ATI

Question 1

A nurse is performing a community assessment in a rural setting. Which of the following types of health care is most likely to be absent in this setting?
• A. Tertiary care
• B. Primary prevention
• C. Chronic care
• D. Secondary prevention

Answer 1

Correct Answer: A.
Tertiary care

Tertiary care, or specialized care through consultation, is usually obtained following a referral from a primary care provider. Specialists provide tertiary care and typically work in large medical centers that have personnel and facilities for special procedures. This level of care is not readily available in most rural settings.
Incorrect Answers:
B. Primary prevention involves avoiding disease before it happens, such as through immunizations or wellness promotion. Primary prevention usually takes place in either a primary care provider’s office or wellness clinic. Primary care providers, although not as numerous in rural settings, are more available than other levels of care. Providers and nurses trained in family practice or internal medicine traditionally provide primary care and primary prevention in rural settings.
C. Chronic care is required by clients who have chronic health conditions. Primary care providers provide care to clients who have chronic conditions in rural communities. In this setting, clients who have chronic care needs are often provided care by family members in the home. Continuing or long-term health care can also be found in long-term care facilities.
D. The focus of secondary prevention is early detection and treatment of acute illness and injury to prevent disability and mortality. This type of care is typically conveyed in a primary care provider’s office or wellness clinic. Primary care providers, although not as numerous in a rural setting, are more available than other levels of care.

Question 2

A nurse is teaching a community group who lives near a nuclear power plant about safety precautions related to radiation exposure. A client asks, “Isn’t there something we should have on hand in case of a nuclear disaster?” The nurse should recognize that the client is referring to which of the following substances?
• A. Potassium iodide
• B. Potassium cyanide
• C. Ciprofloxacin
• D. Atropine

Answer 2

Correct Answer: A.
Potassium iodide

Potassium iodide, if taken in time and at the appropriate dosage, blocks the thyroid’s uptake of radioactive iodine. It can reduce the risk of thyroid cancers and other diseases that might otherwise be caused by exposure to radioactive iodine when dispersed in a severe nuclear accident.
Incorrect Answers:
B. Potassium cyanide is one of the most lethal poisons known and can cause death within minutes. Like carbon monoxide, it causes cellular asphyxiation, depriving cells of oxygen for cellular respiration.
C. Ciprofloxacin is an antibiotic used to treat certain infections caused by bacteria, such as pneumonia, gonorrhea, infectious diarrhea, typhoid fever, and inhalation anthrax (after exposure), as well as bone, joint, skin, and urinary tract infections.
D. Atropine is an anticholinergic agent used to reverse the effects of nerve gas exposure caused by sarin, tabun, and soman. It would not be helpful during radiation exposure.

Question 3

A community health nurse is preparing a disaster preparedness plan for smallpox. Which of the following groups of people should the nurse include for inoculation in the plan?
• A. Newborns
• B. Mortuary workers
• C. Immunosuppressed clients
• D. Clients who have eczema

Answer 3

Correct Answer: B.
Mortuary workers

Smallpox is an extremely contagious, disfiguring, and deadly disease caused by the variola virus. The nurse should plan to provide prophylaxis through immunization to mortuary workers, who have a high risk of exposure to smallpox. The nurse should plan only to provide immunization to the other client groups following a direct exposure because they have an increased risk of complications following immunization.
Incorrect Answers:
A. Taking an immunization for smallpox carries some risks, and newborns are at an increased risk of immunization-related complications or death. For these clients, the vaccine should only be administered after direct exposure to the virus.
C. Immunocompromised clients are at an increased risk of immunization-related complications or death. In these cases, the vaccine should only be administered if a client has been directly exposed to the virus.
D. Clients who have eczema are at an increased risk of immunization-related skin complications, which can be deadly or disfiguring. In these cases, the vaccine should only be administered if a client has been directly exposed to the virus.

Question 4

A nurse is planning a smoking cessation program for women of childbearing age. Which of the following risks is associated with smoking during pregnancy?
• A. Infant developmental delays
• B. Maternal osteoporosis
• C. Maternal ulcers
• D. Infant lung cancer

Answer 4

Correct Answer: A.
Infant developmental delays

Smoking during pregnancy is associated with an increased risk of developmental delays, premature birth, low birth weight, sudden infant death syndrome, bronchitis, and pneumonia in infants.
Incorrect Answers:
B. Smoking during pregnancy does not lead to osteoporosis. Osteoporosis is caused by bone demineralization and is typically seen in older adult clients.
C. Smoking during pregnancy does not lead to ulcers. Ulcers are caused by bacteria (Helicobacter pylori) in the stomach or by hyper-secretions of stomach acid due to stress.
D. Smoking can increase the risk of maternal lung cancer. Infants born to mothers who smoke during pregnancy have an increased risk of bronchitis and pneumonia.

