ECPI VB Nur 168 Concepts 3 Final Review

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. A. The family arranges for a funeral for their loved one. B. The family arranges for a memorial scholarship for their loved one. C. The coroner pronounces the patient's death. D. The family arranges for hospice for their loved one. E. The patient is diagnosed with terminal cancer. F. The patient's daughter writes a poem expressing her sorrow.

A, B, F

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? A. Acceptance B. Anger C. Bargaining D. Denial

A

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide? A. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. B. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. C. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." D. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

A

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. B. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. C. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. D. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

A

A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? A. "We're at the age when we should consider ceasing sexual activity." B. "We need more time for sexual stimulation than we used to." C. "If we are unable to have sex we can still have an intimate relationship." D. "If we change our position we can still have sex and be more comfortable.

A

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? A. Remove the IV from the site and start at another location. B. Immediately notify the primary care provider. C. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. D. Aspirate the catheter and attempt to flush again.

A

A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. A. A 72-year-old man with a history of diabetes B. A 78-year-old man who has a new partner C. A 75-year-old man who has Parkinson's disease D. An 80-year-old man who is an alcoholic E. An 85-year-old man who takes antihypertensive medication F. A 76-year-old man who smokes tobacco

A, D, E

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A. Group decision making B. Group leadership C. Group power D. Group identity E. Group patterns of interaction F. Group cohesiveness

A, D, E, F

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? A. Lack of self-esteem B. Deficient self-knowledge C. Unrealistic self-expectation D. Inability to evaluate himself

B

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: A. Kidneys B. Lungs C. Adrenal glands D. Blood vessels

B

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? A. "Oh, don't worry about that now. You need to sleep." B. "What seems to be concerning you the most?" C. "I have talked to your wife and she told me she will be fine." D. "I'm not qualified to advise you, I suggest you discuss this with your wife."

B

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? A. Pouring warm water over the patient's fingers. B. Having the patient ignore the urge to void until her bladder is full. C. Using a warm bedpan when the patient feels the urge to void. D. Stroking the patient's leg or thigh.

B

An RN working in a hospital setting is responsible for patient assessment. For which patient would the nurse perform a focused assessment? A. A patient newly admitted to the unit B. A patient with diabetes who develops secondary hypertension C. A patient who presents with signs of acute respiratory distress syndrome (ARDS) D. A patient who is recovering from abdominal surgery with no complications

B

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient.

B

A nurse is caring for a man with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would best prevent sensory alterations for this patient? A. Turn the radio or television volume up very loud and close the door to his room. B. Prevent embarrassment and emotional discomfort as much as possible. C. Provide daily opportunity for him to participate in a social hour with 6 to 8 people. D. Encourage daily participation in exercise and physical activity.

C

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? A. Decreasing pulse B. Increasing sleepiness C. Increasing energy levels D. Decreasing respirations

C

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more.

C

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? A. Olfactory B. Optic C. Facial D. Vagus

C

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema

C

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A. Recording intake and output. B. Testing skin turgor. C. Reviewing the complete blood count. D. Measuring weight daily.

D

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A. Reposition the extremity and raise the height of the IV pole. B. Apply pressure to the dressing on the IV. C. Pull the catheter out slightly and reinsert it. D. Put on gloves; remove the catheter

D

A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? A. "Depo-Provera is NOT effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." B. "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." C. "Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs." D. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

D

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline.

D

A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 1800, 1900, and 2000. A heart monitor beeps for a patient on one side, and another patient moans frequently. Which patient assessment would the nurse make based on this data? A. Sufficient sensory stimulation B. Deficient sensory stimulation C. Excessive sensory stimulation D. Both sensory deprivation and overload

D

A patient is in the late stages of AIDS, with alterations to the brain as well as other major organ systems. The patient complains of loneliness because of friends being "afraid to visit." Based on this data, what would the nurse determine to be the least likely underlying etiology for this patient's sensory problems? A. Stimulation B. Reception C. Transmission-perception-reaction D. Emotional responses

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 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 patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C. Teach the patient to take short shallow breaths when performing hygiene measures. D. Group personal care activities into smaller steps, allowing rest periods between activities.

