Exam FUCKING 1 Flashcards
A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?
a. Lives in a nursing home
b. Lives with a spouse
c. Lives divorced
d. Lives alone
ANS B:
In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women,
71% of older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all
older adults resided in institutions such as nursing homes or centers. Most older adults have lost a
spouse due to death rather than divorce
A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
a. Should be standardized because most geriatric patients have the same needs
b. Needs to be individualized to the patient’s unique needs
c. Focuses on the disabilities that all aging persons face
d. Must be based on chronological age alone
Every older adult is unique, and the nurse needs to approach each one as a unique individual. The
nursing care of older adults poses special challenges because of great variation in their physiological,
cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence.
Chronological age often has little relation to the reality of aging for an older adult.
Which information from a co-worker on a gerontological unit will cause the nurse to intervene?
a. Most older people have dependent functioning.
b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision.
d. Most older people should be encouraged to have independence
ANS: A
Most older people remain functionally independent despite the increasing prevalence of chronic
disease; therefore, this misconception should be addressed. It is critical for you to respect older adults
and actively involve them in care decisions and activities. You also need to identify an older adult’s
strengths and abilities during the assessment and encourage independence as an integral part of your
plan of care
A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment
findings are consistent with the nurse’ssuspicions?
a. Flea bites and lice infestation
b. Left at a grocery store
c. Refuses to take a bath
d. Cuts and bruises
ANS: A
Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect
infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as
a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities
such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse
includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs,
fractures, lacerations, rope burns, and untreated injuries
A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to
use?
a. Provide several topics of discussion at once to promote independence and making choices.
b. Avoid uncomfortable silences after questions by helping patients complete their statements.
c. Ask patients to recall past experiences that correspond with their interests.
d. Speak in a high pitch to help patients hear better
ANS: C
Teaching strategies include the use of past experiences to connect new learning with previous
knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time
in which to respond because older adults’ reaction times are longer than those of younger persons,
and keeping the tone of voice low; older adults are able to hear low sounds better than high frequency sounds
An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is
concerned about the patient’s ability to care for self, especially during this convalescence. What
should the nurse do?
a. Stress that older patients usually ask for help when needed.
b. Inform the family that placement in a nursing center is a permanent solution. c. Tell the family to enroll the patient in a ceramics class to maintain quality of life.
d. Provide information and answer questions as family members make choices among care options
ANS: D
Nurses help older adults and their families by providing information and answering questions as they
make choices among care options. Some older adults deny functional declines and refuse to ask for
assistance with tasks that place their safety at great risk. The decision to enter a nursing center is
never final, and a nursing center resident sometimes is discharged to home or to another less-acute
residence. What defines quality of life varies and is unique for each person
What is the best suggestion a nurse could make to a family requesting help in selecting a local
nursing center?
a.
Have the family members evaluate nursing home staff according to their ability to get tasks done efficient
safely.
b. Make sure that nursing home staff members get patients out of bed and dressed according to staff’s prefer
c. Explain that it is important for the family to visit the center and inspect it personally.
d. Suggest a nursing center that has standards as close to hospital standards as possible
ANS: C
An important step in the process of selecting a nursing home is to visit the nursing home. The nursing
home should not feel like a hospital. It is a home, a place where people live. Members of the nursing
home staff should focus on the person, not the task. Residents should be out of bed and dressed
according to their preferences, not staff preferences.
A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The
nurse is discussing health care services and possible long-term living arrangements with thepatient’s
only son. What will the nurse suggest?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
d. That placement is irrelevant because the patient is retreating to a place of inactivity
ANS: C
Some family caregivers consider nursing center placement when in-home care becomes increasingly
difficult or when convalescence from hospitalization requires more assistance than the family is able
to provide. An apartment setting and the use of home health visits are not appropriate because living
at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning
A nurse is caring for an older adult. Which goal is priority?
a. Adjusting to career
b. Adjusting to divorce
c. Adjusting to retirement
d. Adjusting to grandchildren
ANS: C
Adjusting to retirement is one of the developmental tasks for an older person. A young or middle aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing?
a. Loss of finances through changes in income
b. Loss of relationships through death
c. Loss of career through retirement
d. Loss of home through relocation
ANS: B
The universal loss for older adults usually revolves around the loss of relationships through death.
