Fundamentals Final Exam Practice FINAL

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

a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches. Chapter 41

A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause or andropause. Chapter 19

In addition to standard precautions, the nurse would initi- ate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diptheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Air- borne precautions are used for patients who have infections spread through the air with small particles, for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA. Chapter 23

A nurse is assessing a 49-year-old male patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors

a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress. Chapter 41

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. a. A newborn who has hypothermia b. A child who has pneumonia c. An older patient who is post myocardial infarction (heart attack) d. A teenager who has leukemia e. A patient receiving erythropoietin to replace red blood cells f. An adult patient who is newly diagnosed with pancreatitis

a, c, d, e. The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts. Chapter 24

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol- based handrub to decontaminate the hands? Select all that apply. a. The nurse is providing a bed bath for a patient. b. The nurse has visibly soiled hands after changing the bedding of a patient. c. The nurse removes gloves when patient care is completed. d. The nurse is inserting a urinary catheter for a female patient. e. The nurse is assisting with a surgical placement of a cardiac stent. f. The nurse removes old magazines from a patient's table.

a, c, d, f. It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after remov- ing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contami- nated by the patient. Chapter 23

The student nurse learns that illnesses are classified as either acute or chronic. Which are examples of chronic illnesses? Select all that apply. a. Diabetes mellitus b. Bronchial pneumonia c. Rheumatoid arthritis d. Cystic fibrosis e. Fractured hip f. Otitis media

a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time. Chapter 3

A nurse working with adolescents in a juvenile detention center teaches parents about behaviors that place adolescents at high risk for injury. Which statements accurately describe these risks? Select all that apply. a. Each year, underage drinking claims the lives of approximately 5,000 individuals under the age of 21. b. Approximately one in three high school students reported using some type of tobacco product. c. The CDC (2012i) lists motor vehicle accidents as the number-one cause of death for adolescents. d. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. e. Homicide rates for adolescents are high, and youths aged 10-19 years committed almost 500 suicides using firearms. f. As many as 30% of children are bullied during their school years and cyber bullying is even more damaging to children.

a, c, d. Each year, underage drinking claims the lives of approximately 5,000 people under the age of 21. The CDC (2012j) lists motor vehicle accidents as the number one cause of death for adolescents. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. Approximately one in five (20%) high school students reported using some type of tobacco product. Homicide rates for youths using firearms are higher than any other age group and the most recent statistics indicate that youths aged 10-19 years com- mitted almost 1,500 suicides using firearms (Kagler, Annest, Kresnow & Mercy, 2011). According to the American Acad- emy of Child & Adolescent Psychiatry, as many as 50% of children are bullied during their school years and some experts believe that cyber bullying is more dangerous and damaging to children than bullying that occurs in the schoolyard. Chapter 26

A nurse witnesses a street robbery and is assessing a 26-yearold female patient who is the victim. The patient has minor scrapes and bruises and tells the nurse, "I've never been so scared in my life." What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a. Increased heart rate b. Decreased muscle strength c. Increased mental alertness d. Increased blood glucose levels e. Decreased cardiac output f. Decreased peristalsis

a, c, d. The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest. Chapter 41

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

a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes. Chapter 20

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply. a. A 4-month old infant whose temperature is 38.1°C (100.5°F) b. A 3-year old whose blood pressure is 118/80 c. A 9-year old whose temperature is 39°C (102.2°F) d. An adolescent whose pulse rate is 70 bpm e. An adult whose respiratory rate is 20 bpm f. A 72-year old whose pulse rate is 42 bpm

a, d, e, f. The normal temperature range for infants is 37.1°C to 38.1°C (98.7°F-100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 bpm and the normal pulse for an older adult is 40 to 100 bpm. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8°C to 37.8°C (98.2°F-100°F; refer to Table 24-1, Age-Related Variations in Normal Vital Signs). Chapter 24

