ADULT HEALTH - ENDOCRINE

Question 1

You are caring for a substance-abusing client who is chemically dependent and in severe pain. Which of the following medications would be the drug of choice for this client?

A. Methadone

B. Amitriptlyine

C. Nalbuphine

D. Talwin

Answer 1

Explanation

Correct Answer is C

Correct. Nalbuphine, an opioid agonist-antagonist, is used for severe pain and it should be used with caution among clients with a history of drug or substance abuse, however, of all the choices above nalbuphine is the only medication that is appropriate for severe pain and not one, like Talwin, is contraindicated for a substance-abusing client who is chemically dependent at the current time.

Choice A is incorrect. Methadone is not used for the management of pain, methadone is used for the treatment of opioid addiction to prevent withdrawal and withdrawal syndrome.

Choice B is incorrect. Amitriptyline, which is a tricyclic antidepressant medication, is used for pain management, however, amitriptyline is not used alone to manage severe pain; amitriptyline is an adjuvant medication used in combination with an opioid analgesic to potentiate the effects of the opioid analgesic.

Choice D is incorrect. Talwin would be the drug of choice for a substance-abusing client who is chemically dependent and in severe pain. Talwin must be avoided for clients who are chemically dependent because it could lead to withdrawal and withdrawal syndrome.

Reference: McCuistion, Linda E., Joyce LeFever Kee , and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 2

You are the charge nurse in the nursing care unit today. As you are preparing the assignments for the team members on the group, which of the following legal documents must you consider when you are writing up the tasks for the day?

A. The competency checklists for all of the team members on the unit

B. The job descriptions of all of the team members on the unit

C. The American Nurses Association’s scopes of practice for RNs and LPNs

D. The state’s scopes of practice for RNs, LPNs and unlicensed assistive personnel

Answer 2

Explanation

Correct Answer is D.The state’s scopes of practice for RNs, LPNs, and unlicensed assistive personnel are the legal documents that you must you consider when you are writing up the assignments for the day because the state laws about the differentiated practice of members of the nursing team outline what the RNs, LPNs, and unlicensed assistive personnel are legally permitted to do.

Although you would also consider the job descriptions and competency checklists, these documents are not legal documents. Lastly, the American Nurses Association does not publish legal documents about the differentiated practice of members of the nursing team.

Choice A is incorrect. Although the competency checklists for all of the team members on the unit are considered when writing up assignments for the day, competency checklists are not legal documents.

Choice B is incorrect. Although the job descriptions for all of the team members on the unit are considered when writing up assignments for the day, job descriptions are not legal documents.

Choice C is incorrect. The American Nurses Association does not publish legal documents about the differentiated practice of members of the nursing team.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Sommer, Johnson, Roberts, Redding, and Churchill. (2013) Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 3

Which of the following is an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve?

A. The client will not experience sensory overload in the hospital.

B. The client will list ways to effectively decrease their blood pressure.

C. The client will participate in physical therapy to improve balance.

D. The client will remain free of falls despite 2nd cranial nerve impairment.

Answer 3

Explanation

Correct Answer is D

Correct. “The client will remain free of falls despite 2nd cranial nerve impairment” is an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve; visual deficits place clients at risk for falls.

Choice A is incorrect. “The client will not experience sensory overload in the hospital” is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits place clients at risk for sensory deprivation in the hospital, rather than sensory overload.

Choice B is incorrect. “The client will list ways to effectively decrease their blood pressure” is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits are not associated with hypertension.

Choice C is incorrect. “The client will participate in physical therapy to improve balance” is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits are not corrected with physical therapy, but instead with low vision specialists and other members of the ophthalmology team.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 4

Which term is synonymous with analgesic?

A. Equianalgesic

B. Placebo

C. NSAID

D. Adjuvant

Answer 4

Explanation

Correct Answer is D

Correct. The term that is synonymous with analgesics is adjuvant. Coanalgesic drugs, or adjuvant drugs, are analgesic medications that can be used alone or in combination with other analgesics to relieve pain.

Choice A is incorrect. Equianalgesic is not synonymous with analgesic; equianalgesic is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine.

Choice B is incorrect. Placebo is not synonymous with analgesic; a placebo is an

oral sugar pill or normal saline that may have an effect that is not related to the properties and composition of the placebo.

Choice C is incorrect. NSAIDs are not synonymous with analgesic; NSAIDs are nonsteroidal anti-inflammatory drugs.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 5

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. The first thing that you should do for this client is to:

A. Assess their current psychosocial functioning.

B. Generate a nursing diagnosis.

C. Establish trust with the client.

D. Allow the client to ventilate their feelings.
V

Answer 5

Explanation

Correct Answer is C

Correct. The first thing that you should do for this client is to establish trust with the client. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client and their current psychosocial functioning, which is then used to generate a nursing diagnosis that is specific to the client’s needs.

Choice A is incorrect. Although the nurse will assess the client and their current psychosocial functioning, this cannot be done until other phases of the nursing process, and the therapeutic nurse-client relationship is done.

Choice B is incorrect. A nursing diagnosis is not established until other phases of the nursing process, and the therapeutic nurse-client relationship is done.

Choice D is incorrect. Although it is necessary to encourage, facilitate, and allow the client to ventilate their feelings, this cannot be done until something else in terms of the therapeutic nurse-client relationship must be done.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 6

Select the therapeutic communication technique that is accurately paired with an example of it.

A. Reflecting: “I really believe that you should not be thinking in this self destructive and self-deprecating manner”

B. Seeking clarification: “I am sorry. Could you restate that thought so I can be clear about what you are saying”

C. Offering of self: “I am here to talk with you about your fears because you have refused to talk about these before”

D. Probing: “It is now time for you to start telling me about your substance abuse problem without further delay.”

Answer 6

Explanation

Correct Answer is B

Correct. “I am sorry. Could you restate that thought so I can be clear about what you are saying” is an example of seeking clarification, which is a therapeutic communication technique? Seeking clarification aims to ensure that the receiver of the message is precise and clear about the meaning of the sender’s word.

Choice A is incorrect. “I believe that you should not be thinking in this self-destructive and self-deprecating manner” is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should allow the client to ventilate these feelings and then attempt to work with the client to resolve these feelings.

Choice C is incorrect. “I am here to talk with you about your fears because you have refused to talk about these before” is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should offer self and allow the client to ventilate their fears and concerns in an environment of openness, trust, caring, and compassion.

Choice D is incorrect. “It is now time for you to start telling me about your substance abuse problem without further delay” is not at all a therapeutic communication technique. It is highly authoritative, judgmental, and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should not probe the client but, instead, allow the client to ventilate about their substance abuse problem in an environment of openness, trust, caring, and compassion.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 7

Select the diet that would most likely be ordered for a client who is edentulous?

A. A low sodium diet to prevent edema and excessive fluid

B. A mechanical soft diet to facilitate mastication

C. A renal diet to prevent fluid retention and edema

D. A high fiber diet to prevent constipation secondary to edema

Answer 7

Explanation

Correct Answer is B

Correct. A mechanical soft diet to facilitate mastication would most likely be ordered for a client who is edentulous. This diet would help the client who is without teeth, or edentulous, to chew, or gnaw, their food with their gums. Other diets do not meet this nutritional and safe eating need.

Choice A is incorrect. A low sodium diet to prevent edema and excessive fluid is indicated for clients affected with edema, renal disease, and heart disease, but not edentulous clients.

Choice C is incorrect. A renal diet to prevent fluid retention and edema is indicated for clients affected with renal disease and kidney failure, but not edentulous clients.

Choice D is incorrect. A high fiber diet is indicated for clients at risk for and constipated, but it is not indicated for clients who are edentulous.

Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.

Question 8

Which of the following is (are) concepts or constructs associated with cultural competence? Select all that apply.

A. Cultural obedience

B. Cultural skills

C. Cultural encounters

D. Cultural desire

E. Cultural awareness

F. Cultural knowledge

Answer 8

Explanation

Correct Answers: B, C, D, E, and F.The five concepts or constructs associated with cultural competence are cultural skills, cultural encounters, cultural desire, cultural awareness, and cultural knowledge. These five concepts put forth by Campinha-Bacote underscore the need for nurses and other healthcare providers to develop the knowledge, skills, and abilities to provide culturally competent care to individuals, families, and the community.

Cultural obedience is NOT one of the five concepts of constructs associated with cultural competence.

Choice A is incorrect. Cultural obedience is NOT one of the concepts or constructs associated with cultural competence.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 9

You are serving as the preceptor for a new graduate nurse. This unique graduate nurse is caring for a small group of adult clients under your supervision. Your tour of duty is 8 hours, and the intake and output of clients are calculated and documented at the end of the shift. The new graduate nurse reports a total urinary production of 150 MLS from the urinary drainage bag for your 58-year-old male postoperative client at the end of your shift. What should you do?

A. Simply record the urinary output according to your facility’s policy and procedure.

B. Simply report this urinary output to the oncoming shift as part of your “hand off” report.

C. Call the doctor to report this urinary oliguria and initiate hourly urinary output measurements.

D. Call the doctor and report this urinary output as part of your daily doctor’s update.

Answer 9

Explanation

Correct Answer is C

Correct. You would call the doctor to report this urinary oliguria and initiate hourly urinary output measurements because 150 MLS over 8 hours, which is less than 19 mL per hour and less 450 MLS for 24 hours. This output is considered oliguria because the expected urinary production for an adult client is about 1,500 mL per day. Additionally, a urinary output of less than 19 mL per hour is a significant finding that can indicate a severe medical problem; therefore, the doctor must be notified immediately.

Choice A is incorrect. You would not merely record the urinary output according to your facility’s policy and procedure; there is something else that you must do in addition to this recording and documentation.

Choice B is incorrect. You would not merely report this urinary output to the oncoming shift as part of your “hand-off” report; there is something else that you must do in addition to this reporting.

Choice D is incorrect. You would not call the doctor and report this urinary output as part of your daily doctor’s update; there is another reason why you would call the doctor.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 10

Which of the following is NOT typically integrated into an environment that is planned and maintained to support milieu therapy?

A. Negative reinforcement with the use of seclusion

B. Consistent routines

C. Consistent boundaries

D. Positive reinforcement with giving privileges

Answer 10

Explanation

Correct Answer is A

Correct. Negative reinforcement with the use of seclusion is strictly prohibited, according to the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations. Restraints and privacy are never used for punishment or negative reinforcement. They are used only to protect the client and others from harm when all other preventive measures have been deemed ineffective to protect the client and others from damage.

