Adult Health Exam 3 EAQs

Which domain of learning would the nurse focus on while teaching a patient with heart failure about behavioral and lifestyle modifications? Select all that apply. One, some, or all responses may be correct. A. Cognitive B. Affective C. Psychomotor D. Attentive E. Psychosocial

A, B The cognitive domain involves acquisition of knowledge, comprehension, and application of the acquired knowledge. The affective domain involves expressing feelings and accepting attitudes, opinions, and values. The nurse should focus on these two domains while teaching the patient about behavioral modifications. The psychomotor domain involves the use of mental and muscular activity. "Attentive" and "Psychosocial" are not domains of learning.

Which method is appropriate to teach a patient how to self-administer insulin? Select all that apply. One, some, or all responses may be correct. A. Lecture B. Demonstration C. Return demonstration D. Role playing E. Question and answer session

A, B, C Learning how to self-administer insulin requires handling a needle and syringe and occurs in the psychomotor domain. Demonstration and return demonstration are the appropriate methods of teaching this patient. A demonstration of the procedure by the nurse helps the patient observe the nurse's behavior and allows the nurse to control questioning. A return demonstration allows the patient to perform the procedure as the nurse observes and provides feedback. A lecture is a teaching method involving the cognitive domain. Role playing focuses on the cognitive and affective domains of learning. A question and answer session is appropriate when addressing a patient's particular concerns in the cognitive domain.

Which approach is likely to be effective when communicating with a Spanish-speaking patient who has a hand fracture? Select all that apply.One, some, or all responses may be correct. A. Assessing the patient's level of fluency in English B. Incorporating the patient's communication methods C. Providing written information in English and the primary language D. Designating a family member of the patient as an interpreter E. Perceiving patient nodding or statements such as "OK" as indications of effective understanding

A, B, C The nurse would include the following: assessing the patient's level of fluency in English, incorporating the patient's communication methods, and providing written information in English and the primary language. It is necessary to assess the patient's primary language and level of fluency in English. Incorporating the patient's communication methods or need into plan of care is an important action. Providing written information in English and in the primary language of the patient is an essential action while communicating with a non-English-speaking patient. While caring for a non-English-speaking patient, a professional interpreter should be provided; a family member should not be used as an interpreter. Nodding or making statements such as "OK" are not necessarily indications of understanding.

Which quality will enable the patient to perform dressing changes at home? Select all that apply. One, some, or all responses may be correct. A. Adequate strength B. Sensory acuity C. Coordination D. A caregiver's attitude E. Self-esteem

A, B, C The patient should have enough strength to get up and perform dressing changes. The patient should also possess sensory acuity and proper coordination to perform and learn the required tasks. A caregiver's attitude is required when providing care to others. Having self-esteem is unrelated to performing dressing changes.

Which teaching method would the nurse use to teach preschoolers how to wash their hands? Select all that apply. One, some, or all responses may be correct. A. Use role playing and imitation. B. Encourage questions and offer explanations. C. Encourage the children to learn together through short stories and pictures. D. Encourage participation in a teaching plan. E. Encourage independent learning.

A, B, C The teaching methods should be appropriate to the developmental stage of the preschoolers. Role play and imitation should be used to make learning fun. Asking questions should be encouraged; simple explanations should be provided. Preschoolers love to learn through short stories and pictures. Learning in a group is more fun than learning alone. Preschoolers will not be able to participate in a teaching plan or do independent learning. These teaching methods are more suitable for a young or middle-aged adult.

The nurse is designing a teaching plan for a patient to prevent urinary tract infections. When planning the teaching, which factor would the nurse keep in mind? Select all that apply. One, some, or all responses may be correct. A. It should cater to the needs of the patient. B. Teaching should be problem based. C. Provide only necessary information. D. Teaching should be based on mutually exclusive experiences. E. It should prompt the learner to engage in activities that lead to a desired change.

A, B, C, E Before preparing the teaching plan, the nurse should understand the patient's needs. The nurse should consider the problem the patient is facing and provide only the necessary information. This will help prevent information overload for the patient. The objective of the teaching is to educate the patient about the prevention of urinary tract infections. Therefore the teaching should prompt the patient to adopt preventive measures against urinary tract infections. The teaching should be based on real-life experiences rather than mutually exclusive ones.

A middle-aged patient is diagnosed with erectile dysfunction. Which associated condition might the nurse find in the patient? Select all that apply.One, some, or all responses may be correct. A. Diabetes mellitus B. Hypertension C. Anorexia D. Hyperlipidemia E. Hyperthyroidism

A, B, D Diabetes mellitus, hypertension, and hyperlipidemia are risk factors associated with erectile dysfunction. Obesity, not anorexia, is a risk factor for erectile dysfunction. Hypothyroidism, not hyperthyroidism, is associated with erectile dysfunction.

Which skill would facilitate attentive listening while interacting with the patient? Select all that apply.One, some, or all responses may be correct. A. Sit at an angle facing the patient. B. Maintain intermittent eye contact. C. Lean away from the patient. D. Be relaxed and comfortable. E. Keep arms and legs crossed.

A, B, D Skills to facilitate attentive listening include the following: sit at an angle facing the patient, maintain intermittent eye contact, and be relaxed and comfortable. It is essential to sit at an angle facing the patient, because this posture conveys the message that the nurse is there to listen to what the patient is saying. The nurse should maintain intermittent eye contact to convey involvement in and willingness to listen to what the patient is saying. It is important to communicate with a sense of being relaxed and comfortable with the patient. It is important to lean toward the patient and not away from the patient, because this position conveys that the nurse is involved and interested. The nurse should sit in an open position by keeping his or her arms and legs uncrossed, because this position suggests that the nurse is "open" to what the patient says. A "closed" position, such as crossing arms, conveys a defensive attitude.

While studying the different domains of learning, the nurse finds discussion to be the appropriate teaching method based on cognitive learning. Which characteristic is true of the discussion method? Select all that apply. One, some, or all responses may be correct. A. It allows peer support. B. It involves both the nurse and the patient. C. It involves presentation of procedures or skills by the nurse. D. It helps the patient learn from others' experiences. E. It allows the patient to assume responsibility for completing learning activities at his or her own pace.

A, B, D The discussion method involves interaction between both the nurse and the patient. This method allows peer involvement and enables the patient to learn from others' experiences. Demonstration is the teaching method that involves presentation of procedures or skills by the nurse. Unlike the role play method, the demonstration method does not allow the patient to assume responsibility for completing learning activities at his or her own pace.

When conducting a comprehensive sexual history assessment, which question would the nurse include? Select all that apply. One, some, or all responses may be correct. A. "To how many babies have you given birth?" B. "Do you know about contraception?" C. "Have you had a urinary tract infection?" D. "How many sexual partners have you had in the past?" E. "Have you undergone a surgical removal of a kidney?"

A, B, D While assessing a patient's sexual history, the nurse should ask about the number of children and the means of contraception. A comprehensive sexual assessment also gathers information about the number of sexual partners the patient has had in the past. Questions regarding urinary tract infection or surgical removal of a kidney do not provide information about the sexual history and hence are not included in the assessment.

Which vitamin should be provided to a patient to promote wound healing? Select all that apply. One, some, or all responses may be correct. A. A B. B C. C D. D E. E

A, C Vitamin A helps in epithelialization and closure of the wound. It helps in angiogenesis and promotes collagen formation. Vitamin C promotes collagen synthesis. It also enhances fibroblast function and immunological function. Vitamin B, Vitamin D, and Vitamin E do not have a role in wound healing.

The nurse is teaching a patient about hygiene practices. During the interaction, the patient expresses feelings and opinions about the teaching provided and hygiene practices. The nurse understands that these expressions are a part of the affective domain of learning. Which behavior is included in affective learning? Select all that apply. One, some, or all responses may be correct. A. Organizing B. Perception C. Responding D. Characterizing E. Comprehension

A, C, D Affective learning deals with the expression of feelings, beliefs, or values. It includes behaviors like organizing, responding, and characterizing. Organizing refers to developing a value system by identifying and organizing values and resolving conflicts. Responding refers to active participation through listening and reacting verbally and nonverbally. Characterizing refers to acting and responding with a consistent value system. Comprehension is a part of cognitive learning. Perception is a type of psychomotor learning.

A patient with heart disease asks the nurse if medications for heart disease can cause erectile dysfunction. Which drugs can cause erectile dysfunction? Select all that apply One some or all responses may be correct. A. Illicit drugs B. Antidiabetics C. Diuretic agents D. Antiplatelet drugs E. Antihypertensives

A, C, E Drugs that have been associated with erectile dysfunction include illicit drugs, diuretic agents, and antihypertensive medications. Antidiabetic and antiplatelet drugs are not associated with erectile dysfunction but are associated with minor side effects such as nausea, diarrhea, and itchy skin.

Certain cultural groups in the United States are disproportionately affected by infectious diseases such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Which factor increases the risk of HIV and AIDS? Select all that apply.One, some, or all responses may be correct. A. Expectations about behavior by men or women in the culture B. Higher percentages of LGBTQ+ (lesbian, gay, bisexual, transgender, queer, questioning, asexual, and others) individuals in the culture C. Genetic predisposition to the disease in the culture D. Communication patterns and language practiced by the culture E. Varied climate in different geographic locations

A, D Cultural factors such as gender, education, socioeconomic status, religion, language, and values influence the use of the health care system. Populations that are at increased risk of HIV include those who are intravenous drug users, those with hemophilia, and those who practice unprotected sex. Simply having a higher percentage of LGBTQ+ individuals in the culture does not increase the risk of HIV or AIDS in that population; unsafe sexual practices increase the risk. Genetic factors often increase the risk of certain health problems such as cardiovascular disease or cancers, but do not usually increase the risk of HIV because it is a viral infection and not a genetic disease. Climate does not increase the risk of HIV.

The nurse attends to a group of patients with depression. The nurse conducts a group discussion with the patients to teach them effective learning skills. How will the group discussion help the patients? Select all that apply. One, some, or all responses may be correct. A. Allow patients to receive support from other patients in the group. B. Encourage patients to express concerns. C. Allow patients to discuss personal and sensitive things. D. Help patients learn from others' experiences. E. Promote responsiveness, valuing others, and organization.

A, D, E If patients with depression sit in a group and interact with other patients who have similar symptoms, they receive support from other patients in the group. The group discussion helps them learn from the experiences of others and promotes responsiveness, valuing others, and organization. However, patients may not speak of their concerns or about sensitive topics in a group. In that case, the nurse will need to have a one-on-one conversation.

A couple approaches the nurse for advice about nonprescription contraceptive methods. Which method would the nurse discuss with the couple? Select all that apply.One, some, or all responses may be correct. A. Abstinence from intercourse B. Skin patches C. Vaginal rings D. Condoms and spermicides E. Timing of coitus

A, D, E Nonprescription contraceptive options for couples include abstinence from sexual intercourse, condoms and spermicidal products, and timing coitus with women's ovulation cycles. Skin patches and vaginal rings contain hormonal substances that require a health care provider's prescription for use.

A couple approaches the nurse for advice about nonprescription contraceptive methods. Which method would the nurse discuss with the couple? Select all that apply. One, some, or all responses may be correct. A. Abstinence from intercourse B. Skin patches C. Vaginal rings D. Condoms and spermicides E. Timing of coitus

A, D, E Nonprescription contraceptive options for couples include abstinence from sexual intercourse, condoms and spermicidal products, and timing coitus with women's ovulation cycles. Skin patches and vaginal rings contain hormonal substances that require a health care provider's prescription for use.

Which statement by the nurse indicates a correct understanding of the elements of professional communication? Select all that apply. One, some, or all responses may be correct. A. "I should introduce myself by giving my name and title." B. "I will address patients by their first names during initial interactions." C. "I should address patients with a confused cognitive status by their last names." D. "I will avoid referring to patients by diagnosis, room number, or other attributes." E. "I should avoid terms such as 'honey,' 'dear,' or 'grandma' while addressing the patients."

A, D, E The nurse would have a correct understanding by the following statements: "I should introduce myself by giving my name and title," "I will avoid referring to patients by diagnosis, room number, or other attributes," and "I should avoid terms such as 'honey,' 'dear,' or 'grandma' while addressing the patients." The nurse should introduce him- or herself by giving his or her name and status, such as nursing student, registered nurse (RN), or licensed practical nurse (LPN). It is important that the nurse avoid referring to patients by diagnosis, room number, or other attributes, because this approach would be demeaning to patients. The nurse should avoid terms of endearment while addressing patients, even with close nurse-patient relationships. Addressing patients by the last name is respectful in most cultures; nurses usually use a patient's last name in an initial interaction and then use the first name if the patient requests it. Using first names is appropriate for infants, young children, and patients who are confused or unconscious, as well as close team members.

Which statement about chlamydia is appropriate? Select all that apply.One, some, or all responses may be correct. A. It affects the genitourinary tract. B. There is no cure for this disorder. C. It does not cause ectopic pregnancy. D. The rectum is resistant to chlamydia infection. E. It may cause infection of the eyes and lungs in newborns.

A, E Chlamydia infection affects the genitourinary system and causes conjunctivitis and pneumonia in newborns. Chlamydia can be cured with antibiotics. Chlamydia infection may cause pelvic inflammatory disease (PID), infertility, and ectopic pregnancy. Chlamydia also infects the rectum.

The nurse is educating a couple about sexually transmitted infections. Which sexual infection cannot be cured? Select all that apply. One, some, or all responses may be correct. A. Herpes B. Syphilis C. Chlamydia D. Gonorrhea E. Human papillomavirus infection

A, E Sexually transmitted infections that cannot be cured include herpes and human papillomavirus. Syphilis, chlamydia, and gonorrhea are sexually transmitted infections caused by bacteria; they can be cured by antibiotics. Syphilis is caused by the bacteria Treponema pallidum. Chlamydia is caused by the bacteria Chlamydia trachomatis. Gonorrhea is caused by the bacteria Neisseria gonorrhoeae.

Which learning objective would be evaluated in the discharge notes of a patient with coronary artery disease? Select all that apply. A. Able to state the signs of heart attack B. Understands the importance of exercises to improve heart function C. Verbalizes feelings of anxiety related to limitation of activity imposed by the condition D. Expresses knowledge about the lifestyle modifications required to prevent heart failure E. Able to perform exercises in the correct way that is necessary to improve cardiac function and prevent trauma as well

A, E To evaluate a learning objective, it should be measurable. The nurse can evaluate patient learning by asking the patient to state the signs of heart attack and to demonstrate exercises because these performances can be measured. Objectives such as understanding a concept, verbalizing feelings, and increasing knowledge are vague and ambiguous and cannot be measured.

Which communication technique is nontherapeutic? A, Sympathizing B. Focusing C. Clarifying D. Summarizing

A, Sympathizing Sympathizing is a nontherapeutic communication technique. The nurse may take patient's feelings on as his or her own, which may hinder the nurse's ability to be objective and help the patient process feelings. Focusing, clarifying, and summarizing are therapeutic techniques, not nontherapeutic. Focusing is a therapeutic communication technique that involves centering a conversation on key elements or concepts of a message. Clarifying is a therapeutic communication technique to check whether one understands a message accurately by restating an unclear or ambiguous message to clarify the sender's meaning. Summarizing is a therapeutic communication technique that involves a concise review of key aspects of an interaction

Which lifestyle factor increases the risk of developing cardiovascular disease? Select all that apply. One, some, or all responses may be correct. A. Unhealthy diet B. Obesity C. Excessive sun exposure D. Texting while driving E. Lack of immunizations

A,B An unhealthy diet and obesity could increase the risk of cardiovascular disease. Excessive sun exposure can cause skin cancer, not cardiovascular disease. Texting while driving can lead to unintentional injuries and death but not cardiovascular disease. A lack of immunizations may leave one susceptible to diseases such as influenza and hepatitis, not cardiovascular disease.

A dark-skinned hospitalized patient is bedridden. While examining the patient, which characteristic will determine that the patient has developed a pressure injury? Select all that apply. One, some, or all responses may be correct. A. The skin color remains unchanged on application of pressure. B. The localized area of the skin appears purple. C. There is blanching of the skin. D. The area of the skin with a pressure injury appears darker. E. As the tissue changes color, the intact skin becomes warm.

