Nur142 Exam 2 Practice Questions

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: 1. "You're correct; spiritual care should be left to a pastoral care professional." 2. "You're correct; religion is a personal decision." 3. "Nurses should explain their own religious beliefs to patients." 4. "Spiritual, mind, and body connections can affect health."

4

The nurse is administering a benzodiazepine sleep aid to an older adult. What should be the priority assessment for the patient? 1. Incontinence 2. Nausea and vomiting 3. Bradycardia 4. Respiratory depression

4

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? 1. Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. 2. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. 3. Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. 4. Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.

2

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? 1. Have patient follow hospital routines. 2. Avoid waking patient for nonessential tasks. 3. Give prescribed sleeping medications at dinner. 4. Turn television on low to late-night programming.

2

The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson's stages of development? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Autonomy versus sense of shame and doubt

2

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day

2

What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

2

What is an appropriate nursing diagnosis for an individual who experiences confusion in the mental picture of his physical appearance? 1. Acute Confusion 2. Disturbed Body Image 3. Chronic Low Self-Esteem 4. Situational Low Self-Esteem

2

What is the most common reason for calling on grandparents to raise their grandchildren? 1. Single parenthood 2. Legal interventions 3. Dual-income families 4. Increased divorce rate

2

You are caring for a 4-year-old child who is hospitalized for an infection. He tells you that he is sick because he was "bad." Which is the most correct interpretation of his comment? 1. Indicative of extreme stress 2. Representative of his cognitive development 3. Suggestive of excessive discipline at home 4. Indicative of his developing sense of inferiority

2

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows all hospital staff access to your medical record. 2. HIPAA limits the information that is documented in your medical record. 3. HIPAA provides you with greater protection of your personal health information. 4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

3

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

3

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive compulsive behavior. 2. Personal preferences. 3. The patient's cultural norm. 4. Controlling behaviors.

3

The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? 1. Rapid eye movement (REM) sleep 2. Stage 1 nonrapid eye movement (NREM) sleep 3. Stage 4 NREM sleep 4. Transition period from NREM to REM sleep

3

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? 1. Rip the papers up into small pieces and place the pieces into a standard trash can 2. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit 3. Place papers with patient information in a secure canister marked for shredding 4. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

3

Which nursing intervention is most important when caring for a patient with an ileostomy? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting or cutting a pouch with an appropriate-size stoma opening 4. Wearing sterile gloves while caring for the stoma

3

Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia? 1. Ask open-ended questions 2. Speak to the patient as if he or she is a child 3. Use a dry-erase board or paper and pen for writing messages 4. Avoid the use of gestures and other nonverbal forms of communication

3

The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? 1. Encourage the patient to rearrange her home furnishings regularly to keep active. 2. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility. 3. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. 4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.

4

The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? 1. Dementia. 2. Elder abuse. 3. Delirium. 4. Alcohol abuse.

4

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? 1. Loss of autonomy caused by health problems 2. Physical appearance, family, friends, and school 3. Self-esteem issues, changing family structure 4. Search for identity with peer groups and separation from family

4

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4

Which approach would be best for a nurse to use with a hospitalized toddler? 1. Always give several choices. 2. Set few limits to allow for open expression. 3. Use noninvasive methods when possible. 4. Establish a supportive relationship with the mother.

4

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4

Which of the following statements is most descriptive of the psychosocial development of school-age children? 1. Boys and girls play equally with each other. 2. Peer influence is not yet an important factor to the child. 3. They like to play games with rigid rules. 4. Children frequently have "best friends."

4

When doing an assessment of a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the crash whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

PTSD

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________.

Promote venous return to the heart.

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses. 2. Follow recommendations of lens manufacturer when inserting the lenses. 3. Keep lenses moist or wet when not worn. 4. Use fresh solution daily when storing and disinfecting lenses.

1

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

1

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Delirium. 2. Depression. 3. New-onset dementia. 4. Worsening dementia.

1

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Hypoglycemic reaction.

2

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? 1. Reminiscence 2. Validation therapy 3. Reality orientation 4. Body image interventions

3

Which of the following are possible outcomes with clear family communication? (Select all that apply.) 1. Family goals 2. Increased socialization 3. Decision making 4. Methods of discipline 5. Improved education 6. Impaired coping

3,4,5

Place the steps for an ostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5,8,7,2,3,4,1

Fill-in-the-Blank. Swanson's caring process of ______ is demonstrated by a nurse helping a new mother through the birthing experience.