Choice B is incorrect. Consistent routines are an integral part of the environment that is planned and maintain to support milieu therapy. A milieu environment is planned and maintained in a manner that eliminates all possible stressors, including the lack of consistency of routines, so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than extraneous stressors, such as the inconsistencies that have been eliminated from the environment of care.

Choice C is incorrect. Consistent boundaries are an integral part of the environment that is planned and maintain to support milieu therapy. A milieu environment is planned and maintained in a manner that eliminates all possible stressors, including the lack of consistency of routines, so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than extraneous stressors, such as the inconsistencies that have been eliminated from the environment of care.

Choice D is incorrect. Positive reinforcement and rewards include giving privileges, and this is an integral part of the environment that is planned and maintained to support milieu therapy.

Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education.

Question 11

Which statement about the normal changes of the aging process is accurate?

A. The progression of dementia continues to worsen as the person ages.

B. The elderly are at risk for skin tears secondary to thinning of the skin.

C. The aging person ‘s developmental task is industry versus inferiority.

D. Maslow’s theory of aging explains how the aging body ages.

Answer 11

Explanation

Correct Answer is B. The elderly are at risk for skin tears secondary to the thinning of the skin, as occurs as part of the normal aging process.

It is NOT accurate to state that the progression of dementia continues to worsen as the person ages because NOT all people have dementia, and dementia is not a normal part of the aging process. The aging person ‘s developmental task is integrity versus despair and not industry versus inferiority. And, lastly, Maslow has the Hierarchy of Human Needs and not a theory of aging that explains how the aging body ages.

Choice A is incorrect. It is NOT accurate to state that the progression of dementia continues to worsen as the person ages because NOT all people have dementia, and dementia is not a normal part of the aging process.

Choice C is incorrect. The aging person ‘s developmental task is integrity versus despair and not industry versus inferiority.

Choice D is incorrect. Maslow has the Hierarchy of Human Needs and not a theory of aging that explains how the aging body ages.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 12

Which statement about patient-controlled analgesia (PCA) is accurate?

A. A client is often given a loading dose of their ordered pain medication before they are able to activate their own titrated dosage.

B. A method of pain management, other than patient-controlled analgesia, must be used when a client is not able to take morphine.

C. The lockout mechanism must be activated when the client with patient-controlled analgesia attempts to dose in less than ½ hour.

D. The lockout mechanism must be activated when the client with patient-controlled analgesia attempts to dose in less than 1 hour.

Answer 12

Explanation

Correct Answer is A

Correct. A client is often given a loading dose of their ordered pain medication before they can activate their own titrated dosage. For example, the client will be given perhaps 4mg of morphine before enabling their individual titrated dosage of 1 mg morphine, as per the doctor’s order.

Choice B is incorrect. It is not necessary to consider a method of pain management, other than patient-controlled analgesia when a client is not able to take morphine. Medications such as fentanyl and hydromorphone can also be used for patient-controlled analgesia when a client is not able to take morphine.

Choice C is incorrect. The lockout mechanism, which controls the amount of the medication given at any specific time, can be activated when the client with patient-controlled analgesia attempts to dose in less than ½ hour. At times, the ordered titrated dose can be every several minutes.

Choice D is incorrect. The lockout mechanism, which controls the amount of the medications given at any specific time, can be activated when the client with patient-controlled analgesia attempts to dose in less than 1 hour. At times, the ordered titrated dose can be every several minutes.

Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 13

You are supervising a nursing assistant and observing their competency in providing personal care and hygiene for a group of clients. As you are reviewing this nursing assistant’s documentation you see that the nursing assistant has documented shaving one of the clients, who is taking warfarin. What should you do? You should:

A. Tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings.

B. Complete an incident report because shaving clients are outside the nursing assistant’s scope of practice.

C. Tell the nursing assistant to cross off the documented evidence of having shaved the client.

D. Ask the nursing assistant what kind of razor was used and about the client’s response to the shave.

Answer 13

Explanation

Correct Answer is D

Correct. You would ask the nursing assistant what kind of razor was used and about the client’s response to the shave when you learn that the nursing assistant has documented shaving one of the clients who is taking warfarin.

You would determine what kind of razor was used because an electric or battery operated razor is much safer than a dull razor blade to use for clients who are on an anticoagulant like warfarin. If the nursing assistant used a regular razor blade, instead of an electric or battery operated razor, you would ask the nursing assistant about the client’s response to the shave. For example, you would determine whether or not there was any skin nicking or bleeding. After these things are determined, you would also ask the nursing assistant to document the type of razor that was used in addition to the client’s responses to the shave.

Choice A is incorrect. You would not tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings because this is not accurate and true. Clients who are taking warfarin can and should be shaved with an electric or battery operated razor because these razors are much safer than a dull razor blade.

Choice B is incorrect. You would not complete an incident report because shaving clients are outside the nursing assistant’s scope of practice. Shaving, personal care, and hygiene are within the legal reach of unlicensed assistive personnel, including nursing assistants and patient care technicians, provided that they have the training and documented competency to do so.

Choice C is incorrect. You would not tell the nursing assistant to cross off the documented evidence of having shaved the client. If the person cut, this documentation must remain in place.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 14

What is the medical device shown below used for?

A. Automated back massage

B. At home ECGs

C. Pain management

D. Vibratory massage

Answer 14

Explanation

Correct Answer is C

Correct. The medical device above is a transcutaneous electrical nerve stimulation device or TENS, which is used for nonpharmacological pain management.

Choice A is incorrect. The medical device above is not used for automated back massage; this device is used for something else.

Choice B is incorrect. The medical device above is not used for ECGs; this device is used for something else.

Choice D is incorrect. The medical device above is not used for vibratory massage; this device is used for something else.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 15

You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14 years of age, and the daughter is eight years of age. Both of these children are being prepared for their father’s end of life and his imminent death. Which consideration should be incorporated into your explanations of death with these children?

A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.

B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or its lack thereof.

C. The cognitive development of young children impacts their understanding of death.

D. The cognitive development of young children before 12 has no impact on their understanding of death.

Answer 15

Explanation

Correct Answer is C

Correct. The cognitive development of young children impacts their understanding of death. Because death, the meaning of death and the finality of death vary according to the age of the child, the nurse should listen to and support these children according to their level of understanding.

Nurses should openly discuss death with children as the need arises. Young children do not view death as terrifying they do not even view death as final. Children before the age of 12 do have perspectives about death, its meaning, and its finality or its lack thereof, although these perspectives are not the same as older children and adults.

Choice A is incorrect. Nurses should openly discuss death with children as the need arises. Young children do not view death as terrifying they do not even see death as final.

Choice B is incorrect. Children before the age of 12 do have perspectives about death, its meaning, and its finality or its lack thereof, although these perspectives are not the same as older children and adults.

Choice D is incorrect. The cognitive development of young children before 12 most definitely impacts their understanding of death and its finality.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 16

When should the rubber tip on a cane be changed?

A. At least every month

B. At least every 2 months

C. Whenever it appears even slightly worn

D. When the cane begins to slip while in use.

Answer 16

Explanation

Correct Answer is C. The rubber tip on a cane must be changed whenever it appears even slightly worn upon inspection. The same is true for the rubber tips on walkers and crutches. These pieces of equipment must be inspected and examined for safety before they are used.

Choice A is incorrect. You would not replace the rubber tips on a cane at least every month because, as based on the frequency of use and the surface that the client is walking on, these tips may be worn and unsafe more often than once a month.

Choice B is incorrect. You would not replace the rubber tips on a cane every two months because, as based on the frequency of use and the surface that the client is walking on, these tips may be worn and unsafe more often than once every two months.

Choice D is incorrect. You would not replace the rubber tips on a cane when the cane begins to slip while in use. This tip must be changed before moving, and possible client injury occurs.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 17

Select the form of therapeutic communication that is accurately paired with its description.

A. Seeking clarification: Using open-ended questions rather than closed-ended questions.

B. Providing leads: Ensuring that the client fully understands the sent message.

C. Reflection: Relating the client’s feelings rather than words back to the client.

D. An offering of self: Giving the client advice that is based on the nurse’s opinions.

Answer 17

Explanation

Correct Answer is C. Reflection is a form of therapeutic communication used when the nurse relates the client’s feelings rather than words back to the client.

Choice A is incorrect.Seeking clarification is done using both open and closed-ended questions.

Choice B is incorrect. Providing leads is not done to ensure that the client fully understands the sent message, providing points; providing leads entails the therapeutic exploration of the client’s feelings and beliefs with some coaching and encouragement by the nurse.

Choice D is incorrect. The offering of self does not entail giving the client advice based on the nurse’s opinions; the therapeutic offering of a person requires the nurse’s unconditional presence in a compassionate and caring manner.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 18

Select the client care supply or piece of equipment that is accurately paired with the correct type of asepsis.

A. Medical asepsis: An autoclave

B. Medical asepsis: Sterile gloves

C. Surgical asepsis: A single use blood pressure cuff

D. Surgical asepsis: An autoclave

Answer 18

Explanation

Correct Answer is D. An autoclave is used to sterilize client care supplies and equipment; therefore, an autoclave is accurately paired with surgical asepsis.

Choice A is incorrect. An autoclave is used to sterilize; therefore, it is not used for medical asepsis.

Choice B is incorrect. Sterile gloves are sterilized and used for sterile procedures, and not for medical asepsis procedures.

Choice C is incorrect. Single-use blood pressure cuffs are medically aseptic and not sterilized. Therefore, it is not an example of surgical asepsis.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 19

Which statement(s) about intravenous fluid administration is (are) accurate? Select all that apply.

A. Lowering the level of the intravenous fluid vasodilates the vein and increases the flow rate.

B. Raising the level of the intravenous fluid vasodilates the vein and increases the flow rate.

C. Lowering the level of the intravenous fluid vasoconstricts the vein and decreases the flow rate.

D. Raising the level of the intravenous fluid vasoconstricts the vein and decreases the flow rate.

E. Intravenous containers should be labeled and dated directly on the container using a smooth ball point pen.

F. Intravenous containers should be labeled and dated directly on the container using an indelible marker.

G. None of the above

Answer 19

Explanation

The Correct Answer isG.

Correct. The following statement about intravenous therapy is NOT true.

Lowering the level of the intravenous fluid vasodilates the vein and increases the flow rate.
Raising the level of the intravenous fluid vasodilates the vein and increases the flow rate.
Lowering the level of the intravenous fluid vasoconstrictors the vein and decreases the flow rate.
Raising the level of the intravenous fluid vasoconstrictors the vein and decreases the flow rate.
Intravenous containers should be labeled and dated directly on the container using a smooth ballpoint
Intravenous containers should be labeled and dated directly on the container using an indelible marker.