Life transitions, of which loss is a major component, include retirement and the associated financial
changes, changes in roles and relationships, alterations in health and functional ability, changes in
one’s social network, and relocation. However, these are not the universal loss
A nurse is discussing sexuality with an older adult. Which action will the nurse take?
a. Ask closed-ended questions about specific symptoms the patient may experience.
b. Provide information about the prevention of sexually transmitted infections .c. Discuss the issues of sexuality in a group in a private room.
d. Explain that sexuality is not necessary as one ages.
ANS: B
Include information about the prevention of sexually transmitted infections when appropriate. Openended questions inviting an older adult to explain sexual activities or concerns elicit more
information than a list of closed-ended questions about specific activities or symptoms. You need to
provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and
the need to express sexual feelings remain throughout the human life span.
A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4
ANS: BHeart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents).
A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men
ANS: C
Loss of skin elasticity is a common finding in the older adult. Other common findings include
pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair:
decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles
An older-adult patient in no acute distress reports being less able to taste and smell. What is the
nurse’s bestresponse to this information?
a. Notify the health care provider immediately to rule out cranial nerve damage.
b. Schedule the patient for an appointment at a smell and taste disorders clinic.c. Perform testing on the vestibulocochlear nerve and a hearing test.
d. Explain to the patient that diminished senses are normal findings.
ANS: D
Diminished taste and smell senses are common findings in older adults. Scheduling an appointment
at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out
cranial nerve damage is unnecessary at this time as per the information provided
A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills
ANS: C
Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment,
such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are
not normal aging changes and require further investigation of underlying causes
An older patient with dementia and confusion is admitted to the nursing unit after hip
replacement surgery. Which action will the nurse include in the plan of care?
a. Keep a routine.
b. Continue to reorient.
c. Allow several choices.
d. Socially isolate patient
ANS: A
Patients with dementia need a routine. Continuing to reorient a patient with dementia is
nonproductive and not advised. Patients with dementia need limited choices. Social interaction based
on the patient’s abilities is to be promoted
A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse
will be assisting the patient with which activity?
a. Taking a bath
b. Getting dressed
c. Making a phone call
d. Going to the bathroom
ANS: CInstrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare
meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and
toileting) are essential to independent living
A male older-adult patient expresses concern and anxiety about decreased penile firmness during
an erection. What is the nurse’s best response?
a. Tell the patient that libido will always decrease, as well as the sexual desires.
b. Tell the patient that touching should be avoided unless intercourse is planned.
c. Tell the patient that heterosexuality will help maintain stronger libido.
d. Tell the patient that this change is expected in aging adults
ANS: D
Aging men typically experience an erection that is less firm and shorter acting and have a less
forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of
libido. However, for both men and women sexual desires, thoughts, and actions continue throughout
all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of
intercourse. Touch complements traditional sexual methods or serves as an alternative sexual
expression when physical intercourse is not desired or possible. Clearly not all older adults are
heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender
individuals and their health care needs.
. A patient asks the nurse what the term polypharmacy means. Which information should the nurse
share with the patient?
a. This is multiple side effects experienced when taking medications.
b. This is many adverse drug effects reported to the pharmacy.
c. This is the multiple risks of medication effects due to aging.
d. This is concurrent use of many medications
ANS: D
Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with
side effects, adverse drug effects, or risks of medication use due to aging
An outcome for an older-adult patient living alone is to be free from falls. Which statement
indicates the patient correctly understands the teaching on safety concerns?
a. “I’ll take my time getting up from the bed or chair.”
b. “I should dim the lighting outside to decrease the glare in my eyes.”
c. “I’ll leave my throw rugs in place so that my feet won’t touch the cold tile.”
d. “I should wear my favorite smooth bottom socks to protect my feet when walking around.”
ANS: APostural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a
correct understanding of this concept. Environmental hazards outside and within the home such as
poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs
are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls
and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also
contributes to falls.
