Book Questions Flashcards
Basic Care and Comfort
A client with Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion would the nurse provide to the client to alleviate this problem?
1. Use a wheelchair to move around.
2. Stand erect and use a cane to ambulate.
3. Keep the feet close together while ambulating and use a
walker.
4. Consciously think about walking over imaginary lines on the floor.
Answer: 4
This question addresses the subcategory Basic Care and Comfort in the Client Needs category Physiological Integrity and addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Focus on the subject, akinesia. Clients with Parkinson’s disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.
Health Promotion and Maintenance
The nurse is choosing age-appropriate toys for a toddler.
Which toy is the best choice for this age?
1. Puzzle
2. Loy soldiers
3. Large stacking blocks
4. A card game with large pictures
Answer: 3
This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Note the strategic word, best. Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.
Psychosocial integrity
A client with end stage chronic obstructive pulmonary disease
As selected guided imagery to help cope with psychological Ares. Which dient statement indicates an understanding o this stress-reduction measure?
1. “This will help only if I play music at the same time.”
2.”This will work for me only if I am alone in a quiet area
3. “I need to do this only when I lie down in case I fa asleep.”
4. “The best thing about this is that I can use it anywhere anytime.”
Answer: 4
This question addresses the Client Needs categ Psychosocial Integrity and the content addresses cop mechanisms. Focus on the subject, a characteristic of guic imagery. Guided imagery involves the client creating image in the mind, concentrating on the image, and gradu: becoming less aware of the offending stimulus. It can be dor: anytime and anywhere; some clients may use other relaxation techniques or play music with it.
Pharmacological and Parenteral Therapies
The nurse monitors a client receiving digoxin for which manifestation of digoxin toxicity?
1. Anorexia
2. Facial pain
3. Photophobia
4. Yellow color perception
Answer: 1
This question addresses the subcategory Pharmacologic and Parenteral Therapies in the Client Needs categon Physiological Integrity. Note the strategie word, early!! Digoxin is a cardiac glycoside that is used to manage and treat her failure and to control ventricular rates in clients with ate fibrillation. The most common early manifestations oftoxico include gastrointestinal disturbances such as anorens nausea, and vomiting. Neurological abnormalities c also occur early and include fatigue, headache, depressien weakness, drowsiness, confusion, and nightmares Facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs.
Reduction of Risk Potential
A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse would implement which action to prepare the client for this test?
1. Shave the groin for insertion of a femoral catheter.
2. Remove all metal-containing objects from the client.
3. Keep the client NO (nothing by mouth) for 6 hours be.
fore the test.
4. Instruct the client in inhalation techniques for the administration of the radioisotope.
Answer: 2
This question addresses the subcategory Reduction of Risk Potential in the Client Needs category Physiological Integrity, and the nurse’s responsibilities in preparing the client for the diagnostic test. Focus on the subject, preparing a client for an MRI. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a histor should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. A femoral catheter is not used for this diagnostic test.
An intravenous (IV) catheter may be inserted if a contrast agent is prescribed. Additionally, shaving is not a common practice because of the risk for microabrasions and infection. If needed, hair may be clipped away from a surgical or insertion site. NPO status is not necessary for an MRI study of the head. Inhalation of the radioisotope may be prescribed with other types of scans but is not a part of the procedures for an MRI.
Physiological Adaptation
A client with renal insufficiency has a magnesium level of 3.5 mEq/L (1.44 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant?
1. Hyperpnea
2. Drowsiness
3. Hypertension
4. Physical hyperactivity
Answer: 2
This question addresses the subcategory Physiological Adaptation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. Focus on the data in the question. The normal magnesium level is 1.8 to 2.6 mEq/L (0.74 to 1.07 mmol/L). A magnesium level of 3.5 m Eq/L (1.44 mmol/L). indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.
A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic?
1. “Can you tell me what you understand about the procedure?”
2. “Your fears are a sign that you really should have this procedure.”
3. “Those are very normal fears, but please be assured that everything will be okay.”
4. “Try not to worry. This is a well-known and easy procedure for the cardiologist.”
Answer: 1
This question addresses the subcategory Caring in the category of Integrated Processes. The correct option utilizes a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold.
Option 4 diminishes the client’s feelings by directing attention away from the client and toward the health care provider’s importance.
Fill-in-the-Blank Question
A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads:
500 mg/15 mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank. Record your answer using one decimal place.
Answer: 19.5 mL
BOX 1-8 Multiple-Response Question
The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply.
1. Obtain a throat culture.
2. Auscultate lung sounds.
3. Prepare the child for a chest x-ray.
4. Maintain the child in a supine position.
5. Obtain a pediatric-size tracheostomy tray.
6. Place the child on an oxygen saturation monitor.
- Auscultate lung sounds.
