Nursing Health Assessment

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. I can always trust my family. b. It seems like I always have bad luck. c. You never know who will turn against you. d. I hear evil voices that tell me to do bad things.

d

The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patients temperature, the nurse may: a. touch the patients skin with the dorsum of her hand. b. touch the patients skin with the pads of her fingers. c. palpate the skin using the bimanual method. d. tap the patients skin using the fingertips.

touch the patients skin with the dorsum of her hand.

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally

Thready pulses

What should the nurse do when preparing to complete an assessment for a 16-year-old patient? a. Focus on illness behaviors. b. Plan for a diminished energy level. c. Treat the patient as an individual. d. Have the parents present throughout.

Treat the patient as an individual.

Measurement of the patients ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve? a. Abducens b. Facial c. Trigeminal d. Oculomotor

Trigeminal

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures.

Use the translation services supplied by the hospital.

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the client's life goals. Into which of Gordon's functional health patterns should the nurse identify this client's comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern

Value/belief pattern

Which skin condition would cause a nurse to suspect chickenpox? a. Wheals b. Nodules c. Pustules d. Vesicles

Vesicles

Which of the following may a nursing assistant be responsible for determining? a. Vital signs b. Cranial nerve function c. Neck vein distention d. Auscultation of bowel sounds

Vital signs

A leader plans to start a new self-esteem building group. Which intervention would be most helpful for assuring mutual respect within the group? a. Describe the importance of mutual respect in the first session and make it a group norm. b. Exclude potential members whose behavior suggests they are likely to be disrespectful. c. Give members a brochure describing the purpose, norms, and expectations of the group. d. Explain that mutual respect is expected and confront those who are not respectful.

a

A nurse surveys medical records. Which finding signals a violation of patients rights? a. A patient was not allowed to have visitors. b. A patients belongings were searched at admission. c. A patient with suicidal ideation was placed on continuous observation. d. Physical restraint was used after a patient was assaultive toward a staff member.

a

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: more than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

c

A nurse at the well child clinic realizes that many parents have misconceptions about effective ways of disciplining their children. The nurse decides to form a group to address this problem. What should be the focus of the group? a. Support c. Health education b. Socialization d. Symptom management

c

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, Encourage patient to attend one psychoeducational group daily? a. Assessment c. Implementation b. Analysis d. Evaluation

c

The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patients projected length of stay. How should the nurse instruct the unit secretary to handle the request? a. Obtain the information from the patients medical record and relay it to the caller. b. Inform the caller that all information about patients is confidential. c. Refer the request for information to the patients case manager. d. Refer the request to the health care provider.

c

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. self-responsibility and autonomy. c. rapport and trust with the nurse. b. a greater sense of independence. d. resolved transference.

c

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. c. milieu management. b. health teaching. d. psychobiological intervention.

c

Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

c

Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness? a. Clubhouse model b. Cognitive Behavioral Therapy (CBT) c. Assertive Community Treatment (ACT) d. Cognitive Enhancement Therapy (CET)

c

. A patient says to the nurse, I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadnt rested well. Which response should the nurse use to clarify the patients comment? a. It sounds as though you were uncomfortable with the content of your dream. b. I understand what youre saying. Bad dreams leave me feeling tired, too. c. So you feel as though you did not get enough quality sleep last night? d. Can you give me an example of what you mean by stoned?

d

During a group therapy session, a newly admitted patient suddenly says to the nurse, How old are you? You seem too young to be leading a group. Select the nurses most appropriate response. a. I am wondering what leads you to ask. Please tell me more. b. I am old enough to be a nurse, which qualifies me to lead this group. c. My age is not pertinent to why we are here and should not concern you. d. You are wondering whether I have enough experience to lead this group?

d

Guidelines followed by the leader of a therapeutic group include focusing on recognizing dysfunctional behavior and thinking patterns, followed by identifying and practicing more adaptive alternate behaviors and thinking. Which theory is evident by this approach? a. Behavioral c. Psychodynamic b. Interpersonal d. Cognitive-behavioral

d

Nursing behaviors associated with the implementation phase of nursing process are concerned with: a. participating in mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

d

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. Patient will: a. show improved use of language. b. demonstrate improved social skills. c. become more independent in decision making. d. select and participate in one group activity per day.

d

The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a. consistently demonstrated. c. sometimes demonstrated. b. often demonstrated. d. never demonstrated.

d

The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Examine interventions for possible revision of the target date.

d

A student nurse is working with a patient who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear: a. coarse crackles and bubbling. b. high-pitched musical sounds. c. dry, grating noises. d. loud, low-pitched rumbling.

high-pitched musical sounds.

A nurse is documenting a patients breath sounds. Crackles are heard as: a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds at the end of inspiration.

high-pitched, fine sounds at the end of inspiration.

The nurse assigned to assertive community treatment (ACT) should explain the programs treatment goal as: a. assisting patients to maintain abstinence from alcohol and other substances of abuse. b. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization. c. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness. d. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.

d

The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient: a. feeling anxiety and a sad mood after separation from a spouse of 10 years. b. who self-inflicted a superficial cut on the forearm after a family argument. c. experiencing dry mouth and tremor related to taking haloperidol (Haldol). d. who is a new parent and hears voices saying, Smother your baby.

d

Which outcome would be most appropriate for a symptom-management group for persons with schizophrenia? Group members will: a. state the names of their medications. b. resolve conflicts within their families. c. rate anxiety at least two points lower. d. describe ways to cope with their illness.

d

Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with: a. a phobic fear of crowded places. b. a single episode of major depression. c. a catastrophic reaction to a tornado in the community. d. schizophrenia and four hospitalizations in the past year.

d

Which remark by a group participant would the nurse expect during the working stage of group therapy? a. My problems are very personal and private. How do I know people in this group will not tell others what you hear? b. I have enjoyed this group. Its hard to believe that a few weeks ago I couldnt even bring myself to talk here. c. One thing everyone seems to have in common is that sometimes its hard to be honest with those you love most. d. I dont think I agree with your action. It might help you, but it seems like it would upset your family.

d

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. I dont have any problems. b. It is so difficult for me to talk about problems. c. I dont know how it will help to talk to you about my problems. d. I want to find a way to deal with my anger without becoming violent.

d

The recently graduated nurse recognizes that standards provide information and guidelines for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Nurses in their practice 2. Development of policies and protocols 3. Developing basic nursing care 4. Writing a states nurse practice act 5. Who can and cannot consent to treatment

1,2

The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: Select all that apply. 1. Penlight 2. Snellen's chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler

1,2,4,5

Ovarian hormones include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Estrogens 2. Progesterone 3. Parathyroid hormone 4. Luteinizing hormone 5. Testosterone

1,2,5

The nurse teaches a client that luteinizing hormone (LH) is important in the ovarian cycle for which purposes? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Proliferation of the endometrial mucosa 2. Ovulation 3. Corpus luteum development 4. Maturation of the ovarian follicle 5. Cyclic changes that allow pregnancy not to occur

2,3

The transcultural nursing theory was developed in 1961 by Dr. Madeleine Leininger. Its foundation is in which of the following? 1. The framework categorizes a familys progression over time 2. The family life cycle of a traditional nuclear family 3. Anthropology and nursing 4. Holistic health beliefs

3

What is the increased vascularization causing the softening of the cervix known as? 1. Hegar sign 2. Chadwick sign 3. Goodell sign 4. McDonald sign

3

The nurse researcher will use descriptive statistics for a research project that has been assigned. A characteristic of descriptive statistics is that they provide which of the following? 1. They can answer specific questions. 2. They can generate theories. 3. They allow the investigator to draw conclusions. 4. They are the starting point for the formation of a research question.

4

The nurse teaching a class on the reproductive system is discussing what happens at puberty. Which statement does the nurse make? 1. Boys and girls go through puberty at the same time. 2. Most girls develop breasts and start their menses at about the same time. 3. The nocturnal emissions that adolescent boys have contain a large number of sperm. 4. The onset and progress of puberty varies widely from person to person.

4

The nurse teaching a client describes the effect of a vasectomy on fertilization by saying a man who has had a vasectomy becomes functionally sterile because of which of the following? 1. Sperm are no longer being produced. 2. Sperm are no longer motile and fertile. 3. Sperm sit in the testes where they are formed. 4. Sperm cannot reach the outside of the body.

4

The nurse teaching the phases of the menstrual cycle should include the fact that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and extensive vascular changes occur in which phase? 1. Menstrual phase 2. Proliferative phase 3. Secretory phase 4. Ischemic phase

4

The nurse working with a client describes cellular multiplication and how the zygote moves through the fallopian tube, a movement that takes place via what process? 1. A squeezing motion 2. Pushing from another ovum that has not been fertilized 3. Hormone action 4. A very weak fluid current in the fallopian tube resulting from the beating action of ciliated epithelium

4

The general survey begins with a review of the patients primary health problems and an evaluation of the patients vital signs, height and weight, general behavior, and appearance. It also provides information about the patients illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel? a. Reporting subjective signs and symptoms b. Measuring the patients height and weight c. Monitoring I&O d. Obtaining initial vital signs

Obtaining initial vital signs

. What technique should the nurse implement for assessment of the carotid artery? a. Massaging the arteries briskly b. Using the diaphragm of the stethoscope c. Palpating each carotid artery separately d. Placing the patient in a supine position

Palpating each carotid artery separately

The nurse is preparing to assess a client's reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight

Percussion hammer

The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment

Vital signs assessment

During an initial interview, the client says "I don't understand why I have to have surgery; I'm really not that sick or in pain right now." How should the nurse respond to the client? 1. "It's OK to be worried. Surgery is a big step." 2. "What kind of questions do you have about your surgery?" 3. "I think these are things you should be asking your doctor." 4. "Have you had surgery before?"