Question 5

A nurse manager at a clinic for the homeless notes that many of the clients have a history of mental illness and substance use disorder. While compiling figures for a regulatory agency about individuals who visit the clinic, the nurse should classify these clients as having which of the following conditions?
• A. Codependency
• B. Bipolar disorder
• C. Comorbidity
• D. Somatization disorder

Answer 5

Correct Answer: C.
Comorbidity

Comorbidity is the presence of multiple diseases or health conditions in an individual at a given time. This phenomenon is also called a concomitant disorder or dual diagnoses.
Incorrect Answers:
A. Codependency is a set of maladaptive, compulsive behaviors learned by family members to survive in an emotionally painful and stressful environment.
B. Previously referred to as manic-depressive illness, bipolar disorder is a mood disorder characterized by the occurrence of mania alternating with episodes of depression.
D. Somatization disorder is a psychiatric condition manifesting as a physical complaint. Internal psychological conflicts are unconsciously expressed as physical manifestations.

Question 6

A school nurse is called to the scene of a large fight that just ended. The school security officers have called the police to the scene. Which of the following actions should the nurse take first?
• A. Teach coping skills to the children who witnessed the fight.
• B. Triage the injured students.
• C. Provide support to help staff members deal with the traumatic situation.
• D. Compare the response to the incident with school policies.

Answer 6

Correct Answer: B.
Triage the injured students.

The school nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client’s status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The school nurse will likely be the first medical responder to the site and should begin triaging the injured clients to assist medical personnel as they arrive.
Incorrect Answers:
A. The nurse should teach coping skills to the students who witnessed the fight to prevent or reduce stress levels; however, there is another action that the nurse should take first.
C. A nurse frequently provides counseling support for traumatized clients; however, this action should take place during the days following the incident.
D. The nurse should compare the response to the incident with school policies in order to ensure the continued safety of students; however, there is another action that the nurse should take first.

Question 7

A nurse is providing psychological counseling at a community center for families whose loved ones died in a fire. After learning that both of their children died in the fire, 2 parents express disbelief at the loss of their children. One parent states, “How will I make it through this?” Which of the following is an appropriate response by the nurse?
• A. “Are you feeling overwhelmed right now?”
• B. “Don’t worry. You will have plenty of help.”
• C. “Can I call someone to sit here with you?”
• D. “Anyone who has experienced a loss like this would feel the same way.”

Answer 7

Correct Answer: A.
“Are you feeling overwhelmed right now?”

In this response, the nurse uses the therapeutic communication skill of restatement to encourage the client to express feelings.
Incorrect Answers:
B. This is not a therapeutic response and uses the communication block of devaluing the clients’ feelings and offering false reassurance.
C. This is not a therapeutic response because it ignores the client’s feelings and does not encourage further sharing.
D. This is not a therapeutic response and uses the communication block of a stereotypical comment or cliché.

Question 8

A nurse is planning a teaching session at a community center about preventing suicide. Which of the following groups should the nurse recognize is most at risk for suicide?
• A. Older adult male clients ages 75 to 90 years old
• B. School-age children ages 6 to 12 years old
• C. Adolescent female clients ages 12 to 20 years old
• D. Middle-aged adult clients ages 25 to 44 years old

Answer 8

Correct Answer: A.
Older adult male clients ages 75 to 90 years old

The nurse should focus on older adult male clients, whose risk of committing suicide is about 36.1 per 100,000 clients.
Incorrect Answers:
B. While suicide rates among this age group are higher than in previous years, school-age children are not at the highest risk of committing suicide.
C. Adolescent female clients are not at the highest risk of committing suicide. Suicide rates for female clients are highest after the age of 55 years.
D. Middle-aged adult clients are not at the highest risk of committing suicide. Men are more likely than women to commit suicide, and being married with children reduces the risk of suicide.

Question 9

A home health nurse is providing teaching about respite care to the primary caregiver of a client with Alzheimer’s disease. Which of the following pieces of information should the nurse include in this teaching?
• A. “Respite care refers to a community support group for family caregivers.”
• B. “Respite care requires placing the client in an assisted living facility.”
• C. “Respite care provides family members with temporary relief from caregiving.”
• D. “Respite care involves daily assistance from a home health aide.”

Answer 9

Answer: C.
“Respite care provides family members with temporary relief from caregiving.”

Respite care services provide family caregivers with temporary relief from the tasks associated with caregiving for chronically ill family members, such as adults who have Alzheimer’s disease or children who have complex medical or developmental needs. Caring for a client who has complex care needs in the home is a difficult and draining task. Respite care allows overwhelmed caregivers to leave the house, have some time away, or get an uninterrupted night of sleep.
Incorrect Answers:
A. Community groups provide family caregivers with social support in a setting with others who are also confronting the problems of caregiver strain. While this may be a helpful referral for the client, this does not describe respite care.
B. Admission to an assisted living facility is typically a permanent change. Most family caregivers do not need or want the client to be removed from their home permanently.
D. A daily visit from a home health aide is not considered respite care.

Question 10

A charge nurse is assembling a list of clients who can be safely discharged home to accommodate incoming casualties following an earthquake. The nurse should recognize that discharging which of the following clients would be unsafe?
• A. A client who has osteomyelitis and will require 6 weeks of IV antibiotic therapy
• B. A client who has Crohn’s disease and is 1 day preoperative for an ileostomy
• C. A client who has Alzheimer’s disease and is awaiting placement in a long-term care facility
• D. A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace

Answer 10

Correct Answer: D.
A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace

This client requires nasogastric suction and cannot be discharged safely home. A postoperative ileus causes bowel obstruction, which could be life-threatening.
Incorrect Answers:
A. A client who requires long-term IV therapy can be discharged home with a peripherally inserted central catheter (PICC) line and home intravenous therapy.
B. A client who has a chronic condition and is preoperative for an elective procedure should be discharged. In a disaster plan, all elective surgeries are cancelled to keep the surgical suites open for clients who have emergency trauma.
C. The nurse should recognize that a client who is awaiting placement in a long-term care facility may need to be discharged temporarily to the home of a family member with support from community services.

