Practice Test 5

Which assessment finding is considered an age-related change? A. Presbycusis B. Hyperopia C. Increased sensitivity to touch D. Increased sensitivity to taste

A This is correct. Presbycusis, the loss of high-frequency tones, is an age-related change.

Which actions would the nurse take to prevent sensory overload? Select all that apply. A. Leave the television on low volume to block out other noises. B. Minimize ambient light in the patient's room. C. Plan care to provide periods of sleep. D. Speak with a moderate tone of voice. E. Restrict caffeine intake during hospitalization.

B, C, D, and E This is incorrect. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. This is correct. To prevent sensory overload, the use of unnecessary light should be minimized. This is correct. The nurse should plan care to provide uninterrupted periods of sleep. This is correct. The nurse would speak to the patient in a moderate tone of voice. This is correct. Medications and some substances that stimulate the central nervous system, such as caffeine, may also contribute to sensory overload.

The nurse in the intensive care unit enters the patient's room and observes that they are experiencing a seizure. Which are the most appropriate interventions by the nurse? Select all that apply. A. Insert a padded tongue depressor in the patient's mouth. B. Turn the patient to their side. C. Restrain the patient to control their jerking movements. D. Loosen any restrictive clothing. E. Pad the side rails of the patient's bed.

B, D, and E This is incorrect. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). This is correct. When a seizure is occurring, the nurse would turn the patient to their side to prevent aspiration. This is incorrect. Do not attempt to restrain the patient, as this may result in muscle and joint injury. This is correct. In the event of a seizure, the nurse should loosen any restrictive clothing. This is correct. The nurse would pad the siderails, head, and foot of the bed to prevent injury sustained during a seizure.

The nurse documents a patient's radial pulse rate as 100 beats/min and regular. One hour later, the nurse rechecks the pulse, and it is irregular at 120 beats/min. What is the most appropriate nursing action? A. Ask another nurse to check the pulse. B. Administer fluids while the patient is in bed. C. Place the patient on a cardiac monitor. D. Check the pulse in the opposite arm.

C This is correct. When heart rate is of concern, the nurse will most likely place a patient on a cardiac monitor to determine not only the rate but also the rhythm and intensity of the pulse.

The nurse is teaching a client about their chest drainage system. Which of the following should the nurse include in the teaching? Select all that apply. A. Perform frequent coughing and deep-breathing exercises. B. Sit up in a chair, but do not walk while the drainage system is in place. C. Get out of bed independently as often as possible. D. Immediately notify the nurse of any increased shortness of breath. E. If the tube becomes disconnected, pinch it off, and use your call light to get help.

A and D This is correct. Clients should regularly perform coughing and deep-breathing exercises to promote lung re-expansion. This is incorrect. The nurse should also encourage the client to be as active as their condition permits, rather than telling them not to walk. Chest drainage systems are bulky, but clients with disposable systems can still get out of bed and ambulate. This is incorrect. The client will need assistance from one or two staff members to protect and monitor the system and to monitor their responses to activity. Getting out of bed independently is not safe for this client. This is correct. If a client with a chest drainage system becomes acutely short of breath, the client should immediately notify the nurse so that the nurse can check for occlusion of the system, which can result in a tension pneumothorax. This is incorrect. Although the client must get immediate help, the client should not "pinch it off," as it may cause a pneumothorax.

Which patient would probably have a higher than normal respiratory rate? A patient who has: A. Had surgery and is receiving a narcotic analgesic. B. Had surgery and lost a unit of blood intraoperatively. C. Lived at a high altitude and then moved to sea level. D. Been exposed to the cold and is now hypothermic.

B This is correct. A reduction in hemoglobin from blood loss would increase respiratory rate.

Which behavior by a parent indicates an understanding of teaching regarding stimuli used to develop the infant's auditory nervous system? A. Cuddling B. Speaking C. Feeding D. Soothing

B This is correct. Exposure to voices, music, and ambient sound helps develop the infant's auditory nervous system.

After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which parameter would the nurse document as a 7/10? A. Pulse pressure B. Pain C. Oxygen saturation D. Emotional distress

B This is correct. Pain is considered the "fifth vital sign."

When using sterile technique to perform care of a new tracheostomy, which of the following is correct? A. Cleanse the area with hot, soapy water and rinse well. B. Place the client in a semi-Fowler's position, if possible. C. Clean the stoma under the faceplate with hydrogen peroxide. D. Cut a slit in sterile 4 × 4 inch gauze halfway through to make a dressing.

B This is correct. Semi-Fowler's position promotes lung expansion and oxygenation.

Which of these steps in taking blood pressure is correct? Select all that apply. A. Use a bladder that encircles 40% of the arm. B. Wrap the cuff snugly around the client's arm. C. Ask the client to hold the arm at heart level. D. Have the client sit with feet flat on the floor. E. Identify clients with one identifier.

B and D This is incorrect. The bladder length should encircle 80% of the arm. The cuff width is 40% of the arm circumference. This is correct. The cuff should be wrapped snugly around the client's arm. This is incorrect. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported at heart level with palm facing upward. This is correct. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. This is incorrect. The client is identified with two identifiers, not one.

Which of the following methods would the nurse plan to use to assess kinesthetic deficit in a patient? A. Instruct the patient to read from the Snellen chart. B. Ask the patient to close their eyes and identify common smells. C. Have the patient perform alternating rapid movements. D. Touch the patient using a wisp of cotton.

C This is correct. Asking a patient to perform alternating rapid movements, such as clapping, assesses for kinesthetic deficits.

The nurse palpates a radial pulse on an 80-year-old patient and notes that it feels irregular. What is the most appropriate method to count this patient's pulse? A. Count for 15 seconds, multiply by 4 B. Count for 30 seconds, multiply by 2 C. Count for 1 full minute D. Count for 10 seconds, multiply by 6

C This is correct. When assessing an irregular pulse, it is important to determine whether the beat is regularly irregular (an irregular rhythm that forms a pattern) or irregularly irregular (an unpredictable rhythm). To make this distinction, the nurse must count the rate for 1 full minute.

For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who: A. Had abdominal surgery 2 hours ago. B. Suffered a fractured hip yesterday. C. Is dehydrated from vomiting. D. Has a heart or lung disease.

D This is correct. Conditions that require assessment of pulse deficit include digitalis therapy, blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status.

The pediatric nurse is assessing the 3-year-old client when the mother states the child is having sleep disturbances lately. The pediatric nurse recognizes the most likely cause of sleep disturbances would be which of the following? A. Concerns about friends B. Staying up to watch television C. Side effect of medication D. Fear of imaginary monsters

D This is correct. Toddlers and preschoolers are likely to fear monsters or imaginary figures.

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? A. Decreased blood pressure (BP) after standing up B. Decreased temperature after a period of diaphoresis C. Increased heart rate after walking down the hall D. Increased respiratory rate when the heart rate increases

A This is correct. A decrease in the client's blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. This is incorrect. Temperature decreasing after a period of diaphoresis is a normal finding and should not be referred to the primary care provider. This is incorrect. Heart rate increases after activity and does not have to be reported. This is incorrect. Respiratory rate increases when the heart rate increases and does not have to be referred to the primary care provider.

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Intravenous (IV) fluids are infusing. Which action would be most important for the nurse to take? A. Compare the left pedal pulse with the right pedal pulse B. Count the client's respiratory rate for 1 full minute C. Take blood pressure on the arm without an IV line D. Obtain oral temperature with an electronic thermometer

A This is correct. For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This assessment can be made only by comparing one leg with the other. This is incorrect. While the nurse would count the respiratory rate for 1 full minute, it is not the most important. This is incorrect. Taking blood pressure on the arm without the IV is standard practice, but there is another action that is more important. This is incorrect. Oral temperatures are commonly obtained using electronic thermometers. However, this is not the most important.

The nurse has been explaining advance directives to a patient. Which response by the patient would indicate successful teaching? A. "It specifies your healthcare instructions should you become unable to make self-directed decisions." B. "It identifies the activities considered to be evidence of quality care." C. "It verifies your understanding of the risks and benefits associated with a procedure." D. "It allows you the autonomy to leave the hospital when you decide, even if it is against medical advice."

A This is correct. An advance directive is a group of instructions stating the patient's healthcare wishes should they become unable to make decisions.

Which procedure technique has the most effect on the accuracy of an irregular apical pulse count? A. Counting the rate for 1 full minute B. Exposing only the left side of the chest C. Determining why assessment of apical pulse is indicated D. Using the ring finger to palpate the intercostal spaces

A This is correct. Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often, they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for 1 full minute.

The nurse is preparing a presentation for older adults regarding alternative living options. Which best describes an assisted-living facility? A. Residence that provides 24-hour supervision and assistance with scheduled and unscheduled activities B. An aging-in-place residence that provides services to meet the increasing needs of the resident C. A facility that provides skilled and unskilled nursing services to residents with disabilities D. Residence that accepts only Medicare and Medicaid for persons 65 years and older

A This is correct. Assisted-living facilities are congregate residential settings that provide or coordinate personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services.

The nurse administers a beta-adrenergic agent to a client with congestive heart failure. What assessment findings would indicate that the drug is working? A. Heart rate changes from 92 beats/min to 76 beats/min. B. Cardiac monitor shows narrowing of the QRS segment. C. Client experiences tingling in the fingers and toes. D. Urine output has increased to equal input.

A This is correct. Beta-adrenergic blockers reduce heart rate and myocardial oxygen demand and improve contractility of the heart. They decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Therefore, the client's reduced rate would be an expected finding that indicates the drug is working.

The nurse is caring for a client newly diagnosed with narcolepsy. What is the priority teaching point the nurse would share with the client? A. Do not drive or operate heavy equipment. B. Men are more likely to be diagnosed than women. C. There is no treatment; symptoms must be managed. D. Getting more sleep will correct narcolepsy.

A This is correct. For safety reasons, it is important to advise clients with a sleep disorder to avoid driving or operating heavy equipment until their condition is stabilized.

Which statement by the nurse best describes macular degeneration? A. "The portion of the eye called the macula, which is responsible for central vision, is damaged." B. "The lens becomes cloudy, causing blurred vision. This cloudiness will increase over time." C. "The pressure in the anterior cavity of the eye becomes elevated, shifting the position of the lens." D. "There's an irregular curvature of the cornea, causing blurred vision."

A This is correct. Macular damage (degeneration) causes diminished central vision.

A patient tells the nurse that since starting a new medication, they have suffered from excessively dry mouth. Which assessments would be needed to plan interventions for that symptom? A. Asking the patient whether foods taste different now B. Checking the patient's sense of smell C. Having the patient stand to check for balance D. Assessing for a history of seizures

A This is correct. Many medications cause xerostomia (dry mouth), which is the most common cause of impaired taste.

Which factor reflects the nurse's understanding of the characteristics of older adults? A. Fewer than 5% of all older adults live in nursing homes. B. Average life expectancy at birth has declined slightly during the past 10 years. C. In general, males tend to live longer than females do. D. Black men have the lowest life expectancy, but the gap decreases as a person ages.

A This is correct. Only 1% of people aged 65 years and older live in nursing homes; this rises to 9% for those older than 85 years.

The nurse is teaching a client how to use a portable blood pressure device to monitor the blood pressure at home. Which action is most important for the nurse to take? A. Ask the client to demonstrate the use of the blood pressure device. B. Explain the importance of frequent calibration of the device. C. Give the client a chart to record the blood pressure readings. D. Provide written instructions of the information taught.

A This is correct. Self-monitoring of blood pressure is of little value unless it is done using proper technique. Requesting the client demonstrate the procedure would allow the nurse to evaluate the client's technique.

The primary focus of the nursing interventions for a 6-year-old client who experiences somnambulation (sleep walking) would be to: A. Maintain client safety during episodes of somnambulation. B. Administer and teach about medications to suppress stage III sleep. C. Encourage the client to verbalize feelings regarding sleep pattern. D. Provide a quiet environment for nighttime sleep.

A This is correct. Sleepwalking places the client at risk for injury because of their lack of awareness of their surroundings. The nurse's primary intervention would be to protect the client from injury (e.g., falls) while sleepwalking, also called somnambulation.

The nurse is triaging clients in a busy emergency department. The nurse knows that chest pain should be treated seriously and accurately assessed. After assessment, which of the following clients reporting chest pain should be prioritized for intervention? A. 42-year-old female reporting mild, intermittent chest pain and an "aching" jaw B. 26-year-old male reporting right-sided chest pain that increases on inhalation C. 53-year-old female receiving cancer treatment with unilateral calf swelling and warmth D. 49-year-old male chronic smoker reporting chest pain after shoveling snow that has improved since coming to the hospital

A This is correct. Some women have milder chest pain, sometimes none at all. They are more likely than men to experience symptoms like jaw or back pain, nausea, fatigue, and shortness of breath.

The nurse is caring for a client on mechanical ventilation with a water-seal chest tube in place. The nurse recognizes which of the following as abnormal? A. The water-seal chamber's fluid level increases on inspiration and decreases on exhalation. B. The water-seal chamber's fluid level decreases on exhalation and increases on inhalation. C. There is an absence of bubbling in the bottom of the water-seal chamber. D. The client's respirations are rhythmic.

A This is correct. The fluctuations in the water-seal chamber's fluid level will increase on inspiration and decrease on exhalation. In a mechanically ventilated patient, however, the fluctuations are opposite.

The client diagnosed with inadequate closure of the mitral valve is scheduled for surgery and asks the nurse, "Why does it matter if my valve leaks?" What is the nurse's best response to explain why this mitral valve needs to be repaired? A. "Blood backflows from the left ventricle to the left atrium, reducing available blood flowing to the body." B. "Blood backflows from the right ventricle to the right atrium, reducing available blood flow to the lungs." C. "Blood backflows from the aorta into the left ventricle, reducing blood pressure and causing dizziness." D. "Blood backflows from the pulmonary artery into the right ventricle, reducing blood flow to the lungs."

A This is correct. The mitral valve is located between the left atrium and left ventricle, so backflow of blood results in reduced cardiac output to the body.

The nurse would expect to document which normal outcome following removal of impacted cerumen? A. Improved hearing acuity B. Bloody drainage C. Decreased sense of smell D. Severe dizziness

A This is correct. The nurse would expect to document an improvement in hearing following removal of cerumen. Impacted cerumen can lead to diminished hearing.

Which step would the nurse take first when performing otic irrigation in an adult? A. Warm the irrigation solution to room temperature. B. Position the patient so they are sitting with their head tilted away from the affected ear. C. Straighten the ear canal by pulling up and back on the pinna. D. Place the tip of the nozzle into the entrance of the ear canal.

A This is correct. The nurse would first warm the irrigation solution to room temperature.

Which structure within the brain is responsible for consciousness and alertness? A. Reticular activating system B. Cerebellum C. Thalamus D. Hypothalamus

A This is correct. The reticular activating system, located in the brainstem, controls consciousness and alertness.

A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because they are unable to care for themself at home. Which type of loss is this patient most likely experiencing? A. Environmental loss B. Internal loss C. Perceived loss D. Psychological loss

A This is correct. This patient is most likely experiencing an environmental loss because they are unable to return to their familiar home setting. Instead, they are being transferred to the new environment of a nursing home.

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), HR 76 beats/min, RR 16 breaths/min, and BP 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (39.6°C), HR 76 beats/min, RR 14 breaths/min, and BP 120/66 mm Hg. Which should be the nurse's first intervention at this time? A. Ask the client whether they have had a warm drink in the last 30 minutes. B. Notify the primary care provider of the client's temperature. C. Determine if the client is feeling chilled. D. Take the temperature by a different route.

A This is correct. With a fever, heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading.

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which of the following are known to trigger seizures? Select all that apply. A. Fever B. Missing a dose of anticonvulsants C. Sleep deprivation D. Food allergens E. Mood-altering substances

A, B, C, and E This is correct. Fever is a common trigger of seizures. This is correct. The most common reason for seizures in a person with epilepsy is failure to take the prescribed antiseizure medication. This is correct. Lack of sleep can trigger a seizure. This is incorrect. Ingesting a food allergen invokes an immunological response with reactions related to anaphylaxis. This is correct. Ingestion of a mood-altering substance can trigger a seizure.

A 70-year-old homeless patient is admitted to the emergency department for heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alert to which signs and symptoms are associated with heat stroke. Select all that apply. A. Temperature of 103.8°F (39.9°C) B. Throbbing headache C. Diaphoresis D. Confusion E. Red, hot, dry skin

A, B, D, and E This is correct. Heat stroke occurs when the body's temperature regulation fails, usually when the hyperthermia progresses to a temperature above 103°F (39.4°C). This is correct. Throbbing headache is a symptom of heat stroke. This is incorrect. Diaphoresis occurs in heat exhaustion. In heat stroke, the body is unable to sweat. This is correct. Confusion is a manifestation of heat stroke. This is correct. Red, hot, dry skin is a sign of heat stroke.

Which of the following describe the sensory changes that occur with aging? Select all that apply. A. Decreased number of nerve conduction fibers results in slower reflexes. B. The lens of the eye becomes less flexible and less able to focus on near objects. C. Taste buds atrophy and decrease in number, causing decreased ability to perceive taste. D. Impaired regulation of body temperature causes an increased risk for seizures. E. The amount and waxiness of cerumen increases with aging.

A, B, and C This is correct. A decreased number of nerve conduction fibers resulting in slower reflexes occurs with aging. This is correct. Less flexibility of the lens resulting in decreased ability to focus on near objects is an age-related change. This is correct. Atrophy of taste buds resulting in decreased ability to taste is a sensory change occurring with aging. This is incorrect. Regulation of body temperature is not a sensory deficit. This is incorrect. Cerumen is drier and more solid with aging, creating hearing loss.

The nurse is assessing a healthy older client who comes to the health clinic and reports not feeling like themself. The client complains of increased fatigue when walking up stairs and performing normal household activities. What are normal physiological changes in the cardiovascular system that occur with aging? Select all that apply. A. Cardiac contractile strength is reduced. B. Heart valves become more rigid. C. Peripheral vessels lose elasticity. D. Heart responds to increased oxygen demands. E. Sympathetic nervous system activity decreases.

A, B, and C This is correct. Cardiac efficiency gradually declines as the heart muscle loses contractile strength. This is correct. Heart valves become thicker and more rigid during the aging process. This is correct. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. This is incorrect. As a result of physiological changes from aging, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. This is incorrect. There is no correlation with the sympathetic nervous system and aging in relation to the cardiac system.

The nurse caring for a postsurgical patient obtains an oral temperature reading of 102°F (38.9°C). The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? Select all that apply. A. Obtained oral temperature of 102°F (38.9°C) B. Called the surgeon to obtain the order C. Administered acetaminophen 650 mg orally D. Administered aspirin 650 mg orally E. Obtained rectal temperature of 102°F (38.9°C)

A, B, and C This is correct. The nurse should record the correct temperature and route. This is correct. The nurse should document notifying the provider. This is correct. The nurse should document interventions taken for the elevated temperature. This is incorrect. The order was for acetaminophen, not aspirin. This is incorrect. The route was oral, not rectal.