What kind of questions do you have about your surgery?"

A therapy group adds new members as others leave. What type of group is evident? a. Open c. Homogeneous b. Closed d. Heterogeneous

a

Inpatient hospitalization for persons with mental illness is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medication at home. c. have limited support systems in the community. d. develop new symptoms during the course of an illness.

a

While talking with a patient diagnosed with major depression, a nurse notices the patient is unable to maintain eye contact. The patients chin lowers to the chest, while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication c. A cultural barrier b. A message filter d. Social skills

a

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

b

A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing? a. Behavior c. Affect and mood b. Cognition d. Perceptual disturbances

b

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparentsso helpless. Which response is the nurse demonstrating? a. Transference c. Catastrophic reaction b. Countertransference d. Defensive coping reaction

b

Type: MCSA The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. "How would you describe your sleep pattern?" 2. "Can you describe your coughing pattern?" 3. "Is there anything that makes your breathing worse?" 4. "What medications are you on?"

"How would you describe your sleep pattern?"

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. "I'm going to set up your physical assessment now. Do you have any questions?" 2. "Tell me more about how you feel." 3. "Could you give examples of what types of other treatments you've had?" 4. "Is there anything you're worried about?"

"I'm going to set up your physical assessment now. Do you have any questions?"

The nurse manager is examining the descriptive statistics of increasing teen pregnancy rates in the community. Which inferential statistical research question would the nurse manager find most useful in investigating the reasons for increased frequency of teen pregnancy? 1. What providers do pregnant teens see for prenatal care? 2. What are the ages of the parents of pregnant teens in the community? 3. Do pregnant teens drink caffeinated beverages? 4. What do pregnant teens do for recreation?

1

The nurse teaching a class on reproductive anatomy knows that no further instruction is needed when a student shows an understanding of the pelvic cavity divisions by making which statement? 1. The true pelvis is made up of the sacrum, coccyx, and innominate bones. 2. The false pelvis consists of the inlet, the pelvic cavity, and the outlet. 3. The true pelvis is the portion above the pelvic brim. 4. The relationship between the false pelvis and the fetal head is of paramount importance.

1

The pregnant client who is at 14 weeks gestation asks the nurse why the doctor used to call her baby an embryo, and now calls it a fetus. What is the best answer to this question? 1. A fetus is the term used from the ninth week of gestation and onward. 2. We call a baby a fetus when it is larger than an embryo. 3. An embryo is a baby from conception until the eighth week. 4. The official term for a baby in utero is really zygote.

1

The nurse manager is consulting with a certified nurse-midwife about a client. What is the role of the CNM? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Be prepared to manage independently the care of women at low risk for complications during pregnancy and birth. 2. Give primary care for high-risk clients who are in hospital settings. 3. Give primary care for healthy newborns. 4. Obtain a physician consultation for any technical procedures at delivery. 5. Be educated in two disciplines of nursing.

1, 3, 5

A client at 32 weeks gestation comes to the clinic with urinary burning and frequency. The nurse explains that urinary tract infections are common in pregnancy due to which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ureteral atonia 2. Stasis of urine 3. Increased glomerular filtration rate 4. Increased renal plasma flow 5. Increased clearance of urea

1,2

A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine Standard Text: Select all that apply. 1. the progress of the client's health problem. 2. the physiological impact of the prescribed medication. 3. baseline data. 4. data to support nursing diagnoses. 5. areas for health promotion.

1,2

The maternal-child nurse stresses to the recently graduated nurse that primary care focuses on which aspect? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Health promotion 2. Illness prevention 3. Hospital care 4. Skilled nursing care 5. Curing disease

1,2

The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Standard Text: Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction

1,2

Why is it important for the nurse to understand the type of family that a client comes from? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Family structure can influence finances. 2. Some families choose to conceive or adopt without a life partner. 3. The nurse can anticipate which problems a client will experience based on the type of family the client has. 4. Understanding if the clients family is nuclear or blended will help the nurse teach the client the appropriate information. 5. The values of the family will be predictable if the nurse knows what type of family the client is a part of.

1,2

The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Standard Text: Select all that apply. 1. Obtain baseline data. 2. Obtain data to help determine nursing diagnoses. 3. Identify areas for disease prevention. 4. Identify the client's employment status. 5. Obtain data about the client's leisure activities.

1,2, 3

The nurse is planning to perform indirect percussion on an area of a client's body during a physical examination. Which actions should the nurse take to use this assessment technique? Standard Text: Select all that apply. 1. Place the middle finger of the nondominant hand on the client's skin. 2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. Perform a striking motion by moving the wrist. 4. Perform short, rapid, firm blows. 5. Use a stethoscope to transmit sounds to the ears.

1,2, 3, 4

During the assessment phase of a family, the community nurse recognizes that culture influences childrearing and childbearing in which of the following ways? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Beliefs about the importance of children 2. Beliefs and attitudes about pregnancy 3. Norms regarding infant feeding 4. Acculturation is important in rearing children 5. Time orientation to the future is very important

1,2,3

In assessing a family, the community nurse uses a family assessment tool, which provides an organized framework to collect data concerning which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Access to laundry and grocery facilities 2. Access to health care 3. Sharing of religious beliefs and values 4. Acculturation to traditional lifestyles 5. Ability to include a new spouse into the family unit

1,2,3

In working with immigrants in an inner-city setting, the nurse recognizes that acculturation of immigrants often brings with it which of the following benefits? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Improved socioeconomic status 2. Use of preventive care services 3. Better nutrition 4. Increase in substance abuse over time 5. More physician visits due to language barriers

1,2,3

Several student nurses are discussing advanced practice, and know that the term advanced practice nurse includes which of the following types of nurses? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Nurse practitioners 2. Certified nurse-midwives 3. Clinical nurse specialists 4. Certified registered nurses 5. Professional nurses

1,2,3

The Quality and Safety Education for Nurses (QSEN) project focused on competencies in which areas? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Client-centered care 2. Teamwork and collaboration 3. Evidence-based practice 4. Family planning 5. Injury and violence prevention

1,2,3

The client in the first trimester of pregnancy tells the nurse she regularly sees a massage therapist to help with pain in her shoulders and neck. The nurse tells her that massage has which of the following added advantages? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Increasing circulation 2. Reducing anxiety 3. Promoting a sense of well-being 4. Eliminating energy blockages 5. Allowing coordination of breathing and moving

1,2,3

The maternal-newborn nurse reviewing charts recognizes that negligence (malpractice) occurs when which action occurs? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. There is no notification to the physician of change in condition. 2. There is a failure to give an ordered medication. 3. An infant is placed in the wrong crib. 4. There is compliance with medication administration principles. 5. There is compliance with the standards of care.

1,2,3

The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: Select all that apply. 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare

1,2,3

The nurse is counseling a pregnant woman who intends to see a naturopathic physician. The nurse tells the woman that she can expect education on which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Clinical nutrition 2. Botanical medicine 3. Lifestyle modification 4. Use of like to cure like 5. The role of yin and yang

1,2,3

The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: Select all that apply. 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response

1,2,3

The nurse is teaching about reproduction, and explains that which of the following are the purposes of meiosis? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Produce gametes 2. Reduce the number of chromosomes 3. Introduce genetic variability 4. Produce cells for growth and development 5. Divide somatic cells into new cells with identical characteristics

1,2,3

The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? Standard Text: Select all that apply. 1. Visually observe a body area. 2. Obtain information through the sense of smell. 3. Obtain information through the sense of hearing. 4. Examine the body through the use of touch. 5. Strike the body to elicit a sound from a body part.

1,2,3

The nurse working in a community clinic is aware that differences in beliefs between families and healthcare providers are common in which areas? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Help-seeking behaviors 2. Pregnancy and childbirth practices 3. Causes of disease or illness 4. What defines a community 5. Educational level

1,2,3

The nurse working in the emergency department of a hospital is caring for a woman whom the nurse suspects is the victim of domestic violence. The nurse knows that which of the following are contributing factors to domestic violence? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Experiencing or witnessing abuse as a child 2. Strong patriarchal family traditions 3. Linking masculinity to male honor 4. Low levels of marital conflict 5. Alcohol and drug abuse cause the violence

1,2,3

A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses.

1,2,3,4

The student nurse working for a nurse researcher recognizes that the researcher will use descriptive statistics to do which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Describe a set of data. 2. Summarize a set of data. 3. Report the facts. 4. Identify certain trends. 5. Allow conclusions to be drawn. 6. Use a small sample size.

1,2,3,4

The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region

1,2,3,5

A homeless individual diagnosed with serious mental illness, anosognosia, and a history of persistent treatment nonadherence is persuaded to come to the day program at a community mental health center. Which intervention should be the teams initial focus? a. Teach appropriate health maintenance and prevention practices. b. Educate the patient about the importance of treatment adherence. c. Help the patient obtain employment in a local sheltered workshop. d. Interact regularly and supportively without trying to change the patient.

d

Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient? a. Hygiene assistance c. Assistance with job hunting b. Diversional activities d. Building assertiveness skills

d

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. "Hello, I'm your nurse and I'll be taking care of you today." 2. "You're lucky—there are no students on the unit today." 3. "Good morning, is there anything you need right now?" 4. "Hi. If you need anything, put on your call light."