Enabling

A family has decided to care for a grandparent with terminal cancer in the daughter's home. Family caregiving is new to the family. When helping this family as they begin to plan for their caregiving roles, what are the two top priority assessments to best learn about family functioning? (Select all that apply.) 1. Communication 2. Decision making 3. Development 4. Economic status 5. Family structure

1,2

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1,2,6,8

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1,3

During a visit to a family clinic, a nurse teaches a mother about immunizations, car-seat use, and home safety for an infant and toddler. Which type of nursing interventions are these? 1. Health promotion activities 2. Acute care activities 3. Restorative care activities 4. Growth and development care activities

1

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

1,2,5

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess patient's cognitive status.

2

A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange is an example of which element of the transactional communication process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent

2

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? 1. "Only your family can read your medical record." 2. "You have the right to read your record." 3. "Patients are not allowed to read their records." 4. "Only health care workers have access to patient records."

2

According to Piaget's cognitive theory, a 12-year-old child is most likely to engage in which of the following activities? 1. Using building blocks to determine how houses are constructed 2. Writing a story about a clown who wants to leave the circus 3. Drawing pictures of a family using stick figures 4. Writing an essay about patriotism

2

An 18-month-old child is noted by the parents to be "angry" about any change in routine. This child's temperament is most likely to be described as: 1. Slow to warm up. 2. Difficult. 3. Hyperactive. 4. Easy.

2

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

2

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?" 1. Sharing feelings about the importance of having regular woman's health examinations 2. Gaining an understanding of what a woman's health examination means to the patient 3. Recognizing that the patient is modest; and obtaining gender-congruent caregiver 4. Explaining the risk factors for cervical cancer

2

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? 1. Fidelity 2. Beneficence 3. Nonmaleficence 4. Respect for autonomy

2

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2

A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. When the nurse visits, the focus is on symptom management for the grandmother and helping the family with coping skills. This approach is an example of which of the following? 1. Family as context 2. Family as patient 3. Family as system 4. Family as structure

2

In planning nursing care for an 85-year-old male, what is the most important basic need that must be met? 1. Assurance of sexual intimacy 2. Preservation of self-esteem 3. Expanded socialization 4. Increase in monthly income

2

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, label the documentation for each task with the time that it was completed. 1. ______ Morphine 2 mg IV given for pain rating of 8/10 2. ______ Dressing changed over midline abdominal incision using aseptic technique 3. ______ Ancef 1 g given IVPB over 30 minutes.

1= 15:45 2= 17:34 3= 20:00

Label each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]). 1. ______ Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2. ______ "The pain increases every time I try to turn on my left side." 3. ______ Acute pain related to tissue injury from surgical incision. 4. ______ Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

1=P 2=S 3=A 4=O

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1A 2D 3B 4C

Match the following caring behaviors with their definitions. 1. Knowing 2. Being with 3. Doing for 4. Maintaining belief a. Sustaining faith in one's capacity to get through a situation b. Striving to understand an event as meaning for another person c. Being emotionally there for another person d. Providing for another as he or she would do for themselves

1B 2C 3D 4A

Match the examples with the professional nursing code of ethics: a. Advocacy b. Responsibility c. Accountability d. Confidentiality 1. You see an open medical record on the computer and close it so no one else can read the record without proper access. 2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure. 3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request. 4. You tell your patient that you will return in 30 minutes to give him his next pain medication.

1D 2C 3A 4B

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus

3

A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: 1. Community mouthwash. 2. Alcohol-based mouth rinse. 3. Normal saline rinses. 4. Firm toothbrush.

3

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night."

4S 1B 2A 3R

Place the steps to administering a prepackaged enema the correct order. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6,4,3,1,5,2

Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) 1. Uneven gait 2. Slumped posture and poor personal hygiene 3. Avoidance of eye contact when answering a question 4. Requests for visits from the chaplain 5. Frequent use of the call light

2,3

Which of the following cause Clostridium difficile infection? (Select all that apply.) 1. Chronic laxative use 2. Contact with C. difficile bacteria 3. Overuse of antibiotics 4. Frequent episodes of diarrhea caused by food intolerance 5. Inflammation of the bowel

2,3

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use antimicrobial toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

1,3,4

What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in correct order. 1. Clarify values. 2. Ask the question, Is this an ethical dilemma? 3. Verbalize the problem. 4. Gather information. 5. Identify course of action. 6. Evaluate the plan. 7. Negotiate a plan

2,4,1,3,5,7,6

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: 1. Presbyopia. 2. Presbycusis 3. Cataract(s). 4. Depression.

3

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness

4

Which of the following most greatly affects a family's access to adequate health care, opportunity for education, and sound nutrition? 1. Development 2. Family function 3. Family structure 4. Economic stability

4

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

4

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1,3,4

A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as, "I'm such a failure ... I can't do anything right." What is the nurse's best response? 1. Remain with the patient until he or she validates feeling more stable. 2. Tell the patient that is not true and that every person has a purpose in life. 3. Review recent behaviors or accomplishments that demonstrate skill ability. 4. Reassure the patient that you know how he is feeling and that things will get better.