The nurse is caring for a client admitted to the hospital's hospice unit with terminal cancer and acute cancer pain. What factors does this client have that will interrupt circadian rhythms? Select all that apply. A. Poorly controlled pain B. Fear of the unknown C. Nursing rounds at night D. Extraneous lights in room E. Cool, dark room

A, B, and D This is correct. Uncontrolled pain can disrupt circadian rhythms and make sleep difficult. This is correct. Fear of the unknown, such as fear of death, can disrupt circadian rhythms and make sleep difficult. This is incorrect. Nursing rounds can be performed without waking the client. Vital signs would not be taken at night for a client who is terminal, as changes in vital signs will not require interventions or alter outcome. This is correct. Lights in the client's room in a hospice unit should be turned out to avoid alterations in circadian rhythm, and the door to the room can be closed to block out light from the hallway. This is incorrect. The room should have good sleep hygiene such as cool temperatures, turned off lights in the client's room, and a closed door to the room to block out light from the hallway. These conditions promote sleep.

The nurse is caring for a patient who has cancer and is terminally ill. What are the most appropriate actions by the nurse in providing end-of-life care that will address the patient's spiritual needs? Select all that apply. A. Be an empathetic listener for the patient. B. Allow the patient to participate in spiritual rituals. C. Recognize that this is an emotional time and prepare for intense crying. D. Contact pastoral care or the patient's clergyperson before the patient asks. E. Provide time for meditation, if requested.

A, B, and E This is correct. One way to address spirituality needs is to be an empathetic listener. Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings, whereas others gauge the value of the deceased by the amount of crying that occurs. This is correct. One way to address spirituality needs is to allow special, spiritual rituals. This is incorrect. Nurses cannot assume that all persons will engage in intense crying or wailing. This is incorrect. Only contact pastoral care or clergy, if the person asks for them, not before. This is correct. One way to address spirituality needs is to provide time for meditation, if requested.

The nurse is aware that health-promotion activities for all older adults include teaching about and facilitating for which immunizations? Select all that apply. A. Pneumonia B. Measles and mumps C. Influenza D. Herpes zoster E. Varicella

A, C, D, and E This is correct. Health promotion activities for all older adults include teaching and facilitating immunizations for pneumonia. The vaccine is a two-step process required only once in a lifetime. This is incorrect. Immunizations against measles and mumps are not recommended or required for older adults; these immunizations are most likely to be given in childhood. This is correct. It is recommended that older adults receive a yearly immunization against influenza. Influenza can be fatal in both the older and younger populations. This is correct. It is recommended that older adults receive a two-step immunization for herpes zoster (shingles). Shingles is most common in older adults and is restricted to those who had chicken pox. The previous one-step immunization is determined to be less effective. This is correct. It is recommended that older adults who never had varicella (chicken pox) receive the varicella immunization to prevent the disease. A history of varicella puts the older adult at risk for developing herpes zoster later.

Which interventions are necessary to promote patient safety in an unconscious patient? Select all that apply. A. Talk to the patient while providing care. B. Incorporate more touch in the plan of care. C. Provide frequent eye care if the blink reflex is absent. D. Keep the side rails up and the bed in low position. E. Perform diligent oral care by irrigating with diluted mouthwash.

A, C, and D This is correct. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. This is incorrect. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. This is correct. If the patient's blink reflex is absent or their eyes do not totally close, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. This is correct. Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. This is incorrect. The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore, you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

The nurse hears rhonchi when auscultating a patient's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? A. Have the client take several deep breaths. B. Ask the client to take a deep breath and cough. C. Take the client's blood pressure and apical pulse readings. D. Count the client's respiratory rate for 1 minute.

B This is incorrect. Deep breathing will not help clear rhonchi. This is correct. Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how the nurse differentiates between rhonchi and other adventitious sounds. This is incorrect. Taking blood pressure and apical pulse readings are not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi. This is incorrect. Counting the respiratory rate is not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range? A. Oral temperature: 100°F (37.8°C) B. Respiratory rate: 26 breaths/min and shallow C. Apical heart rate: 56 beats/min D. Blood pressure: 124/72 mm Hg

B This is correct. "Respiratory rate: 26 breaths/min and shallow" best supports a report of severe pain in such a client. Acute pain causes an increase in respiratory rate but a decrease in depth.

Throughout the course of a patient's illness, the patient has denied its seriousness, even though the health professionals have explained the prognosis of death very clearly. Physiological signs now indicate that the patient will probably die, but they are still firmly in a state of emotional denial. The patient says to the nurse, "Tell my wife to stop hovering and go home. I'm going to be fine." How should the nurse respond? A. "Your physical signs indicate that you will likely not live more than a few more hours." B. "You seem very sure that you are not going to die. Please tell me more about what you are feeling." C. "It seems to me you would be feeling some anger and wondering why all this is happening to you." D. "It would be best for your family if you were able to work through this and come to accept the reality of your situation."

B This is correct. "You seem very sure . . . Please tell me . . . what you are feeling" repeats what the patient has said (indicating understanding) and encourages expression of feelings—both are supportive. Remember that it is not the nurse's responsibility to move people to the next stage so that dying patients accept death. It is the nurse's responsibility to accept and support people "where they are" and to help them verbalize their feelings. Nurses need to understand patients, not change them.

An 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry, and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's report and the nurse's assessment, the nurse associates these findings with which of the following? A. Strabismus B. Cataracts C. Glaucoma D. Presbyopia

B This is correct. A cataract is a cloudy film over the lens of the eyes, resulting in blurred vision, sensitivity to glare and bright light, halos around lights, fading or yellowing of colors, and image distortion.

The mental health nurse has assessed a male patient who has repeatedly made sexual comments and advances toward other patients. The nurse recognizes these behaviors as what possible mental health disorder? A. Anxiety disorder B. Bipolar disorder C. Depressive disorder D. Paranoid schizophrenia

B This is correct. Clients with bipolar disorder, particularly during manic phases, are likely to be preoccupied with pleasurable activities and commonly display increased sexual activity in the form of verbalizing and acting out.

The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the client comprehends the teaching when she makes the following statement: A. "I may need to drink more fluids to make more oxygen." B. "I may need to take an iron supplement so that I am not anemic." C. "I will need a multivitamin supplement for several months." D. "I will need to eat more fruits and vegetables."

B This is correct. During pregnancy, oxygen demand increases dramatically. To compensate, the mother's blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother.

A client with heart failure has BP 120/60 mm Hg, heart rate (HR) 64 beats/min, respiratory rate (RR) 18 breaths/min, temperature (T) 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. The most appropriate nursing diagnosis for this client is: A. Impaired gas exchange. B. Excess fluid volume. C. Ineffective tissue perfusion. D. Deficient knowledge.

B This is correct. Excess fluid volume is an appropriate nursing diagnosis for someone demonstrating increased isotonic fluid retention, as demonstrated by adventitious breath sounds (crackles bilaterally) and edema.

A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), HR 110 beats/min, RR 26 breaths/min, and BP 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find? A. 16 B. 18 C. 20 D. 22

B This is correct. For every degree Fahrenheit (0.6°C) the temperature falls, the respiratory rate may decrease up to four breaths per minute. The client's temperature has fallen by 2°F; multiplied by 4, this is 8. Respiratory rate was 26 breaths/min. Thus, 26 minus 8 = 18 breaths/min.

The nurse works at a geriatric clinic. The nurse recognizes which situation as the most common major challenge for older adults? A. Dealing with the needs of their children B. Chronic health problems causing loss of independence C. Loss of the ability to reminisce about the past D. Decline of intellectual abilities

B This is correct. Older adults have many losses to deal with, including the development of chronic health concerns and loss of independence.

A client complains of trouble falling asleep at night despite extreme fatigue. A review of symptoms reveals no physical problems or a history of medications. The client has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. The client's sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be disturbed sleep pattern related to: A. Increased exercise. B. Nicotine withdrawal. C. Caffeine intake. D. Environmental changes.

B This is correct. People who use nicotine tend to have more difficulty falling asleep and are more easily aroused than those who are nicotine free. People who stop smoking often experience temporary sleep disturbances during the withdrawal period.

The nurse is planning a teaching workshop at the local community center for a group of men and women who are considered young-old. Which information is most important for the nurse to include at the workshop? A. A booklet on heart disease and diabetes B. Planning leisure activities and exercise C. How to stay connected with family members D. A list of doctors in the community

B This is correct. Persons 66 years old are in the young-old stage of older adulthood. Physical and psychological adaptations to retirement are paramount in this age group. One key indicator of well-being is use of leisure time. On an average day, young-old persons spend most of their time (57%) watching television, 18% in solitary activities, and 3% participating in sports, exercise, and recreation.

A patient comes to the clinic reporting a taste disturbance. Which medication is most likely responsible for this disturbance? A. Furosemide B. Phenytoin C. Glyburide D. Heparin

B This is correct. Phenytoin is a medication that has a high incidence of associated taste disturbance.

A 16-year-old boy recently lost his father in a tragic motorcycle accident. In assessing how well this teenager is managing and coping with the death of his father, the nurse should be most alert for which high-priority behavior? A. Exhibiting excessive crying B. Engaging in health-risk behaviors C. Not doing his homework D. Distancing himself from friends

B This is correct. Research shows that bereaved youths who have lost a parent have a high frequency of engaging in health-risk behaviors. The nurse must be alert to these behaviors and make appropriate interventions, as these are of the highest priority.

When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? A. To prevent blood from settling in the head, neck, and shoulders B. To perform these actions more easily before rigor mortis develops C. To set the mouth in a natural position for viewing by the family D. To avoid discoloration caused by blood settling in the facial area

B This is correct. Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patient's eyes and mouth before that time.

The nurse is providing care to the adult client receiving mechanical ventilation who has a tracheostomy. The client has a pulse oximetry reading at 85%, heart rate at 113 beats/min, and respiratory rate at 30 breaths/min. The client has become restless and has labored gurgling respirations. The nurse auscultates bilateral crackles and rhonchi. What is the most appropriate nursing action at this time? A. Call the respiratory therapist for ventilator assessment. B. Provide sterile endotracheal suctioning. C. Provide sterile tracheostomy and stoma care. D. Notify the physician of the client's signs of fluid overload.

B This is correct. Signs that indicate the need for suctioning include restlessness, cyanosis, labored respirations, decreased oxygen saturation, increased heart and respiratory rates, visible secretions in the airway, increased peak airway pressures on the ventilator, decreasing Sao2 or Pao2, and presence of adventitious breath sounds during auscultation.

The nurse is providing care to the client who complains of chest pain after large meals and strenuous exercise. The pain is mild and relieved with rest. What is the most appropriate nursing intervention with this client's pain? A. Immediately administer a vasodilator at the onset of the chest pain. B. Have the client recognize triggers and keep a log of any symptoms. C. Obtain CRP and a venogram to rule out myocardial infarction. D. Prepare the client for emergency cardiac catheterization.

B This is correct. Stable angina is a predictable pattern of ischemic chest pain precipitated by known triggers, such as activity, large meals, temperature extremes, smoking, stimulants, sex, strong emotion, or circadian rhythm patterns. Keeping a log will support the patient in identifying and avoiding triggers.

The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse's plan of care? A. Infants breathe more rapidly than adults. B. Infants' airways are narrower and easily obstructed. C. Infants' lower hemoglobin (HgB) levels reduce oxygenation. D. Infants have enlarged tonsils and adenoids.

B This is correct. The narrower airways mean that the copious secretions caused by the infection could result in airway obstruction, so the plan of care must include mobilizing secretions to maintain a clear airway to allow for adequate oxygenation.

The nurse is interviewing a new client at the community geriatric clinic. The client is in the young-old age range but seems to have multiple issues with pain and physical functioning. The client states, "I have always been active and athletic. Now I hardly feel like doing anything because of pain." Which theory of aging is the nurse likely to apply to the client? A. Genetic theories B. Wear and tear theory C. Cellular malfunction D. Autoimmune reaction

B This is correct. The wear and tear theory proposes that repeated insults and the accumulation of metabolic wastes eventually cause cells to wear out and cease functioning. The client is most likely to have pain and issues of physical functioning from being an athlete and being physically active.

The nurse is providing smoking-cessation counseling to a current smoker with a 20 pack-year history. The client explains that they know a guy who quit smoking by using e-cigarettes. Which of the following is true about e-cigarettes? A. E-cigarettes do not contain the cancer-causing chemicals that other forms of tobacco do. B. E-cigarette use is increasing. C. E-cigarettes and other forms of tobacco can be used simultaneously. D. E-cigarettes are an effective smoking-cessation aid.

B This is correct. There has been a significant increase in the use of e-cigarettes among middle and high school students over the past decade.

The nurse is teaching reproduction to a class of adolescents. In the class, the nurse teaches about what female reproductive organs that become engorged and sensitive during stimulation? Select all that apply. A. Bartholin's glands B. Clitoris C. Labia minora D. Labia majora E. Vagina

B and C This is incorrect. Although Bartholin's glands secrete mucus during sexual arousal, they do not become engorged or sensitive. This is correct. The clitoris becomes engorged and increases in sensitivity during sexual stimulation. This is correct. The labia minora become engorged and increase in sensitivity during sexual stimulation. This is incorrect. The labia majora do not increase in sensitivity or engorge with stimulation. This is incorrect. The vagina does not increase in sensitivity or engorge with stimulation.

A parent expresses concern that their 7-year-old has episodes of nocturnal enuresis approximately three to four times per week. The nurse's best response would be which of the following? Select all that apply. A. "Your child's bladder is still developing at this point in life." B. "Be patient; most children outgrow enuresis." C. "Wake your child every 4 hours to use the bathroom." D. "You might consider purchasing protective pads for the bed." E. "Try a bed alarm when the child starts wetting the bed at night."

B and D This is incorrect. Enuresis is a nighttime incontinence past the stage at which toilet training has been well established and does not involve the development of the bladder. This is correct. As the great majority of children outgrow enuresis, the best strategy is patience. This is incorrect. Most incidents occur during NREM sleep, when the child is difficult to arouse. This is correct. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. This is incorrect. A bed alarm can be used for older children (typically older than age 10 to 12 years) who are resistant to other behavioral strategies.

The nurse is caring for a client in an outpatient setting. The client explains that they don't want the flu vaccination because if they gets influenza, they will just take medications to cure it. Which of the following are correct about influenza? A. Antiviral medications are effective within the first 72 hours of influenza infection. B. The most effective strategy for preventing influenza is vaccination. C. It is important to distinguish influenza and upper-respiratory infection. D. Aspirin is the preferred treatment for influenza symptoms. E. Clients with influenza should cough throughout expiration in several short bursts to clear secretions.

B and C This is incorrect. To be effective, antiviral medications must be started within the first 48 hours after symptoms emerge. This is correct. The most effective strategy for preventing influenza is vaccination. Though less effective in preventing the disease in older adults, immunization decreases the severity of the disease, the development of secondary complications, and the incidence of death. This is correct. Although influenza and upper-respiratory infections have similar presenting symptoms, it is important to distinguish between them because antiviral medications are available for influenza, but are not effective against other upper-respiratory infections. Additionally, the flu can have serious complications. This is incorrect. Over-the-counter medications can be given for influenza and upper-respiratory infections, including fever reducers, antihistamines, decongestants, cough medications, acetaminophen, ibuprofen, or naproxen sodium. Aspirin should not be given to anyone under 19 years of age. It is linked with Reye's syndrome. This is incorrect. Clients with chronic lung disease should exhale through pursed lips and cough throughout expiration in several short bursts to avoid high expiratory pressures, which collapse diseased airways. Influenza is not a chronic lung disease.

Which of the following medications would the nurse expect to be included in the treatment of a client with congestive heart failure (CHF)? Select all that apply. A. Nitrates B. Beta-adrenergic agents C. Anticoagulants D. Diuretics E. Statins

B and D This is incorrect. Nitrates are used to control blood pressure but are not indicated for the treatment of CHF. This is correct. Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the atrioventricular (AV) node, and decrease myocardial oxygen demand by reducing myocardial contractility. This is incorrect. Anticoagulants may be indicated for treatment of cardiac dysrhythmias, not CHF. This is correct. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation. This is incorrect. Anticholesterol (statin) medications would not be used for CHF.

Which statements indicate the nurse has a good understanding of Dr. Elisabeth Kübler-Ross's theory? Select all that apply. A. Patients must pass through each of the five stages of death and dying. B. Kübler-Ross's theory includes psychological responses from the terminal diagnosis to the actual death. C. The nurse's role is to help patients move from one stage to the next, and finally to acceptance. D. Patients may experience two or three stages at the same time. E. Kübler-Ross's theory includes completing one stage and moving on to the next in sequence.

B and D This is incorrect. The theory states that a person may not go through every stage, not that a patient must pass through each of the five stages. This is correct. Kübler-Ross found that people tend to experience one or more of five psychological stages during the period from the terminal diagnosis to the actual death. This is incorrect. Kübler-Ross does not address the nurse's specific role; however, it should be noted that as nurses, it is not our responsibility to move people to the next stage so that the dying patient accepts death. It is the nurse's responsibility to accept and support people "where they are" and help them to verbalize their feelings. This is correct. Kübler-Ross's theory states that patients may experience two or three stages simultaneously. This is incorrect. Kübler-Ross's theory states that patients do not necessarily complete one stage and move on to the next; it can be in random order, not in sequence.

The client tells the nurse, "I've always been able to maintain a steady weight by exercising and watching what I eat, but lately I seem to be steadily gaining weight." The nurse then collects a thorough sleep history. Why will the nurse ask the client about their sleep habits? Select all that apply. A. Lack of sleep causes increased insulin production. B. Lack of sleep reduces activity levels. C. Lack of sleep increases appetite. D. Lack of sleep leads to poor glucose tolerance. E. Lack of sleep reduces total energy expenditure.

B, C, D, and E This is incorrect. Lack of sleep increases insulin resistance, not insulin production. This is correct. Lack of sleep may increase the body's energy output to maintain the body's function. This leads to reduced activity levels to conserve energy. This is correct. Leptin and ghrelin hormone levels (hormones that regulate appetite) are altered with lack of sleep. These are appetite-regulating hormones and altered levels increase appetite. This is correct. Lack of sleep makes the body less able to tolerate glucose and causes greater insulin resistance, leading to weight gain. This is correct. Sleep deprivation leads to reduced energy expenditure.

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply. A. Reduced alveolar-capillary gas exchange B. Lower respiratory tract infections C. Sleep apnea D. Hypertension E. Atherosclerosis

B, C, D, and E This is incorrect. Obesity does not cause reduced alveolar-capillary gas exchange. This is correct. Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. This is correct. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. This is correct. Obesity also increases the risk of developing hypertension. This is correct. Obesity increases the risk of developing atherosclerosis.

A nurse is suctioning a client via an open-system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A. 5 seconds. B. 15 seconds. C. 30 seconds D. 45 seconds.

B This is correct. Hypoxemia and tissue trauma can be caused by prolonged suctioning. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to no longer than 15 seconds.

Which intervention by the nurse is most appropriate when a patient who is dying develops a "death rattle"? A. Turn the patient to the prone position. B. Raise the head of the bed. C. Provide intravenous (IV) fluids. D. Administer pain medication intravenously.