"Hello, I'm your nurse and I'll be taking care of you today."

The nurse is assessing a client's level of pain. Which open-ended question should the nurse use for this situation? 1. "Is your pain worse at night?" 2. "What brought you to the clinic?" 3. "How has the pain impacted your life?" 4. "You're feeling down about having pain, aren't you?"

"How has the pain impacted your life?"

The public health nurse is working with a student nurse. The student nurse asks which of the six groups of people they have seen today are considered to be families. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The married heterosexual couple without children 2. The gay couple with two adopted children 3. The unmarried heterosexual couple with two biological children 4. The lesbian couple not living together that have no children 5. The married heterosexual couple with three children, living with grandparents

1,2,3,5

The OB-GYN nurse knows that the proliferative phase of the menstrual cycle includes which changes? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Thin, clear cervical mucus 2. Estrogen peaks just before ovulation 3. No ferning pattern of cervical mucus 4. A pH change to 7.5 5. Epithelium warps into folds

1,2,4

What are the three functions of the fallopian tubes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide transport for the ovum from the ovary to the uterus 2. Serve as a warm, moist, nourishing environment for the ovum or zygote 3. Secrete large amounts of estrogens 4. Provide a site for fertilization to occur 5. Support and protect the pelvic contents

1,2,4

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurse's physical assessment 3. Physician's orders 4. A list of current medications 5. Information about the client's cultural preferences 6. Discharge instructions

1,2,4,5

The nurse educator is teaching student nurses what a fetus will look like at various weeks of development. Which descriptions would be typical of a fetus at 20 weeks gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The fetus has a body weight of 435-465 g. 2. Nipples appear over the mammary glands. 3. The kidneys begin to produce urine. 4. Nails are present on fingers and toes. 5. Lanugo covers the entire body.

1,2,4,5

In learning about Duvalls life-cycle stages ascribed to traditional families, the nursing student recognizes that developmental tasks of each stage include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Adjusting to new roles as mother and father 2. Working out authority and socialization roles with the school 3. Becoming a single parent with custodial responsibilities 4. Becoming a couple and dating 5. Adjusting to the loss of a spouse

1,2,5

The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented.

1,2,5

Therapeutic insemination has legal concerns for the donor of the sperm. To eliminate legal issues, the clinic nurse will have the donor do which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Sign a form waiving all parental rights. 2. Furnish accurate health information. 3. Agree to adopt the child. 4. Furnish a complete family tree. 5. Sign an agreement if married to the recipient.

1,2,5

The nurse is assessing a client in the third trimester of pregnancy. What physiologic changes in the client are expected? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The clients chest circumference has increased by 6 cm during the pregnancy. 2. The client has a narrowed subcostal angle. 3. The client is using thoracic breathing. 4. The client may have epistaxis. 5. The client has a productive cough.

1,3,4

The nurse manager is planning a presentation on ethical issues in caring for childbearing families. Which example should the nurse manager include to illustrate maternal-fetal conflict? 1. A client chooses an abortion after her fetus is diagnosed with a genetic anomaly. 2. A 39-year-old nulliparous client undergoes therapeutic insemination. 3. A family of a child with leukemia requests cord-blood banking at this birth. 4. A cesarean delivery of a breech fetus is court ordered after the client refuses.

4

The nurse understands that a clients pregnancy is progressing normally when what physiologic changes are documented on the prenatal record of a woman at 36 weeks gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The joints of the pelvis have relaxed, causing a waddling gait. 2. The cervix is firm and blue-purple in color. 3. The uterus vasculature contains one sixth of the total maternal blood volume. 4. Gastric emptying time is delayed, and the client complains of constipation and bloating. 5. Supine hypotension occurs when the client lies on her back.

1,3,4,5

A nurse is working in a clinic where clients from several cultures are seen. As a first step toward the goal of personal cultural competence, the nurse will do which of the following? 1. Enhance cultural skills. 2. Gain cultural awareness. 3. Seek cultural encounters. 4. Acquire cultural knowledge.

2

A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following? 1. Estrogen 2. Human chorionic gonadotropin (hCG) 3. Progesterone 4. Luteinizing hormone

2

A nursing student investigating potential career goals is strongly considering becoming a nurse practitioner (NP). The major focus of the NP is on which of the following? 1. Leadership 2. Physical and psychosocial clinical assessment 3. Independent care of the high-risk pregnant client 4. Tertiary prevention

2

A pregnant woman tells the nurse-midwife, Ive heard that if I eat certain foods during my pregnancy, the baby will be a boy. The nurse-midwifes response should explain that this is a myth, and that the sex of the baby is determined at what time? 1. At the time of ejaculation 2. At fertilization 3. At the time of implantation 4. At the time of differentiation

2

A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone? 1. Estrogen 2. Progesterone 3. FSH 4. LH

2

A woman pregnant with twins asks the nurse about differences between identical and fraternal twins. The nurse explains that since it has been determined that she is having a boy and a girl, they are fraternal, and will have with of the following? 1. One placenta, two amnions, and two chorions 2. Two placentas, two amnions, and two chorions 3. Two placentas, one amnion, and two chorions 4. Two placentas, two amnions, one chorion

2

During a class on genetics for pregnant families, the nurse is discussing the how the egg and sperm are formed before fertilization takes place. The nurse explains that these cells have only half the number of chromosomes, so when fertilization takes place, there will be the correct number. What is the process by which the egg and sperm are formed called? 1. Oogenesis 2. Gametogenesis 3. Meiosis 4. Spermatogenesis

2

The external and internal female reproductive organs develop and mature in response to what hormones? 1. Adrenocorticotropic hormones (ACTH) 2. Estrogen and progesterone 3. Steroid hormones 4. Luteinizing hormones (LH)

2

The female and male reproductive organs are homologous, which means what? 1. They are believed to cause vasoconstriction and muscular contraction 2. They are fundamentally similar in function and structure 3. They are rich in sebaceous glands 4. They are target organs for estrogenic hormones

2

The nurse is preparing a class on reproduction. What is the cell division process that results in two identical cells, each with the same number of chromosomes as the original cell called? 1. Meiosis 2. Mitosis 3. Oogenesis 4. Gametogenesis

2

The nurse is preparing a report on the number of births by three service providers at the facility (certified nurse-midwives, family practitioners, and obstetricians). What is this an example of? 1. Inferential statistics 2. Descriptive statistics 3. Evidence-based practice 4. Secondary use of data

2

The nurse is presenting a class to pregnant clients. The nurse asks, The fetal brain is developing rapidly, and the nervous system is complete enough to provide some regulation of body function on its own, at which fetal development stage? It is clear that education has been effective when a participant makes which response? 1. The 17th-20th week 2. The 25th-28th week 3. The 29th-32nd week 4. The 33rd-36th week

2

The nurse is reviewing care of clients on a mother-baby unit. Which situation should be reported to the supervisor? 1. A 2-day-old infant has breastfed every 3 hours and voided four times. 2. An infant was placed in the wrong crib after examination by the physician. 3. The client who delivered by cesarean birth yesterday received oral narcotics. 4. A primiparous client who delivered today is requesting discharge within 24 hours.

2

The nurse is teaching a community education class on complementary and alternative therapies. To assess learning, the nurse asks, In traditional Chinese medicine, what is the invisible flow of energy in the body that maintains health and ensures physiologic functioning? Which answer indicates that teaching was successful? 1. Meridians 2. Chi 3. Yin 4. Yang

2

The nurse is teaching the students in their obstetric rotation about fertilization. What processes must the sperm undergo before fertilization can occur? 1. Capacitation and ovulation 2. Capacitation and the acrosomal reaction 3. Oogenesis and the acrosomal reaction 4. Gametogenesis and capacitation

2

The nurse is working with a client whose religious beliefs differ from those of the general population. What is the best nursing intervention to use to meet the specific spiritual needs of this family? 1. Ask how important the clients religious and spiritual beliefs are when making decisions about health care. 2. Show respect while allowing time and privacy for religious rituals. 3. Ask for the clients opinion on what caused the illness. 4. Identify healthcare practices forbidden by religious or spiritual beliefs.

2

The nurse manager in a hospital with a large immigrant population is planning an in-service. Aware of how ethnocentrism affects nursing care, the nurse manager asks, The belief that ones own values and beliefs are the only or the best values has which of the following results? 1. It implies newcomers to the United States should adopt the norms and values of the country. 2. It can create barriers to communication through misunderstanding. 3. It leads to an expectation that all clients will exhibit pain the same way. 4. It improves the quality of care provided to culturally diverse client bases.

2

The nurse teaching a high school class explains that during the menstrual cycle, the endometrial glands begin to enlarge under the influence of estrogen and cervical mucosal changes occur; the changes peak at ovulation. In which phase of the menstrual cycle does this occur? 1. Menstrual 2. Proliferative 3. Secretory 4. Ischemic

2

The nursing instructor explains to the class that according to the 1973 Supreme Court decision in Roe v. Wade, abortion is legal if induced: 1. Before the 30th week of pregnancy. 2. Before the period of viability. 3. To provide tissue for therapeutic research. 4. Can be done any time if mother, doctor, and hospital all agree.