A patient complains of severe abdominal pain. When assess- ing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. a. An increase in the pulse rate b. A decrease in body temperature c. A decrease in blood pressure d. An increase in respiratory depth e. An increase in respiratory rate f. An increase in body temperature

a, e. The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase res- piratory rate but decrease respiratory depth. Chapter 24

It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small? a. An incorrect reading b. Injury to the patient c. Prolonged pressure on the arm d. Loss of Korotkoff sounds

a. A blood pressure cuff that is not the right size may cause an incorrect reading. Chapter 24

A nurse sees a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the patient for: a. Pain b. Anxiety c. Depression d. Fluid volume deficit

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. Chapter 20

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

a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the ChooseMyPlate dietary guidelines. Chapter 41

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? a. Follow-up measurements of blood pressure b. Immediate treatment by a physician c. No action, because the nurse considers this reading is due to anxiety d. A change in dietary intake

a. A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck. Chapter 24

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother's construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks. Chapter 26

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

a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified. Chapter 41

A nurse is caring for an 80-year-old female patient who is living in a long-term care facility. To help this patient adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday? d. "Why don't you want to talk about your feelings?"

a. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences. Chapter 19

A patient's spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess? a. Transmission of tactile stimuli b. Adequate stimulation in the environment c. Reception of visual and auditory stimuli d. General orientation and ability to follow commands

a. Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of lesser importance at this time. Chapter 43

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teach- ing plan? a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat. Chapter 26

A patient who is febrile may lose body heat through perspira- tion. The nurse recognizes that this is an example of what mechanism of heat loss? a. Evaporation b. Convection c. Radiation d. Conduction

a. Evaporation is the conversion of a liquid to a vapor as occurs when body fluid in the form of perspiration is vapor- ized from the skin. With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. An example of radiation (diffusion of heat by electromagnetic waves) is the body giving off heat from uncovered areas. In conduction, the heat is transferred to another object during direct contact, for example, body heat melting an ice pack. Chapter 24

A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors b. By not requiring sick days from work c. By never exposing others to any type of illness d. By spending less money on food

a. Good personal health enables the nurse to serve as a role model for patients and families. Chapter 3

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

a. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress. Chapter 41

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

a. Safety is a basic physiologic need that must be met before higher-level needs—such as love and belonging, self-esteem, and self-actualization—can be met. Chapter 43

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate com- munication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject

a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition. Chapter 20

Two nurses are taking an apical-radial pulse and note a dif- ference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following? a. Pulse deficit b. Pulse amplitude c. Ventricular rhythm d. Heart arrhythmia

a. The difference between the apical and radial pulse rate is called the pulse deficit. Chapter 24

The agent-host-environment model of health and illness is based on what concept? a. Risk factors b. Demographic variables c. Behaviors to promote health d. Stages of illness

a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease. Chapter 3

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

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. Chapter 20

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

a. The patient confined to bedrest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate. Chapter 43

When a fire occurs in a patient's room, what would be the nurse's priority? a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate. Chapter 26

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

a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coor- dinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care. Chapter 20

A nurse is using the SOAP format of documentation to docu- ment care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes

a. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narra- tive notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by exception, and planned interventions and patient expected outcomes are the focus of the case management model. Chapter 16

According to the Health Insurance Portability and Account- ability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. News media are preparing a report on the condition of a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's wants to help provide care.

b, c, d, e. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no cir- cumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease. Chapter 16

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

b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs. Chapter 3

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which state- ments accurately describe these factors? Select all that apply. a. Blood pressure decreases with age. b. Blood pressure is usually lowest on arising in the morning. c. Women usually have lower blood pressure than men until menopause. d. Blood pressure decreases after eating food. e. Blood pressure tends to be lower in the prone or supine position. f. Increased blood pressure is more prevalent in African Americans.

b, c, e, f. Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in Afri- can American men and women. Chapter 24

