CM Final

An woman 80 years of age has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this client, which of the following activities constitutes tertiary prevention? A) Assessment of her blood pressure B) Daily bleeding and clotting times C) Gait training and speech therapy D) Education on the symptoms of a CVA

C) Gait training and speech therapy

Which developmental theory suggests success in achieving developmental tasks during later stages of life? 1. A) Kohlberg's theory 2. B) Piaget's theory 3. C) Havighurst's theory 4. D) Kubler-Ross' theory

C) Havighurst's theory

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of 32. dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

C) Hydrocolloid dressing

What are the 3 learning domains? SATA A) Knowledge B) Attitude C) Psychomotot D) Cognitve E) Skills F) Effective

C) Physchomotot D) Cognitive F) Effective (KSA is apart of it but she said this was the answer)

Of all possible nursing interventions to break the chain of infection, which is the most effective? A) Administering medications B) Providing good skin care C) Practicing hand hygiene D) Wearing gloves at all times

C) Practicing hand hygiene

What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body (especially its limbs) independent of vision? A) Stereognosis B) Visceral C) Proprioception D) Sensory perception

C) Proprioception

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? 1. A) Clear, watery blood 2. B) Large numbers of red blood cells 3. C) Mixture of serum and red blood cells 4. D) White blood cells, debris, bacteria

D) White blood cells, debris, bacteria

Which of the following definitions best describes community-based nursing? A) A focus on populations within the community B) A focus on older adults living in nursing homes C) Care provided in the client's home for chronic illnesses D) care centered on individual and family health care needs

D) care centered on individual and family health care needs

According to Erikson, the crisis of identity versus role confusion is characteristic of adolescence. Consequently, anurse who provides care in a junior high school is likely to see frequent manifestations of this crisis. Early childhood, middle adulthood, and late adulthood are not typical life stages for the resolution of this crisis. A child gains weight and becomes taller each year. What is this process called? 1. A) Development 2. B) Orderly change 3. C) Progression 4. D) Growth

D) growth

A baby is born with Down syndrome, which influences his health-illness status. This is an example of which of the 15. following human dimensions? A) Physical B) Emotional C) Environmental D) Sociocultural

A) Physical

The nurse is preparing a care plan for an African American man age 68 years who was recently diagnosed with hypertension. Age, race, gender, and genetic inheritance are examples of what human dimension? A) Physical B) Emotional C) Environmental D) Sociocultural

A) Physical

A school nurse often observes adolescents challenging the decision making of their parents and teachers. Which of these developmental theorists relates this as an expected occurrence? A) Piaget B) Freud C) Havighurst D) Erikson

A) Piaget

A nurse is giving a talk to a local community group on the importance of proper diet and regular exercise. This is an example of which type of health promotion? A) Primary health promotion B) Secondary health promotion C) Tertiary health promotion D) Chronic health promotion

A) Primary health promotion

A client age 71 years has recently integrated large amounts of blueberry and pomegranate juice into her diet, touting their antioxidant properties that mitigate the effects of separated high-energy electrons. The client's actions reflect which 1. of the following theories of aging? 1. A) Free radical theory 2. B) Genetic theory 3. C) Cross-linkage theory 4. D) Immunity theory

1. A) Free radical theory

A school nurse often observes adolescents challenging the decision making of their parents and teachers. Which of these developmental theorists relates this as an expected occurrence? 1. A) Piaget 2. B) Freud 3. C) Havighurst 4. D) Erikson

1. A) Piaget

A female client age 35 years explains to the community health nurse that her primary focus daily is the care of her family, her job, and her volunteer activities at her church. The client verbalizes contentment with her various roles and the balancing of these roles. According to the theory on "individual life structure" developed by Daniel Levinson and associates, this client is demonstrating characteristics associated with what phase of adulthood? 1. A) Settling down 2. B) Early adult transition 3. C) Entering the adult world 4. D) Midlife transition