- Prepare the child for a chest x-ray.
- Obtain a pediatric-size tracheostomy tray.
- Place the child on an oxygen saturation monitor.
The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea during activity. After assisting the client to bed and placing the client in high-Fowler’s position, the nurse would take which immediate action?
1. Administer high-flow oxygen to the client.
2. Call the consulting cardiologist to report the findings.
3. Prepare to administer an additional dose of furosemide.
4. Obtain a set of vital signs and perform focused respiratory and cardiovascular assessments.
Answer: 4
When a question is talking about prioritization, what skills and orders need to be remembered?
ABCs
Maslow’s Hierarchy of Needs
Nursing Process
Cognitive skills in CJMM (AAPIE)
Maslow’s Hierarchy of Needs
Bottom to Top
- Basic Physiological Needs (airway, breathing, circulation, nutrition, and elimination)
- Safety and Security ( protect from injury, promote feeling secure, trust in client-nurse relationship)
- love and belonging ( support systems and protect from isolation)
- self esteem ( control, competence, positive regard, and acceptance)
- self actualization (hope, spiritual well-being, and enhanced growth)
A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action would the nurse take first?
1. Elevate the arm.
2. Document the findings.
3. Medicate with an additional dose of an opioid.
4. Check for paresthesias and paralysis of the right arm.
Answer: 4
Test-Taking Strategy: This question measures the cognitive skill, take action. Note the strategic word, first. Based on the data in the question, determine whether an abnormality exists. The question event indicates that the client complains of pain at the wrist when the arm is passively moved. This could indicate an abnormality; therefore, the nurse needs to take action and further assessment or intervention is required. Use the steps of the nursing process, remembering that assessment is the first step. The only option that addresses assessment is the correct option. Options 1, 2, and 3 address the implementation step of the nursing process.
Also, these options are incorrect first actions. The arm in a cast should should have already been elevated. The client may be experiencing compartment syndrome, a complication following trauma to the extremities and application of a cast. Additional data need to be collected to determine whether this complication is present.
Remember that assessment is the first step in the nursing process.
AAPIE
Assessment (subjective and objective data)
Analysis( connect data to patient’s problems- expected or unexpected)
I wish they would like make in the books like little flaps. Can’t see the answer until you flip it over.
Planning(prioritize hypothesis highest needs to lowest)
- actual problems prior to potential problems
Implement (doing the nursing action)
Evaluation (compare observed outcomes to expected)
- usually negative event queries
If the question presents and emergency situation what takes priority?
Action rather than obtaining more data
If a patient presents with an abnormality what would the nurse do?
Further investigation or assessment of the problem
NOT continuing to monitor and document
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco, 30 mm Hg, and HCO, 22 mEq/L (22 mmol/L). The nurse analyzes these results as indicating which condition?
1. Metabolic acidosis, compensated
2. Respiratory alkalosis, compensated
3. Metabolic alkalosis, uncompensated
4. Respiratory acidosis, uncompensated
Answer: 2
Test-Taking Strategy: Use the steps of the nursing process and analyze cues, the blood gas values. The question does not require further assessment; therefore, it is appropriate to move to the next step in the nursing process, analysis.
The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco,. In this situation, the pH is at the high end of the normal value and the Pco, is low. So, you can eliminate options 1 and 3. In an alkalytic condition, the pH is elevated. The values identified indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred.
Remember that analysis is the second step in the nursing process.
BOX 4-13
practice Question: The Nursing
Process–Planning
The nurse developing a plan of care for a client with a catara, understands that which problem is the priority?
1. Concern about the loss of eyesight
2. Altered vision due to opacity of the ocular lens
3. Difficulty moving around because of the need for glasses
4. Becoming lonely because of decreased community immersion
Answer: 2
Test-Taking Strategy: Note the strategic word, priority, and use the steps of the nursing process. This question relates to prioritizing hypotheses and planning nursing care and asks you to identify the priority problem. Use Maslow’s Hierarchy of Needs theory to answer the question, remembering that physiological needs are the priority.
Concern and becoming lonely are psychosocial needs and would be the last priorities. Note that the correct option directly addresses the client’s problem. Remember that planning is the third step of the nursing process.
BOX 4-14 Practice Question: The Nursing
Process–Implementation
The nurse is caring for a hospitalized client with angina pectoris who begins to experience chest pain. The nurse administers a nitroglycerin tablet sublingually as prescribed, but the pain is unrelieved. The nurse would take which action next?