Health promotion activities may occur on a primary, secondary, or tertiary level. Which activities are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students. f. A nurse teaches new parents how to choose and use an infant car seat.

b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity. Chapter 3

A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? Select all that apply. a. A patient's increased skin elasticity causes wrinkles on the face and arms. b. Exposure to sun over the years causes a patient's skin to be pigmented. c. A patient's toenails have become thinner with a bluish tint to the nail beds. d. A patient experiences a hip fracture due to porous and brittle bones. e. Fragile blood vessels in the dermis allow for more easy bruising of a patient's forearm. f. Increased bladder capacity causes decreased voiding in an older patient.

b, d, e. Exposure to sun over the years can cause a patient's skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura. Wrinkling and sagging of skin occur with decreased skin elasticity. A patient's toenails may become thicker, with a yellowish tint to the nail beds. Bladder capacity decreases by 50%, making voiding more frequent; two or three times a night is usual. Chapter 19

A nurse who is assessing an older female patient in a longterm care facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding? Select all that apply. a. Use a lower tone when communicating with the patient. b. Provide interaction with children and pets. c. Decrease environmental noise. d. Ensure that the patient shares meals with other patients. e. Discourage the use of sedatives. f. Provide adequate lighting and clear pathways of clutter.

b, d, e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit, decreasing environmental noise is an intervention for sensory overload, and providing adequate lighting and removing clutter is an intervention for a vision deficit. Chapter 43

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 60 years b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, docu- mented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics. Chapter 26

Following a fall that left an elderly male patient temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S - Senility b. P - Problems with feeding c. I - Irritableness d. C - Confusion e. E - Edema of the legs f. S - Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S - Sleep disorders P - Problems with eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown (Fulmer & Wallace, 2012). Chapter 19

A nurse assesses patients in a physician's office who are experiencing different levels of health and illness. Which statements best define the concepts of health and illness? Select all that apply. a. Health and illness are the same for all people. b. Health and illness are individually defined by each person. c. People with acute illnesses are actually healthy. d. People with chronic illnesses have poor health beliefs. e. Health is more than the absence of illness. f. Illness is the response of a person to a disease.

b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward one's maximum potential. An illness is the response of the person to a disease. Chapter 3

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. The nurse removes all jewelry including a platinum wedding band. b. The nurse washes hands to one inch above the wrists. c. The nurse uses approximately two teaspoons of liquid soap. d. The nurse keeps hands higher than elbows when placing under faucet. e. The nurse uses friction motion when washing for at least 15 seconds. f. The nurse rinses thoroughly with water flowing toward fingertips.

b, e, f. Proper hand hygiene includes removing jewelry with the exception of a plain wedding band, wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 15 seconds, washing to one inch above the wrists with a fric- tion motion for at least 15 seconds, and rinsing thoroughly with water flowing toward fingertips. Chapter 23

A nurse is diagnosing an 11-year-old 6th grade student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Which nursing diagnosis would be most appropriate? a. Deficient Knowledge related to visual impairment b. Ineffective Role Performance (Student) related to visual impairment c. Disturbed Body Image related to visual impairment d. Delayed Growth and Development related to visual impairment

b. An important role for an 11-year-old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may also represent accurate diagnoses for this patient, they do not flow from the data presented. Chapter 43

A student nurse is learning to assess blood pressure. What does the blood pressure measure? a. Flow of blood through the circulation b. Force of blood against arterial walls c. Force of blood against venous walls d. Flow of blood through the heart

b. Blood pressure is the measurement of the force of blood against arterial walls. Chapter 24

A nurse observes that a patient who has cataracts is sitting closer to the television than usual. The nurse would interpret that the etiologic basis of this sensory problem is an alteration in: a. Environmental stimuli b. Sensory reception c. Nerve impulse conduction d. Impulse translation

b. Cataracts are interfering with the patient's ability to receive visual stimuli: altered sensory reception. The nature of incoming stimuli, the conduction of nerve impulses, and the translation of incoming impulses in the brain are not a problem here. Chapter 43