1. A) Settling down

The nurse is caring for a woman 55 years of age who has been admitted for a hernia repair. The nurse is doing an initial nursing assessment and considers developmental theories. Where would the nurse place the client according to the theory of Daniel Levinson and associates? 1. A) The pay-off years 2. B) Later maturity 3. C) Generativity versus stagnation 4. D) Postconventional level

1. A) The pay-off years

The nurse is visiting with the mother of a child age 20 months. The mother reports concern about the frequency of the toddler's loud outbursts of temper and saying no. The nurse recalls Erikson's theory about negativism and tells the mother which of the following? 1. A) This is normal, and this is how your child tries to exert control over his environment. 2. B) This is unacceptable and you must provide appropriate discipline. 3. C) This has to do with regression and is a response to stress. 4. D) This is normal and has to do with learning right from wrong.

1. A) This is normal, and this is how your child tries to exert control over his environment.

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Residual prevention

A) Primary prevention

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? 1. A) Remove ingrown toenails 2. B) Cut the nail straight across 3. C) Protect the foot from blisters 4. D) Soak the foot in witch hazel

2. B) Cut the nail straight across

According to Erikson, the middle adult is in a period of generativity versus stagnation. What happens if developmental 7. tasks are not achieved? 1. A) Physical changes are denied 2. B) Health needs become a major concern 3. C) Motivation to learn is decreased 4. D) Awareness of own mortality increases

2. B) Health needs become a major concern

According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the 13. purpose of this behavior in adolescents? 1. A) To establish a sense of security 2. B) To establish a sense of identity 3. C) To gain autonomy 4. D) To avoid inferiority

2. B) To establish a sense of identity

Which aging theory describes a chemical reaction that produces damage to the DNA and cell death? 1. A) Genetic theory 2. B) Immunity theory 3. C) Cross-linkage theory 4. D) Free radical theory

3. C) Cross-linkage theory

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process? A) Prodromal stage B) Incubation period C) Full stage of illness D) Convalescent period

A) Prodromal stage

Which of the following sets of terms best characterizes the school-aged child? 1. A) Reflexes, alert state, temperament 2. B) Negativism, regression, anal stage 3. C) Preoperational, asking "why," fears 4. D) Doing, succeeding, accomplishing

4. D) Doing, succeeding, accomplishing

According to the free radical theory of aging, what substance is affected by aging and causes damage? 1. A) Carbohydrates 2. B) Proteins 3. C) Water 4. D) Lipids

4. D) Lipids

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate? 1. A) The radial pulse is more rapid than the apical pulse. 2. B) This is a normal finding and should be ignored. 3. C) The client's arteries are very compliant. 4. D) Not all of the heartbeats are reaching the periphery.

4. D) Not all of the heartbeats are reaching the periphery.

Which of the following actions would generally take place in the settling down stage of Daniel Levinson's Individual 19. Life Structure theory? Select all that apply. 1. A) Breaking away from the family 2. B) Making initial career choices 3. C) Trying new lifestyles 4. D) Striving to gain respect 5. E) Investing in family

4. D) Striving to gain respect 5. E) Investing in family

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury? A) "Always test the temperature of bath water before stepping in." B) "Take your insulin twice a day as we have discussed." C) "Remember to follow your diet so you lose weight this month." D) "Rub lotion on the skin of your legs and feet twice a day."

A) "Always test the temperature of bath water before stepping in."

The nurse is assessing a client's gustatory function. What approach by the nurse will assist in assessing this sensation A) "Tell me if the taste on your tongue is sweet, sour, bitter, or salty." B) "Repeat the words that I speak softly to you." C) "Please read this paragraph to me." D) "Close your eyes and tell me what you smell."

A) "Tell me if the taste on your tongue is sweet, sour, bitter, or salty."