A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action
will the nurse take?
a. Review the patient’s list of medications at each visit.
b. Teach that polypharmacy is to be avoided at all cost.
c. Avoid information about adverse effects.
d. Focus only on prescribed medications
ANS: A
Strategies for reducing the risk for adverse medication effects include reviewing the medications with
older adults at each visit; examining for potential interactions with food or other medications;
simplifying and individualizing medication regimens; taking every opportunity to inform older adults
and their families about all aspects of medication use; and encouraging older adults to question their
health care providers about all prescribed and over-the-counter medications. Although polypharmacy
often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary
when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse
drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion
of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all
medications—both prescribed medications and over-the-counter medications and herbal options
An older-adult patient has developed acute confusion. The patient has been on tranquilizers for
the past week. The patient’s vital signs are normal. What should the nurse do?
a. Take into account age-related changes in body systems that affect pharmacokinetic activity.
b. Increase the dose of tranquilizer if the cause of the confusion is an infection.
c. Note when the confusion occurs and medicate before that time.
d. Restrict phone calls to prevent further confusion
ANS: A
Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or
exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into
account age-related changes in body systems that affect pharmacokinetic activity. When confusion
has a physiological cause (such as an infection), specifically treat that cause, rather than the confused
behavior. When confusion varies by time of day or is related to environmental factors,
nonpharmacological measures such as making the environment more meaningful, providing adequate
light, etc., should be used. Making phone calls to friends or family members allows older adults to
hear reassuring voices, which may be beneficial.
Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. Confusionb. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago
ANS: A
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause
requires further assessment. There may be another reason for the confusion. Confusion is not a
normal finding in the older adult, even though it is commonly seen with concurrent infections.
Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have
lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed
after the acute physiological concern in this case
Which patient statement is the most reliable indicator that an older adult has the correct
understanding of health promotion activities?
a. “I need to increase my fat intake and limit protein.”
b. “I still keep my dentist appointments even though I have partials now.”
c. “I should discontinue my fitness club membership for safety reasons.”
d. “I’m up-to-date on my immunizations, but at my age, I don’t need the influenza vaccine.”
ANS: B
General preventive measures for the nurse to recommend to older adults include keeping regular
dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercisingregularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis,
shingles, and pneumococcal disease.
A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and
has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that
does not have public transportation. Which psychosocial change does the nurse focus on as
a priority?
a. Sexuality
b. Retirement
c. Environment
d. Social isolation
ANS: D
The highest priority at this time is the potential for social isolation. This woman does not know how
to drive and lives in a rural community that does not have public transportation. All of these factors
contribute to her social isolation. Other possible changes she may be going through right now include
sexuality related to her advanced age and recent death of her spouse; however, this is not the priority
at this time. She has been retired for 5 years, so this is also not an immediate need. She may
eventually experience needs related to environment, but the data do not support this as an issue at this
time
A recently widowed older-adult patient is dehydrated and is admitted to the hospital for
intravenous fluid replacement. During the evening shift, the patient becomes acutely confused.
Which possible reversible causes will the nurse consider when assessing this patient? (Select all that
apply.)
a. Electrolyte imbalance
b. Sensory deprivation
c. Hypoglycemia
d. Drug effects
e. Dementia
ANS: A, B, C, D
Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due
to a physiological event. Physiological causes include electrolyte imbalances, untreated pain,
infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and
cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such
as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or
psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible
cerebral dysfunction
A nurse is caring for a young adult. Which goal is priority?
a. Maintain peer relationships.
b. Maintain family relationships.
c. Maintain parenteral relationships.
d. Maintain recreational relationships
ANS: B
Family is important during young adulthood. Challenges may include the demands of working and
raising families. Peer is more important in the adolescent years. Young adults are much freer from
parental control. While recreation is important, the family and work are the priorities in young adults.