B This is correct. If a "death rattle" occurs, turn the patient to the side, and elevate the head of the bed.

The nurse is preparing client teaching for a client diagnosed with peripheral edema secondary to right-sided heart failure. What intervention will promote circulation and reduce edema in the lower extremities? A. Encourage frequent ambulation. B. Administer antihypertensive medications. C. Encourage vigorous exercise for 30 minutes a day. D. Administer oxygen when the client is short of breath.

A This is correct. Frequent walking will not overtax the client's heart but will provide muscle activity to promote venous return.

A nurse who is trained to insert oropharyngeal airways is inserting an airway in a client to prevent airway obstruction. Which of the following is an appropriate action during oropharyngeal airway insertion? A. Choose an airway length equal to the distance from the earlobe to the front of teeth. B. Recognize that an oropharyngeal airway is appropriate for a conscious client. C. Hyperextend the neck prior to insertion. D. After insertion, tape the airway in place and position the client on their side.

C This is correct. Unless contraindicated, mild hyperextension allows the airway to slide naturally toward the pharynx.

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? A. Otosclerosis B. Conduction deafness C. Presbycusis D. Central deafness

D This is correct. Central deafness results from damage to the auditory areas in the temporal lobe.

The nurse is conducting a case meeting of an older patient in the Alzheimer's unit. The healthcare team is assembled to discuss the family's concerns. The older patient has developed a close relationship with another patient in the facility. It appears that the two have become intimate recently and the family voices concerns that the patient is unable to make decisions regarding this intimate relationship. Which of the following would be an appropriate nursing intervention for this patient? A. Assess whether the client is able to consent to sexual intimacy. B. Assess and transfer one of the clients to another unit. C. Provide privacy for the clients to engage in sexual activities. D. Bring in the other client's family members to discuss this fully.

A This is correct. Although this may be a difficult situation for the family, the relationship may be consensual. If both clients are safe and have a mutual relationship, they may be deemed to have a healthy relationship.

The nurse in a rehabilitation center is providing care to a client who complains of insomnia. The client states that the room is noisy and that they often take naps during the day because they are a "night owl" from working the night shift for several years. The nurse develops a care plan that allows the client to start their rehab therapy later in the day. The nurse administers a sleep aid as prescribed, places a white noise fan in the room, and allows the client to nap during the day when tired. Which of the following would be a priority for this plan? A. Allowing the client to sleep later in the day B. Providing a white noise fan in the room C. Administering a sleep aid as prescribed D. Promoting frequent naps during the day

A This is correct. An individual's circadian rhythm is a biorhythm based on the day-night pattern in a 24-hour cycle. Sleep quality is best when the time at which the person goes to sleep and awakens is in synchrony with their circadian rhythm.

The nurse recognizes that the client with anxiety has the potential for sleep disorders. Which of the following would be an explanation for the physiological factors in this sleep disorder? A. Anxiety increases norepinephrine levels. B. Anxiety can decrease insulin production. C. Anxiety alters the central nervous system. D. Anxiety can cause malfunction of melatonin.

A This is correct. Anxiety can stimulate the sympathetic nervous system and increase the norepinephrine levels.

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? A client whose: A. Resting morning BP is 128/78 mm Hg, whereas the afternoon BP is 122/76 mm Hg B. Oral temperature is 97.9°F (36.6°C) in the morning and 99.8°F (37.7°C) in the evening C. Heart rate is 76 beats/min before eating and 88 beats/min after eating D. Respiratory rate is 16 breaths/min when standing and 18 breaths/min when lying down

A This is correct. Both systolic and diastolic BP would be classified as elevated, and the resting BP is higher than the afternoon BP, so the client would need further observation.

The nurse is providing care to the client who is 3 days status post-cardiac bypass grafting. The client has incisions to their medial right leg from the graft harvest of the saphenous vein. The client complains of warmth and tenderness to their right calf. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the client has what kind of complication? A. Deep vein thrombosis (DVT) B. Dehiscence of the wound C. Internal bleeding D. Infection at the incisional site

A This is correct. DVT is formation of a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratt's sign (squeezing calf to trigger pain) are not reliable in diagnosing DVT.

The nurse had been caring for a patient in a hospice facility for 1 month. When the patient dies, the family invites the nurse to attend the funeral. What is the most appropriate action for the nurse to take? A. Attend the services, if the nurse wishes to do so, as this can help to defuse the nurse's feelings of loss and can be meaningful to the family. B. Ask another nurse for an opinion on this matter, because the nurse's own judgment may not be reliable at this time. C. Do not attend the service, because nurses cannot become attached or overly involved with family members after the death of their patients. D. Be present at the service but stay for only a short period of time, as these occasions are reserved for close friends and family.

A This is correct. If the nurse wishes to do so, it is appropriate to attend calling hours or attend funeral services. This often helps a nurse to defuse some of their own feelings associated with the loss and is very meaningful to family members. It acknowledges that a nurse took the time to remember them and their loved one.

The nurse feels uncomfortable when preparing to assess a patient's sexual health. Which of the following would be most important for a nurse to be able to do during the assessment? A. Recognize and set aside personal biases or experiences related to sexuality. B. Perform an accurate and comprehensive physical assessment. C. Collect an accurate and comprehensive sexual history. D. Acquire theoretical knowledge of sexual health concerns.

A This is correct. In many cultures, people have been socialized to avoid talking openly about sexuality. The nurse must discuss a variety of issues that are vital for a client's optimal wellness. Some of these discussions may include sexual concerns, dysfunctions, infections, or behaviors. As the nurse reflects on the issues of human sexuality, the nurse will be challenged to confront personal biases related to sexuality and to set those aside as while working with clients.

The nurse is caring for a patient with a history of postural hypotension. The nurse obtains a BP reading of 130/80 mm Hg with the patient lying and 100/60 mm Hg with the patient standing. What is the highest priority nursing diagnosis for this patient? A. Risk for falls B. Risk for fatigue C. Risk for dizziness D. Risk for activity intolerance

A This is correct. Orthostatic or postural hypotension occurs when a person's BP drops suddenly on moving from the lying position to the sitting or standing position. Orthostatic hypotension is defined as a decrease of 10 mm Hg in standing BP when associated with dizziness or fainting. With this decrease, the patient is most at risk for falls.

The nurse is providing care to a client in the long-term care facility. The nurse notes that the night-shift staff have reported that the client has been sleepwalking this past week. What is the medical term for this behavior? A. Parasomnias B. Dyssomnias C. Insomnia D. Hypersomnia

A This is correct. Parasomnias are patterns of waking behavior that appear during sleep. Sleepwalking, sleep talking, and bruxism are parasomnias. Sleepwalking is also called somnambulism.

The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient? A. Temperature B. Pulse C. Respirations D. Blood pressure

A This is correct. Temperature regulation is controlled by the hypothalamus; therefore, the nurse would monitor temperature closely. To keep the body temperature constant, the body must balance heat production and heat loss. This balance is controlled by the hypothalamus, which is located between the cerebral hemispheres of the brain.

The nurse analyzes the client's electrocardiogram (ECG) and compares it with a baseline ECG recorded before the client began having chest pain. What finding indicates a problem with the ventricle? A. Prolonged QRS segment B. Elevated P wave C. Absence of T wave D. Prolonged P-R interval

A This is correct. The QRS segment is an indicator of contraction of the ventricle. If there is ischemia to the ventricle, the impulse will travel more slowly, especially if there are damaged or dead cells along the impulse pathway; therefore, the QRS segment would prolonged.

For which client might the nurse use the nursing diagnosis risk for ineffective renal tissue perfusion? A. The client with hypertension who is noncompliant with medication administration B. The client with angina who takes nitroglycerine when experiencing chest pain C. The client diagnosed with pneumonia, becoming short of breath with activity D. The client with a hemorrhagic stroke secondary to head trauma

A This is correct. The client with hypertension who is not taking medications as prescribed can risk damage to the tiny arterioles in the kidneys, resulting in poor renal tissue perfusion. This would be an appropriate diagnosis.

The nurse is preparing the care plan for a middle-aged client admitted to the intensive care unit for acute myocardial infarction (MI). The client's symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate? A. Decreased cardiac output B. Impaired tissue perfusion C. Impaired cardiac contractility D. Impaired activity tolerance

A This is correct. The client's symptoms reflect decreased cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability.

A client's average normal temperature is 98°F (36.7°C). Which temperature would be expected during the night in this healthy, young adult client who does not have a fever, inflammatory process, or underlying health problems? A. 97.2°F (36.2°C) B. 98.0°F (36.7°C) C. 98.6°F (37°C) D. 99.2°F (37.3°C)

A This is correct. The lowest temperature occurs during sleep (usually at night) when metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening.

The wife of a terminally ill client reports recent nightmares and difficulty falling asleep over the past week. The spouse explains she has been worried about her husband's afterlife because he quit going to church with her 10 years ago. The nurse knows that the most appropriate nursing diagnosis for the spouse is: A. Spiritual distress. B. Insomnia. C. Disturbed sleep pattern. D. Sleep deprivation.

A This is correct. The most appropriate nursing diagnosis for the spouse is spiritual distress related to challenges to belief system as evidenced by nightmares, sleep disturbances, and verbalization of inner conflict about belief. This is the most appropriate nursing diagnosis because focusing interventions on spiritual distress would improve her sleep patterns.

The nurse is developing a plan of care for a client admitted following a motor vehicle accident (MVA) who reports regularly sleeping only 2 to 3 hours per night. The client says this is the third MVA they've been involved in this year. The client thinks they might have been asleep when they got into the accident. What is the most appropriate nursing diagnosis for this client? A. Insomnia B. Sleep deprivation C. Disturbed sleep pattern D. Risk for injury

A This is correct. The most appropriate nursing diagnosis for this client is insomnia. Insomnia is a NANDA-I label used for patients who experience a disruption in the amount and quality of sleep to the extent that it impairs functioning. This client has had multiple MVAs related to falling asleep while driving.

The nurse is assessing the 19-month-old client in the family clinic. The mother states that she is concerned that the child doesn't sleep enough, as the child has stopped taking their usual morning nap. What is the nurse's best response to this concern? A. Oftentimes, most toddlers take only one nap per day and require about 11 to 14 hours of sleep in a 24-hour period. B. Oftentimes, most toddlers take at least two naps and need approximately 11 to 16 hours of sleep in a 24-hour period. C. Oftentimes, most toddlers should be sleeping approximately 8 to 10 hours in a 24-hour period. D. Oftentimes, most toddlers need approximately 7 to 9 hours of sleep in a 24-hour period, without any naps.

A This is correct. The nurse should provide reassurance to the mother that a toddler needs less sleep than an infant. By 18 to 21 months, most toddlers take only one nap per day and need a total of 11 to 14 hours in a 24-hour period.

Which nursing interventions are appropriate for a patient who has been admitted with a diagnosis of dehydration and has a temperature of 101.5°F (38.6°C)? Select all that apply. A. Provide oral or intravenous (IV) fluids. B. Take vital signs every 2 hours. C. Contact the provider for respirations of 18 breaths/min. D. Keep the patient on a "nothing by mouth" (NPO) diet until defervescence occurs. E. Increase physical activity level.

A and B This is correct. An elevated temperature can be expected in a patient with dehydration. A temperature of 101.5°F (38.6°C) in an adult will require fluids to replace those lost through diaphoresis. This is correct. A temperature of 101.5°F (38.6°C) in an adult will require monitoring of vital signs at least every 2 hours. The frequency of measuring vital signs may increase if the patient's temperature continues to increase. This is incorrect. The provider should not be notified for respirations of 18 (normal rate). An increase in respirations is expected with an elevated temperature (respiratory rate increases by up to four breaths/min for every 1°F [0.6°C] increase in temperature). This is incorrect. The nurse should encourage the patient to drink fluids, not place the patient on an NPO diet. This is incorrect. Physical activity is limited, not increased.

Which interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply. A. Talk to the patient as you provide care. B. Incorporate touch when providing care, as appropriate. C. Turn on bright, fluorescent light for reading. D. Encourage waiting to drink water until after the meal. E. Offer spicy seasoning for the resident to use on food.

A and B This is correct. Talking to the patient while providing care is not only important for personal and meaningful interaction, but also reduces social isolation and sensory deprivation. This is correct. If the patient consents, you can stimulate the sense of touch by brushing their hair or giving a back rub, for example. However, use touch carefully, considering personal and cultural preferences, while observing the patient's reaction. This is incorrect. Provide enough light, but avoid glare; use soft, diffuse lighting, not bright, fluorescent light. This is incorrect. Teach clients to drink water between bites (not waiting until after the meal) to distinguish the taste of the food more readily. This is incorrect. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods and encourage the client's appetite. But avoid overseasoning food with excessively spicy food that overpowers the person's sense of taste.

Which findings lead the nurse to suspect sensory overload in a patient in the intensive care unit? Select all that apply. A. Disorientation B. Restlessness C. Hallucinations D. Depression E. Preoccupation with somatic complaints

A and B This is correct. The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. This is correct. The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. This is incorrect. Sensory deprivation leads to hallucinations. This is incorrect. Sensory deprivation causes depression. This is incorrect. Sensory deprivation can cause preoccupation with somatic complaints.

The nurse is performing a sleep assessment for a newly admitted client. They say their sleep habits are satisfactory and that they normally feel well rested. What question would the nurse ask next? A. "Would you be willing to complete a sleep diary?" B. "What time do you usually go to bed and awaken?" C. "How many times do you usually awaken?" D. "Do you have trouble falling asleep at night?"

B This is correct. If the client is happy with their sleep habits and feels rested, the nurse only needs to support normal sleep habits and bedtime rituals; therefore, asking when the client goes to bed would be important to meet their needs.

Many older adults suffer from chronic health problems. Which are the most common and costly chronic problems in the older adult? Select all that apply. A. Heart disease B. Diabetes C. Alzheimer's disease D. Pneumonia E. Obesity

A and B This is correct. There are 10 leading causes of death among older Americans. Six of the seven leading causes of death among older adults are chronic diseases; of these, heart disease, cancer, stroke, and diabetes are the most costly health conditions. This is correct. Diabetes is a common and costly health condition in older adults. The condition can be prevented or modified with therapeutic lifestyle changes. However, the cumulative effects of condition over time can be severely damaging. This is incorrect. Alzheimer's disease is, unfortunately, most common in younger or young-old clients. Older clients are more likely to develop age-related dementia. This is incorrect. Pneumonia is a diagnosis that is not exclusive to the older client. Children and adults with chronic obstructive pulmonary disease (COPD) are prone to pneumonia. This is incorrect. Obesity is a condition found across the life span and is not exclusive to the older adult. However, obesity can be a precursor to other diseases and conditions that can worsen over time.

The nurse is providing care to a menopausal patient in the women's health clinic. The patient states she is tired all the time and has frequent hot flashes, and then she asks about the advantages of hormone replacement therapy (HRT). Which of the following are advantages of HRT? Select all that apply. A. HRT is the most effective treatment to relieve symptoms of menopause, such as hot flashes and sleep disturbances. B. HRT decreases the risk of heart and vascular disease, such as arteriosclerosis and myocardial infarctions. C. HRT often prevents loss of bone density (osteoporosis) and leads to fewer hip fractures. D. HRT prevents blood clots and certain cancers, such as breast, ovarian, and colorectal cancers. E. HRT decreases the likelihood of cerebral vascular accidents and dementia.

A and C This is correct. HRT remains the most effective treatment to relieve symptoms of menopause, such as itching, dryness, discomfort with intercourse, hot flashes, and sleep disturbances. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia. This is correct. Prevention of loss of bone density in menopausal women leads to fewer hip fractures. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia.

Which interventions would be appropriate for a client who has a fever? Select all that apply. A. Put an ice pack on the client's neck and axillae. B. Provide the client with several blankets. C. Offer the client fluids to drink every 1 to 2 hours. D. Take the temperature using a tympanic thermometer. E. Place caffeinated drinks by patient's bedside.

A and C This is correct. If ice packs are used, they are applied to the groin, neck, or axillae. This is incorrect. Instruct the client to use minimal bedcovers. This is correct. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. This is incorrect. A tympanic thermometer is prone to errors and is not appropriate when an accurate temperature is needed, as when a client has a fever. This is incorrect. Caffeinated drinks are to be avoided during a fever.

As the nurse caring for a client who has suffered myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Select all that apply. A. Decreased heart rate B. Increased heart rate C. Decreased cardiac output D. Decreased strength of ventricular contractions E. Increased peripheral edema

A and C This is correct. Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. This is incorrect. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. This is correct. Cardiac output will decrease as a result of the decrease in heart rate. This is incorrect. Damage to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart. This is incorrect. Although cardiac output will decrease as a result of the decreased heart rate, there is no indication that this will cause peripheral edema.

For a patient to be eligible for insurance benefits covering hospice care, a physician must certify which conditions? Select all that apply. A. Life expectancy is not more than 6 months. B. Life expectancy is not more than 12 months. C. The condition is expected to improve slightly. D. The condition is not expected to improve. E. The condition is severe and long-term

A and D This is correct. For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient will most likely die within 6 months. This is incorrect. Twelve months is too long of a time period. Hospice care is less than 12 months. This is incorrect. For hospice care, the condition cannot improve, not even slightly. This is correct. For a patient to be eligible for hospice care insurance benefits, a physician must certify that the condition will not improve. This is incorrect. A severe, long-term condition does not qualify for hospice care. Hospice care focuses on holistic care of patients who are dying or debilitated and not expected to improve.

For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which medications may need to be discontinued if the patient is taking them? Select all that apply. A. Furosemide B. Digoxin C. Famotidine D. Aspirin E. Penicillin

A and D This is correct. Furosemide may cause ototoxicity, leading to auditory nerve impairment. This is incorrect. Digoxin does not place the patient at risk for auditory nerve impairment. This is incorrect. Famotidine does not place the patient at risk for auditory nerve impairment. This is correct. Aspirin may cause ototoxicity, leading to auditory nerve impairment. This is incorrect. Penicillin does not place the patient at risk for auditory nerve damage.

The nurse is evaluating the treatment plan for the client with erectile dysfunction (ED). Which statement made by the client indicates treatment was successful? A. "I feel very good about the treatment. I am now comfortable with my sexual orientation." B. "I am happy with the treatment, as I can now maintain an erection through orgasm." C. "Now I can communicate my sexual needs to my partner without embarrassment." D. "I now know how to communicate my sexual desires with my partner."

B This is correct. Men with ED have persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual performance. When the patient is maintaining penile erection through orgasm, this is an indication the interventions were successful.

The nurse practitioner is performing an annual physical examination on a female client who is 86 years old. Which assessments are most important for the nurse to include in the client's examination? Select all that apply. A. Height and weight B. Papanicolaou (Pap) test C. Colon cancer screening D. Gain and balance E. Screening mammogram

A and D This is correct. It is recommended that all older adults have an annual physical examination. The exam for the oldest-old adult should include the same categories as in middle adulthood, as well as screening for mood, cognition, and ability to perform ADLs. Height and weight are measured to screen for osteoporosis, chronic illness, diet, and appetite. This is incorrect. At this time, a Pap test is not generally recommended for women past 65 years of age. This is incorrect. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years. This is correct. Gait and balance are assessed for functional status such as ability to perform ADLs and safety. This is incorrect. Screening mammograms are not recommended for a woman of 86 years of age. However, if pain, lumps, or nipple discharge occurs, a diagnostic test is warranted.