Which of the following clients is most likely to face an increased risk of falls due to his or her medication regimen? A) A female client age 77 years who has received a benzodiazepine to minimize her anxiety B) A male client age 79 years whose recent high blood pressure has required a PRN dose of an angiotensin-convertingenzyme (ACE) inhibitor C) A woman age 81 years who has required a blood transfusion to treat a gastrointestinal bleed D) A man 90 years of age whose venous ulcer has required the administration of intravenous antibiotics

A) A female client age 77 years who has received a benzodiazepine to minimize her anxiety

Which of the following nursing interventions is an example of health promotion and preventive care on the primary level? Select all that apply. A) A nurse counsels a teenager to stop smoking. B) A nurse conducts a health fair for high blood pressure screening. C) A nurse counsels the family of a client diagnosed with lung cancer. D) A home health care nurse arranges for rehabilitation services for a patient. E) A school nurse arranges for a career seminar for graduating seniors.

A) A nurse counsels a teenager to stop smoking.

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a 6. carrier. What component of the infection cycle does the woman illustrate? A) A reservoir B) An infectious agent C) A portal of exit D) A portal of entry

A) A reservoir

Which of the following are conditions that must be met for a person to receive the necessary data to experience the 31. world? Select all that apply. A) A stimulus must be present. B) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. C) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. D) The stimulus must be recognized by the cardiovascular system and sent to the brain. E) The person must physically and mentally recognize the stimulus and accept or reject it in the brain. F) A particular area in the brain must receive and translate the impulse into a sensation.

A) A stimulus must be present. B) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. C) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. F) A particular area in the brain must receive and translate the impulse into a sensation.

According to Havighurst, which of the following are developmental tasks of middle adulthood? Select all that apply. A) Accept and adjust to physical changes. B) Maintain a satisfactory occupation. C) Assist children to become responsible adults. D) Maintain social contacts and relationships. E) Relate to one's spouse or partner as a person.

A) Accept and adjust to physical changes. B) Maintain a satisfactory occupation. D) Maintain social contacts and relationships. E) Relate to one's spouse or partner as a person.

Which of the following developmental tasks is an important component of middle adulthood within Havighurst's theory of psychosocial development? 1. A) Accepting and adjusting to physical changes 2. B) Adjusting to reduced income 3. C) Adjusting to decreasing health 4. D) Learning to live with a marriage partner

A) Accepting and adjusting to physical changes

A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness. What would be the most appropriate nursing diagnosis? A) Acute Confusion B) Chronic Confusion C) Impaired Memory D) Disturbed Sensory Perception

A) Acute Confusion

Which of the following activities related to respiratory health is an example of tertiary health promotion and illness prevention? A) Administering a nebulized bronchodilator to a client who is short of breath B) Assisting with lung function testing of a client to help determine a diagnosis C) Teaching a client that "light" cigarettes do not prevent lung disease D) Advocating politically for more explicit warning labels on cigarette packages

A) Administering a nebulized bronchodilator to a client who is short of breath

Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? A) Airway/oxygen therapy/pulse oximetry B) Teaching deep breathing exercises C) Reviewing the meaning of p.r.n. orders for pain medications D) Putting in IV lines and administering fluids

A) Airway/oxygen therapy/pulse oximetry

An older adult male client is admitted to the cardiac ICU after suffering a heart attack. Upon taking a history after the client is stable, the nurse charts that he weighs over 275 pounds, has a history of heart disease in his family, suffers frequent stress at work, drinks alcohol daily, and smokes two packs of cigarettes daily. What are some modifiable risk factors for this client that has attributed to his heart attack? Select all that apply. A) Alcohol intake B) Smoking C) Stress D) Age E) Family history F) Sex

A) Alcohol intake B) Smoking C) Stress

The nurse is caring for a client who has prescribed extremity restraints. The nurse is required to document which of the following? A) Alternative measures attempted before applying the restraints B) A verbal order for renewal of the restraints every 48 hours C) Detailed description of the restraint application process D) Type of personal protective equipment (PPE) used by the nurse during restraint application

A) Alternative measures attempted before applying the restraints

Which of the following individuals would the nurse assess as being most at risk for altered family health? A) An unmarried adolescent with a newborn B) A newly married couple who ask about birth control C) A middle-aged man and woman with no children D) An older adult, living in an assisted-living community

