Exam 2 Practice Questions
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "What medications do you take?" e. "Is movement painful?" f. "Have you ever fallen?"
"Can you easily change your position?" "Do you have sensitivity to heat or cold?" "How often do you need to use the toilet?" "Is movement painful?"
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. "I am so weak and tired. I want to feel better." b. "I am thinking I will be ready to go home early next week." c. "I am ready for my bath and linen change right now since this is awful." d. "I am hoping there will be something good for dinner tonight."
"I am ready for my bath and linen change right now since this is awful."
A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a. "I think you've had a hard day." b. "I feel uncomfortable hearing that statement." c. "I don't think you should say things like that. It is not right." d. "I have been checking on you regularly. How can you say that?"
"I feel uncomfortable hearing that statement."
When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "You will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"
"It must be difficult not to know what the surgeon will find. What can I do to help?"
A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are."
"This must be hard news to hear."
. The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? a. 4, 3, 1, 5, 6, 2 b. 1, 3, 4, 5, 6, 2 c. 4, 1, 3, 5, 6, 2 d. 1, 4, 3, 5, 6, 2
1, 3, 4, 5, 6, 2
The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. a. Absorbs drainage through the use of exudate absorbers in the dressing b. Very soothing to the patient and do not adhere to the wound bed c. Barrier to external fluids/bacteria but allows wound to "breathe" d. Manufactured from seaweed and comes in sheet and rope form e. Oldest and most common absorbent dressing 1. Gauze 2. Transparent 3. Hydrocolloid 4. Hydrogel 5. Calcium alginate
1.ANS:E 2.ANS:C 3.ANS:A 4.ANS:B 5.ANS:D
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b. 17 c. 20 d. 23
20
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 12 b. 13 c. 20 d. 23
23
A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation a. 5, 4, 2, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 5, 3, 1, 2 d. 1, 5, 2, 3, 4
5, 4, 2, 1, 3
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care? a. A patient with a clean Stage I b. A patient with a clean Stage II c. A patient with a clean Stage III d. A patient with a clean Stage IV
A patient with a clean Stage I
The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with a Stage IV pressure ulcer b. A patient with a Braden Scale score of 18 c. A patient with appendicitis using a heating pad d. A patient with an incision that is approximated
A patient with appendicitis using a heating pad
The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures.
A person's compliance is affected by economic status.
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? a. Low-air-loss b. Air-fluidized c. Lateral rotation d. Standard mattress
Air-fluidized
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? a. Vitamin E b. Potassium c. Albumin d. Sodium
Albumin
The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations.
Allow the patient to reminisce.
A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.
Allow time for the patient to respond.
The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? a. Monitor vital signs every 15 minutes. b. Check pulses in the right foot. c. Keep the leg dependent. d. Apply ice.
Apply ice.
The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? a. Assessing a surgical patient for risk of pressure ulcers b. Applying an elastic bandage to a medical-surgical patient c. Treating a pressure ulcer on the buttocks of a medical patient d. Implementing negative-pressure wound therapy on a stable patient
Applying an elastic bandage to a medical-surgical patient
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next? a. Call the health care provider; a blockage is present in the tubing. b. Chart the results on the intake and output flow sheet. c. Do nothing, as long as the evacuator is compressed. d. Remove the drain; a drain is no longer needed.
Call the health care provider; a blockage is present in the tubing.
The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? a. Allow the solution to flow from the most contaminated to the least contaminated. b. Scrub vigorously when applying noncytotoxic solution to the skin. c. Cleanse in a direction from the least contaminated area. d. Utilize clean gauze and clean gloves to cleanse a site.
Cleanse in a direction from the least contaminated area.
The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results. b. Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR). c. Consult the wound care nurse about the change in status and the potential for infection. d. Check with the charge nurse about the change in status and the potential for infection.
Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.
A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action
Contemplation
The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) a. Cover exposed wounds. b. Mark the sites of all abrasions. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. e. Cleanse the area with hydrogen peroxide. f. Assess the skin at underlying areas for circulatory impairment.
