Exam Five - Practice Questions

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? A. Give the patient a hug and tell him that his life still has meaning. B. Arrange for a spiritual adviser to visit the patient C. Ask if the patient would like to talk about his feelings. D. Call in a close friend or relative to talk to the patient.

C

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan? A. Ask the patient which spiritual adviser he would like you to call. B. Recommend that the patient read spiritual biographies or religious books. C. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past. D. Introduce the belief that God is a loving and personal God.

C

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? A. Gently massage the region, document the finding, and verbally report it to the health care provider B. Avoid massaging the area and apply a thin layer of a topical antibiotic ointment C. Avoid massaging this area and report the finding to the health care provider D. Massage the area in an attempt to restore adequate circulation

C

A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? A. Tertiary B. Secondary C. Primary D. Promotive

C

A nurse in NICU fails to monitor a premature newborn according to the protocols in place, and is charge with malpractice. What is the term for those bringing the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys

C

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A. The use of a central nervous system stimulant B. Continuous positive airway pressure machine (CPAP) C. Chronotherapy D. The application of heat or cold therapy to promote sleep

C

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A. Drinking a cup of regular tea at night induces sleep. B. Using alcohol moderately promotes a deep sleep. C. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D. Exercising right before bedtime can hinder sleep.

C

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A. "Do you think you will be able to eat the food we have here?" B. "Do you understand that we can't prepare special meals?" C. "What types of food do you eat for meals?" D. "Why can't you just eat our food while you are here?"

C

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs? A. Can you describe your usual spiritual practices and how you maintain them daily? B. Are your spiritual beliefs causing you any concern? C. How can I and the other nurses help you maintain your spiritual practices? D. How do your religious beliefs help you feel at peace?

C

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? A. Ask Me 3 B. Newest Vital Sign (NVS) C. Teach-back method D. TEACH acronym

C

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which ones is MOST basic to providing culturally competent care? A. Learning the predominant language of the community B. Obtaining signification information about the community C. Treating each patient at the clinic as an individual D. Recognizing the importance of the patient's family

C

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval

C

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in the patient's legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? A. Prostaglandins B. Substance P C. Endorphins D. Serotonin

C

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality? A. The child's church or religious organization B. What parents say about God and religion C. How parents behave in relationship to one another, their children, others, and to God D. The spiritual adviser for the family

C

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also from God - if there is a God." Analysis of these date reveals which unmet spiritual need? A. Need for meaning and purpose B. Need for forgiveness C. Need for love and relatedness D. Need for strength for everyday living

C

A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery? A. A patient of the Adventist faith B. A patient who practices Buddhism C. A patient who is a Jehovah's Witness D. A patient who is an Orthodox Jew

C

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A. Preparing the family for a diagnosis of insomnia and related treatments. B. Preparing the family for a diagnosis of narcolepsy and related treatments. C. Anticipating the scheduling of polysomnography to confirm OSA. D. No action would be taken, as this is a normal finding for hospitalized children.

C

Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms? A. Jane, whose best friend had a benign breast lump removed B. Sarah, who lives in a low-income neighborhood C. Tricia, who has a family history of breast cancer D. Nancy, whose family encourages regular physical examinations

C

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness? A. Assure Mr. Brown that many parents feel the same way. B. Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass. C. Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive. D. Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

C

When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method? A. Using the highest effective dose of an opioid on a PRN (as needed) basis B. Using nonopioid drugs conservatively C. Using consistent nonpharmacologic and nonopioid pharmacologic therapies D. Administering a continuous intravenous infusion on a regular basis

C

When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain? A. Position the client of several pillows B. Teach the client relaxation techniques C. Give the client a back rub D. Darken the room

C

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. A. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. B. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. C. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. F. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

C, D, E

A mother brings her child to his 18-month well-baby visit. The nurse would not give the child his routine immunizations in which situations? a. He cried at his last immunization. b. He developed a fever or rash after his last immunization. c. He currently has a fever and symptoms of a cold. d. He is allergic to aspirin. e. He is currently taking oral corticosteroids. f. His siblings are all currently being treated for a viral infection.

C, E, F

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A. He is aware of his surroundings at this point. B. He is in delta sleep at this time. C. It would be most difficult to awaken him at this time. D. This is most likely an NREM stage. E. This stage constitutes around 20% to 25% of total sleep. F. The muscles are relaxed in this stage.