A,B Dark-skinned patients have different characteristics of skin when integrity is lost. The color of the skin remains unchanged on application of pressure. The localized area of the skin appears purple or blue instead of red. Blanching of the skin does not occur in dark-skinned patients. The area of the skin with a pressure injury appears lighter than the surrounding area. In addition, as the tissue changes color, the intact skin becomes cool.

The nurse is providing a sex education session to a group of grade- school students. Which aspect of sexual education would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct. A. Body changes B. Menstruation C. Sexually transmitted infections D. Contraception E. Sexual relationships

A,B School-age children have questions about changes in their bodies and emotions, and they need accurate information about these changes. Body changes are more evident in adolescents because of hormonal changes that influence their health. Menstruation is the periodic discharge of blood from the uterus through the vagina. Because of their lack of information about menstruation, grade-school children may view it as a dreadful disease. Therefore the nurse should teach or encourage parents and teachers to educate children about menstruation. Adolescents who are sexually active may have several sexual partners. They may seek sexual relationships to achieve the goals of intimacy and pleasure. Therefore the nurse should teach adolescents (not grade-school children) about sexually transmitted infections, contraception, and sexual relationships.

Which activity is included in primary prevention? Select all that apply. One, some, or all responses may be correct. A. Health education programs B. Protection from occupational hazards C. Physical fitness activities D. Screening tests E. Drug therapy

A,B,C Health education programs, protection from occupational hazards, and physical fitness activities aim at preventing illness and promoting health; thus these are primary prevention. Screening tests and drug therapy are secondary, not primary prevention, and are performed when disease is already present.

Which statement is true regarding the hemostasis phase of blood clotting? Select all that apply. One, some, or all responses may be correct. A. Clots form a fibrin matrix. B. Blood vessels constrict, and platelets gather. C. Blood loss is controlled, establishing bacterial control. D. Epithelial cells migrate from a wound's edges to resurface. E. Collagen fibers go through remodeling before assuming a normal appearance.

A,B,C In the hemostasis phase, clots form a fibrin matrix that offers a structure for cellular repair in a later stage. During this phase, blood vessels constrict and platelets gather to stop bleeding. Blood loss is controlled, and bacterial control is established in this phase. In the proliferative phase, the epithelial cells migrate from the wound edges to resurface. In the maturation phase, the collagen fibers go through remodeling before assuming a normal appearance.

The nurse understands that a protein deficiency can adversely affect wound healing. Which parameter should be measured to determine this deficiency in the patient? Select all that apply. One, some, or all responses may be correct. A. Serum albumin B. Serum transferrin C. Serum prealbumin D. Hemoglobin levels E. Serum creatinine levels

A,B,C Serum albumin is a biochemical indicator of protein deficiency and malnutrition. Serum transferrin levels also indicate protein status in the body. Serum prealbumin is the best indicator of nutritional status. It not only reflects what the patient has ingested but also what the body has metabolized. Hemoglobin levels indicate the oxygen-carrying capacity of the blood. Serum creatinine levels indicate kidney function.

Which technique would the nurse use to develop trust? Select all that apply.One, some, or all responses may be correct. A. Treat the patient with respect. B. Answer the patient honestly. C. Display consistent behavior when responding to patients. D. Withhold key information that may make the patient depressed. E. Leave immediately after providing care to allow the patient to rest

A,B,C Trust is developed by the following techniques: treat the patient with respect, answer the patient honestly, and display consistent behavior when responding to patients. Trust is a firm belief in the reliability, truth, or ability of someone without doubt or question. Treating the patient with respect fosters trust, as does answering the patient with honesty and responding to patients with consistent behavior. Withholding key information may violate the legal and ethical standards of practice and result in a breach of trust. Leaving the patient immediately after providing care may be perceived as avoiding spending time with the patient and may thereby hinder the development of trust.

The nurse is reviewing the sexual and physical examination data of a patient diagnosed with sexual dysfunction. Which sign and symptom might the nurse anticipate finding in the assessment data? Select all that apply.One, some, or all responses may be correct. A. Dyspareunia B. Erectile dysfunction C. Uncontrolled hypertension E. Depression and guilt E. Foul-smelling genitals

A,B,C,D Sexual dysfunction is the inability to accomplish sexual desires. It can occur for many reasons. Dyspareunia is pain occurring with sexual intercourse that may lead to decreased sexual desire. Erectile dysfunction that prevents erection required for satisfactory copulation may also lead to decreased desire. Uncontrolled hypertension is a risk factor for sexual dysfunction. Sexual dysfunction may also be related to various psychological factors, including anxiety, depression, and guilt. Foul-smelling genitals call into question cleanliness or suggest the presence of infection.

The nurse is planning to prepare a teaching plan on healthy nutrition. Which factor would be considered before preparing the teaching plan on healthy nutrition? Select all that apply. One, some, or all responses may be correct. A. The patient's educational status B. The socioeconomic status of the patient C. The culture to which the patient belongs D. The consent of the health care provider E. The willingness of the patient to participate

A,B,C,E The teaching plan should be based on the patient's educational status so that the patient understands what is being taught. An important factor is the consideration of culture because there are many practices that are specific to certain cultures. If the patient experiences symptoms such as pain, the patient may not be receptive to the teaching. Therefore the nurse should determine if the patient is willing to accept the teaching. Socioeconomic status should be considered to provide the most useful and helpful information to the patient regarding his or her current situation. It is the nurse's duty to inform the patient about his or her condition; the nurse does not need the consent of the health care provider to do so.

Which example is classified as an external variable? Select all that apply. One, some, or all responses may be correct. A. Family practices B. Socioeconomic factors C. Developmental stages D. Cultural beliefs E. Spiritual factors

A,B,D Family practices, socioeconomic factors, and cultural beliefs are all external variables. Family health practices have a huge impact on how a person thinks and acts. An individual tends to follow the same health practices that the family members follow. An individual usually seeks support and approval for health practices and beliefs from social support systems. These social systems include a spouse, neighbors, and peers. Cultural beliefs influence the way an individual seeks medical care and affects personal health practices. Developmental stages and spiritual factors are internal (not external) variables, which influence a person's health and health care beliefs and practices

Which patient group would be at increased risk of wound dehiscence? Select all that apply. One, some, or all responses may be correct. A. Malnourished patients B. Obese patients C. Young adults D. Female patients E. Patients with wound infections

A,B,E A malnourished patient may have poor wound healing, which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. In addition, fat tissue has poor wound healing. Infection interferes with the wound healing process and may increase the risk of wound dehiscence. A young adult may have a better wound healing and has less risk of wound dehiscence. Gender does not affect wound healing and dehiscence.

Which finding is characteristic of a stage 3 pressure injury? Select all that apply. One, some, or all responses may be correct. A. It has full-thickness skin loss. B. The subcutaneous fat may be visible. C. The wound may present as an open, serum-filled blister. D. There may be a reddish-pink wound bed without slough. E. Neither the bone, tendon, nor muscle is exposed.

A,B,E A stage 3 pressure injury has a full-thickness skin loss involving the epidermis and dermis. Because of this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open, serum-filled blister or one having a reddish-pink wound bed without slough is a stage 2 pressure injury.

Which finding is characteristic of a stage 3 pressure injury? Select all that apply. One, some, or all responses may be correct. A. It has full-thickness skin loss. B. The subcutaneous fat may be visible. C. The wound may present as an open, serum-filled blister. D. There may be a reddish-pink wound bed without slough. E. Neither the bone, tendon, nor muscle is exposed.

A,B,E A stage 3 pressure injury has a full-thickness skin loss involving the epidermis and dermis. Because of this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open, serum-filled blister or one having a reddish-pink wound bed without slough is a stage 2 pressure injury.

The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in the intake of citrus fruits. Which information would the nurse share with the patient? Select all that apply. One, some, or all responses may be correct. A. Citrus fruits have antioxidant properties. B. These fruits help in collagen synthesis. C. They help in protein synthesis. D. The fruits provide an essential fluid environment. E. Citrus provides fuel for cell energy.

A,B,E Citrus fruits are rich in vitamin C, which has antioxidant properties and helps in collagen synthesis, thus helping to heal the wound. Citrus fruits also contain calories for cell energy. Zinc-rich foods help in protein synthesis. Water provides an essential fluid environment for healing cells.

Which statement about human immunodeficiency virus (HIV) is appropriate? Select all that apply. One, some, or all responses may be correct. A. HIV is a bloodborne pathogen. B. HIV spreads through oral-genital sex. C. HIV is not found in bodily fluids. D. HIV causes ectopic pregnancy. E. The risk of contracting HIV can be reduced by the use of condoms.

A,B,E HIV is primarily a bloodborne pathogen. It spreads through vaginal and anal intercourse and through oral-genital sex. The use of condoms reduces the incidence of HIV infection, whereas unprotected sex increases the risk of HIV transmission. Bodily fluids contain HIV, and any exchange of body fluids can result in HIV transmission. Unlike chlamydia, HIV infection is not known to cause ectopic pregnancy.

Which information would the nurse provide the patient on how hormonal contraceptives work? Select all that apply.One, some, or all responses may be correct. A. Hormonal contraceptives cause thinning of the lining of the uterus. B. They prevent ovulation. C. Hormonal contraceptives reduce sperm motility. D. They act as a spermicidal barrier. E. Hormonal contraceptives thicken the cervical mucus.

A,B,E Hormonal contraceptives work by thinning the uterus so the fertilized ovum does not get implanted. They also prevent ovulation and thicken the cervical mucus, preventing sperm cells from ascending into the uterus. Hormonal contraceptives do not affect the motility of sperm and do not have any spermicidal effect. Spermicidal creams and jellies kill sperm cells before they enter the uterus.

Which risk factor for cerebrovascular disease is considered modifiable? Select all that apply. One, some, or all responses may be correct. A. Smoking five times a day B. Sedentary lifestyle C. History of insulin dependent diabetes D. Thromboembolic disease E. Eating pizza for dinner every night

A,B,E Smoking five times a day, sedentary lifestyle, and eating pizza for dinner every night are modifiable risk factors. Modifiable risk factors for a disease are in the patient's ability to control and/or change. Tobacco use is modifiable. A sedentary lifestyle also increases the risk of cerebrovascular disease, and it is modifiable. Eating foods with poor nutritional value frequently increases risk of cerebrovascular disease, and it is modifiable. A history of insulin dependent diabetes is a genetic and physiological factor, so is a nonmodifiable risk factor. Likewise, a patient with thromboembolic disease has a physiological factor that is nonmodifiable, not modifiable.

Which characteristic differentiates a friction injury from a shear injury? Select all that apply. One, some, or all responses may be correct. A. Type of force B. Location of the injury C. Involvement of tissue D. Condition of the patient E. Presentation of the injury

A,C,E A friction injury is different from a shear injury because of the type of force, involvement of tissue, and presentation of injury. In a shear injury, underlying muscle and tissue are involved, whereas in a friction injury the epidermis of the skin is affected. Shear injury presents as necrosis in the deep tissues with intact skin, while a friction injury presents as denuded epidermis and torn skin. Redness and pain are observed in affected areas. Shear force is a sliding movement of the skin and subcutaneous tissue while the underlying muscles and bones remain stationary. Frictional force is the force between two surfaces moving against each other, such as skin and a bedsheet, when the patient is being transferred. Shear injuries and friction injuries are not differentiated by the condition of the patient or the location of the injury.

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion? Select all that apply. One, some, or all responses may be correct. A. The wound is filled with granulation tissue. B. There is localized redness, edema, warmth, and throbbing. C. The wound contracts to reduce the area that requires healing. D. There is vasodilation of the surrounding capillaries and exudation of serum. E. There is reepithelialization of the wound surface.

A,C,E In the proliferative phase, fibroblasts and the cells that synthesize collagen provide the matrix for granulation. The wound contracts to reduce the area that requires healing during the proliferative phase. The epithelial cells migrate to the edges to resurface the wound, thus causing reepithelialization. Vasodilatation of the surrounding capillaries and exudation of serum happen during the inflammatory phase. The inflammatory phase is also characterized by localized redness, edema, warmth, and throbbing.

Which primary prevention intervention would the nurse suggest to a patient who is a smoker, allergic to milk and seafood, and supposed to walk to decrease effects of peripheral vascular disease? Select all that apply. One, some, or all responses may be correct. A. Counseling for smoking cessation B. Taking narcotic drugs for pain relief C. Encouraging the patient to exercise regularly D. Advising the patient to avoid milk products E. Instructing about a high-fiber diet to prevent colon cancer

A,D,E Primary prevention interventions include counseling for smoking cessation, advising the patient to avoid milk products, and instructing about a high-fiber diet to prevent colon cancer. In primary prevention, measures are taken before the occurrence of disease or dysfunction. In this case, activities for primary prevention include counseling for smoking cessation, advising the patient to avoid milk products, and instructing about a high-fiber diet. Taking narcotics for pain relief is a secondary (not primary) prevention, which is done after diagnosis. Encouraging the patient to exercise is a tertiary (not primary) prevention against effects of peripheral vascular disease.

Which statement holds true about sexuality? Select all that apply.One, some, or all responses may be correct. A. It is influenced by personal beliefs. B. It is not affected by medications in use. C. It is influenced by the place where one lives. D. Pregnancy may affect sexual interest. E. It may be affected by chronic respiratory disease. F. Ethnicity plays a role in shaping sexual values.

A,D,E,F Sexuality is influenced by various factors. An individual's sexuality may be affected by personal beliefs and notions of sexual health. Pregnancy leads to fluctuation in sexual desire because of the hormonal and bodily changes that occur. In addition, presence of disease conditions may shift the focus and energy of the patient toward healing, thus affecting sexuality. The sociocultural environment of a person always influences conduct. The rules and norms of society often determine acceptable and nonacceptable behavior within the culture, thus affecting sexuality. Sexuality is affected by the medications in use. The global location of a person has not been found to affect sexuality.

The nurse at a community health center is teaching a group of menopausal women about normal changes in the female sexual response that occur with aging. Which statement by one of the women indicates that the information is understood? A. "It's normal for me to take longer to reach an orgasm." B. "I might experience chest pain or shortness of breath during intercourse." C. "It's normal for me to lose interest in sexual relationships." D. "I won't need to be concerned about contraception or sexually transmitted infections because of my age."

A. "It's normal for me to take longer to reach an orgasm." Normal changes in the female sexual response include a decrease in sex hormone levels, decrease in vaginal lubrication, longer time to reach orgasm, and longer refractory times. Many factors such as chronic illness, medications, stress, or loss of partner can influence the older adult's sexual activity. Older adults may not be comfortable using barrier methods such as condoms and therefore are at increased risk of sexually transmitted infections.

After interacting with the wife of a patient who has terminal cancer, the nurse anticipates that the patient is experiencing denial. Which statement by the wife supports the nurse's conclusion? A. "My husband wants to get another opinion, even after a clear diagnosis." B. "My husband is blaming the health care provider for his condition." C. "My husband is not showing any interest in his favorite games and movies." D. "My husband says he wants to spend as much time as possible with the family."

A. "My husband wants to get another opinion, even after a clear diagnosis." The patient is not ready to accept reality and thinks his diagnosis is wrong, so he wants a second opinion. This indicates that the patient is in the denial stage. The patient blames and shows anger toward his health care provider in the anger stage of grief. If the patient does not show any interest in normal activities, such as playing games and watching movies, it indicates that the patient is experiencing depression and has lost the will to live. Wanting to spend as much time as possible with family indicates that the patient is showing acceptance.

Which communicative statement indicates a defensive response? A. "No one here would intentionally lie to you." B. "This work is incomplete, and it's all your fault." C. "Things are bad, and there's nothing I can do about it." D. "How can you say you didn't sleep when I heard you snoring all night?"

A. "No one here would intentionally lie to you." Stating that no one would intentionally lie indicates defensive behavior. Blaming someone for incomplete work indicates an aggressive response, not a defensive response. Stating that things are bad and nothing can be done is a passive response, not a defensive response. Asking how someone can claim not to have slept when he or she was heard snoring indicates arguing or challenging, not a defensive response.

Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? A. 1 B. 2 C. 3 D. 4

A. 1 A stage 1 pressure injury does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or may feel soft if the blood flow is compromised. The patient may report pain in the area. Stages 2, 3, and 4 all have breaks in the skin at different degrees of depth

Which stage of pressure injury can be dressed with a transparent or hydrocolloid dressing? A. 1 B. 2 C. 3 D. 4

A. 1 A stage 1 pressure injury is an intact injury that can be dressed with a transparent or hydrocolloid dressing. Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage 2 pressure injuries. Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage 3 pressure injuries. Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage 4 pressure injuries.

Which activity represents secondary prevention? A. A home health care nurse visits a patient's home to change a wound dressing. B. A college-bound healthy student obtains the meningococcal vaccine before living in a dormitory. C. The school health nurse provides a program to the first-year students on healthy eating. D. A patient attends cardiac rehabilitation sessions weekly.

A. A home health care nurse visits a patient's home to change a wound dressing. The home health nurse changing the wound dressing is an activity that is focused on preventing complications ( secondary prevention). Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk of developing complications or worsening conditions. The meningococcal vaccine and educational programs for healthy eating are examples of primary preventive measures, not secondary. Attending cardiac rehabilitation sessions is tertiary prevention, not secondary.

Which action is involved in the characterizing level of affective learning? A. Acting and responding with a consistent value system B. Listening to a process and responding verbally or nonverbally C. Developing a value system by organizing values according to their worth D. Paying attention to the process of learning while receiving information

A. Acting and responding with a consistent value system Affective learning involves the expression of feelings and development of values, attitudes, and beliefs. It may include value clarifications as an example. Characterizing is the most complex behavior of affective learning. It involves an action and response with a consistent value system. The responding level of affective learning involves active participation through listening along with a verbal or nonverbal response. The organizing level requires the development of a value system by organizing values according to their worth. At the receiving level, the learner is passive and simply takes in information by paying attention.

Which domain of learning occurs when a patient is both verbally and nonverbally participating in group activities? A. Affective B. Cognitive C. Attentional D. Psychomotor

A. Affective The patient who participates in affective learning will exhibit good responding behavior. Verbal and nonverbal responses in group activities indicate affective learning development. The patient is not acquiring any knowledge about new factors or new facilities; instead, the patient is showing effective verbal and nonverbal communication. Therefore the patent is not exhibiting cognitive learning. The attentional set is not a domain of learning; it is a mental state that allows a learner to focus on an activity. The patient is not using his or her mental or muscular activity to acquire a skill. Therefore the patient is not exhibiting psychomotor development.

Which physical sign often indicates the possibility of sexual abuse in children? A. Chronic pain B. Excessive masturbating C. Vomiting or abdominal tenderness D. Trauma to the labia, vagina, cervix, or anus

A. Chronic pain Children who have been victims of sexual abuse often experience chronic pain. Excessive masturbating is a behavioral sign that the child is a victim of sexual abuse, not a physical sign. Vomiting or abdominal tenderness and trauma to the labia, vagina, cervix, or anus are physical signs more common in adults who have been victims of sexual abuse.

The nurse is teaching a patient how to adjust insulin dosages based on blood glucose results. This is an example of which type of learning? A. Cognitive B. Affective C. Adaptation D. Psychomotor

A. Cognitive Cognitive learning requires thinking; learning how to adjust insulin requires analysis, synthesis, and evaluation, which are all types of cognitive learning. Affective learning might include role play. Adaptation learning occurs when motor skills are developed but can be modified if a problem occurs. Psychomotor learning includes demonstration.

The nurse is teaching a patient how to adjust insulin dosages based on blood glucose results. This is an example of which type of learning? A. Cognitive B. Affective C. Adaptation D. Psychomotor

A. Cognitive Cognitive learning requires thinking; learning how to adjust insulin requires analysis, synthesis, and evaluation, which are all types of cognitive learning. Affective learning might include role play. Adaptation learning occurs when motor skills are developed but can be modified if a problem occurs. Psychomotor learning includes demonstration.

The nurse is counseling a couple on contraceptive methods. Which nonprescription method would the nurse recommend? A. Condom B. Diaphragm C. Vaginal ring D. Transdermal skin patch

A. Condom Condoms are nonprescription methods of contraception. A condom prevents entry of sperm into the vagina. It is made of a thin rubber sheath and fits over the penis. A diaphragm is a barrier with spermicide to be used by women; it must be fitted by a gynecologist and thus requires a prescription. Vaginal rings and transdermal skin patches are hormonal methods of contraception and require a health care provider's prescription.

Which critical thinking attitude motivates the nurse to communicate and know more about a patient? A. Curiosity B. Creativity C. Perseverance D. Self-confidence

A. Curiosity Curiosity motivates the nurse to communicate and know more about a patient. Creativity and perseverance are attitudes conducive to communication, because they motivate the nurse to identify innovative solutions but do not motivate the nurse to know more about a patient. Self-confidence is important because the nurse who conveys confidence and comfort while communicating can more readily establish an interpersonal caring relationship, but it does not focus on learning more about the patient.

Which term describes the use of the word basketball in a conversation about a basketball game in which both the nurse and patient are referring to the sport? A. Denotative B. Connotative C. Intonation D. Metacommunication

A. Denotative A word that has the same meaning for all people who speak the same language is considered denotative. The dictionary meaning of the word basketball is denotative. A connotative meaning is influenced by the thoughts, feelings, or ideas of individuals and means different things to different people; this did not occur in this scenario. Intonation refers to the tone of voice; not the definition of the word. Metacommunication refers to all factors influencing communication, not just the denotative meaning of basketball as a sport.

Which nonverbal or behavioral sign often indicates the possibility of sexual abuse in an adult? A. Depression B. Physical aggression C. Excessive masturbating D. Running away from home

A. Depression Adults who have been victims of sexual abuse often exhibit depression. Physical aggression, excessive masturbating, and running away from home are behavioral signs of possible sexual abuse more common among child victims.

Which priority nursing intervention would be included in the plan of care based on the fact that the majority of sexually transmitted infections (STIs) have few if any symptoms? A. Encourage regular screenings in all sexually active individuals. B. Provide information about contraception options. C. Administer prescribed antibiotics for human papillomavirus (HPV) or genital herpes outbreaks. D. Ask all patients if they are experiencing any symptoms.

A. Encourage regular screenings in all sexually active individuals. One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in men or women. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Screening after each new sex partner is the most effective method to detect and manage STIs. Providing information about contraceptive options does not reduce the incidence of STIs. HPV and herpes are viral infections and cannot be treated with antibiotics. Asking all patients if they have any symptoms is not effective, because the majority of STIs have few if any symptoms.

Decreased levels of which hormone may result in painful sexual intercourse? A. Estrogen B. Testosterone C. Growth hormone D. Follicle-stimulating hormone (FSH)

A. Estrogen Decreased estrogen levels result in decreased vaginal lubrication and vaginal tissue thinning. These changes can result in painful sexual intercourse. Testosterone, growth hormone, and FSH do not affect the vaginal tissues and do not cause painful intercourse when their levels decrease. Testosterone is responsible for sexual growth and development in men. Growth hormone is responsible for overall growth and development in an individual. FSH promotes sexual growth in women.

A patient recently diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I am perfectly fine, and I don't want to discuss my treatment and condition." After considering the patient's current stage of grief, which action by the nurse would be appropriate? A. Explain the situation to the patient's family. B. Focus on skills the patient will require in the coming weeks. C. Provide necessary information to the family for the patient's discharge. D. Convince the patient that the treatment for the illness is essential.

A. Explain the situation to the patient's family. It is difficult for a patient to accept a temporary or permanent loss of health. The patient needs to grieve. This process of grieving provides time to adapt psychologically to the emotional and physical implications of the illness. Here, the patient is avoiding discussion about the illness and may be distorting information that has not been presented clearly. Therefore the nurse should carefully explain the situation to the patient's family. The nurse should not focus on teaching important skills or knowledge because the patient has not accepted the reality of the condition. When a patient reaches the psychosocial stage of acceptance, the nurse should provide necessary discharge information to the patient or the patient's family. The nurse should avoid any attempt to convince the patient about the illness. This will likely result in further anger or withdrawal.

Which nursing intervention is considered primary prevention for school children younger than 10 years old? A. Explaining the importance of a nutritious diet B. Supplying a nutritious diet to children with malnutrition C. Teaching disabled children to use their capacities to the fullest D. Conducting health examinations to identify children with malnutrition

A. Explaining the importance of a nutritious diet Explaining the importance of a nutritious diet is primary prevention. Primary prevention interventions are done before the development of a disease or disorder. Interventions can take the form of health education or nursing interventions such as immunizations. Primary prevention also includes a nutritious diet to maintain health and prevent illness. Supplying a nutritious diet to children with malnutrition is secondary prevention, not primary, because a disease (malnutrition) is already present. Teaching disabled children to use their capacities to the fullest would be considered tertiary (not primary) prevention, because disability has already occurred. Conducting health examinations to identify children with malnutrition and supplying nutritious diets to children with malnutrition would be considered secondary (not primary) prevention, because these measures are directed toward managing a disease that has already manifested.

Which parameter would the nurse focus on when using the Transtheoretical Model of Change to help treat a patient? A. Health behaviors B. Disease condition C. Medication strengths D. Pathology of the disease

A. Health behaviors The focus is on health behaviors. The nurse tries to change the negative health behaviors to positive ones using the Transtheoretical Model of Change. The nurse applies the model by focusing on the patient's health behaviors, strengths, and capabilities. Understanding the disease condition is not part of the Transtheoretical Model of Change. Strength of the medicine and pathology of the disease are also not part of the Transtheoretical Model of Change, which focuses on an individual's health- damaging or health-promoting behaviors.

Which health model is described when the nurse routinely asks patients if they take any vitamins or herbal medications, encourages family members to reminisce, and frequently suggests the use of therapeutic touch? A. Holistic B. Health belief C. Transtheoretical D. Health promotion

A. Holistic The nurse is using a holistic health model of care that considers the relationship among body, mind, and spirit. Holistic measures include herbs, reminiscence, and therapeutic touch. The health belief model addresses the relationship between a person's beliefs and behaviors; this approach was not used in the question. The transtheoretical theory assesses an individual's readiness to change, which was not performed in this scenario. While the nurse is promoting health, the nurse in this situation did not use the health promotion model in which the person commits to or changes a behavior.

A patient is admitted with a stage 2 pressure injury. Which characteristic of a pressure injury is the nurse likely to find during a wound assessment? A. It has a reddish-pink wound bed without slough. B. The subcutaneous fat is visible. C. It may include undermining and tunneling. D. The wound extends to muscles and bones.

A. It has a reddish-pink wound bed without slough. A stage 2 pressure injury has a partial thickness loss of dermis and is shallow. It has a reddish-pink wound bed without slough. The subcutaneous fat is visible in a stage 3 pressure injury because of a full-thickness tissue loss. Stage 3 and stage 4 wounds involve undermining and tunneling. A stage 3 wound extends to the muscles and bones, because there is a full-thickness tissue loss.

Which term describes snide remarks or put-downs between colleagues? A. Lateral violence B. Metacommunication C. Therapeutic confrontation D. Nonverbal communication

A. Lateral violence Lateral violence is a term to describe workplace bullying, such as snide remarks or put- downs between colleagues. Metacommunication is not the term that describes this scenario, but is a broad term that describes factors influencing communication. Therapeutic communication, not confrontation, takes place between a nurse and patient. Nonverbal communication describes communication without verbal messages; snide remarks or put-downs are verbal messages.

Which type of communication pattern would be exhibited when the nurse observes and acknowledges a patient's verbal and nonverbal indications of stress and prompts the patient to elaborate on these feelings? A. Metacommunication B. Nonverbal communication D. Intrapersonal communication D. Nontherapeutic communication

A. Metacommunication The nurse is using metacommunication. Metacommunication is a broad term that refers to all factors that influence communication. It involves being aware of influencing factors and helping people better understand what is communicated. Therefore by acknowledging the patient's nonverbal and verbal signs of stress and understanding the situation better, the nurse employs metacommunication. Nonverbal communication involves the five senses and anything that does not involve the spoken or written word; the patient's facial expression is an example of nonverbal communication. This situation involves more than just nonverbal communication. Nurses use intrapersonal communication to develop self-awareness and a positive self- esteem that enhances appropriate self-expression; this scenario does not focus on intrapersonal communication. Nontherapeutic communication blocks communication and involves asking personal questions or giving personal opinions, which discourages further expression of patient's feelings and ideas. Nontherapeutic communication is not the focus of this question.

Which aspect of psychomotor learning involves an awareness of qualities through the use of sensory stimulation? A. Perception B. Adaptation C. Origination D. Mechanism

A. Perception Psychomotor learning involves acquiring motor skills that require coordination. It also includes learning skills that require integration of mental and physical movements. Perception is the simplest behavior in the hierarchy. It involves the awareness of objectives or qualities through the use of sensory stimulation. In adaptation, motor skills are well developed and movements are modified when unexpected problems arise. Origination includes the use of existing psychomotor skills for the creation of new movement patterns.

Which level of prevention describes the nurse participating at a health fair in the local mall by administering influenza vaccines to senior citizens? A. Primary B. Secondary C. Tertiary D. Quaternary

A. Primary The level of prevention is primary. Primary prevention is aimed at health promotion and includes health education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protections, such as immunization for influenza. Secondary prevention is diagnosing and treating an illness and limiting disabilities; it does not include giving vaccines. Tertiary prevention includes restoration and rehabilitation; it does not focus on vaccine administration. There are only three levels of prevention; the quaternary level does not exist.

Which concept describes the nurse providing information to a group of healthy adolescents about contraception and the risk of human immunodeficiency virus (HIV) infection? A. Primary prevention B. Secondary prevention C. The health belief model D. The holistic approach model

A. Primary prevention The concept is primary prevention. The nurse is teaching adolescents the measures that should be taken to prevent HIV infection and unplanned pregnancy. When providing secondary prevention, the nurse educates the patient about screening techniques available for specific diseases, not about the risks of HIV to healthy adolescents. Neither the health belief model nor the holistic approach model is considered preventive (primary prevention) care.

Which level of communication is applicable when the registered nurse (RN) is teaching a group of nursing students about the care of patients? A. Public B. Electronic C. Small-group D. Interpersonal

A. Public Public communication is interaction with an audience. This level of communication may involve the registered nurse speaking to a group of nursing students about patient care. Electronic communication is the use of technology to create ongoing relationships with patients and their health care teams, not teaching nursing students. Small-group communication occurs when a small number of people meet in committees and patient care conferences, not when teaching nursing students. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face; it does not involve teaching a group of nursing students.

The nurse is applying which teaching technique when allowing a patient to actively apply knowledge in controlled situations? A. Role play B. Discussion C. Independent project D. Question and answer session

A. Role play In the role play method of teaching, the nurse allows the patient to actively apply knowledge in controlled situations. This method promotes the synthesis of information and problem-solving skills. The discussion method promotes the patient's active participation and focuses on topics of interest to the patient. An independent project allows a patient to assume responsibility for completing learning activities at his or her own pace. Question and answer sessions help address the patient's specific concerns.

Which communication technique is the nurse using when he or she comments on positive aspects of a patient's behavior and response? A. Sharing hope B. Sharing feelings C. Sharing empathy D. Sharing observations

A. Sharing hope Commenting on the positive aspects of a patient's behavior and response develops hope in the patient. Sharing feelings involves helping patients share emotions by encouraging openness and modeling healthy self-expression, not commenting on positive aspects. Sharing empathy is the ability to understand the patient's reality, perceive feelings accurately, and communicate this understanding to the patient, not pointing out positive aspects. Sharing observations involves commenting on observations such as the looks, sounds, or actions of the patient, not commenting on positive aspects of the patient's behavior and response.

Which communication technique is nontherapeutic? A. Sympathizing B. Focusing C. Clarifying D. Summarizing

A. Sympathizing Sympathizing is a nontherapeutic communication technique. The nurse may take patient's feelings on as his or her own, which may hinder the nurse's ability to be objective and help the patient process feelings. Focusing, clarifying, and summarizing are therapeutic techniques, not nontherapeutic. Focusing is a therapeutic communication technique that involves centering a conversation on key elements or concepts of a message. Clarifying is a therapeutic communication technique to check whether one understands a message accurately by restating an unclear or ambiguous message to clarify the sender's meaning. Summarizing is a therapeutic communication technique that involves a concise review of key aspects of an interaction.