Choice A is incorrect. Lowering the level of the intravenous fluid does not vasodilate the vein and lowering the level of the intravenous fluid decreases, and not increases, the flow rate.

Choice B is incorrect. Although raising the level of the intravenous fluid does increase the rate of flow, it does not vasodilate the vein.

Choice C is incorrect. Although lowering the level of the intravenous fluid decreases blood flow, it does not vasoconstrict the vein.

Choice D is incorrect. Raising the level of the intravenous fluid does not vasoconstrict the vein and it increases, rather than decreases, the flow rate.

Choice E is incorrect. Intravenous containers should not be labeled and dated directly on the container using a smooth ballpoint pen because this pen can pierce the intravenous fluid container. Instead a label should be used and then affixed to the intravenous fluid container.

Choice F is incorrect. Intravenous containers should be not labeled and dated directly on the container using an indelible marker because the fluid from the marker can possibly contaminate the sterile intravenous fluid if it seeps through the intravenous fluid container.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 20

Select the psychiatric mental health disorder that is accurately paired with its signs and symptoms.

A. Borderline personality disorder: Intense irrational fears and the need for orderliness and perfection

B. Obsessive compulsive disorder: The need for control, orderliness and perfection

C. Bipolar disorder: Fears of abandonment, feelings of emptiness and unstable relationships with others

D. Codependency: Fears of abandonment, a need for control, and a need for perfection

Answer 20

Explanation

Correct Answer is B. Obsessive-compulsive disorder is characterized by the client’s unyielding need for control, orderliness, and perfection, as well as the performance of compulsive behaviors to relieve the stressors of their obsession.

Choice A is incorrect. A borderline personality disorder is characterized by unstable relationships, fears of abandonment, feelings of emptiness, weak ego strength, impulsive behaviors, and impaired anger management, and not intense irrational fears or phobias or the need for orderliness and perfection.

Choice C is incorrect. The client’s ongoing cycling characterizes bipolar disorder with periods of high activity and mood and periods of low activity and depression and not fears of abandonment, feelings of emptiness, and unstable relationships with others.

Choice D is incorrect. Codependency is characterized by the client’s dysfunctional relationship with another that enables another’s dependency or addiction to substances and other things like gambling, for example, and not fears of abandonment, a need for control, and a need for perfection.

Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education

Question 21

What is the nurse doing in the picture below? measuring the subscapular skin fold

A. A neurological assessment

B. A musculoskeletal assessment

C. A nutritional assessment

D. A sensory perception assessment

Answer 21

Explanation

Correct Answer is C

Correct. The picture above shows that the nurse is performing a nutritional assessment by measuring the subscapular skin fold. The subscapular skinfold measurement, which measures the underlying skin subcutaneous tissue and not underlying muscle, is done to assess the number of fat stores. Among other assessments, the subscapular skin fold is a part of the anthropometric data that is collected as part of a comprehensive nutritional assessment.

Choice A is incorrect. The picture above does not show the nurse performing a neurological assessment. Neurological assessments are not done using calipers.

Choice B is incorrect. The picture above does not show the nurse performing a musculoskeletal assessment. Musculoskeletal assessments are not done using calipers.

Choice D is incorrect. The picture above does not show the nurse performing a sensory perception assessment. Musculoskeletal assessments are not done using calipers.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 22

Which term is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine?

A. Morphine equivalency

B. Equianalgesia

C. Morphine equivalent

D. The morphine factor

Answer 22

Explanation

Correct Answer is B

Correct. Equianalgesia is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. The equianalgesic of an opioid analgesic, when compared to parenteral morphine, is mathematically calculated.

Choice A is incorrect. Morphine equivalency is not the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. However, this term relates to the equivalency of an opioid analgesic when compared to parenteral morphine.

Choice C is incorrect. Morphine equivalent is not the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. However, this term relates to the equivalency of an opioid analgesic when compared to parenteral morphine.

Choice D is incorrect. The morphine factor is not the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine, although this term elements in the power of parenteral morphine.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 23

You are precepting a new nurse on a med-Surg floor and teaching her about the importance of compliance with treatment for people with type I diabetes. When discussing the complication of ketoacidosis, you teach her the process of how ketones are produced. Place the following components of the ketone production process in order of occurrence:
Ketones produced
Ketoacidosis
Insulin deficiency
Hyperglycemia
Cellular starvation

Answer 23

Correct Answer is:
Insulin deficiency
Hyperglycemia
Cellular starvation
Ketones produced
Ketoacidosis

Explanation

In patients with TIDM, there is not enough insulin produced by the pancreas. Insulin deficiency is the first and most vital part of the physiology of ketones being produced. Because the patient does not have enough insulin, they are hyperglycemic. Their blood sugar is too high because there is not enough insulin to carry glucose into their cells. Because their glucose is in their bloodstream and not their cells, their cells are starving! They become fatigued, are hungry all the time, and lose weight. This is why hyperglycemia leads to cellular starvation. With the patient’s cells starving in the absence of glucose, there are ketones produced. This is all because the body cannot nourish the battery in the lack of insulin. After sufficient ketones are created, you finally have ketoacidosis. This is a dangerous complication of TIDM, and can be avoided by careful management of the condition!

NCSBN Client Need

Topic: Physiological Adaptation Subtopic: Pathophysiology

Reference: McKinney E, James S, Murray S, Ashwill J: Maternal-child nursing, ed 4, St. Louis, 2013, Saunders.

Question 24

According to the American Liver Foundation, the maximum dosage of acetaminophen with long term use should be limited to no more than:

A. 3,000 mg per day.

B. 4,000 mg per day.

C. 5,000 mg per day.

D. 6,000 mg per day.

Answer 24

Explanation

Correct Answer is A

Correct. According to the American Liver Foundation, the maximum dosage of acetaminophen with long term use should be limited to no more than 3,000 mg per day. The American Liver Foundation also limits the daily dosage of acetaminophen to no more than 4,000 mg when the client is at risk for hepatic damage.

Choice B is incorrect. According to the American Liver Foundation, the maximum dosage of acetaminophen with long term use should be limited to less than 4,000 mg per day.

Choice C is incorrect. According to the American Liver Foundation, the maximum dosage of acetaminophen with long term use should be limited to less than 5,000 mg per day.

Choice D is incorrect. According to the American Liver Foundation, the maximum dosage of acetaminophen with long term use should be limited to less than 6,000 mg per day.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 25

Select the blood product that is accurately paired with its indications for use in terms of the client’s disorder or disease. Select all that apply.

A. Packed red blood cells: A clotting disorder

B. Whole blood: Relatively all cases of bleeding and hemorrhage

C. Plasma: Anemia and a low hematocrit

D. A plasma expander: A platelet disorder

E. Cryoprecipitate: A clotting disorder

F. Platelets: A bleeding disorder

G. Albumin: An excess of plasma proteins

Answer 25

Explanation

Correct Answers are E and F

Correct. Cryoprecipitate, which contains fibrinogen, is used for the treatment of clotting disorders, and platelets are used for the treatment of a bleeding disorder and a platelet deficiency disorder.

Choice A is incorrect. Packed red blood cells are used for several disorders, including anemia, post-operative blood replacement, and slow bleeding, but not for a clotting disorder.

Choice B is incorrect. Whole blood is reserved for only the most severe cases of bleeding and illness and not for relatively all instances of bleeding and hemorrhage.

Choice C is incorrect. Plasma transfusions are indicated for clients adversely affected with the need for blood volume expansion and depleted clotting factors and not for clients affected with anemia or a low hematocrit.

Choice D is incorrect. A plasma expander is used for hypovolemic circulatory shock and not a platelet disorder. Plasma expanders include crystalloids and colloids; 0.9% Na Cland lactated Ringer’s are examples of crystalloid plasma expanders, and albumin and Gelofusin are examples of colloid plasma expanders.

Choice G is incorrect. Albumin is indicated for clients adversely affected with the need for blood volume expansion and depleted plasma proteins and not an excess of plasma proteins.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 26

Which technique is effective for determining and evaluating the effectiveness of the nurse’s therapeutic communication and therapeutic communication techniques?

A. Performance improvement studies

B. ISBAR

C. Critical thinking

D. Process recording

Answer 26

Explanation

Correct Answer is D

Correct. Process recording is an effective way to determine and to evaluate the effectiveness of the nurse’s therapeutic communication and therapeutic communication techniques. Process recording is used in academic environments and also by an individual nurse who wants to reflect on their therapeutic methods. Process recording entails the writing of the contents of the nurse-client conversation or dialogue and then analyzing each statement to determine whether or not therapeutic communication was used throughout this conversation or discussion.

Choice A is incorrect. Performance improvement studies are used to identify and correct faulty processes in the healthcare organization and not a way to determine and evaluate the effectiveness of the nurse’s therapeutic communication and therapeutic communication techniques.

Choice B is incorrect. ISBAR, like I-PASS and BATON, are formalized communication methods that are used for hand off reports, as required by the Joint Commission on the Accreditation of Healthcare Organizations; ISBAR is not a way to determine and evaluate the effectiveness of the nurse’s therapeutic communication and therapeutic communication techniques.

Choice C is incorrect. Critical thinking is an intellectual and cognitive process that is used in nursing for decision making and problem solving; it is not a way to determine and evaluate the effectiveness of the nurse’s therapeutic communication and therapeutic communication techniques, although critical thinking is a part of this evaluation process.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 27

Which of the following is (are) management functions that nurses fulfill? Select all that apply.

A. Being a visionary

B. Directing

C. Coordinating

D. Organizing

Answer 27

Explanation

Correct Answer is B, C, D.The four management functions that nurses fulfill are directing, coordinating, organizing, and planning. Serving as a visionary is a function of leadership and not management.

Choice A is incorrect. Being a visionary is part of the leadership role and not one of the functions that nurses fulfill as a manager.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Sommer, Johnson, Roberts, Redding, and Churchill. (2013) Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 28

You are caring for a female client who is 5 foot 2 inches tall and has a BMI of 17. This client is now on a regular diet. You would most likely recommend:

A. Continuing their diet as it is.

B. A weight reduction diet and exercise.

C. A high caloric diet to gain weight.

D. Nothing at all, this client is normal.

Answer 28

Explanation

Correct Answer is C

Correct. You would most likely recommend a high caloric diet to gain weight for this client who is 5 foot 2 inches tall and has a body mass index (BMI) of 17 because this client is overweight. The ranges for BMI are as follows:

    Underweight: Under 18.5
    Normal: From 18.5 to 24.9
    Overweight: From 25 to 29.5
    Obesity: From 30 to 39.9
    Extreme obesity: Over 40

Choice A is incorrect. A body mass index (BMI) of 17 indicates the need for education about dietary intake, so there are things that you would do for this client.