Which of the following is/are accurate about nasotracheal suctioning? Select all that apply. A. Apply suction for no longer than 15 seconds during a single pass. B. Apply suction while inserting and removing the catheter. C. Reapply oxygen between suctioning passes for clients on a ventilator. D. Gently rotate the suction catheter as you remove it. E. This may be delegated to an LPN on the unit.

A and D This is correct. Limiting suctioning to 15 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. This is incorrect. Suction should be applied only while withdrawing the catheter. This is incorrect. Endotracheal suctioning is used when the client is being mechanically ventilated, and most ventilator clients have in-line suctioning, so there is no need to reapply oxygen. This is correct. Suction should be applied only while withdrawing the catheter by using a continuous rotating motion to prevent trauma to the airway. This is incorrect. As a rule, an RN should not delegate tracheostomy or endotracheal suctioning to an LPN or UAP, because both procedures require professional-level theoretical knowledge, assessment skills, and problem-solving ability. Refer to the individual state board of nursing for rules on delegating this procedure.

The nurse is providing care to the client who was sexually assaulted. What is the nurse's best approach for collecting information surrounding the event? Select all that apply. A. Use a calm, reassuring voice when asking questions of the client. B. Ask only close family members to describe events related to the incident. C. Provide privacy by asking questions behind a closed curtain. D. Document the details using the patient's own words. E. Refer the client to the sexual assault support group immediately.

A and D This is correct. Therapeutic communication skills such as the use of a calm, professional approach, will help with the collection of sexual data from the client. These skills will not only help clients to feel more comfortable and confident but will also yield more honest and complete information. This is incorrect. The client might have difficulty discussing the events relating to the assault; however, this is a private matter and not a topic to discuss with family members, regardless of the apparent closeness of the relationship. This is incorrect. When asking personal questions, provide privacy and be sensitive to your client's cues. A curtain is not secure enough because conversation easily could be overheard. This is correct. Clear, unambiguous documentation is extremely important because of the criminal nature of sexual crime. Using the patient's own words is a way for the nurse to avoid misinterpreting the facts as well as to keep from introducing bias or drawing conclusions about the event. This is incorrect. The referral should occur quickly, but the client should not be made to wait for the referral to discuss the rape.

The nurse is assessing a young adult client in the allergy clinic. The nurse recognizes that an allergic reaction will cause which of the following cardiac events? Select all that apply. A. Erythema of the affected areas B. Rhinitis and runny eyes C. Swelling of the area D. Pruritus and hives E. Bradycardia

A, B, C, and D This is correct. Blood vessels dilate in areas affected by the allergen and may be seen as erythema (redness of the site.) This is correct. When eosinophils are attracted to the reaction site, rhinitis (runny nose) may occur. This is correct. Swelling or edema from an allergic reaction would be caused by an increase in the capillary permeability and fluid leakage. This is incorrect. Although this is an allergic reaction, it is not a cardiac event. This is incorrect. The parasympathetic nervous system is not affected by an allergic reaction. Parasympathetic fibers innervate the heart through the vagus nerve, which can result in a slowed heart rate. The sympathetic nervous system may stimulate an increased heart rate in response to the allergen.

What are common reasons that a victim of domestic abuse might not report an incident of sexual assault? Select all that apply. A. Fear that the significant other would be angry if the client reported it and repeat the assault B. Belief that it was the client's behavior that caused the significant other to "lose their temper" C. Idea that the legal system couldn't prosecute the significant other for the assault D. Desire to have the incident behind the client, as if it never happened in the first place E. Financial independence of the client from the significant other

A, B, C, and D This is correct. Reasons for not reporting sexual assault include fear of the assailant, fear of consequences to the assailant, and knowledge of the low conviction rate for perpetrators of assault. This is correct. Reasons for not reporting sexual assault include fear of consequences by the assailant, the desire to avoid a trial, shame and embarrassment, and self-blame. This is correct. Reasons for not reporting sexual assault include knowledge of the low conviction rate for perpetrators of assault, the desire to avoid a trial, and past sexual history. This is correct. Reasons for not reporting sexual assault may include the desire to "move on" and not face possible consequences involving pregnancy and sexually transmitted infection. This is incorrect. Many abused individuals are either emotionally or financially dependent on their partners and believe that staying in the relationship is their only option. If a client is financially independent from their significant other, this status would not be a common reason for the client to not report an incident of sexual assault.

A 2-year-old boy has come to the well-child clinic with his mother for a checkup. When the nurse asks his mother whether she has any concerns, the mother expresses concern that her son often touches his genitals. She says, "I have tried sitting him in a chair, smacking his hand, and telling him no, but he continues to do this. I just don't know how to make him stop." Which of the following would be the nurse's most appropriate responses to address the mother's concerns? Select all that apply. A. "Give him a little time. The first two years of a child's life are a time for them to explore their bodies. He'll grow out of it." B. "How often do you punish him by giving him a time-out or by using physical discipline?" C. "Physical punishment, such as smacking his hand, is not the best way to modify a child's behavior." D. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body." E. "Perhaps he needs something to do. Have you tried distracting him with new toys and other activities?"

A, B, C, and D This is correct. The first 2 years of life are highly sensual as infants are nursed, stroked, bathed, and massaged, and they develop their first attachment experience through bonding with the mother. It is not unusual for infants and preschoolers to fondle their genitals and enjoy being nude. This is part of their exploration of their bodies, and parents should not overreact. This is correct. Although health teaching about normal sexual development of toddlers is important, this mother's comments are a red flag with regard to appropriate discipline. Her exaggerated response using physical reprimands to a 2-year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternative methods of dealing with the behavior. This is correct. The mother's exaggerated response using physical reprimands to a 2-year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternate methods of dealing with the behavior. This is correct. This statement explains normal childhood behaviors and may alleviate the mother's concerns. This is incorrect. This may reinforce the mother's concerns that this is not a normal behavior.

Which areas would the nurse include in a mental status assessment for an adult patient? Select all that apply. A. Behavior B. Judgment C. Knowledge D. Reflexes E. Appearance

A, B, C, and E This is correct. Behavior is included in the mental status assessment. This is correct. Judgment is included in the mental status assessment. This is correct. Knowledge is included in the mental status assessment. This is incorrect. Assessment of reflexes is associated with a complete and in-depth neurological assessment. This is correct. Appearance is part of the mental status assessment.

Which medical conditions have a direct effect on sensory function, contributing to sensory deficits? Select all that apply. A. Diabetes B. Hypertension C. Multiple sclerosis D. Breast cancer E. Zinc deficiency

A, B, C, and E This is correct. Diseases that affect circulation may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. Diabetic retinopathy is the leading cause of blindness among adults aged 20 to 74. This is correct. Hypertension can damage the retina of the eye. This is correct. Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. This is incorrect. There is no indication that breast cancer leads to sensory deficits. This is correct. Zinc deficiency can cause anosmia, which is reduced sense of smell.

The nurse suspects that an older adult patient may have difficulty hearing. Prior to validating a hearing problem, which strategies does the nurse use in communicating with this patient? Select all that apply. A. Look directly at the patient when speaking. B. Pace speech more slowly than usual. C. Speak loudly toward the patient's ears. D. Allow some extra time for the patient to respond. E. Rely on body language more than usual.A,

A, B, D, and E This is correct. Many normal changes of aging affect communication with older adults. However, do not assume that all older adults are deaf or that they do not understand the meaning of your communication. Check for sensory deficits at the beginning of your interaction. Until you know there is no hearing deficit, look at the patient as you speak to allow for lip reading. This is correct. Older adults tend to process information more slowly, so speak slowly and clearly. This is incorrect. Speaking loudly into the older adult's ears may or may not be helpful. When an older adult has hearing issues, it is more effective to use a deeper tone at a normal volume. This is correct. Older adults may or may not have hearing problems, but they may process information more slowly. The nurse needs to give the older adult more time to process and form an answer. This is correct. If the nurse suspects a hearing deficit, it is helpful for the nurse to rely on body language more than usual.

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply. A. Place personal objects where the patient can see them. B. Introduce yourself each time you have contact with the patient. C. Encourage the patient to relax while the nurse gives the bath. D. Encourage the patient to participate in familiar activities. E. Do not offer many choices when it comes to activities of daily living (ADLs).

A, B, D, and E This is correct. Place personal objects, photos, and mementos in the immediate environment, and discuss them with the client. This is correct. Introduce yourself and state the client's name each time you meet with them; wear a readable (large, plain type) nametag to reinforce your introduction. Also identify the day, date, and time as you interact. This is incorrect. While you may sometimes find it necessary to bathe the patient, that intervention wouldn't be expected to improve orientation. Furthermore, encouraging the patient to relax would likely be ineffective in relaxing the patient, and might even elicit anger. This is correct. Encourage the patient to participate in familiar activities, such as bathing. This is correct. To promote orientation for a patient with confusion (e.g., dementia), use simple communication and offer few choices with ADLs to prevent overwhelming the patient.

Which populations are considered to be at high risk for sensory deprivation? Select all that apply. A. The homebound B. Those in prison C. Those who are depressed D. Those experiencing high anxiety E. Those feeling pain

A, B, and C This is correct. A nonstimulating, monotonous environment increases the risk for sensory deprivation, such as in people who are homebound. This is correct. Individuals in prison are at risk for sensory deprivation due to being in an isolated environment. This is correct. Patients with depression are at risk for sensory deprivation, as they might be withdrawn from others and activities or less apt to interact within the usual context of their lives. This is incorrect. Patients with anxiety often experience sensory overload. This is incorrect. Pain lowers the threshold for processing sensory input, which increases the risk for sensory overload.

The nurse works as a home-visiting nurse for older adults. Which risk factors for physical abuse of this population does the nurse recognize? Select all that apply. A. Socioeconomic status below the poverty level B. Residence in low-income housing C. Physical and mental impairment D. Frequent visits to respite care E. Deterioration as a young-old person

A, B, and C This is correct. Elder abuse is seen in all cultures and socioeconomic groups, but risk for physical abuse increases in clients who are of low income status. This is correct. Older adults who live in inadequate or unsafe housing are at greater risk for physical abuse. This is correct. Older adults who have physical, functional, or cognitive impairment; who experience mental illness, alcoholism, or drug abuse (in either the client or caregiver); or who are dependent on others are at greater risk for physical abuse. This is incorrect. Frequent visits to respite care do not increase the risk for physical abuse and, in fact, may be a determent. This is incorrect. Deterioration as a young-old person does not necessarily place the client at greater risk for physical abuse.

The home health nurse is developing a plan of care for a client who is 76 years of age. Which primary nursing goals does the nurse include in the plan of care? Select all that apply. A. Maintain the patient's independent functioning as much and for as long as possible. B. Teach the patient and caregivers how and when to call for professional help. C. Arrange for appropriate care and equipment that is needed in the home. D. Teach the patient and family strategies to reduce caregiver role strain. E. Provide information about community activities of interest to the older adult.

A, B, and C This is correct. Nursing goals for all older adults should be to maintain the person's ability to function as independently as possible for as long as possible. This is correct. A nursing goal for all older adults needs to include information about when clients and caregivers need to call for professional help and how they can reach the appropriate professional. This is correct. A nursing goal for all older adults is to arrange for appropriate care and equipment, as needed. This is incorrect. One cannot assume that there will be caregiver role strain or that the patient needs home care. Additionally, this is not a nursing goal for all older adults. This is incorrect. Providing information about community activities of interest to the older adult is not an appropriate nursing goal and may not be appropriate for all older adults.

A client is concerned about the age-related changes of their mother, who is 80 years old. Which statements made by the client likely represent a normal change of aging? Select all that apply. A. "My mother seems to get cold very easily." B. "My mother complains of her mouth being dry." C. "My mother goes around the house turning on all the lights." D. "My mother complains of urine leaking when she coughs." E. "My mother will only eat the food she personally prepares."

A, B, and C This is correct. The thinning of the layers of skin causes older adults to feel cold; this is a normal part of aging. With aging, the brown fat layer, which contributes to generating and maintaining body temperature, becomes thinner as well. This is not the same type of fat as adipose, which is a white fat layer. Additionally, older adults who are sedentary often feel cooler. This is correct. The elderly normally experience a decrease in saliva production, so although this is also a symptom of dehydration, dry mouth is a normal change of aging. This is correct. Visual acuity decreases with age; this is a normal part of aging. Brighter lighting helps with this problem. This is incorrect. Incontinence is not a normal part of aging and should be explored further. This is incorrect. Aging does not include a reluctance to eat food prepared by others; this behavior warrants exploration.

The nurse is assessing the client with a history of chronic obstructive pulmonary disease (COPD). At this time, the client's pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply. A. Normal urine output B. Strong peripheral pulses C. Clear breath sounds bilaterally D. Pink mucous membranes E. Abnormal muscle twitching

A, B, and D This is correct. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). This is correct. To determine adequacy of tissue oxygenation, the nurse should assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. This is incorrect. Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed. This is correct. Adequate oxygenation is demonstrated by activity tolerance, oxygen saturation, and mucous membrane color. This is incorrect. This is an indication of hypocarbia (hypocapnia)—a low level of dissolved carbon dioxide in blood—not oxygenation.

The nurse is providing care to the older adult client who complains of sleep issues. Which of the following statements are factors that may help resolve the client's sleep issues? Select all that apply. A. "I use a fan on low to help me sleep." B "I take my thyroid medicine every morning." C. "I have had Parkinson's disease for over 10 years." D. "I have 4 beers a night to help me sleep." E. "I take a small dose of melatonin to help me sleep."

A, B, and E This is correct. White noise machines may facilitate sleep. This is correct. Although this needs more information, because many disease processes, such as hyperthyroidism, can negatively affect sleep patterns, proper adherence to the medication regime may facilitate sleep. This is incorrect. Disease processes, such as Parkinson's disease, may negatively affect sleep patterns. This information does not help resolve the client's sleep issues. This is incorrect. Alcohol use is an example of a lifestyle factor that negatively affects sleep. Alcohol use does not help resolve sleep issues. This is correct. Often, older adults have decreased production of melatonin. Taking a supplemental dose at the correct time of day may facilitate sleep.

The nurse is assessing the client's home medication and notes that although the client denies hypertension, there are several antihypertensive medications. Which of the following medications lower blood pressure? Select all that apply. A. Atenolol B. Digoxin C. Lisinopril D. Nifedipine E. Warfarin

A, C and D This is correct, beta blockers, such as atenolol, control blood pressure. This is incorrect. Cardiac glycosides, such as digoxin, are used to control cardiac rhythm, not blood pressure. This is correct, angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, are used to control blood pressure. This is correct. Calcium channel blockers, such as nifedipine, may control blood pressure. This is incorrect. Anticoagulants, such as warfarin, do not control blood pressure.

The nurse is assessing an older female patient in the clinic, when the patient states that she is having issues with sexual intercourse due to lubrication. The nurse begins to use the PLISSIT model as the guideline for counseling for sexual problems. Which of the following are examples of the components of the PLISSIT model? Select all that apply. A. "Some women experience decreased vaginal lubrication after menopause. Tell me how well you have been lubricating." B. "Should your sexual partner be in the room to further discuss this issue and find some methods to help you?" C. "Some women experience decreased vaginal lubrication because of decreased hormone levels." D. "Some women have found that using a water-soluble lubricant prior to sexual intercourse to be helpful." E. "I will send this information to your gynecologist for you to further discuss possible treatments."

A, C, D, and E This is correct. This is the permission component of PLISSIT. By using an open, accepting attitude, the client may feel free to ask open-ended questions. This is incorrect. This implies that the client is comfortable discussing sexual issues with her partner. This is correct. This is the limited information component. Supplying limited information may include teaching normal sexual functioning and expected changes in sexual functioning. This is correct. Specific suggestions for self-care may facilitate sexual health. This is correct. Intensive therapy may be the next step if the client's concerns are not relieved.

The nurse is counseling a 17-year-old client on smoking cessation. The nurse should include which of the following helpful tips in their education? Select all that apply. A. "Keep healthy snacks or gum available to chew instead of smoking a cigarette." B. "Don't tell anyone that you are trying to quit until you are confident of your success." C. "Plan a time to quit when you will not have many other demands or stressors in your life." D. "Reward yourself with an activity you enjoy when you quit smoking." E. "Ask your physician for a prescription for smoking-cessation medications."

A, C, and D This is correct. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. This is incorrect. People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. This is correct. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. This is correct. Self-reward for meeting goals is a form of positive reinforcement. This is incorrect. If the above-mentioned interventions do not work, then the client might consider a medication.

Which of the following are considered sexual response cycle disorders? Select all that apply. A. Arousal disorder B. Dysmenorrhea C. Orgasmic disorder D. Low libido E. Retrograde ejaculation

A, C, and D This is correct. Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle. These disorders affect desire, arousal, excitement, and orgasm. This is incorrect. Dysmenorrhea is painful menstruation caused by strong uterine contractions that cause ischemia of the uterus. This may prevent sexual intercourse but is not a sexual response cycle disorder. This is correct. Orgasmic disorders affect the sexual response cycle. This is correct. Low libido affects the sexual response cycle. This is incorrect. Retrograde ejaculation may be considered an arousal or orgasmic disorder.

Which of the following factors influence normal lung volumes and capacities? Select all that apply. A. Age B. Race C. Body size D. Activity level E. Environment

A, C, and D This is correct. Normal lung volumes and capacities vary with body size, age, and exercise. This is incorrect. Normal lung volumes and capacities vary with body size, age, and exercise. Race does not influence normal lung volumes and capacities. This is correct. Normal lung volumes and capacities vary with body size, age, and exercise. Volumes and capacities are higher in men, in large people, and in athletes. This is correct. Normal lung volumes and capacities vary with body size, age, and exercise. Volumes and capacities are higher in athletes. This is incorrect. Normal lung volumes and capacities vary with body size, age, and exercise. Although environmental factors such as altitude, air quality, and stress can affect oxygenation, it does not correlate with lung volumes and capacities.

What are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply. A. Increases socialization B. Increases blood pressure C. Decreases pain D. Decreases loneliness E. Decreases insomnia

A, C, and D This is correct. Pet therapy has been shown to increase socialization in residents in long-term care facilities. This is incorrect. Pet therapy decreases blood pressure. This is correct. Pet therapy is known to decrease pain in residents of long-term care facilities. This is correct. Pet therapy is known to decrease loneliness in residents of long-term care facilities. This is incorrect. There is no evidence supporting insomnia is decreased in residents participating in pet therapy.

The nurse is preparing to teach an older woman strategies to reduce the risk of osteoporosis. Which interventions does the nurse include as part of the teaching plan? Select all that apply. A. Begin a daily walking regimen. B. Take supplemental hormones. C. Avoid cigarette smoking. D. Increase calcium in the diet. E. Start non-weight-bearing exercises.