A nurse is interviewing a patient who just received news that he has pancreatic cancer. The patient tells the nurse that getting cancer could never happen to him. Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression

b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing. Chapter 41

A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of ill- ness, before disappearing by the convalescent period. Chapter 23

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

b. Effective communication by the sender involves the imple- mentation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time. Chapter 20

A patient is having dyspnea. What would the nurse do first? a. Remove pillows from under the head b. Elevate the head of the bed c. Elevate the foot of the bed d. Take the blood pressure

b. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion. Chapter 24

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered: a. The nurse's preference b. Safe for the home setting c. Unethical behavior d. Grossly negligent

b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is neither unethical nor grossly negligent. Chapter 23

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

c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development. Chapter 41

Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagna- tion. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs. Chapter 19

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

b. No matter what the technique, relaxation involves rhythmic breathing, a slower pulse, reduced muscle tension, and an altered state of consciousness. Chapter 41

Which action would be most important for a nurse to include in the plan of care for a patient who is 85 years old and has presbycusis? a. Obtaining large-print written material b. Speaking distinctly, using lower frequencies c. Decreasing tactile stimulation d. Initiating a safety program to prevent falls

b. Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. The other choices refer to interventions for other sensory problems. Chapter 43

A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, what would the nurse do in this situation? a. Take the blood pressure in the right arm b. Take the blood pressure in the left arm c. Use the smallest possible cuff d. Report inability to take the blood pressure

b. The blood pressure should be taken in the arm opposite the one with the infusion. Chapter 24

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

b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones. Chapter 20

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. The nurse positions a patient in a supine position prior to applying wrist restraints. b. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered. Chapter 26

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family mem- ber asks." c. "Because of the Health Insurance Portability and Account- ability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mention- ing the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do. Chapter 16

A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Draw a single line through the entry and rewrite it above or beside it. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly

b. The nurse should not use dittos, erasures, or correcting flu- ids. A single line should be drawn through an incorrect entry, and the words "mistaken entry" or "error in charting" should be printed above or beside the entry and signed. The entry should then be rewritten correctly. Chapter 16

A nurse is providing instruction to a patient regarding the procedure to change his colostomy bag. During the teach- ing session, he asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior

b. The patient's question allows the nurse to clarify informa- tion that is new to the patient or that requires further explanation. Chapter 20

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure? a. Report the incident to the appropriate person and file an incident report. b. Wash the exposed area with warm water and soap. c. Consent to postexposure prophylaxis at appropriate time. d. Set up counseling sessions regarding safe practice to protect self.

b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to postexposure prophylaxis, and attend counseling sessions regarding safe practice to protect self and others. Chapter 23

A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the neighbor exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming a dependent role d. Achieving recovery and rehabilitation

b. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities. Chapter 3

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a. The nurse puts on PPE after entering the patient room. b. The nurse works from "clean" areas to "dirty" areas during bath. c. The nurse personalizes the care by substituting glasses for goggles. d. The nurse removes PPE prior to leaving the patient room.

b. When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom. Chapter 23

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

c. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. Chapter 41

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. 60% of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Over 1/3 of fire deaths occur in a home without a smoke detector. e. Fires are more likely to occur in homes without electricity or gas. f. More fires occur in homes occupied by single parents.

c, d, e. Of all fire deaths in the United States, 85% occur in the home (CDC, 2011a). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. More than one-third of home fire deaths occur in a home without a smoke detector (CDC, 2011a). People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Being a single parent is not a risk factor for fire occurrences. Chapter 26

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which instruction would the nurse provide in this type of stress management? a. The nurse teaches patients rhythmic breathing to perform prior to the procedure. b. The nurse tells patients to focus on a pleasant place, mentally place themselves in it, and breathe slowly in and out. c. The nurse teaches patients about the pain involved in the procedure and methods to cope with it. d. The nurse teaches patients to create and focus on a mental image during the procedure to become less responsive to the pain.