Choice B is incorrect. You would not advise the client to begin a weight reduction diet because a body mass index (BMI) of 17 indicates the need for education about dietary intake but not in terms of decreasing weight.

Choice D is incorrect. A body mass index (BMI) of 17 indicates the need for education about dietary intake and other things for this client.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 29

Which of the following nursing diagnoses is appropriate for your client when your client is not coping with a progressive disease in an adaptive manner?

A. Ineffective coping related to fear secondary to a progressive disease

B. Ineffective coping related to role ambiguity secondary to a progressive disease

C. Ineffective coping related to role changes secondary to a progressive disease

D. Ineffective coping related to role conflict secondary to a progressive disease

Answer 29

Explanation

Correct Answer is C

Correct. “Ineffective coping related to role changes secondary to a progressive disease” is the nursing diagnosis that is appropriate for your client when your client is not coping with a progressive disease adaptively.

“Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected with fear; “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role, there is no indication that this client is affected with this uncertainty. Lastly, “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict.

Choice A is incorrect. “Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected by fear.

Choice B is incorrect. “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role. Still, there is no indication that this client is affected by this uncertainty.

Choice D is incorrect. “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 30

What is the priority nursing intervention for a newly admitted client with the possible nursing diagnosis of Self-care deficit: Bathing and hygiene?

A. Helping the client with their self care needs in terms of bathing and hygiene

B. Asking a family member to assist the client with their bathing and hygiene self care needs

C. A thorough assessment of the client in terms of their self care strengths and weaknesses

D. A thorough assessment of the client in terms of their bathing and hygiene preferences

Answer 30

Explanation

Correct Answer is C

Correct. The priority nursing intervention for a newly admitted client with the possible nursing diagnosis of “Self-care deficit: Bathing and hygiene” is to perform the priority first phase of the nursing process. Your priority nursing intervention is to perform a thorough assessment of the client in terms of their bathing and hygiene self-care strengths and weaknesses so that you can determine if the client has or does not have a possible self-care deficit in terms of bathing and hygiene.

Choice A is incorrect. Helping the client with their self-care needs in terms of bathing and hygiene may be an appropriate nursing intervention for this client. However, you do not know this yet. There is something else that you would do first and as the priority.

Choice B is incorrect. Asking a family member to assist the client with their bathing and hygiene self-care needs may be an appropriate nursing intervention for this client. However, you do not know this yet. There is something else that you would do first and as the priority.

Choice D is incorrect. Although you would perform a thorough assessment of the client in terms of their bathing and hygiene preferences, this is not the priority. There is something else that you would do first and as the priority.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 31

Select the category of pain medication that is accurately paired with the level of pain that this medication is indicated for AND an example of a pain medication that is included in this category of pain medication.

A. Coanalgesic medications: Severe pain: A tricyclic antidepressant medication

B. Opioid analgesic medications: Severe pain: Tramadol

C. Opioid analgesic medications: Moderate pain: Tramadol

D. Nonopioid analgesic medications: Moderate pain: Ibuprofen

Answer 31

Explanation

Correct Answer is C

Correct. The category of pain medication that is accurately paired with the level of pain that this medication is indicated for AND an example of a pain medication that is included in this category of pain medication is Opioid analgesic medications: Moderate pain: Tramadol. Opioid analgesic medications like tramadol are used for moderate pain.

Choice A is incorrect. Although analgesic medications like tricyclic antidepressant medications are used for severe pain, these analgesic medications are used for all levels of anxiety in combination with a nonopioid or opioid medication.

Choice B is incorrect. Although opioid analgesic medications are indicated for severe pain, a drug other than tramadol is used to manage acute pain.

Choice D is incorrect. Nonopioid analgesic medications like ibuprofen are not indicated for moderate pain; ibuprofen is indicated for minor pain.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 32

Parts of a pain assessment entail the subjective comments of the client in terms of their sensory and affective, emotional comments that can indicate the quality and intensity of their pain. Select the type of pain that can be shown with the client’s emotions of “nagging and tender”?

A. Hurting pain

B. Pain

C. Somatic pain

D. Aching pain

Answer 32

Explanation

Correct Answer is D

Correct. Aching pain in terms of affective, emotional descriptors can include the client’s subjective comments that include “nagging and tender.” Other personal affective descriptors can consist of “troublesome,” “annoying,” and “tiring.”

Affective, emotional, and sensory pain descriptors and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense.

Choice A is incorrect. “Nagging and tender” are affective, emotional descriptors of another type of pain. Hurting the client can describe pain with affective, emotional descriptors such as “robbing” and not “nagging and tender.”

Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense.

Choice B is incorrect. “Nagging and tender” are affective, emotional descriptors of another type of pain in terms of its quality and intensity. Pain, in contrast to other intensity pain, is the highest level possible, and its affective, emotional descriptors include comments such as “agonizing,” suffocating” and “unbearable” and not “nagging and tender.”

Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense.

Choice C is incorrect. “Nagging and tender” are not sufficient, emotional descriptors of bodily pain. “Nagging and tender” indicates another type of pain in terms of its quality and intensity.

Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 33

An expected outcome that is most appropriate for the recipient of palliative care is:

A. The terminally ill client will be free of any physical, psychological, or spiritual distress.

B. The primary caregiver will be free of any physical, psychological, or spiritual distress.

C. The terminally ill client will have extraordinary life-saving measures to preserve life.

D. The primary caregiver will be physically and emotionally rested.

Answer 33

Explanation

Correct Answer is A

Correct. An expected outcome that is appropriate for the recipient of palliative care is that “The terminally ill client will be free of any physical, psychological or spiritual distress.” Palliative care is not curative care; palliative care, or hospice care, aims to maintain the client’s freedom from pain and distress.

Although palliative and hospice care philosophies and treatments are also applied and given to loved ones, it is not reasonable to expect that “The primary caregiver will be free of any physical, psychological or spiritual distress.”

The terminally ill client will not have extraordinary life-saving measures to preserve life at the end of life, these life saving, and life prolongation, tests are used in curative rather than palliative care.

Respite care, rather than palliative care, provides time off for the primary caregiver of the ill client so that the caregiver gets to rest and the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver.

Choice B is incorrect. Although palliative and hospice care philosophies and treatments are also applied and given to loved ones, it is not reasonable to expect that “The primary caregiver will be free of any physical, psychological or spiritual distress.”

Choice C is incorrect. The terminally ill client will not have extraordinary life-saving measures to preserve life at the end of life, these life saving, and life prolongation, tests are used in curative rather than palliative care.

Choice D is incorrect. Respite care, rather than palliative care, provides time off for the primary caregiver of the ill client so that the caregiver gets to rest and the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 34

You will be teaching a group of student nursing assistants about oral care. Which of the following oral care principles should you include in this teaching plan? Select all that apply.

A. Oral acids in addition to plaque lead to dental caries.

B. Sugar in addition to plaque leads to dental caries.

C. Bottle teeth are a complication of formula feeding.

D. Teeth should be thoroughly brushed twice a day.

E. Flossing should be thoroughly done once a day.

F. Plaque and tartar can be prevented and eliminated with oral care.

Answer 34

Explanation

Correct Answers are A, B, C, and D

Correct. Oral acids, in addition to the plaque, lead to dental caries; sugar in addition to plate leads to dental caries; bottle teeth and decay is a complication of formula feeding when the infant falls asleep with the formula in their mouth and teeth should be thoroughly brushed twice a day.

Choice E is incorrect. Flossing should be thoroughly done twice a day and not once a day.

Choice F is incorrect. Plaque can be removed with tooth brushing, flossing, and good oral care, but tartar, which is hardened plaque, can only be removed with a professional dental cleaning, which should be done at least every six months.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 35

Select the age-related stressor that is accurately paired with an expected outcome that would indicate that the client is effectively coping with their age-related stressor.

A. Infant: The infant will develop autonomy

B. Toddler: The toddler will compete in the school environment

C. Adolescent: The adolescent will begin to manage their home

D. Middle years adult: The client will cope with the challenges of the “sandwich generation”.

Answer 35

Explanation

Correct Answer is D

Correct. During the middle years, the adult, under any circumstances, will have to cope with and juggle the challenges associated with work, raising adolescent children, and caring for their adult aging parents. Caring for one’s children and caring for aging parents places middle years adults in the sandwich generation.

Infants have to cope with and develop trust and not autonomy. Toddlers have to deal with and build independence and not a competition in the school environment, and adolescents have to cope with the changes associated with puberty and the development of interpersonal relationships, and not managing the home.

Choice A is incorrect. Infants have to cope with and develop trust and not autonomy.

Choice B is incorrect. Toddlers have to cope with and develop autonomy and not a competition in the school environment.

Choice C is incorrect. Adolescents have to cope with the changes associated with puberty and the development of interpersonal relationships and not managing the home.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 36

Which of the following statements about carbon monoxide is accurate?

A. Carbon monoxide is a gas that is gray in color and deadly.

B. Carbon monoxide is a gas that is clear, odorless and deadly.

C. Carbon monoxide is a gas that is yellow and odorless.

D. Carbon monoxide is a gas that smells like rotten eggs.

Answer 36

Explanation

Correct Answer is B. Carbon monoxide is a gas that is clear, odorless, and deadly. This invisible gas most often builds up in enclosed areas where engines, such as car engines, are running idly.

Choice A is incorrect. Carbon monoxide is deadly, but it is not gray.

Choice C is incorrect. Carbon monoxide is odorless, but it is not yellow.

Choice D is incorrect. Carbon monoxide is odorless; it does not smell like rotten eggs or sulfur.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 37

What is shown in the picture below that is labeled 13?

A. The anterior horn

B. The dorsal root ganglion

C. The anterior root

D. The posterior root

Answer 37

Explanation

Correct Answer is B

Correct. The dorsal root ganglion is shown in the picture above that is labeled 13. The dorsal root ganglion contains the nerve fibers that sense painful and noxious stimuli that can be chemical, thermal, and chemical.

All the above anatomical structures play a role in pain and pain perception.

Choice A is incorrect. The anterior horn is not shown in the picture above, which is labeled 13. The anterior horn is shown in the image above that is labeled 1.

Choice C is incorrect. The anterior root is not shown in the picture above, which is labeled 13. The anterior origin is shown in the image above that is marked 11.