Question 11

A nurse is caring for several clients who have become ill after a company picnic. After extensive interviews and a review of the event’s food-handling practices, the nurse determines the most likely cause of the illnesses was a poultry dish that had been allowed to cool for several hours before being served. Which of the following steps in the epidemiological process is this nurse performing?
• A. Planning
• B. Assessing
• C. Implementing
• D. Evaluating

Answer 11

Correct Answer: B.
Assessing

This step in the epidemiological process identifies the problem and provides the information necessary to plan interventions designed to prevent future outbreaks of foodborne illnesses.
Incorrect Answers:
A. During the planning phase of the epidemiological process, the nurse should use the data obtained from the assessment phase to determine a course of action to prevent future incidents of foodborne illnesses.
C. During the implementation phase of the epidemiological process, the planned intervention is enacted to prevent future outbreaks of foodborne illnesses.
D. The evaluation phase of the epidemiological process should take place after a future company picnic to determine if the intervention was successful in maintaining food safety.

Question 12

A community health nurse who works in a refugee center is evaluating children who are new arrivals to the United States. An assessment of a listless 20-month-old toddler indicates that the child is in the 6th percentile for weight and the 40th percentile for height. The toddler has thin limbs, a protuberant abdomen, and dull, dry hair. This assessment should raise suspicion for which of the following conditions?
• A. Chronic hypoxemia
• B. Anemia
• C. Protein deficit
• D. Fluid overload

Answer 12

Correct Answer: C.
Protein deficit

Growth failure, thin limbs, a protuberant abdomen, and dry, dull hair characterize a protein deficit.
Incorrect Answers:
A. The expected manifestations of chronic hypoxemia are clubbed nail beds, polycythemia, and failure to thrive.
B. The expected manifestations of anemia are pallor, fatigue, and weakness.
D. An expected manifestation of fluid overload is edema, and extreme fluid overload would be assessed as anasarca (gross, generalized edema).

Question 13

A home health nurse is caring for a client who is living in a mental health group home. During a visit, the nurse discovers that the client has been hoarding psychotropic medications. Which of the following actions should the nurse take first?
• A. Have the client transported to an acute care facility
• B. Determine the reason for the client’s hoarding behavior
• C. Alert the staff members who have been administering the client’s medications
• D. Require the client to return any hoarded medications

Answer 13

Correct Answer: B.
Determine the reason for the client’s hoarding behavior

The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client’s status, the nurse must first collect adequate data. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first determine the reason for the client’s hoarding behavior.
Incorrect Answers:
A. The client should be transported to an acute care facility if harm is suspected; however, there is another action the nurse should take first.
C. The home health nurse should alert the staff members that the client is hoarding medications to prevent similar occurrences in the future; however, there is another action the nurse should take first.
D. The nurse should retrieve the medications from the client to prevent future harm; however, there is another action the nurse should take first.

Question 14

A nurse is providing teaching to a client who has a prescription for ciprofloxacin following exposure to anthrax. Which of the following statements by the client indicates that further teaching is required?
• A. “I will limit my intake of coffee, tea, and carbonated beverages.”
• B. “I will wear a large-brim hat and long sleeves if I am out in the sun.”
• C. “I will take the ciprofloxacin with an antacid if I get an upset stomach.”
• D. “I will avoid taking ciprofloxacin along with dairy products.”

Answer 14

Correct Answer: C.
“I will take the ciprofloxacin with an antacid if I get an upset stomach.”

Ciprofloxacin is an antibiotic prescribed for a wide range of serious skin infections and is also effective against inhalation anthrax. Taking ciprofloxacin with antacids can impair the absorption of the medication, reducing its effectiveness.
Incorrect Answers:
A. The client should avoid caffeine while taking ciprofloxacin because it can trigger adverse effects of the nervous system, including irritability, anxiety, and restlessness.
B. A common adverse effect of ciprofloxacin is extreme photosensitivity, so clients taking ciprofloxacin must avoid sun exposure to prevent sunburns and blistering.
D. Taking ciprofloxacin with dairy products can impair the absorption of the medication, reducing its effectiveness, so clients should not take ciprofloxacin with milk or other dairy products

Question 15

A home hospice nurse is caring for a client who is dying. A family member of the client is talking to the nurse. Which of the following statements by the family member requires clarification by the nurse?
• A. “Although my father can’t get around very much, at least he is alert.”
• B. “My siblings and I have a schedule of when we are available to provide care for our father.”
• C. “My biggest concern is that I don’t want my father to be in any pain.”
• D. “I’m glad that professionals will be here in case my father stops breathing.”

Answer 15

Correct Answer: D.
“I’m glad that professionals will be here in case my father stops breathing.”

