN can affect anyone at any age. We should start screening for HTN at 3 years. HTN diagnosis is made when the patient has an elevated blood pressure on 3 different occasions. We can't diagnose a patient with one reading (e.g. white coat syndrome, stress, etc). The best response is to have the patient see their primary care so they can have their blood pressure retaken and further workup can be done. 130s/90s is not an emergency; Drinking more water and sleeping may help but it doesn't address the elevated blood pressure.

34.) As a community health nurse, Joshua understands that illness orientation differs between men and women. Interventions toward getting men to seek medical care should be designed with the knowledge that a.boys are socialized to ignore symptoms and "toughen up." b.men only make a conscious decision to seek health care when they feel sick. c.men are more likely to interpret symptoms as indicators of illness. d.men have increased somatic awareness.

Answer: A Rationale: The stereotypical view of men as strong and invulnerable is incongruent health promotion. Boys are socialized to ignore symptoms and "toughen up." Men may be aware of being ill, but they make a conscious decision not to seek health care to avoid being labeled as "sick." Men lack the somatic awareness and are less likely to interpret symptoms as indicators of illness.

28.) A nurse is seeing a patient who just had a sleep study to rule out sleep apnea. At the end of the converstioan, the patinet asked the nurse to tell him the signs and symptoms of sleep apnea. Which of the following is an appropriate response a.) Periodic cessation of breathing, snoring, and feeling tired even after a full night of sleep b.) Periodic cessation of breathing, coughing, and feeling tired even after a full night of sleep c.) Periodic cessation of breathing, snoring, and upset stomach d.) Periodic cessation of breathing, eye pain, and feeling tired even after a full night of sleep

Answer: A Sleep apnea is the periodic cessation of breathing during sleep. The episodes can last several times/night and may last for 1 minutes. A typical pattern: snoring, breathing , marked snoring, breathing resumes, and increased CO2 levels..client wakes up.

33.) A 40 years old female patient is beeing seen in the primairy care settings for a well visit. She reports increased workload related to a recent promortion at work. She has been recently unable to handle the increased amount of work. To cope with her stress, she started drinking 4 glasses of wine a night. This is an example of which type of coping strategy is she using? a.) Adaptive b.) Maladaptive c.) Appropriate d.) Unhealthy

Answer: B Maladaptive Rational: Adaptive examples: Healthy choices, Directly reduce negative effects of stress Examples: change in lifestyle; problem-solving Maladaptive examples: Unhealthy style; temporary fix, Possible other harmful effects Examples: substance abuse; overeating

31.) To assist an adult client to sleep better the nurse recommends which of the following? a.) Drinking a glass of wine just before retiring to bed b.) Eating a large meal 1 hour before bedtime c.) Consuming a small glass of warm milk at bedtime d.) Performing mild exercises 30 minutes before going to bed

Answer: C A small glass of milk relaxes the body and promotes sleep

36.) a nurse is working in the nursery. Today is her first day on the job. She notices that almost 100% of newborn babies receive vitamin K IM injections. Which of the followin is true about vitamin K injections postnatal? a.) Vitamin K is administered to newborn to prevent newborn blindness. b.) Vitamin K is administered to newborn to prevent heart murmurs. c.) Vitamin K is administered to newborn to prevent Vitamin K Deficiency Bleeding. d.) Vitamin K is administered to newborn to prevent hepatitis B.

Answer: C Rational: Vitamin K is administered to newborn to prevent Vitamin K Deficiency Bleeding. Newborns have little vitamin K in their bodies. VKDB is a rare BUT life threatening condition.

17.) A patient has a decreased hemoglobin level because of low intake of dietary iron. The nurse knows that the patient understood the teaching if he say: a.) "I will eat more eggs" b.) "I will eat more fruits" c.) "I will eat more red meat" d.) "I will eat more eggs"

Answer: C Rational: While all the other sources may provide dietary iron, meat (especially liver) is the best source of dietary iron.

18.) The nurse is asked to give a talk on patient education. The nurse knows that her audience understood her talk if they state: a.) "The three domains of learning include watching, listening, and repeating" b.) "The three domains of learning include cognitive, language, and psychological" c.) "The three domains of learning include demonstrating, repeating, and verbalizing" d.) "The three domains of learning include cognitive, affective, and psychomotor"

Answer: D

32.) When assessing a client for obstructive sleep apnea (OSA), the nurse understands the most common symptom is: a.) Headache b.) Early awakening c.) Impaired reasoning d.) Excessive daytime sleepiness

Answer: D Excessive daytime sleepiness

16.) A nurse is counseling a patient with a diagnosis of osteoporosis. Based on the practitioner's prescription, which vitamin should the nurse instruct the patient to include in a daily health regimen? a.) B b.) K c.) C d.) D

Answer: D Increased intestinal absorption of calcium, stimulates the kidneys to return calcium, and stimulate bone cells (O'blasts)

19.) A nurse is working in an endocrinology outpatient clinic. Some of her job duties is to teach newly diagnosed diabetic clients how to self administer insulin. She uses a syringe and insulin and shows the client how to administer insulin; then she asks the client to demonstrate and give himself his first insulin shot. This method of teaching falls under what learning domain? a.) Cognitive b.) Affective c.) Demonstration d.) Psychomotor

Answer: D Rational: Cognitive-thinking domain: remember, understand, apply, analyze, evaluate... Affective-feeling domain: feeling, emotions, interest, attitudes, appreciations Psychomotor: motor skills, demonstrate how to self-administer insulin.

38.) A nurse is caring for a patient who is expending energy greater than the caloric intake. WHich human response most likely will occur a.) Fever b.) Malnutrition c.) Anorexia d.) Hypertension

Answer: Malnutrition

20.) A nurse is holding an smoke cessation event at a local church. After the event, Kevin (one of the attendants) approached her stating "The last time I had a cigarette was over 7 months ago. I have been keeping busy and avoiding thinking about smoking again." The nurse is aware that Kevin is which stage of change? a.) Precontemplation b.) Maintenance c.) Action d.) Preparation

Answer: b Rational: Taking steps to sustain change and resist the temptation to relapse.

15.) A patient is diagnosed with Vitamin A deficiency, Which type of pie should the nurse encourage the patient to eat? a.) Blueberry b.) Pumpkin c.) Cherry d.) Pecan

Answer: b While all the choices contain vitamin A, pumpkin is an excellent source of vitamin A.

27.) A nurse is helping a client with his morning care. The client is awake, alert, and oriented to self, place, and time. Following morning care, the client asked the nurse to put up the 4 side rails The nurse's most appropriate response: a.) Sure, I would feel more secure with the side rails up too b.) I will put them up for 1 hour then come back to put one down c.) I can put 3 side rails up as 4 is considered restraints d.) I will not be able to put any side rails up as it is considered restraints

Answer: c 4 side rails is considered restraints

29.) The nurse in the hospital has a prescription to administer medication at 0400 to Mrs. Giovanni. Mrs. Giovanni is asleep when the nurse enters the room. She is difficult to arouse and confused. Identify the stage of sleep Mrs. Giovanni was likely in when the nurse awakened her. a.) Stage II b,) Stage III c.) Stage IV d.) REM

Answer: c.) Stage IV Rationale: Stage IV is the deepest sleep and the most restorative. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep, and if awakened, the person may appear confused and react slowly.

1.) A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? a.) Tomato soup b.) Boiled shrimp c.) Instant oatmeal d.) Summer squash

Summer Squash (d) Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, oatmeal) are higher in sodium unless their food label specifically state "Low Sodium". Saltwater fish and shellfish are high in sodium.