Which activity does the nurse carry out while maintaining a zone of personal distance? A. Teaching or educating a patient B. Giving directions to visitors in the hallway C. Performing a physical assessment D. Testifying at a legislative hearing

A. Teaching or educating a patient The nurse maintains a personal distance while teaching a patient and taking a patient's nursing history. The nurse maintains varying distances while carrying out different activities. The zone of personal distance is 18 to 40 inches (46 to 102 cm). The nurse maintains a social distance (not personal distance) of 4 to 12 feet (122 to 366 cm) while giving directions to visitors in the hallway. The nurse enters the intimate zone, a distance of 0 to 18 inches (0 cm to 46 cm) from the patient, when performing physical assessment; this is not personal distance. The nurse enters the public distance 12 feet or more (355 cm or more) when testifying at a legislative hearing; this does not represent personal distance.

The nurse finds that a 12-year-old girl displays physical aggression, excessive masturbation, poor school performance, and a lack of peer relationships. Which other finding would indicate a history of sexual abuse? Select all that apply.One, some, or all responses may be correct. A. Difficulty eating B. Difficulty walking or sitting C. Unusual odor in the genital area D. Vomiting or abdominal tenderness E. Fractures of the face, nose, and arms

B, C Physical aggression, excessive masturbation, poor school performance, and poor peer relationships are behavioral symptoms of sexual abuse. Symptoms such as difficulty walking or sitting and an unusual odor in the genital area often indicate sexual abuse. Therefore the nurse should confirm the history of sexual abuse during assessment. Difficulty eating occurs because of anorexia, which is a common finding in adults. Vomiting or abdominal tenderness and fractures of the face, nose, and arms are physical signs that often indicate sexual abuse in adults.

When would the nurse plan to teach a patient about the importance of exercise? Select all that apply. One, some, or all responses may be correct. A. When there are visitors in the room B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life E. In the evening, when the patient is tired but the floor is quiet

B, C Plan teaching when the patient is most attentive, receptive, alert, and comfortable. The patient will be distracted if there are visitors in the room, if they are upset or stressed, or if they are tired.

Which communication skill would the nurse use during the assessment phase of the nursing process? Select all that apply.One, some, or all responses may be correct. A. Document nursing diagnoses. B. Verbally interview and ask for a history. C. Visually observe for nonverbal behavior. D. Gather data during a physical examination. E. Modify and update the patient's care plan.

B, C, D Skills the nurse would use during the assessment phase include verbally interviewing and asking for a history, visually observing for nonverbal behavior, and gathering data during a physical examination. Documenting nursing diagnoses is included under the nursing diagnosis phase, not the assessment phase. Modifying and updating the patient's care plan occurs during the evaluation phase, not the assessment phase.

Which component is included in the PLISSIT model of assessment? Select all that apply.One, some, or all responses may be correct. A. Palliation B. Permission C. Limited information D. Specific suggestions E. Intravenous therapy

B, C, D The PLISSIT model is used for sexual assessment of the patient. P stands for permission from the patient to discuss sexual history. LI stands for limited information regarding sexual health problems. SS stands for specific suggestions made when the nurse is clear about the problem. IT stands for intensive therapy by a professional. Palliation and intravenous therapy are not part of the PLISSIT model.

In the context of teaching a mother about her infant's developmental capacity, which statement by the nurse would be appropriate? Select all that apply. One, some, or all responses may be correct. A. "Encourage learning through the use of pictures." B. "Keep consistent routines of feeding and bathing." C. "Use role play and imitation to make learning fun." D. "Speak softly to convey a sense of trust to the baby." E. "Use simple words to promote the infant's understanding."

B, D The nurse should implement teaching methods and actively involve the mother in learning activities. The nurse should guide the mother to keep consistent routines of feeding and bathing. The mother should also foster a sense of trust by speaking softly to her infant. The mother should encourage learning in a preschooler through pictures and short stories. The use of role play, imitation, and play would make the learning healthy and interesting for a preschooler. The mother of a toddler, not an infant, should use simple words while communicating

The nurse is caring for a patient with cancer who was previously in a state of denial but has now accepted the illness. The patient asks the nurse questions about the illness and expresses emotions openly. Which intervention would the nurse perform at this stage? Select all that apply. One, some, or all responses may be correct. A. Provide support and empathy. B. Involve the family in teaching information for discharge. C. Introduce only reality. D. Encourage the expression of feelings. E. Set aside formal times for discussion.

B, D, E

Which nursing action would encourage active participation of students regarding the importance of donating blood? Select all that apply. One, some, or all responses may be correct. A. Hand out pamphlets. B. Teach while touring the blood bank. C. Give a lecture in a hallway. D.Ask the students questions during the session. E. Demonstrate the procedure of blood donation in the actual setting.

B, D, E The nurse should teach the students about blood donation while touring the blood bank where students can see the blood bank activities, which can increase their interest levels. The nurse should ask questions to engage the students in the learning activity and should demonstrate an actual blood donation. This would allow active participation of the students, make them aware of the procedure, and allow them to make informed decisions. Handing out pamphlets would not engage the students in learning. Giving a lecture in the hallway would be distracting, and the students might not participate in the teaching.

Which communication strategy would the nurse use when caring for a patient who is unresponsive? Select all that apply. One, some, or all responses may be correct. A. Converse only verbally with the patient. B. Call the patient by name during interactions. C. Discuss the patient with others while in the patient's room. D. Provide orientation to person, place, and time. E. Articulate to the patient as though the patient can hear.

B, D, E The strategies to use include the following: call the patient by name during interactions; provide orientation to person, place, and time; and articulate to the patient as though the patient can hear. It is essential to communicate not only verbally, but also by touch; thus conversing only verbally is incorrect. The nurse should avoid discussing the patient with others in the patient's presence, not talk about the patient with others in the patient's room.

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. One, some, or all responses may be correct. A. Skin tag B. Bedsore C. Skin wound D. Pressure sore E. Pressure ulcer F. Decubitus ulcer

B, D, E, F Bedsore, pressure sore, pressure ulcer, and decubitus ulcer are the terms used to describe loss of or deteriorated skin condition because of pressure. A pressure injury is the most current terminology used. A skin tag is not a result of deteriorated skin condition. A skin wound is a general term used to describe any wound of the skin, be it pressure-related or any other abnormality in the skin.

Which statement demonstrates that the older adult understands the correct use of condoms? Select all that apply.One, some, or all responses may be correct. A. "I can use any kind of lubricant such as lotions or baby oil." B. "Before using the condom, I should check the package for damage or expiration." C. "I need to use a condom to help reduce the risk of sexually transmitted infections." D. "A good place to store condoms is in the bathroom so they don't dry out." E. "I should not use a condom because I have a latex allergy."

B,C Older adults sometimes are not familiar with condom use and storage. Before using the condom, the packaging should be checked for damage or expiration, because the condom's integrity may be compromised. Using a condom helps reduce the risk of sexually transmitted infections. Teach older adults to use water-based lubricants because oil-based products contribute to breakage of latex condoms. Condoms should be stored in a cool, dry location away from sunlight. Condoms are available in nonlatex varieties.

A patient presents with decreased libido, depression, and ineffective coping. Which nursing intervention would be helpful for the patient? Select all that apply.One, some, or all responses may be correct. A. Assess for influence of cultural beliefs. B. Assess the causes of ineffective coping. C. Help the patient to set realistic goals. D. Encourage the patient to express feelings. E. Explain to the patient about the use of condoms.

B,C,D Assessment of the cause of ineffective coping will help the nurse to understand the patient's problems and plan the treatment accordingly. Helping the patient set realistic goals would help increase the patient's confidence and prevent frustration. Encouraging the patient to express feelings will provide greater insight into the problem. Assessing the influence of cultural beliefs is helpful regarding social isolation. Explaining to the patient about the use of condoms would not help increase libido or enhance coping.

Which holistic intervention would the nurse suggest to the patient with a headache to attain a good outcome? Select all that apply. One, some, or all responses may be correct. A. Drug therapy B. Music therapy C. Therapeutic touch D. Relaxation therapy E. Radiation therapy

B,C,D Holistic interventions include music therapy, therapeutic touch, and relaxation therapy. Music therapy helps provide a soothing environment. Therapeutic touch helps in relieving anxiety. Relaxation therapy helps relax the body and mind. Drug therapy and radiation therapy are not holistic interventions; they are medical interventions.

Which sexual disease is caused by bacteria? Select all that apply.One, some, or all responses may be correct. A. Herpes B. Syphilis C. Chlamydia D. Gonorrhea E. Genital warts

B,C,D Sexually transmitted infections (STIs) caused by bacteria include syphilis, chlamydia, and gonorrhea. Herpes and genital warts are sexually transmitted but are caused by viruses. Herpes is caused by the herpes simplex virus, and genital warts are caused by the human papillomavirus.

A 36-year-old man is admitted to the hospital after a motor vehicle accident. He has sustained multiple injuries to the forehead, right elbow, and left knee. An x-ray of the knee shows a hairline fracture of the left patella. When giving cold therapy to this patient, which factor would the nurse keep in mind? Select all that apply. One, some, or all responses may be correct. A. Patient has to adjust the temperature settings whenever required. B. Patient should be informed that a change in sensation is normal. C. Patient should be within the reach of the nurse call system. D. Position of the patient should allow him to move away from the cold source. E. Patient should remove the application if he becomes uncomfortable

B,C,D The nurse should be aware of the safety measures that need to be used when applying heat or cold therapy. The patient should be told about sensations that he will feel during the procedure. The patient should report changes in sensation or discomfort immediately; the nurse call system should be within the patient's reach to call for help if needed. The patient should be positioned so that he can move away from the source for safety. The patient cannot adjust the temperature setting. The patient should not be allowed to move an application or place hands on the wound site.

A senior nurse is teaching a group of nursing students to assess skin changes related to development of pressure injuries. Which information should the students keep in mind when assessing dark-skinned patients? Select all that apply. One, some, or all responses may be correct. A. Darker skin is more vulnerable to tans and sunburns. B. Blanching is not a conclusive sign in these patients. C. Differentiate skin color changes with reference to baseline skin tone. D. Mongolian spots may not be present in dark-skinned patients because of sun exposure. E. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

B,C,E Assessing the development of pressure injuries in a patient with a dark skin tone can be challenging. Blanching may not be distinctly visible in a patient with dark skin, and the students should be taught to first determine the baseline skin tone and check skin color changes in the affected area. The nurse should inform the students that the GNASC is a useful tool in assessing pressure injuries in dark-skinned patients. Dark skin is not more vulnerable to tans and sunburns. The nurse should be aware that Mongolian spots may be present on the sacral area of African, Asian, and Native- American patients and should not be confused with a skin lesion.

Which question represents a nonjudgmental approach when gathering a sexual health history? A. "How do you and your wife/husband feel about intimacy?" B. "Do you have sex with men, women, or both?" C. "Are you heterosexual or homosexual?" D. "What is your sexual orientation?"

B. "Do you have sex with men, women, or both?" A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Inquiring about all genders during a sexual health history represents a nonjudgmental approach. Using terms such as wife or husband limits how a patient may define him- or herself in regard to his or her sexuality and does not allow patients to identify their sexual preference. The terms gay, lesbian, bisexual, or transgender are preferred over the terms heterosexual or homosexual and are more specific in reference to sexual practices. Asking about specific sexual orientation does not represent a nonjudgmental approach, as it does not allow the patient to express his or her sexuality and it limits his or her response.

Which statement is related to the perception of susceptibility to an illness according to the health belief model? A. "I don't have time to exercise because I have to work after school every night." B. "I'm worried about becoming overweight and getting diabetes because my father has diabetes." C. "The statistics of how many teenagers are overweight is scary." D. "I've decided to start a walking club at school for interested students."

B. "I'm worried about becoming overweight and getting diabetes because my father has diabetes." The statement "I'm worried about becoming overweight and getting diabetes because my father has diabetes" indicates that the individual is concerned about developing diabetes and believes there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the individual may perceive the personal risk of diabetes. None of the other options recognizes a risk factor or susceptibility.

Which statement by the nurse indicates effective learning about assertive behavior? A. "It helps the nurse avert ethical dilemmas." B. "It helps resist intentionally imposed guilt." C. "It may result in the nurse using 'you' statements." D. "It may result in an environment conducive to lateral violence."

B. "It helps resist intentionally imposed guilt." Assertive behavior can help nurses deal with criticism and manipulation by others and learn to say no, set limits, and resist intentionally imposed guilt. Assertive behavior will not necessarily help nurses avoid ethical dilemmas; on the contrary, ethical dilemmas may arise that make assertiveness difficult to implement for fear of retaliation. Assertive messages contain "I," not "you." Effective assertive behavior can help reduce the incidence of lateral violence in the workplace, not make it conducive

Which nursing student statement regarding a nurse's role with victims of sexual abuse indicates a need for further teaching? A. "Nurses should educate individuals regarding all available community services." B. "They do not have the authority to report suspected abuse to the authorities." C. "Nurses are in an ideal position to assess different occurrences of sexual violence." D. "They should ask the victim about abusive behaviors in the absence of the suspected abuser."

B. "They do not have the authority to report suspected abuse to the authorities." Nurses are mandated reporters; therefore depending on the victim's age and vulnerability, nurses have the authority to report sexual abuse to the proper authorities. To enable the victims to cope with the abuse, the nurse should educate them regarding available community services. Nurses are in an ideal position to assess occurrences of sexual violence and help patients cope. This may help victims remain safe from further abuse. When abuse is suspected, the nurse should provide privacy to the victim and obtain information in the absence of the suspected abuser.

The nurse is a part of a campaign on cervical cancer that involves administering the human papillomavirus (HPV) vaccine. For which age- group is the HPV vaccine most effective? A. 20 to 50 years of age B. 11 to 26 years of age C. 20 to 30 years of age D. 25 to 35 years of age

B. 11 to 26 years of age The HPV vaccine is most effective when given before first sexual exposure in the age- group of 11 to 26 years. Individuals in the age-groups of 20 to 50 years, 20 to 30 years, and 25 to 35 years are usually already sexually active and may already be infected with the HPV virus. Therefore the vaccine may not be as effective in these age-groups as in the younger age-group.

The nurse determines that after teaching first grade children about healthy nutrition, the students will be able to name three examples of foods that are fruits. Which phrase does this describe? A. A teaching plan B. A learning objective C. Reinforcement of content D. Enhancing the children's self-efficacy

B. A learning objective A learning objective describes what the learner will do after the teaching session. Naming three examples of fruits is a part of a teaching plan. Reinforcement of content would occur if the students could not name three fruits. Enhancing self-efficacy would occur if the students could successfully name fruits.

Which stage of cognitive learning involves the breakdown of information into organized parts? A. Applying B. Analyzing C. Evaluating D. Understanding

B. Analyzing The analyzing level of cognitive learning involves the ability to break information down into organized parts. Applying involves using learned concepts in real situations. The cognitive process of evaluation is the ability to judge the value of an action for a given purpose. Understanding is described as the ability to understand the meaning of learned material.

A 26-year-old married woman recently discovered that she is pregnant and is at her first prenatal visit. While assessing the patient, the nurse practitioner discovers that the patient has purulent vaginal discharge. The patient states, "It burns when I urinate, and I seem to have to go to the bathroom frequently." Based on these symptoms, which follow-up would the nurse practitioner likely advise for this patient? A. Be tested for human immunodeficiency virus (HIV). B. Be tested for a sexually transmitted infection (STI) such as Chlamydia. C. There is no need for follow-up because this is a normal sign of pregnancy. D. Obtain education on proper perineal hygiene

B. Be tested for a sexually transmitted infection (STI) such as Chlamydia. Chlamydia does not cause symptoms in about 75% of women; thus they are often unaware that they have an STI. It often causes genitourinary tract infections in men and women. Serious complications can result from untreated STIs in pregnancy such as preterm labor, rupture of membranes, and premature delivery of the newborn. Purulent discharge indicates infection and is not an expected finding from HIV, pregnancy, or poor hygiene practices.