c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, their anxiety is reduced, which occurs when teaching about the pain involved and related pain relief measures. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. Chapter 41

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after she communicates the plan of care. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninter- rupted. c. Discuss the silence with the patient to ascertain its mean- ing. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speak- ing. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor. Chapter 20

A nurse formulates the following diagnosis for an older female patient in a long-term care facility: Disturbed Sensory Perception: Chronic Sensory Deprivation related to the effects of aging. The patient walked out the door unobserved and was lost for several hours. Which interventions would be most effective for this patient? Select all that apply. a. Ignore when the patient is confused or go along to prevent embarrassment. b. Reduce the number and type of stimuli in the patient's room. c. Orient the patient to time, place, and person frequently. d. Provide daily contact with children, community people, and pets. e. Decrease background or loud noises in the environment. f. Provide a radio and television in the patient's room.

c, d, f. Even if well motivated, ignoring a patient's confusion to prevent embarrassment may be dangerous, as it was in this case in which the appropriate safety precautions were never implemented. Reducing the type of stimuli in the room and decreasing environmental noise is appropriate for a patient who is experiencing sensory overload. The other options are related to sensory deprivation and are appropriate for this patient. Chapter 43

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appen- dicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/15 0945 30 minutes following administration of mor- phine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/15 0945 Patient states she does not want pain medica- tion despite return of pain. After discussing situation, patient agrees to medication administration.

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "seems comfortable today." The nurse should never document an intervention before carrying it out. Chapter 16

A nurse caring for adults in a physician's office notes that some patients age more rapidly that other patients of the same age. The nurse researches aging theories that attempt to describe how and why aging occurs. Which statements apply to the immunity theory of aging? Select all that apply. a. Chemical reactions in the body produce damage to the DNA. b. Free radicals have adverse effects on adjacent molecules. c. Decrease in size and function of the thymus causes infections. d. There is much interest in the role of vitamin supplementation. e. Lifespan depends on a great extent to genetic factors. f. Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the func- tions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infec- tions. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. In the cross-linkage theory, cross-linkage is a chemical reac- tion that produces damage to the DNA and cell death. The free radical theory states that free radicals, formed during cellular metabolism, are molecules with separated high-energy electrons, which can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic fac- tors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors (Eliopoulos, 2010). Chapter 19

A nurse is assessing a 78-year-old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. a. The nurse asks the patient if he is bored, and if so, why. b. The nurse asks the patient if anything interferes with the functioning of his senses. c. The nurse asks the patient if he noticed any changes in the way he perceives his body. d. The nurse asks the patient if he has found it difficult to communicate verbally. e. The nurse notes if the patient withdraws from being touched. f. The nurse notes if the patient seems unsure of his body parts and/or position.

c, e, f. To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation, asking if anything interferes with his senses assesses reception, and asking about difficulty communicating assesses for transmission- perception-reaction. Chapter 43

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appro- priate nursing action in this situation? a. Ask another nurse to hold the hand of the patient and continue setting up the field. b. Remove the instrument that was touched by the patient and continue setting up the sterile field. c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. d. No action is necessary since the patient has touched his or her own sterile field.

c. If the patient touches a sterile field, the nurse should dis- card the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening. Chapter 23

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal. d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

c. According to the principles of medical asepsis, the nurse should move equipment away from the body when brush- ing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas. Chapter 23

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

c. Although all the options listed are appropriate, providing daily opportunities for this patient to participate in a social hour builds on his strength of being able to lip-read and provides sufficient sensory stimulation to prevent sensory deprivation resulting from his hearing loss, thereby meeting his needs. Chapter 43

A nursing instructor teaching classes in gerontology to nurs- ing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes, and although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others. Chapter 19