2

The true moment of fertilization occurs when what happens? 1. Cortical reaction occurs 2. Nuclei unite 3. Spermatozoa propel themselves up the female tract 4. Sperm surrounding the ovum release their enzymes

2

When planning care for a client who has undergone an episiotomy, it would be important for the nurse to include a goal that addresses the need for pain relief of which part of the body? 1. Mons pubis 2. Perineal body 3. Labia minora 4. Hymen

2

Which of the following best describes a nuclear family? 1. A family is composed of an unmarried woman who chooses to conceive or adopt without a life partner. 2. Children live in a household with both biologic parents and no other relatives or persons. 3. A couple shares household and childrearing responsibilities with parents, siblings, or other relatives. 4. The head of the household is widowed, divorced, abandoned, or separated or most often the mother remains unmarried.

2

Which questions are appropriate for the nurse to ask during a cultural assessment of a client who is new to the clinic? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. What genetic and other biological differences affect caregiving? 2. Which family member must be consulted for decisions about care? 3. What type of health provider is the most appropriate? 4. Does the client have beliefs or traditions that might impact the care plan? 5. Are communications patterns established?

2,3,4

The nurse educator teaching reproductive anatomy wants to make sure the students understand what stabilizes the uterus. Which statements about the individual ligaments would the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The infundibulopelvic ligaments suspend and support the uterus. 2. The broad ligament keeps the uterus centrally placed. 3. The uterosacral ligaments sweep back around the rectum and insert on the sides of the first and second sacral vertebrae. 4. The ovarian ligaments anchor the ovary to the uterus. 5. The cardinal ligaments prevent uterine prolapse and support the upper vagina.

2,3,4,5

The nurse in the prenatal clinic will tell the client at 38-weeks gestation to lie on her left side when the client complains of which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Nausea 2. Pallor 3. Clamminess 4. Constipation 5. Dizziness

2,3,5

The nurse working with pediatric clients knows that the primary hormone secretions that induce puberty include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Thyroid hormone 2. Follicle-stimulating hormone 3. Leuteinizing hormone 4. Adrenocorticotropic hormone 5. Gonadotropin-releasing hormones

2,3,5

Under the influence of progesterone, which of the following occur? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Temperature decreases 2. Cervix secretes thick, viscous mucus 3. Breasts prepare for lactation 4. Breast glandular tissue decreases in size 5. Vaginal epithelium proliferates

2,3,5

What are the three functions of cervical mucosa? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Form the relatively fixed axis of the birth passage 2. Provide lubrication for the vaginal canal 3. Provide nourishment and protective maternal antibodies to infants 4. Provide an alkaline environment to shelter deposited sperm from the acidic vaginal secretions 5. Act as a bacteriostatic agent

2,4,5

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours

24 hours

A client with a normal prepregnancy weight asks why she has been told to gain 25-35 pounds during her pregnancy while her underweight friend was told to gain more weight. What should the nurse tell the client the recommended weight gain is during pregnancy? 1. 25-35 pounds, regardless of a clients prepregnant weight 2. More than 25-35 pounds for an overweight woman 3. Up to 40 pounds for an underweight woman 4. The same for a normal weight woman as for an overweight woman

3

A nurse teaching a sex education class is asked by a male student, What exactly happens when my body gets aroused? The nurses reply includes which statement? 1. The vas deferens thickens and expands. 2. The sympathetic nerves of the penis are stimulated. 3. The penis elongates, thickens, and stiffens. 4. The prepuce of the penis elongates.

3

A prenatal client asks the nurse how the baby can possibly come out through her vagina, because a vagina is not nearly as big as a baby. How does the nurse best answer this clients question? 1. The vagina usually tears as it stretches during childbirth. 2. The vagina is designed to allow a baby come through. 3. The vagina changes due to pregnancy allow the vagina to stretch more. 4. The vagina dilates and effaces in labor so the baby can get out.

3

A school nurse teaching a health class to adolescent boys explains that spermatozoa become motile and fertile during the 2-10 days they are stored in which part of the male body? 1. Prostate gland 2. Vas deferens 3. Epididymis 4. Urethra

3

A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6C (1.0F) over the past 36 hours. This most likely indicates what? 1. Menstruation is about to begin. 2. Ovulation will occur soon. 3. Ovulation has occurred. 4. She is pregnant, and will not menstruate.

3

Client safety goals, which are evaluated and updated regularly, are requirements for what? 1. Clinical practice guidelines 2. Scope of practice 3. Accreditation 4. Standards of care

3

During her first months of pregnancy, a client tells the nurse, It seems like I have to go to the bathroom every 5 minutes. The nurse explains to the client that this is because of which of the following? 1. The client probably has a urinary tract infection. 2. Bladder capacity increases throughout pregnancy. 3. The growing uterus puts pressure on the bladder. 4. Some women are very sensitive to body function changes.

3

For prenatal care, the client is attending a clinic held in a church basement. The clients care is provided by registered nurses and a certified nurse-midwife. What is this type of prenatal care? 1. Secondary care 2. Tertiary care 3. Community care 4. Unnecessarily costly care

3

In caring for pregnant clients, the nurse realizes that information on conventional, complementary, and alternative medicine is best obtained by which of the following means? 1. Obtained at the medical office if the physician feels it is appropriate 2. Obtained from family and friends who have already experienced a situation 3. Readily obtainable on the Internet 4. Passed on by word of mouth

3

The client reports using an alternative therapy that involves the manipulation of soft tissues. This therapy has reduced the clients stress, diminished pain, and increased circulation. Which therapy has this client most likely received? 1. Guided imagery 2. Homeopathy 3. Massage therapy 4. Reflexology

3

The current emphasis on healthcare reform and the implementation of the Affordable Care Act has yielded what unexpected benefit? 1. Assessment of the details of the familys income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. Many healthcare providers and consumers are becoming more aware of the vitally important role nurses play in providing excellent care to clients and families 4. Education of the family about the need for keeping regular well-child visit appointments

3

The nurse educator describes the uterus and ovaries as being held in place in the pelvic cavity by what structures? 1. Muscles 2. Tendons 3. Ligaments 4. Peritoneum

3

The nurse educator is discussing human chromosomes with her students, and knows that the teaching has been effective when a student makes which statement? 1. All humans have 48 chromosomes and 2 sex chromosomes. 2. Human chromosomes are shaped like a Y. 3. Humans have 46 chromosomes, 2 of which are the sex chromosomes. 4. Only certain body cells contain the chromosomes.

3

The nurse educator is lecturing on the changes that take place during puberty. What is a change that girls experience? 1. Elongation of the hips 2. Deepening of the voice 3. Broadening of the hips and budding of breasts 4. Preparation of the uterus for pregnancy

3

The nurse has completed a presentation on reproduction. Which statement indicates that the teaching has been successful? 1. A male is born with all the sperm he will ever produce. 2. Females create new ova throughout their reproductive life. 3. Ova separate into two unequally sized cells. 4. Each primary spermatocyte divides into four haploid cells.

3

The nurse in a rural clinic is talking with some clients about biofeedback. The nurse explains to the clients that biofeedback is which of the following? 1. An alternative therapy 2. A state of great mental and physical relaxation in which one is susceptible to suggestion 3. A method used to help individuals learn to control their physiologic responses based on the concept that the mind controls the body 4. A complementary therapy in which one goes into a relaxed state and focuses on positive scenes

3

The nurse in the community should use a family assessment tool to obtain what type of information? 1. How long the family has lived at its current address 2. What other health insurance the family has had in the past 3. How the family meets its nutritional needs and obtains food 4. What eye color the family desires in its unborn child

3

The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of what? 1. A risky practice without evidence of efficacy 2. A folk remedy 3. A complementary therapy 4. An alternative therapy

3

The nurse is creating a handout on reproduction for teen clients. Which piece of information should the nurse include in this handout? 1. The fertilized ovum is called a gamete. 2. Prior to fertilization, the sperm are zygotes. 3. Ova survive 12-24 hours in the fallopian tube if not fertilized. 4. Sperm survive in the female reproductive tract up to a week.

3

The nurse is creating a poster for pregnant mothers. Which description of fetal development should the nurse include? 1. Four primary germ layers form from the blastocyst. 2. After fertilization, the cells only become larger for several weeks. 3. Most organs are formed by 8 weeks after fertilization. 4. The embryonic stage is from fertilization until 5 months.

3

The nurse is examining a pregnant woman in the third trimester. What skin changes should the nurse highlight as an alteration for the womans healthcare provider? 1. Linea nigra 2. Melasma gravidarum 3. Petechiae 4. Vascular spider nevi

3

The nurse is listening to the fetal heart tones of a client at 37 weeks gestation while the client is in a supine position. The client states, Im getting lightheaded and dizzy. What is the nurses best action? 1. Assist the client to sit up. 2. Remind the client that she needs to lie still to hear the baby. 3. Help the client turn onto her left side. 4. Check the clients blood pressure.

3

The nurse is planning a community education program on the role of complementary and alternative therapies during pregnancy. Which statement about alternative and complementary therapies should the nurse include? 1. They bring about cures for illnesses and diseases. 2. They are invasive but effective for achieving health. 3. They emphasize prevention and wellness. 4. They prevent pregnancy complications.