1

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? 1. "CPOE reduces transcription errors." 2. "CPOE reduces the time needed for health care providers to write orders." 3. "CPOE eliminates verbal and telephone orders from health care providers." 4. "CPOE reduces the time nurses use to communicate with health care providers."

1

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? 1. Caring touch 2. Protective touch 3. Task-oriented touch 4. Interpersonal touch

1

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

1

A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase

1

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy

1

A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulation. 2. It covers a larger area of the leg. 3. It completes care in a timely fashion. 4. It prevents blood clots in legs.

1

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

1

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction

1

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement.

1

Allison, age 15 years, calls her best friend Laura and is crying. She has a date with John, someone she has been hoping to date for months, but now she has a pimple on her forehead. Laura firmly believes that John and everyone else will notice the blemish right away. This is an example of the: 1. Imaginary audience. 2. False-belief syndrome. 3. Personal fable. 4. Personal absorption syndrome.

1

An 8-year-old child is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which of the following will most help her adjust to the hospital? 1. Explain hospital routines such as mealtimes to her. 2. Use terms such as "honey" and "dear" to show a caring attitude. 3. Explain when her parents can visit and why siblings cannot come to see her. 4. Since she is young, orient her parents to her room and hospital facility.

1

An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. The nurse's approach should be based on an understanding of which of the following? 1. Patients need support in dealing with the loss of a body part. 2. The patient's family should take the lead role in providing support. 3. The nurse should explain that breast tissue is not essential to life. 4. The patient should focus on the cure of the cancer rather than loss of the breast.

1

At a well-child examination, the mother comments that her toddler eats little at mealtime, will only sit briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend? 1. Provide nutritious snacks. 2. Offer rewards for eating at mealtimes. 3. Avoid snacks so she is hungry at mealtime. 4. Explain to her firmly why eating at mealtime is important.

1

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What is your priority nursing intervention? 1. Stop the instillation 2. Ask the patient to take deep breaths to decrease the pain 3. Add soapsuds to the enema 4. Tell the patient to bear down as he would when having a bowel movement

1

In an interview with a pregnant patient, the nurse discussed the three risk factors that have been cited as having a possible effect on prenatal development. They are: 1. Nutrition, stress, and mother's age. 2. Prematurity, stress, and mother's age. 3. Nutrition, mother's age, and fetal infections. 4. Fetal infections, prematurity, and placenta previa.

1

On the basis of knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will: 1. Increase his self-esteem with mastery of a new skill. 2. Accept changes in his appearance and physical endurance. 3. Experience success in role transitions and increased responsibilities. 4. Appreciate his body appearance and function.

1

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following best describes the role of the nurse in the resolution of ethical dilemmas? 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. 2. To study the literature on current research about the possible clinical interventions available for the patient in question. 3. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal opinion. 4. To allow the patient and the physician to resolve the dilemma on the basis of ethical principles without regard to personally held values or opinions.

1

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of: 1. Object permanence. 2. Sensorimotor play. 3. Schemata. 4. Magical thinking.

1

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: 1. Instilling hope and faith. 2. Forming a human-altruistic value system. 3. Cultural caring. 4. Being with.

1

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? 1. Fidelity 2. Beneficence 3. Nonmaleficence 4. Respect for autonomy

1

When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to: 1. Form a sense of identity. 2. Create intimate relationships. 3. Separate from parents and live independently. 4. Achieve positive self-esteem through experimentation.

1

When nurses are communicating with adolescents, they should: 1. Be alert to clues to their emotional state. 2. Ask closed-ended questions to get straight answers. 3. Avoid looking for meaning behind adolescents' words or actions. 4. Avoid discussing sensitive issues such as sex and drugs.

1

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? 1. Results in neurophysiological response 2. Reduces body temperature 3. Causes a person to be hypervigilant 4. Reduces level of consciousness to conserve energy.

1

Which patient is most likely to experience sensory overload? 1. A patient in the intensive care unit whose pain is not well controlled 2. A patient with a protective patch on her right eye following cataract surgery 3. A woman whose hearing aids were lost when she transferred to a long-term care facility 4. A visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities

1

Which statement made by the parent of a school-age child requires follow-up by the nurse? 1. "I encourage evening exercise about an hour before bedtime." 2. "I offer my daughter a glass warm milk before bedtime." 3. "I make sure that the room is dark and quiet at bedtime." 4. "We use quiet activities such as reading a book before bedtime."