D

A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? A. "Each person is born with a certain amount of sexual drive, which can be depleted in later years." B. "If you want to be a great athlete, sexual abstinence is necessary when you are training." C. "If you have a nocturnal emission (wet dream), it is an indicator of a sexual disorder." D. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

D

An older patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient? A. Assist the patient to ambulate by walking slightly behind her and grasping the arm. B. Concentrate on the patient's sense of sight and limit diversions that involve other senses. C. Stay outside of the patient's field of vision when performing personal hygiene for her. D. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.

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 family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? A. Inform the family that there is no need for them to wash the body since the mortician typically does this. B. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. C. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. D. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

D

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What does this finding indicate? A. Secretions in the lungs B. Fluid in the airways C. Normal breath sounds D. Narrowed airways

D

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? (ASK) A. "Do you currently have a new partner?" B. "Have you been diagnosed with a neurologic disorder?" C. "Do you take antihypertensive medication?" D. "Do you use antihistamines?"

D

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I will be careful not to shake up the canister before using it." B. "I will hold the canister upside down when using it." C. "I will inhale the medication through my nose." D. "I will continue to inhale when the cold propellant is in my throat." E. "I will only inhale one spray with one breath." F. "I will activate the device while continuing to inhale."

D, E, F

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare? A. POLST form B. Durable power of attorney for health care C. Living will D. Allow Natural Death (AND) form

B

A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED, but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? A. Getting the patient into a safe environment and mobilizing support for her B. Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped C. Convincing the student to be assessed for pregnancy, STIs, or other complications D. Convincing the student to tell her parents so that she can receive their support

A

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? A. The patient B. The patient's daughter C. The patient's health care provider D. The ethics consult team

A

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

A

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? A. The nurse leaves the patient in a sitting position while the family visits. B. The nurse places identification tags on both the shroud and the ankle. C. The nurse removes soiled dressings and tubes. D. The nurse makes sure a death certificate is issued and signed.

A

A nurse performing a spiritual assessment collects assessment data 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 patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife's health care provider about which type of order? A. Comfort Measures Only B. Do Not Hospitalize C. Do Not Resuscitate D. Slow Code Only

A

A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? A. Diaphragm B. Oral contraceptive pills C. Depo-Provera D. Evra patch

A

A patient's spinal cord was severed, causing paralysis from the waist down. When obtaining data about this patient, which component of the sensory experience would be a priority for the nurse to assess? A. Transmission of tactile stimuli B. Adequate stimulation in the environment C. Reception of visual and auditory stimuli D. General orientation and ability to follow commands

A

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? A. "HPV causes genital warts and cervical and other genital cancers." B. "HPV causes a single painless genital lesion and can lead to sterility." C. "50% of women between the ages of 14 and 19 are infected with HPV." D. "The HPV vaccination is only recommended for the female population.

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

In a group home in which most patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns? A. Maintaining safety and preventing sensory deterioration B. Insisting that every patient participate in as many self-care activities as possible C. Emphasizing and reinforcing individual patient strengths D. Encouraging reminiscence and life review in groups

A

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

A

Which patient would a nurse assess as being at greatest risk for sensory deprivation? A. An older adult confined to bed at home after a stroke B. An adolescent in an oncology unit working on homework supplied by friends C. A woman in labor D. A toddler in a playroom awaiting same-day surgery

A

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. A. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. B. Explain to the family what will happen at each phase of the weaning and offer support. C. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. D. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. E. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. F. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

A, B, C

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. A. Actual B. Perceived C. Psychological D. Anticipatory E. Physical F. Maturational