3

The student nurse encounters a 15-year-old girl who reports that she has no pubic or axillary hair and has not yet experienced growth of her breasts. The student asks the nurse about the physiology of this occurrence. The nurse explains that the client probably lacks which hormone? 1. Testosterone 2. Progesterone 3. Estrogen 4. Prolactin

3

What is the term for when children alternate between two homes, spending varying amounts of time with each parent in a situation called co-parenting and usually involving joint custody? 1. Blended or reconstituted nuclear family 2. Extended kin network family 3. Binuclear family 4. Extended family

3

Which statement by a pregnant client to the nurse would indicate that the client understood the nurses teaching? 1. Because of their birth relationship, fraternal twins are more similar to each other than if they had been born singly. 2. Identical twins can be the same or different sex. 3. Congenital abnormalities are more prevalent in identical twins. 4. Identical twins occur more frequently than fraternal twins.

3

While a child is being admitting to the hospital, the parent receives information about the pediatric units goals, including the statement that the unit practices family-centered care. The parent asks why that is important. The nurse responds that what communication dynamic is characteristic of the family-centered care paradigm? 1. The mother is the principal caregiver in each family. 2. The childs physician is the key person in ensuring the health of a child is maintained. 3. The family serves as the constant influence and continuing support in the childs life. 4. The father is the leader in each home; thus, all communications should include him.

3

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator.

3,4,5,2,1

The nurse is explaining the difference between meiosis and mitosis. Which statements would be best? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Meiosis is the division of a cell into two exact copies of the original cell. 2. Mitosis is splitting one cell into two, each with half the chromosomes of the original cell. 3. Meiosis is a type of cell division by which gametes, or the sperm and ova, reproduce. 4. Mitosis occurs in only a few cells of the body. 5. Meiotic division leads to cells that halve the original genetic material.

3,5

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle

30- to 45-degree angle

A nurse is examining different nursing roles. Which example best illustrates an advanced practice nursing role? 1. A registered nurse who is the manager of a large obstetrical unit 2. A registered nurse who is the circulating nurse during surgical deliveries (cesarean sections) 3. A clinical nurse specialist working as a staff nurse on a mother-baby unit 4. A clinical nurse specialist with whom other nurses consult for her expertise in caring for high-risk infants

4

Duvalls eight stages in the family life cycle of a traditional nuclear family have been used as the foundation for contemporary models that describe the developmental processes and role expectations for different family types. Which of the following is an example of Stage IV of this family life cycle? 1. Families launching young adults (all children leave home) 2. Families with preschool-age children (oldest child is between 2.5 and 6 years of age) 3. Middle-aged parents (empty nest through retirement) 4. Families with schoolchildren (oldest child is between 6 and 13 years of age)

4

The nurse at an elementary school is performing TB screenings on all of the students. Permission slips were returned for all but the children of one family. When the nurse phones to obtain permission, the parent states in clearly understandable English that permission cannot be given because the grandmother is out of town for 2 more weeks. Which cultural element is contributing to the dilemma that faces the nurse? 1. Permissible physical contact with strangers 2. Beliefs about the concepts of health and illness 3. Religion and social beliefs 4. Presence and influence of the extended family

4

The nurse explains to a preconception class that if only a small volume of sperm is discharged into the vagina, an insufficient quantity of enzymes might be released when they encounter the ovum. In that case, pregnancy would probably not result, because of which of the following? 1. Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus. 2. The block to polyspermy (cortical reaction) would not occur. 3. The fertilized ovum would be unable to implant in the uterus. 4. Sperm would be unable to penetrate the zona pellucida of the ovum.

4

The nurse explains to the client that the obstetric conjugate measurement is important because of which reason? 1. This measurement determines the tilt of the pelvis. 2. This measurement determines the shape of the inlet. 3. The fetus passes under it during birth. 4. The size of this diameter determines whether the fetus can move down into the birth canal so that engagement can occur.

4

The nurse is admitting a client in labor who states that she is a naturopath. The nurse understands that this client believes which of the following? 1. An initial worsening of symptoms after treatment means the correct remedy has been used. 2. There are five elements that take form in the body. 3. Her pregnancy is a kapha condition. 4. Naturopathy is a form of medicine that utilizes the healing forces of nature.

4

The nurse is preparing a community presentation on family development. Which statement should the nurse include? 1. The youngest child determines the familys current stage. 2. A family does not experience overlapping of stages. 3. Family development ends when the youngest child leaves home. 4. The stages describe the familys progression over time.

4

The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include? 1. The hormone human chorionic gonadotropin stimulates ovulation. 2. Irregular menstrual cycles have varying lengths of the luteal phase. 3. The ovum leaves its follicle during the follicular phase. 4. There are two phases of the ovarian cycle: luteal and follicular.

4

The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that which of the following is the primary use of a family assessment tool? 1. Obtain a comprehensive medical history of family members. 2. Determine to which clinic the client should be referred. 3. Predict how a family will likely change with the addition of children. 4. Understand the physical, emotional, and spiritual needs of members.

4

The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information? 1. Estrogen is what causes females to look female. 2. The presence of some hormones causes other to be secreted. 3. Progesterone is present at the end of the menstrual cycle. 4. Prostaglandin is responsible for achieving conception.

4

A 7-year-old client tells the nurse that Grandpa, Mommy, Daddy, and my brother live at my house. The nurse identifies this as what type of family? 1. Binuclear 2. Extended 3. Gay or lesbian 4. Traditional

2

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document? 1. Restlessness 2. "Leave me alone" 3. Not talkative 4. Pale and diaphoretic

"Leave me alone"

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. "In order to make sure all of your information is complete, I need to ask these questions." 2. "You're right. Let me know if there's anything you need right now." 3. "I'll be done shortly, just give me a few more minutes." 4. "You shouldn't be upset. We're only doing our jobs."

"You're right. Let me know if there's anything you need right now."

The nurse is working with a client who has experienced a fetal death in utero at 20 weeks. The client asks what her baby will look like when it is delivered. Which statement by the nurse is best? 1. Your baby will be covered in fine hair called lanugo. 2. Your child will have arm and leg buds, not fully formed limbs. 3. A white, cheesy substance called vernix caseosa will be on the skin. 4. The genitals of the baby will be ambiguous.

1

The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information? 1. Because both of my twins are boys, I know that they are identical. 2. If my twins came from one fertilized egg that split, they are identical. 3. If I have one boy and one girl, I will know they came from two eggs. 4. It is rare for both twins to be within the same amniotic sac.

1

The nurse is caring for a postpartal client of Hmong descent who immigrated to the United States 5 years ago. The client asks for the regular hospital menu because American food tastes best. The nurse assesses this response to be related to which of the following cultural concepts? 1. Acculturation 2. Ethnocentrism 3. Enculturation 4. Stereotyping

1

The nurse is teaching a class to the community on mind-based therapies. A class participant gives an example of a friend with leukemia who was taught by her complementary therapist to concentrate on making antibodies that will fight and kill the cancer cells in the bloodstream. How would the nurse identify this technique? 1. Guided imagery 2. Qigong 3. Biofeedback 4. Homeopathy

1

The nurse is telling a new client how advanced technology has permitted the physician to do which of the following? 1. Treat the fetus and monitor fetal development. 2. Deliver at home with a nurse-midwife and doula. 3. Have the father present as the coach and cut the umbilical cord. 4. Breastfeed a new baby on the delivery table.

1

A client tells you that her mother was a twin, two of her sisters have twins, and several cousins either are twins or gave birth to twins. The client, too, is expecting twins. Because there is a genetic predisposition to twins in her family, there is a good chance that the client will have what type of twins? 1. Dizygotic twins 2. Monozygotic twins 3. Identical twins 4. Nonzygotic twins

1

A nurse who tells family members the sex of a newborn baby without first consulting the parents would have committed which of the following? 1. A breach of privacy 2. Negligence 3. Malpractice 4. A breach of ethics

1

After explaining how meiotic division occurs within the ovum, the nurse knows that the pregnant client understands when she makes what statement? 1. The second meiotic division is arrested until and unless the oocyte is fertilized. 2. Meiosis in the oocyte begins at puberty. 3. The first meiotic division continues when the female infant is born. 4. Fertilization does not take place in the secondary oocyte.

1

At her first prenatal visit, a woman is discussing fetal development with the nurse. The client asks, When will my baby actually have a heartbeat? The nurse should say the heartbeat of an embryo is distinguishable by what time? 1. The fourth week 2. The sixth week 3. The eighth week 4. The twelfth week

1

Care delivered by nurse-midwives can be safe and effective and can represent a positive response to the healthcare provider shortage. Nurse midwives tend to use less technology, which often results in which of the following? 1. There is less trauma to the mother. 2. More childbirth education classes are available. 3. They are instrumental in providing change in the birth environment at work. 4. They advocate for more home healthcare agencies.

1

In evaluating information taught about conception and fetal development, the client verbalizes understanding about transportation time of the zygote through the fallopian tube and into the cavity of the uterus with which statement? 1. It will take at least 3 days for the egg to reach the uterus. 2. It will take 8 days for the egg to reach the uterus. 3. It will only take 12 hours for the egg to go through the fallopian tube. 4. It will take 18 hours for the fertilized egg to implant in the uterus.

1

It is 1 week before a pregnant clients due date. The nurse notes on the chart that the clients pulse rate was 74-80 before pregnancy. Today, the clients pulse rate at rest is 90. What action should the nurse should take? 1. Chart the findings. 2. Notify the physician of tachycardia. 3. Prepare the client for an electrocardiogram (EKG). 4. Prepare the client for transport to the hospital.