Choice D is incorrect. The posterior root is not shown in the picture above, which is labeled 13. The dorsal root is shown in the image above that is marked 12.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 38

Select the complication(s) of intravenous therapy that is (are) accurately paired with its possible treatment after the intravenous line is discontinued.

A. Mechanical phlebitis: The application of ice

B. Bacterial phlebitis: Lower the extremity below the level of the heart

C. Extravisation: Immobilization of the affected limb

D. Infiltration: The application of only warm compresses

E. Site ecchymosis: Elevation of the extremity and applying warm compresses

F. Cellulitis: Placing a tourniquet above the site

G. Catheter embolus: Placing a tourniquet above the site to limit blood flow and catheter particles migration

H. Thrombophlebitis: The injection of a thrombolytic directly into the IV

Answer 38

Select the complication(s) of intravenous therapy that is (are) accurately paired with its possible treatment after the intravenous line is discontinued.

A. Mechanical phlebitis: The application of ice

B. Bacterial phlebitis: Lower the extremity below the level of the heart

C. Extravisation: Immobilization of the affected limb

D. Infiltration: The application of only warm compresses

E. Site ecchymosis: Elevation of the extremity and applying warm compresses

F. Cellulitis: Placing a tourniquet above the site

G. Catheter embolus: Placing a tourniquet above the site to limit blood flow and catheter particles migration

H. Thrombophlebitis: The injection of a thrombolytic directly into the IV

Question 39

Select the culture that is accurately paired with an example of its associated cultural practice in terms of nutrition.

A. Arabs: Liquids must be available with the meal to aid digestion and the enjoyment of the meal.

B. Navajo: The major protein content for this culture is the consumption of sheep meat.

C. Mexican Americans: All gifts of food should be not rejected, but instead, graciously accepted

D. African Americans: Foods included in the meal are served in the traditional order.

Answer 39

Explanation

Correct Answer is B

Correct. The original protein content for the Navajo culture is the consumption of sheep meat. Other cultural Navajo practices include corn and squash as their major vegetable and food being a significant part of the Navajo Indians celebrations.

Choice A is incorrect. Arabs do not consume liquids with the meal to aid digestion and the enjoyment of the meal. Instead, Arabs do not consume juices or beverages until after the meal is completed.

Choice C is incorrect. African American clients, rather than Mexican Americans, graciously accept gifts of food, and they do not reject them.

Choice D is incorrect. The Chinese cultures, rather than African Americans, serve foods in a specific order according to their cultural practices.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 40

Which of the following data would NOT be included in a client’s pain history?

A. The client’s affective responses to pain

B. The client’s past alleviating measures

C. The client’s current vital signs

D. The client’s meaning of pain

Answer 40

Explanation

Correct Answer is C

Correct. The client’s current vital signs would NOT be included in a client’s pain history. However, these vital signs are part of the initial nursing assessment and ongoing assessments.

Choice A is incorrect. The client’s affective responses to pain are an integral part of a client’s pain history; some emotional responses to pain include the client’s feelings such as depression and anxiety in response to pain.

Choice C is incorrect. The client’s past alleviating measures that lessened their pain are an integral part of a client’s pain history; therefore, this would be included in the client’s pain history.

Choice D is incorrect. The client’s meaning of pain is an integral part of a client’s pain history; therefore, this would be included in the client’s pain history.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 41

Select the parenting style that is accurately paired with one of its advantages.

A. The democratic style of parenting: It is relatively quick and easy to solve problems.

B. The autocratic style of parenting: It gives the impression that the family is strong.

C. The permissive style of parenting: It facilitates satisfaction among the members of the family.

D. The laissez faire style of parenting: It gives the impression that the family is loving.

Answer 41

Explanation

Correct Answer is C

Correct. The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors.

The democratic style of parenting is not a quick and easy way to solve problems; the democratic style of parenting is time-consuming but it also allows all members of the family to all have input and a voice that is heard.

The autocratic style of parenting does not give the impression that the family is strong; the impression that it gives is one that the family is rigid and highly structured.

The laissez-faire style of parenting does not give the impression that the family is loving; the impression that it gives is one of being lazy and not caring.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 42

You are caring for a client who has a healthcare proxy. This healthcare proxy is

A. The next of kin such as a wife.

B. Responsible for all medical bills.

C. A decision maker for the client.

D. The person who is the caregiver.

Answer 42

Explanation

Correct Answer is C.A healthcare proxy, also called a healthcare surrogate, has been given the legal authority to make medical decisions for the client. Although the next of kin is typically the healthcare surrogate and the caregiver, this is not always the case. The client may have chosen another to make decisions for them. Healthcare proxies are not necessarily required to pay the client’s medical bills.

Choice A is incorrect. Although the next of kin is typically the healthcare surrogate, this is not always the case.

Choice B is incorrect. Healthcare proxies are not necessarily required to pay the client’s medical bills.

Choice D is incorrect. Although the caregiver is often the healthcare surrogate, this is not always the case.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 43

You are teaching a class to new graduate nurses about responding to medical emergencies. Which content about anaphylaxic shock should you include in this class?

A. Anaphylaxis is characterized with hypotension and respiratory stridor.

B. Anaphylaxis is characterized with severe hypertension and bradycardia.

C. Anaphylaxis is also referred to as a type of septic shock.

D. Anaphylaxis is also referred to as a type of hypovolemic shock.

Answer 43

Explanation

Correct Answer is A

Correct. You would include the fact that anaphylaxis is characterized by hypotension and respiratory stridor in your class for new graduate nurses about responding to medical emergencies.

Other contents that you should include in this class include the fact that anaphylaxis can occur with a second exposure to a medication, such as penicillin, that the client is allergic to and the other signs, symptoms, and characteristics of this medical emergency include systemic circulatory relaxation, decreased cardiac output, hypotension, laryngeal edema, respiratory distress, and bounding tachycardia.

Anaphylactic shock is immediately treated with adrenaline or noradrenaline and well as other life-saving interventions, as indicated.

Choice B is incorrect. Although anaphylaxis, which is a severe life-threatening emergency, adversely affects the cardiovascular system and the respiratory system, anaphylaxis is not characterized by severe hypertension and bradycardia.

Choice C is incorrect. Although anaphylaxis is a type of shock, anaphylaxis is a type of trauma other than septic shock, which occurs as the result of an infection.

Choice D is incorrect. Although anaphylaxis is a type of shock, anaphylaxis is a type of shock other than hypovolemic shock which occurs as the result of bleeding, hemorrhage, and depleted circulating volume.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 44

According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS), which of the following is mandated at all times in respect to restraints?

A. A written order from the client’s physician.

B. A written order from the client’s licensed independent practitioner.

C. The use of the least restrictive restraint possible.

D. The monitoring of the restrained client at least every 6 hours.

Answer 44

Explanation

Correct Answer is C. The use of the least restrictive restraint possible is mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). Restraint orders can be written by the client’s physician, the client’s licensed independent practitioner, and by the registered nurse in an emergency situation or by using an established protocol.

Choice A is incorrect. A written order from the client’s physician is NOT mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). There are other ways that restraints can be initiated.

Choice B is incorrect. A written order from the client’s licensed independent practitioner is NOT mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). There are other ways that restraints can be initiated.

Choice D is incorrect. The monitoring of the restrained client is required more frequently than every 6 hours, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS).

References: Centers for Medicare and Medicaid Services (CMS) and Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

Question 45

he most accurate definition of the family is:

A. A unit comprised of members who are related or not related.

B. A unit comprised of blood-related relatives.

C. A dyad of a male and female.

D. A dyad of heterogeneous or homogeneous genders.

Answer 45

Explanation

The correct answer is A. The most accurate definition of the family is a unit comprised of members who can be related or not related and bound legally or in a nonlegal manner.

Choice B is incorrect. Families do not necessarily consist of only blood relatives; the traditional family has a man and a woman who are not blood relatives.

Choice C is incorrect. Families do not necessarily consist of males and females; some families are gay or lesbian units and still have more than two people like a commune.

Choice D is incorrect. Families do not necessarily consist of only a dyad of heterogeneous or homogeneous genders; they can consist of many members, such as communal families and extended families.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 46

Case management, as a form of patient care delivery and documentation, is most closely aligned with:

A. The SOAP method of documentation

B. The SOAPIE method of documentation

C. Variances

D. Case mix

Answer 46

Explanation

Correct Answer is C. Variances, including patient variances, system variances and practitioner variances are deviations from the expected plan of care and treatment that is documented on the critical pathway of the case management method of patient care delivery and documentation.

Choice A is incorrect. The SOAP method of documentation is part of the problem-oriented medical record documentation system and not the case management method of patient care delivery and documentation.

Choice B is incorrect. The SOAPIE method of documentation is part of the problem-oriented medical record documentation system and not the case management method of patient care delivery and documentation.

Choice D is incorrect. Case-mix reflects the collective conditions of the clients and it is not part of the case management method of patient care delivery and documentation.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Sommer, Johnson, Roberts, Redding, and Churchill. (2013) Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 47

Many clients at the end of life experience symptoms, such as pain that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association’s position on pain management at the end of life?

A. The American Nurses Association advocates for pain management unless life-threatening side effects occur.

B. The American Nurses Association advocates for pain management even if the life-threatening side effects hasten death.

C. The American Nurses Association prohibits the respiratory system depressing drugs because this is euthanasia.

D. The American Nurses Association allows that families can administer respiratory system depressing drugs to hasten death.

Answer 47

Explanation

Correct Answer is B

Correct. The American Nurses Association advocates for pain management even if the life-threatening side effects hasten death. In the past, pain management agents like narcotic analgesics were not given if they caused a respiratory depression that could lead to the cessation of life.

This administration of respiratory system depressing drugs at the end of life is not considered euthanasia; and the American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death but it does allow families to administer respiratory system depressing drugs to relieve pain at the end of life.

.

Choice A is incorrect. The American Nurses Association does not advocate for pain management unless life-threatening side effects occur.

Choice C is incorrect. The American Nurses Association does not prohibit the respiratory system depressing drugs because this is euthanasia; this Association does permit respiratory system sad medications for a specific reason.

Choice D is incorrect. The American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death. Still, it does allow families to apply respiratory system sad drugs to relieve pain at the end of life.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 48

The most appropriate nursing diagnosis for a caregiver who is abusing alcohol or drugs to self medicate to overcome caregiver stress is:

A. Ineffective coping is related to alcohol abuse.

B. Ineffective coping is related to the caregiver role.

C. The client will make better lifestyle choices.

D. The client will attend a 12 step recovery program.

Answer 48

Explanation

Correct Answer is B. “Ineffective coping related to the caregiver role” is an appropriate nursing diagnosis for a caregiver who abuses alcohol or drugs to self-medicate to overcome caregiver stress.