A nurse formulated the following nursing diagnosis for an 8-month-old infant: Disturbed Sensory Perception: Sensory Deprivation related to inadequate parenting. Since that diagnosis was made, both parents have attended parenting classes. However, both parents work while the infant stays with her 86-year-old grandmother, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor sucking her thumb and rocking her body. Her facial expression is dull, and she vocalizes only in a low monotone ("uh-h-h"). Which statement accurately reflects evaluation about the child's sensory deprivation? a. The infant's parents lack motivation to provide necessary stimulation. b. The grandmother is unable to improve the infant's care. c. The infant's sensory deprivation is still severe. d. This is normal behavior for an 11-month-old infant.

c. Although the data show that the parents have been motivated to improve their parenting skills, it is clear from the data that the infant's sensory deprivation is still severe. The data suggest that the grandmother is not improving the infant's care, but there is nothing to suggest that she is unable to do so if shown how. Chapter 43

What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. Alzheimer disease d. Loss of cardiac reserve

c. Alzheimer disease is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. Chapter 19

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired Gas Exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for Suffocation related to unfamiliarity with fire prevention guidelines d. Deficient Knowledge related to lack of follow-through of recommendation to stop smoking

c. Because Mrs. Fuller is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation. Chapter 26

A nursing student is nervous and concerned about the work she is about to do at the clinical facility. To allay anxiety and be successful in her provision of care, it is most important for her to: a. Determine the established goals of the institution b. Be sure her verbal and nonverbal communication is congruent c. Engage in self-talk to plan her day and decrease her fear d. Speak with her fellow colleagues about how they feel

c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety. Chapter 20

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

c. Giving influenza injections is an example of primary health promotion and illness prevention. Chapter 3

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. Remove gown, goggles, mask, gloves, and exit the room. b. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. c. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene. d. Remove goggles, mask, gloves, gown, and perform hand hygiene

c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room. Chapter 23

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is: a. "Thank you for taking care of this!" b. Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it. c. "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift.

c. In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Chapter 16

The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm3 c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c. Indwelling urinary catheters have been implicated in most health care-associated infections. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs. Chapter 23

A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing? a. Gustatory b. Olfactory c. Tactile d. Kinesthetic

c. The nurse is assessing for tactile (touch) disturbances by brushing the skin with a cotton ball and touching the skin with a safety pin. Gustatory disturbances involve taste, olfactory disturbances involve the sense of smell, and kinesthetic disturbances are related to body positioning. Chapter 43

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

c. The nursing diagnosis of Anxiety indicates situational/ maturational crises or changes in role status. Ineffective coping refers to the inability to appraise stressors or use available resources. Ineffective denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem diagnoses feelings of worthlessness related to the current situation the person is experiencing, not related to the fear of role changes. Chapter 41

Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, whose her best friend had a benign breast lump removed b. Sarah, who lives in a low-income neighborhood c. Tricia, who has a family history of breast cancer d. Nancy, whose family encourages regular physical examinations

c. The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor. Chapter 3

A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: a. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction b. The lowest pressure present on arterial walls while the ventricles relax c. The highest pressure present on arterial walls while the ventricles contract d. The difference between the pressure on arterial walls with ventricular contraction and relaxation

c.Thesystolicpressureis120mmHg.Thediastolicpressureis 80 mm Hg, the lowest pressure present on arterial walls when the heart rests between beats. The difference between the systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction is the pulse. Chapter 24

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I to Phase V. a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery c. The last sound heard before a period of continuous silence, known as the second diastolic pressure d. Characterized by the first appearance of faint but clear tap ping sounds that gradually increase in intensity; known as the systolic pressure e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

d, a, b, e, c. Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows rela- tively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure. Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure. Chapter 24

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient- controlled analgesia pump (PCA) for pain related to pancre- atic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: identity/introduction, situation, background, assessment, recommendation, and read-back. Chapter 16