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development? A. Gaskin's Nursing Assessment of Skin Color (GNASC) tool B. Braden Scale C. Bates-Jensen Wound Assessment Tool (BWAT) D. Wound, Ostomy, and Continence Nurses Society (WOCN) scale

B. Braden Scale The Braden Scale is a widely used tool for risk assessment of pressure injury development and is composed of six subscales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess stage 1 pressure injuries in patients with dark skin tone. The BWAT is used to assess the wound status. WOCN does not provide any measurement or assessment tools.

A woman has been diagnosed with infertility. The nurse finds that the patient has multiple sexual partners and suspects a correlation between the patient's infertility and her promiscuous lifestyle. Which condition could have caused infertility in this patient? A. Human immunodeficiency virus (HIV) B. Chlamydia C. Herpes simplex D. Human papillomavirus (HPV)

B. Chlamydia Chlamydia trachomatis infection, if left untreated, may cause infertility, pelvic inflammatory disease, and ectopic pregnancy. Most chlamydia infections are untreated because they do not cause any symptoms in women. HIV usually does not cause infertility. Herpes simplex causes painful genital lesions but does not cause infertility. HPV causes warts and cervical and anogenital malignancies.

Which learning domain involves learning about a disease and understanding how it relates to another condition? A. Affective B. Cognitive C. Psychosocial D. Psychomotor

B. Cognitive Cognitive learning occurs when a patient acquires knowledge and comprehends it to gain information about his or her condition. Because the patient is not expressing feelings, opinions, or values about the disease, the patient is not exhibiting affective learning. "Psychosocial" is not a learning domain; rather, psychosocial adaptation involves a patient coming to terms with a temporary or permanent loss of health. Psychomotor learning (integrating mental and muscular activity to learn about a disease) is not involved

Which special zone of touch requires the nurse to get permission to take a pulse at a patient`s wrist? A. Social B. Consent C. Intimate D. Vulnerable

B. Consent The consent zone requires permission to touch a patient's wrist. In the consent zone, the nurse needs permission to touch a patient`s mouth, wrists, and feet. In the social zone, the nurse does not need permission to touch the patient's hands, arms, back, or shoulders. In the intimate zone, great sensitivity and permission are needed in the areas involving the genitalia and rectum. In the vulnerable zone, the nurse takes special care to handle the patient`s face, neck, and front of the body.

Which outcome is the desired behavioral goal of the health promotion model (HPM)? A. Healthy People 2020 B. Health-promoting behavior C. Perceived self-efficacy D. Activity-related affect

B. Health-promoting behavior Health-promoting behavior is the desired behavioral outcome and the end point in the HPM. Healthy People 2020 is a health initiative, not the desired behavioral goal of the HPM. Perceived self-efficacy and activity-related affect are behavior-specific cognitions and affect; they are not the behavioral outcome. The nurse is addressing the need for safety and security. Throw rugs, low lighting, and low footstool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults. Physiological needs refer to the need for food, fluid, elimination, and so forth, not removing throw rugs. Love and belonging refers to the need for relationships, not for improving the lighting in the home. Self-actualization is the need to feel fulfilled in life, not about removing a low footstool.

Which term describes people reacting in different ways because of attitudes about illness? A. Health belief B. Illness behavior C. Health promotion D. Illness prevention

B. Illness behavior The term illness behavior describes people reacting in different ways because of attitudes about illness. Illness behavior affects how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use health care resources. Health beliefs are a person's ideas, convictions, and attitudes about health and illness, not behaviors when ill. Health promotion involves activities related to maintaining, attaining, or regaining good health and preventing illness, not describing behaviors when ill. Illness prevention motivates people to avoid a decline in health or functional levels, and are not behaviors people exhibit when ill.

Which nontherapeutic communication technique is the nurse using when saying, "Don't worry; you'll be fine" to a patient? A. Demonstrating sympathy B. Offering false reassurance C. Giving personal opinions D. Asking personal questions

B. Offering false reassurance The nurse is using false reassurance. When a patient is seriously ill or distressed, the nurse may be tempted to offer false hope statements such as, "Don't worry, you'll be fine." Sympathy is concern, sorrow, or pity felt for another person. This is indicated by stating, "I'm so sorry about your condition," not, "Don't worry; you'll be fine." Giving personal opinions may be indicated by stating, "I think you should consider terminating treatment," not, "Don't worry; you'll be fine." "How would you describe your relationship with Sue?" is an example of asking a personal question, not "Don't worry; you'll be fine."

Which phase of the helping relationship is involved when the nurse and a patient meet and become acquainted? A. Working B. Orientation C. Termination D. Preinteraction

B. Orientation In the orientation phase, the nurse and a patient meet and become acquainted. In the working phase, the nurse and patient work together to solve problems and accomplish goals, not become acquainted. In the termination phase, the nurse evaluates goal achievement with the patient and relinquishes responsibility for patient care, not become acquainted. In the preinteraction phase, the nurse reviews available data, including medical and nursing histories, before meeting the patient.

The edges of a patient's surgical incision are approximated, and no drainage is noted. Which type of healing does this signify? A. Granulation B. Primary intention C. Tertiary intention D. Secondary intention

B. Primary intention Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with injuries and wounds and results in scar formation. Secondary intention wound healing occurs more slowly than primary intention.

During which stage of the grieving process does the patient begin to express emotions openly? A. Anger B. Resolution C. Bargaining D. Acceptance

B. Resolution In the resolution stage of grieving, the patient starts expressing emotions openly. In the anger stage, the patient may avoid discussion of the illness. In the bargaining stage, the patient may offer to live a better life in exchange for the promise of better health. In the acceptance stage, the patient recognizes the reality of the situation.

During which stage of the grieving process does the patient begin to express emotions openly? A. Anger B. Resolution C. Bargaining D. Acceptance

B. Resolution In the resolution stage of grieving, the patient starts expressing emotions openly. In the anger stage, the patient may avoid discussion of the illness. In the bargaining stage, the patient may offer to live a better life in exchange for the promise of better health. In the acceptance stage, the patient recognizes the reality of the situation.

Which criteria does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk of pressure injury C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk of poor wound healing

B. Risk factors that place the patient at risk of pressure injury The Braden Scale measures factors in six subscales that can predict the risk of pressure injury development. It does not assess skin or wounds, repositioning, or wound healing.

Which level of need according to Maslow is being addressed when the nurse discusses with the elderly couple about removing the throw rugs and low footstool and improving the lighting in the home? A. Physiological B. Safety and security C. Love and belonging D. Self-actualization

B. Safety and security The nurse is addressing the need for safety and security. Throw rugs, low lighting, and low footstool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults. Physiological needs refer to the need for food, fluid, elimination, and so forth, not removing throw rugs. Love and belonging refers to the need for relationships, not for improving the lighting in the home. Self-actualization is the need to feel fulfilled in life, not about removing a low footstool.

Which level of Maslow's hierarchy of needs is being addressed when the nurse teaches the parents of a school-age child about the risks of physical and sexual abuse and methods necessary to educate the child about them? A. Self-esteem B. Safety and security C. Love and belonging D. Physiological needs

B. Safety and security The nurse is addressing the safety and security level of Maslow's hierarchy of needs. The nurse is instructing the parents to teach the child about physical and sexual abuse to ensure the child's physical and psychological safety. The nurse addresses self-esteem when parents are instructed to praise the child, not talk about physical and sexual abuse. The nurse addresses the child's need to feel love and belonging when instructing the parents to love and include the child in family outings and meals, not about physical and sexual abuse. The nurse addresses the physiological needs of Maslow's hierarchy when instructing the parents to provide proper nutrition, fluids, and basic needs, not about physical and sexual abuse.

While caring for a pregnant patient who is in the first trimester of pregnancy, the nurse discusses sexual activity during pregnancy with the patient. During which trimester are pregnant women most likely to experience increased libido? A. First trimester B. Second trimester C. Third trimester D. Libido is unaffected during pregnancy

B. Second trimester During the second trimester of pregnancy, patients are most likely to experience an increased libido because of an increased blood supply to the pelvic area to nourish the placenta. In the first trimester, there is usually a decrease in libido because of nausea and vomiting. In the third trimester a comfortable position for sex is difficult. Therefore sexual desire is usually unequal during all trimesters of pregnancy.

Which level of prevention describes an obese patient who follows a healthy low-calorie diet and after 6 months the patient has lost weight? A. Primary B. Secondary C. Tertiary D. Specific

B. Secondary This situation describes secondary prevention. Patients with health problems or who are at risk of developing complications need medical interventions. Early diagnosis and treatment can limit further damage and help patients recover. Primary prevention occurs before development of a medical problem; the patient is currently obese. Tertiary prevention is required for patients who need rehabilitation for a permanent or irreversible defect or disability; obesity is not permanent or irreversible. While the focus is specific for diet, it is not classified as specific prevention.

Which context factor influencing communication is problem resolution to be categorized as? A. Relational B. Situational C. Environmental D. Psychophysiological

B. Situational Situational context involves the reason for communication, which in this case is problem resolution. Relational context (not situational) indicates the nature of the relationship among participants, such as a social, helping, or working relationship. Environmental context, not situational, involves the physical surroundings in which communication occurs. The psychophysiological context (not situational) involves internal factors affecting communication, such as physiological status and emotional status.

Which part of the PLISSIT model would the nurse use when he or she is clear about the victim's problem? A. Intensive therapy B. Specific suggestions C. Permission to discuss sexuality issues D. Limited information related to sexual health problems

B. Specific suggestions According to the PLISSIT model, SS stands for specific suggestions, which the nurse should provide to the victim when he or she is clear about the problems that the victim is facing. IT stands for intensive therapy, in which the nurse refers the victim to a professional with advanced education if necessary. P stands for permission to discuss sexuality issues. LI stands for limited information, which is related to the sexual health problems being experienced.

A 25-year-old patient in the emergency department states that she has had a cough and fever for the past 3 days. While performing a physical assessment, the nurse finds several bruises that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. Which action would the nurse perform first? A. Refer the patient to a sexual counselor. B. Tell the patient about a safe house for women. C. Ask the patient to describe how she got the bruises. D. Report the abuse immediately to the proper authorities.

B. Tell the patient about a safe house for women. The first action is to educate the patient about available resources in the community to help her develop an escape plan. Referring the patient to a sexual counselor and asking about the bruises are not the immediate priority. Reporting the abuse to authorities may put her at increased risk of violence but is legally required.

Which statement regarding the skin is true? A. The stratum corneum prevents entrance of topical medications. B. The dermis and the inner layer of the skin provide tensile strength. C. The basal layer of the epidermis is responsible for collagen formation. D. The three layers of the skin are the epidermis, dermis, and endodermis.

B. The dermis and the inner layer of the skin provide tensile strength The dermis and the inner layer of the skin provide tensile strength and mechanical support to the muscles, bones, and inner organs. The stratum corneum promotes, not prevents, absorption of topical medications. Fibroblasts, not the basal layer of the epidermis, are responsible for collagen formation. The skin has two layers only: the epidermis and the dermis.

In the communication process, which person is the receiver of the message? A. The person who encodes a message B. The person who decodes a message C. The person who delivers a message D. The person who seeks feedback

B. The person who decodes a message The receiver is the person who receives and decodes a message. The sender (not the receiver) is the person who encodes and delivers a message. The sender also seeks both verbal and nonverbal feedback, while the receiver provides feedback to the sender.

The nurse is gathering a sexual history from a 68-year-old man in a nursing home. Which factor would the nurse keep in mind regarding older adults? A. Older adults are usually not part of a sexual minority group. B. They sometimes do not reveal intimate details. C. This group loses interest in sex. D. Seniors in nursing homes do not usually participate in sexual activity.

B. They sometimes do not reveal intimate details. Older adults are sometimes hesitant to reveal information relating to sexual issues because they are embarrassed. It is important that the nurse includes a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Research indicates that many older adults are more sexually active than previously thought, and this group is not a minority. Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest.

Which nursing action is an example of teaching to a patient's cognitive learning style? A. Giving patients examples of other patients' experiences B. Verbally explaining to the patient how to use the wheelchair C. Asking the patient to demonstrate the use of the wheelchair after teaching D. Showing the patient how to use the wheelchair

B. Verbally explaining to the patient how to use the wheelchair The cognitive domain of learning involves discussion of specific patient concerns. Therefore the action of the nurse verbally teaching the patient about the use of the wheelchair is an example of the cognitive domain of teaching. In the affective domain of teaching, the nurse will allow the patient to learn from others' experiences. Psychomotor teaching enables the patients to perform skills as observed. Therefore showing the patient how to use the wheelchair and asking the patient to demonstrate its use is an example of psychomotor teaching.

Which nutrient supports healing by promoting wound closure? A. Protein B. Vitamin A C. Vitamin C D. Zinc

B. Vitamin A One role of vitamin A in healing is to promote wound closure. Protein promotes collagen formation and immunity, vitamin C promotes collagen synthesis and immunity, and zinc promotes collagen formation and protein synthesis.

Which type of physical sign is often seen in adult victims of sexual abuse? A. Unusual odor in the genital area B. Vomiting or abdominal tenderness C. Torn, stained, or bloody underclothing D. Wounds that match the patient's "story"

B. Vomiting or abdominal tenderness Vomiting and abdominal tenderness are often seen in adult victims of sexual abuse. Child victims of sexual abuse may have an unusual odor in the genital area or torn, stained, or bloody underclothing. Adult victims of sexual abuse often have wounds that do not match their stories. It is not a physical sign of sexual abuse.

Which situational context factor influences communication? Select all that apply.One, some, or all responses may be correct. A. Privacy levels B. Emotional status C. Expression of feelings D. Information exchange E. Balance of power and control

C, D Expression of feelings and information exchange are the situational context factors that influence communication. Privacy level is an environmental context factor that influences communication, not a situational one. Emotional status is a psychophysiological context factor that influences communication, not a situational one. Balance of power and control is a relational context factor that influences the communication, not a situational one.

Which factor influences the relational context of communication? Select all that apply.One, some, or all responses may be correct. A. Expression of feelings B. Customs and expectations C. Balance of power and control D. Shared history of participants E. Growth and development status

C, D Factors of communication that influence the nature of the relationship ( relational context) among participants include the balance of power and control and a shared history of participants. Expression of feelings is a factor related to situational context, not relational. Customs and expectations are sociocultural elements that affect an interaction, not relational aspects. Growth and development status is related to psychophysiological context, not the relational context.

A patient has opted for a diaphragm as a mode of contraception. Which advice would the nurse provide to the patient? Select all that apply.One, some, or all responses may be correct. A. The diaphragm should be used along with an intrauterine device (IUD). B. This device should be used along with condoms. C. It should be refitted after pregnancy. D. It should be refitted after a significant change in weight. E. The diaphragm should be used with a contraceptive cream.

C, D, E Diaphragms require refitting after pregnancy and after a significant change in the patient's weight (more than a 10-pound gain or loss). Diaphragms are always used with contraceptive creams (spermicides) to ensure their effectiveness. An IUD is placed inside the uterus for its contraceptive effects. A patient using an IUD need not use a diaphragm. Although not necessary for contraception when using a diaphragm with spermicide, condoms can be used with a diaphragm and spermicide to decrease transmission of sexually transmitted infections.

Which information would the registered nurse (RN) include regarding learning in the nursing plan? Select all that apply. One, some, or all responses may be correct. A. Learning involves setting an appropriate pace. B. It requires the educator to be knowledgeable about subject matter. C. Learning includes both understanding and applying newly acquired concepts. D. Learning involves imparting knowledge through a series of directed activities. E. It is the acquisition of new knowledge, behaviors, and skills through an experience.

C, E Learning is a process that includes both understanding and application of newly acquired concepts. It is the purposeful acquisition of new knowledge, behaviors, and skills through an experience. Teaching involves the educator or guide pacing the learning process appropriately. The educator should be knowledgeable about the subject matter in the process of teaching. Teaching imparts knowledge through a series of directed activities.

Which information would the registered nurse (RN) include regarding learning in the nursing plan? Select all that apply. One, some, or all responses may be correct. A. Learning involves setting an appropriate pace. B. It requires the educator to be knowledgeable about subject matter. C. Learning includes both understanding and applying newly acquired concepts. D. Learning involves imparting knowledge through a series of directed activity. E. It is the acquisition of new knowledge, behaviors, and skills through an experience.