A, C, and D This is correct. The risk for osteoporosis increases with age and is much greater for women, in part because of their decreased bone density compared with that of men. Weight-bearing activity, such as walking, will stimulate bone density. This is incorrect. There is some controversy around the use and overuse of hormone supplements, and their use is not necessarily recommended. This is correct. Cigarette smoking increases the risk for osteoporosis, and women need to become nonsmokers early in adult life to decrease the risk. This is correct. An adequate dietary intake of calcium is an important way to decrease the risk of osteoporosis; however, women should take calcium supplements in addition to dietary calcium early in adult life. This is incorrect. Non-weight-bearing exercises are not helpful for reducing the risk of osteoporosis. It is the bone stimulation from weight-bearing activities that increases bone density.

A client who lives alone is very weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. Their personal hygiene is poor. The client moves very slowly even during performance of small tasks, such as eating a meal. Which are appropriate interventions for this patient? Select all that apply. A. Arrange for a home aide to assist with activities of daily living (ADLs). B. Refer the client to a senior center for an adapted physical activity (APA) program. C. Assess the patient for symptoms of depression and memory loss. D. Arrange for nutritious meals to be delivered to the patient's home. E. Make arrangements for admission into an assisted-care facility.

A, C, and D This is correct. This client has the characteristics of frailty: low physical activity, muscle weakness, fatigue, and slowed performance. Clearly, the client is not able to perform ADLs adequately; therefore, a home aide is needed. This is incorrect. Adapted physical activity (APA) programs are designed for adults in better physical health, not for frail elders. The client would be unlikely to benefit from an APA program and probably could not even participate in such a group activity. This is correct. Depression and impaired mental abilities tend to accompany frailty, so it is important to assess those for this client. This is correct. Nutrition is essential to slow the progression of frailty, so having meals delivered is both appropriate and important. This is incorrect. The nurse needs to implement measures to improve the client's condition and living needs. At some point, admission into an assisted-care facility may need to be discussed; however, it is not appropriate for the nurse to independently begin the process.

The nurse assesses a client diagnosed with pneumonia. Which data findings indicate that the client is not oxygenating adequately? Select all that apply. A. Oxygen saturation 87% B. Arterial blood gas pH 7.33 C. Respiratory rate 52 breaths/min D. Fine rales in the left lower lobe E. Cyanosis of the nail beds and lips

A, C, and E This is correct. An oxygen saturation of 87% is below the accepted range and indicates inadequate oxygenation. This is incorrect. A pH of 7.33 indicates acidosis, but further information is needed to determine whether the cause is respiratory or metabolic. A respiratory acidosis indicates poor gas exchange, but oxygenation may be adequate with inadequate carbon dioxide exchange. This is correct. A respiratory rate of 52 breaths/min does not allow adequate time for gas exchange and would contribute to a finding of inadequate oxygenation. This is incorrect. Fine rales indicate an altered airway, but this finding alone is not adequate for indicating lack of oxygenation. This is correct. Cyanosis is caused by lack of oxygen to the tissues and is a good indicator of inadequate oxygenation.

Which factors in a patient's health history place them at risk for hearing loss? Select all that apply. A. Being an older adult B. Childhood chickenpox C. Frequent otitis media D. Diabetes mellitus E. Congenital rubella

A, C, and E This is correct. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. This is incorrect. Chickenpox does not place the patient at risk for hearing loss. This is correct. Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. This is incorrect. Diabetes mellitus does not place the patient at risk for hearing loss. This is correct. Sensorineural deafness, eye abnormalities, and congenital heart disease are the classic triad that occurs with congenital rubella.

The nurse is preparing to teach a group of adolescent male students about testicular self-exams. Which of the following would be an indication that the teaching was effective? A. Monthly exams are necessary for early detection of lumps in the testicle. B. Monthly exams for any changes in the testicle are a personal preference. C. Monthly exams are not warranted if both testicles have not fully descended. D. Monthly exams are not necessary once the male has become sexually active.

B This is correct. Monthly exams are a personal preference; checking for lumps after puberty is a good idea to detect changes in the testicles.

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating? A. Chemoreceptors B. Photoreceptors C. Proprioceptors D. Mechanoreceptors

B This is correct. Photoreceptors located in the retina of the eyes detect visible light.

The nurse is assessing the client in the family clinic, who asks about the difference between rest and sleep. Which of the following statements would explain the main difference between sleep and rest? A. In sleep, the body may respond to external stimuli. B. Short periods of sleep do not restore the body as much as short periods of rest. C. Sleep is characterized by an altered level of consciousness. D. The metabolism slows less during sleep than during rest.

C This is correct. During rest, the mind remains active and conscious; sleep is characterized by altered consciousness.

Which set of vital signs are all within normal limits for patients at rest? A. Infant: Temperature (T) 98.8°F (37.1°C) (rectal); heart rate (HR) 160; respiratory rate (RR) 16; blood pressure (BP) 120/54 mm Hg B. Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg C. Adult: T 99.6°F (37.6°C) (oral); HR 48; RR 22; BP 130/84 mm Hg D. Older adult: T 98.6°F (37°C) (oral); HR 110; RR 28; BP 170/100 mm Hg

B This is incorrect. The infant's temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. HR for an infant is normal, RR is low, and BP is high for the age. This is correct. All of the adolescent's vital signs are within normal parameters for the age. This is incorrect. For the typical adult, the temperature is high, HR is low, RR is high, and BP is elevated for the age. This is incorrect. For the older adult, the temperature is high-end normal, HR is high, RR is high, and BP is high for the age.

On postoperative day 1, a client has a temperature of 36.8°C. What is the nurse's next best action? A. Contact the primary care provider for guidance. B. Document the temperature, and continue with nursing care. C. Administer the prescribed antipyretic medication. D. Instruct the client to drink more fluids.

B This is incorrect. The primary care provider does not have to be contacted for a normal temperature. This is correct. The temperature of 36.8°C is equivalent to 98.2°F. This is a normal temperature for a postoperative client. To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. Because this is a normal temperature, no change in action is needed. The nurse should compare this reading with the previous temperature reading and document the temperature in the medical records. This is incorrect. The client's temperature is not elevated and should not require antipyretic medication. This is incorrect. Since the client's temperature is not elevated, extra fluids are not needed.

The emergency room nurse cares for a patient experiencing severe abdominal pain. When the nurse addresses the patient with the pronoun he, the patient quickly corrects the nurse, saying, "I do not identify with a specific gender." Which of the following statements is accurate regarding this patient's gender identity? A. The patient is transgender. B. The patient is gender nonbinary. C. The patient is cisgender. D. The patient is in gender transition.

B This is correct. A person who identifies as gender nonbinary does not identify with a specific gender.

The nurse is providing teaching to the client who comes to the sleep clinic. The nurse instructs the client to start a sleep diary. What is the rationale of using a sleep diary? A. Identify sleep-rest patterns over a 1-year period. B. Note the trend in sleep-wakefulness patterns over a 2-week period. C. Note typical sleep habits and most common daily routines. D. Examine the preparation, preferences, and routines surrounding sleep.

B This is correct. A sleep diary provides specific information about the client's sleep-wakefulness patterns over a certain period. It allows identification of trends in sleep-wakefulness patterns and associates specific behaviors interfering with sleep. The diary is typically kept for 14 days.

The nurse is assessing an adult client diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues? A. Blood pressure reading of 102/64 mm Hg B. Absence of hair on the lower legs and feet C. Pulse rate of 104 beats/min D. Shortness of breath when supine

B This is correct. Absence of hair on the lower extremities is an indicator of poor perfusion because hair growth requires adequate gas exchange.

The nurse teaches a class for new parents promoting safe sleep for infants. The nurse determines a participant understood the important safety points when they make which statement? A. "I will gently lay my son down on his back with a soft pillow to support his head." B. "I will put my son on a firm crib mattress on his back and remove all padding." C. "I will position my son to sleep on his stomach." D. "I will have my son sleep in my bed so I can be sure he is safe at night."

B This is correct. According to the American Academy of Pediatrics, it is safest for infants to sleep positioned on their back on a firm surface with no soft padding (e.g., stuffed animals, blankets, or pillows).

Which patient is at most risk for experiencing difficult grieving? A. The middle-aged woman whose grandmother died of advanced Parkinson's disease B. A young adult with three small children whose wife died suddenly in an accident C. The middle-aged person whose spouse suffered a chronic, painful death D. An older adult whose spouse died of complications of chronic renal disease

B This is correct. Although it is impossible to predict with certainty and the grieving process is highly individual and personal, those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death.

The nurse is reviewing the results of the client's laboratory findings and notes an elevated C-reactive protein (CRP) level. What does this indicate? A. The client had a myocardial infarction. B. The client has inflammation in the body. C. The client has reduced cardiac output. D. The client's diet is high in cholesterol.

B This is correct. An elevated CRP level indicates the presence of inflammation in the body. This may, but does not necessarily, include arterial inflammation or a myocardial infarction.

The nurse is providing discharge teaching to a client diagnosed with hypertension and atherosclerosis. The nurse knows that all of the following teaching points are accurate, except: A. Yoga may decrease heart rate and improve blood pressure. B. As the body ages, cardiovascular decline is expected and cannot be controlled. C. Consuming a diet low in fat, cholesterol, and sodium can support cardiovascular health. D. Even small amounts of tobacco can increase cardiovascular risk.

B This is correct. Cardiac efficiency gradually declines as the body ages. However, endurance training and regular exercise slow the rate of these changes. Additionally, cardiovascular decline can be slowed by modifying diet, stress, proper nutrition, and smoking cessation.

The nurse is caring for four clients on a well-staffed medical-surgical unit. Of the four clients, which is likely to have the best lung function and lowest risk for acute lung complications? A. 24-year-old client 1 day post-op who diligently uses the incentive spirometer B. 62-year-old client who is awaiting discharge who walks 2 miles each morning C. 34-year-old client smoker who is 2 days post-op D. 16-year-old client visitor who is overweight and does not exercise regularly

B This is correct. Endurance training and regular exercise minimize the rate of respiratory system changes. This client, although in their 60s, is likely physically conditioned by regular exercise. They are also awaiting discharge, indicating that they are less likely than the other clients to experience acute lung complications.

While admitting a young adult male into the family health clinic, the nurse asks about his occupation. The patient appears embarrassed and says, "You're going to think I'm lazy, but I stay home with our young children while my wife works." The nurse recognizes this patient is experiencing what type of conflict? A. Sexual confusion B. Gender role C. Gender identity D. Sexual orientation

B This is correct. Gender roles are those behaviors society identifies as being male or female. This patient indicates conflict over being male and being the nurturer in the family instead of the breadwinner.

An 85-year-old client is admitted through the emergency department for confusion and disorientation. The family states, "We don't know what is wrong. He has been fine at home. This confusion just started 2 days ago and seems like it is getting worse." What is the most appropriate first response for the nurse to make? A. "We will have to place him in temporary restraints for safety purposes." B. "Can you tell me about his home medications and other illnesses he has?" C. "Sometimes older people become more confused when they are away from home." D. "He is 85 years old, and this is the age when Alzheimer's disease begins."

B This is correct. Polypharmacy is a risk factor for acute confusion, delirium, and depression in older adults, and there is growing research in the area of pharmacogenomics. In this item, the first and most appropriate response by the nurse is to ask about medications and other health issues that could be causing or contributing to the confusion.

The nurse is obtaining vital signs on a newborn and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse? A. Apply oxygen immediately. B. Document the finding while continuing the assessment. C. Contact the obstetrician for orders. D. Compare the finding with other infants in the nursery.

B This is correct. The developmental level of the newborn is consistent with the respiratory rate obtained, so the nurse would continue the assessment. A newborn's respiratory rate usually ranges from 40 to 60 breaths/min. Some references give an upper limit of 90 breaths/min.

The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? A. Review and implement the primary care provider's prescriptions for treatments. B. Perform a quick physical examination of breathing, circulation, and oxygenation. C. Gather a thorough medical history, including current symptoms, from the family. D. Administer supplemental oxygen to the client through a nasal cannula.

B This is correct. The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation to determine the most appropriate intervention. The nurse's assessment should focus on current symptoms.

The nurse is preparing education for the prepubescent female client on her menstrual cycle. Which of the following statements best explains the portion of the cycle when the ovum is released? A. Fertilization B. Follicular phase C. Luteal phase D. Menstrual phase

B This is correct. The follicular phase occurs when the ovarian follicles mature until the ovum is released.

A healthy client who is 80 years of age sees the nurse practitioner at the doctor's office. The client states, "I sit around a lot, and now I notice my legs seem to get tired when I walk." Which is the most appropriate response by the nurse? A. "This indicates you don't have as good circulation as you did when you were younger." B. "How do you feel about joining a regular exercise program at the senior center?" C. "You will need to speak to the doctor about this; your age may cause health problems." D. "Have you thought about using a cane or a walker to help you get around better?"

B This is correct. The most appropriate response by the nurse in this item is to address the fact that weakness is most likely the result of a sedentary lifestyle. The developmental challenge of middle-old persons is an increasingly solitary, sedentary lifestyle. This age group spends one-fourth of their leisure time in solitary activities, such as reading, relaxing, and thinking. They spend only 3% of their time participating in sports, exercise, and recreation.

Which patient goal is most appropriate when managing the patient dying of cancer? A. The patient will request pain medication when needed. B. The patient will report or demonstrate satisfactory pain control. C. The patient will use only nonpharmacological measures to control pain. D. The patient will verbalize understanding that it may not be possible to control the pain.

B This is correct. The most important goal is that the patient will report or demonstrate satisfactory pain control.

The nurse administers two BP medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took the BP." What is the most appropriate response by the nurse? A. "Take it again so that we can be sure nothing else is wrong with the patient." B. "I need to check the patient's response to the BP medications." C. "If BP drops too much, I'll need to discontinue one of the medications." D. "If you just took the BP, then recheck it in 2 hours instead."

B This is correct. The nurse must evaluate the effectiveness of the BP medications and also unintended effects, such as too great a fall in BP. This effect may be intended, as with antihypertensive medications, or unintended, such as the drop in BP that often results when a patient receives pain medication.

A patient's wife has told nurses that she wants to be with her husband when he dies. The patient's respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? A. "Certainly, go ahead. Your husband will most likely hold on until you return." B. "Your husband could live for days or a few hours. You can do whatever you are comfortable with." C. "I'll stay continuously at his bedside while you are gone." D. "Don't worry. Your husband is in good hands. I'll look out for him."

B This is correct. The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband's bedside.

The nurse is assessing a client and asks if they have any chronic stress. The client wants to know how chronic stress affects the body. The nurse responds that when the body is under stress, it releases a chemical that increases the heart rate and the tendency of the blood to clot. Which of the following chemicals is the nurse discussing? A. Histamine B. Catecholamines C. Cortisol D. Protease

B This is correct. The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot.

The nurse assesses a patient's medical history in a gynecology office prior to admission. As the nurse prepares the patient for a female examination, the client confides about a form of cultural practice that she has been subjected to that is illegal in the United States. What is the name of that form of cultural practice? A. Genitalia piercing B. Hysterectomy C. Female circumcision D. Transgender surgery

C This is correct. Female circumcision, or female genital mutilation, is considered atypical and is illegal in many countries, including the United States.

The nurse is discussing workplace issues with a 35-year-old client. The client tells the nurse that his boss requires him to massage her shoulders. His boss also rubs his legs, thighs, and genitals. He further states that he does not want to upset her because he needs the job. Which statement best applies to this situation? A. The male is receiving sexual satisfaction from having his legs, thighs, and genitals massaged. B. This is an example of quid pro quo sexual harassment and should be reported to a supervisor. C. This is an example of a hostile work environment and sexual harassment and should be immediately reported to a supervisor. D. This is not a situation of harassment because no sexual intercourse has occurred, and the client can refuse.

B This is correct. This is an example of quid pro quo sexual harassment—the employer makes the employee feel that he must engage in unwelcome sexual advances to maintain employment.

A nurse is preparing to obtain a sputum specimen from an adult client. Which of the following nursing actions will facilitate obtaining the specimen? A. Limiting fluid intake prior to collection B. Having the client take deep breaths C. Asking the client to spit into the collection container D. Asking the client to obtain the specimen after eating

B This is correct. To collect sputum, the client should breathe deeply for three or four breaths, and then, after a full inhalation, hold the breath and cough. The client should then expectorate directly into the specimen container.

The nurse is teaching the client about foods that promote sleep versus those that may disrupt sleep. Which diet chosen by the client demonstrates understanding of foods that promote sleep? A. Hamburger, fried potatoes, and a milkshake B. Turkey fettuccine, whole wheat bread, and a glass of milk C. Chicken salad sandwich, pineapple salad, and a diet cola D. Fish, broccoli, applesauce, and a cup of tea

B This is correct. Turkey, pasta, whole wheat bread, and milk (presuming the client is not lactose intolerant or gluten sensitive) contain L-tryptophan and carbohydrates that may help to promote sleep. Carbohydrates found in fruit also promote relaxation.

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient's carotid pulse, careful technique must be followed to prevent which response? A. Increase in heart rate B. Decrease in heart rate C. Increase in blood pressure D. Irregular heart rhythm

B This is correct. When assessing for a pulse using palpation of the carotid artery, it is important to palpate only one side of the neck at a time. Additionally, palpation should be light and the nurse must avoid massaging the area. Massaging the carotid can create a Valsalva response, causing a decrease in heart rate and blood pressure.

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. A. Rhythm of the pulses B. Strength of the pulses C. Bilateral equality of pulses D. Rate compared with apical pulse E. Intervals between heartbeats

B and C This is incorrect. Rhythm of the pulses refers to rhythm, not quality. This is correct. The quality of a pulse refers to the pulse volume (strength). This is correct. The quality of a pulse refers to the bilateral equality of the pulses. This is incorrect. The rate compared with apical pulse is the apical-radial pulse, not quality. This is incorrect. Intervals between heartbeats indicate rhythm.

Which warning signs would indicate that a child needs professional help after the death of a loved one? Select all that apply. A. Interested in usual activities B. Extended regression C. Withdrawal from friends D. Inability to sleep E. Intermittent sadness

B, C, and D This is incorrect. A warning sign would be a loss of interest in daily activities, not interest in usual activities. Remaining interested in usual activities is a sign of coping. This is correct. A warning sign in children is extended regression. This is correct. Withdrawal from friends is a warning sign in children. This is correct. A warning sign in children is inability to sleep. This is incorrect. Intermittent expressions of sadness and anger are to be expected, even over a long period of time, so this would not indicate a need for professional help.

Nurses frequently encounter death of patients in many healthcare settings. What are some strategies nurses can use to better care for themselves when dealing with death and the dying? Select all that apply. A. Remain detached and unemotional when working with dying patients. B. Talk with colleagues about feelings related to death and dying. C. Use relaxation and focus on peaceful thoughts. D. Understand own feelings about death and dying. E. Suppress grieving when patients die.