A) An unmarried adolescent with a newborn

A mother brings her toddler, age 20 months, to the clinic today for immunizations. She talks about trying to initiate toilet training a few weeks ago, but her son wasn't interested. She decided to put it off for a while. She told her son he was a good boy, and they would try again another time. According to Erik Erikson's theory, what is the likely outcome for Matt's developmental stage? 1. A) Autonomy 2. B) Identity 3. C) Intimacy 4. D) Initiative

A) Autonomy

A nurse documents the following on a client chart: "client manifests difficulties with spatial orientation, memory language, and changes in personality." What state of arousal/awareness does this describe? A) Delirium B) Dementia C) Confusion D) Locked-in syndrome

A) Delirium

A boy age 4 years is constantly seeking out and exploring new experiences, and repeatedly asking his parents why-type questions. The boy's behavior suggests that he is successfully navigating an important developmental task within the 5. developmental theory of: 1. A) Erikson 2. B) Freud 3. C) Kohlberg 4. D) Fowler

A) Erikson

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

A) Full-thickness skin loss

Which of the following is not one of the six general types of risk factors in regard to increasing an individual 's chances for illness and injury? A) Gender B) Age C) Environment D) Lifestyle

A) Gender

A nurse educator uses models of health and illness when teaching. Which model of health and illness places high-level 3. health and death on opposite ends of a graduated scale? A) Health-Illness Continuum B) Agent-Host-Environment Model C) Health Belief Model D) Health Promotion Model

A) Health-Illness Continuum

A nurse is educating an elderly client with diabetes and his family members about the importance of a nutritious diet. The nurse knows that client education promotes which of the following purposes? Select all that apply. A) Helps the nurse to restore optimal health in the client B) Helps the client to cope with alterations in health status C) Helps the nurse to be more aware of the client's health D) Helps the nurse to diagnose the client's illness early E) Helps the nurse to be well-informed about the client's care

A) Helps the nurse to restore optimal health in the client B) Helps the client to cope with alterations in health status

The nursing student is visiting a middle school with an assignment to observe and visit with students while walking around with the school nurse. Then nursing student is interested to learn that some students seem to be rebelling against authority figures like teachers and parents. The nursing student recalls that, according to Erikson's theory, this is not abnormal behavior. To which stage of Erikson's theory does this behavior belong? 1. A) Identity versus role confusion 2. B) Industry versus inferiority 3. C) Initiative versus guilt 4. D) Autonomy versus shame

A) Identity versus role confusion

A nurse is giving a talk to a local community group on health promotion and illness prevention. The nurse explains the different levels of promotion. Which of the following does the nurse include when talking about primary promotion? Select all that apply. A) Immunization clinics B) Poison control information C) Screenings for blood pressure D) Recommending mammograms for women E) Teaching about a healthy diet

A) Immunization clinics B) Poison control information E) Teaching about a healthy diet

A nursing student is visiting a third-grade class to observe growth and development in action and does assessments on the children. They are learning to think logically and to classify and relate objects and ideas. According to Erikson, in what developmental stage are they? A) Industry versus inferiority B) Latency C) Acceptance of deity D) Concrete operational

A) Industry versus inferiority

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? A) Inform the physician that it is his or her responsibility to obtain the signature. B) Obtain the signature and ask another nurse to cosign the signature. C) Inform the physician that the nurse manager will need to obtain the signature. D) Call the house officer to obtain the signature.

A) Inform the physician that it is his or her responsibility to obtain the signature.

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs .which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply. A) Make sure he wears his hearing aid. B) Speak in a lower tone of voice. C) Speak so he can observe your lip movement. D) Keep his environment clear of clutter. E) Orient to person, place, and time frequently

A) Make sure he wears his hearing aid. B) Speak in a lower tone of voice. C) Speak so he can observe your lip movement.