1

The OB-GYN nurse knows that the most common shape for the female pelvis is which of the following? 1. Gynecoid type 2. Android type 3. Anthropoid type 4. Platypelloid type

1

The nurse is addressing a college class on the topic of domestic violence. Which information would the nurse be sure to convey to her students? 1. The American Nurses Association advocates client advocacy for all nurses to help identify and prevent violence against women. 2. The American Nurses Association has concluded that there is little nurses can do to eliminate violence. 3. The nurse who suspects abuse should ask the doctor to deal with it, per American Nurses Association guidelines. 4. The nurse who suspects abuse should ask the hospitals social work department to deal with it, per American Nurses Association guidelines.

1

The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask? 1. What other treatments have you used for your abdominal pain? 2. In what country were you were born? 3. When you talk to family members, how close do you stand? 4. How would you describe your role within your family?

1

Student nurses in their obstetrical rotation are learning about fertilization and implantation. The process of implantation is characterized by which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The trophoblast attaches itself to the surface of the endometrium. 2. The most frequent site of attachment is the lower part of the anterior uterine wall. 3. Between days 7 and 10 after fertilization, the zona pellucida disappears, and the blastocyst implants itself by burrowing into the uterine lining. 4. The lining of the uterus thins below the implanted blastocyst. 5. The cells of the trophoblast grow down into the uterine lining, forming the chorionic villi.

1,3,5

The nurse is teaching a group of adolescents that sperm must undergo the process of capacitation in order to fertilize the ova. The characteristics of sperm that have undergone capacitation include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ability to undergo an acrosomal reaction 2. Ability to block polyspermy 3. Ability to bind to the zona pellucida 4. Ability to release norepinephrine 5. Acquisition of hypermotility

1,3,5

The nurse recognizes the importance of the interaction between the nervous and endocrine systems in the female reproductive cycle. The interaction involves which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Hypothalamus 2. Adrenal cortex 3. Ovaries 4. Thyroid 5. Anterior pituitary

1,3,5

The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this client's nails to make this clinical decision? Standard Text: Select all that apply. 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails

1,4,5

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position

1,4,5

The nurse explains the functions of the male reproductive organs to a client. Which correct functions will the nurse include? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ejaculatory ducts move semen and seminal fluid. 2. The adrenal gland is the major source of testosterone. 3. The vas deferens ends before reaching the prostate gland. 4. Sertolis cells nourish spermatozoa. 5. The testes house seminiferous tubules.

1,5

In assessing a new family coming to the clinic, the nurse determines they are an extended kin family because the family exhibits what as characteristics of an extended kin network family? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. A sharing of a social support network 2. Each family establishes their own sources of goods and services 3. Elderly parents share housing 4. Children are members of two nuclear families 5. A sharing of goods and services

1,5,

A client at 16 weeks gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change? 1. Because of your pregnancy, youre not making enough red blood cells. 2. Because your blood volume has increased, your hematocrit count is lower. 3. This change could indicate a serious problem that might harm your baby. 4. Youre not eating enough iron-rich foods like meat.

2

A client who is in the second trimester of pregnancy tells the nurse that she has developed a darkening of the line in the midline of her abdomen from the symphysis pubis to the umbilicus. What other expected changes during pregnancy might she also notice? 1. Lightening of the nipples and areolas 2. Reddish streaks called striae on her abdomen 3. A decrease in hair thickness 4. Small purplish dots on her face and arms

2

A couple who came to the United States two years ago with their two children are seeing the nurse in the community clinic. The nurse knows their family is acculturating when the mother makes which statement? 1. The children are much less well-behaved than they used to be. 2. Our diet now includes hamburgers and French fries. 3. We celebrate the same holidays that we used to at home. 4. When the children leave the house, I worry about them.

2

A fetus has been diagnosed with myelomeningocele. Which of the following surgeries would be performed to correct this condition? 1. Tubal ligation 2. Intrauterine fetal surgery 3. Cesarean section 4. Sterilization

2

A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure? 1. The nurse 2. The physician 3. The unit secretary 4. The social worker

2

A nurse is performing an assessment on a family with a father and mother who both work. What type of family does she record this family as being? 1. A traditional nuclear family 2. A dual-career/dual-earner family 3. An extended family 4. An extended kin family

2

A nurse is providing guidance to a group of parents of children in the infant-to-preschool age group. After reviewing statistics on the most common cause of death in this age group, the nurse includes information about prevention of which of the following? 1. Cancer by reducing the use of pesticides in the home 2. Accidental injury by reducing the risk of pool and traffic accidents 3. Heart disease by incorporating heart-healthy foods into the childs diet 4. Pneumonia by providing a diet high in vitamin C from fruits and vegetables

2

The nurse reviewing charts for quality improvement notes that a client experienced a complication during labor. The nurse is uncertain whether the labor nurse took the appropriate action during the situation. What is the best method for the nurse to take to determine what the appropriate action should have been? 1. Call the nurse manager of the labor and delivery unit and ask what the nurse should have done. 2. Ask the departmental chair of the obstetrical physicians what the best nursing action should have been. 3. Examine other charts to find cases of the same complication, and determine how it was handled in those situations. 4. Look in the policy and procedure book, and examine the practice guidelines published by a professional nursing organization.

4

The nurse works in a facility that cares for clients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation to recently hired nurses on the client population of the facility? 1. Our clients come from a broad range of backgrounds, but we have a good interpreter service. 2. Many of our clients come from backgrounds different from your own, but it doesnt cause problems for the nurses. 3. Because most of the doctors are bilingual, we dont have to deal with the differences in cultural backgrounds of our clients. 4. Understanding the common values and health practices of our diverse clients will facilitate better care and health outcomes.

4

The registered nurse who has completed a masters degree program and passed a national certification exam has clinic appointments with clients who are pregnant or seeking well-woman care. What would the role of this nurse be considered? 1. Professional nurse 2. Certified registered nurse (RNC) 3. Clinical nurse specialist 4. Nurse practitioner

4

What is the function of the scrotum? 1. Produce testosterone, the primary male sex hormone 2. Deposit sperm in the female vagina during sexual intercourse so that fertilization of the ovum can occur 3. Provide a reservoir where spermatozoa can survive for a long period 4. Protect the testes and the sperm by maintaining a temperature lower than that of the body

4

When teaching a culturally diverse group of childbearing families about hospital birthing options, the culturally competent nurse does which of the following? 1. Understands that the families have the same values as the nurse 2. Teaches the families how childbearing takes place in the United States 3. Insists that the clients answer questions instead of their husbands 4. Incorporates the specific beliefs of the cultural groups that are attending the class

4

The nurse is teaching an in-service educational presentation about working with battered women. The nurse should explain that it is often frustrating for nurses to work with battered women for which reasons? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. There is little the nurse can really do to help. 2. Healthcare policies and practices are not supportive of abused women. 3. Both husband and wife must agree to therapy. 4. These women might return to the abusive situation. 5. Women often believe that they are the cause of the abuse.

4,5

The nurse is assessing the neurologic status of a patient. She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan. What does this indicate? a. A positive Rombergs test b. A negative Babinskis reflex c. A hyperactive patellar tendon reflex d. A normal reflex in a child younger than age 2

A normal reflex in a child younger than age 2

Which of the following is an unexpected finding after a cardiac assessment? a. A pulse rate of 72 beats per minute b. Jugular vein pulsation with the patient supine c. PMI found at the midclavicular line d. A sustained swishing sound during systole or diastole

A sustained swishing sound during systole or diastole

The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the procedures, she: (Select all that apply.) a. speaks to the patient to minimize anxiety. b. drapes the body parts not being examined. c. encourages the patient to ask questions. d. uses medical terms to let the patient know that she is professional.

A,B

1. The purpose of the physical assessment is to: (Select all that apply.) a. compare the patients status with previous findings. b. help the nurse gather additional data. c. help select the best nursing measures. d. teach patients about better health promotion.

A,B,C,D

The patient has come to the clinic complaining of bleeding from what she calls a mole on her neck. She states that her mother died from skin cancer at a fairly early age because she was fair-skinned and had a lot of exposure to the sun. Because of this, the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun. The nurse prepares to examine the mole while being especially watchful for: (Select all that apply.) a. uneven shape of the mole (asymmetry). b. ragged or blurred edges of the mole border. c. pigmentation that is not uniform. d. size of the mole.

A,B,C,D

While performing a physical examination, the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are: (Select all that apply.) a. arsenic. b. asbestos. c. radiation. d. air pollution.

A,B,C,D

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client's interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated

After the client has settled in and been oriented to the room

1) The nurse is speaking to students about changes in maternal-newborn care. One change is that self-care has gained wide acceptance with clients and the healthcare community due to research findings that suggest that it has which effect? 1. Shortens newborn length of stay 2. Decreases use of home health agencies 3. Decreases healthcare costs 4. Decreases the number of emergency department visits

Answer: 3

The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test

Apical pulse

Type: MCSA The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate.

Ask the client to urinate

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

Assessment

The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus

Asymmetrical chest expansion

Which technique is most appropriate for a nurse to implement during the assessment of the abdomen? a. Assessing painful areas first b. Auscultating for 5 minutes over each quadrant c. Positioning the patient in a supine position with the arms behind or over the head d. Palpating painful masses or organ enlargement deeply and firmly

Auscultating for 5 minutes over each quadrant

The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure

Easy to palpate upper extremity arteries

The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions

Cognitive and affective functions

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment

Emergency assessment

The nurse decides to seek wound care alternatives for a client's stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment

Evaluation

While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. Erythema 2. Cyanosis 3. Exophthalmos 4. Normocephalic

Exophthalmos

The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia

Expressive aphasia

The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate? a. Stage I pressure ulcer b. Increased blood flow to the area c. Localized vasodilation d. Dehydration

Dehydration

During the assessment of a client's breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurse's notes as normal. 4. Document the findings in the nurse's notes as abnormal.

