Fundamentals of Nursing; exam 5

Question 1

You have a patient that says they feel discomfort in their right shoulder, constantly, at a scale level of 8 out of 10.
What is your patient experiencing?
A. being dramatic
B. pain
C. pathological pain
D. quality

Answer 1

B- nurses classify pain at “whatever the person says it is, and existing whenever the person says it does”

Question 2

You are assessing when your patients pain is located and where the pain is arising from. What are you looking for within the pain?
A. Origin
B. Causes
C. Somatic
D. visceral
E. Duration
F. Quality

Answer 2

A- origin pain is the type of where it extends from, extends to, how deep the pain is, and what type of body part it is affecting

Question 3

Your patient states that they are in labor and their abdomen is in severe pain. What type of pain is this?
A. Origin
B. Causes
C. Somatic
D. visceral
E. Duration
F. Quality

Answer 3

D- visceral pain is the type of pain that is not well localized, but can be a strong indication of what is wrong.

Question 4

your patient had broken their ankle, and stating their pain is in their ankle? What type of pain is your patient experiencing?
A. Origin
B. Causes
C. Somatic
D. visceral
E. Duration
F. Quality

Answer 4

C- somatic pain is pain that is well localized that arise from the musculoskeletal structures or skin.

Question 5

Your patient is having chronic phantom pain from an amputation. What type of pain is this caused from?
A. Origin
B. Nociceptive
C. Neuropathic
D. visceral
E. Duration
F. Quality

Answer 5

C- neuropathic pain; that is abnormal pain processing, usually chronic caused by a long end nerving damage (stroke, diabetes, cancer)

Question 6

Your patient is stating her pain has lasted for 6 months. What part of the pain are you assessing?
A. Origin
B. Causes
C. Somatic
D. visceral
E. Duration
F. Quality

Answer 6

E- acute pain (less than 6 months)
chronic (longer than 6 months)
intractable (chronic pain that is highly resistant)

Question 7

Your patient is starting thier pain is stabbing and static like. What part of the pain are you assessing?
A. Origin
B. Causes
C. Somatic
D. visceral
E. Duration
F. Quality

Answer 7

F- quality of pain describes the type of pain (stabbing), periodicity (how often?) and intensity (scale 1-10)

Question 8

What category of data would you put your patient explaining their pain under?
A. chronic pain
B. acute pain
C. objective data
D. subjective data

Answer 8

D- pain is a subjective experience, categorized under subjective data

Question 9

a patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain?
A. cutaneous
B. superficial
C. visceral
D. somatic

Answer 9

C

Question 10

which of the following is most important when assessing a client’s pain?
A. the physical location of the pain
B. the client appears uncomfortable
C. the client’s vital signs
D. the client’s perception of the pain

Answer 10

D

Question 11

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain?
A. transient pain
B. superficial pain
C. phantom pain
D. referred pain

Answer 11

D- referred pain is the type of pain that can be located

Question 12

what is the first step in the process of beginning to feel pain?
Short answer: what is happening?
A. modulation
B. transduction
C. perception
D. transmission

Answer 12

B- this is when your neurons are stimulated and they release excitatory compounds

Question 13

what is the second step in the process of beginning to feel pain?
Short answer: what is happening?
A. modulation
B. transduction
C. perception
D. transmission

Answer 13

D- conduction of pain message to spinal cord via nerve fibers

Question 14

what is the third step in the process of beginning to feel pain?
Short answer: what is happening?
A. modulation
B. transduction
C. perception
D. transmission

Answer 14

C- marks the end of nerve transmission and involves the conscious awareness of pain. also can cause an emotional response

Question 15

what is the final step in the process of beginning to feel pain?
Short answer: what is happening?
A. modulation
B. transduction
C. perception
D. transmission

Answer 15

A- this changes the pain perception

Question 16

You have acute pain that maintains vitals organs and minimizing your blood loss while fighting infection. What type of pain response is this?
A. parasympathetic
B. behavioral response
C. psychological
D. sympathetic

Answer 16

D- this is also your fight or flight response

Question 17

Your patient is feeling chronic pain. she is no longer getting out of bed and she is severely depressed caused by her pain. What type of pain response is she feeling?
A. parasympathetic
B. behavioral response
C. psychological
D. sympathetic

Answer 17

A- pain that consumes thoughts and change daily living patterns. as well as the body adapts to continued pain

Question 18

Your patient is having a sympathetic pain response, what is happening to her alertness, pupils, heart rate, respiratory rate?
A. decreased
B. stays the same
C. increased and decreased
D. increased

Answer 18

D- sympathetic increases all symptoms

Question 19

Your patient is having a parasympathetic response to pain, what is happening to her pupils, pulse rate, blood pressure, and breathing patterns?
A. decreased
B. stays the same
C. increased and decreased
D. increased

Answer 19

A- parasympathetic decreases all symptom responses

Question 20

A nurse is assessing a patient who complains of “awful” abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? Select all that apply.
a.Tachycardia
b. Irritability
c. Increased blood pressure
d. Depression
e. Insomnia
f. Sweating

Answer 20

a, c, f

Question 21

you have a patient that is rolling around crying, moaning, and is very irritable. What is she experiencing?
A. wanting to leave the hospital
B. pain
C. missing her family
D. happiness

Answer 21

B- these are nonverbal signs of pain

Question 22

The nurse is assessing the confused client. In trying to determine the client’s level of pain, the nurse should:
A. Be aware that confused clients do not feel as much pain due to their confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client’s family how much pain the client normally has.
D. Use only pain scales that feature numbers or “faces” the client can point to.