This statement will require clarification for two reasons. First, when a client is admitted to hospice, the care changes from curative to palliative. Hospice clients do not receive major medical interventions or resuscitative measures to prolong life like CPR. The nurse needs to determine if the family member understands and accepts the goals of hospice care. Second, home hospice care is provided primarily by family and volunteers. The nurse makes frequent visits to evaluate the client and provide support and education to the client’s primary caregivers, and assistive personnel might assist with the client’s ADL needs; however, a professional health care provider is not always in the client’s home.

Incorrect Answers:
A. A major goal of hospice care is maintaining the client’s quality of life. This statement does not require clarification.
B. Home hospice care is provided primarily by family members and volunteers. The goals of hospice care include providing support and instruction to these caregivers. This statement does not require clarification.
C. A major goal of hospice care is keeping the client as comfortable as possible. This statement does not require clarification.

Question 16

A community health nurse is caring for a client who was exposed to human immunodeficiency virus (HIV) 2 days ago. The client asks the nurse what she should do. Which of the following responses should the nurse provide?
• A. “I will administer an HIV vaccine today, and it will need to be repeated in 3 months.”
• B. “I will administer an HIV test today, and you will need to return in 48 hours to have me read the results.”
• C. “You will need to have an HIV test every other week for 6 months.”
• D. “You will need to take prophylactic medications for 4 weeks.”

Answer 16

Correct Answer: D.
“You will need to take prophylactic medications for 4 weeks.”

The client will need to take prophylactic medications for 4 weeks to prevent the virus from replicating within the body.
Incorrect Answers:
A. While vaccines for HIV are in the trial phase of development, a preventive vaccine is not currently available.
B. Once a test for tuberculosis is administered, the client must return in 48 to 72 hours for the nurse to read the test.
C. Following exposure to HIV, the client should return for testing at 4 to 6 weeks, 3 months, and 6 months.

Question 17

A community health nurse is teaching a group of adult clients about factors that influence health behaviors. Which of the following is a modifiable risk factor that the nurse should include in the teaching?
• A. Family history of diabetes
• B. Immunization status
• C. Mental illness
• D. Air pollution

Answer 17

Correct Answer: B.
Immunization status

Clients can modify their immunization status. A client can receive immunizations at any stage throughout his/her lifespan.
Incorrect Answers:
A. Clients cannot modify a family history of diabetes but can make lifestyle changes to prevent disease in the future.
C. Clients cannot modify a current illness or disease, such as mental illness. However, they can make lifestyle changes to help control the illness or disease.
D. Clients cannot modify air pollution. They can make changes to modify indoor pollutants in the home, but pollution outside and in other buildings occurs due to factors that clients cannot modify

Question 18

A home health nurse is prioritizing visits for four clients. Which of the following clients should the nurse plan to visit first?
• A. A client who has heart failure and reports a weight loss of 2.2 kg (1 lb) over the past week
• B. A client who has osteoarthritis of the knees and reports joint pain when ambulating
• C. A client who has Alzheimer’s disease and is not able to remember the current year
• D. A client who has type 2 diabetes mellitus and reports a new fissure between her toes

Answer 18

Correct Answer: D.
A client who has type 2 diabetes mellitus and reports a new fissure between her toes
The home health nurse should apply the acute versus chronic priority-setting framework when prioritizing home visits. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Since chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. The nurse should also attend to alterations in the acute phase so they do not escalate into a life-threatening event or evolve into a chronic alteration in health.
Clients who have type 2 diabetes mellitus are at risk for neurovascular compromise; therefore, the home health nurse should visit this client first to determine needed treatment and prevent further complications due to impaired skin integrity.

Incorrect Answers:
A. Heart failure is a chronic disorder, and weight fluctuations are expected. However, the nurse would be more concerned if the client reported a weight gain over the past week; therefore, the nurse should visit another client first.
B. Osteoarthritis is a chronic disorder, and joint pain is expected to worsen with movement or exercise; the nurse should visit another client first.
C. Alzheimer’s disease is a degenerative neurological disorder, and an inability to remember the current year is an expected finding; therefore, the nurse should visit another client first.

Question 19

A charge nurse in an emergency department is notified by the county’s emergency medical services of a multiple-casualty crash involving a truck carrying radioactive waste. Which of the following actions should the nurse take first?
• A. Designate a decontamination area to accommodate clients who are irradiated.
• B. Notify the admissions office to clear as many critical care beds as possible.
• C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area.
• D. Determine the number of casualties the emergency department can accommodate.

Answer 19

Correct Answer: C.
Clear the department of all non-urgent clients and move those awaiting admission to a holding area.

Evidence-based practice indicates the nurse should first clear the emergency department of non-urgent clients and open as many treatment areas as possible. Casualties of the crash will be brought to the emergency department, so the nurse must make room to accommodate the high number of clients.
Incorrect Answers:
A. The nurse should designate an area in which to decontaminate clients who are irradiated to prevent cross-contamination of hospital staff; however, evidence-based practice indicates the nurse should take a different action first.
B. The nurse should notify the admissions office to clear critical care beds to allow treatment of incoming clients who may have more critical injuries; however, evidence-based practice indicates the nurse should take a different action first.
D. The nurse should determine the number of casualties the emergency department can accommodate as an ongoing part of managing the flow of people into and out of the facility and to ensure resources are not overwhelmed. However, evidence-based practice indicates the nurse should take a different action first.