A, B, C

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

A, B, D, E

Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. A. A patient who is breast-feeding B. A patient who is diagnosed with anorexia C. A patient who chooses to abstain from sexual intercourse D. A patient who has pelvic inflammatory disease E. A patient who is obsessed with exercising F. A patient who has a spinal cord injury

A, B, D, E

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 certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. A. Progressive muscle relaxation B. Meditation C. Anticipatory socialization D. Biofeedback E. Rhythmic breathing F. Guided imagery

A, B, E, F

A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. A. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." B. "I should wean my infant by 4 months and encourage him to use a sippy cup." C. "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." D. "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." E. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." F. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

A, B, E, F

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. A. "Try to drink at least six to eight glasses of water each day." B. "Try to limit your fluid intake to 1 quart of water daily." C. "Limit sugar, salt, and alcohol in your diet." D. "Report side effects of medications you are taking, especially diarrhea." E. "Temporarily increase foods containing caffeine for their diuretic effect." F. "Weigh yourself daily and report any changes in your weight."

A, C, D, F

A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care? A. To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient. B. The nurse sits on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient. C. The nurse refers to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father. D. The nurse tells a dying patient to sit back and relax and performs patient hygiene for the patient because it is easier than having the patient help.

B

A nurse is diagnosing an 11-year-old student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Based on this assessment data, which alteration would the nurse document for this patient? A. Self-care deficit B. Altered Role Performance (Student) C. Disturbed Body Image D. Delayed Growth and Development

B

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? A. Encourage foods and fluids with high sodium content. B. Administer oral K supplements as ordered. C. Caution the patient about eating foods high in potassium content. D. Discuss calcium-losing aspects of nicotine and alcohol use.

B

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the nurse would be most appropriate? A. "You can't be feeling this way. You know you are going to die." B. "It does seem unfair. Tell me more about how you are feeling." C. "You'll be all right; who knows how much time any of us has." D. "Tell me about your pain. Did it keep you awake last night?"

B

A nurse observes that a patient who has cataracts is sitting closer to the television than usual. Which alteration would the nurse suspect is causing this patient behavior? A. Altered stimulation B. Altered sensory reception C. Altered nerve impulse conduction D. Altered impulse translation

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 patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. B. Keeping fluids readily available for the patient. C. Emphasizing the long-term outcome of increasing fluids when the patient returns home. D. Planning to offer most daily fluids in the evening.

B

The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? A. "Children should be taught not to masturbate because most people believe self-stimulation is wrong." B. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." C. "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." D. "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

B

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? A. 1 B. 2 C. 3 D. 4

B

Which action would be most important for a nurse to include in the care plan for a patient diagnosed with presbycusis? A. Obtaining large-print written material B. Speaking distinctly, using lower frequencies C. Decreasing tactile stimulation D. Initiating a safety program to prevent falls

B

A nurse is assessing a patient for tactile disturbances. Which question asked by the nurse would be appropriate for this assessment? A. "Have you been experiencing any strange tastes lately?" B. "Have you smelled odors lately that other cannot smell?" C. "Can you tell me what I am placing in your hand right now?" D. "Have you found it difficult to communicate verbally?"

C

A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply. A. LGBT youth are four times more likely to attempt suicide. B. LGBT youth are more likely to be homeless. C. Lesbians are less likely to get preventive services for cancer. D. Lesbians and bisexual females are more likely to be underweight. E. Transgender people have a high prevalence of HIV and sexually transmitted infections. F. LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

B, C, E

A nurse is assessing a patient in a long-term care facility. The nurse notes that the patient is at risk for sensory deprivation due to limited activity related to severe rheumatoid arthritis. Which interventions would the nurse recommend based on this finding? Select all that apply. A. Use a lower tone when communicating with the patient. B. Provide interaction with children and pets. C. Decrease environmental noise. D. Ensure that the patient shares meals with other patients. E. Discourage the use of sedatives. F. Provide adequate lighting and clear pathways of clutter.