C, E Learning is a process that includes both understanding and application of newly acquired concepts. It is the purposeful acquisition of new knowledge, behaviors, and skills through an experience. Teaching involves the educator or guide pacing the learning process appropriately. The educator should be knowledgeable about the subject matter in the process of teaching. Teaching imparts knowledge through a series of directed activities.

The nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure injuries. Which characteristic will alert the nurse to the possibility the patient may develop pressure injuries? Select all that apply. One, some, or all responses may be correct. A. The skin appears flabby. B. Localized areas of skin may appear red. C. The color remains unchanged when pressure is applied. D. The circumscribed area of intact skin may be warm to touch. E. Inflammation may be detected when compared with the surrounding skin.

C,D,E Assessing the development of pressure injuries in a patient with dark skin may be difficult. If the skin color remains unchanged when pressure is applied, or the skin is warm to the touch, it indicates a potential for the development of pressure injuries. These skin changes should be compared with the surrounding skin, looking for signs of inflammation. Intact, unaffected skin appears flabby, whereas skin areas that appear taut and shiny may have the potential to develop pressure injuries. Instead of red, the affected area of skin may appear purple/blue or violet in dark-skinned patients.

Which factor is considered an external variable influencing illness and illness behavior? Select all that apply. One, some, or all responses may be correct. A. Coping skills B. Locus of control C. Cultural background D. Employment status E. Visibility of symptoms

C,D,E External variables influencing illness and illness behavior include cultural background, employment status, and visibility of symptoms. Internal (not external) variables include coping skills and locus of control.

According to Maslow's hierarchy of needs, which patient need is most basic? Select all that apply. One, some, or all responses may be correct. A. Reassuring the patient B. Allowing family members to visit C. Feeding the patient D. Ensuring adequate fluid intake E. Assisting with bladder or bowel elimination

C,D,E Feeding the patient, ensuring adequate fluid intake, and assisting with bladder or bowel elimination are most basic. According to Maslow's hierarchy of needs, some human needs are more basic than other needs and should be met before other needs are met. Food, water, and elimination are basic needs and should be given priority over others. Reassurance helps make the patient feel emotionally secure, but it is not a most basic need. Allowing family members to visit is appropriate, but it is not one of the most basic needs; visits by family members make the patient feel loved, a higher need, not a basic need.

Which statement by a patient supports the nurse's conclusion that the patient follows a holistic approach of healing? A. "I am implementing changes in my behavior for better health." B. "I am following a perfect regimen of diet and exercise every day." C. "I am also using guided imagery and music therapy for treatment." D. "I am taking prescribed medications to lower the risk of heart attack."

C. "I am also using guided imagery and music therapy for treatment." The patient following a holistic approach would say, "I am also using guided imagery and music therapy for treatment." A patient who follows a holistic approach to healing recognizes the natural healing abilities of the body and may prefer guided imagery and music therapy. Implementing changes in behavior for better health is not a holistic approach. While diet and exercise are healthy choices, they do not include the body, mind, and spirit; they are not holistic approaches. Taking prescribed medications is not a holistic approach, it is a medical approach.

Which statement by the nurse represents "background" when using the SBAR (Situation-Background-Assessment-Recommendation) technique? A. "The blood pressure of the patient is 150/90 mm Hg." B. "The patient has severe perspiration and chest pain." C. "The patient has a history of congestive heart failure." D. "The nurse requests a prescription from the health care provider to treat the patient."

C. "The patient has a history of congestive heart failure." "The patient has a history of congestive heart failure" is a statement that represents background in SBAR. SBAR is an acronym for Situation- Background- Assessment- Recommendation, which is used as a communication technique among professionals. The nurse informs the health care provider about the patient's history of congestive heart failure when communicating the patient's background information. Blood pressure findings are included when communicating assessment information. The reporting of perspiration and chest pain is included when communicating the patient's situation. Requesting a prescription from the health care provider to treat the patient represents a recommendation.

Which distance of personal space is involved when giving a verbal report to a group of nurses? A. 2 feet (61 cm) B. 3 feet (91 cm) C. 9 feet (274 cm) D. 13 feet (396 cm)

C. 9 feet (274 cm) Nine feet (264 cm) is the distance when giving a verbal report to a group of nurses. While giving verbal report to a group of nurses, this is a social distance of 4 to 12 feet (122 to 366 cm). Two and 3 feet (61 and 91 cm) are too close, while 13 feet (396 cm) is too far. While taking a patient's nursing history or teaching an individual patient, a personal distance of 18 inches (46 cm) to 40 inches (102 cm) is followed. While speaking at a community forum, a public zone of 12 feet (366 cm) or more is typical.

Which intervention is classified as an active strategy of health promotion? A. Fortification of milk with vitamin D B. Fluoridation of municipal drinking water C. A weight reduction program for obese people D. Fortification of cereals with vitamin A

C. A weight reduction program for obese people A weight reduction program for obese people is an active strategy. Active strategies of health promotion require a person to be actively involved in the measures taken to improve a condition and reduce the risk of disease. In passive strategies of health promotion, individuals gain from the activities of others without acting themselves. Interventions such as fortification of milk with vitamin D, fluoridation of municipal drinking water, and fortification of cereals with vitamin A are classified as passive strategies, not active.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? A. Pallor or molting B. Dark red or purple discoloration C. Blanchable erythema D. Nonblanchable erythema

C. Blanchable erythema Blanchable erythema is an early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting is a sign of persistent hypoxia. Dark red or purple discoloration may indicate potential damage to blood vessels and tissue. Nonblanchable erythema is a sign of a stage 1 pressure injury.

Which method of contraception does not require a health care provider's prescription? A. Hormonal injection B. Subdermal implant C. Condom D. Intrauterine device

C. Condom A condom is a barrier method of contraception. It is a thin rubber sheath worn on the penis to prevent sperm from entering the vagina. Hormonal injections are hormonal preparations to prevent pregnancy and must be prescribed by a health care provider. The subdermal implants are hormonal preparations placed under the skin. They need a health care provider's prescription. An intrauterine device is a plastic or copper device placed inside the uterus through the cervical opening. It is inserted by a health care provider.

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention would the nurse do first? A. Allow the area to be exposed to air until all drainage has stopped. B. Place several cold packs over the area, protecting the skin around the wound. C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. Allowing the area to be exposed to air until all drainage has stopped invites infection and could cause the exposed bowel to become necrotic. Cold packs should not be used, as they could freeze the sensitive exposed bowel portions and decrease blood flow to them, which might result in necrosis. This is not a minor opening, and the patient should be prepped for immediate surgery. A binder should not be applied, as it may damage the exposed bowel.

The school nurse is about to teach a freshman-level high-school health class about nutrition. Which instructional approach ensures that the students meet the learning outcomes? A. Provide information using a lecture. B. Use simple words to promote understanding. C. Develop topics for discussion that require problem solving. D. Complete an extensive literature search focusing on eating disorders.

C. Develop topics for discussion that require problem solving. Adolescents learn best when they are able to use problem solving to help them make choices. Providing information using a lecture, using simple words, and completing a literature review does not assist the students in meeting learning objectives. Including the students in the learning will ensure they learn the information.

Which factor is a possible cause of dyspareunia? A. Diminished sexual desire B. Diabetes and hypertension C. Diminished vaginal lubrication D. Increased vaginal elasticity

C. Diminished vaginal lubrication Dyspareunia is painful sexual intercourse. In perimenopausal women, estrogen secretion decreases and leads to diminished vaginal lubrication and elasticity. These changes may cause dyspareunia. Diminished sexual desire could be because of low estrogen but does not lead to dyspareunia. Diabetes and hypertension do not cause dyspareunia.

Which element of the communication process is the patient displaying when frequently nodding and saying, "I see" as the nurse explains the steps of a dressing change? A. Channel B. Referent C. Feedback D. Interpersonal variable

C. Feedback The patient is displaying feedback. Feedback is the verbal and nonverbal messages the receiver sends indicating whether or not he or she has understood the sender's message. In this case, the feedback indicates whether the patient has understood the meaning of the nurse's message. Channels of communication are means of sending and receiving messages through different aids, such as visual, auditory, and tactile senses; they do not involve responding to instructions. The referent process helps motivate one person to communicate with the other; it does not involve nodding and saying, "I see" when receiving instructions about a dressing change. Interpersonal variables such as educational, developmental, and sociocultural background, and values and beliefs are characteristics of both the sender and receiver that influence communication, but they do not represent nodding and saying, "I see" while receiving instructions.

Which attribute is exhibited by the nurse when a patient wants a regular diet but a regular diet would delay recovery and after a discussion both mutually agree upon a full liquid diet? A. Humility B. Curiosity C. Integrity D. Creativity

C. Integrity The nurse exhibited integrity. Integrity involves recognizing patients' opinions when they conflict with the nurse's opinions, reviewing positions, and finally determining how to communicate to reach mutually beneficial decisions. The scenario did not portray humility, curiosity, or creativity. Humility involves the nurse asking for help if he or she is uncomfortable with an aspect of patient care. Curiosity involves the nurse being motivated to communicate and know more about a person. Creativity involves identifying innovative solutions.

Which level of communication is exhibited by the nurse performing a mental rehearsal on how to deal effectively in difficult situations with increased confidence? A. Public B. Small-group C. Intrapersonal D. Interpersonal

C. Intrapersonal This scenario is describing intrapersonal communication. Intrapersonal communication involves developing self-awareness and self-esteem that enhances appropriate self-expression. This level of communication is also called self-talk and may involve a mental rehearsal to deal effectively with difficult tasks or situations with increased confidence. Public communication is interaction with an audience, which may include speaking to groups of consumers about health-related topics, not a mental rehearsal. Small-group communication is the interaction that occurs when a small number of people meet and discuss issues; it does not involve a mental rehearsal. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face-to-face; it is not a mental rehearsal.

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? A. Low-air-loss surface B. Nonpowered surface C. Lateral rotation surface D. Air-fluidized bed

C. Lateral rotation surface A lateral rotation support surface is useful in treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss and nonpowered support surfaces help in preventing and treating skin breakdown. An air- fluidized bed support surface prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites.

Which blood cells are known as garbage cells? A. Neutrophils B. Erythrocytes C. Macrophages D. T-lymphocytes

C. Macrophages Macrophages are called garbage cells because they ingest bacteria, dead cells, and debris from wounds. Neutrophils ingest bacteria and small debris. Erythrocytes are red blood cells. T-lymphocytes are cells that play an important role in immunity.

Which behavioral symptom is often found in children who have been victims of sexual abuse? A. Depression B. Facial grimacing C. Physical aggression D. Strong peer relationships

C. Physical aggression Physical aggression is common in children who have been victims of sexual abuse. Depression and facial grimacing are symptoms more commonly found in adults who have been victims of sexual abuse. Children who have been victims of sexual abuse often have poor peer relationships, not strong ones.

According to the Braden Scale for predicting pressure injury risk, which factor most puts the patient at risk of developing a pressure injury? A. Dry skin B. Walks occasionally C. Poor nutrition D. Slightly limited sensory perception

C. Poor nutrition Of these factors, the patient's poor nutrition carries the highest risk of the patient developing a pressure injury. The better the nutrition, the lower the risk. Moist, not dry, skin puts a patient at a greater risk of developing a pressure injury. Although frequent, rather than occasional, activity is ideal for reducing the risk of developing a pressure injury, the more immobile the patient is, the greater the chance of pressure injury development. Slightly limited sensory perception puts a patient at less of a risk than does very limited or completely limited sensory perception.

Which aspect is the primary contraceptive action of an intrauterine device (IUD)? A. Prevents ovulation B. Acts as a physical barrier C. Prevents fertilization D. Kills sperm cells

C. Prevents fertilization The primary action of an IUD is to prevent fertilization of the ovum. It has no effect on ovulation, does not act as a physical barrier, and has no effect on the sperm. Hormonal contraception (e.g., use of oral contraceptive pills) prevents ovulation. Condoms and diaphragms act as physical barriers to contraception. Spermicidal products, such as spermicidal creams and jellies, kill sperm cells.

Which role does vitamin A play in wound healing? A. Quickens fibroplasia B. Acts as an antioxidant C. Promotes wound closure D. Acts as immune function

C. Promotes wound closure Vitamin A promotes epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. Protein quickens fibroplasia and acts as immune function. Vitamin C acts as an antioxidant.

Which factor increases the risk of wound infection? A. Absence of necrotic tissue B. Absence of foreign body in the wound C. Reduced local tissue defenses D. Adequate blood supply

C. Reduced local tissue defenses Reduced local defenses may prevent any counter activity against the microorganisms infecting the wound. Absence of necrotic tissue decreases the risk of infection by improving the blood supply. A foreign body in the wound increases the risk of infection by acting as a port of entry for the microorganisms. An adequate blood supply is important for preventing infection.

According to the circular transactional model, which element motivates a patient to communicate with the nurse? A. Channels B. Message C. Referent D. Environment

C. Referent According to the circular transactional model, the referent motivates one person (a patient) to communicate with another (the nurse), initiating the communication process. Communication channels are means of sending and receiving messages through visual, auditory, and tactile senses; they do not motivate a person/patient to communicate. The message is the content of the communication. It contains verbal and nonverbal expressions of thoughts and feelings; it does not involve the motivation to communicate. The environment is the setting for sender-receiver interaction. Environmental distractions are common in health care settings and interfere with messages sent between people; they do not reflect the motivation to communicate.

How can a nurse establish trust and encourage patient disclosure about sexuality? A. Ask how often the patient has sexual intercourse. B. Ask the patient to disrobe in preparation for the physical assessment. C. Request permission to discuss sexual issues. D. Request specific examples of sexual practices and problems.

C. Request permission to discuss sexual issues. According to the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) assessment of sexuality, the nurse should first ask for permission to discuss sexual issues with the patient, followed by open-ended questions to determine the patient's concerns. The other options do not establish trust or encourage patient disclosures about sexuality.

A patient who was hospitalized for a smoking-related illness tells the nurse, "I am ready to accept responsibility for learning, and I need your help." Which stage of psychosocial grief is reflected in this statement? A. Anger B. Disbelief C. Resolution D. Bargaining

C. Resolution It is difficult for a patient to accept a temporary or permanent loss of health. The process of grieving provides time to adapt psychologically to the emotional and physical implications of illnesses. In the resolution stage, the patient begins to sense a need for help, is ready to accept responsibility for learning, and begins to express his or her emotions openly. The stage of anger is reflected when the patient directs anger toward the nurse or others. The stage of disbelief would be characterized by the patient avoiding discussions about illness. The bargaining stage would be indicated by the patient offering to live a better life in exchange for the promise of better health.

A patient who was hospitalized for a smoking-related illness tells the nurse, "I am ready to accept responsibility for learning, and I need your help." Which stage of psychosocial grief is reflected in this statement? A. Anger B. Disbelief C. Resolution D. Bargaining

C. Resolution It is difficult for a patient to accept a temporary or permanent loss of health. The process of grieving provides time to adapt psychologically to the emotional and physical implications of illnesses. In the resolution stage, the patient begins to sense a need for help, is ready to accept responsibility for learning, and begins to express his or her emotions openly. The stage of anger is reflected when the patient directs anger toward the nurse or others. The stage of disbelief would be characterized by the patient avoiding discussions about illness. The bargaining stage would be indicated by the patient offering to live a better life in exchange for the promise of better health

A patient newly diagnosed with Alzheimer's disease expresses sadness and feeling concern that the disease has affected her daily life. This patient is in which stage of grieving? A. Denial B. Anger C. Resolution D. Acceptance

C. Resolution The patient is concerned that Alzheimer's disease will change her life and openly expresses her emotions about it. This is the resolution stage of grieving. In the stage of denial, the patient is not ready to accept the altered condition. During the anger stage, the patient expresses anger toward others. During the acceptance stage, the patient accepts the medical condition, pursues information, and is willing to deal with the implications of the diagnosis.