C, F

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? A. Increase physical activities during the day. B. Encourage short periods of napping during the day. C. Increase fluids during the evening. D. Dispense diuretics during the afternoon hours.

A

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? A. An older adult on bedrest following cervical spine surgery B. A patient with a severe sunburn being treated for dehydration C. An industrial worker who has burns caused by a caustic acid D. A patient experiencing cardiac disturbances from an electrical shock

A

A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? A. Demonstration B. Lecture C. Discovery D. Panel session

A

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

A

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A. No action is necessary as this is a normal finding during sleep. B. Call the primary care provider to report possible neurologic deficit. C. Lower the temperature in the patient's room. D. Awaken the patient as this is an indication of night terrors.

A

A nurse performing a spiritual assessment collects assessment date from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing? A. Spiritual Alienation B. Spiritual Despair C. Spiritual Anxiety D. Spiritual Pain

A

A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility? A. By being a role model for healthy behaviors B. By not requiring sick days from work C. By never exposing others to any type of illness D. By budgeting time and resources efficiently

A

A patient is to receive immune globulin after exposure to hepatitis A. The patient has a previous history of allergies to various drugs. Before giving the immune globulin, the nurse should a. have emergency equipment readily available. b. premedicate the patient with aspirin. c. make sure all of the patient's vaccinations are up to date. d. make sure the patient has a ride home.

A

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? A. Naloxone B. Diphenhydramine C. Atropine D. Epinephrine

A

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? A. The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. B. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. C. The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. D. The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

A

After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? A. Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands." B. Patient has slept from 10 PM to 6 AM for three consecutive nights without medication. C. Patient has developed mutually caring relationships with two women and one man. D. Patient has identified several spiritual beliefs that give purpose to her life.

A

After teaching a parent about common adverse effects associated with routine immunizations, which of the following, if stated by the parent, would indicate the need for additional teaching? a. Difficulty breathing and fainting b. Fever and rash c. Drowsiness and fretfulness d. Swelling and nodule formation at the site of injection

A

An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney." B. "I will answer your questions so you'll understand how the situation occurred." C. "I hope I won't be blamed for the death because it was so busy that day." D. "First tell me why you are doing this to me. This could ruin my career!"

A

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching? A. "I will remind my family member to push the PCA pump button for me if I doze off during the day." B. "I will let my nurse know if the pain medication is not effective enough to help me move after surgery." C. "I can push the button whenever I feel pain." D. "I will use the PCA pump until oral pain medication controls my pain."

A

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? A. CRIES scale B. COMFORT scale C. FLACC scale D. FACES scale

A

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? A. Respiratory status, oxygen saturation, pain, and sedation level B. Heart rate, capillary refill, bowel sounds and pedal pulses C. Temperature, pedal pulses, and assessment of cranial nerves D. Gastrointestinal status, bowel movements, and urine output

A

The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client? A. Use massage and heat application to the lower back B. Administer opioid analgesics C. Have the client perform active exercises to stretch the back muscles D. Encourage the client to have an epidural steroid injection

A

The nurse practitioner sees patients in a community clinic that is located in a predominantly White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A. Cultural assimilation B. Cultural imposition C. Culture shock D. Ethnocentrism

A

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit? A. Naloxone B. Furosemide C. Lisinopril D. Digoxin

A

The nurse uses the agent-host-environment model of health and illness to assess diseases in patients. This model is based on what concept? A. Risk factors B. Demographic variables C. Behaviors to promote health D. Stages of illness

A

To promote sleep in a patient, a nurse suggests what intervention? A. Follow the usual bedtime routine if possible. B. Drink two or three glasses of water at bedtime. C. Have a large snack at bedtime. D. Take a sedative-hypnotic every night at bedtime.