B, D, E

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Refrain from exercise. B. Reduce anxiety. C. Eat meals 1 to 2 hours prior to breathing treatments. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. F. Drink 2 to 3 pints of clear fluids daily.

B, D, E

A nurse is assessing a patient who is visiting her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? A. Human papillomavirus (HPV) B. Syphilis C. Trichomoniasis D. Herpes simplex virus

C

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 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 assessing an 8-month-old infant suspects the infant is experiencing sensory deprivation related to inadequate parenting. Since this assessment, both parents have attended parenting classes. However, both parents work while the infant stays with a grandparent, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor, rocking back and forth and has a dull facial expression with few vocalizations. Which nursing action would be appropriate for this patient and family? A. Explore why the infant's parents lack motivation to provide necessary stimulation. B. Remove the infant from the grandmother's care as the child has not progressed. C. Suggest counseling since the infant's sensory deprivation is still severe. D. No action is needed, as this is normal behavior for an 11-month-old infant.

C

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? A. Somatic grief B. Anticipatory grief C. Unresolved grief D. Inhibited grief

C

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia

C

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A. A pinched and drawn facial expression B. Deep, rapid respirations. C. Moist crackles heard upon auscultation D. Tachycardia

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 to feel at peace?

C

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A. Instruct the assistant to notify the primary care provider. B. Assess the patient's vital signs. C. Remove the tape, adjust the depth to ordered depth and reapply the tape. D. No action is required as depth will adjust automatically.

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 data 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 patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. How would the nurse document this data? A. Masochism B. Pedophilia C. Voyeurism D. Sadism

C

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document? A. Grieving B. Ineffective Coping C. Caregiver Role Strain D. Powerlessness

C

An 18-year-old presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? A. "Vaginal intercourse is most commonly performed in the missionary position." B. "The side-by-side position achieves better clitoral stimulation than the missionary position." C. "Achieving simultaneous orgasms is the goal of vaginal intercourse." D. "The period after coitus is just as significant as the events leading up to it."

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

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C

An older adult in a long-term care facility walked out the door unobserved and was lost for several hours. Upon assessment, the nurse notes that the patient is confused and documents: chronic sensory deprivation related to the effects of aging. Which interventions would be most effective for this patient? Select all that apply. A. Ignore the patient's confusion, or go along with it to prevent embarrassment. B. Reduce the number and type of stimuli in the patient's room. C. Orient the patient to time, place, and person frequently. D. Provide daily contact with children, community people, and pets. E. Decrease background or loud noises in the environment. F. Provide a radio and television in the patient's room.

C, D, F

A nurse is assessing an older adult patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. A. The nurse asks the patient if he is bored, and if so, why. B. The nurse asks the patient if anything interferes with the functioning of his senses. C. The nurse asks the patient if he noticed any changes in the way he perceives his body. D. The nurse asks the patient if he has found it difficult to communicate verbally. E. The nurse notes if the patient withdraws from being touched. F. The nurse notes if the patient seems unsure of his body parts or position.

C, E, F

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. A. 5% dextrose in 0.9% NaCl B. 0.9% NaCl (normal saline) C. Lactated Ringer's solution D. 0.33% NaCl (⅓-strength normal saline) E. 0.45% NaCl (½-strength normal saline) F. 5% dextrose in Lactated Ringer's solution

D, E

A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? (Select all that apply.) A. The charge nurse polls the other nurses for input on nursing protocols. B. The charge nurse dictates break schedules for the other nurses. C. The charge nurse schedules a mandatory in-service training on new equipment. D. The charge nurse allows the other nurses to divide up nursing tasks. E. The charge nurse delegates nursing responsibilities to the staff. F. The charge nurse encourages the nurses to work independently.

B, C, E

A nurse manager is attempting to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: A. The nurse devises a plan to switch to EHR. B. The nurse records the time spent on written records versus EHR. C. The nurse attains approval from management for new computers. D. The nurse analyzes all options for converting to EHR. E. The nurse installs new computers and provides an in-service for the staff. F. The nurse explores possible barriers to changing to EHR. G. The nurse follows up with the staff to check compliance with the new system. H. The nurse evaluates the effects of changing to EHR.