Answer 22

B

Question 23

you are going in every thirty minutes to add or remove heat to your patients leg. What type of pain management is this?
A. non pharmacological
B. pharmacological
C. patient controlled analgesia
D. chemical pain relief

Answer 23

A- anything like repositioning, distraction, heat and cold, anything that can relieve pain without taking any medicines.

Question 24

your patient is prescribed hydrocodone and acetaminophen PRN with a max of 4 doses per day. What type of pain management is this?
A. non pharmacological
B. pharmacological
C. patient controlled analgesia
D. chemical pain relief

Answer 24

B- you are prescribing medications and altering pain reception through the nerve endings

Question 25

Your patient is going under local anesthesia. What type of pain management is this?
A. non pharmacological
B. pharmacological
C. patient controlled analgesia
D. chemical pain relief

Answer 25

D- nerve blocks, epidural injection, local anesthesia, topical anesthesia

Question 26

Mr. Zenobia’s chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relation to his long-acting morphine, which is an appropriate response by the nurse?
A. “If you take more morphine, it will not change your pain relief.“
B. “I’ll call the primary care provider and inquire about an increased dose.”
C. “The amount you are taking now is all I can give you.”
D. “I’m worried if we increase your dose that you will stop breathing.”

Answer 26

B- There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

Question 27

You are teaching patient to recall information about Krohn’s disease they have recently been diagnosed with. What type of learning is this?
A. psychomotor
B. affective
C. Cognitive

Answer 27

C

Question 28

You are teaching your patient how to change their wound dressing for when they go home. What type of learning is this?
A. psychomotor
B. affective
C. Cognitive

Answer 28

A- hands on skills and require thinking and doing

Question 29

You are teaching your patient about a surgery they are having because they are feeling anxious. What type of learning are they doing?
A. psychomotor
B. affective
C. Cognitive

Answer 29

B- changing feelings, beliefs, attitudes, and values

Question 30

Your client is upset that she has diabetes now, and you are trying to educate her on it. She states “i don’t care, i don’t want to deal with this for the rest of my life.”
What is your response?
A. “you are just emotional right now, ill come back later.”
B. “i understand you are upset, do you want me to have your family members educate you?”
C. “i’m sorry you feel this way but you have to learn”
D. “okay, i will leave.”

Answer 30

B

Question 31

Nurses must possess the knowledge and skills needed for patient teaching so that

A. They can complete the documentation forms related to client teaching accurately.
B. They can help the hospital meet The Joint Commission standards requiring client teaching.
C. They can promote the health, safety, and rights of clients through education.
D. They can meet the patient rights delineated in the “Patient Care Partnership.”

Answer 31

C

Question 32

The client needs to be taught how to find and check his own radial pulse. The nurse will complete this teaching

A. Only if the client asks her to do so, to avoid causing stress.
B. When the client recognizes the need to learn the skill.
C. Before pain medication is administered when the client is alert.
D. Right before the client is discharged so he can remember the skill.

Answer 32

B

Question 33

The client is given a pamphlet to read about how to manage his newly inserted central venous access device at home. It will be most important for the nurse to assess the client’s

A. Health beliefs
B. Literacy level
C. Fine motor abilities
D. Ability to see

Answer 33

D

Question 34

your body is not at equal homeostasis, what is going to allow that to be fixed?
A. the five sense
B. sleeping
C. eating
D. resting

Answer 34

A- the five senses help with maintaining homeostasis, and necessary for human growth and development.

Question 35

When you are tasting a sour fruit, what part of the sensory experience are you currently in?
A. reception
B. perception
C. arousal
D. stimulus

Answer 35

D- stimulus is a trigger of the nerve receptors that may be a sight, sound, taste, touch, pain

Question 36

Your patient keeps complaining of being cold, what part of the sensory experience is your patient experiencing?
A. reception
B. perception
C. arousal
D. stimulus

Answer 36

A- reception is the process of receiving stimuli from a nerve ending. several different types of nerve endings.

Question 37

your patient is currently under anesthesia for a surgery that is about to begin. what part of the sensory experience is your patient in?
A. reception
B. perception
C. arousal
D. stimulus

Answer 37

C- arousal is dealt with your consciousness and alertness, which is mediated by your reticular activating system

Question 38

You are assessing a patient who is responding to stimuli, when you shine your pen light into a patient’s eye they begin to squint, what type of response is this?
A. intensity of stimuli
B. contrasting stimuli
C. adaption to stimuli
D. previous experience

Answer 38

A- this is when an intense stimulus excites more receptors leading to a greater response.