A

What is the verbal and behavioral system of culture, when it is transmitted from one generation to the other? A. Culture is learned B. Culture is shared C. Culture is adapted D. Culture is universal

A

When performing as assessment on a client with chronic pain, the nurse notes that the client frequently shifts conversational topics. What does the nurse determines that this may be an indicator of? A. Anxiety B. Depression C. Boredom D. Moodiness

A

When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? A. Acute Pain related to fear of taking prescribed postoperative medications B. Impaired Physical Mobility related to surgical procedure C. Anxiety related to outcome of surgery D. Risk for Infection related to surgical incision

A

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? A. Respiratory B. Cardiovascular C. Peripheral Vascular D. Neuromuscular

A

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? A. Pain assessment may require multiple methods in order to ensure accurate pain date B. The developing neurologic system of children transmits less pain than in older clients C. Pharmacologic pain relief should be used only as an intervention of last resort D. A numeric scale should be used to assess pain if the child is older than 5 years of age

A

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When it the most appropriate time to do so? A. When obtaining patient vital signs B. Before the patient is discharged C. The first question you ask the patient D. At several points throughout your history-taking

A

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. D. A patient who is HIV positive. E. A patient who is taking corticosteroids for arthritis. F. A patient with a urinary tract infection.

A, B, C

A public education campaign to stress the importance of childhood immunizations should include which points? a. Prevention of potentially devastating diseases outweighs the discomfort and risks of immunization. b. Routine immunization is standard practice in the United States. c. The practice of routine immunizations has virtually wiped out many previously deadly or debilitating diseases. d. The risk of severe adverse reactions is on the rise and is not being addressed. e. If there is a family history of autism, that person should avoid immunizations. f. The temporary discomfort associated with the immunization can be treated with over-the-counter drugs.

A, B, C, F

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply. A. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days. B. A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. C. A nurse administering medications to a Muslim patient avoids touching the patient's lips D. A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday. E. The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient. F. The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

A, B, D, F

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. A. Daily mental activities B. Daily physical activities C. Morning and evening body temperature D. Daily measurement of fluid intake and output E. Presence of anxiety or worries affecting sleep F. Morning and evening blood pressure readings

A, B, E

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A. Arrange for assessment for depression and treatment. B. Discourage napping during the day. C. Decrease fluids during the evening. D. Administer diuretics in the morning. E. Encourage patient to engage in some type of physical activity. F. Assess medication for side effects of sleep pattern disturbances.

A, B, E, F

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. A. A patient cradles a wrist that was injured in a car accident B. A child is moaning and crying due to a stomachache C. A patient's pulse is increased following a myocardial infarction D. A patient in pain strikes out at a nurse who attempts to provide a bath E. A patient who has chronic cancer pain is depressed and withdrawn F. A child pulls away from a nurse trying to give an injection

A, B, F

A nurse working in a hospital setting cares for patients with acute and chronic conditions. Which disease states are chronic illnesses? Select all that apply. A. Diabetes mellitus B. Bronchial pneumonia C. Rheumatoid arthritis D. Cystic fibrosis E. Fractured hip F. Otitis media

A, C, D

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A. A Native American patient B. An African-American patient C. An Alaska Native D. An Asian patient E. A White patient F. A Hispanic patient

A, C, E, F

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A. A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B. A nurse treats all patients the same whether or not they come from a different culture. C. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E. A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

A, D

Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply. A. Violations that may result in disciplinary action B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

A, D

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply. A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysm D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to an accident that occurred last year F. A patient is experiencing pain from second-degree burns

A, D, E

Three critical development areas to consider when developing a teaching plan are: the patient's physical maturation and abilities, psychosocial development, and _______ capacity.

Cognitive

What occurs when members of a minority group, living with a dominant group, begin to blend in and lose the characteristics that made them distinct?

Cultural assimilation

Accepting cultural differences in the assessment of health care needs is an example of _______ competent nursing care.

Culturally

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible, because the nurse was following the doctor's orders. B. Only the nurse is responsible, because the nurse actually administered the medication. C. Only the health care provider is responsible, because the health care provider actually ordered the drug. D. Both the nurse and the health care provider are responsible for their respective actions.

D

A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health-illness continuum and the high-level wellness models? A. Illness as a fixed point in time B. The importance of family C. Wellness as a passive state D. Health as a constantly changing state

D

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing? A. transduction B. transmission C. perception D. modulation

D

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain? A. the client's recent responses to pain and to pain medication B. nonverbal cues of the client C. the nurse's impression of the client's pain D. the client's pain based on a pain rating

D

A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? A. "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." B. "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." C. "You should concentrate on other sports that you could play even with prosthesis." D. "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

D

A nurse states, "That patient is 78 years old - too old to learn how to change a dressing." What is the nurse demonstrating? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

D

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? A. "It's not a good idea to ask for pain medication regularly as it can be addictive." "B. It is better to wait until the pain is severe before asking for pain medication." C. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." D. "Your doctor has prescribed pain medications for you, which you should request when you have pain."