B, F, D, C, A, E, H, G

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? A. Personal Identity Disturbance B. Body Image Disturbance C. Self-Esteem Disturbance D. Altered Role Performance

C

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? A. Recommend that she discipline her daughter more strictly and consistently. B. Make a list of things her husband can do to give her more time and help her improve her parenting skills. C. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. D. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

C

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? A. The nurse teaches a patient rhythmic breathing to perform prior to the procedure. B. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. C. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. D. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

C

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? A. An infant who learns to turn over B. A school-aged child who learns how to add and subtract C. An adolescent who is a "loner" D. A young adult who has a variety of friends

C

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? A. Teach the patient that incontinence is a normal occurrence with aging. B. Ask the patient's family to purchase incontinence pads for the patient. C. Teach the patient to perform PFMT exercises at regular intervals daily. D. Insert an indwelling catheter to prevent skin breakdown.

C

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? A. Irrigation of long-term urinary catheters is a routine order. B. Irrigation is recommended to prevent the introduction of pathogens into the bladder. C. A blood clot threatens to block the catheter. D. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.

C

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? A. Negative self-concept and low self-esteem B. Negative self-concept and high self-esteem C. Positive self-concept and fairly high self-esteem D. Positive self-concept and low self-esteem

C

A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? A. Ineffective Coping related to the new parenting role B. Ineffective Denial related to ability to care for a newborn C. Anxiety related to change in role status D. Situational Low Self-Esteem related to fear of parenting

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 nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? A. Determining the established goals of the institution B. Ensuring that verbal and nonverbal communication is congruent C. Engaging in self-talk to plan the day and decrease fear D. Speaking with fellow colleagues about how they feel

C

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as: A. The patient can see twice as well as normal. B. The patient has double vision. C. The patient has less than normal vision. D. The patient has normal vision.

C

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? A. "I love my child so much I 'hug him to death' every day." B. "I think children need challenges, don't you?" C. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." D. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

C

An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? A. The assessment of a patient who has just arrived on the unit B. Teaching a patient with newly diagnosed diabetes about foot care C. Documentation of a patient's I & O on the flow chart D. Helping a patient who has recently undergone surgery out of bed for the first time

C

During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is more comfortable for the patient

C

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A. "Do you take two injections of insulin to decrease the complications?" B. "Most health care providers recommend diet and exercise to regulate blood sugar." C. "Most complications of diabetes are related to neuropathy." D. "What specific complications have you experienced?"

D

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? A. Personal Identity Disturbance B. Body Image Disturbance C. Self-Esteem Disturbance D. Altered Role Performance

D

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? A. Arrange to have the infant removed from the home. B. Inform other members of the family of the situation. C. Increase the number of visits by the visiting nurse. D. Notify the care provider and recommend respite care for the mother.

D

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? A. The incontinence pattern B. State of physical mobility C. Medications being taken D. Age of the patient

D

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? A."You need to speak to the patient quietly so you don't disturb the other patients." B. "Let me help you with your transfer technique." C."When you are finished, be sure to apologize for your rough demeanor." D. "When your patient is safe and comfortable, meet me at the desk."

D

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. A. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. B. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. C. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. E. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. F. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

D, E, F

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? A. "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." B. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C. "I will need to call in on the 8th of August because I have a doctor's appointment." D. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B

A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? A. Ask the patient to sit about 3 ft away facing the nurse. B. Keep a penlight about 1 ft from the patient's face and move it slowly through the cardinal positions. C. Move a penlight in a circular motion in front of the patient's eyes. D. Ask the patient to cover one eye with a hand or index card.