Document the findings in the nurse's notes as normal

A client in the emergency department has a non-life-threatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the client's back is to the rest of the room so as not to be heard by passersby.

Draw curtains around the client and nurse to provide as much privacy as possible.

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurse's hands

Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be? a. Have the patient turn onto his left side. b. Have the patient lean forward. c. Have the patient move to a sitting position. d. Palpate the PMI to the right of the midclavicular line.

Have the patient turn onto his left side.

The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back 4. Head, neck, lower extremities, abdomen

Head, upper extremities, abdomen, lower extremities

The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate, percuss 3. Inspect, auscultate, percuss, palpate 4. Palpate, percuss, auscultate, inspect

Inspect, auscultate, percuss, palpate

. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation b. Percussion c. Inspection d. Auscultation

Inspection

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients.

Implement a plan that is close to the medical model.

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

Implementation

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment

Inference

How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient? a. Lordosis b. Osteoporosis c. Scoliosis d. Kyphosis

Kyphosis

Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds? a. Supine b. Sitting up c. Dorsal recumbent d. Left lateral recumbent

Left lateral recumbent

Family of a client demonstrating confusion state that this is not the client's usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data

Objective data

The nurse documents: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing

Observing

Which of the following is an expected outcome for a patient after cardiac assessment? a. Apical pulse rate equals 58 beats per minute b. Carotid bruits present c. PMI palpable at left fifth intercostal space at midclavicular line d. Jugular veins distended with patient in sitting position

PMI palpable at left fifth intercostal space at midclavicular line

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam

Pap test

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the child's birth 2. Grandmother 3. Parents 4. Admitting physician

Parents

. How does a nurse appropriately measure intake and output? a. Recording 50% of ice chip consumption b. Checking urinary output every 24 hours c. Emptying the chest tube drainage every 2 hours d. Subtracting liquid medications from the total intake

Recording 50% of ice chip consumption

Unlicensed assistive personnel measure a newly admitted client's vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse.

Retake the vital signs.

Where is the pulmonic area for auscultation found? a. Second intercostal space on the right side b. Second intercostal space on the left side c. Third intercostal space (Erbs point) d. Fourth intercostal space along the sternum

Second intercostal space on the left side

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the client's chair. 4. Stand at the counter to take notes during the interview.

Sit next to the client, a few feet apart.

Which patient position maximizes the nurses ability to assess the patients body for symmetry? a. Sitting b. Supine c. Prone d. Dorsal recumbent

Sitting

The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient most likely will need to be in which position for the examination? a. Sitting upright b. Supine c. Side-lying d. Prone

Sitting upright

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs 2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients

Skull and face assessment

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-orkers discussing their clients' conditions

Whirring of ventilators

A nurses neighbor says, My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions? Select the nurses best response. a. The National Alliance on Mental Illness offers a family education series that you might find helpful. b. Since your sister is noncompliant, perhaps its time for her to be changed to injectable medication. c. You have done all you can. Now its time to put yourself first and move on with your life. d. You cannot help her. Would it be better for you to discontinue your relationship?

a

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? a. Implement suicide precautions. b. Offer high-calorie snacks and fluids frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

a

A patient says, Please dont share information about me with the other people. How should the nurse respond? a. I will not share information with your family or friends without your permission, but I share information about you with other staff. b. A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know. c. It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others. d. I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us.

a

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

a

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication. a. I notice you keep looking toward the door. b. This is our time together. No one is going to interrupt us. c. It looks as if you are eager to end our discussion for today. d. If you are uncomfortable in this room, we can move someplace else.

a

During group therapy, one patient says to another, When I first started in this group, you were unable to make a decision, but now you can. Youve made a lot of progress. I am beginning to think that maybe I can conquer my fears too. Which therapeutic factor is evident by this statement? a. Hope c. Catharsis b. Altruism d. Cohesiveness

a

Select the example of tertiary prevention. a. Helping a person diagnosed with a serious mental illness learn to manage money b. Restraining an agitated patient who has become aggressive and assaultive c. Teaching school-age children about the dangers of drugs and alcohol d. Genetic counseling with a young couple expecting their first child

a

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. Are you having difficulty hearing when I speak? b. How can I make this assessment interview easier for you? c. I notice you are frowning. Are you feeling annoyed with me? d. Youre having trouble focusing on what Im saying. What is distracting you?

a

Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting? a. Resolve the crisis with the least restrictive intervention possible. b. Swift intervention is justified to maintain the integrity of a therapeutic milieu. c. Rights of an individual patient are superseded by the rights of the majority of patients. d. Patients should have opportunities to regain control without intervention if the safety of others is not compromised.

a

Which scenario best depicts a behavioral crisis? A patient is: a. waving fists, cursing, and shouting threats at a nurse. b. curled up in a corner of the bathroom, wrapped in a towel. c. crying hysterically after receiving a phone call from a family member. d. performing push-ups in the middle of the hall, forcing others to walk around.

a

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. You must have been very upset when you tried to hurt yourself. b. It makes me sad to see you going through such a difficult experience. c. If you tell me what is troubling you, I can help you solve your problems. d. Suicide is a drastic solution to a problem that may not be such a serious matter.

a

Which technique will best communicate to a patient that the nurse is interested in listening? a. Restating a feeling or thought the patient has expressed. b. Asking a direct question, such as Did you feel angry? c. Making a judgment about the patients problem. d. Saying, I understand what youre saying.

a

. During a therapy group that uses existential/Gestalt theory, patients shared feelings that occurred at the time of their admission. After a brief silence, one member says, Several people have described feeling angry. I would like to hear from members who had other feelings. Which group role is evident by this comment? a. Energizer c. Compromiser b. Encourager d. Self-confessor

b

A black patient says to a white nurse, Theres no sense talking. You wouldnt understand because you live in a white world. The nurses best action would be to: a. explain, Yes, I do understand. Everyone goes through the same experiences. b. say, Please give an example of something you think I wouldnt understand. c. reassure the patient that nurses interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

b

A homeless patient diagnosed with a serious mental illness became suspicious and delusional. Depot antipsychotic medication began, and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement? a. They will not let me drink. They have many rules in the shelter. b. I feel comfortable here. Nobody bothers me. c. Those shots make my arm very sore. d. Those people watch me a lot.

b

A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitors closet is locked. These observations relate to: a. coordinating care of patients. b. management of milieu safety. c. management of the interpersonal climate. d. use of therapeutic intervention strategies.

b

A nurse introduces the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.

b

A nurse receives these three phone calls regarding a newly admitted patient. The psychiatrist wants to complete an initial assessment. An internist wants to perform a physical examination. The patients attorney wants an appointment with the patient. The nurse schedules the activities for the patient. Which role has the nurse fulfilled? a. Advocate c. Milieu manager b. Case manager d. Provider of care

b

A nurse wants to assess an adult patients recent memory. Which question would best yield the desired information? a. Where did you go to elementary school? b. What did you have for breakfast this morning? c. Can you name the current president of the United States? d. A few minutes ago, I told you my name. Can you remember it?

b

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-revelation in patient interactions. d. consistently interpret the patients behaviors.

b

A patient diagnosed with a serious mental illness died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, How could this happen? Which response by the nurse accurately reflects research and addresses the familys question? a. A certain number of people die young from undetected diseases, and its just one of those sad things that sometimes happen. b. Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight. c. We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death. d. We are all surprised. The patient had been doing so well and saw the nurse every other week.

b

A patient diagnosed with schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic? a. Lets talk about something other than the CIA. b. It sounds like youre concerned about your privacy. c. The CIA is prohibited from operating in health care facilities. d. You have lost touch with reality, which is a symptom of your illness.

b

A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, You cause too much trouble. What problem is the patient experiencing? a. Grief c. Homelessness b. Stigma d. Nonadherence

b

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurses next best action? a. Report the findings to the health care provider. b. Assess the patient for a history of renal problems. c. Assess the patients family history for cardiac problems. d. Arrange for the patients hospitalization on the psychiatric unit.

b

A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority? a. Find supported employment. b. Develop a trusting relationship. c. Administer prescribed medication. d. Teach appropriate health care practices.

b

After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires persistent direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of: a. side effects of antipsychotic medications. b. dependency caused by institutionalization. c. cognitive deterioration from schizophrenia. d. stress associated with acclimation to the community.

b

After formulating the nursing diagnoses for a new patient, what is a nurses next action? a. Designing interventions to include in the plan of care b. Determining the goals and outcome criteria c. Implementing the nursing plan of care d. Completing the spiritual assessment

b

Before assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isnt much improvement by the time of discharge. The nurses responsibility is to: a. document the other workers assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the workers impression by contacting the patients significant other. d. discuss the workers impression with the patient during the assessment interview.

b

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patients hand. Select the correct analysis of the nurses behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patients cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Psychiatric patients should not be touched.

b

For patients diagnosed with serious mental illness, what is the major advantage of case management? a. The case manager can modify traditional psychotherapy. b. With one coordinator of services, resources can be more efficiently used. c. The case manager can focus on social skills training and esteem building. d. Case managers bring groups of patients together to discuss common problems.