The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local
restaurant. He states that he would like to get a better job but has no education. How can the
nurse best assist this patient psychosocially?
a. By providing information and referrals
b. By focusing on the patient’s medical diagnoses
c. By telling the patient that he needs to go back to school
d. By expecting the patient to be flexible in decision making
ANS: A
Support from the nurse, access to information, and appropriate referrals provide opportunities for
achievement of a patient’s potential. Health is not merely the absence of disease (focusing on
medical diagnoses) but involves wellness in all human dimensions. Telling a patient what to do (go
back to school) is inappropriate. Each person (not the nurse) needs to make these decisions based on
individual factors. Insecure persons tend to be more rigid in making decisions
Which goal is priority when the nurse is caring for a middle-aged adult?
a. Maintain immediate family relationships.
b. Maintain future generation relationships.
c. Maintain personal career relationships.
d. Maintain work relationships.
ANS: B
Many middle-aged adults find particular joy in helping their children and other young people become
productive and responsible adults. While immediate family is important, this goal is priority in young
adults, not as important in middle-aged adults. During this period, personal and career achievements
have often already been experienced; therefore, these goals are not priority
A nurse is teaching young adults about health risks. Which statement from a young adult indicates
a correct understanding of the teaching?
a. “It’s probably safe for me to start smoking. At my age, there’s not enough time for cancer to develop.”
b. “My mother had appendicitis so this increases my chance for developing appendicitis.”
c. “Controlling the amount of stress in my life may decrease the risk of illness.”
d. “I don’t do drugs. I do drink coffee, but caffeine is not a drug.
ANS: C
Lifestyle habits that activate the stress response increase the risk of illness; so, controlling this will
decrease risk. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease
as well as cancer in smokers and in individuals who receive secondhand smoke. The presence of
certain chronic illnesses (not acute illnesses—appendicitis) in the family increases the family
member’s risk of developing a disease. Caffeine is a naturally occurring legal stimulant that is readily
available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous
system; it also increases gastric acid secretion, heart rate, and basal metabolic rate
A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include? a. Retirement b. Menopause c. Climacteric factors d. Unplanned pregnancies
ANS: D
Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for
the mother (young adult), infant, and family. Retirement is an issue for middle-aged, not young
adults. The onset of menopause and the climacteric affect the sexual health of the middle-aged adult,
not the young adult
A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP? a. White males b. Pregnant females c. Middle-aged adults d. Nonsubstance abusers
ANS: BThe greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6%
greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults,
and nonsubstance abusers are not as high risk as pregnant women
A patient states that she is pregnant and concerned because she does not know what to expect, and
she wants her husband to play an active part in the birthing process. Which information should the
nurse share with the patient?
a. Lamaze classes can prepare pregnant women and their partners for what is coming.
b. The frequency of sexual intercourse is key to helping the husband feel valued.
c. After the birth, the stress of pregnancy will disappear and will be replaced by relief.
d. After the baby is born, the wife should accept the extra responsibilities of motherhood
ANS: A
Childbirth education classes (like Lamaze) can prepare pregnant women, their partners, and other
support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is
as important as the type or frequency of sexual intercourse to young adults; however, this does not
relate to the issue the patient reports (lack of knowledge and participation). The stress that many
women experience after childbirth has a significant impact on the health of postpartum women.
Ideally partners should share all responsibilities; however, this does not relate to the patient’s
concerns
Which information from the nurse indicates a correct understanding of emerging adulthood?a. It is a type of young adulthood.
b. It is a type of extended adolescence.
c. It is a type of independent exploration.
d. It is a type of marriage and parenthood
ANS: C
This newly identified stage of development from age 18 to 25 (emerging adulthood) has been
described as neither an extended adolescence, as it is much freer from parental control and is much
more a period of independent exploration, nor young adulthood, as most young people in their
twenties have not made the transitions historically associated with adult status, especially marriage
and parenthood.
A nurse is planning care for a 30 year old. Which goal is priority?
a. Refine self-perception.
b. Master career plans.
c. Examine life goals.
d. Achieve intimacy
ANS: B
From 29 to 34, the person directs enormous energy toward achievement and mastery of the
surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals andrelationships. Between the ages of 23 and 28, the person refines self-perception and ability for
intimacy.