B

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document? A. Awake and alert B. Lethargic C. Stuporous D. Comatose

B

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure

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 choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? A. The age of the patient B. The size of the endotracheal tube C. The type of secretions to be suctioned D. The height and weight of the patient

B

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? A. Projection B. Denial C. Displacement D. Repression

B

A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? A. The nurse would use different equipment for catheterization of male versus female patients. B. The nurse should use the smallest appropriate indwelling urinary catheter. C. The nurse should always sterilize the equipment prior to insertion. D. The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.

B

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A. A closed-ended answer B. Information clarification C. The nurse to give advice D. Assertive behavior

B

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? A. "I must breathe in and out in rhythm." B. "I should take my pulse and expect it to be faster." C. "I can expect my muscles to feel less tense." D. "I will be more relaxed and less aware."

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 FOUR coma scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent? A. Localizing to pain B. Flexion response to pain C. Extension response to pain D. No response to pain

B

A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? A. Containing the anxiety in a small group and moving forward with the initiative B. Explaining the change and listing the advantages to the person and the organization C. Reprimanding those who oppose the new initiative and praising those who willingly accept the change D. Introducing the change quickly and involving the staff in the implementation of the change

B

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? A. "Would you prefer a bath or a shower?" B. "May I help you with a bed bath now or later this morning?" C. "I will be giving you your bath. Do you use soap or shower gel?" D. "I prefer a shower in the evening. When would you like your bath?"

B

A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. A. Wear underwear with a synthetic crotch B. Take baths rather than showers C. Drink 8 to 10 8-oz glasses of water per day D. Drink a glass of water before and after intercourse and void afterward E. Dry the perineal area after urination or defecation from the front to the back F. Observe the urine for color, amount, odor, and frequency

C, E, F

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 caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. A. A 78-year-old male patient diagnosed with an enlarged prostate B. An 83-year-old female patient who is on bedrest C. A 75-year-old female patient who is diagnosed with vaginal prolapse D. An 89-year-old male patient who has dementia E. A 73-year-old female patient who is taking antihistamines to treat allergies F. A 90-year-old male patient who has difficulty walking to the bathroom

A, C, E

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) B. A young clergyperson whose vocal cords are paralyzed after a motorbike accident C. A 32-year-old accountant who survives a massive heart attack D. A 23-year-old model who just learned that she has breast cancer

A

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? A. "I need to identify the problem first." B. "Listing alternatives is the initial step." C. "I will list alternatives after I develop the plan." D. "I do not need to evaluate the outcome of my plan."

A

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? A. Personal Identity Disturbance B. Body Image Disturbance C. Self-Esteem Disturbance D. Altered Role Performance

A

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? A. Decreased and highly concentrated B. Decreased and highly dilute C. Increased and concentrated D. Increased and dilute

A

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? A. "New mothers need support." B. "The lack of a father is difficult." C. "How are you today?" D. "It is a very sad situation."

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

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? A. The male urethra is more vulnerable to injury during insertion. B. In the hospital, a clean technique is used for catheter insertion. C. The catheter is inserted 2 to 3 in into the meatus. D. Since it uses a closed system, the risk for UTI is absent.

A

When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding? A. Jaundice B. Cyanosis C. Erythema D. Pallor

A

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A. Cliché B. Giving advice C. Being judgmental D. Changing the subject

A

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? A. "Are you worried about failing your exams?" B. "Have you been staying up late studying?" C. "Are you using any recreational drugs?" D. "Do you have trouble managing your time?"

A

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding? A. Document and report the finding of abnormal Rhonchi breath sounds B. Document the finding of normal bronchovesicular breath sounds C. Document and report the finding of abnormal stridor breath sounds D. Document the finding of normal bronchial sounds

A

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A. Determining the progress made in achieving established goals B. Clarifying when the patient should take medications C. Reporting the progress made in teaching to the staff D. Including all family members in the teaching session

A

A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? A. Preventing the tubing from kinking to maintain free urinary drainage B. Not removing the sheath for any reason C. Fastening the sheath tightly to prevent the possibility of leakage D. Maintaining bedrest at all times to prevent the sheath from slipping off

A

A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish red today; is there something wrong with me?" What would be the nurse's best response? A. "This is a normal finding when taking phenazopyridine." B. "This may be a sign of blood in the urine." C. "This may be the result of an injury to your bladder." D. "This is a sign that you are allergic to the medication and must stop it."