Choice A is incorrect. “Ineffective coping related to alcohol abuse” is not an appropriate nursing diagnosis for a caregiver who is abusing alcohol or drugs; ineffective coping is related to the caregiver role and its stressors and not as the result of alcohol abuse.

Choice C is incorrect. “The client will make better lifestyle choices” is an example of an appropriate patient outcome, but it is not a nursing diagnosis.

Choice D is incorrect. “The client will attend a 12 step recovery program” is an example of an appropriate patient outcome, but it is not a nursing diagnosis.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 49

Select the age group along the life span that is accurately paired with a physiological characteristic that places them at risk for adverse effects, contraindications, side effects, and/or interactions relating to medications.

A. Neonates: Acidic gastric acids that affect absorption

B. Toddler: Immature hepatic functioning that affects distribution

C. The elderly: Decreased renal perfusion that affects excretion

D. Adolescents: An undeveloped blood – brain barrier

Answer 49

Explanation

Correct Answer is C

Correct. The elderly population, as the result of the regular changes of the aging process, is at high risk for adverse medication effects, contraindications, side effects, and interactions. Among these frequent changes of the aging process include decreased renal perfusion and functioning, decreased hepatic perfusion and functioning, lowered bodily water, reduced gastric acid production, increased adipose tissue, and polypharmacy as the result of multiple chronic diseases and disorders which also increase the elderly’s risk for adverse effects, contraindications, side effects and/or interactions.

Choice A is incorrect. Neonates can be affected by adverse effects, contraindications, side effects, and interactions with medications because their gastric acid is more alkaline and not more acidic.

Choice B is incorrect. Neonates and infants less than one year of age have immature hepatic functioning that affects distribution, not toddlers.

Choice D is incorrect. Neonates and infants less than one year of age have an undeveloped blood-brain barrier and not adolescents.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 50

Which client will most likely get this device for intravenous therapy?

A. A client in the home who needs long term fluid replacements

B. A client in the home who needs parenteral nutrition

C. A client in the home who needs intermittent vesicant administration

D. A client in the home who needs intermittent doxorubicin

Answer 50

Explanation

Correct Answer is A

Correct. The PICC, or peripherally inserted central venous catheter, is indicated when the client will need long term intravenous therapy and intravenous access. They are particularly useful to clients who will be getting long term intravenous therapy and intravenous access in the home because they are less prone to complications, such as infection when compared to other intravenous therapy and intravenous access devices such as a central venous catheter.

Choice B is incorrect. A client in the home who needs parenteral nutrition will need another type of venous access device.

Choice C is incorrect. A client in the home who needs intermittent vesicant administration will need another type of venous access device because vesicant medications are irritating to the veins, and they are prone to extravasation.

Choice D is incorrect. A client in the home who needs intermittent doxorubicin will need another type of venous access device because doxorubicin is a vesicant medication that is irritating to the veins, and it is prone to extravasation.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 51

Which of the following are (are) sign(s) and symptom(s) of renal failure? Select all that apply.

A. Metabolic alkalosis

B. Metabolic acidosis

C. Hyperkalemia

D. Hypomagnesemia

Answer 51

Explanation

Correct Answer is B, and C.The signs and symptoms of renal failure include metabolic acidosis and hyperkalemia, among many other signs and symptoms.

Choice A is incorrect. Metabolic alkalosis can occur as the result of vomiting, Cushing’s syndrome, and other causes, not including renal failure.

Choice D is incorrect. Hypomagnesemia can occur as the result of diarrhea, pancreatitis, and burn, among other causes, not including renal failure.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 52

Select the nonverbal cue to physical and/or psychological stressors that is accurately paired with its basic human need.

A. Safety and security: Signs of an internal locus of control

B. Self-actualization: The lack of insight into one’s limitations

C. Self-esteem: The need to draw attention to self

D. Safety and security: An inability to have a clear picture of reality

Answer 52

Explanation

Correct Answer is C

Correct. The need for the client to draw attention to themselves with the exclusion of others is a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of love and belonging. Other love and belonging deficits can also include social withdrawal and isolation, as well as unnecessary dependency on others.

Choice A is incorrect. Signs of an internal locus of control, rather than an external locus of control, is a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of love and belonging and not safety and security. The person with an external locus of control blames others and other things for their problems, and a person with an internal locus of control can look at themselves and how they can control and eliminate their problems.

Choice B is incorrect. The lack of insight into one’s limitations, including physical limitations, is a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of safety and security and not self-actualization. This lack of insight into one’s limitations places clients at risk for incidents and accidents like falls, for example.

Choice D is incorrect. An inability to have a clear picture of reality and to accept the fact is nonverbal cues of physical and psychological stressors that can occur primarily among those with the basic human need of self-actualization rather than safety and security. Self-actualization needs are fulfilled when the individual can accept reality and have insight into their accomplishments and limitations.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 53

Which method of pain management would you anticipate using when your client is adversely affected with nociception in the transduction phase?

A. Progressive relaxation.

B. Meditation.

C. The administration of narcotic analgesics like codeine or morphine.

D. The administration of a nonsteroidal anti-inflammatory medication like Ibuprofen.

Answer 53

Explanation

Correct Answer is D.The administration of a nonsteroidal anti-inflammatory medication like Ibuprofen is the method of pain management that you would you anticipate using when your client is adversely affected with nociception in the transduction phase. Nociception is the type of pain that occurs when the body has suffered an injury or inflammation, and the client has a sound and well-functioning nervous system.

Choice A and B are incorrect. Although progressive relaxation can be used to control pain and anxiety, it is not the method of pain management that you would you anticipate using when your client is adversely affected with nociception in the transduction phase.

Choice C is incorrect. The administration of narcotic analgesics like codeine or morphine can be used to control pain; it is not the pain management method that you would anticipate using when your client is adversely affected with nociception in the transduction phase.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 54

Your pediatric client has just begun oral penicillin for a throat infection. The mother of this child calls you 12 hours after you saw the client, and she states, “He has taken one dose of the medication, and he has a rash. I think something is wrong with him in addition to the throat infection.” You should respond to this mother’s comment by:

A. Stating “Many young children get a rash from the slight fever when they have with a respiratory infection.”

B. Stating “ I don’t think it is anything important or serious. I suggest you use calamine lotion if he is itchy.”

C. Asking “Has your son ever taking any penicillin in the past? He may be allergic to it.”

D. Asking “Have you recently changed your laundry soap? It could be contact dermatitis.”

Answer 54

Explanation

Correct Answer is C

Correct. You should respond to this mother’s comment by asking, “Has your son ever taking any penicillin in the past? He may be allergic to it.” This data is essential because an allergy to penicillin can be characterized by a diffuse rash with the first dose, which is called the sensitizing dose, after which a second dose can lead to anaphylaxis which is a potentially life-threatening complication of penicillin when a person is allergic to it.

Choice A is incorrect. You would not state, “Many young children get a rash from the slight fever when they have a respiratory infection” because this rash could indicate a severe problem.

Choice B is incorrect. You would not state, “I don’t think it is anything important or serious. I suggest you use calamine lotion if he is itchy” because this rash could indicate a severe problem.

Choice D is incorrect. You would not respond to this mother by asking, “Have you recently changed your laundry soap? It could be contact dermatitis?” because this rash could indicate a serious problem and another question, therefore, should be asked first.-*

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 55

Select the complication of intravenous therapy that is accurately paired with one of its preventive measures. Select all that apply.

A. Catheter embolus: Never reinserting the stylet into the catheter

B. Hematoma: Start the infusion prior to releasing the tourniquet

C. Infiltration: Insuring that the catheter is securely stabilized

D. Site ecchymosis: Changing the intravenous site every 48 hours

E. Fluid overload: Insuring that the client’s arm is not swollen

Answer 55

Explanation

Correct Answer is A and C

Correct. Catheter embolus can be prevented by never reinserting the stylet into the catheter during insertion, and infiltration can be restricted by ensuring that the catheter is securely stabilized and insuring that the intravenous site and the catheter are appropriate.

Choice B is incorrect. Hematomas, as a complication of intravenous therapy, can be prevented by a variety of interventions, which do not include starting the infusion before releasing the tourniquet. Hematomas can be avoided by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process.

Choice D is incorrect. Site ecchymosis, as a complication of intravenous therapy, can be prevented by starting the infusion before releasing the tourniquet hematomas can be restricted by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process. Site ecchymosis not prevented with changing the intravenous site every 48 hours

Choice E is incorrect. Fluid overload, as a complication of intravenous therapy, can be prevented by monitoring the rate of administration, checking the client’s vital signs, monitoring the client’s intake and output, assessing the client for the signs and symptoms of fluid overload, and ensuring that the client, particularly a confused client, cannot reach and manipulate the intravenous flow rate. Observing the client’s arm for swelling is not a way to prevent fluid overload.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 56

Which of the following nursing diagnoses is the most appropriate for an immobilized client on complete bed rest who has a blood calcium level of 9.9 mg/dL and a urinary pH of 9.9?

A. Impaired urinary function related to an alkaline urinary pH

B. Demineralization related to immobilization and complete bed rest

C. At risk for impaired urinary function related to immobilization

D. At risk for hypocalcemia related to bone demineralization

Answer 56

xplanation

Correct Answer is A

Correct. “Impaired urinary function related to an alkaline urinary pH” is the most appropriate nursing diagnosis for an immobilized client on complete bed rest.

A urinary pH of 9.9 is not normal and it is outside of the normal parameters; the normal urinary pH ranges from 4.5 to 8 and a pH less than 4.5 is considered abnormally acidic and a pH of more than 8 is considered abnormally alkaline. Abnormal alkalinity, which is a hazard of immobility, places the client at risk for the formation of renal calculi and urinary impairments.

Choice B is incorrect. “Demineralization related to immobilization and complete bed rest” is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because there is no data in this question that indicates that this client has bone demineralization with a blood calcium level within normal limits which can range from 8.5 to 10.5 mg/dL, although bone demineralization and hypercalcemia are commonly occurring complications of immobilization and non-weight bearing activity.

Choice C is incorrect. “At risk for impaired urinary function related to immobilization” is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because this client’s urinary pH is outside of normal limits and this indicates the need for an actual rather than an “at-risk” nursing diagnosis.