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? a. Check the pulse again in 2 hours. b. Check the blood pressure. c. Record the information. d. Report the rate to the primary care provider.

d. A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient. Chapter 24

When completing a safety event report, the nurse should: a. Include suggestions on how to prevent the incident from recurring. b. Provide minimal information about the incident. c. Discuss the details with the patient before documenting them. d. Objectively describe the incident in detail.

d. A safety event report is a legal document, which must be as objective and complete as possible. It is not a collabora- tive effort with the patient, and any suggestions to prevent the occurrence from happening again should be discussed at a postincident conference. Chapter 26

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medi- cal records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of agency policies regarding the patient's right to access and copy records. Chapter 16

A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature? a. Febrile b. Hypothermia c. Hypertension d. Afebrile

d. Afebrile means without fever. This temperature is within the normal range for an adult. Fever (pyrexia) is an elevation of body temperature; a person with fever is said to be febrile. Hypothermia is a low body temperature and hyperthermia is a high body temperature. Chapter 24

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. Harassment b. Whistle blowing c. Racism d. Ageism

d. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant per- son takes advantage of or overpowers a less dominant person (may involve sexual harassment or power struggles). Whistle blowing involves reporting illegal or unethical behavior in the workplace. Racism is prejudice against other races and ethnic groups. Chapter 19

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c. Even small doses of radiation result in bone marrow depression and cancer. d. Blast lung injury is a serious consequence following detonation of an explosive device.

d. Blast lung injury is a recognized consequence following exposure to an explosive device. The CDC is the federal agency that has collaborated with the pharmaceutical com- panies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one-third of survivors) may exhibit posttraumatic stress disorder. Chapter 26

When providing health promotion classes, a nurse uses concepts from models of health. What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Both these models view health as a dynamic (constantly changing state). Chapter 3

The nurse has opened the sterile supplies and put on two ster- ile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: a. Keep splashes on the sterile field to a minimum. b. Cover the nose and mouth with gloved hands if a sneeze is imminent. c. Use forceps soaked in a disinfectant. d. Consider the outer 1 inch of the sterile field as contaminated.

d. Considering the outer inch of a sterile field as contami- nated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile. Chapter 23

A patient is in the late stages of AIDS, which is now affecting his brain as well other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least likely underlying etiology for his sensory problems would be: a. Stimulation b. Reception c. Transmission-perception-reaction d. Emotional responses

d. Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for his condition. This patient is receiving decreased environmental stimuli (a) (e.g., from his friends), is more than likely experiencing problems with reception because of major organ involvement (b), and his impaired brain function will impair impulse transmission- perception- reaction (c). Chapter 43

When describing safety issues and related mortality to a local senior citizens group, what would the nurse identify as the leading cause of hospital admissions for trauma in older adults? a. Fires b. Exposure to temperature extremes c. Intimate partner violence d. Falls

d. Falls among older adults are the most common cause of hospital admissions for trauma. Fires and temperature extremes are also significant hazard for older adults but are not the most common cause of trauma admissions. Intimate partner violence occurs more frequently in adults as opposed to older adults. Chapter 26

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

d. Fear is a response (feeling of dread) to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation. Chapter 41

A nurse working in a busy emergency department is caring for a teenage patient who presents with a burning pain in his mouth, edema of the lips, vomiting, and hemoptysis. The teen admits that he was playing a dare game with friends and was forced to swallow a drain opener preparation. What would be the nurse's priority intervention? a. Induce vomiting and call the primary care provider. b. Perform stomach lavage and call the poison control center. c. Give activated charcoal orally and call the physician. d. Dilute the poison with milk and call the primary care provider.

d. For the ingestion of drain opener, the nurse should never induce vomiting; instead, the poison should be diluted with milk or water and the primary care provider should be called. For vitamin preparations, stomach lavage is used to remove undigested pills and for acetaminophen poisoning, activated charcoal may be used. Chapter 26