Question 20

A nurse is teaching a community group about smallpox. When discussing the possible means of transmission, which of the following statements by a member of the group indicates that further teaching is required?
• A. “Smallpox can be transmitted through bodily fluids, such as blood or vomit.”
• B. “Smallpox can be transmitted through contaminated objects, such as bedding and clothing.”
• C. “Smallpox can be transmitted through bites from insects, such as mosquitoes.”
• D. “Smallpox can be transmitted through inhalation of droplets, such as from coughing.”

Answer 20

Correct Answer: C.
“Smallpox can be transmitted through bites from insects, such as mosquitoes.”

Animals and insects have not been shown to be vectors (i.e. organisms capable of spreading a contagious disease to humans) for the smallpox virus.
Incorrect Answers:
A. Direct contact with the smallpox virus via exposure to an infected client’s bodily fluids, such as blood or vomit, is a known route for the transmission of smallpox.
B. Direct contact with the smallpox virus via contaminated objects, such as the bedding and clothing of an infected client, is a known route for the transmission of smallpox.
D. Direct contact with the smallpox virus via inhalation of droplets, such as from the cough of an infected client, is a known route for the transmission of smallpox.

Question 21

A nurse is responding to a community-wide request for health care providers to assist at the scene of an explosion. When using the North Atlantic Treaty Organization triage system, the nurse should put which of the following tags on a client who is unresponsive and has third-degree burns over 75% of her body?
• A. Red
• B. Yellow
• C. Green
• D. Black

Answer 21

Correct Answer: D.
Black

The nurse should put a black tag on clients who have extensive injuries to indicate a minimal chance of survival, such as a client who is unresponsive and has third-degree burns over 75% of her body.
Incorrect Answers:
A. The nurse should put a red tag on clients who have injuries that are life-threatening to indicate survival is expected with minimal interventions.
B. The nurse should put a yellow tag on clients who have significant injuries to indicate they can wait hours before treatment.
C. The nurse should put a green tag on clients who have minor injuries to indicate treatment can be delayed for multiple hours to days.

Question 22

A charge nurse in an emergency department is informed that a tornado touched down in a nearby town, and mass casualties are on the way. Which of the following actions should the nurse take first?
• A. Follow facility policy to activate the disaster plan.
• B. Prepare the triage rooms.
• C. Obtain additional supplies.
• D. Call in off-duty staff members.

Answer 22

Correct Answer: A.
Follow facility policy to activate the disaster plan.
The nurse has little information about this situation other than that several clients are expected in a short period of time. According to evidence-based practice, the nurse should first follow the facility’s policy for activating the disaster plan; this might mean calling the nursing supervisor or the administrator. The disaster plan will delineate the role and responsibilities of all responders, ensuring clients are treated in a safe and orderly manner by an adequate number of caregivers.

Incorrect Answers:
B. The nurse should prepare the triage rooms to facilitate rapid client prioritization; however, evidence-based practice indicates the nurse should take a different action first.
C. The nurse should obtain additional supplies to ensure the emergency department is stocked and ready to treat clients; however, evidence-based practice indicates the nurse should take a different action first.
D. The nurse might need to call in off-duty staff to care for a high number of incoming clients; however, evidence-based practice indicates the nurse should take a different action first.

Question 23

A nurse is caring for a client who has a positive Mantoux skin test following screening for tuberculosis (TB). The nurse should inform the client that this positive reaction indicates which of the following findings?
• A. The client has never been exposed to TB.
• B. The client had infectious TB in the past, but the infection is not active.
• C. The client has active TB.
• D. Further evaluation is required.

Answer 23

Correct Answer: D.
Further evaluation is required.

A positive Mantoux skin test indicates only that the client has been exposed to TB. Further evaluation will be needed through the use of sputum cultures and chest X-rays.
Incorrect Answers:
A. A Mantoux skin test screens for TB and detects tissue sensitivity to the bacteria that causes TB.
B. A positive Mantoux skin test indicates that body tissues are sensitive to TB, but it does not mean that the client currently has or previously had the disease.
C. A positive Mantoux skin test is not diagnostic for active TB.

Question 24

A community health nurse at a family-planning clinic is developing a program about adolescent sexuality. Which of the following is a developmental task of adolescence according to Erikson’s theory of psychosocial development?
• A. Adjusting to dramatic changes in body image
• B. Developing hypothetical reasoning skills
• C. Establishing the capacity for an intimate love relationship
• D. Learning to make good choices and avoid risk-taking behaviors

Answer 24

Correct Answer: A.
Adjusting to dramatic changes in body image

According to Erikson, the major developmental task in adolescent clients (12 to 18 years of age) is identity vs. role confusion. In this stage, adolescents are preoccupied with their changing bodies and how their bodies appear to others.
Incorrect Answers:
B. This task describes Piaget’s stage of formal operational thought, which is characterized by the development of logical and hypothetical reasoning in adolescents.
C. This task describes Erikson’s stage of intimacy vs. isolation, which occurs in early adulthood.
D. Safety is not a major developmental task for adolescents. However, risk-taking behaviors are the primary reason for unintentional injury, which is the most common cause of death in adolescents.