Choice D is incorrect. “At risk for hypocalcemia related to bone demineralization” is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because this client is at risk for hypercalcemia secondary to bone demineralization and not hypocalcemia.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 57

Which phenomena is defined as a subjective human experience that is what the client says it is, it exists when the client says it is the presence, and it alerts humans to actual or potential bodily tissue damage?

A. Anxiety

B. Pain

C. Fear

D. Perception

Answer 57

xplanation

Correct Answer is B. Pain is defined as a subjective human experience that is what the client says it is; it exists when the client says it is the presence, and it alerts humans to actual or potential bodily tissue damage. It is an unpleasant and distressing experience that has both physical and emotional components.

Choice A is incorrect. Anxiety is a psychological and emotional response to an anticipated threat to self that leads to unpleasant feelings such as feelings of dread and not a subjective human experience that is what the client says it is; it exists when the client says it is the presence and it alerts humans to actual or potential bodily tissue damage with both physical and emotional components.

Choice C is incorrect. Fear is defined as the emotional response to an actual and present danger and not a subjective human experience that is what the client says it is; it exists when the client says it is the presence and it alerts humans to actual or potential bodily tissue damage with both physical and emotional components.

Choice D is incorrect. Perception is defined as the human being’s ability to interpret the environment exterior to the person as interpreted by the person’s senses, including hearing, vision, and tactile sensation and not a subjective human experience that is what the client says it is. It exists when the client says it is the presence, and it alerts humans to actual or potential bodily tissue damage with both physical and emotional components.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 58

Your client has been typed and cross-matched in anticipation of the infusion of pack red cells. This client has B agglutinogens and A agglutinins. Which blood type would you administer to this client?

A. Type A packed red cells.

B. Type B packed red cells.

C. Type AB packed red cells.

D. Type O packed red cells.

Answer 58

Explanation

The correct answer is B. You would administer type B packed red cells to your client who has been cross-matched with B agglutinogens and A agglutinins. Type A packed red cells are delivered to clients who have been cross-matched as with A agglutinogens and B agglutinins: type AB packed red cells are delivered to clients who have been cross-matched as with both A and B agglutinogens and no agglutinins, and type O packed red cells are delivered to clients who have been cross-matched as with no agglutinogens and both A and B agglutinins.

Choice A, B, C are incorrect. Type A, AB, O packed red cells are not administered to clients with B agglutinogens and A agglutinins; another blood type is applied to prevent severe and possibly life-threatening ABO incompatibility reactions to the improper blood.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 59

Your client has an order for one unit of packed red blood cells. One of the other nurses picked the blood up at the blood bank at 11 am, and you began the infusion of the packed red blood cells at noon after you have completed all of the safety, client identification, and preparation procedures. At what time should this unit of packed red blood cells be thoroughly infused?

A. 1 pm

B. 2 pm

C. 3 pm

D. 4 pm

Answer 59

Explanation

Correct Answer is C

Correct. This unit of packed red blood cells must be infused entirely by 3 pm, which is 4 hours after the group of this unit of packed red blood cells was taken from the blood bank. This time limit prevents the degradation and damage to the red blood cells.

Choice A is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is more than 2 hours.

Choice B is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is more than 3 hours.

Choice D is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after the group of this unit of packed red blood cells was taken from the blood bank to prevent degradation and damage to the red blood cells, this time is less than 5 hours.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 60

The client shown in the picture below is most likely affected by which alteration of their bodily system?

A. Alteration in urinary function related to renal failure.

B. Alteration in urinary function related to chronic renal failure.

C. Alteration in bodily defense mechanisms related to peritonitis.

D. Alteration in bodily defense mechanisms related to sepsis.

Answer 60

Explanation

The Correct Answer is A.The client shown in the picture is most likely affected by alteration of urinary functioning related to renal failure. This picture shows peritoneal dialysis, and peritoneal dialysis is not only used for chronic renal failure. It is also used for acute renal failure.

Choice B is incorrect. This picture does not necessarily connote that the client is experiencing an alteration in urinary function related to chronic renal failure.

Choice C and D are incorrect. This picture does not show treatment for peritonitis or sepsis.

Reference: Hinkle, Janice, and Kerry H. Cheever. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.

Question 61

You are conducting a class for new graduate nurses working on the psychiatric/mental health unit. One of these nurses asks you about the term used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills. How should you respond to this new graduate nurse’s question?

A. “A planned elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills is not therapeutic.”

B. “The term that is used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills is modeling.”

C. “The term that is used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills is behavioral modification.”

D. “The term that is used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills is a therapeutic milieu.”

Answer 61

Explanation

Correct Answer is D. “The term that is used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills is a therapeutic milieu.”

Choice A is incorrect. “A planned elimination of all triggers and stressors on the unit to facilitate the client’s development of better coping skills IS therapeutic.”

Choice B is incorrect. Modeling is the facilitation of the client’s ability to mimic and copy acceptable behaviors.

Choice C is incorrect. Behavior modification is a planned contract that the client follows to correct inappropriate and dangerous behaviors.

References: Sommer, Johnson, Roberts, Redding, Churchill et al. RN Mental Health Nursing Edition 9.0; ATI Nursing Education and Videbeck, Sheila. Psychiatric-Mental Health Nursing.

Question 62

What is the process with which members of another culture adopt the culture of the host, predominant culture?

A. Immigration

B. Emigration

C. Acculturation

D. Assimilation

Answer 62

Explanation

Correct Answer is C

Correct. Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment.

Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own.

Immigration is the process with which citizens of one country enter another country, and emigration is the process with which individuals of a nation leave it. Both immigration and migration can lead to cultural dissonance.

Choice A is incorrect. Immigration is the process with which citizens of one country enter another country rather than the method with which members of another culture adopt the culture of the host, predominant religion.

Choice B is incorrect. Emigration is the process with which individuals of a country leave it rather than the method with which members of another culture adopt the culture of the host, predominant religion.

Choice D is incorrect. Assimilation is the process with which a person develops a new cultural identity process rather than the method with which members of another culture adopt the culture of the host, predominant religion.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 63

The first bodily area to be washed with a complete bed bath is the:

A. Inner canthus of the right eye.

B. Cheeks

C. Forehead

D. Chin

Answer 63

Explanation

Correct Answer is A

Correct. The first bodily area to be washed with a complete bed bath is the inner canthus of either eye, including the right or left eye. The washing is done from the inner to the outer canthus of the eye.

The next steps for the bath are the rest of the face, the upper chest, the arms, and hands, after which you would proceed downward on the body from the head to the toes.

Choice B is incorrect. Although the cheeks are washed near the beginning of a complete bed bath, washing the cheeks is not the first bodily area to be washed.

Choice C is incorrect. Although the forehead is washed near the beginning of a complete bed bath, washing the forehead is not the first bodily area to be washed.

Choice D is incorrect. Although the chin is washed near the beginning of a complete bed bath, washing the chin is not the first bodily area to be washed.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 64

The nurse is caring for a client who presents with blood glucose level 45mg/dL. Which of the following finding(s) is/are expected?Select all that apply.

A. Blurred vision

B. Increased urinary output

C. Cool and clammy skin

D. Palpitations

E. Orthostatic Hypotension

F. Paresthesias

Answer 64

Explanation

Correct Answers are A, C, D, and F. Blurred vision (Choice A), Cool and clammy skin (Choice C), Palpitations (Choice D), and Paresthesias (Choice F) are expected findings with hypoglycemia.

Hypoglycemia is a blood sugar less than 70 mg/dl. Symptoms of hypoglycemia can be divided into two broad categories:

Neurogenic ( autonomic): adrenergic and cholinergic symptoms. Adrenergic symptoms include those of catecholamine releases such as tremor, palpitations (Choice D) and anxiety (catecholamine-mediated, adrenergic) and sweating, hunger, and paresthesias (Choice F) (acetylcholine-mediated, cholinergic).
Neuroglycopenic: Neuroglycopenia refers to a deficiency of glucose in the brain and neurons secondary to hypoglycemia. Symptoms of moderate Neuroglycopenia include blurred vision (Choice A), slurred speech, drowsiness, dizziness, and extreme fatigue. Severe Neuroglycopenia can cause delirium, confusion, and eventually, seizure and coma.

Choice B is incorrect. Increased urinary output is a manifestation of Osmotic diuresis from Hyperglycemia, not hypoglycemia.

Choice E is incorrect. Orthostatic Hypotension is an expected finding due to dehydration from osmotic diuresis related to hyperglycemia,not hypoglycemia.
NCSBN Client Need:
Topic Physiological adaptation; Sub-Topic: Alteration in body systems

Question 65

You are caring for an adolescent client who is experiencing pain as a result of spontaneous pneumothorax. Which independent nursing intervention would you implement in terms of this pain?

A. Irrigate the chest tubes.

B. Encourage diversion such as television.

C. Administer ordered analgesics.

D. Encourage the adolescent to be brave.

Answer 65

Explanation

Correct Answer is B

Correct. The independent nursing intervention would you implement for this adolescent in terms of this pain is to encourage diversions such as television, music, or a device with video games.

Choice A is incorrect. Irrigating the chest tubes is not an independent nursing intervention. It is a dependent nursing intervention because a doctor’s order is necessary for the administration of medications.

Choice C is incorrect. Although you would administer the adolescent’s ordered analgesic medication, this is not an independent nursing intervention. It is a dependent nursing intervention because a doctor’s order is necessary for the administration of drugs. Additionally, there is no indication in this question that chest tubes are in place.

Choice D is incorrect. You would not encourage the adolescent to be brave; adolescents are often reluctant to express pain because they feel that they must be bold and not weak in terms of pain.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 66

Which question would you ask to assess the family as the basic unit of society as you are applying the systems theory of family?

A. Tell me about the traditions that your family has and practices.

B. What form of discipline is used in the home?

C. Tell me about your involvement in school activities with your children.

D. Are you able to share home responsibilities with your spouse?

Answer 66

Explanation

Correct Answer is C

Correct. Asking the family about their involvement in school activities with your children is an example of applying the systems theory to the family and its interactions with and exchanges with others outside of the boundaries of the family.

“Tell me about the traditions that your family has and practices,” “What form of discipline is used in the home,” and “Are you able to share home responsibilities with your spouse?” are assessment questions applying a structural-functional theory of family and not systems theory.

Choice A is incorrect. “Tell me about the traditions that your family has and practices” assesses intrafamily dynamics and functioning and not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family and not systems approach.

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Choice B is incorrect. “What form of discipline is used in the home? “assesses intrafamily dynamics and functioning and not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family and not systems approach.