1. Reposition the client.
2. Call the client’s family.
3. Contact the health care provider.
4. Administer another nitroglycerin tablet.
Answer: 4
Test-Taking Strategy: This question measures the cognitive skill, take action. Note the strategic word, next, and use the steps of the nursing process. Implementation questions address the process of organizing and managing care. This question also requires that you prioritize nursing actions. Additionally, focus on the data in the question to assist in avoiding reading into the question. You may think it is necessary to check the blood pressure before administering another tablet, which is correct. However, there are no data in the question indicating that the blood pressure is abnormal and could not sustain if another tablet were given. In addition, checking the blood pressure is not one of the options. Recalling that the nurse would administer 3 nitroglycerin tablets 5 minutes apart from each other to relieve chest pain in a hospitalized client will assist in directing you to the correct option. Remember that implementation is the fourth step of the nursing process.
The nurse is evaluating the client’s response to treatment of a pleural effusion with a chest tube. The nurse notes a respiratory rate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 ml since the previous shift. Based on this information, which interpretation would the nurse make?
1. The client is responding well to treatment.
2. Suction should be decreased to the system.
3. The system should be assessed for an air leak.
4. Water should be added to the water seal chamber.
Answer: 1
Test-Taking Strategy: Use the steps of the nursing process and note that the nurse needs to evaluate the client’s response to treatment; therefore this question measures the cognitive skill, evaluate outcomes. Focus on the subject and the data in the question. Also, determine whether an abnormality exists based on these data. Remember that fluctuation in the water seal chamber is a normal and expected finding with a chest tube.
Because the client is being treated for a pleural effusion, it can be determined that he or she is responding well to treatment if the amount of drainage is gradually decreasing because the fluid from the pleural effusion is being effectively removed. If the drainage were to stop suddenly, the chest tube should be assessed for a kink or blockage. There is no indication based on the data in the question to decrease suction to the system; in fact, it is unclear as to whether the client is on suction at all.
There are also no data in the question indicating an air leak.
Lastly, there are no data in the question indicating the need to add water to the water seal chamber; again, it is unclear as to whether the client has this type of chest tube versus a dry suction chest tube. Remember that evaluation is the fifth step of the nursing process.
What are hallmark signs of digoxin toxicity?
Anorexia, nausea, and vomiting
BOX 4-17 Practice Question: Communication
A client scheduled for surgery states to the nurse, “I’m not sure if I should have this surgery.” Which response by the nurse is appropriate?
1. “It’s your decision.”
2. “Don’t worry. Everything will be fine.”
3. “Why don’t you want to have this surgery?”
4. “Tell me what concerns you have about the surgery.”
Answer: 4
Test-Taking Strategy: This question measures the cognitive skill, take action. Use therapeutic communication techniques to answer communication questions and remember to focus on the client’s thoughts, feelings, concerns, anxieties, and fears. The correct option is the only one that addresses the client’s concern. Additionally, asking the client about what specific concerns he or she has about the surgery will allow for further decisions in the treatment process to be made.
Option 1 is a blunt response and does not address the client’s concern. Option 2 provides false reassurance. Option 3 can make the client feel defensive and uses the nontherapeutic communication technique of asking “why” Remember to use therapeutic communication techniques and focus on the client.
BOX 4-18 Practice Question: Eliminate
Comparable or Alike Options
The nurse is caring for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
1. The client taking diuretics
2. The client with an ileostomy
3. The client with kidney disease
4. The client undergoing gastrointestinal suctioning
Answer: 3
Test-Taking Strategy: This question measures the cognitive skill, analyzing cues. Focus on the subject, the client at risk for excess fluid volume. Think about the pathophysiology associated with each condition identified in the options. The only client who retains fluid is the client with kidney disease. The client taking diuretics, the client with an ileostomy, and the client undergoing gastrointestinal suctioning all lose fluid; these are comparable or alike options. Remember to eliminate comparable or alike options.
A client is to undergo a computed tomography (CT) scan of the abdomen with oral contrast, and the nurse provides preprocedure instructions. The nurse instructs the client to take which action in the preprocedure period?
1. Avoid eating or drinking for at least 3 hours before the test.
2. Limit self to only 2 cigarettes on the morning of the test.
3. Have a clear liquid breakfast only on the morning of the test.
4. Take all routine medications with a glass of water on the morning of the test.
Answer: 1
Test-Taking Strategy: This question measures the cognitive skill, take action. Note the closed-ended words “only” in options 2 and 3 and “all” in option 4. Eliminate options that contain closed-ended words, because these options are usually incorrect. Also, note that options 2, 3, and 4 are comparable or alike options in that they all involve taking in something on the morning of the test. Remember to eliminate options that contain closed-ended words.