1

You are caring for a recently retired man who appears withdrawn and says he is "bored with life." Applying the work of Havinghurst, you would help this individual find meaning in life by: 1. Encouraging him to explore new roles. 2. Encouraging relocation to a new city. 3. Explaining the need to simplify life. 4. Encouraging him to adopt a new pet.

1

A new immigrant family consisting of a grandparent, two adults, and three school-age children has decided to receive their health promotion care at the Community Wellness Center. This is their first visit, and a family assessment, a health history, and a physical of each family member are needed. Which of the following are included in a family function assessment? (Select all that apply.) 1. Cultural practices 2. Decision making 3. Neighborhood services 4. Rituals and celebrations 5. Neighborhood crime data 6. Availability of parks

1,2,4

A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of Situational Low Self-Esteem. Which of the following nursing interventions would be appropriate to address self-esteem? (Select all that apply.) 1. Offer independent decision-making opportunities. 2. Review previously successful coping strategies. 3. Provide a quiet environment with minimal stimuli. 4. Support a dependent role throughout treatment. 5. Increase calorie intake to promote weight stabilization.

1,2

Which of the following are examples of the conventional reasoning form of cognitive development? (Select all that apply.) 1. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. 2. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son. 3. A teenage girl is encouraged by her peers to engage in shoplifting. She decides not to join her peers in this activity because she is afraid of getting caught in the act. 4. A single mother of two children is unhappy with her employer. She has been unable to secure alternate employment but decides to quit her current job.

1,2

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."

1,2,3

The nurse can increase a patient's self-awareness through which of the following actions? (Select all that apply.) 1. Helping the patient define her problems clearly 2. Allowing the patient to openly explore thoughts and feelings 3. Reframing the patient's thoughts and feelings in a more positive way 4. Having family members assume more responsibility during times of stress 5. Recommending self-help reading materials

1,2,3

Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? (Select all that apply.) 1. Giving the patient a backrub 2. Turning on quiet music 3. Dimming the lights in the patient's room 4. Giving a patient a cup of coffee 5. Monitoring for the effect of the sleeping medication that was given

1,2,3

Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine if the ostomy is healing appropriately

1,2,3,5

A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she likes. Which of the following contribute to this family's hardiness? (Select all that apply.) 1. Family meetings 2. Established family roles 3. New neighborhood 4. Willingness to change in time of stress 5. Passive orientation to life

1,2,4

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the earmold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.

1,2,4

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. Which of the following are true about work-related stress? (Select all that apply.) 1. Job-related stress can affect the quality of patient care. 2. Stress can affect nurses' efficiency and decision making. 3. Nurses who talk about feeling stress are unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in health care technology. 5. Nurses cannot resolve job-related stress.

1,2,4

Which of the following activities are examples of the use of activity theory in older adults? (Select all that apply.) 1. Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state 2. Introducing golf as a new hobby 3. Leading a group walk of older adults each morning 4. Engaging an older adult in a community project with a short-term goal 5. Directing a community play at the local theater

1,2,4

Which of the following properly applies an ethical principle to justify access to health care? (Select all that apply.) 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability. 6. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1,2,4

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) 1. The patient's name, age, and admitting diagnoses 2. The discussion of any allergies to food and medications that the patient has 3. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" 4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol 5. Description of any unresolved problems and current interventions in place

1,2,4,5

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help. 5. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

1,2,5

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? (Select all that apply.) 1. Ethics of care pays attention to the environment in which caring occurs. 2. Ethics of care pays attention to the stories of the people involved in the ethical issue. 3. Ethics of care is used only in nursing practice. 4. Ethics of care focuses only on the code of ethics for nurses 5. Ethics of care focuses only on understanding relationships.

1,2,5

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1,3

A crisis intervention nurse is working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in special-school classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1,3,4

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Teaching how activities such as reading and using crossword puzzles provide stimulation 2. Moving him to a room away from the nurse's station 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions 5. Providing auditory stimulation for the patient by keeping the television on continuously

1,3,4

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool

1,3,4

Which of the following are possible outcomes with clear family communication? (Select all that apply.) 1. Family goals 2. Increased socialization 3. Decision making 4. Methods of discipline 5. Improved education 6. Impaired coping

1,3,4

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

1,3,5

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1,3,5

You are caring for a family that consists of a father and 3-year-old boy who has well-managed asthma but misses care infrequently. They live in state-supported housing. The father is in school studying to be an information technology professional. His income and time are limited, and he admits to going to fast-food restaurants frequently for dinner. However, he and his son spend a lot of time together. The family receives state-supported health care for his son, but he does not have health insurance or a personal physician. He has his son enrolled in a government-assisted day care program. Which of the following are risks to this family's level of health? (Select all that apply.) 1. Economic status 2. Chronic illness 3. Underinsured 4. Government-assisted day care 5. Frequency of fast-food dinners 6. State-supported housing