A nurse is planning care for young-adult patients. Which information should the nurse consider
when planning care?
a. Fertility issues do not occur in young adulthood.
b. Young adults tend to suffer more from severe illness.
c. Substance abuse is easy to observe in young-adult patients.
d. Young adults are quite active but are at risk for illness in later years
ANS: D
Young adults are generally active and experience severe illnesses less frequently. However, their
lifestyles may put them at risk for illnesses or disabilities during their middle or older-adult years. An
estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Substance
abuse is not always diagnosable, particularly in its early stages
During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old
female patient reports pain and redness in the right breast. Which action is best for the nurse to take
in response to this finding?
a. Assess the patient as thoroughly as possible.b. Explain to the patient that breast tenderness is normal at her age.
c. Tell the patient that redness is not a cause for concern and is quite common.
d. Inform her that redness is the precursor to normal unilateral breast enlargement
ANS: A
A comprehensive assessment offers direction for health promotion recommendations, as well as for
planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal
physical assessment findings in the middle-aged adult. Increased size of one breast is an abnormal
physical assessment finding in the middle-aged adult
A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and
hot flashes. Which information should the nurse share with the patient?
a. The patient’s assessment points toward normal menopause.
b. Those symptoms are normal when a woman undergoes the climacteric.
c. An assessment is not really needed because these problems are normal for older women.
d. The patient should stop regular exercise because that is probably causing these symptoms
ANS: A
The most significant physiological changes during middle age are menopause in women and the
climacteric in men. Menopause typically occurs between 45 and 60 years of age. The nurse should
continue with the examination because a comprehensive assessment offers direction for health
promotion recommendations, as well as for planning and implementing any acutely needed
interventions. Exercise should not be stopped, especially in middle-aged adults
The nurse is teaching a class to pregnant women about common physiological changes during
pregnancy. Which information should the nurse include in the teachingsession?
a. Pregnancy is not a time to be having sexual activity.
b. Urinary frequency will occur early in the pregnancy.
c. Breast tenderness should be reported as soon as possible.
d. Late in the pregnancy Braxton Hicks contraction may occur
ANS: D
During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short
contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have
morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that
sexual activity will not harm the fetus
A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response
will the nurse most expect from this patient?
a. “I should consider participating in a health fair about safe sun practices.”
b. “I’ll make an appointment with my doctor right away for a full skin check.”
c. “I’ve had this mole my whole life. So what if it changed color? My skin is fine.”
d. “I have a mole that has been bothering me. I’ll call my family doctor for an appointment to get it checked
ANS: C
Most typically young adults would say that their skin is fine. Young adults often ignore physical
symptoms and often postpone seeking health care. Making an appointment right away with the
doctor and participating in health fairs are not typical behaviors of young adults for the same reason
Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and
decreased range of joint motion. Which area is priority?
a. Abuse potential
b. Fall precautions
c. Stroke prevention
d. Self-esteem issues
ANS: B
With uneven weight bearing and decreased range of joint motion, falling is a priority. Abuse
potential would indicate other findings such as bruising or unkept appearance. While stroke
prevention is important in a middle-aged adult, these are not the signs of stroke. While self-esteem
issues may arise from physical changes, safety is a priority over self-esteem issues
A young-adult patient is brought to the hospital by police after crashing the car in a high-speed
chase when trying to avoid arrest for spousal abuse. Which action should the nursetake?
a. Question the patient about drug use.
b. Offer the patient a cup of coffee to calm nerves.
c. Discretely assess the patient for sexually transmitted infections.
d. Deal with the issue at hand, not asking about previous illnesses
ANS: A
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are
reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a
naturally occurring legal stimulant that stimulates the central nervous system and is not the choicefor
calming nerves. Although sexually transmitted infections occur in the young adult, this is not an
action a nurse should take in this situation. The nurse may obtain important information by making
specific inquiries about past medical problems, changes in food intake or sleep patterns, and
problems of emotional lability
A nurse determines that a middle-aged patient is a typical example of the “sandwich generation.”