Which of the following populations, based on their development stage, would benefit from strategies to prevent falls? 28. Select all that apply. A) Newborns B) Toddlers C) Adolescents D) Adults E) Older Adults

A) Newborns B) Toddlers E) Older Adults

A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after 17. hospitalization for hip replacement surgery. What name is given to this type of infection? A) Nosocomial B) Viral C) Iatrogenic D) Antimicrobial

A) Nosocomial

The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

A) Penrose drain

On which of the following components is Rosenstock's health belief model based? Select all that apply. A) Perceived susceptibility to a disease B) Perceived consequences of treating disease C) Perceived seriousness of a disease D) Perceived benefits of action E) Perceived immunity to disease

A) Perceived susceptibility to a disease C) Perceived seriousness of a disease D) Perceived benefits of action

The nurse is assessing the functions of a family. Which items are functions of the family? Select all that apply. A) Provide a safe, comfortable home in which to reside. B) Communicate cultural values and beliefs to family members. C) Provide emotional support to family members. D) Secure adequate income to meet the needs of the family. E) Make referrals to community-based healthcare resources

A) Provide a safe, comfortable home in which to reside. B) Communicate cultural values and beliefs to family members. C) Provide emotional support to family members. D) Secure adequate income to meet the needs of the family.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following 30. actions is correct? A) Remove the antiembolism stockings during the bath. B) Leave the antiembolism stockings in place, but be sure to remove all wrinkles. C) Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse. D) Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.

A) Remove the antiembolism stockings during the bath.

After a client falls out of bed, the nurse completes which of the following? A) Safety event report (incident report) B) Telephone call to hospital's attorney C) Progress note stating event report was completed D) Malpractice report

A) Safety event report (incident report)

The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes 2. that seeking and utilizing support systems is an example of which human dimension? A) Sociocultural dimension B) Physical dimension C) Environmental dimension D) Intellectual and spiritual dimension

A) Sociocultural dimension

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

A) Stage II pressure ulcer

A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation 31. precautions should the nurse follow? A) Standard precautions B) Droplet precautions C) Contact precautions D) Airborne precautions

A) Standard precautions

An elderly resident of a long-term care facility has developed diarrhea and dehydration as a result of exposure to clostridium difficile during a recent outbreak. The resident's primary care provider has consequently prescribed the antibiotic metronidazole (Flagyl). Which model of health promotion and illness prevention is most clearly evident in these events? A) The Agent-Host-Environment Model B) The Health-Illness Continuum C) The Health Promotion Model D) The Health Belief Model

A) The Agent-Host-Environment Model

Which of the following models of health promotion and illness prevention was developed to illustrate how people interact with their environment as they pursue health? A) The health promotion model B) The health belief model C) The health-illness continuum D) The agent-host-environment model

A) The health promotion model

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurses's best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity.

A) They promote venous blood return to the heart.

In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints? A) Tie the client's hand restraint to the bed frame rather than the side rail. B) Obtain a physician's order for the restraints within 24 hours. C) Ensure the client is under continuous surveillance while restrained. D) Choose a restraint device that best minimizes the client's mobility.

A) Tie the client's hand restraint to the bed frame rather than the side rail.

The emergency department nurse is caring for an infant age 2 months who was brought in by a hired caregiver. The infant is underweight and looks uncared for. The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory? 1. A) Trust 2. B) Autonomy 3. C) Initiative 4. D) Identity

A) Trust

What care should the nurse take when providing foot care for a client with peripheral vascular disease? Select all that apply. 1. A) Use an emery board to file toenail edges 2. B) Cut the toenails short 3. C) Cut the nail in one piece 4. D) Avoid cutting into calluses 5. E) Cut the nails straight across

A) Use an emery board to file toenail edges D) Avoid cutting into calluses E) Cut the nails straight across

A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure? A) Use sterile gloves to handle the entire drape surface. B) Fold the lower edges of the drape over the sterile-gloved hands. C) Touch only the outer two inches of the drape when not wearing sterile gloves. D) When reaching over the drape do not allow clothing to touch the drape.