Question 25

An occupational health nurse is teaching a group of clients about work environment risks. Which of the following actions is the nurse performing? • A. Case management • B. Secondary prevention • C. Tertiary prevention • D. Primary prevention

Answer 25

Correct Answer: D. Primary prevention This nursing action is an example of primary prevention of accidents in the workplace. Incorrect Answers: A. Case management is the coordination of care in order to improve client outcomes. B. The goal of secondary prevention is to detect levels of disease in a population and refer people for treatment. An example of secondary prevention is a hearing screening program that is indicated due to excessive noise in the work environment. C. The goal of tertiary prevention is to limit disability caused by disease in a population. An example of tertiary prevention is working with members of the population who have diabetes to decrease the number of work days lost due to complications.

Question 26

A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse’s responsibility in this setting? • A. Fostering positive public relations for the facility • B. Performing a comprehensive client assessment • C. Preventing cross-contamination of infectious clients • D. Educating a client and his family members

Answer 26

Correct Answer: D. Educating a client and his family members In the triage setting, the nurse’s priority is assessment and control of client flow. The triage nurse does not allocate time to provide education to clients or their families. Education is handled by the emergency department staff once the treatment of a client begins. Incorrect Answers: A. In most instances, the triage nurse is the first professional the client encounters when seeking emergency services. Professionalism and positive client relations are necessary behaviors for the triage nurse to implement in order to foster a positive perception of the facility. B. The triage nurse does perform comprehensive assessments to determine the urgency status of the clients' conditions. C. Preventing cross-contamination of infectious clients is a responsibility of the triage nurse. In this setting, the nurse must be able to separate clients to prevent cross infection from one client to another.

Question 27

A nurse is providing teaching to a client about healthy lifestyle changes. The client states, "I work long hours. I never have time for exercising or eating anything besides fast food." Which of the following goals should the nurse include in the client’s nursing plan of care? • A. The client will improve overall health by the next visit. • B. The client will introduce two green vegetables into her diet by the end of the month. • C. The client will reduce daily stress and increase activity by exercising. • D. The client will reduce her weight by 4.5 kg (10 lb) within 2 weeks.

Answer 27

Correct Answer: B. The client will introduce two green vegetables into her diet by the end of the month. This goal is simple, measurable, and realistic. The nurse should work with the client to develop goals that are realistic and achievable in order to promote client success. Incorrect Answers: A. This goal is vague and difficult to measure. Goals should not include terms that require interpretation. C. This is actually two goals when it should be one goal that states a single idea. In addition, these goals are somewhat vague, difficult to measure, and have no set timeframe for achievement. D. This goal is unrealistic. Losing a large amount of weight in a short period of time is difficult, potentially unsafe, and challenging to maintain.

Question 28

A home health nurse is performing an assessment of an older adult client’s home. Which of the following findings should the nurse recognize as a potential hazard? • A. Hot water temperature set at 46°C (115°F) • B. A night light in each room of the house • C. A secured large area rug in the living room • D. Wires to the television tunneled under the carpet

Answer 28

Correct Answer: D. Wires to the television tunneled under the carpet The nurse should recognize that wires tunneled under the carpet are a fire hazard. Incorrect Answers: A. To prevent burns, the nurse should ensure the hot water temperature is set at or below 49°C (120°F). B. To prevent injury, the nurse should ensure the home has adequate lighting for when the client gets out of bed at night. C. To prevent falls, the nurse should ensure throw rugs are secured.

Question 29

A home health nurse and an assistive personnel (AP) are discussing the care needs of a client. Which of the following statements by the AP requires intervention by the nurse? • A. "I will change the client’s PICC line dressing on my next visit." • B. "Bathing the client is something that I can do without assistance." • C. "I will assist the client in ambulating outdoors each time I visit." • D. "Next time I visit, I plan to clean up the clutter in the client’s bedroom."

Answer 29

Correct Answer: A. "I will change the client’s PICC line dressing on my next visit." Changing IV dressings is not within the AP's scope of practice. The nurse should investigate this statement. Incorrect Answers: B. The AP can provide personal hygiene care for the client without supervision or assistance from the nurse. C. Ambulation is within the scope of practice for the AP. D. Light homemaking activities, such as changing linens and cleaning rooms, are within the scope of practice for the AP.

Question 30

A nurse is conducting a screening class for hypertension. Which of the following should be the nurse's goal for secondary prevention? • A. Prevent the onset of the condition • B. Identify the severity of the condition • C. Identify the condition early • D. Deter condition-related complications

Answer 30

Correct Answer: C. Identify the condition early Secondary prevention measures identify and treat asymptomatic people who have already developed risk factors or preclinical disease but do not have a clinically apparent condition. The goal of secondary prevention is early identification of the target condition. Incorrect Answers: A. Primary prevention is used to prevent a health condition or disease outcome. Primary prevention measures are provided to individuals to prevent the onset of a targeted condition. A classic example of primary prevention is immunization. B. Identification of the severity of a condition is not a secondary prevention measure. Secondary prevention is used for early identification of the target condition. D. Tertiary prevention activities involve the care of established disease. Attempts are made to restore clients to optimal levels of function, minimize the negative effects of the disease, and prevent disease-related complications.