What did the nurse discover the patient is caught between?
a. Job responsibilities or family responsibilities
b. Stopping old habits and starting new ones
c. Caring for children and aging parents
d. Advancing in career or retiring
ANS: C
Middle-aged adults also begin to help aging parents while being responsible for their own children,
placing them in thesandwich generation. It does not include job and family responsibilities; old
habits and new ones; or career and retiring
A nurse is assessing a middle-aged patient’s barriers to change in eating habits. Which areas will
the nurse assess that are external barriers? (Select all that apply.)
a. Lack of facilities
b. Lack of materials
c. Lack of knowledge
d. Lack of social supports
e. Lack of short- and long-term goals
ANS: A, B, D
External barriers to change include lack of facilities, materials, and social supports. Internal barriers
are lack of knowledge, insufficient skills, and undefined short- and long-term goals
A home health nurse is providing care to a middle-aged couple with children at home. The patient
has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.)a. Adherence to treatment and rehabilitation regimens
b. Coping mechanisms of patient and family
c. Need for community services or referrals
d. Knowledge base of patient only
e. Use of a doula for care
ANS: A, B, C
Along with the current health status of the chronically ill middle-aged adult, you need to assess the
knowledge base of both the patient and family. In addition, you must determine the coping
mechanisms of the patient and family; adherence to treatment and rehabilitation regimens; and the
need for community and social services, along with appropriate referrals. A doula is a support person
to be present during labor to assist women who have no other source of support
A nurse is providing prenatal care to a first-time mother. Which information will the nurse share
with the patient? (Select all that apply.)
a. Regular trend for postpartum depression
b. Protection against urinary infection
c. Strategies for empty nest syndrome
d. Exercise patterns
e. Proper diet
ANS: B, D, E
Prenatal care includes a thorough physical assessment of the pregnant woman during regularly
scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections
that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are
important for a pregnant woman. Empty nest syndrome occurs as children leave the home.
Postpartum depression is rare.
A patient has dehydration. While planning care, the nurse considers that the majority of the
patient’s total water volume exists in with compartment?
a. Intracellular
b. Extracellular
c. Intravascular
d. TranscellulaR
ANS: A
Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water.
Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid
(liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular
compartment
The nurse is teaching about the process of passively moving water from an area of lowerparticle
concentration to an area of higher particle concentration. Which process is the nursedescribing?
a. Osmosisb. Filtration
c. Diffusion
d. Active transport
ANS: A
The process of moving water from an area of low particle concentration to an area of higher particle
concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher
pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles
down the concentration gradient (from areas of higher concentration to areas of lower concentration).
Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes
across cell membranes against the concentration gradient (from areas of lower concentration to areas
of higher concentration
The nurse observes edema in a patient who has venous congestion from right heart failure.Which
type of pressure facilitated the formation of the patient’s edema?
a. Osmotic
b. Oncotic
c. Hydrostatic
d. Concentration
ANS: CVenous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes
edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic
pressures involve the concentrations of solutes and can contribute to edema in other situations, such
as inflammation or malnutrition. Concentration pressure is not a nursing term
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which directionwill the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial
ANS: A
Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A
hypertonic solution has a concentration greater than normal body fluids, so water will shift out of
cells because of the osmotic pull of the extra particles. Movement of water from the extracellular
(intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution
of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic
and osmotic pressures
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6
ANS: D
The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release
tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure
The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood?a. Sodium b. Chloride c. Potassium d. Magnesium
ANS: A
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation.
Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is
found predominantly inside cells and in bone
The nurse receives the patient’s most recent blood work results. Which laboratory value isof greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
ANS: BNormal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and
of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145
mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L
The nurse observes that the patient’s calcium is elevated. When checking the phosphate level,what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate
ANS: B
Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is
elevated, the other decreases, except in some patients with end-stage renal disease
Four patients arrive at the emergency department at the same time. Which patient will the nurse
see first?
a. An infant with temperature of 102.2° F and diarrhea for 3 daysb. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
ANS: A
The infant should be seen first. An infant’s proportion of total body water (70% to 80% total body
weight) is greater than that of children or adults. Infants and young children have greater water needs
and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia
because body water loss is proportionately greater per kilogram of weight. A teenager with excessive
edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older
adult with a blood pressure of 112/60
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order
will the nurse perform the steps, starting with the first one?