A) Use sterile gloves to handle the entire drape surface.

A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed? A) "I will wash my hands before and after going to the bathroom." B) "I don't wear a condom when I have sex, but I know my partners." C) "I always eat fruits and vegetables, and I sleep eight hours a night." D) "When I have an infection, I rest and take my medications."

B) "I don't wear a condom when I have sex, but I know my partners."

A middle-aged woman is 40 pounds over her ideal weight. Which of the following statements best illustrates the effect of her self-concept on health and illness? A) "I am just too busy with my kids to bother about a diet." B) "Why should I lose weight? I'll still be fat." C) "My sister is thin, but I don't think she looks that good." D) "My husband loves me this way."

B) "Why should I lose weight? I'll still be fat."

What is the term for the change that takes place in response to a stressor? A) Rehabilitation B) Adaptation C) Positive movement D) Negative movement

B) Adaptation

Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? A) Assess abdominal distention, especially if bowel sounds are audible or are low pitched. B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. C) Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. D) Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery.

B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake.

What are the general nursing care guidelines that the nurse should follow when caring for clients in a health care 29. facility? A) Avoid physical contact with the infected client. B) Avoid jewelry with prongs or protruding stones. C) Isolate the client and keep the room door closed. D) Shake linens properly when changing the beds.

B) Avoid jewelry with prongs or protruding stones.

What is the major effect of a health crisis on family structure? A) Adaptation to stress B) Change in roles of family members C) Respect for family values D) Loss of individual identities

B) Change in roles of family members

Which statement is true of health care personnel and good hand hygiene? A) Hand hygiene is carefully followed. B) Compliance is difficult to achieve. C) Only nurses need to practice hand hygiene. D) Wearing gloves reduces the need for hand hygiene.

B) Compliance is difficult to achieve.

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her 27. life. Which of the following statements describes an accurate action to take when applying these restraints? A) Apply restraints to the hands or wrists, never to the ankles. B) Ensure that two fingers can be inserted between the restraint and the client's extremity. C) Use a quick-release knot to tie the restraint to the side rail. D) Remove the restraint at least every four hours, or according to agency policy.

B) Ensure that two fingers can be inserted between the restraint and the client's extremity.

Which of the following is a correct guideline to follow when providing a bed bath for a client? 1. A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. 2. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. 3. C) Clean the perineal area before cleaning the gluteal area. 4. D) Change the bath water after washing each body part.

B) Fold the washcloth like a mitt on your hand so that there are no loose ends.

In what order do you put on PPE? A) Mask, gloves, gown, goggles B) Gown, mask, goggles, gloves C) Mask, goggles, gown, gloves D) gloves, goggles, gown, mask

B) Gown, mask, goggles, gloves

A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend? 1. A) Mandating antibiotics for all nursing home residents 2. B) Have written, infection-prevention practices for all employees 3. C) Requiring all employees to have monthly screenings for skin flora 4. D) Restricting visitors and community activities for residents

B) Have written, infection-prevention practices for all employees

A student is preparing for her first client care assignment. She wakes up at 4 AM with a pounding pulse and diarrhea. 7. What type of adaptive response to stress is she experiencing? A) General adaptation syndrome B) Mind-body interaction C) Local adaptation syndrome D) Coping or defense mechanism

B) Mind-body interaction

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? A) Securing informed consent from the client B) Signing the consent form as a witness C) Ensuring the client does not refuse treatment D) Refusing to participate based on legal guidelines

B) Signing the consent form as a witness

Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply. A) It is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. B) Specific signs and symptoms are present. C) The organisms are growing and multiplying. D) The signs and symptoms disappear, and the person returns to a healthy state. E) Early signs and symptoms of disease are present, but these are often vague and nonspecific.

B) Specific signs and symptoms are present.