1,3,5

A family is undergoing a major change. Just as twins graduate from college and leave home to begin their careers, the husband loses his executive well-paying job. Because the family had two children in college at the same time, they did not save for retirement. They planned to save aggressively after the children left college. In this situation, which of the following demonstrate family resiliency? (Select all that apply.) 1. Resuming full-time work when spouse loses job 2. Increasing problems among siblings 3. Developing hobbies when children leave home 4. Placing blame on family members 5. Expecting children to help financially 6. Consulting a financial planner

1,3,6

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination if the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1,4

A school nurse is counseling an obese 10-year-old child. Which factors would be important to consider when planning an intervention to support the child's health? (Select all that apply.) 1. Consider both the child and the family when addressing the issue. 2. Consider the use of medications to suppress the appetite. 3. First plan for weight loss through dieting and then add activity as tolerated. 4. Plan food intake to allow for growth. 5. Consider consulting a bariatric surgeon if other measures fail.

1,4

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1,4

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) 1. Dentures do not always fit properly. 2. Most older adults have an increase in saliva secretions. 3. With aging the periodontal membrane becomes tighter and painful. 4. Many older adults are edentulous, and remaining teeth are often decayed. 5. The teeth of elderly patients are more sensitive to hot and cold.

1,4

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) 1. Documents a medication given by another nursing student. 2. Includes the date and time of the entry into the medical record. 3. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. 4. Leaves a slip of paper with her user name and password in the patient's room. 5. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

1,4

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1,4,5

A nurse demonstrated caring by helping family members to: (Select all that apply.) 1. Become active participants in care. 2. Remove themselves from personal care. 3. Make health care decisions for the patient. 4. Have uninterrupted time for family and patient to be together. 5. Have opportunities for the family to discuss their concerns.

1,4,5

A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

1,4,5

The nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat the large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil (Provigil).

1,4,5

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high-school students. Which points should be included in the education? (Select all that apply.) 1. Go to bed at the same time each night. 2. Study in your bedroom to have a quiet place. 3. Turn on the television to help you fall asleep. 4. Avoid drinking coffee or soda before bedtime. 5. Turn off your cell phone at bedtime.

1,4,5

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1,4,6

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet 2. Use a low-volume enema daily 3. Avoid gluten in the diet 4. Take laxatives twice a day 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day 7. Take probiotics 5 times a week

1,5,6

Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.

1,5,7,6,3,2

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member

2,3

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) 1. Prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

2,3

Which of the following nursing actions do you take after placing a bedpan under an immobilized patient? 1. Lift the patient's hips off the bed and slide the bedpan under the patient 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

2

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? 1. "I'll give the baby a bottle to help her fall asleep." 2. "We'll place the baby on her back to sleep." 3. "We put the baby's stuffed animals in the crib to make her feel safe." 4. "I know the baby will not need to be fed until morning."

2

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because these can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

2

Several staff members complain about an adult patient's constant questions such as, "Should I have a cup of coffee or a cup of tea?" and "Should I take a shower now or wait until later?" Which interpretation of the patient's behavior helps the nurses provide optimal care? 1. Asking questions is attention-seeking behavior. 2. Inability to make decisions reflects a self-concept issue. 3. Dependence on staff must be stopped immediately. 4. Indecisiveness is aimed at testing how the staff reacts.

2

The nurse asks the patient, "How do you feel about yourself?" The nurse is assessing the patient's: 1. Identity. 2. Self-esteem. 3. Body image. 4. Role performance.

2

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. Checking distal pulses 2. Providing range-of-motion (ROM) exercises to extremities 3. Determining type of treatment for stage 1 pressure ulcer 4. Changing the dressing over an intravenous site

2

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? 1. The nurse caring for the patient forgot to document on the pulmonary system. 2. The EMR uses a charting-by-exception format. 3. The computer shut down unexpectedly when the nurse was documenting the assessment. 4. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

2

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F).

2,1,4,3

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs. 4. Stand one step ahead of mom at the top of the stairs. 5. Place yourself alongside your mom and hold onto her waist.

2,3

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning.

2,3

A family has decided to care for their father who is in the last stages of a debilitating neurological illness. Although he is alert, he cannot speak clearly or carry out self-care activities; he indicates that he wants to remain involved in family life as long as possible and loves spending time with his wife and two teenage children. Which best defines family caregiving? (Select all that apply.) 1. Designing a nurturing family to raise children 2. Providing physical and emotional care for a family member 3. Establishing a safe physical environment for a family 4. Monitoring for side effects of illness and treatments 5. Reducing the use of community resources

2,3,4

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2,3,4

A nurse is providing information on prevention of sudden infant death syndrome (SIDS) to the mother of a young infant. Which of the following statements indicates that the mother has a good understanding? (Select all that apply.) 1. "I won't use a pacifier to help my baby sleep." 2. "I'll be sure that my baby doesn't spend any time sleeping on her abdomen." 3. "I'll place my baby on her back for sleep." 4. "I'll be sure to keep my baby's room cool." 5. "I'll keep a crib bumper in the bed to prevent drafts."