B, C, and D This is incorrect. When nurses become involved with dying persons and their families at such an intimate time in their lives, nurses become connected to them. There is nothing wrong with this emotional involvement; it helps nurses be effective in their work. This is correct. Nurses should talk with other colleagues about feelings. Don't be afraid to ask for what is needed. This is correct. When away from work, do some nice things, like taking time for relaxing and a little "pampering" (e.g., a bubble bath or a massage). This is correct. When caring for dying patients, nurses will confront their own feelings of mortality. It is important to understand your own attitudes, fears, and beliefs concerning death, so think about these before you encounter dying patients. This is incorrect. Suppressing feelings associated with death of patients can take a heavy toll on nurses emotionally. There is nothing wrong with grieving.

Which statements describe legal responsibilities after the death of a patient? Select all that apply. A. Next of kin must sign a consent before any autopsy can be performed. B. If the patient is donating organs, necessary arrangements must be made. C. The person who pronounces death must sign the death certificate. D. Family members are not allowed to participate in postmortem care. E. Special preparations must be followed when the patient dies from a communicable disease.

B, C, and E This is incorrect. An autopsy requires signed permission from the next of kin, except in cases in which an autopsy is required by law (e.g., a suspicious or unwitnessed death). This is correct. Legal responsibilities when a death has occurred includes reviewing and making any necessary arrangements for organ donation. This is correct. The person who pronounces death must sign the death certificate. This is incorrect. Postmortem care is usually provided by the nurse; however, this is often per agency policy. There is no law about family members' participation in postmortem care; in fact, family members are encouraged if they choose to participate in postmortem care. This is correct. By law, there are special preparations to perform when the patient has died of a communicable disease.

When providing safety education to the parent of a toddler, the nurse would inform the parent that based on the child's developmental stage, they are at high risk for which of the following factors that influence oxygenation? Select all that apply. A. Frequent, serious respiratory infections B. Airway obstruction from aspiration of small objects C. Drowning in small amounts of water D. Development of asthma E. Frequent bouts of tonsillitis

B, C, and E This is incorrect. As a toddler's respiratory and immune systems mature, the risk for frequent and serious infections is less than it is in infancy. Most children recover from upper-respiratory infections without difficulty. This is correct. Toddlers' airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. This is correct. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). This is incorrect. The risk for developing asthma is not significantly influenced by the child's developmental stage. This is correct. The tonsils and adenoids are relatively large, predisposing to tonsillitis.

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client's oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? A. 62 B. 82 C. 112 D. 132

C This is incorrect. Sixty-two beats/min is too low. Pulse rate would increase with a fever. This is incorrect. With an increase in fever, pulse rate should have increased to greater than 82 beats/min. With a fever, heart rate would not stay the same. This is correct. Heart rate would have increased from 82 to 112 beats/min. Temperature increased by 3°C (3 × 10 = 30; 82 + 30 = 112). Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation. This is incorrect. A heart rate of 132 beats/min is too high for this temperature increase.

The nurse is caring for a patient in a persistent vegetative state (PVS). Which finding would the nurse expect to observe? A. Is aware of family but can't respond to them B. Obeys the nurse's commands C. Has occasional grimaces and tears D. Speaks intermittently

C This is correct. A patient in a PVS may occasionally grimace, cry, or laugh. A patient in a PVS has lost the higher cerebral functions.

Which intervention takes priority for the patient receiving hospice care? A. Turning and repositioning the patient every 2 hours B. Assisting the patient out of bed into a chair twice a day C. Administering pain medication to keep the patient comfortable D. Providing the patient with small, frequent, nutritious meals

C This is correct. A priority intervention for the hospice team is administering pain medication to keep the patient comfortable.

The nurse provides patient education regarding hypertension prevention and management. Which statement indicates the client understands the instructions? A. "I don't have to worry if my BP is high once in a while." B. "I guess I will have to make sure I don't drink too much water." C. "I can lose some weight to help lower my BP." D. "I will need to reduce the amount of milk and other dairy products I use."

C This is correct. A single lifestyle change, such as weight loss, can lower BP.

The nurse is assessing a 16-year-old female client's knowledge of sexuality. Which of her statements indicates that she requires further teaching? A. "I don't practice oral sex because it could lead to sexually transmitted infections (STIs)." B. "I don't have sexual intercourse because I want to remain a virgin until marriage." C. "My boyfriend and I practice abstinence because we always use a condom when we have sex." D. "My parents are lesbians, but it has not affected my sexual orientation."

C This is correct. Abstinence is a state in which an individual refrains from sexual intercourse. This client is using a barrier method while having sex and needs further teaching to clarify the two concepts.

The nurse is providing care for a 75-year-old patient on the medical-surgical unit. The patient states, "I hope I can go home soon. I want to get back to the gym. I like to do a little walking on the treadmill and lift some light weights." Which response by the nurse demonstrates the use of ageism? A. "That's great. I should go to the gym more often myself." B. "Exercising is important, but concentrate on your illness for now." C. "At your age, you need to be careful with exercise and avoid injuries." D. "Follow up with your doctor on how much activity you can do when you get home."

C This is correct. Ageism is age-based discrimination. Negative expectations for older adults can cloud nursing assessments, planning, and interventions. The response in this item that is most indicative of ageism is use of the phrase "at your age." This is a negative response by the nurse.

The nurse is instructing a client on how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include? A. Be sure to put mittens on the infant. B. Layer the infant's clothing. C. Place a cap on the infant's head. D. Put warm booties on the infant.

C This is correct. Because of the many blood vessels close to the skin surface in the head, infants lose approximately one-third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head.

For the majority of grief theories and models, which response typically occurs in the initial phase? A. Awareness B. Adjustment C. Disbelief D. Confrontation

C This is correct. Disbelief is the typical response in the initial stages of grief. It can also be called shock, denial, and numbness.

A white female patient who is 75 years of age states, "I've heard that women live to an older age than men. My husband and I are the same age, so I am afraid I will have to spend some years without him. This really worries me." Which answer by the nurse is based on correct information? A. "That is a realistic concern, as women do have a longer life expectancy than men. But many things can happen to change that." B. "You need not worry because both you and your husband are white. That statistic is true only for black men and women." C. "It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65." D. "That is true only in certain geographical areas, such as those with a high population of newly retired persons."

C This is correct. For infants born in 2005, the average total life expectancy for females is 80.4 years. Life expectancy measured at age 65 was nearly the same for men and women in 1900; however, women had a lead of about 3 years over men in 2005, narrowing the gap as men age. So the longer men live, the longer they will live.

The nurse is caring for a patient in a skilled nursing center. What is the likely schedule for measuring the patient's vital signs? A. Every 4 hours B. Once per shift C. Once a week D. Every 2 hours for 24 hours

C This is correct. In skilled nursing facilities, vital signs can be taken weekly or monthly.

The nurse obtains the following vital signs on an adult patient: temperature (T) 100.6°F (38.1°C); BP 100/60 mm Hg; HR 110 beats/min; RR 36 breaths/min. What is the first action by the nurse? A. Offer oral fluids B. Begin an intravenous (IV) infusion C. Obtain a pulse oximetry reading D. Administer oxygen

C This is correct. In this item, all vital signs values are slightly abnormal; however, the most significant abnormality is an RR of 36 breaths/min. If the patient has an elevated temperature, the respiratory rate will increase. Corresponding elevation in pulse with RR may indicate hypoxemia. If respirations are not within normal parameters, oxygenation should be assessed with a pulse oximeter. It is important to routinely monitor oxygen saturation with the other vital signs.

The nurse is developing a plan of care for a female patient who expresses loss of interest in sexual intimacy with her husband following a total hysterectomy several months ago. The patient states, "I just don't have the energy to be intimate. Besides, I don't feel like a woman anymore because I cannot have children." What nursing diagnosis would be most appropriate for this patient? A. Activity intolerance and fatigue B. Disturbed body image C. Ineffective sexuality patterns D. Sexual dysfunction

C This is correct. Ineffective sexuality patterns manifest as reported difficulties or alterations in sexual behavior or activities. It may result in a patient expressing broader concerns about sexuality and desirability as a sex partner. Therefore, the patient's lack of sexual intimacy resulted from the hysterectomy and the loss of the ability to bear children most closely matches a diagnosis of ineffective sexuality patterns.

The nurse is caring for a client with reduced perfusion to the extremities. The nurse evaluates the client and finds the response to therapy is not optimal. What lifestyle change does the nurse suspect is contributing to the lack of response? A. Following a vegetarian diet B. Taking daily brisk walks C. Ingesting 1,500 mL of fluid per day D. Smoking cessation when the diagnosis was received

C This is correct. Intake of 1,500 mL of fluid is lower than optimal, and the client should be encouraged to increase fluid intake to 2,000 mL per day. Even mild dehydration could have a negative impact on perfusion.

The nurse administers sublingual nitroglycerin to a client diagnosed with angina. When the client's chest pain is not relieved, the nurse prepares to give a second nitroglycerin tablet. The nurse knows that when administering vasodilators, it is a priority to: A. Notify the physician. B. Monitor the heart rate. C. Monitor blood pressure. D. Place the client on a cardiorespiratory monitor.

C This is correct. It is most important at this time for the nurse to measure the client's blood pressure because vasodilating medications can result in a significant drop in blood pressure.

The nurse is planning care for an elderly client diagnosed with end-stage heart failure and a nursing diagnosis of decreased cardiac output secondary to ineffective left ventricular function. What outcome would the nurse plan for this client to measure improvement in cardiac output? A. Brisk capillary refill in feet bilaterally B. Heart rate within expected range C. Breath sounds clear with no shortness of breath D. Regular pulse rhythm

C This is correct. Left-sided failure causes blood to back up into the lungs and can result in pulmonary edema; therefore, clear breath sounds with no shortness of breath would be an effective outcome.

The client asks the nurse for suggestions to promote rest. Which of the following would be the most appropriate intervention suggestions to promote rest? A. Take routine benzodiazepine as prescribed. B. Avoid caffeine for several hours after meals. C. Meditate for 30 to 60 minutes in the evening. D. Avoid watching television in the bedroom.

C This is correct. Meditation helps to calm and relax the client, reducing anxiety and stress, and promoting rest. People rest by doing things that they find calm and relaxing.

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" Which is the best response by the nurse? A. "This means that your eye pressure readings are quite high and may be indicative of glaucoma." B. "These are numbers associated with left and right eye readings for identifying macular degeneration." C. "This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance." D. "This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close."

C This is correct. Myopia, or nearsightedness, means that the person is able to see close objects well but not distant objects. For example, a person with 20/100 vision can see an object from 20 feet away that a person with normal sight could see from a distance of 100 feet.

The nurse is planning care for an older adult client newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of ineffective airway clearance. Which of the following is the nurse's priority intervention? A. Teach the importance of pneumonia immunization. B. Teach coughing and deep-breathing exercises. C. Position the client to optimize maximum ventilation. D. Encourage the use of an incentive spirometer every hour.

C This is correct. The highest priority is to optimize ventilation as soon as the client is admitted. Only when the client is adequately oxygenating can other interventions be addressed.

The nurse is providing smoking-cessation education to an older client with emphysema. The client states, "My doctor wants me to quit smoking. It's too late now, though. I already have lung problems." Which of the following would be the best response to his statement? A. "You should quit so your family does not get sick from exposure to secondhand smoke." B. "You will need to use an oxygen tank, but remember it is a fire hazard to smoke with the oxygen tank in your home." C. "Once you stop smoking, your body will begin to repair some of the damage to your lungs." D. "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

C This is correct. Once a person stops smoking, the body begins to repair the damage. In the first few days, the person will cough more as the cilia begin to clear the airways. As the coughing subsides, breathing will become easier. Even long-time smokers can benefit from smoking cessation. Smoking cessation also makes other treatments work better.

The nurse is performing a sleep assessment and suspects a client is experiencing sleep apnea. What will be implemented next to confirm the diagnosis? A. Instruct the client to start a sleep diary. B. Assess the client's sleep history. C. Arrange for a polysomnography. D. Arrange for continuous positive airway pressure (CPAP) therapy.

C This is correct. Polysomnography is the sleep study often implemented to confirm sleep apnea and to determine the significance and cause of the problem.

The nurse is providing care to a pregnant woman in preterm labor. The client is 32 weeks pregnant. Initially, the client states, "I've gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now." After teaching the client about fetal development, the nurse will know her teaching is effective if the client makes which of the following statements? A. "The baby's lungs are well developed now, but he will be at increased risk for sudden infant death syndrome (SIDS) if I deliver early." B. "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." C. "If I deliver this early, my baby is at risk for respiratory distress syndrome (RDS), a condition that can be life-threatening." D. "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

C This is correct. Premature infants (younger than 35 weeks' gestation) are born before the alveolar surfactant system is fully developed and have immature pulmonary circulation. They are at high risk for RDS, characterized by widespread atelectasis.

The adult child of a patient who is 82 years of age tells the nurse, "When I ask my dad to do something, it takes him a long time to respond to me. But he does do what I ask." Which is the most appropriate response by the nurse? A. " At this age, your dad does not have the same intelligence he had when he was younger." B. "He may be embarrassed because it is difficult for him to learn new things at this age." C. "Reaction time slows in older adults, so it takes him more time to process your requests." D. "It is likely that some dementia is developing because this is a normal occurrence in his age group."

C This is correct. Reaction time slows in older adults, and short-term memory declines; it takes longer to respond to a stimulus, and it takes more time to process incoming information.

A patient in a cancer clinic says to the nurse, "I'm just so angry. I feel like God is punishing me. I know this is a bad way to think, but I don't deserve to die of cancer." What is the most appropriate response by the nurse? A. "Death is part of life. With the passing of more time, you will learn to accept this." B. "It sounds like you are losing your faith in God. God does not punish people." C. "It is normal for you to feel this way. I'm interested in hearing more about how you feel." D. "Anger is not good for you at this time. We can talk about some more helpful, positive feelings."

C This is correct. Reassure the patient that it is not wrong or bad to feel anger, guilt, relief, or other feelings they may believe are unacceptable. Patients need to feel that their feelings are not wrong and that they are going through a difficult time and a normal process. It is further helpful to allow the patient to express these feelings by asking patients how they are feeling.

A client's axillary temperature is 100.8°F (38.2°C). The nurse realizes that this is outside the normal range for this client and that axillary temperatures do not reflect the core temperature. What should the nurse do to obtain a good estimate of the core temperature? A. Add 1°F to 100.8°F to obtain an oral equivalent B. Add 2°F to 100.8°F to obtain a rectal equivalent C. Obtain a rectal temperature reading D. Obtain a tympanic membrane reading

C This is correct. Rectal temperatures are reliable and accurately reflect the core temperature. Body temperatures, from lowest to highest, are axillary, oral, tympanic, rectal, and temporal.

A couple who is considered middle-aged is moving out of state to be closer to family members. Which residence is considered most appropriate for this couple? A. Second-story apartment with safety bars in the bathrooms B. Small two-bedroom home close to a shopping center and a church C. One-level living area condominium with good lighting inside and outside D. Two-level living area condominium close to family members

C This is correct. Residences for older adults should be safe and allow for daily interaction within a living environment for persons with normal changes in aging. However, the focus is on safety first. Features include ground-level entry or no-step entry, one-level living area, wide doorways, adequate lighting inside and outside, and grab bars, shower seats, and elevated toilets in the bathroom. The choice that is most appropriate for this couple is the one-level living condominium with good lighting inside and out.

Which essential oil might the nurse use to uplift and stimulate a patient? A. Lavender B. Roman chamomile C. Rosemary D. Ylang-ylang

C This is correct. Rosemary is stimulating and uplifting for many people.

The home-care nurse suspects physical and emotional abuse of an adult client identified as middle-old. Which is the primary nursing intervention for an older adult who is a victim of abuse? A. Assess the scope of the problem. B. Analyze the family dynamics. C. Ensure the safety of the victim. D. Teach the victim coping skills.

C This is correct. Safety is a priority consideration for clients who are experiencing abuse.

A 19-year-old male client asks if he is normal because he has always viewed himself as a woman, although he has acted like a man to please his parents. The nurse should provide the client with education on which concept? A. Bisexual B. Intersex C. Transgender D. Erectile dysfunction (ED)

C This is correct. Transgender is the concept that describes a person whose gender identity is not the same as their assigned gender.

The nurse is providing preoperative screening for the older adult male client who is scheduled for prostate surgery due to cancer. The client states that he knows that his girlfriend will leave him now because the surgery will ruin his sex life. What statement by the nurse would be most appropriate? A. "I am so sorry to hear that. A close sexual relationship is so important." B. "It is possible to have a close, intimate relationship without intercourse." C. "Let's talk a little more about the ways in which your sex life has been ruined." D. "You might want to try one of the medications available to treat erectile dysfunction."

C This is correct. Seeking more specific information about the patient's sex life and what he means by "ruined" will help the nurse understand the problem that the patient is experiencing. The nurse might ask further questions regarding the relationship with the girlfriend, knowing that human sexuality has more than just a physical aspect.

When making rounds on the night shift, the nurse observes their client to be in a deep sleep. The client's muscles are very relaxed. When they arouse as the nurse changes the intravenous (IV) tubing, they are confused. What stage of sleep was the client most likely experiencing? A. NREM I B. NREM II C. NREM III D. REM

C This is correct. Stage III NREM is the deepest sleep. 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 III sleep; if awakened, the person may appear confused and react slowly. During this stage, the body releases human growth hormone, which is essential for repair and renewal of the brain and other cells.

A nurse is performing CPR on an adult. When performing chest compressions, the nurse understands that the compression rate should be at least: A. 60 times a minute. B. 80 times a minute. C. 100 times a minute. D. 120 times a minute.

C This is correct. The American Heart Association's current guidelines for effective CPR are to focus on effective, uninterrupted chest compressions; push hard and fast in the center of the chest, and administer about 100 compressions per minute. Before beginning CPR, you are responsible for knowing whether your patient has an advance directive stating whether or not they would want CPR. In the event of cardiac arrest, you have only 4 to 6 minutes before the brain is damaged by lack of oxygen.

Which statement best describes the difference between a "DNAR" and an "AND" order? A. There is no difference in the two terms. Both are used synonymously. B. A DNAR is an order not to resuscitate; an AND is an order to attempt to resuscitate. C. AND contains the word death, so the intent of the order by the provider is clear. D. A DNAR order provides specific instructions for hydration and feeding, while an AND does not.

C This is correct. The acronym "AND" stands for allow natural death and is being recommended to replace the term do not resuscitate (DNR) and do not attempt to resuscitate (DNAR) because "AND" contains the word death, so the intent of the provider's order is clear.

The nurse is assessing a patient in the pediatric office, when the patient's parent voices concern about the new neighbor who is a convicted sex offender. They ask for advice on how to protect their child. What is the nurse's best response? A. "Keep the child indoors to prevent any contact with the sex offender." B. "Discuss your concerns with the sex offender and neighbors." C. "Teach your child to never let another person touch their private parts." D. "Teach your child to avoid the house of the known sex offender."

C This is correct. The best way to protect children is to teach them how to protect themselves from strangers and sexual predators. The child should be taught not to let anyone touch their private parts or to be shown anyone's private parts. The child should know never to get in the car with strangers and to tell an adult or parent if another person makes them feel uncomfortable.