Question 31

A public health nurse is assisting community leaders to develop a disaster response plan in the event of an outbreak of a serious communicable disease. When teaching the community leaders about infectious disease, the nurse should explain that a vector is which of the following? • A. A mode of transmission for the disease • B. A microorganism that causes the infection • C. An environment where the pathogen can survive • D. A client who is susceptible to the infection

Answer 31

Correct Answer: A. A mode of transmission for the disease In the chain of infection, the vector is the mode of transmission for the disease or the method of transfer by which the organism moves or is carried from one place to another. Incorrect Answers: B. The microorganism that causes the infection is the pathogen or infectious agent. Infectious agents include viruses, bacteria, fungi, and parasites. C. The environment where the pathogen can survive is the reservoir, a place within which microorganisms can thrive and reproduce. D. A client who is susceptible to infection is a susceptible host. The host is susceptible to the disease due to a lack of immunity or physical resistance to overcome the invasion by the pathogenic microorganism.

Question 32

An industrial health nurse is caring for a client who states, "I have been under a lot of stress lately." When the nurse suggests stress-management techniques, the client calmly states that he has a pistol in his car and intends to take his life in the parking lot after work that day. Which of the following actions should the nurse take? • A. Have the industrial facility's security officers search the client’s car and remove the pistol • B. Call emergency medical services to transport the client to a proper treatment facility • C. Contact the client’s family member to pick him up from work and take him for treatment • D. Explore the client’s reasons for suicide

Answer 32

Correct Answer: B. Call emergency medical services to transport the client to a proper treatment facility Client safety is the nurse's primary concern. This client must be transported to a treatment facility as soon as possible. In addition, the nurse should not leave the client alone until he is safely evaluated by or admitted to a proper care facility. Incorrect Answers: A. There may be privacy and legal issues associated with having a facility employee enter a client's private vehicle. C. Privacy issues and HIPAA regulations restrict the nurse from contacting the client’s family without his permission. In addition, once the client has revealed his suicidal intent to the nurse, it is the nurse’s responsibility to make certain that he receives proper mental health care as soon as possible. D. The tertiary intervention phase will involve exploration of the client’s feelings about suicide.

Question 33

A nurse on a bioterrorism committee is developing a brochure to increase public awareness about the threat of inhalation anthrax. Which of the following pieces of information should the nurse plan to include in the brochure? • A. An immunization for inhalation anthrax is recommended for administration to children. • B. Clients who have manifestations of inhalation anthrax will need antibiotic treatment for 60 days. • C. The initial manifestations of inhalation anthrax include an itchy skin lesion that blisters and scabs. • D. Clients exposed to housemates who have inhalation anthrax must receive prophylactic treatment.

Answer 33

Correct Answer: B. Clients who have manifestations of inhalation anthrax will need antibiotic treatment for 60 days. Anthrax is an infectious disease caused by a spore-forming bacterium called Bacillus anthracis. Infection in humans most often involves the skin (cutaneous anthrax), the gastrointestinal tract, or the lungs (inhalation anthrax). After infection, anthrax is treated with antibiotics for 60 days. The success of the treatment depends on how long the client has had the infection prior to beginning treatment and the type of anthrax. Incorrect Answers: A. An immunization for inhalation anthrax has been developed and is given in a 6-dose series, but it is not given to children. C. The first stage of inhalation anthrax is a flu-like syndrome. D. There is no transmission of inhalation anthrax from person to person. Household contacts of individuals with inhalation anthrax do not need antibiotics unless they have also been exposed to the same source of anthrax.

Question 34

A public health nurse is responsible for several activities in the local community. Through which of the following actions is the nurse is implementing tertiary prevention? • A. Teaching stress-reduction techniques to parents of children who have developmental delays • B. Advocating for the expansion of mental health rehabilitation facilities with community leaders • C. Performing screenings for depression for older adult clients • D. Coordinating a drive-through clinic for influenza immunizations

Answer 34

Correct Answer: B. Advocating for the expansion of mental health rehabilitation facilities with community leaders The nurse is implementing tertiary prevention when advocating for the expansion of mental health rehabilitation facilities with community leaders. These services will assist with limiting negative outcomes related to a mental health diagnosis. Incorrect Answers: A. The nurse is implementing primary prevention when teaching stress-reduction techniques to parents of children who have developmental delays. This action will help clients prevent anxiety and promote overall wellbeing. C. The nurse is implementing secondary prevention when performing screenings for depression for older adult clients. This action allows early detection and intervention for those exhibiting manifestations of depression. D. The nurse is implementing primary prevention when coordinating a drive-through clinic for influenza immunizations. This action will assist with the prevention of a local outbreak of influenza.

Question 35

A triage nurse is in the emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. Which of the following clients requires immediate treatment? • A. A client who has neck pain and was transported to the facility on a backboard • B. A client who has epigastric and left arm pain and is diaphoretic • C. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min • D. A client who has abdominal pain and is 2 months pregnant

Answer 35

Correct Answer: B. A client who has epigastric and left arm pain and is diaphoretic The nurse should apply the unstable versus stable priority-setting framework. Using this framework, unstable clients are the priority because of needs that threaten survival. Threats or problems involving the airway, breathing, or circulatory status are life-threatening needs that the nurse should address first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. A report of severe epigastric and left arm pain accompanied by diaphoresis is a classic manifestation of a myocardial infarction, which is life-threatening and requires immediate treatment. Incorrect Answers: A. A client who has neck pain and was transported to the facility on a backboard is stable. Neck pain is most commonly associated with a whiplash injury. C. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min is stable. A broken nose or a black eye is common following a collision. This respiratory rate indicates an adequate airway. D. A client who has abdominal pain and is 2 months pregnant is stable. Although the client's pregnancy can cause a complication, at 2 months of gestation, little can be done to prevent fetal demise if she has suffered serious abdominal trauma.