The daughter of an older adult calls the nurse practitioner to report that her mother is becoming very confused after dark. What is this type of confusion named? A) Night-time confusion B) Sundowning syndrome C) Alzheimer's disease D) Cognitive dysfunction

B) Sundowning syndrome

Which of the following statements accurately describes the concepts of disease and illness? A) A disease is traditionally diagnosed and treated by a nurse. B) The focus of nurses is the person with an illness. C) A person with an illness cannot be considered healthy. D) Illness is a normal process that affects level of functioning.

B) The focus of nurses is the person with an illness.

A doctor orders restraints for an older adult client who is disoriented from the pain medication she is taking. Which of 26. the following is an appropriate guideline for applying these restraints? A) Chemical restraints should be tried before using physical restraints. B) The restraints can be ordered by the nursing supervisor in emergency situations. C) The client's vital signs must be assessed every hour. D) Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and children under 9 years within D) one hour.

B) The restraints can be ordered by the nursing supervisor in emergency situations.

What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU? A) Use bright lights B) Use limited light C) Play loud music D) Avoid touch

B) Use limited light

The National Patient Safety Foundation recently collaborated with the Partnership for Clear Health Communication (2007) to create awareness of the need for improved health literacy and developed the Ask Me 3 tool. Which of the following is an Ask Me 3 question? Select all that apply. A) Who will be my health care provider? B) What is my main problem? C) What do I need to do? D) Where will I get help? E) Why is it important for me to do this?

B) What is my main problem? C) What do I need to do? E) Why is it important for me to do this?

A nurse is ordered to apply a transcutaneous electrical nerve stimulation (TENS) unit to a client recovering from 30. abdominal surgery. Which of the following is a consideration when using this device? A) TENS is an invasive technique for providing pain relief. B)TENS involves the electrical stimulation of large-diameter fibers to inhibit the transmission of painful impulses carried over small-diameter fibers. C) TENS is most beneficial when used to treat pain that is generalized. D) A TENS unit is applied intermittently throughout the day and should not be worn for extended periods of time.

B)TENS involves the electrical stimulation of large-diameter fibers to inhibit the transmission of painful impulses carried over small-diameter fibers.

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is 10. characteristic of the bargaining stage? A) "The doctors must have made a mistake." B) "Why did this happen to me? I always exercised." C) "Just let me live to see my grandson born." D) "I've had a good life and I can die in peace."

C) "Just let me live to see my grandson born."

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3 A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6

C) 1, 5, 4, 2, 3, 6

What prevents air from re-entering the pleural space when chest tubes are inserted? A) The location of the tube insertion B)The sutures that hold in the tube C) A closed water-seal drainage system D) Respiratory inspiration and expiration

C) A closed water-seal drainage system

Which of the following statements accurately describes how risk factors may increase a person's chances for illness or injury? Select all that apply. A) Risk factors are unrelated to the person or event. B) All risk factors are modifiable. C) An increase in risk factors increases the possibility of illness. D) A family history of breast cancer is not a modifiable risk factor. E) School-aged children are at high risk for communicable diseases.

C) An increase in risk factors increases the possibility of illness. D) A family history of breast cancer is not a modifiable risk factor. E) School-aged children are at high risk for communicable diseases.

A nurse is caring for a client who is unconscious. Which of the following is a recommended guideline for communication with this client? A) Do not assume the person can hear you. B) Keep environmental noise level high to stimulate the client. C) Be careful what is said in front of the client as he or she might hear you. D) Touch the person before speaking to them.

C) Be careful what is said in front of the client as he or she might hear you.

What may happen to the family when one of the family members suffers an illness? A) Alterations in values and religious beliefs B) More public displays of affection C) Changes in roles for the client and family D) Increased resistance to stress

C) Changes in roles for the client and family

A nurse has completed morning care for a client. There is no visible soiling on her hands. What type of technique is 21. recommended by the CDC for hand hygiene? A) Do not wash hands, apply clean gloves. B) Wash hands with soap and water. C) Clean hands with an alcohol-based handrub. D) Wash hands with soap and water, follow with handrub.

C) Clean hands with an alcohol-based handrub.