D

A patient states she feels so isolated from her family and church, and even from God, "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress? A. The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living. B. The patient will identify spiritual beliefs that meet her need for meaning and purpose. C. The patient will express peaceful acceptance of limitations and failings. D. The patient will identify spiritual supports available to her in this medical center.

D

A patient who is having a myocardial infarction reports pain that is situated in the neck. The nurse documents this as what type of pain? A. Transient pain B. Superficial pain C. Phantom pain D. Referred pain

D

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding? A. The nurse should have ordered kosher dishes also. B. The staff must have behaved condescendingly or critically. C. Mr. Goldstein is a problem patient and difficult to satisfy. D. Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

D

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of what side effect? A. Pruritus B. Urinary retention C. Vomiting D. Respiratory depression

D

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A. Public law B. Private law C. Civil law D. Criminal law

D

The process of cultural assimilation or ________ occurs when a minority group living within a dominant group takes on the values of the dominant culture.

Acculturation

It is important for nurses to remember that patients learn in three domains: _______, cognitive, and psychomotor.

Affective

Pedagogy, the science of teaching, generally refers to the teaching of children and adolescents, whereas _______ refers to the study of teaching adults.

Andragogy

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A. Keep the room light dimmed during the day. B. Keep the room cool. C. Keep the door of the room open. D. Offer a sleep aid medication to patients on a regular basis.

B

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? A. "This agreement forms a legal bond between the two of us to achieve your weight goals." B. "This agreement will motivate the two of us to do what is necessary to meet your weight goals." C. "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." D. "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

B

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? A. By determining the patient's motivation to learn B. By deciding if the learning outcomes have been achieved C. By allowing the patient to practice the skill he has just learned D. By documenting the teaching session in the patient's medical record

B

A nurse is assessing a patient receiving a continuous opioid infusion. For which related condition would the nurse immediately notify the primary care provider? A. A respiratory rate of 10/min with normal depth B. A sedation level of 4 C. Mild confusion D. Reported constipation

B

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? A. Long-term developmental B. Short-term situational C. Short-term motivational D. Long-term motivational

B

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A. Circadian rhythm sleep-wake disorder B. Narcolepsy C. Enuresis D. Sleep apnea

B

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? A. Promoting health B. Preventing illness C. Restoring health D. Facilitating coping

B

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model - Explanatory model of health and illness? A. How do you get your medications? B. How does having COPD affect your lifestyle? C. Are you concerned about the side effects of your medications? D. Can you describe how you will take your medications?

B

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A. "I can expect my newborn to sleep an average of 16 to 24 hours a day." B. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C. "I will place my infant on his back to sleep." D. "I will not place pillows or blankets in the crib to prevent suffocation."

B

A nurse suffers a needlestick after injecting a patient with suspected hepatitis B. The nurse should a. have repeated titers to determine whether she was exposed to hepatitis B and if she was have hepatitis immune globulin. b. immediately receive hepatitis immune globulin and begin hepatitis B vaccines if she has not already received them. c. start antibiotic therapy immediately. d. go on sick leave until all screening tests are negative.

B

A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients? A. Calling the patient's own spiritual adviser first B. Asking whether the patient has a spiritual adviser the patient wishes to consult C. Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser D. Advising the patient and spiritual adviser concerning health options and the best choices for the patient

B

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury. B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

B

A patient in a community health clinic tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the patient exhibiting? A. Stage 1: Experiencing symptoms B. Stage 2: Assuming the sick role C. Stage 3: Assuming a dependent role D. Stage 4: Achieving recovery and rehabilitation

B

A patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain? A. Cutaneous B. Visceral C. Superficial D. Somatic

B

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A. Use short words and talk more loudly. B. Ask an interpreter for help. C. Explain why care can't be provided. D. Provide instructions in writing.

B

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? A. Encouraging regular use of analgesics B. Applying a moist heating pad to the area at prescribed intervals C. Reviewing the pain experience with the patient D. Ambulating the patient after administering medication

B

It is now recommended that all people over the age of 6 months should receive a flu vaccine every fall based on the understanding that the vaccine is repeated because a. the immunity wears off after a year. b. the strains of virus predicted to cause the flu change every year. c. a booster shot will activate the immune system. d. flu shots do not produce good antibodies.