2,3,4

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication

2,3,4

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

2,3,4

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm, incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Indirect lighting to reduce glare

2,3,4

It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? (Select all that apply.) 1. Average income varies in different regions of the country. 2. Community values influence definitions of quality, and they are subject to change over time. 3. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 4. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 5. Statistical analysis is difficult to apply when the outcome cannot be quantified. 6. Whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life.

2,3,4,5

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.) 1. Yell so the patient can hear you. 2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 4. Send a written copy of the instructions home with him and tell him to have the family review them. 5. Include the family caregiver in the teaching session.

2,3,5

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2,3,5

The nurse is providing health teaching for a patient using herbal compounds such as kava for sleep. Which points need to be included? (Select all that apply.) 1. Can cause urinary retention 2. Should not be used indefinitely 3. May have toxic effects on the liver 4. May cause diarrhea and anxiety 5. Are not regulated by the U.S. Food and Drug Administration (FDA)

2,3,5

An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the body

2,4

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2,4

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2,4

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "Let me help you two calm down a bit so I can take you to your daughter."

2,4,3,1

A patient with type 2 diabetes is experiencing a lot of work-related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, and his doctors want him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? (Select all that apply.) 1. Increases in antidiuretic hormone (ADH) 2. Increases in cortisol 3. Increases in aldosterone 4. Increases in adrenocorticotropic hormone (ACTH) 5. Increases in epinephrine

2,4,5

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

2,4,5

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.

2,5,1,3,6,4

What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment? 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks 2. Use diapers and heavy padding on the bed 3. Initiate bowel or habit training program to promote continence 4. Help the patient to toilet once every hour

3

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3

Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand

3

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? 1. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." 2. "Sleep medicines won't cause any sleep problems once I stop taking them." 3. "I'll talk to my health care provider before I use an over-the-counter sleep medication." 4. "I'll contact my health care provider if I feel extremely sleepy in the mornings."

3

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient who prefers a bath in the evening when his wife visits and can help him 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

3

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis.

3

A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better

3

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? 1. Caring touch 2. Protective touch 3. Task-oriented touch 4. Interpersonal touch

3

A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? 1. The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. 2. The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. 3. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. 4. The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.

3

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Are your bowel movements soft and formed? 3. Have you experienced frequent, small liquid stools recently? 4. Have you taken antibiotics recently?

3

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3

A parent has brought her 6-month-old infant in for a well-child check. Which of her statements indicates a need for further teaching? 1. "I can start giving her whole milk at about 12 months." 2. "I can continue to breastfeed for another 6 months." 3. "I've started giving her plenty of fruit juice as a way to increase her vitamin intake." 4. "I can start giving her solid food now."

3

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident."

3

A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse

3

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: 1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. 2. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. 3. Gives a newly ordered medication before entering the order in the patient's medical record. 4. Asks the preceptor to listen in on the phone conversation.

3

An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? 1. Talk to the patient at a distance so he or she may read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so the light is on his or her face when speaking.

3

Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: 1. Avoid activities in which there may be crowds. 2. Delay childhood immunizations until hearing can be verified. 3. Take precautions when involved in activities associated with high-intensity noises. 4. Prophylactically administer antibiotics to reduce the incidence of infections.

3

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? 1. Nurses understand the principle of autonomy to guide respect for a patient's self-worth. 2. Nurses have a scope of practice that encourages their presence during ethical discussions. 3. Nurses develop a relationship with the patient that is unique among all professional health care providers. 4. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

3

Nine-year-old Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in: 1. A sense of guilt. 2. A poor sense of self. 3. Feelings of inferiority. 4. Mistrust.

3

Of the five caring processes described by Swanson, which describes "knowing the patient?" 1. Anticipating the patient's cultural preferences 2. Determining the patient's physician preference 3. Establishing an understanding of a specific patient 4. Gathering task-oriented information during assessment

3

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

3

Parents are concerned about their toddler's negativism. To avoid a negative response, which of the following is the best way for a nurse to demonstrate asking the toddler to eat his or her lunch? 1. Would you like to eat your lunch now? 2. When would you like to eat your lunch? 3. Would you like apple slices or applesauce with your sandwich? 4. Would you like to sit at the big table to eat?