1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve.
a. 1, 2, 3, 4
b. 2, 3, 4, 1c. 3, 4, 1, 2
d. 4, 1, 2, 3
ANS: A
Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove
a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient’s
privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV
solution container from its stand, and pass it and the tubing through the sleeve. (If this involves
removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental
infusion of a large volume of solution or medication.
A 2-year-old child is brought into the emergency department after ingesting a medication that
causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor
this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: B
Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and
respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease inCO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting,
diarrhea, or other conditions that affect metabolic acids.
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent
suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis
ANS: B
The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung
problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much
acid is in the body like kidney failure
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?
a. pH 7.60, PaCO2 40 mm Hg, HCO – 30 mEq/L
b. pH 7.53, PaCO2 30 mm Hg, HCO – 24 mEq/L
c. pH 7.35, PaCO2 35 mm Hg, HCO – 26 mEq/L
d. pH 7.25, PaCO2 48 mm Hg, HCO – 23 mEq/L
ANS: B
Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a
normal HCO –
. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45
mm Hg), and HCO – is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO –
30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO – 26 mEq/L is within normal
limits. pH 7.25, PaCO2 48 mm Hg, HCO – 23 mEq/L is respiratory acidosis
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia.
Which assessment finding will the nurse expect?
a. Dry mucous membranes
b. Abdominal distention
c. Distended neck veins
d. Flushed skin
ANS: B
Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel
sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral
pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration
and hypernatremia
In which patient will the nurse expect to see a positive Chvostek sign?
a. A 7-year-old child admitted for severe burns
b. A 24-year-old adult admitted for chronic alcohol abuse
c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism
d. A 75-year-old patient admitted for a broken hip related to osteoporosis
ANS: B
A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia
is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis
(which also can be affected by alcohol consumption). Burn patients frequently experience
extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is
associated with hypercalcemia
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal
ANS: A
The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the
respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate.
Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these
systems cannot compensate for an existing imbalance.
.A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse
assign to the nursing assistive personnel?
a. Recording intake and output
b. Regulating intravenous flow rate
c. Starting peripheral intravenous therapy
d. Changing a peripheral intravenous dressing
ANS: A
A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating
flow rate, starting an IV, or changing an IV dressing to an NAP
. The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which
laboratory findings are consistent with metabolic acidosis?
a. pH 7.3, PaCO2 36 mm Hg, HCO – 19 mEq/L
b. pH 7.5, PaCO2 35 mm Hg, HCO – 35 mEq/L
c. pH 7.32, PaCO2 47 mm Hg, HCO – 23 mEq/L
d. pH 7.35, PaCO2 40 mm Hg, HCO – 25 mEq/L
ANS: A
The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO – 19 mEq/L.
A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO – 35 mEq/L is metabolic alkalosis. pH 7.32,
PaCO2 47 mm Hg, HCO – 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO – 25
mEq/L values are within normal range
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids
ANS: C
The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action.
Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is
the second action. Increasing fluids is contraindicated and would make the situation worse
.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse
is mostappropriate?
a. “Are you following any weight loss program?”
b. “How many calories a day do you consume?”
c. “Do you have dry mouth or feel thirsty?”
d. “How many times a day do you urinate?”
ANS: D
A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with
normal ECV. Asking the patient about urination habits will help determine whether the body is trying
to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a
weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not
help determine the cause of the problem. Caloric intake does not account for rapid weight changes.
Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered.
Which IV bag will the nurse prepare?
a. 0.45% sodium chloride (1/2 NS)b. 0.9% sodium chloride (NS)
c. Lactated Ringer’s (LR)
d. Dextrose 5% in Lactated Ringer’s (D5LR)
ANS: A
0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient
and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for
monitoring both of these patients?
a. Assess the patients for edema in extremities.
b. Ask the patients to record their intake and output.
c. Weigh the patients every morning before breakfast.
d. Measure the patients’ blood pressures every 4 hours.
ANS: C
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is
equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time
every day using the same scale and the same amount of clothing. Although intake and output records
are important assessment measures, some patients are not able to keep their own records themselves.
Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical
dehydration
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and
elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN)
will the nurse add to the care plan?
a. Stimulate the patient’s appetite to eat.
b. Deliver antibiotics to fight off infection.
c. Replace fluid, electrolytes, and nutrients.
d. Provide medication to raise blood pressure
ANS: C
Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace
the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain
blood pressure medication or antibiotics
A patient presents to the emergency department with reports of vomiting and diarrhea for the past
48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse
prepare?a. 0.225% sodium chloride (1/4 NS)
b. 0.45% sodium chloride (1/2 NS)
c. 0.9% sodium chloride (NS)
d. 3% sodium chloride (3% NaCl)
ANS: C
Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace
extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45%
sodium chloride are hypotonic. 3% sodium chloride is hypertonic
A nurse is administering a diuretic to a patient and teaching the patient about foods to increase.
Which food choices by the patient will best indicate successful teaching?
a. Milk and cheese
b. Potatoes and fresh fruit
c. Canned soups and vegetables
d. Whole grains and dark green leafy vegetables
ANS: B
Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and
vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patientwith
hypernatremia. Which finding indicates goal achievement?
a. Urine output increases to 150 mL/hr.
b. Systolic and diastolic blood pressure decreases.
c. Serum sodium concentration returns to normal.
d. Large amounts of emesis and diarrhea decrease
ANS: C
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an
accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous
therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large
dilute urine output can cause further hypernatremia
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice
at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice
chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the
nurse document in the patient’s medical record?
a. Intake 255; output 375b. Intake 285; output 375
c. Intake 505; output 125
d. Intake 535; output 125
ANS: A
Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of
the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and
250 mL of vomitus; 125 + 250 = 375.
A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema
ANS: B
Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry
mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining
excess extracellular fluid.
.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.
The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute
flow rate (drops/min)?
a. 12 drops/min
b. 24 drops/min
c. 125 drops/min
d. 150 drops/min
ANS: C
Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing:
(125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to
infuse at 50 mL/hr. At what time should the infusion be completed?
a. 2300 Monday
b. 2345 Monday
c. 0015 Tuesday
d. 0045 Tuesday
ANS: B
250 mL ÷ 50 mL/hr = 5 hr
1845 + 5 hr = 2345, which would be 2345 on Monday.
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the
volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9%
sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice
chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output.
The patient has voided 400 mL of urine. After reporting these values to the health care provider,
which order does the nurse anticipate?
a. Add a potassium supplement to replace loss from output.
b. Decrease the rate of intravenous fluids to 100 mL/hr.
c. Administer a diuretic to prevent fluid volume excess.
d. Discontinue the nasogastric suctioning
ANS: A
The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with
nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium
supplement to correct this condition. Remember to record half the volume of ice chips when
calculating intake. The other measures would be unnecessary because the net fluid volume is equal
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the
nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse
notices a red streak that is warm to the touch. What is the nurse’s initial action?
a. Record a phlebitis grade of 4.
b. Assign an infiltration grade.
c. Apply moist compress.
d. Discontinue the IV
ANS: D
The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has
phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued
.A nurse is assisting the health care provider in inserting a central line. Which action indicates the
nurse is following the recommended bundle protocol to reduce central line-associated bloodstream
infections (CLABSI)?
a. Preps skin with povidone-iodine solution.
b. Suggests the femoral vein for insertion site.
c. Applies double gloving without hand hygiene.
d. Uses chlorhexidine skin antisepsis prior to insertion
ANS: DA recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of
maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion
and during dressing changes; avoidance of the femoral vein for central venous access for adults; and
daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not
recommended
The nurse is caring for a group of patients. Which patient will the nurse see first?
a.
A patient with D5W hanging with the blood
b. A patient with type A blood receiving type O blood
c. A patient with intravenous potassium chloride that is diluted
d. A patient with a right mastectomy and an intravenous site in the left arm
ANS: A
The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to
administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis
or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O.
Type O is considered the universal donor. A patient with a mastectomy should have the IV in the
other arm. Potassium chloride should be diluted, and it is never given IV push