A

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate

A

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? A. Monitoring food and drink temperatures to prevent burns B. Providing adequate pain relief measures to reduce stress C. Monitoring for depression related to social isolation D. Providing meals high in carbohydrates to promote healing

A

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? A. Realistic and positively motivating his development B. Unrealistic and negatively motivating his development C. Unrealistic but positively motivating his development D. Realistic but negatively motivating his development

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 suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter. B. Notify the primary care provider. C. Check that the airway is the appropriate size for the patient. D. Place the patient on his or her back.

A

A nurse is using the circular technique to palpate the breast of a woman during an assessment. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall. How would the nurse proceed with the palpation? A. Start at the tail of Spence and move in increasing smaller circles. B. Start at the outer edge of the breast and palpate up and down the breast. C. Work in a counterclockwise direction and palpate from the periphery toward the areola. D. Start at the inner edge of the breast and palpate up and down the breast.

A

A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? A. The nurse asks patients to prioritize what they want to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

A

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? A. Pain B. Anxiety C. Depression D. Fluid volume deficit

A

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. A. Changes in appetite B. Changes in elimination patterns C. Decreased pulse and respirations D. Use of ineffective coping mechanisms E. Withdrawal F. Attention-seeking behaviors

A, B

A nurse who is newly hired to manage a busy pediatric office is encouraged to use a transactional leadership style when dealing with subordinates. Which activities best exemplify the use of this type of leadership? Select all that apply. The manager institutes a reward program for employees who meet goals and work deadlines. The manager encourages the other nurses to participate in health care reform by joining nursing organizations. The manager promotes compliance by reminding subordinates that they have a good salary and working conditions. The manager makes sure all the employees are kept abreast of new developments in pediatric nursing. The manager works with subordinates to accomplish all the nursing tasks and goals for the day. The manager allows the other nurses to set their own schedules and perform nursing care as they see fit.

A, C

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. A. The nurse makes a point to address the patient by name upon entering the room. B. The nurse avoids fatiguing the patient by performing all procedures in silence. C. The nurse performs care in a manner that respects the patient's privacy and sensibilities. D. The nurse offers the patient a simple explanation before moving her in any way. E. The nurse ignores negative feelings from the patient since they are part of the grieving process. F. The nurse avoids conversing with the patient about her life, family, and occupation.

A, C, D

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. A. Increased heart rate B. Decreased muscle strength C. Increased mental alertness D. Increased blood glucose levels E. Decreased cardiac output F. Decreased peristalsis

A, C, D

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. A. Measure the patient's fluid intake and output. B. Keep the skin around the stoma moist. C. Empty the appliance frequently. D. Report any mucus in the urine to the primary care provider. E. Encourage the patient to look away when changing the appliance. M. Monitor the return of intestinal function and peristalsis.

A, C, F

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. A. Teach the parents to reinforce their child's positive qualities. B. Teach the parents to overlook occasional negative behavior. C. Teach parents to ignore neutral behavior that is a matter of personal preference. D. Teach parents to listen and "fix things" for their children. E. Teach parents to describe the child's behavior and judge it. F. Teach parents to let their children practice skills and make it safe to fail.

A, C, F

A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply. A. Are you able to dress yourself? B. Do you have a history of smoking? C. What is the problem for which you are seeking care? D. Do you prepare your own meals? E. Do you manage your own finances? F. Whom do you rely on for support?