Cover exposed wounds. Assess the condition of current dressings. Inspect the skin for abrasions and edema. Assess the skin at underlying areas for circulatory impairment.
A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d. Focus on illness treatment to provide fast recuperation.
Create social and physical environments that promote good health
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate? a. Monitor the wound. b. Document the wound. c. Debride the wound. d. Manage drainage from wound.
Debride the wound.
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development? a. Decreased level of consciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain
Decreased level of consciousness
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first? a. Offer favorite fluids. b. Turn the patient every 2 hours. c. Determine the patient's risk factors. d. Encourage increased quantities of carbohydrates and fats.
Determine the patient's risk factors.
A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better off dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. Which action should the nurse take? a. Develop a plan of care for the family. b. Contact psychiatric services for a referral. c. Assure the patient that things will work out. d. Focus the plan of care solely on maximizing patient function.
Develop a plan of care for the family.
A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? a. Interpersonal communication to change negative self-talk to positive self-talk b. Small group communication to present information to an audience c. Electronic communication to assess a patient in another city d. Intrapersonal communication to build strong teams
Electronic communication to assess a patient in another city
A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate healthy life in America.
Eliminate health disparities in America.
The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take? a. Turn on the television. b. Explain the procedure. c. Tell the patient "Close your eyes." d. Ask the family to leave the room.
Explain the procedure.
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial-thickness wound repair b. Full-thickness wound repair c. Primary intention d. Tertiary intention
Full-thickness wound repair
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage
Granulation
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient? a. Disposable measuring tape b. Cotton-tipped applicator c. Sterile gloves d. Halogen light
Halogen light
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer
Healing Stage III pressure ulcer
The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs
Health belief model
The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) a. Hemostasis b. Maturation c. Inflammatory d. Proliferative e. Reproduction f. Reestablishment of epidermal layers
Hemostasis Maturation Inflammatory Proliferative
A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed
History of angina
The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs
Holistic health model
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin
Hyperemia Induration Blanching Temperature of skin
A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. Which element will the nurse identify as feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.
I don't feel good.
The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next? a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Teach the patient that choices will have to change. d. Instruct the patient that relapses will not be tolerated
Identify the patient's stage of change.
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain
Impaired skin integrity
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? a. Imbalanced nutrition: less than body requirements b. Ineffective peripheral tissue perfusion c. Risk for infection d. Acute pain
Ineffective peripheral tissue perfusion
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take? a. Inspect the wound for foreign bodies. b. Inspect the wound for bleeding. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.
Inspect the wound for bleeding.
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Dakin's solution. c. Apply a hydrogel dressing. d. Consult a dietitian.
Irrigate with Dakin's solution.
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. It reduces edema at the surgical site. b. It secures the dressing in place. c. It immobilizes the abdomen. d. It supports the abdomen.
It supports the abdomen.
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Less than 2 hours c. No longer than 30 minutes d. As long as the patient remains comfortable
Less than 2 hours
Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Action
Maintenance
A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Making sure the patients are disease free b. Making sure to involve the whole person c. Making sure care is strictly personal in nature d. Making sure to focus only on the pathological state
Making sure to involve the whole person
A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend
Mutuality
A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Nonjudgmental b. Socializing c. Narrative d. SBAR
Narrative
The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary
Nonverbal
A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members
Not eating
A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take? a. Obtain an interpreter. b. Refer to a speech therapist. c. Let a close family member talk. d. Find a mental health nurse specialist.
Obtain an interpreter.
During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination
Orientation
The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion
Passive health promotion
A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices
Perception of functioning
A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Socio-consultative b. Personal c. Intimate d. Public
Personal
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) a. Place moist sterile gauze over the site. b. Gently place the organs back. c. Contact the surgical team. d. Offer a glass of water. e. Monitor for shock.
Place moist sterile gauze over the site. Contact the surgical team. Monitor for shock.
Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination
Preinteraction
The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress
Pressure
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points
Pressure points
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention
Primary Intention
The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention
Primary prevention
The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate
Protein
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? a. Explain the risks of immobility to the patient. b. Turn the patient every 3 hours while in bed. c. Encourage the patient to sit up in the chair. d. Provide analgesic medication as ordered.