A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance? A. Keep the head of the bed flat for 6 hours. B. Avoid using mouth rinses or mouthwashes. C. Provide the client with a paper and pencil or letter board. D. Drain condensation into the humidifier when it collects in the tubing.

C This is correct. The client being mechanically ventilated is unable to speak. This can produce extreme anxiety. An alternative method of communication must be used so the client can express their needs and concerns.

The nurse is assessing an older adult patient who states that although he can achieve an erection, he is unable to achieve an orgasm. The nurse recognizes that the client may be having difficulty completing which of the following phases of sexual arousal? A. Desire B. Excitement C. Plateau D. Resolution

C This is correct. The client may experience an erection but is not able to achieve an orgasm. The sexual response cycle is the sequence of physiological events that occur when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution.

During an initial assessment of the client's sexual orientation, the nurse may utilize the PLISSIT model. What is the first step of this model? A. Provide information about sexual orientation and common alterations. B. Plan time to discuss concerns with the client in a private, comfortable setting. C. Permit the client to speak openly by communicating an open, accepting attitude. D. Provide referrals to the client so they can identify resources to assist them in the future.

C This is correct. The first step of the PLISSIT model, P, is to provide permission. Permission means that you communicate an open, accepting attitude so the client feels free to ask questions and express concerns and feelings.

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? A. The amount of sputum the client expectorates decreases with each dose administered. B. Cough is completely suppressed, and the client is able to sleep through the night. C. Dry, unproductive cough is reduced, but the client's voluntary coughing is more productive. D. Involuntary coughing produces large amounts of thick yellow sputum.

C This is correct. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

Which of the following best describes the function of type 1 alveolar cells? A. They add moisture to the inhaled air in the lungs. B. They open the airway during breathing to allow air to move. C. They facilitate gas exchange in the lungs. D. They produce surfactant to lubricate the lungs.

C This is correct. Type 1 alveolar cells within the lungs are the gas exchange cells.

The patient tells the nurse, "My partner and I never have intercourse when I have my period because I read that it is dangerous." What statement by the nurse is most appropriate? A. "You can protect the bed linens by placing protective padding under the buttocks." B. "Reaching orgasm during your period can help to relieve menstrual cramps." C. "The blood is from the uterus, not the vagina, so intercourse will not harm the vagina." D. "The increased blood flow to the pelvis will make sex more pleasurable for you."

C This is correct. The most important point for the nurse to make is that it is safe to have intercourse during menstruation so that the patient can make an informed choice about whether to do so; therefore, explaining that intercourse will not harm the vagina is the best response. This is a part of therapeutic communication and addressing the client's concerns; the nurse may need to ask the client to clarify why she thinks this would be dangerous.

The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child? A. Take the child to the funeral even if the child is frightened. B. Notify the physician immediately if the child shows signs of regression. C. Spend as much time as possible with the child. D. Provide distraction whenever the child begins to express feelings of sadness.

C This is correct. The nurse should advise the family to spend as much time as possible with the child.

The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication? A. Radial B. Temporal C. Apical D. Brachial

C This is correct. The nurse should count the pulse rate for 1 full minute using the apical site. It is the most accurate of any of the peripheral sites. When administering medications that affect the heart rate, an accurate rate is essential.

How should the nurse respond to a family immediately after a patient dies? A. Ask the family to leave the patient's room so postmortem care can be performed. B. Leave tubes and IV lines in place until the family has the opportunity to view the body. C. Express sympathy to the family by saying, "I am sorry for your loss." D. Tell the family that they will have limited time with their loved one.

C This is correct. The nurse should express sympathy to the family immediately after the patient's death.

Which intervention is appropriate for the patient with a nursing diagnosis of disturbed sensory perception: gustatory? A. Limit oral hygiene to one time a day. B. Teach the patient to combine foods in each bite. C. Assess for sores or open areas in the mouth. D. Instruct the patient to avoid salt substitutes.

C This is correct. The nurse would assess for sores or open areas in the mouth.

The nurse must irrigate the ear of a 4-year-old child. How would the nurse pull the pinna to straighten the child's ear canal? A. Up and back B. Straight back C. Down and back D. Straight upward

C This is correct. The nurse would straighten the ear canal of a small child by pulling the pinna down and back.

A patient reports an impaired sense of smell. Which cranial nerve might have been affected? A. Trigeminal B. Glossopharyngeal C. Olfactory D. Vagus

C This is correct. The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell.

For a patient with impaired tactile perception, which nursing diagnosis would be considered of highest priority? A. Self-care deficit: dressing and grooming B. Impaired adjustment C. Risk for injury D. Activity intolerance

C This is correct. The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing them at risk for injury. Risk for injury is directly related to safety, which must always be a priority.

Which statement by the nurse indicates an understanding of a patient's diagnosis of higher-brain death? A. "The patient has a normal electroencephalogram." B. "The patient has purposive responses to external stimuli." C. "The patient's cephalic responses are absent." D. "The patient's status indicates improved cognitive function."

C This is correct. The patient's cephalic reflexes are absent.

Which of the following is a priority nursing diagnosis for a patient with visual impairment? A. Self-neglect B. Social isolation C. Risk for falls D. Risk for imbalanced nutrition: less than body requirements

C This is correct. The priority nursing diagnosis for a patient with a visual impairment is risk for falls.

The nurse is caring for a client requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable? A. 78°F B. 84°F C. 96°F D. 105°F

C This is correct. The temperature should be near body temperature, so 96°F would be acceptable.

The nurse is assessing a middle-aged patient's compliance with his medications. The client states that he has stopped all medications because he could not "perform sexually." Which of the following medications do NOT negatively influence his sexual activity? A. Beta blocker antihypertensive medication B. Allergy and antihistamine medications C. First-generation antibiotics D. Antipsychotics and antidepressants

C This is correct. There is no proof that antibiotics negatively affect sexual activity.

A patient dying of heart failure has changed their choice of end-of-life treatment measures several times. They say, "I just can't make up my mind about it." Which nursing diagnosis is most appropriate for this patient? A. Deficient knowledge B. Spiritual distress C. Decisional conflict D. Complicated grieving

C This is correct. This patient is experiencing decisional conflict related to their end-of-life treatment measures because they state that they cannot make up their mind, indicating indecision about treatment options.

Which question should the nurse ask an elderly patient to best assess their level of orientation? A. "Will you please repeat these three words for me: glasses, rocket, truck?" B. "Can you tell me the date of your retirement from your workplace?" C. "What is your name and today's date? Can you tell me where you are?" D. "What did you eat for breakfast this morning?"

C This is correct. To assess level of orientation, the best question is to ask the patient for name, date, and current location.

The nurse is caring for an unresponsive, near-death patient in the intensive care unit, and it is unclear whether or not this patient is an organ donor. The family states, "I think he put 'organ donor' on his license but we don't want to donate his organs." What is the nurse's priority action at this time? A. Review the driver's license and prepare for donation. B. Honor the family's wishes, as the patient is unable to make a decision. C. Maintain the viability of organs until a resolution is made. D. Contact the primary care provider.

C This is correct. Until a resolution is made, maintaining the viability of the organs has the highest priority. A conflict between a potential organ donor's wishes, advance directive, and measures to ensure viability of the organs must be resolved as soon as possible by checking with the donor (if possible), the surrogate decision maker, or another person as authorized under state law.

The nurse plans to maintain hydration for the client at risk for thrombus formation. What evaluation finding is an indicator that the intervention is successful? A. The client denies pain in the lower legs. B. The client denies chest pain or difficulty breathing. C. Urine output exceeds 1,500 mL per 24-hour period. D. There is a weight gain of 5 pounds within 24 hours.

C This is correct. Urine output is the best indicator of hydration, and urine output greater than 1,500 mL would be expected within the normal range.

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." Which is the best response by the nurse? A. "The vital signs confirm that your infection is resolved. How do you feel?" B. "I'll let your healthcare provider know so that you can be discharged." C. "Your vital signs are stable, but there are other things to monitor." D. "We still need to keep monitoring your blood pressure for a while."

C This is correct. Vital signs are one indicator of a client's physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active.

Comparing the changes in vital signs as a person ages, which statements are correct? Select all that apply. A. Blood pressure decreases, but less than heart rate and respiratory rate. B. Respiratory rate remains fairly stable throughout a person's life. C. Blood pressure increases; respiratory rate declines. D. Men have higher blood pressure than women until after menopause. E. Body temperature rises slightly as one ages.

C and D This is incorrect. Blood pressure increases as one ages, but heart rate and respirations decline. Resting heart rate increases with age. This is incorrect. Respirations change from 40 to 60 breaths/min to 12 to 20 breaths/minutes. This is not a fairly constant rate. This is correct. Heart rate and respiratory rate tend to decrease as people age, whereas blood pressure increases because of increased vascular resistance. However, resting heart rate can increase in the older adult. This is correct. Men's blood pressure tends to be higher than that of women's until after menopause, when women's blood pressure typically increases. This is incorrect. The nurse can think of the average normal temperature for older adults as about 95°F to 96.8°F (35°C to 36°C). Older adults have difficulty maintaining body heat because of slower metabolism, decreased vasomotor control, and loss of subcutaneous tissue.

The nurse is providing care to the client who has recently been diagnosed with obstructive sleep apnea (OSA). Which of the following are symptoms associated with OSA? Select all that apply. A. Bruxism B. Enuresis C. Daytime fatigue D. Snoring E. Drooling

C and D This is incorrect. Bruxism is defined as grinding or clenching of the teeth. This is not a symptom of OSA. This is incorrect. Enuresis is defined as nighttime urination or bedwetting. This is correct. OSA is caused by partial airway occlusion (usually by the tongue or palate) during sleep. The client experiences interrupted sleep due to frequent arousal to clear the airway. As a result, the client has episodes of daytime fatigue. This is correct. OSA is caused by partial airway occlusion (usually by the tongue or palate) during sleep. As a result, the client has episodes of snoring. This is incorrect. Drooling is not often a symptom of OSA, which is caused by partial airway occlusion during sleep.

Which blood pressure reading has a pulse pressure within normal limits? Select all that apply. A. 104/50 mm Hg B. 120/62 mm Hg C. 120/80 mm Hg D. 130/86 mm Hg E. 180/70 mm Hg

C and D This is incorrect. Pulse pressure is systolic blood pressure (SBP) minus diastolic blood pressure (DBP). Pulse pressure is usually approximately one-third of SBP. Thus, 104 - 50 = 54; one-third of 104 = 34.7; 54 and 34.7 are not within normal limits. This is incorrect. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 120 - 62 = 58; one-third of 120 = 40; 58 and 40 are not within normal limits. This is correct. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 120 - 80 = 40; one-third of 120 = 40. Both indicate a normal pulse pressure. This is correct. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 130 - 86 = 44; one-third of 130 = 43. This is incorrect. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 180 - 70 = 110; one-third of 180 = 60; 110 and 60 are not within normal limits.

Which interventions are appropriate for a client receiving palliative care? Select all that apply. A. Surgically inserting a device to decrease the workload of the heart in a client awaiting heart transplantation B. Infusing intravenous dopamine to raise the blood pressure of a client with end-stage lung cancer C. Providing moisturizing eye drops to an unconscious client whose eyes are dry D. Administering a medication to relieve the nausea of a client with end-stage leukemia E. Withholding pain medication from a terminally ill client with bone cancer

C and D This is incorrect. Surgically inserting a device to decrease heart workload is an aggressive treatment measure, not palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is incorrect. Administering dopamine is an aggressive treatment measure, not palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is correct. Providing moisturizing eye drops to an unconscious client whose eyes are dry is palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is correct. Administering antinausea medication to a client with end-stage leukemia is an example of palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is incorrect. Palliative care involves administering pain medication (not withholding) to help make terminally ill clients comfortable. Withholding pain medication is unethical and inappropriate.

Of the following interventions, which of may reduce the risk of postoperative atelectasis? Select all that apply. A. Administer bronchodilators. B. Apply low-flow oxygen. C. Encourage coughing and deep breathing. D. Administer pain medication. E. Suction the airway.

C and D This is incorrect. There is no indication for a need of a bronchodilator for the postoperative client, and it will not reduce the risk for atelectasis. This is incorrect. This will increase oxygenation but will not reduce the risk for postoperative atelectasis. This is correct. By encouraging the client to cough and breathe deeply, this will help to open air sacs and mobilize secretions in the airways. This is correct. Pain alters the rate and depth of respirations. Often, clients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all clients for pain. This is incorrect. There is no indication for a need to suction, and it will not prevent atelectasis.

The nurse has finished teaching a class for adolescents and young adults on STIs and safe sexual practices. The nurse determines that the teaching has been effective when class participants make which statements? Select all that apply. A. "It is important for me to avoid STIs, so I will get a prescription for birth control pills." B. "I cannot contract an STI if we only perform oral sex on one another." C. "I should see my provider to be tested if I experience burning on urination." D. "If I contract an STI, it isn't my fault because I had sex with only one person." E. "I need to have a discussion with my sexual partner about our past sexual histories."

C and E This is incorrect. Oral birth control pills will not protect the individual from STIs. This statement indicates the need for further teaching. This is incorrect. STIs can be transmitted through oral sex, which involves an exchange of body fluids; therefore, further teaching is needed. This is correct. A person should see a provider with symptoms of burning on urination; the statement is correct and would not indicate the need for further teaching. This is incorrect. Blaming the partner suggests that the person is not taking personal responsibility; therefore, teaching is needed to encourage actions of self-protection from STIs. This is correct. Partners should discuss sexual histories with each other; that statement is correct and does not indicate need for further teaching.

Which tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply. A. Irrigating the ear of a child with impacted cerumen B. Administering eye drops for a patient in a coma C. Obtaining vital signs every 15 minutes after a seizure D. Padding the sides of a bed for seizure precautions E. Suctioning the patient's oropharynx after a seizure

C, D, and E This is incorrect. A CNA may not perform ear irrigation. This requires knowledge and skill of a professional nurse. This is incorrect. A CNA cannot administer eye drops, as this intervention requires skill of a professional nurse. This is correct. A CNA may obtain vital signs. This is correct. A CNA may initiate seizure precautions. This is correct. A CNA may suction a patient following a seizure.

The American Nurses Association (ANA) lists recommendations concerning DNAR and AND. Which statements indicate the nurse has a correct understanding of the ANA recommendations? Select all that apply. A. A DNAR means that the nurse can discontinue care, including removal of a feeding tube. B. If there is no DNAR or AND written, the nurse can participate in a "slow code" until a written order is obtained. C. Nurses should take an active role in developing policies related to DNAR and AND. D. If there is any conflict or confusion regarding a DNAR or an AND, the competent patient's choices will always have the highest priority. E. Nurses should advocate for a patient's end-of-life preference to be honored over the family's.

C, D, and E This is incorrect. A DNAR does not mean to discontinue care or provide substandard care. There is nothing written by the ANA to address removal of a feeding tube when a DNAR is written. This is incorrect. The ANA recommends that nurses have a responsibility to avoid participation in "slow codes" or "partial codes." This is correct. Nurses should be aware of and have an active role in developing DNR policies in the institutions where they work. This is correct. The competent patient's choices have highest priority when there is conflict. If the patient is not competent, highest priority is given to the advance directive or surrogate decision makers. This is correct. Nurses have a duty to advocate for a patient's end-of-life preferences to be honored above the family's.

The nurse works in a geriatric clinic where Havighurst's activity theory is applied. The nurse recognizes which as the physical, cognitive, and social developmental tasks of older adults? Select all that apply. A. Older adults and society gradually and mutually withdraw or disengage from each other. B. The older adult accepts that life has meaning and death is part of the continuum of life. C. Older adults need to focus on adjusting to their decreasing physical strength and health. D. The older adult accepts the need for establishing satisfactory physical living arrangements. E. Older adults will need to adjust to retirement and the impact of a lower income on living.

C, D, and E This is incorrect. The gradual and mutual withdrawal or disengagement of older adults and society is part of the disengagement theory developed by Cumming and Henry. This is incorrect. Erikson's developmental theory identifies ego integrity versus despair as the task of the older adult. This stage of development has as its cornerstone the acceptance that one's life has had meaning and that death is a part of the continuum of life. This is correct. Havighurst's activity theory states that older adults need to adjust to decreasing levels of physical strength and health. This is correct. According to Havighurst's activity theory, the older adult accepts the need for establishing satisfactory physical living arrangements. This is correct. Older adults will need to adjust to retirement and the impact of a lower living income, according to Havighurst's activity theory.

The home-health nurse is seeing a patient who is 80 years of age for the first time. In developing a home plan of care, which is the nurse's highest priority for this visit? A. Assessing the proximity of family members B. Planning for provision of a nutritious diet C. Planning activities for functional status D. Assessing the home for environment safety

D This is correct. "Aging in place" means that as people age, they continue to live in their own residences and receive supportive services for their changing needs, rather than moving to another location or type of housing. Housing should be elder friendly. The goal is a safe environment with accommodations to meet the normal changes of aging. The nurse's highest priority is safety of the home.

When developing a care plan for the sleep-deprived client, the nurse should consider major factors that regulate sleep. Which is a major factor regulating sleep? A. Electrical impulses transmitted to the cerebellum B. Level of sympathetic nervous system stimulation C. Individual patterns for amounts of sleep D. Amount of light received through the eyes

D This is correct. A major factor in regulating sleep is the amount of light received through the eyes.

A person who is deprived of rapid eye movement (REM) sleep for several nights in succession will usually experience: A. Extended non-rapid eye movement (NREM) sleep. B. Insomnia. C. Parasomnia. D. REM rebound.

D This is correct. A person who is deprived of REM sleep for several nights will usually experience REM rebound. The person will spend a greater amount of time in REM sleep on successive nights, generally keeping the total amount of REM sleep constant over time.

The nurse volunteers to work at the annual summer 20-mile marathon in the community. Which assessment finding will alert the nurse that a runner is experiencing heat exhaustion? A. Slurred speech B. Impaired judgment C. Bradycardia D. Diaphoresis

D This is correct. A runner with heat exhaustion will experience diaphoresis (heavy sweating).

The nurse is interviewing an older adult client who verbally expresses a personal dilemma about staying in the client's own home or seeking residence in an age-friendly residence. Which information does the nurse seek to determine if the client is suited to this type of change? A. The financial status of the client to relocate B. The support available from the client's family C. The client's ability to live closely with others D. The current level of the client's independence

D This is correct. Age-friendly residences are designed to promote client safety and an environment in which the client can function most easily. The important information for the nurse to acquire is the level of the client's independence. An inability to live independently may impact the type of residence the client considers.

The nurse is providing education to the client who has difficulty sleeping. Which of the following teachings would be most therapeutic for this client with sleep disturbance? A. "Give yourself at least 60 minutes to fall asleep." B. "Eat carbohydrates before going to sleep." C. "Catch up on sleep by napping or sleeping in, when possible." D. "Do not go to bed feeling upset about a conflict."

D This is correct. Avoid going to bed angry or frustrated. Intense emotion before bedtime can interfere with rest and sleep.

In evaluating a client's BP for hypertension, it would be most important for the nurse to take which action? A. Use the same type of manometer each time. B. Auscultate all five Korotkoff sounds. C. Measure BP in both arms. D. Monitor BP for a pattern.