Question 36

A nurse is planning a health fair for a local community. Which of the following should be the nurse's priority when deciding which screening programs will benefit this population the most? • A. Identify prevalent health problems in the community • B. Identify health care resources available to clients in the community • C. Identify the cost of the screening programs • D. Identify the availability of transportation to the health fair

Answer 36

Correct Answer: A. Identify prevalent health problems in the community In order to meet the needs of the local community, the nurse should identify prevalent health problems within the area; therefore, this should be the nurse’s priority consideration when deciding which screening programs to have available at the health fair. Incorrect Answers: B. The nurse should identify health care resources available to clients in the community in order to determine what needs are already being met; however, there is another action that is the nurse’s priority. C. The nurse should identify the cost of screening programs in order to ensure money is being allocated to the highest-priority needs; however, there is another action that is the nurse’s priority. D. The nurse should identify the availability of transportation to the health fair in order to ensure community members can attend; however, there is another action that is the nurse’s priority.

Question 37

A nurse is planning to participate in a public education program about preventing West Nile virus. Which of the following instructions should the nurse include in the presentation? • A. "Eliminate sources of standing water." • B. "Make sure your immunizations are up to date." • C. "Keep all of your pets indoors." • D. "Spray insect nests with a repellant that contains DEET."

Answer 37

Correct Answer: A. "Eliminate sources of standing water." Standing water provides an environment for mosquitoes to lay eggs. Therefore, clients should empty water from flower pots, pet dishes, birdbaths, swimming pool covers, buckets, barrels, and cans at least once per week. Discarded tires and other items that collect water should be disposed of. Incorrect Answers: B. There is no known immunization against the West Nile virus; therefore, clients should be educated about other prevention measures. C. West Nile virus is not transmitted through pets but can be transmitted from person to person through blood products, breast milk, or organ transplantation. D. West Nile virus can be transmitted when an infected mosquito bites a human to take in blood. Diethyltoluamide (DEET) is the most effective and best-studied insect repellent available. Studies using humans and mosquitoes report that only products containing DEET offer long-lasting protection after a single application; however, DEET only repels; it does not kill. There would be no benefit to spraying DEET anywhere except on the human body or clothing.

Question 38

A public health nurse is caring for an older adult client who has chronic airflow limitation disease and is a former cigarette smoker. The client’s medications include ipratropium bromide and albuterol inhalers, and she has a new prescription for home oxygen to use as needed. Primary prevention for this client should include which of the following? • A. Periodic pulmonary function tests • B. Review of appropriate use of oxygen in the home • C. Yearly mammography examinations • D. Annual influenza immunizations

Answer 38

Correct Answer: D. Annual influenza immunizations An influenza immunization is an example of primary prevention. This client should receive influenza immunizations annually because she is at increased risk of complications of influenza. Incorrect Answers: A. Periodic pulmonary function tests for a client who has an existing lung disorder are an example of tertiary prevention. B. Reviewing the appropriate use of oxygen in the home is an example of tertiary prevention. C. Screening examinations, such as a mammogram, are examples of secondary prevention.

Question 39

A charge nurse in an emergency department receives notification of a massive explosion at a local industrial plant. More than 30 casualties from the explosion will begin arriving shortly. Which of the following actions should the nurse take first? • A. Activate the emergency response plan. • B. Call in available personnel. • C. Obtain additional supplies. • D. Move current clients to hospital rooms.

Answer 39

Correct Answer: A. Activate the emergency response plan. The greatest risk to the incoming clients is further injury due to delayed assessment and intervention. There is also a risk of injury to current clients due to lack of care while the emergency department personnel attend to incoming clients. The emergency response plan activates protocols to mitigate these risks. Incorrect Answers: B. The designated person in a disaster should call in available personnel in order to ensure enough people are on duty to address clients' needs; however, this is not the first action the nurse should take. C. The designated person in a disaster should obtain additional supplies for all the clients coming to the emergency department; however, this is not the first action the nurse should take. D. The designated person in a disaster should move current clients to hospital rooms to make space for treating the clients coming to the emergency department; however, this is not the first action the nurse should take.

Question 40

A nurse is teaching a group of older adult clients about complementary and alternative therapies. Which of the following interventions should the nurse recommend to improve balance? • A. Naturopathic medicine • B. Magnet therapy • C. Tai chi • D. Progressive relaxation therapy

Answer 40

Correct Answer: C. Tai chi Tai chi is an ancient Chinese martial art consisting of a series of slow, gentle, continuous movements. Older adult clients who take part in structured tai chi programs improve their balance and physical strength, which reduces the risk of falls. Incorrect Answers: A. Naturopathic medicine focuses on treating the whole client and promoting health. B. Magnet therapy can aid chronic pain and musculoskeletal disorders. D. Progressive relaxation therapy can lower blood pressure and heart rate, increase wellbeing, and decrease muscle tension.