In the pyramid of Maslow's hierarchy of needs, which need of the patient is placed at the highest level? A. Food B. Love C. Self-actualization D. Physical safety

C. Self-actualization Self-actualization is placed at the highest level. Self-actualization is considered the highest expression of one's individual potential, and it allows for the continual discovery of self. Maslow's model of the hierarchy of needs is used to understand the interrelationships of basic human needs. According to this model, basic needs are at the bottom and self-actualization is at the top. Food is considered a basic need and is thus placed at the bottom, not the top. The need for love comes after the need for physical safety; however, both are below the highest level.

A 50-year-old male patient comes for a follow-up visit a few months after a myocardial infarction. The nurse plans to interview the patient to assess his sexual health. During assessment, the patient expresses that he is not able to perform well sexually. Which explanation would the nurse give to the patient? A. The patient's sexuality is affected by his age and is absolutely normal. B. The patient must undergo surgery and extensive medication therapy to get back to normal. C. Sexuality can be affected by ailments such as myocardial infarction, but the patient should return to normal soon. D. Sexuality can be affected by ailments such as myocardial infarction, and the damage is permanent.

C. Sexuality can be affected by ailments such as myocardial infarction, but the patient should return to normal soon. Sexuality may be altered by disease states such as myocardial infarction, unstable angina, diabetes, and spinal cord injury. Medications such as antihypertensives also alter sexual function. These alterations are usually temporary and resolve with time. Because the patient is only 50 years old, his decline in sexual activity is not related to age alone. The patient does not need to undergo surgery or medication therapy; he should return to normal without them.

Which communication technique is the nurse exhibiting when stating, "I'm so very sorry about your condition; you probably are devastated after your surgery?" A. Using humor B. Sharing feelings C. Showing sympathy D. Giving personal opinions

C. Showing sympathy The nurse is showing sympathy in this scenario. Sympathy, a nontherapeutic technique, is concern, sorrow, or pity felt for another person. Using humor is a therapeutic communication technique. Humor is an important but often underused resource in nursing interactions; this scenario did not focus on humor. The nurse saying, "I'm so very sorry about your condition; you probably are devastated . . ." is not sharing feelings. However, sharing feelings can be a therapeutic communication technique as long as the focus is on the patient, not the nurse. The nurse's statement is not reflective of giving personal opinions. Giving personal opinions is a nontherapeutic communication technique in which the nurse injects his or her own views; this may serve to take decision-making power away from patients. An example of giving personal opinions includes, "If I were you, I'd put your mother in a nursing home."

Which phase of the helping relationship is represented when the nurse recalls a funny shared experience with a patient shortly before the patient is transferred to another unit? A. Working B. Orientation C. Termination D. Preinteraction

C. Termination When the nurse ends the relationship with a patient, it indicates the termination phase of the helping relationship. This phase may involve the nurse and the patient reminiscing about their relationship and what occurred. The working phase involves taking actions to meet the goals set for the patient. The nurse sets the tone for the relationship by adopting a warm, empathetic, caring manner during the orientation phase. The preinteraction phase involves the time before the nurse's initial interaction with the patient.

Which level of prevention describes a patient who experienced a myocardial infarction (heart attack) 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center? A. Primary B. Secondary C. Tertiary D. Quaternary

C. Tertiary Tertiary prevention is being described. Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration after a disease (myocardial infarction). Tertiary prevention activities are directed at restoration and rehabilitation (cardiac rehabilitation sessions). Care at this level aims to help patients achieve as high a level of functioning as possible despite the limitations caused by illness or impairment. Primary prevention is aimed at health promotion and includes health education programs, immunizations, and physical and nutritional fitness activities before an illness occurs, not after. Secondary prevention includes diagnosing and treating an illness and limiting disabilities, not attending cardiac rehabilitation sessions. There are only three levels of prevision; the quaternary level does not exist.

A patient is diagnosed with colorectal cancer and is scheduled for surgery. After the surgery, the health care provider informs the patient the surgery was successful. However, the patient is told that she needs chemotherapy because the cancer had spread to other organs. The patient asks the nurse whether the spread of cancer will stop if she stops smoking and consuming alcohol. Which stage of grieving is the patient experiencing? A. The stage of denial B. The stage of anger C. The stage of bargaining D. The stage of resolution

C. The stage of bargaining The patient is experiencing the bargaining stage of grief. In this stage, the patient offers to live a healthier life in exchange for better health. The stage of denial indicates that the patient is unable to accept illness or disability. In the stage of anger, the patient tends to blame him- or herself and others for the condition. The anger is often directed toward the nurse and the family members. In the stage of resolution, the patient starts accepting the illness and asks questions related to the illness and care.

A couple is diagnosed as positive for the human immunodeficiency virus (HIV). Which information would the nurse include when educating this couple about HIV? A. They should not engage in sexual intercourse. B. Their children will also be HIV positive. C. Their duration of survival would increase with treatment. D. They can be cured by highly active antiretroviral therapy (HAART).

C. Their duration of survival would increase with treatment Individuals infected with HIV can survive for about 10 years if left untreated. Because they are already infected, they may have sexual intercourse with each other. Their children are at risk, but not all children born to mothers with HIV test positive for HIV. HAART greatly increases the longevity of infected individuals but does not cure the disease.

Which patient behavior indicates that a patient who smokes is in the preparation stage of the Transtheoretical Model of Change? A. Has no intention of quitting tobacco B. Sustains the behavior of not smoking for longer than 6 months C. Thinks the advantages outweigh the disadvantages of smoking D. Thinks about quitting tobacco in another 4 months

C. Thinks the advantages outweigh the disadvantages of smoking In the preparation stage of the Transtheoretical Model of Change, the patient believes the advantages outweigh the disadvantages of smoking. In the precontemplation (not preparation) stage, the patient has no intention of quitting tobacco. Sustaining the behavior of not smoking for longer than 6 months is part of the maintenance stage, not the preparation stage. A plan to quit tobacco use at a distant point in the future indicates the patient is in the contemplation stage, not the preparation stage.

Which model that consists of five stages of health behavior change would the nurse use to manage a patient who needs to exercise? A. Health belief model B. Holistic health model C. Transtheoretical model D. Maslow's hierarchy of needs

C. Transtheoretical model The Transtheoretical Model of Change describes the five stages of health behavior change that a patient undergoes while trying to change a behavior (in this case, exercising). The health belief model helps the nurse understand the patient's beliefs, behaviors, and perceptions of illness and plans to provide an appropriate intervention; it does not have five stages. While the holistic health model is an approach in which the nurse creates conditions to promote the patient's fitness and well-being, it does not have five stages. Maslow's hierarchy of needs helps nurses understand the importance of and relationships among basic human needs; it does not focus on changing health behaviors.

Which teaching method would the nurse include for a toddler? A. Having the toddler touch different textures B. Speaking softly to convey a sense of trust C. Using play to teach procedures and activities D. Using pictures to teach how to perform hygiene

C. Using play to teach procedures and activities For a toddler, the nurse uses play to teach procedures and activities. The nurse would have an infant touch different textures. The nurse speaks softly to an infant to convey a sense of trust. For a preschooler, the nurse uses pictures to teach how to perform hygiene.

Which nutrient is an antioxidant that promotes wound healing? A. Zinc B. Protein C. Vitamin C D. Vitamin A

C. Vitamin C Vitamin C is an antioxidant that is useful in wound healing by promoting collagen synthesis, capillary wall integrity, fibroblast function, and immunity. Zinc is an essential nutrient that promotes collagen formation, protein synthesis, and cell membrane and host defenses. Proteins support healing with fibroplasia, angiogenesis, collagen formation, and wound remodeling while boosting immunity. Vitamin A supports healing with epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.

The nurse is caring for older-adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure injuries and other wounds. Which factor makes older adults more vulnerable to developing pressure injuries? Select all that apply. One, some, or all responses may be correct. A. Increased skin elasticity B. Increased inflammatory response C. Increase of the hypodermis in size with age D. Diminished inflammatory response E. Loss of collagen and thinning of muscles

D, E With age the skin loses elasticity, has decreased collagen, and the underlying muscles thin out, causing the skin to be easily torn with shearing and friction trauma. This leads to development of pressure injuries. The decreased inflammatory response in older adults results in poor healing processes because of slow epithelialization. In old age, the hypodermis decreases in size and there is little padding in the skin over bony prominences, causing easy skin breakdown.

Which statement made by a young adult patient with an amputation indicates a problem with body image? A. "I just don't have any energy to get out of bed in the morning." B. "I've been attending church regularly with my wife since I got out of the hospital." C. "My wife has taken over paying the bills since I've been in the hospital." D. "I don't go out very much because everyone stares at me."

D. "I don't go out very much because everyone stares at me." The statement, "I don't go out very much because everyone stares at me" indicates a problem with body image. The amputation resulted in a change in physical appearance that caused a change in body image. Not having the energy to get out of bed indicates a problem with fatigue or depression, not a problem with body image. Attending church indicates a positive adjustment to the amputation, not a problem with body image. Having the wife pay the bills is an impact of the amputation on the family roles and dynamics that can occur from an illness or amputation, but it does not indicate a problem with body image.

After teaching a group of young adults about contraception, the nurse concludes that there is a need for further teaching. Which statement made by a young adult supports the nurse's conclusion? A. "A vasectomy is a contraceptive method that is permanent." B. "A condom is the most effective barrier method for contraception." C. "I consult a health care provider before starting hormonal contraceptive therapy." D. "I prefer to use a combined method of birth control to reduce the risk of sexually transmitted infections (STIs)."

D. "I prefer to use a combined method of birth control to reduce the risk of sexually transmitted infections (STIs)." Contraception, also known as birth control, is the method or device used to prevent pregnancy. The nurse teaches about contraception to people who are sexually active to provide higher protection against a number of diseases. However, methods that are effective for contraception do not always reduce the risk of STIs. Therefore the nurse should correct the statement about using a combined method of contraception to reduce the risk of STIs. A vasectomy or male sterilization is a permanent contraceptive surgical method. A condom is the most effective barrier method. A condom is a thin rubber sheath that fits over the penis to prevent the entrance of sperm into the vagina. The use of hormonal contraception requires a health care provider's prescription. Therefore the young adult will consult a health care provider before beginning a suitable therapy.

Which statement by the nurse would make the patient pay more attention to the care being provided? A. "You should learn about the medical tests." B. "You should ask questions if you do not understand something." C. "You should ask a trusted family member to be your advocate." D. "You should make sure that you are getting the right treatment from the right health care professional."

D. "You should make sure that you are getting the right treatment from the right health care professional." The nurse is responsible for teaching patients about their rights. This teaching helps patients make informed decisions about their care, and the information must be accurate, complete, and relevant to patients' needs, language, and literacy level. The nurse may need to emphasize that the patient should pay more attention to the care being provided by asking the patient to ensure the right treatment from the right health care professional. The nurse may encourage the patient to be more educated by learning about the medical tests being prescribed, the patient is advised to actively ask questions in case of any lack of clarity, and the nurse may ask the patient to include a trusted family member or friend as an advisor or supporter; but these statements by the nurse don't encourage the patient to pay attention to his or her care.

The nurse understands that any weight change necessitates a resizing of the diaphragm. A loss or gain of how much weight would be significant? A. 4 pounds B. 6 pounds C. 8 pounds D. 10 pounds

D. 10 pounds A diaphragm is a round, rubber dome that is fitted into the cervical opening to provide contraception. It must be used with a contraceptive cream or jelly. It must be refitted if the patient has a weight gain or loss of 10 pounds. Weight changes of 4, 6, or 8 pounds have no adverse effect on the placement of the diaphragm and thus do not require the patient to be refitted.

Which stage of behavioral change is a patient exhibiting when he or she joins a fitness club and attends aerobics class three nights a week? A. Precontemplation B. Contemplation C. Preparation D. Action

D. Action The patient is in the action stage of behavioral change because the patient is actively engaged in strategies to change behavior. In precontemplation, the patient is not considering a change in behavior within the next 6 months. This patient is actively exercising. In contemplation, the patient is considering a change in 6 months; and in preparation, the patient makes small changes in anticipation of change that will occur in the next month. The patient is past both of these stages because he or she is actively engaged in strategies to change behavior.

Which activity is classified as tertiary prevention? A. Attending to personal hygiene B. Taking measures to shorten a period of disability C. Providing services to limit disability and prevent death D. Aiding with rehabilitation for physically handicapped people

D. Aiding with rehabilitation for physically handicapped people Aiding with rehabilitation for physically handicapped people is tertiary prevention. Tertiary preventive measures are taken when permanent, irreversible damage has occurred as a result of a medical problem or accident. Attending to personal hygiene is a primary preventive measure, not tertiary. Taking measures to shorten the period of disability comes under secondary prevention, not tertiary. Providing services to limit disability and prevent death is a secondary preventive measure, not tertiary.

Which action taken by the patient indicates that the patient needs further teaching about The Joint Commission (TJC) Speak Up program? A. Asking about medication errors B.Asking about the qualifications of the health care provider C. Asking about the purpose of medications given during the treatment D. Asking the health care provider to act as his or her advocate

D. Asking the health care provider to act as his or her advocate According to the TJC Speak Up program, the patient should ask a trusted family member or a friend to act as his or her advocate (advisor or supporter). The patient should know the medications and their purpose in the treatment and medication errors that result in common health care mistakes. Patients should make sure that the treatment and medications they are getting are right and are provided by the right health care professionals. Therefore the patient has a full right to ask about the qualifications of the health care provider. The patient should have knowledge about the medications and their purpose in the treatment.

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage 3 pressure injury needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of bed sores. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely. A stage 3 pressure injury is open and has full-thickness skin loss.

Which bacterial sexually transmitted infection (STI) is most commonly reported in the United States? A. Syphilis B. Gonorrhea C. Genital herpes D. Chlamydia

D. Chlamydia Syphilis, gonorrhea, genital herpes, and chlamydial infections are all commonly reported; however infection with Chlamydia organisms is the most common bacterial STI in the United States. Other STIs include syphilis, gonorrhea, and genital herpes. Syphilis is caused by Treponema pallidum. Gonorrhea is caused by Neisseria gonorrhoeae. Genital herpes is caused by the herpes simplex virus.

The nurse has to teach a group of morbidly obese patients the significance of proper eating habits and exercise. Where would be an ideal setting to impart this teaching? A. Cafeteria B. Hospital lobby C. Gymnasium D. Classroom

D. Classroom An ideal setting for teaching would be a classroom because patients would be able to sit comfortably, the room would have proper ventilation and light so that everyone could see and hear the teacher without distraction, and the patients would be able to observe one another during the teaching session. A cafeteria, hospital lobby, or noisy and busy places would have numerous distractions that could interfere with the teaching process. A gymnasium would not have comfortable seating arrangements for the patients to optimally concentrate on the teaching.

Which situation is typical regarding lateral violence? A. An individual ingests alcohol and illicit drugs that are harmful not only to him- or herself but also to others. B. A known individual uses power and control over another individual through physical, sexual, or emotional threats. C. An individual touches another individual without consent or forces him or her to take part in sexual activity against his or her will. D. Colleagues, especially in the workplace, use badmouthing, nasty remarks, or nonverbal expressions of disapproval.

D. Colleagues, especially in the workplace, use badmouthing, nasty remarks, or nonverbal expressions of disapproval. Lateral violence occurs when colleagues, especially in the workplace, use badmouthing, nasty remarks, or nonverbal expressions of disapproval. Substance abuse (not lateral violence) occurs when an individual ingests alcohol and illicit drugs that are harmful not only to him or herself but also to others. Interpersonal violence occurs when an individual uses power and control over another individual through physical, sexual, or emotional threats; lateral violence occurs among colleagues, there is no power difference. Sexual violence (not lateral violence) occurs when an individual touches another individual without consent or forces him or her to take part in sexual activity against his or her will.

In which stage of the Transtheoretical Model of Change would a patient have mixed feelings about quitting smoking? A. Action B. Preparation C. Maintenance D. Contemplation

D. Contemplation Mixed feelings (ambivalence) about a behavior change are characteristic of the contemplation stage. In the action stage, the patient actively engages in strategies to quit smoking and does not have mixed feelings about quitting. In the preparation stage, the person understands the advantages and plans how to make small changes; the patient does not have mixed feeling about quitting. The maintenance stage involves integrating positive behavioral changes into the patient's long-term lifestyle to prevent relapse; the patient does not have mixed feelings regarding quitting smoking.