D This is correct. BP fluctuates a great deal during the day and is influenced by age, gender, activity, and many other factors. Any determination of hypertension must be made after two or more BP readings have been taken on 2 separate occasions.

The nurse obtains a BP reading of 160/90 mm Hg from a cardiac patient. What is the first action by the nurse? A. Obtain BP readings with the client in the lying, sitting, and standing positions. B. Contact the primary care provider for medication orders. C. Recheck BP in 30 minutes. D. Check the patient's BP pattern over the past 3 days.

D This is correct. Blood pressure normally changes from minute to minute with changes in activity or in body position. Therefore, the nurse must establish BP patterns rather than relying on individual BP readings when determining whether a patient's BP is normal or abnormal.

The nurse is preparing to administer medication to the client experiencing an asthma exacerbation. Which of the following medications would improve the respiratory function of the client? A. Opioid B. Vasodilator C. Anti-anxiety medication D. Bronchodilator

D This is correct. Bronchodilators relax the smooth muscles lining airways.

The client tells the nurse, "After a couple of glasses of wine, I sleep very soundly." After assessing further about the client's alcohol history, what response by the nurse is most accurate? A. "Although alcohol helps you fall asleep, you will be more likely to awaken during the night and have trouble falling back to sleep." B. "If you quit drinking, you will find falling asleep more difficult, but you'll feel more rested when you awaken." C. "I know alcohol helps you to sleep, but you could take a sleeping pill instead to help you fall asleep." D. "Is there anything else that you do on a regular basis that helps you to fall asleep and stay asleep?"

D This is correct. Collecting a complete sleep history is the first step in caring for a client with sleep difficulty.

During a clinic interview, a client states they have been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? A. Ask the client when in the day dizziness occurs. B. Help the client to assume the Trendelenburg position. C. Take both heart rate and blood pressure with the client standing. D. Measure vital signs with the client supine, sitting, and standing.

D This is correct. Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the client supine, sitting, and standing) to assess for orthostatic hypotension.

The nurse is interviewing a patient in the family practice clinic who has been diagnosed with pelvic inflammatory disease (PID). The patient states that she uses several methods to stay clean "down there," such as occasional condom use by the partner, twice-weekly douches, and taking daily bubble baths instead of showers. Which of the following practices may have increased her likelihood of this infection? A. Wearing cotton underwear B. Inconsistent condom use by the partner C. Daily bubble baths D. Twice-weekly douches

D This is correct. Douching washes away protective bacteria that protect the vagina from infection, so this behavior will increase the patient's risk of PID.

Which sign would the nurse observe in a client who is days to hours before death? A. Absence of heart activity B. Yellowish pallor C. Excessive urine output D. Dry mucous membranes

D This is correct. Dry mucous membranes occur days to hours before death.

The nurse is caring for a client diagnosed with pneumonia, teaching them how to cough and deep-breathe. The client asks, "Why is drinking fluids so important?" What is the nurse's best response? A. "The doctor ordered increased fluid intake." B. "Fluids prevent pathogens from growing in your lungs." C. "Fluids help to flush infection away so it doesn't grow in your lungs." D. "Fluids make secretions thin, making them easier to cough up."

D This is correct. Fluids help to thin secretions and keep them from becoming thick and glue-like, which would be much harder to mobilize. Thin secretions will reduce the effort required by the client to cough mucus into the larger airways and expectorate it.

Which nursing intervention is most helpful for an older adult client with dementia who exhibits moderate to severe cognitive impairment? A. Attempt the application of humor to elevate the client's mood. B. Explore reasons for the client's altered cognitive function. C. Increase environmental stimuli to redirect the client's attention. D. Use reminiscence so the client recalls memories and maintains social interaction.

D This is correct. For older clients with dementia, encouraging the act of reminiscence can be highly beneficial to their cognitive function and their interpersonal skills. Reminiscence involves exchanging memories with the caregivers and professionals and passing on information, wisdom, and skills. It aids the person with dementia in maintaining a sense of value, importance, and belonging.

The nurse is providing teaching for a weight-loss group on the cardiac dangers of obesity. Which statement, if made by the nurse, would be incorrect? A. "Obesity increases the risk of atherosclerosis." B. "Obesity increases the risk of hypertension." C. "Obesity can reduce pumping action of the heart." D. "Obesity can diminish tissue perfusion."

D This is correct. In obesity, the workload of the heart is increased in an attempt to perfuse excess body tissue; however, tissue perfusion is not diminished until the heart is damaged and can no longer adequately perfuse the tissues.

The client was admitted to the intensive care unit (ICU) for respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28; partial pressure of oxygen (Pao2) = 85; partial pressure of carbon dioxide (Paco2) = 60. What changes to care does the nurse anticipate? A. Wean the client from the ventilator. B. Increase the concentration of oxygen delivered. C. Decrease the concentration of oxygen delivered. D. Increase the number of breaths per minute on the ventilator.

D This is correct. Increasing the number of breaths per minute provided by the mechanical ventilator will help the client to blow off more carbon dioxide, which will result in an improved pH.

Which component is contained within the definition of the Uniform Determination of Death Act? A. Cessation of blood flow to vital organs B. Cessation of spontaneous respirations C. Irreversible cessation of higher-brain functions D. Irreversible cessation of brain and brainstem function

D This is correct. Irreversible cessation of all functions of the entire brain, including the brainstem, is one component of the Uniform Determination of Death Act. The other component is irreversible cessation of circulatory and respiratory functions.

A nursing student attending a conference on grief says to one of the presenters, "The patient I cared for last week in clinicals told me they cried for 4 months after they lost their cat. Isn't that an excessive amount of time to cry over a cat?" What is the most appropriate response by the presenter? A. "Yes, 4 months is an excessive amount of time. Encourage them to obtain counseling." B. "No, when I lost my dog, I cried for 4 months. It was a difficult experience for me." C. "As long as the patient is able to get to other things in their life, then it is okay." D. "No, all people grieve differently, depending on how meaningful the loss was in their life."

D This is correct. It is almost impossible to determine the appropriate amount of time needed for grieving and mourning a loss. Much is determined by the meaning of the loss and how significant the loss is to one's life. The best answer is to acknowledge that all people will grieve differently depending on the meaning of that loss.

While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately? A. Clamp the chest tube close to the insertion site with rubber-shod hemostats. B. Set up a new drainage system, and quickly connect it to the chest tube. C. Have the client take a deep breath while the nurse reconnects the tube to the CDU. D. Place the disconnected end into a bottle of sterile water.

D This is correct. Loss of negative pressure can cause recollapse of the lung and is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If the chest tube disconnects from the drainage unit, the nurse should establish a temporary water seal by immersing the open end of the chest tube in a bottle of sterile water at a depth of 2 cm until a new system can be connected.

The nurse has finished teaching a group of adolescents about STIs. Which of the following statements made by one of the adolescents would indicate that the teaching has been effective? A. "A healthcare provider can tell whether you have an STI by asking if you have any symptoms." B. "The healthcare provider can diagnose most STIs with a surgical biopsy or blood draw." C. "A healthcare provider can tell whether you have an STI by getting a detailed sexual history." D. "The healthcare provider can swab the genitals to diagnose whether a person has an STI."

D This is correct. Many STIs have few or no symptoms. To find out whether a patient has an STI, you must obtain a swab culture of secretions. For a man, a culture is obtained from the urethra. For a woman, secretions are swabbed near the cervix.

During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits to drinking at least six alcoholic beverages every night before going to bed. Which type of grief does this best illustrate? A. Delayed B. Uncomplicated C. Disenfranchised D. Masked

D This is correct. Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol.

The student nurse observes the staff nurse providing care to a client with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor? A. Recording drainage from chest tube as output B. Securing the chest tube to the chest tube dressing C. Checking the water seal chamber for bubbling D. Milking the chest tube to promote drainage

D This is correct. Milking the chest tube, or squeezing it from the client to the drainage collection device, is not an evidence-based practice and should not be done. Seeing a nurse doing this would indicate the need for corrective action, which should not be provided by a student.

A client states that their friend told them to ask for Ativan (lorazepam) to help them sleep while hospitalized for a knee replacement surgery. The nurse knows that nonbenzodiazepines like Ambien (zolpidem) are preferred over benzodiazepines in this scenario because: A. All benzodiazepines are long-acting and cause daytime drowsiness. B. Nonbenzodiazepines have a long half-life and cause daytime sleepiness. C. Nonbenzodiazepines cause sleep by depressing the central nervous system. D. Nonbenzodiazepines are sedative-hypnotics with a short half-life.

D This is correct. Nonbenzodiazepines in this scenario are preferred because they have a short half-life and do not cause daytime sleepiness. Also, they do not carry the risk for rebound insomnia, dependency, and tolerance that benzodiazepines do.

Which statement regarding palliative sedation is true? A. Palliative sedation is a type of assisted suicide that is legal in a few states. B. Involuntary euthanasia is a type of palliative sedation that is legal in several states. C. The American Nurses Association enforces the legalities of palliative sedation for terminally ill patients. D. The Hospice and Palliative Nurses Association promotes palliative sedation to manage unendurable and refractory symptoms.

D This is correct. Palliative sedation—controlled and monitored non-opioid and sedative medications to lower the patient's level of consciousness to the extent necessary, for relief of awareness of refractory and unendurable symptoms—is advocated by the Hospice and Palliative Nurses Association.

A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boy's sleep patterns, she says, "Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed." The nurse explains that he is sleepwalking. The best nursing diagnosis for the boy would be: A. Risk for insomnia related to sleepwalking. B. Risk for fatigue related to sleepwalking. C. Disturbed sleep pattern related to dyssomnia. D. Risk for injury related to sleepwalking.

D This is correct. Sleepwalking occurs during stage III NREM sleep. The sleeper leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings.

What is the American Nurses Association's (ANA) position on assisted suicide? A. Since it is legal in some states, nurses can participate in assisted suicide. B. Nurses must follow the policies of their employing agency. C. Because it is legal in some states, the ANA refuses to take a position that may contradict a state law. D. Participation by nurses in assisted suicide is prohibited.

D This is correct. The ANA recognizes that assisted suicide is legal in a few states but is opposed to the practice. Nurses are prohibited from participation in assisted suicide because it is a direct violation of the Code of Ethics.

Which procedure can the nurse safely delegate to an unlicensed assistive personnel (UAP) who is knowledgeable and experienced in the procedure? A. Suctioning the newly placed tracheostomy tube B. Suctioning the endotracheal tube C. Suctioning the laryngopharynx D. Suctioning the oral cavity

D This is correct. The UAP would be capable of performing oral suctioning or assisting a client to suction their own mouth. The UAP, the client, or family can use a Yankauer tube to suction the oral cavity because there is less risk for trauma to mucosa than with oro- or nasopharyngeal suctioning.

The nurse is providing care for a client admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this client? A. Ineffective breathing pattern B. Ineffective airway clearance C. Impaired gas exchange D. Impaired spontaneous ventilation

D This is correct. The best diagnosis for this client is impaired spontaneous ventilation because without external support, this client's muscle strength is inadequate to maintain breathing adequate to support life.

A client confides to the nurse that he feels guilty because when he has intercourse with his girlfriend, he pretends that she is a certain female actress. What is the nurse's most appropriate response? A. "This behavior is known as a minimal voyeuristic disorder and is perfectly normal." B. "Perhaps we should discuss the problems in your relationship with your girlfriend?" C. "Here is a referral to a sexual counselor to help work through your guilty feelings." D. "Fantasy before or during sexual intercourse can add excitement to a relationship."

D This is correct. The client needs to understand that engaging in fantasy can be stimulating for the relationship—it increases self-esteem and arousal.

The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients would the nurse collect a sputum specimen from without using a suction catheter? A. The client with a newly placed tracheostomy B. The client with an endotracheal tube C. The client with late-stage amyotrophic lateral sclerosis D. The client admitted with chronic bronchitis

D This is correct. The client with a chronic cough, if there are no other considerations, would be able to expectorate a sputum specimen and would not require suctioning.

The nurse is developing a care plan for the client experiencing poor sleep patterns. Which of the following would be an expected outcome for a client with disturbed sleep pattern? The client will: A. Limit exercise to 1 hour per day early in the day. B. Consume only one caffeinated beverage per day. C. Demonstrate effective guided imagery to aid relaxation. D. Verbalize that they are sleeping better and feel less fatigued.

D This is correct. The client would verbalize that they are sleeping better and feel less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem.

The client tells the nurse, "I have terrible insomnia. It seems as though I am exhausted all the time." What question is most appropriate for the nurse to ask this client? A. "What time do you go to bed at night?" B. "Are you experiencing much stress right now?" C. "Have you tried meditation to help you relax?" D. "Do you have trouble falling asleep or staying asleep?

D This is correct. The first question the nurse should ask the client with an alteration in sleep is whether there is trouble with falling asleep, staying asleep, or returning to sleep after awakening.

A physician frequently approaches a nurse and compliments her on her appearance, including making inappropriate comments about the nurse's body shape. What is the most appropriate initial action of the nurse? A. Inform the nursing supervisor of the physician's behavior. B. Call the medical board to report the physician's behavior. C. Document the physician's behavior and report concern to the chief of staff. D. Inform the physician the behavior is inappropriate and unwelcome.

D This is correct. The first step the nurse should take is to inform the physician that the behavior is both unwelcome and inappropriate, and the physician should be told to stop immediately.

The nurse is providing teaching to a group of prepubescent students regarding some common myths about sexuality and body functions. Which statement by the students is an indication that teaching was effective? A. "I don't need to worry about birth control or STIs during my first time." B. "Condoms are the most effective birth control and the only way I can be sure I won't get pregnant." C. "I only have to worry about being infected with an STI if I see a sore or have pain." D. "Enjoyable sexual relationships or reaching orgasm simultaneously do not indicate the quality of the relationship."

D This is correct. The goals of this teaching would be to dispel myths about sex and sexuality. The statement is accurate in that simultaneous orgasm and good sexual relations do not predict the quality of a relationship. This dispels a myth and reflects learning.

Which of the following clients with inadequate or poor quality of sleep would be the best choice for a nursing diagnosis of disturbed sleep patterns? A. An adolescent diagnosed with somnambulism B. A client with obstructive sleep apnea C. An attorney who says they have no time for sleep D. A new mother of twins

D This is correct. The new mother of twins would experience disturbed sleep until the babies are mature enough to sleep through the night. Disturbed sleep pattern for the new mother of twins is related to changes in bedtime routines.

Which intervention is helpful when caring for a patient with impaired vision? A. Suggest that the patient use bright overhead lighting. B. Advise the patient to avoid wearing sunglasses when outdoors. C. Do not offer large-print books because this may embarrass the patient. D. Place the patient's eyeglasses within easy reach.

D This is correct. The nurse should place the patient's eyeglasses within easy reach and make sure that they are clean and in good repair.

A 42-year-old female client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 mm Hg since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 beats/min. What is the nurse's best initial action? A. Document the vital signs, and discontinue the assessment. B. Contact the provider immediately due to the alarming changes in the vital signs. C. Obtain a pulmonary artery temperature reading before initiating any type of treatment. D. Ask the unlicensed assistive personnel (UAP) to obtain another set of vital signs in 4 hours.

D This is correct. The nurse simply needs to continue monitoring the client's vital signs. The client's temperature of 102.5°F (39.2°C) is not considered an emergency temperature for an adult. A moderate fever of up to 103°F (39.5°C) is considered a mechanism by which the body fights off infection. The metabolic rate is expected to increase with a fever, which will lead to an increase in the pulse rate. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.

A patient reports to the nurse that since they started taking a new medication, they have suffered from excessively dry mouth. Which term would the nurse use to document this complaint? A. Exophthalmos B. Anosmia C. Insomnia D. Xerostomia

D This is correct. The nurse would document excessively dry mouth as xerostomia.

Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit? A. Install blinking lights to alert the patient about an incoming phone call. B. Have gas appliances inspected regularly to detect gas leaks. C. Wear properly fitting shoes and socks. D. Avoid using throw rugs on the floors.

D This is correct. The nurse would instruct the visually impaired patient to avoid using throw rugs on the floors at home.

Which nursing intervention should be included in the plan of care for a patient dying of cancer? A. Have at least one family member remain at the bedside at all times. B. Follow up weekly with other healthcare team members about family concerns. C. Avoid discussing the dying process with the family to reduce sadness. D. Encourage family members to participate in the care of the patient, when possible.

D This is correct. The plan of care should include encouraging family members to help with the patient's care when they are able.

The spouse of a client recently diagnosed with cancer reports feeling anxious and is having trouble sleeping at night despite feeling tired. The spouse says sleep was never previously a problem. What intervention would be a priority for the spouse? A. Promote physical comfort. B. Support bedtime routines. C. Create a restful environment. D. Promote relaxation.

D This is correct. The stress of having a loved one diagnosed with cancer appears to be causing anxiety; therefore, interventions aimed at helping the spouse to relax would be most helpful in resolving the problem.

The nurse in the local nursing home is planning a memory activity for the older adult residents. Which is the most effective activity the nurse might use to enhance memory? A. Reading a book B. Reading the newspaper C. Baking a cake D. Doing a crossword puzzle

D This is correct. There are many factors that impact memory in the older adult. Research indicates that an active social life with complete engagement and participation in the community delays memory loss with aging. Regular mental exercise, such as doing crossword puzzles and engaging in conversation, appear to stimulate the brain and enhance memory.

The nurse enters the client's room, and before taking vital signs, the nurse hears a piercing, high-pitched sound coming from the client when breathing. Which best action should the nurse take initially? A. Document the finding, and continue with the assessment. B. Ask the client to cough and deep breathe over the next 24 hours. C. Give the client extra fluids to loosen the secretions of mucus. D. Assess the client's airway patency.

D This is correct. These sounds are known as stridor and indicate that the client is in respiratory distress or has an obstructed airway. The nurse's initial action is to assess the patency of the airway.

The nurse is providing presurgical care to a patient scheduled for a total abdominal hysterectomy as treatment for cancer. The patient says, "I won't be a woman after surgery." The nurse recognizes that the patient connects having a uterus with which aspect of sexuality? A. Eroticism B. Intimacy C. Reproduction D. Role and identity

D This is correct. This patient is questioning her identity and role as a woman after removal of her uterus. A patient's gender identity is tied to childbearing.

The nurse is providing care for a young adult client with an intracranial hemorrhage secondary to a closed head injury. During the assessment, the nurse notices that the client's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? A. Biot's breathing B. Kussmaul's respirations C. Sleep apnea D. Cheyne-Stokes respirations

D This is correct. This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

Which statement made by the patient indicates an understanding regarding proper ear care following removal of impacted cerumen? A. "I will use cotton-tipped swabs to clean my ears." B. "I need to keep my ears moist and avoid dryness." C. "I will clean my ears weekly with a washcloth, soap, and water." D. "I will avoid swimming in the pool until my healthcare provider says I can."

D This is correct. This statement indicates effective teaching because swimming pools can increase the risk for bacterial or fungal infections and should be avoided until instructed by a healthcare provider.