Provide analgesic medication as ordered.
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? a. Provide analgesic medications as ordered. b. Avoid accidentally removing the drain. c. Don sterile glov d. Gather supplies.
Provide analgesic medications as ordered.
A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use? a. Public b. Small group c. Interpersonal d. Intrapersonal
Public
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? a. Muscular strength assessment b. Pulse oximetry assessment c. Sensation assessment d. Sleep assessment
Pulse Oximetry Assessment
The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult? a. Respiratory therapist b. Registered dietitian c. Case manager d. Chaplain
Registered dietitian
A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure
Relax
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? a. Protrusion of visceral organs through a wound opening b. Chronic drainage of fluid through the incision site c. Report by patient that something has given way d. Drainage that is odorous and purulent
Report by patient that something has given way
A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe
Scarring that may be severe
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention
Secondary Intention
The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion
Secondary prevention
Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately b. Uses automatic responses fluently c. Demonstrates passive remarks accurately d. Self-examines personal communication skills
Self-examines personal communication skills
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) a. The patient's expectations are not being met. b. Skin is intact with no redness or swelling. c. Nonblanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present.
Skin is intact with no redness or swelling. Nonblanchable erythema is absent. No injuries to the skin and tissues are evident. Granulation tissue is present.
Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support
Socioeconomic status Cultural background Social support
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV
Stage II
A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion
Tertiary prevention
Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding? a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. Risk modification will have no effect on disease prevention. d. The disease is guaranteed not to develop if the risk factor is controlled.
The chances of getting the disease are increased.
Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond.
The nursing assistive personnel is calling the older-adult patient "honey."
Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. The patient has fecal incontinence. b. The patient ate two thirds of breakfast. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.
The patient has fecal incontinence.
A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostomy
The patient who is dyspneic, anxious, and has a tracheostomy
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient's family will demonstrate specific care of the wound site. c. The patient's family members will wash their hands when visiting the patient. d. The patient will remain free of odorous or purulent drainage from the wound.
The patient will remain free of odorous or purulent drainage from the wound.
The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and will never quit smoking. b. The patient must pick up the attempt right where the patient left off. c. The patient will return to the contemplation or precontemplation phase. d. The patient will need to adopt a new lifestyle for change to be effective.
The patient will return to the contemplation or precontemplation phase.
A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's denotative meaning is wrong. b. The patient's personal space was violated. c. The patient's affect is inappropriate. d. The patient's vocabulary is poor.
The patient's affect is inappropriate.
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? a. The site is hurting. b. The site is approximated. c. The site has started to itch. d. The site has a mass, bluish in color.
The site has a mass, bluish in color.
Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who maintain perceptual biases
Those who develop critical thinking skills
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? a. To promote autonomy b. To use common courtesy c. To establish trustworthiness d. To standardize communication
To standardize communication
An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum. b. Turn off the television. c. Speak clearly and loudly. d. Use at least 14-point print.
Turn off the television.
A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system b. Identifies actual and potential risk factors c. Has coined the term "illness behavior" d. Minimizes the effects of illnesses e. Experiences compassion fatigue
Understands the challenges of today's health care system Identifies actual and potential risk factors Minimizes the effects of illnesses
A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.
Use a picture board.
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk? a. Use gentle cleansers, and thoroughly dry the skin. b. Use therapeutic bed and mattress. c. Use absorbent pads and garments. d. Use products that hold moisture to the skin.
Use gentle cleansers, and thoroughly dry the skin.
Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith b. Uses humility c. Portrays self-confidence d. Exhibits supportiveness e. Demonstrates independent attitude
Uses humility Portrays self-confidence Demonstrates independent attitude
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? a. Place the patient in a 30-degree supine position. b. Utilize a transfer device to lift the patient. c. Elevate the head of the bed 45 degrees. d. Slide the patient into the new position.
Utilize a transfer device to lift the patient.
The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation
Withdrawal
A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination
Working