The nurse assures a patient that the nurse is always available to talk. Which stage of grieving would trigger this action of the nurse? A. Anger B. Resolution C. Bargaining D. Denial or disbelief

D. Denial or disbelief In the denial or disbelief stage of grieving, the patient is not prepared to deal with a problem. Therefore, the nurse should provide support and empathy and ensure the patient that he or she is always available for discussion. In the anger stage of grieving, the nurse should not argue with the patient and should calmly listen to the patient's concerns. In the resolution stage of grieving, the nurse should encourage the patient to express his or her feelings. In the bargaining stage of grieving, the nurse should convey only reality to the patient.

Which interpretation would the nurse make about a patient who smokes and is in the precontemplation stage to quit smoking? A. Intends to quit smoking in the next 6 months B. Has started making small lifestyle changes C. Is actively taking measures to quit smoking D. Does not intend to quit smoking in the next 6 months

D. Does not intend to quit smoking in the next 6 months The patient does not intend to quit smoking in the next 6 months when in the precontemplation stage. According to the Transtheoretical Model of Change, there are five stages in health behavior change that a person may go through while trying to change habits. These stages include precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the patient intends to quit smoking in the next 6 months; the patient is in the precontemplation stage. The patient starts making small lifestyle changes in the preparation stage, not the precontemplation stage. In the action (not precontemplation) stage the patient actively takes measures to quit smoking.

The nurse is teaching a group of patients the importance of using sunscreen. Which type of content is the nurse providing? A. Simulation B. Restoring health C. Coping with impaired function D. Health promotion and illness prevention

D. Health promotion and illness prevention Health promotion and illness prevention are the focus when nurses provide information that helps patients improve their health and avoid illness. Simulation teaches problem solving and independent thinking. Restoring health occurs when an individual already has a condition. Coping with impaired function teaches an individual who does not have full health function how to live with what they do have.

The nurse is caring for a patient who is a sex worker. Against which sexually transmitted infection can the patient be vaccinated? A. Human immunodeficiency virus (HIV) B. Herpes C. Chlamydia D. Human papillomavirus (HPV) infection

D. Human papillomavirus (HPV) infection A vaccine is available for various strains of HPV. This virus is known to cause cervical cancer in women and anogenital cancers and genital warts, which cause health concerns in men and women. There are no vaccines for HIV, herpes, or chlamydia. However, chlamydia can be cured by antibiotics. HIV and herpes have no cure.

Which form of communication is appropriate to assess understanding and clarify misinterpretations when the nurse is teaching a patient about a health concern? A. Public B. Small-group C. Intrapersonal D. Interpersonal

D. Interpersonal Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face-to-face. This interaction is useful to assess understanding and clarify misinterpretations when teaching a patient about a health concern. Public communication is interaction with an audience. Nurses often speak with groups of consumers about health-related topics; however, this scenario dealt with just a nurse and a patient. Small-group communication occurs when a small number of people meet, not just a nurse and patient. This type of communication is usually goal directed and requires an understanding of group dynamics. Intrapersonal communication is a powerful form of communication that one uses as a professional nurse. This level of communication is also called self-talk; it does not involve communication with another person.

Which zone of personal space would the nurse be using when holding an inconsolable infant? A. Social B. Public C. Personal D. Intimate

D. Intimate Holding an inconsolable infant is under the intimate zone category (0-46 cm [0-18 inches]). Bathing, dressing, and grooming a patient are also under the intimate zone category. The social zone (122-366 cm [4-12 feet]) includes activities such as making rounds with the health care provider, not holding an inconsolable infant. Speaking at a community forum comes under the public zone (≥366 cm [≥12 feet]), not holding an inconsolable infant. The personal zone (46 to 102 cm [18-40 inches]) includes activities such as sitting at a bedside and taking a history, not holding an inconsolable infant

Which patient challenge would the nurse expect to face while caring for a patient who is in the action stage of the Transtheoretical Model of Change? A. May not participate in the treatment plan B. May underestimate the problem C. May be ambivalent about the change D. May find previous habits become barriers to change

D. May find previous habits become barriers to change The patient may find previous habits become barriers to change in the action stage. The patient may not participate in the treatment plan or may underestimate the problem during the precontemplation stage, not during the action stage. The patient may be ambivalent about the change in the contemplation stage, not the action stage.

In a supine position, which site has the least risk of a pressure injury? A. Ischium B. Elbow C. Occipital bone D. Medial knee

D. Medial knee The medial knee may be at risk of a pressure injury in a patient who is in a side-lying position, but not in a supine position. The ischium, elbow, and occipital bone are all sites at risk of pressure injuries in an immobilized supine patient.

Which type of communication technique is represented when the nurse asks cancer survivors to share their stories on how they went through treatment and how their family members supported them? A. Clarifying B. Silence C. Empathy D. Narrative interaction

D. Narrative interaction In a therapeutic relationship, it is helpful to encourage patients to share personal stories, a process called narrative interaction. Through listening to the patients' stories, the nurse understands the context of patients' lives, their concerns, experiences, and challenges. Clarifying involves checking whether the nurse understands a message accurately, not asking for stories. The nurse did not use silence; the nurse asked for stories. Although sharing stories can lead to empathy, the nurse did not use empathy when asking for patients' stories. The nurse used narrative interaction.

Which strategy would be contraindicated while communicating with a patient who has cognitive impairment? A. Give sufficient time for the patient to answer questions. B. Use pictures or gestures that resemble the desired action. C. Involve a family member in conversation while providing counselling. D. Offer detailed explanations while asking questions to help the patient understand.

D. Offer detailed explanations while asking questions to help the patient understand. Offering detailed explanations is contraindicated. The nurse should use simple sentences and avoid long explanations while communicating with patients who are cognitively impaired. Giving sufficient time for the patient to answer a question is an appropriate strategy in communicating with patients who are cognitively impaired; it is not contraindicated. Using pictures or gestures that resemble the desired action and involving a family member in conversation while providing counseling are also effective strategies for communicating; they are not contraindicated.

Which phase of the health belief model (HBM) describes a female patient who is concerned about getting diabetes mellitus because both her grandfather and father have the disease? A. Perceived threat of the disease B. Likelihood of taking preventive health action C. Analysis of perceived benefits of preventive action D. Perceived susceptibility to the disease

D. Perceived susceptibility to the disease The patient is in the phase of perceived susceptibility to the disease. In this phase, the patient recognizes the familial link to the disease. The HBM addresses the relationship between a person's beliefs and behaviors. Perceived threat of the disease is the second phase of the individual's perception of the seriousness of the illness, and this patient is not at that stage; the patient is just recognizing susceptibility. Likelihood of taking preventive health action is the third phase of the HBM, in which the person does or does not take preventive actions; this patient is not at that phase. Analysis of perceived benefits of preventive action occurs in the fourth phase, and this patient is not at that level.

In which stage of the Transtheoretical Model of Change does a patient display defensive behavior when the nurse provides information regarding the benefits of quitting excessive alcohol drinking? A. Action B. Preparation C. Contemplation D. Precontemplation

D. Precontemplation In the precontemplation stage, a patient is not interested in the information provided and may exhibit defensive behaviors when the nurse tries to explain the benefits of a behavioral change (quitting excessive alcohol drinking). In the action stage, the patient actively takes measures to stop drinking for at least 6 months; the patient would not become defensive in the action stage. In the preparation stage, the patient understands the advantages of making the change and begins to make small changes; the patient does not become defensive. In the contemplation stage, the patient considers quitting excessive alcohol drinking within the next 6 months; the patient would not become defensive about the change.

Which phase of the helping relationship is the nurse exhibiting when reviewing the patient's medical and nursing histories? A. Working B. Orientation C. Termination D. Preinteraction

D. Preinteraction Reviewing available data, such as the medical and nursing histories, is included in the preinteraction phase. The phase before meeting a patient is the preinteraction phase. Working phase is when the nurse and patient work together to solve problems and accomplish goals. The nurse and patient meet and get to know one another during the orientation phase. The termination phase occurs at the end of the relationship with the patient.

Which phase of the helping relationship is the nurse exhibiting when reviewing the patient's medical and nursing histories? A. Working B. Orientation C. Termination D. Preinteraction

D. Preinteraction Reviewing available data, such as the medical and nursing histories, is included in the preinteraction phase. The phase before meeting a patient is the preinteraction phase. Working phase is when the nurse and patient work together to solve problems and accomplish goals. The nurse and patient meet and get to know one another during the orientation phase. The termination phase occurs at the end of the relationship with the patient.

The nurse includes role play, imitation, and play in the teaching method to make learning fun. The nurse is teaching which age-group of children? A. Infant B. Adolescent C. School-aged D. Preschooler

D. Preschooler The nurse uses role play, imitation, and play to make learning fun for a preschooler. For an infant, the nurse would maintain routines; however, an infant would be unable to engage in role pay and imitation. The nurse uses problem solving to help adolescents make choices but would not engage them in play. The nurse teaches a school-aged child the psychomotor skills required to maintain health.

The nurse includes role play, imitation, and play in the teaching method to make learning fun. The nurse is teaching which age-group of children? A. Infant B. Adolescent C. School-aged D. Preschooler

D. Preschooler The nurse uses role play, imitation, and play to make learning fun for a preschooler. For an infant, the nurse would maintain routines; however, an infant would be unable to engage in role pay and imitation. The nurse uses problem solving to help adolescents make choices but would not engage them in play. The nurse teaches a school-aged child the psychomotor skills required to maintain health.

Which action of the nurse would be effective for a patient with cancer who is not prepared to deal with the diagnosis? A. Focusing teaching on future skills and knowledge required B. Avoiding arguing with the patient and listening calmly to the concerns C. Persistently conveying only reality to the patient and helping the patient accept that reality D. Providing support, empathy, and careful explanations of all procedures while they are being performed

D. Providing support, empathy, and careful explanations of all procedures while they are being performed When the patient is not prepared to deal with a problem, it indicates that the patient is in the denial or disbelief stage of grieving. In this stage, the nurse should provide support and empathy to the patient, and give careful explanations of all procedures while they are being performed. This will help control the emotions of the patient. When the patient recognizes the reality of the situation, it indicates the acceptance stage of grieving. In this stage, the nurse should focus teaching on future skills and knowledge required. When the patient shows anger to the nurse, it indicates the anger stage of grieving. In this stage, the nurse should avoid arguing with the patient and listen calmly to the patient's concerns about his or her health. When the patient offers to live a better life in exchange for a promise of better health, it indicates the bargaining stage of grieving. In this stage, the nurse should continue to convey only reality to the patient and help the patient accept that reality.

Which domain is required for learning to use a walker? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain

D. Psychomotor domain Using a walker requires the integration of mental and muscular activity. Affective domain expresses feelings and attitudes through discussion or role play. Cognitive domain would be useful if the nurse was telling the patient how to use a walker. Attentional domain allows a learner to focus on a particular skill.

Which teaching method has the nurse employed when showing a patient how to use a sphygmomanometer to record blood pressure and asking the patient to perform the procedure to confirm understanding? A. Practice B. Demonstration C. Independent projects D. Return demonstration

D. Return demonstration Psychomotor learning involves acquiring motor skills that require coordination. It includes integration of mental and physical movements. With the return demonstration method of teaching, the nurse encourages the patient to use newly learned skills under the nurse's observation. The practice method of teaching involves the nurse providing a controlled environment for the patient to perform skills. With the demonstration method, the nurse provides presentations of the procedures or skills the patient should learn. An independent project involves a teaching method that promotes adaptation and origination of psychomotor learning. It also permits the learner to use new skills.

The nurse teaches a patient with diabetes how to use a glucometer and then asks the patient to use the glucometer to measure his or her blood sugar. The nurse is using which teaching method? A. Practice B. Demonstration C. Independent projects D. Return demonstration

D. Return demonstration The nurse shows the patient how to use the glucometer and then asks the patient to measure his or her blood glucose level using the glucometer, which indicates that the nurse is using the return demonstration teaching method. If the nurse gives the patient an opportunity to perform skills using equipment in a controlled setting, it indicates the practice method. If the nurse provides a presentation of procedures or skills, it indicates the demonstration method. If the nurse promotes adaptation and origination of psychomotor learning, it indicates the independent project method.

Which action would the nurse take when having difficulty communicating with the patient, a young boy, and his father who are both from Greece? A. Care for the boy using hand gestures as if he were from the local community. B. Ask the manager to talk with the father and keep him out of the unit. C. Have another nurse care for the boy because maybe that nurse will do better with the father. D. Search for help with language interpretation while recognizing cultural differences.

D. Search for help with language interpretation while recognizing cultural differences. The nurse would search for help with language interpretation while recognizing cultural differences. The nurse needs to understand how Greek culture influences the father's health beliefs and communication with health care providers. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, the health practices, and the nurse-patient relationship. Utilizing hand gestures is not a genuine way to communicate with a patient from another culture. Parents are integral components in the health and healing of their children, and it is not appropriate to ask the manager to talk with the father and keep him out of the unit. It is not appropriate to pass the child to another nurse.

Which communication technique is the nurse using when stating, "I see you haven't eaten anything" while taking a patient's history? A. Providing information B. Making assumptions C. Using paraphrasing D. Sharing observations

D. Sharing observations Sharing observations involves the nurse making observations on how the other person looks, sounds, or acts. For example, the nurse may comment on the fact that the patient has not eaten. Providing information tells other people what they need or want to know so they are able to make decisions; it is an integral component of teaching, not stating that the patient has not eaten anything. Sharing observations differs from making assumptions, which means drawing unnecessary conclusions about the other person without validating them, not noticing that the patient has not eaten. Using paraphrasing is restating another's message more briefly using one's own words, not commenting on how the patient has not eaten anything

Which zone of personal space is involved when the nurse is instructing visitors in the hallway to avoid talking loudly? A. Public B. Intimate C. Personal D. Social

D. Social The social zone may involve giving directions to visitors in the hallway. The public zone may involve speaking at a community forum, not instructing visitors in the hallway. The intimate zone may involve changing a patient's surgical dressing, not instructing visitors in the hallway. Taking a patient's nursing history involves the use of the personal zone, not instructing visitors in the hallway.

During an interview with a 35-year-old male patient, the nurse finds that the patient has multiple sex partners and is at risk of contracting a sexually transmitted infection (STI). Which symptom would the nurse look for in the patient? A. Diarrhea B. Vomiting C. Pain in the testicles D. Sores on the penis

D. Sores on the penis The presence of sores on the penis is a symptom of an STI. STIs present with few symptoms, and most of them are related to the genital area. Diarrhea and vomiting indicate a gastrointestinal problem. Pain in the testicles is not commonly seen in STIs. It may occur because of injury to the testes or in the case of testicular torsion.

Which characteristic would the nurse infer from the nonverbal cues of a patient who has a quick and purposeful gait? A. The patient is attentive. B. The patient is fatigued. C. The patient is depressed. D. The patient is confident.

D. The patient is confident. A quick and purposeful gait indicates well-being and confidence. Posture and gait convey important clues about a patient's health. A patient who is attentive may lean forward. Fatigue or depression is indicated by a slumped posture and slow, shuffling gait.

While assessing a patient who has a pressure injury, the nurse finds black wound tissue. In which stage is this pressure injury? A. Stage 1 B. Stage 2 C. Stage 3 D. Unstageable

D. Unstageable Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this pressure injury is unstageable. Stage 1 pressure injuries manifest as localized nonblanchable redness over intact skin. Stage 2 pressure injuries are characterized by partial-thickness dermis loss. Stage 3 pressure injuries are characterized by full-thickness skin loss to the extent that subcutaneous fat may be visible.

A couple does not desire to have any more children. Which contraceptive method would the nurse suggest? A. Skin patch B. Intrauterine device C. Abstinence D. Vasectomy

D. Vasectomy Because the couple does not wish to have any more children, it is advisable for them to opt for permanent contraception. Vasectomy is usually a permanent sterilization procedure for men and involves tying and cutting of the vas deferens. Skin patches and intrauterine devices are not as effective and do not offer permanent contraception. Abstinence from sex is difficult to maintain for most couples.