3

Presence involves a person-to-person encounter that: 1. Enables patients to care for self. 2. Provides personal care to a patient. 3. Conveys a closeness and a sense of caring. 4. Describes being in close contact with a patient.

3

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? 1. Yes, because patient privacy would not be violated since patient identifiers were removed 2. Yes, because respect for autonomy implies that you have the autonomy to decide what constitutes privacy 3. No, because, even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work 4. No, because the principle of justice requires you to allocate resources fairly

3

The Collins family includes a mother; stepfather, two teenage biological daughters of the mother; and a 25-year-old biological daughter of the father. The father's daughter just moved home following the loss of her job in another city. The family is converting a study into Stacey's bedroom and is in the process of distributing household chores. When you talk to members of the family, they all think that their family can adjust to lifestyle changes. This is an example of family: 1. Diversity. 2. Durability. 3. Resiliency. 4. Configuration.

3

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry

3

The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is appropriate to include on the plan? 1. Instruct the patient to sleep in a supine position. 2. Have patient limit fluid intake 2 hours before bedtime. 3. Elevate head of bed and assume a side or prone position. 4. Encourage patient to take an over-the-counter sleep aid.

3

You are working in an adolescent health center when a 15-year-old patient shares with you that she thinks she is pregnant and is worried that she may now have a sexually transmitted infection (STI). Her pregnancy test is negative. What is your next priority of care? 1. Contact her parents to alert them of her need for birth control. 2. Refer her to a primary health care provider to obtain a prescription for birth control. 3. Counsel her on safe sex practices. 4. Ask her to have her partner come to the clinic for sexually transmitted infection testing.

3

A 30-year-old patient diagnosed with major depressive disorder has a nursing diagnosis of Chronic Low Self-Esteem related to negative view of self. Which of the following would be appropriate interventions by the nurse? (Select all that apply.) 1. Encourage reconnecting with high school friends 2. Role play to increase assertiveness skills 3. Focus on identifying strengths and accomplishments 4. Provide time for journaling to explore underlying thoughts and feelings 5. Explore new job opportunities

3,4

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

3,4

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

3,4

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair.

3,4,2,1,5

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

3,4,5

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. Which of the following statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3,5

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal 5. Depression

3,5

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? (Select all that apply.) 1. Decreasing the number of consecutive shifts of the nursing staff 2. Increasing salary and vacation benefits of the nursing staff 3. Increasing the number of nurses who work each shift to decrease the nurse-patient ratio 4. Encouraging increased input concerning nursing functions from health care providers 5. Providing nursing staff an opportunity to discuss practice changes they can implement to enhance opportunities for patient caring

3,5

Place the following stages of Freud's psychosexual development in the proper order by age progression. 1. Oedipal 2. Latency 3. Oral 4. Genital 5. Anal

3,5,2,1,4

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: 1. Making health care decisions for patients. 2. Having family members provide a patient's total personal hygiene. 3. Injecting the nurse's perceptions about the level of care provided. 4. Asking permission before performing a procedure on a patient.

4

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "What do you mean when you say you can't go on any longer?"

4

A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? 1. "What's the special occasion?" 2. "You must be feeling better today." 3. "This is the first time I've seen you look this good." 4. "I see that you've combed your hair and put on makeup."

4

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? 1. "Avoid rushing when documenting an entry in the medical record." 2. "Use correction fluid to remove the entry." 3. "Draw a single line through the statement and initial it." 4. Enter only objective and factual information about a patient in the medical record.

4

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: 1. She does not touch the patients either. 2. Touch is a type of verbal communication. 3. Touch is only used when a patient is in pain. 4. Touch forms a connection between nurse and patient.

4

A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility

4

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line 3. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

4

A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed? 1. "I am at risk for injury from temperature extremes." 2. "I may be able to dress more easily with zippers or pullover sweaters." 3. "A home care nurse may help me figure out how to be more independent." 4. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

4

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? 1. Tell the student that temporary confusion is normal and simply requires reorientation 2. Tell the student to increase the patient's fluid intake since the urine is concentrated 3. Tell the student that her assessment findings are normal for an older adult 4. Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

4

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation

4

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? 1. Seeking out the nursing supervisor to talk with the patient 2. Documenting patient fears in the medical record in a timely manner 3. Working to change the hospital environment 4. Assessing the patient's point of view and preparing to articulate it

4

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? 1. "The patient has a defiant attitude and is demanding test results." 2. "The patient appears to be upset with the nurse because he wants his test results immediately." 3. "The patient is demanding and is complaining about the doctor." 4. "The patient stated feelings of frustration from the lack of information received regarding test results."

4

Dave reports being happy and satisfied with his life. What do we know about him? 1. He is in one of the later developmental periods, concerned with reviewing his life. 2. He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives. 3. He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships. 4. It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.