b

QSEN refers to: a. Qualitative Standardized Excellence in Nursing b. Quality and Safety Education for Nurses c. Quantitative Effectiveness in Nursing d. Quick Standards Essential for Nurses

b

Select the example of primary prevention. a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder b. Helping school-age children identify and describe normal emotions c. Leading a psychoeducational group in a community care home d. Medicating an acutely ill patient who assaulted a staff person

b

Serious mental illness is characterized as: a. any mental illness of more than 2 weeks duration. b. a major long-term mental illness marked by significant functional impairments. c. a mental illness accompanied by physical impairment and severe social problems. d. a major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

b

The nurse is planning a new sexuality group for patients. Which location would best enhance the effectiveness of this group? a. The hospital auditorium c. A common area, such as a day room b. A small conference room d. The corner of the music therapy room

b

The patient says, My marriage is just great. My spouse and I always agree. The nurse observes the patients foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patients communication is: a. clear. c. precise. b. mixed. d. inadequate.

b

The sibling of a patient who was diagnosed with a serious mental illness asks why a case manager has been assigned. The nurses reply should cite the major advantage of the use of case management as: a. The case manager can modify traditional psychotherapy for homeless patients so that it is more flexible. b. Case managers coordinate services and help with accessing them, making sure the patients needs are met. c. The case manager can focus on social skills training and esteem building in the real world where the patient lives. d. Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money.

b

Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room? a. Kindness c. Compassion b. Autonomy d. Professionalism

b

A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patients thoughts are now more organized, and discharge is planned. The patients family says, Its too soon for discharge. We will just go through all this again. The nurse should: a. ask the case manager to arrange a transfer to a long-term care facility. b. notify hospital security to handle the disturbance and escort the family off the unit. c. explain that the patient will continue to improve if the medication is taken regularly. d. contact the health care provider to meet with the family and explain the discharge rationale.

c

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. What are the common elements here? b. Tell me again about your experiences. c. Am I correct in understanding that . . . d. Tell me everything from the beginning.

c

A patient in a group therapy session listens to others and then remarks, I used to think I was the only one who felt afraid. I guess Im not as alone as I thought. This comment is an example of: a. altruism. c. universality. b. ventilation. d. group cohesiveness.

c

A patient tells the nurse, I dont think Ill ever get out of here. Select the nurses most therapeutic response. a. Dont talk that way. Of course you will leave here! b. Keep up the good work, and you certainly will. c. You dont think youre making progress? d. Everyone feels that way sometimes.

c

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case managers most appropriate action. a. Postpone the patients discharge from the hospital. b. Contact the landlord who evicted the patient to further discuss the situation. c. Arrange a temporary place for the patient to stay until new housing can be arranged. d. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.

c

A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurses best initial action. a. Explore ways to help the patient stop smoking. b. Report the situation to the manager of the shelter. c. Assess the patients weight; determine foods and amounts eaten. d. Arrange hospitalization for the patient in order to formulate a new treatment plan.

c

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patients reactions toward the nurse seem realistic and appropriate. b. The patient states, Talking to you feels like talking to my parents. c. The nurse feels unusually happy when the patients mood begins to lift. d. The nurse develops a trusting relationship with the patient.

c

An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? Youll just tell my parents whatever you find out. Which response by the nurse is appropriate? a. That isnt true. What you tell us is private and held in strict confidence. Your parents have no right to know. b. Yes, your parents may find out what you say, but it is important that they know about your problems. c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. d. It sounds as though you are not really ready to work on your problems and make changes.

c

An adult diagnosed with a serious mental illness says, I do not need help with money management. I have excellent ideas about investments. This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating: a. rationalization. c. anosognosia. b. identification. d. projection.

c

Documentation in a patients chart shows, Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, I enjoy spending time with you. Which analysis is most accurate? a. The patient is giving positive feedback about the nurses communication techniques. b. The nurse is viewing the patients behavior through a cultural filter. c. The patients verbal and nonverbal messages are incongruent. d. The patient is demonstrating psychotic behaviors.

c

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation c. Working b. Orientation d. Termination

c

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge c. Social isolation b. Ineffective coping d. Powerlessness

c

Termination of a therapeutic nurse-patient relationship has been successful when the nurse: a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

c

The case manager plans to discuss the treatment plan with a patients family. Select the case managers first action. a. Determine an appropriate location for the conference. b. Support the discussion with examples of the patients behavior. c. Obtain the patients permission for the exchange of information. d. Determine which family members should participate in the conference.

c

The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training? a. Patients learn to improve their attention and concentration. b. Group leaders provide support without challenging patients to change. c. Complex interpersonal skills are taught by breaking them into simpler behaviors. d. Patients learn social skills by practicing them in a supported employment setting.

c

A family discusses the impact of a seriously mental ill member. Insurance partially covered treatment expenses, but the family spent much of their savings for care. The patients sibling says, My parents have no time for me. The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful? a. Acknowledge their concerns and consult with the treatment team about ways to bring the patients symptoms under better control. b. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. c. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.

d

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. a. Record the patients answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the patients rights. d. Obtain important information from the family member.

d

A nurse documents: Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker. Which nursing diagnosis should be considered? a. Defensive coping c. Risk for other-directed violence b. Decisional conflict d. Impaired verbal communication

d

A nurse interacts with a newly hospitalized patient. Select the nurses comment that applies the communication technique of offering self. a. Ive also had traumatic life experiences. Maybe it would help if I told you about them. b. Why do you think you had so much difficulty adjusting to this change in your life? c. I hope you will feel better after getting accustomed to how this unit operates. d. Id like to sit with you for a while to help you get comfortable talking to me.

d

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, I really need to talk to you. The nurse should: a. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, I am not available to talk with you at the present time. c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, This session is 5 more minutes; then I will talk with you.

d

A patient diagnosed with schizophrenia has had multiple relapses. The patient usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply as the patient transitions from hospital to community? a. Administer a second-generation antipsychotic to help negative symptoms. b. Use a quick-dissolving medication formulation to reduce cheeking. c. Prescribe a long-acting intramuscular antipsychotic medication. d. Involve the patient in decisions about which medication is best.

d

A patient diagnosed with schizophrenia tells the community mental health nurse, I threw away my pills because they interfere with Gods voice. The nurse identifies the etiology of the patients ineffective management of the medication regime as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. dislike of antipsychotic medication side effects. d. impaired reasoning secondary to the schizophrenia.

d

A patient states, Im not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up. Which nursing intervention should have the highest priority? a. Self-esteembuilding activities c. Sleep enhancement activities b. Anxiety self-control measures d. Suicide precautions

d

A patient tells members of a therapy group, I hear voices saying my doctor is poisoning me. Another patient replies, I used to hear voices too. They sounded real, but I found out later they were not. The voices you hear are not real either. Which therapeutic factor is exemplified in this interchange? a. Catharsis c. Imitative behavior b. Universality d. Interpersonal learning

d

A young female member in a therapy group says to an older female member, You are just like my mother, always trying to control me with your observations and suggestions. Which therapeutic factor of a group is evident by this behavior? a. Instillation of hope b. Existential resolution c. Development of socializing techniques d. Corrective recapitulation of the primary family group

d

An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient? a. You need your medicine. Your schizophrenia will get worse without it. b. Do you want to be hospitalized again? You must take your medication. c. I would like you to come to the medication education group every Thursday. d. I noticed that when you take the medicine, you have been able to hold a job you wanted.

d

An outpatient diagnosed with schizophrenia tells the nurse, I am here to save the world. I threw away the pills because they make God go away. The nurse identifies the patients reason for medication nonadherence as: a. poor alliance with clinicians. b. inadequate discharge planning. c. dislike of medication side effects. d. lack of insight associated with the illness.

d

At what point in an assessment interview would a nurse ask, How does your faith help you in stressful situations? During the assessment of: a. childhood growth and development c. educational background b. substance use and abuse d. coping strategies

d

Clinical pathways are used in managed care settings to: a. stabilize aggressive patients. b. identify obstacles to effective care. c. relieve nurses of planning responsibilities. d. streamline the care process and reduce costs.

d

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. cyanosis. 2. jaundice. 3. pallor. 4. erythema.

jaundice

A nurse is documenting a patients breath sounds. Rhonchi are heard as: a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds at the end of inspiration.

loud, low-pitched, coarse sounds.

. During assessment of a patient with anemia, a nurse is alert for the presence of: a. pallor. b. jaundice. c. cyanosis. d. erythema.

pallor.

Petechiae are noted on the patient as a result of the nurse finding: a. bluish-black patches. b. tenting. c. pinpoint-sized red dots. d. large areas of raised, irritated skin.

pinpoint-sized red dots.

In providing a physical assessment of an 88-year-old patient, the nurse should: a. do it as quickly as possible to prevent fatigue. b. assume that the patient will have disabilities. c. prepare to perform a mental status examination. d. always do the exam in the small exam room to prevent chills.

prepare to perform a mental status examination.

The patient is diagnosed with Bells palsy. The nurse assesses the patient and notices drooping of the patients right eye and the right side of his mouth. When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the: a. seventh cranial nerve. b. trigeminal nerve (CN V). c. oculomotor nerve (CN III). d. glossopharyngeal nerve (CN IX).

seventh cranial nerve.

. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While providing cardiac education, the nurse realizes that the patient needs more education when he: a. describes changes in his behavior that may improve cardiovascular function. b. describes the schedule, dosage, and purpose of his medication. c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100. d. describes the benefits of taking his medication regularly.

states that he will take his medication when he has chest pain or when his heart rate is greater than 100.