A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor? A) Adaptation B) Homeostasis C) Coping mechanism D) Defense mechanism

C) Coping mechanism

A man has noticed bright red blood in his bowel movements for over a month. He says to himself, "Oh, it's just my hemorrhoids." What defense mechanism is the man using? A) Rationalization B) Repression C) Denial D) Compensation

C) Denial

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client? A) Briefly leave the client in order to call the primary physician to assess the client's condition. B) Order x-rays or CT scans for the client, as needed. C) Document the incident, assessment, and interventions in the client's medical record. D) Do not file an event report unless the client is seriously injured in the fall.

C) Document the incident, assessment, and interventions in the client's medical record.

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the 30. nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

C) Respond to the postoperative client's question that baths are given only in the morning.

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What 14. nursing diagnosis would be appropriate based on the client's weight? A) Risk for Aspiration B) Risk for Imbalanced Body Temperature C) Risk for Infection D) Risk for Falls

C) Risk for Infection

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The 23. drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

C) Serosanguineous

A client accepts the fact that he needs bypass surgery for a blocked artery and is admitted into the hospital. Which one of the following stages of illness is this client experiencing? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3

Which of the following most accurately defines "illness"? A) The inability to carry out normal activities of living B) A pathologic change in mind or body structure or function C) The response of a person to a disease D) Achieving maximum potential and quality of life

C) The response of a person to a disease

Dementia is a disorder that progresses over several years, with increasing confusion, forgetting family, and disorientation in familiar surroundings. A common problem with dementia patients is sundowning syndrome, which is described as ... A) a behavior change at sunset as the client becomes more fatigued, listless, and disoriented. B) occasional onset of marked confusion, wandering and feeling lost during the afternoon, before sunset. C) habitual agitation, restlessness, and confusion that occurs after dark. D) increasing sleeplessness at night because the patient cat-naps during the day.

C) habitual agitation, restlessness, and confusion that occurs after dark.

In what situation would the use of side rails not be considered a restraint? A) The nurse keeps them raised at all times. B) The institution's policies mandate using side rails. C) A visitor requests their use. D) A client requests they be​​ up at night.

D) A client requests they be​​ up at night.

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high? A) Liquid or bar hand soap B) Cold water C) Hot water D) Antimicrobial products

D) Antimicrobial products

In what order do you take off PPE? A) Mask, gloves, gown, goggles B) Gown, mask, goggles, gloves C) Mask, goggles, gown, gloves D) Gloves, goggles, gown, mask

D) Gloves, goggles, gown, mask

When providing nursing care to a client, the nurse provides family-centered nursing care. What is one rationale for this nursing action? A) The nurse does not want the client to feel lonely. B) The client will be more compliant with medical instructions. C) The family will be more willing to listen to instructions. D) Illness in one family member affects all family members.

D) Illness in one family member affects all family members.

A client has been prescribed a clear liquid diet. What food or fluids will be served? A) Milk, frozen dessert, egg substitutes B) High-calorie, high-protein supplements C) Hot cereals, ice cream, chocolate milk D) Jell-O, carbonated beverages, apple juice

D) Jell-O, carbonated beverages, apple juice

Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls? A) Keep bed in the high position. B) Keep side rails up at all times. C) Apply restraints to all confused clients. D) Lock wheels on beds and wheelchairs.

D) Lock wheels on beds and wheelchairs.

A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this 19. procedure? A) Surgical clients routinely are given a cleansing enema. B) Cleansing enemas are given before surgery at the client's request. C) There will be less flatus and discomfort postoperatively. D) Peristalsis does not return for 24 to 48 hours after surgery.

D) Peristalsis does not return for 24 to 48 hours after surgery.

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

D) Pressure ulcers

The following procedures have been ordered and implemented for a hospitalized client. Which procedure carries the 18. greatest risk for a nosocomial infection? A) Enema B) Intramuscular injections C) Heat lamp D) Urinary catheterization

D) Urinary catheterization