Choice D is incorrect. Asking “Are you able to share home responsibilities with your spouse?” assesses intrafamily dynamics and functioning and not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family and not systems approach.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 67

Which of the following is a characteristic of the “ideal vein” to select when you have to start intravenous therapy for your client?

A. A highly visible vein

B. A vein that is splinted by bone

C. A constantly filled vein

D. A vein at the point of flexion

Answer 67

Explanation

Correct Answer is B

Correct. A vein that is splinted by bone is one of the characteristics of the “ideal vein” that you would select to perform venipuncture and start intravenous therapy for your client. Other criteria for vein selection include the most distal possible vein, and a full, soft, and easily palpable thread.

Choice A is incorrect. Highly visible veins are typically not right veins to perform venipuncture and start intravenous therapy because they tend to roll away as you are attempting venipuncture.

Choice C is incorrect. An always filled vein is typically not a great vein to perform venipuncture and start intravenous therapy because they tend to be tortuous.

Choice D is incorrect. A vein at the point of flexion is typically not a great vein to perform venipuncture and start intravenous therapy because they tend to become occluded and destabilized when the client flexes the limb.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 68

Which client will most likely get this device for intravenous therapy?

A. A 26-year-old client who has appeared in the emergency department with a sprain

B. A hospitalized client who will be receiving intravenous fluids and electrolytes for 3 days

C. A burn client in the burn unit who has fragile skin secondary to severe burns

D. A 26-year-old client in the emergency department who has uncomplicated acute dehydration

Answer 68

Explanation

Correct Answer is D

Correct. A 26-year-old client in the emergency department who has uncomplicated acute dehydration is the most likely to get this butterfly catheter. Butterfly catheters are used when short term intravenous therapy of fewer than 24 hours, as can be anticipated for this client who most likely will get short term fluid replacements and monitoring in the emergency department. Butterfly catheters are also used for drawing blood specimens and IV push medications.

Choice A is incorrect. A 26-year-old client who has appeared in the emergency department with a sprain will most likely not get an intravenous therapy; therefore, this device would not be used for this client.

Choice B is incorrect. A hospitalized client who will be receiving intravenous fluids and electrolytes for three days will not get this device. Another intravenous device will be needed.

Choice C is incorrect. A burn client in the burn unit who has fragile skin secondary to severe burns is not a candidate for this device. Burn clients need multiple intravenous lines, and this would not be one of them.

Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 69

Which theory of aging describes the aging process as one that results from cellular death that results from collagen?

A. The endocrine theory of aging

B. The immunological theory of aging

C. The free radical theory of aging

D. The cross linked theory of agin

Answer 69

Explanation

Correct Answer is D. The cross-linked theory of aging describes the aging process as one that results from cellular death that results from collagen.

The endocrine theory of aging describes the aging process as one that results from the failure of the endocrine glands such as the pituitary gland and the hypothalamus gland. The immunological theory of aging describes the aging process as one that results from cellular death that results from the breakdown of the person’s immune system. The free radical theory of aging describes the aging process as one that results from the collection and accumulation of free radicals in the body.

Choice A is incorrect. The endocrine theory of aging describes the aging process as one that results from failure of the endocrine glands such as the pituitary gland and the hypothalamus gland and not one that results from cellular death that results from collagen.
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Choice B is incorrect. The immunological theory of aging describes the aging process as one that results from cellular death that results from the breakdown of the person’s immune system and not one that results from cellular death that results from collagen.

Choice C is incorrect. The free radical theory of aging describes the aging process as one that results from the collection and accumulation of free radicals in the body and not one that results from cellular death that results from collagen.
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References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition), Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education and US National Library of MedicineNational Institutes of Health (2010). Modern Biological Theories of Aging. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995895/.

Question 70

Select the barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention.

A. Poverty and the lack of health insurance: Discontinue medications and suggest over the counter remedies

B. Arthritis affecting the hands: Suggest non-child proof medication containers

C. Poor fine motor coordination: Suggest an eye examination

D. Severe confusion and poor memory: Write up a chart for medications

Answer 70

Explanation

Correct Answer is B

Correct. The barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention is suggesting non-childproof medication containers for elderly clients who have arthritis and, for this reason, and others such as poor manual dexterity and poor excellent motor coordination; these non-child proof medication containers are helpful.

Choice A is incorrect. Poverty and the lack of health insurance are not a reason to discontinue medications and suggest over the counter remedies; instead, suggest less expensive alternatives to the doctor, contact social services and also contact pharmaceutical manufacturers for assistance.

Choice C is incorrect. Poor excellent motor coordination interferes with the client’s ability to open childproof medication containers and perhaps even take pills or capsules out of them; however, you could suggest an occupational therapist rather than an eye examination.

Choice D is incorrect. Writing up a chart for medications is most likely of little use for clients who are affected with severe confusion and poor memory; assistance with drugs should, therefore, be suggested.

Reference: McCuistion, Linda E., Joyce LeFever Kee , and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 71

Which statement below relating to pain and pain perception is accurate?

A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied.

B. Scientific evidence does not support the presence of pain during a neonatal circumcision

C. Hyperanalgesia is the opposite of hyperpathia, both of which are abnormal pain responses.

D. The perception of pain and its impact on our clients greatly varies among people.

Answer 71

Explanation

Correct Answer is D

Correct. The perception of pain and its impact on our clients greatly varies among people. For example, gender, cultural beliefs, and individual’ unique pain threshold all impact on our clients’ perceptions of pain.

Choice A is incorrect. Allodynia is the pathophysiological perception of pain when no painful stimulus is applied. Allodynia, like other abnormal pain processing and pain perception processes, indicates the presence of a neuropathic process.

Choice B is incorrect. Scientific evidence supports the presence of pain during a neonatal circumcision, something that was not recognized in the past.

Choice C is incorrect. Hyperalgesia is the same as and a synonym for hyperpathia. Hyperalgesia, or hyperpathia, is an abnormal pain response that is characterized by an intense and severe perception of pain when the stimulus is not at all severe.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 72

an example of:

A. A decreasing level of acuity.

B. Retrospective reimbursement.

C. Movement along the continuum of care.

D. Prospective reimbursement.

Answer 72

Explanation

Correct Answer is C.The movement of a client from a lower to a higher level of care and intensity of care is an example of change along the continuum of care. The continuum of care moves from primary prevention to secondary prevention and then to tertiary prevention. It also moves from a lower to a higher level of acuity when the client’s condition worsens and from a higher to a lower level of acuity when the client’s health improves because the client has needs that can perhaps be met with fewer and less intense services and care.

Choice A is incorrect. The movement of a client from a lower to a higher level of care and intensity of care is an indication that the client has a more elevated and not decreasing level of acuity.

Choice B is incorrect. Retrospective reimbursement is no longer used in healthcare.

Choice D is incorrect. Although prospective reimbursement requires the movement of a client as based on medical necessity, potential compensation is not, in itself, progress along the continuum of care.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition), Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education, Sommer, Johnson, Roberts, Redding, and Churchill. (2013) Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 73

Your client has been taking medication to promote sleep for the last 19 days. This medication was discontinued three days ago, and the client is now complaining about their insomnia ever since the drug was discontinued. You would respond to this client’s concern by stating:

A. “It is likely that you are affected with insomnia rebound which often occurs when a sleeping medication is stopped.”

B. “It is likely that you are affected with REM rebound which often occurs when a sleeping medication is stopped.”

C. “I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep.”

D. “I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep.”

Answer 73

Explanation

Correct Answer is A

Correct. You would respond to this client’s concern by stating, “It is likely that you are affected with insomnia rebound, which often occurs when a sleeping medication is stopped.” This rebound typically affects clients, so, for this and other reasons, sleeping medications should be used for only a brief period, and only when alternatives have been tried and not useful.

Choice B is incorrect. You would not respond to this client’s concern by stating, “It is likely that you are affected with REM rebound which often occurs when a sleeping medication is stopped” because REM rebound, which can affect the client’s increased dreaming, does not induce insomnia.

Choice C is incorrect. You would not respond to this client’s concern by stating, “I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep” because this rebound, which typically affects clients, will only occur again, so, for this and other reasons, sleeping medications should be used for only a brief period and only when alternatives have been tried and not useful.

Choice D is incorrect. You would not respond to this client’s concern by stating, “I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep” because this rebound, which typically affects clients on sleeping medications, will only occur again, so, for this and other reasons, sleeping medications should be used for only a brief period and only when alternatives have been tried and not useful.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 74

What is the manner or pattern of physical growth for the human fetus, infant, and young child?

A. Growth from the distal to the proximal parts of the body

B. Growth from the proximal to the distal parts of the body

C. Growth from the cephalo to the caudal parts of the body

D. Growth from the caudal to the cephalo parts of the body

Answer 74

Correct Answer is C. The manner or pattern of physical growth for the human fetus, infant, and young child is from the cephalon to the caudal parts of the body. This pattern from head to toe is often referred to as cephalocaudal growth, and it is seen in the fetus and infant because the administrator of this human is far larger proportionately to the rest of the body.

Choice A is incorrect. Growth from the distal to the proximal parts of the body is not the manner or pattern of physical growth for the human fetus, infant, and young child; there is another pattern of growth.

Choice B is incorrect. Growth from the proximal to the distal parts of the body is not the manner or pattern of physical growth for the human fetus, infant, and young child; there is another pattern of growth.

Choice D is incorrect. Growth from the caudal to the cephalon parts of the body is not the manner or pattern of physical growth for the human fetus, infant, and young child; there is another pattern of growth.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 75

Which of the following is a cornerstone of a milieu environment?

A. Consistency

B. Commitment

C. Courtesy

D. Continuity

Answer 75

Explanation

Correct Answer is A

Correct. Consistency among all healthcare providers in the psychiatric environment of care is essential to the establishment and maintenance of a milieu environment as clients, affected with psychiatric mental health disorders, are cared for.

The purpose of a milieu environment and milieu therapy is to give the clients more abilities to cope and adapt when extraneous and unnecessary stressors, including those related to the lack of consistency, are removed from the environment of care. Measures that increase the flexibility include things like the maintenance of boundaries and clear expectations about what behaviors are and are not appropriate.

Choice B is incorrect. Although commitment is essential to all nursing care, responsibility is not a hallmark of a milieu environment but a hallmark for all nursing care.

Choice C is incorrect. Although courtesy and respect are essential to all nursing care, civility is not a hallmark of a milieu environment but a hallmark for all nursing care.

Choice D is incorrect. Although the continuity of care is essential to all nursing care, the continuity of care is not a hallmark of a milieu environment but a hallmark for all nursing care.

Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education