B

Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privary D. False imprisonment

B

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? A. "When did you pain begin?" B. "Can you describe the type of pain you are having?" C. "Could you please rate your pain on a 1-10 scale?" D. "How long have you experienced this pain?"

B

When assessing pain in a child, the nurse needs to be aware of what considerations? A. Immature neurologic development results in reduced sensation of pain B. Inadequate or inconsistent relief of pain is widespread C. Reliable assessment tools are currently unavailable D. Narcotic analgesic use should be avoided

B

When preparing a presentation for a local parent group about vaccines, the nurse would describe vaccines as being used to stimulate a. passive immunity to a foreign protein. b. active immunity to a foreign protein. c. serum sickness. d. a mild disease in healthy people.

B

Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply. A. A nurse runs an immunization clinic in the inner city. B. A nurse teaches a patient with an amputation how to care for the residual limb. C. A nurse provides range-of-motion exercises for a paralyzed patient. D. A nurse teaches parents of toddlers how to childproof their homes. E. A school nurse provides screening for scoliosis for the students. F. A nurse teaches new parents how to choose and use an infant car seat.

B, C

When assessing the medical record of an older adult to evaluate the status of his immunizations, the nurse would be looking for evidence of which immunizations? a. Yearly pneumococcal vaccination b. Yearly flu vaccination c. Tetanus booster every 10 years d. Tetanus booster every 5 years e. Measles, mumps, rubella vaccine if the patient was born after 1957 f. Varicella vaccine only if there is evidence that the patient had chickenpox as a child

B, C

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply. A. A White male diagnosed with HIV B. An African American teenager who is 6 months pregnant C. A Hispanic male who has type II diabetes D. A low-income family living in rural America E. A middle-class teacher living in a large city F. A White baby who was born with cerebral palsy

B, C, D, F

A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as disciplinary action against staff members. B. An incident report is used as a means of identifying risks. C. An incident report is used for quality control. D. The facility manager completes the incident report. E. An incident report makes facts available in case litigation occurs. F. Filing of an incident report should be documented in the patient record.

B, C, E

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A. A patient who is taking iron supplements for anemia. B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. D. A patient who is taking antibiotics for an ear infection. E. A patient who is prescribed antidepressants. F. A patient who is taking low-dose aspirin prophylactically.

B, C, E

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. A. Pain is whatever the health care provider treating the pain says it is B. Pain exists whenever the person experiencing it says it exists C. Pain is an emotional and sensory reaction to tissue damage D. Pain is a simple, universal, and easy-to-describe phenomenon E. Pain that occurs without a known cause is psychological in nature F. Pain is classified by duration, location, source, transmission, and etiology

B, C, F

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. A. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. B. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. C. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. D. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. E. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. F. The nurse reinforces the mental benefits of gaining self-control over an addiction.

B, D, F

A nurse working in a primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply. A. Health and illness are the same for all people. B. Health and illness are individually defined by each person. C. People with acute illnesses are actually healthy. D. People with chronic illnesses have poor health beliefs. E. Health is more than the absence of illness. F. Illness is the response of a person to a disease.

B, E, F

Culture conflicts occur when people become aware of cultural differences; cultural _______ occurs when one ignores differences and proceeds as though they do not exist.

Blindness

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? A. NSAIDs B. Corticosteroids C. Opioid analgesics D. Nonopioid analgesics

C

A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. B. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. D. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

D

Evelyn is a 90-year-old woman who just returned from the operating room to your medical unit. She is otherwise healthy and has a history of some mild arthritis. As you examine Evelyn, you know that all of the following are signs of pain EXCEPT which? A. Elevated blood pressure B. Elevated serum glucose C. Elevated lactic acid production D. Elevated kidney function

D

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation? A. Patients usually want to conceal information about their spiritual needs. B. Patients are not concerned about spiritual needs until after their spiritual adviser visits. C. Family members and close friends often initiate spiritual concerns. D. Illness increases spiritual concerns, which may be difficult for patients to express in words.