A, D, E

A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply A. The nurse motivates coworkers to solicit funding to set up the clinic. B. The nurse sets only realistic goals that are present oriented and easily achieved. C. The nurse forms an autocratic governing body to keep the project on track. D. The nurse spends time with supporters to help them grow in their roles. E. The nurse first ensures that other's lowest priority needs are served. F. The nurse prizes leadership because of the need to serve others.

A, D, F

A new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? A. Centralizing the decision-making process B. Promoting self-governance at the unit level C. Deterring professional autonomy to promote teamwork D. Promoting evidence-based practice over innovative nursing practice

B

A nurse caring for a patient's hemodialysis access documents the following: "5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? A. Positive bruit noted. B. Area is warm to touch and edematous. C. Patient denies pain and tenderness. D. Positive thrill noted.

B

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? A. The patient will make above-B grades in all tests at school. B. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. C. The patient reports that she feels more self-confident in her music and art, which she enjoys. D. The patient expresses that she is very smart in school.

B

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? A. Personal Identity Disturbance B. Body Image Disturbance C. Self-Esteem Disturbance D. Altered Role Performance

B

The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing actions could the nurse perform with the patient in this position? Select all that apply. A. Assessing the abdomen B. Taking peripheral pulses C. Performing a breast examination D. Auscultating the heart E. Assessing vital signs F. Assessing balance and gait

B, C, D

Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply. A. The nurse compares the patient's bilateral body parts for symmetry. B. The nurse takes a patient's pulse. C. The nurse touches a patient's skin to test for turgor. D. The nurse checks a patient's lymph nodes for swelling. E. The nurse taps a patient's body to check the organs. F. The nurse uses a stethoscope to listen to a patient's heart sounds.

B, C, D

A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply. A. Bring a penlight from the side of the patient's face and briefly shine the light on the pupil. B. Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. C. Hold a finger about 6 to 8 in from the bridge of the patient's nose. D. Darken the room. E. Ask the patient to look straight ahead. F. Ask the patient to first look at a close object, then at a distant object, then back to the close object.

B, F

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

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. A. Fill the silence with lighter conversation directed at the patient. B. Use the time to perform the care that is needed uninterrupted. C. Discuss the silence with the patient to ascertain its meaning. D. Allow the patient time to think and explore inner thoughts. E. Determine if the patient's culture requires pauses between conversation. F. Arrange for a counselor to help the patient cope with emotional issues.

C, D, E

A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? A. Collaborating B. Competing C. Compromising D. Smoothing

D

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? A. The use of reflective questions B. The use of closed questions C. The use of assertive questions D. The use of clarifying questions

D

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? A. There is no disturbance in self-concept. B. This patient has ego strength and high self-esteem but may have a disturbance of body image. C. The area of self-esteem has very low priority at this time and should be ignored until much later. D. It is probable that there are disturbances in self-esteem and body image.

D

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? A. Negative self-concept B. Modesty (lack of conceit) C. Body image disturbance D. Low self-esteem

D

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A. "I'm just the IV therapist checking your IV." B. "I've been transferred to this division and will be caring for you." C. "I'm sorry, my name is John Smith and I am your nurse." D. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

D

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? A. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." B. The nurse places a hand on the patient's arm and states, "You feel so alone." C. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D

A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? A. "Patient displays moderate anxiety related to her situation." B. "Patient manifests panic related to feelings of impending doom." C. "Patient describes severe anxiety related to her situation." D. "Patient expresses fear of her husband."

D

A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? A. The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities B. The nurse mentor hires the new nurse and assigns duties related to the position C. The nurse mentor makes it possible for the new nurse to participate in professional organizations D. The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

D

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? A. The stoma is hard and dry. B. The stoma is a pale pink color. C. The stoma is swollen. D. The stoma is a purple-blue color.

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 is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? A. Discouraging over verbalization of fears and anxieties B. Focusing on the outcome as opposed to the details of the surgery C. Providing time alone for reflection on personal strengths and weaknesses D. Mutually determining expected outcomes of the care plan

D

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning.

D