4

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent: 1. Imaginary audience. 2. False-belief syndrome. 3. Personal fable. 4. Sense of invulnerability.

4

In viewing the family as context, what is the primary focus? 1. Family members within a system 2. Family process and relationships 3. Family relational and transactional concepts 4. Health needs of an individual member

4

Listening is not only "taking in" what a patient says, but it also includes: 1. Incorporating the views of the physician. 2. Correcting any errors in the patient's understanding. 3. Injecting the nurse's personal views and statements. 4. Interpreting and understanding what the patient means.

4

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Physical changes usually do not affect sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? 1. When the sexual partner passes away, the survivor no longer feels sexual. 2. A decrease in an older adult's libido occurs. 3. Any outward expression of sexuality suggests that the older adult is having a developmental problem. 4. All older adults, whether healthy or frail, need to express sexual feelings.

4

The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks' post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? 1. Self-Care Deficit, Toileting 2. Deficient Knowledge Regarding Resources for the Visually Impaired 3. Disturbed Body Image 4. Risk for Situational Low Self-Esteem

4

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of: 1. Logical reasoning. 2. Egocentrism. 3. Concrete thinking. 4. Animism.

4

The type of injury to which a child is most vulnerable at a specific age is most closely related to which of the following? 1. Provision of adult supervision 2. Educational level of the parent 3. Physical health of the child 4. Developmental level of the child

4

Two single mothers are active professionals and have teenage daughters. They also have busy social lives and date occasionally. Three years ago they decided to share a house and housing costs, living expenses, and child care responsibilities. The children consider one another as their family. What type of family form does this represent? 1. Diverse family relationship 2. Blended family relationships 3. Extended family relationship 4. Alternative family relationship

4

When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure 2. Pneumonia 3. Arthritis 4. Thrombocytopenia

4

When caring for an 87-year-old patient, the nurse needs to understand that which of the following most directly influences the patient's current self-concept? 1. Attitude and behaviors of relatives providing care 2. Caring behaviors of the nurse and health care team 3. Level of education, economic status, and living conditions 4. Adjustment to role change, loss of loved ones, and physical energy

4

When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use? 1. Allowing the child to watch another child undergoing the same procedure 2. Showing the child pictures of what he or she will experience 3. Talking to the child in simple terms about what will happen 4. Preparing the child through play with a doll and toy medical equipment

4

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

Which of the following documentation entries is most accurate? 1. "Patient walked up and down hallway with assistance, tolerated well." 2. "Patient up, out of bed, walked down hallway and back to room, tolerated well." 3. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." 4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

4

Which statement made by the patient indicates a need for further teaching on sleep hygiene? 1. "I'm going to do my exercises before I eat dinner." 2. "I'm going to go to bed every night at about the same time." 3. "I set my alarm to get up at the same time every morning." 4. "I moved my computer to the bedroom so I could work before I go to sleep."

4

Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4

Sequence the skills in the expected order of gross-motor development in an infant beginning with the earliest skill: 1. Move from prone to sitting unassisted 2. Sit down from standing position 3. Sit upright without support 4. Roll from abdomen to back 5. Can turn from side to back

4,3,1,2

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place waterproof bag near bed. 5. Position angiocatheter over wound.

4,3,2,5,1

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which of the following are appropriate responses or actions of the nurse? (Select all that apply.) 1. "I know another patient whose colon cancer was cured by surgery." 2. Straighten the patient's bed and room 3. "Have you thought about how you are going to tell your family?" 4. "Would you like for me to sit down with you for a few minutes so you can talk about this?" 5. Sit quietly with the patient

4,5

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma? 1. List the actions that could be taken to resolve the dilemma. 2. Agree on a statement of the problem or dilemma that you are trying to resolve. 3. Agree on a plan to evaluate the action over time. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. 5. Take time to clarify values and distinguish between facts and opinions—your own and those of others involved. 6. Negotiate a plan.

4,5,2,1,6,3

Fill in the Blank. While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider's offices over the past 6 months. This type of feature is most common in a(n) __________________________.

Electronic Health Record

Name the three important dimensions to consistently measure to determine wound healing.

Width, length, and depth.

Fill in the Blank. The point of the ethical practice is an agreement to reassure the public that in all ways the health care team not only works to heal patients but agrees to do this in the least painful and harmful way possible. This principle is commonly called the principle of ________?

non maleficence

You are working in a clinic that provides services for homeless people. The current local regulations prohibit providing a service that you believe is needed by your patients. You adhere to the regulations but at the same time are involved in influencing authorities to change the regulation. This action represents ___________ stage of moral development.

social contract interaction