D

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed? A. Baptism frequently postpones or prevents death or suffering. B. It is legally required that nurses provide for this care when the family makes this request. C. It is a nursing function to assure the salvation of the baby. D. Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

D

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? A. Compare the client's current assessment with previous admission assessment. B. Educate the client/caregiver about signs of impending death C. Assess the client's serum albumin level D. Examine the effectiveness of the current pain regimen

D

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse? A. Administer a lower dose of the analgesic for the next dose B. Begin CPR C. Place the client in the supine position D. Administration of 0.4 mg of naloxone

D

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? A. judging whether the client is in pain or is just depressed B. beginning pain medications before the pain is too severe C. administering a placebo and performing a reassessment of the pain D. reviewing and revising the pain management treatment plan

D

The nurse reviews a patient's record to make sure that tetanus booster shots have been given a. only with exposure to anaerobic bacteria. b. every 2 years. c. every 5 years. d. every 10 years.

D

Which vaccine would the nurse be least likely to recommend for a 6-month-old child? a. Diphtheria, tetanus, pertussis vaccine b. Haemophilus influenzae b vaccine c. Poliovirus vaccine d. Chickenpox vaccine

D

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A. The United States has become less inclusive of same-sex couples. B. Cultural diversity is limited to people of varying cultures and races. C. Cultural diversity is separate and distinct from health and illness. D. People may be members of multiple cultural groups at one time. E. Culture guides what is acceptable behavior for people in a specific group. F. Cultural practices may evolve over time but mainly remain constant.

D, E, F

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. A. REM sleep constitutes much of the sleep cycle of a preschool child. B. By the age of 8 years, most children no longer take naps. C. Sleep needs usually decrease when physical growth peaks. D. Many adolescents do not get enough sleep. E. Total sleep decreases in adults with a decrease in stage IV sleep. F. Sleep is less sound in older adults and stage IV sleep may be absent.

D, E, F

Patient _______ is the process of influencing the patient's behavior to effect changes in knowledge, attitudes, and skills needs to maintain and improve health.

Education

Which term describes what occurs when a nurse believes that one's own ideas, beliefs, and practices are the best or superior to those of colleagues and patients?

Ethnocentrism

True or False: According to the National Center for Education Statistics, the majority of Americans (65%) are proficient in health literacy.

False

True or False: Patient teaching plans, different than nursing care plans, do not need to follow the steps of the nursing process.

False

True or False: Spider and snake bites that inject venom are treated with antitoxins.

False

True or False: The plague that is easily spread from person to person can be prevented with a vaccine.

False

True or False: When providing care to people from a different culture, it is important to allow past experiences to guide solutions to all cultural situations.

False

True or False: Stereotyping describes the feeling a person experiences when placed in a different culture.

False - Culture shock

True or False: Stereotyping occurs when people ignore differences in the cultures in which they live and proceed as if they do not exist.

False, cultural blindness

The term ________ ________ refers to sera that contain antibodies to specific bacteria or viruses.

Immune sera

The process of artificially stimulating active immunity by exposing the body to weakened or less toxic proteins is called ________.

Immunization

An example of a disease often diagnosed in a specific population is Tay-Sachs disease, which is associated with individuals of Eastern European _______ descent.

Jewish

The process of _______ occurs when a person acquires or increases knowledge, or changes behavior in a measurable way, as the result of a teaching experience.

Learning

_________ immunity is limited and occurs when preformed antibodies are injected into the system and react with a specific antigen.

Passive

The area around a person regarded as _______ space is the area into which others should not intrude during personal interactions.

Personal

A severe immune reaction that occurs most frequently with immune sera than with vaccines is called _______ _______.

Serum sickness

True or False: Active immunity occurs when the body recognizes a foreign body and produces antibodies that react to the specific protein or antigen.

True

True or False: Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one's family.

True

True or False: Ethnicity is a sense of identification with a collective cultural group based on the groups common heritage.

True

True or False: Ethnocentrism is the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture.

True

True or False: Health care information and directions are generally more easily understood when written at a fifth-grade reading level.

True

True or False: Learning readiness, the patients' willingness to engage in the teach - learning process, is distinguished from the patient's actual ability to learn.

True

True or False: One of the most culturally variable forms of nonverbal communication is eye contact.

True

True or False: The cognitive processes of adolescents are similar to those of adults, thus the content and strategies of patient teaching should resemble those used for teaching adults.

True

True or False: The health care system is a culture of its own, with nursing being its largest subculture.

True

True or False: Vaccines are used to promote active immunity and are pathogen specific

True