A nurse orients an older patient to the safety features in her hospital room. What is a priority component of this admission routine? a. Explain how to use the telephone. b. Introduce the patient to her roommate. c. Review the hospital policy on visiting hours. d. Explain how to operate the call bell.

d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury. Chapter 26

Which of the following nursing diagnoses would be appropri- ate for many middle adults? a. Risk for Imbalanced Nutrition: Less Than Body Requirements b. Delayed Growth and Development c. Self-Care Deficit d. Caregiver Role Strain

d. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Chapter 19

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

d. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. Explain all procedures including sensations likely to be experienced during the procedure, and stay with the patient to promote safety and reduce fear. Chapter 41

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every three hours b. Every four hours c. Daily d. As needed

d. PRN means "as needed." Chapter 16

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

d. Reactions of family members to home health care for long periods of time, called caregiver burden, include chronic fatigue, sleep disorders, and an increased incidence of stressrelated illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker and/or arrange for respite care for the family. Chapter 41

A 76-year-old patient states, "I have been experiencing com- plications of diabetes." The nurse needs to direct the patient to gain more information. What is the most appropriate com- ment or question to elicit additional information? a. "Do you take two injections of insulin to decrease the complications?" b. "Most physicians recommend diet and exercise to regulate blood sugar." c. "Most complications of diabetes are related to neuropathy." d. "What specific complications have you experienced?"

d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques. Chapter 20

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which cat- egory of patients? a. Only patients with diagnosed infections b. Only patients with visible blood, body fluids, or sweat c. Only patients with nonintact skin d. All patients receiving care in hospitals

d. Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes. Chapter 23

What consideration should the nurse keep in mind regarding the use of side rails for a confused patient? a. They prevent confused patients from wandering. b. A history of a previous fall from a bed with raised side rails is insignificant. c. Alternative measures are ineffective to prevent wandering. d. A person of small stature is at increased risk for injury from entrapment.

d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident. Chapter 26

During rounds, a charge nurse hears the patient care techni- cian yelling loudly to a patient regarding a transfer from the bed to chair. When entering the room, what is the nurse's best response? a. "You need to speak to the patient quietly. You are disturbing the patient." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the patient care techni- cian to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic commu- nication. Chapter 20

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

d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient. Chapter 20

A nurse is caring for an obese 62-year-old patient with arthri- tis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? a. Imbalanced Nutrition: More Than Body Requirements related to immobility b. Impaired Physical Mobility related to pain and discomfort c. Chronic Pain related to immobility d. Risk for Infection related to altered skin integrity

d. The priority diagnosis in this situation is the possibility of an infection developing in the open skin area. The others may be potential or probable diagnoses for this patient and may also require nursing interventions after the first diagnosis is addressed. Chapter 23

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admis- sion interview, the nurse should implement which commu- nication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions

d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconcep- tions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open- ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for oneself and others using open, hon- est, and direct communication. Chapter 20

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

d. The use of touch conveys acceptance, and the implemen- tation of an open-ended question allows the patient time to verbalize freely. Chapter 20

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bed c. Keeping the bed in the high position d. Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alterna- tive would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall. Chapter 26

A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8 pm. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that that the patient probably is experiencing: a. Sufficient sensory stimulation b. Deficient sensory stimulation c. Excessive sensory stimulation d. Both sensory deprivation and overload

d. This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses. Chapter 43

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down. b. Hold the bottle inside the edge of the sterile field. c. Hold the bottle with the label side opposite the palm of the hand. d. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). Chapter 23

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

d. When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when he or she is leaving the room, assist with ambulation by walking slightly ahead of the person and allowing her to grasp the nurse's arm, provide diversions using other senses, and stay in the person's field of vision if she has partial or reduced peripheral vision. Chapter 43

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Activity flow sheet d. Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequen- tial recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign docu- mentation, and neither does the activity flow sheet. Chapter 16