Question 39

You are going to work where the environment is loud, noisy, lots of light and activity. You are not overwhelmed because you have been doing this job for several years, what type of response is this?
A. intensity of stimuli
B. contrasting stimuli
C. adaption to stimuli
D. previous experience

Answer 39

C. over the years you have adapted to this chaos, and we become accustomed

Question 40

You are assessing a patient who is responding to stimuli, as you draw up the injection you notice your patient has his head turned away with eyes already squinting, what type of response is this?
A. intensity of stimuli
B. contrasting stimuli
C. adaption to stimuli
D. previous experience

Answer 40

D- your patient remembers a past negative experience before you have even started, so they are reacting based off of that.

Question 41

You are assessing a patient who is responding to stimuli, they just had come in from the cold and into the heated room. they begin to take off layers due to the heat, what type of response is this?
A. intensity of stimuli
B. contrasting stimuli
C. adaption to stimuli
D. previous experience

Answer 41

B- contrasting is when you go from one extreme to the next

Question 42

when you walk into your patients room for hourly rounding, you notice your patient is becoming very sensitive to her cold feet. she is freaking out and wants you to fix it. What is your patient experiencing?
A. sensory deficit
B. sensory deprivation
C. sensory overload
D. sensory malfunction

Answer 42

B- sensory deprivation is the lack of stimuli causing minor things, like cold feet and distant noises, to be very overwhelming

Question 43

You walk into your patients room for hourly rounding you notice that she is overly stressed out, and list seven things that are bothering her in that moment. What is your patient experiencing?
A. sensory deficit
B. sensory deprivation
C. sensory overload
D. sensory malfunction

Answer 43

C- sensory overload is when there is an excess amount of stimuli, could be discomfort, anxiety, separation from loved ones, and the unfamiliar environment.

Question 44

Short answer: when your patient is experiencing sensory deprivation, what are you as the nurse wanting to do?

Answer 44

focus is prevention, support senses (glasses, hearing aids), provide stimuli (turning on tv, opening up a window, smells)

Question 45

Short answer: when your patient is experiencing sensory overload, what are you as the nurse supposed to do?

Answer 45

limit stimuli (closing a window, turning the tv off, pain medications if possible, an obnoxious odors, provide rest)

Question 46

Select all that apply:
Your patient has impaired vision, which of the following would you do:
A. provide sufficient light
B. protect eyes in sunlight
C. wear glasses
D. evaluate ability to do certain task
E. provide eye drops at least every 2 hours

Answer 46

A,B,C,D
eye drops is not the answer because they can’t necessarily help you see better

Question 47

Select all that apply:
Your patient has impaired hearing, what are some things you would do
A. put cotton ball in ear to collect drainage
B. use their hearing aid
C. promote safety when not wearing hearing aid
D. irrigate ears to clear them
E. techniques to improve communication

Answer 47

B,C,E
- not A or E because we do not irrigate without provider’s orders and do not want to block ear canal.

Question 48

Select all that apply:
Your patient has impaired taste, what are some things you would do
A. provide frequent oral hygiene
B. make meals free of smell
C. have client eat foods separately
D. educate patient they have to eat or they will become malnourished
E. assess for sores or open areas in mouth

Answer 48

A,C,E
not B or D because you want a good smell for food that is part of tasting your food, and you want to solve the problem on why they are not eating not just tell them they have to eat.

Question 49

Select all that apply:
Your patient has impaired smell, what are some things you would do
A. have client take sinus medicine, to clear airway
B. educate patient to have appliances regularly inspected for gas leaks
C. educated patient to check smoke detectors and replace batteries regularly
D. aromatherapy
E. have client smell strong odors to test

Answer 49

B,C,D
not a or e because it may not be their sinuses that is causing loss of smell, and strong odors is not a good thing and could be toxic

Question 50

Select all that apply:
Your patient has impaired touch, what are some things you would do
A. use of thermometer to ensure not burning themselves
B. inspect for open areas, cuts, abrasions, or areas of redness
C. teach client to immediately report signs of circulatory impairment
D. teach client to wear properly fitting shoes and socks
E. encourage clients to change position frequently

Answer 50

all are correct

Question 51

When your patient is very confused, what is the main topic to ensure your client.
A. news in the world
B. time: place, date, time of day, clocks and calendars
C. random facts to keep them interested
D. what you are currently doing

Answer 51

B: you want to reorient your patient as much as possible

Question 52

What is the main concern for an unconscious patient?
A. family and friends
B. communication
C. healing
D. safety

Answer 52

D- bed in lowest position, side rails up, oral cares, eye cares

Question 53

The client who has had a stroke states to the nurse, “you know i can’t even tell where my left leg is.” this reflects lack of response to stimuli by the
A. proprioceptors
B. chemoreceptors
C. thermoreceptors
D. mechanoreceptors

Answer 53

A- determine the position of our bodies in space

Question 54

Mr. Arbor complains to the nurse that he is feeling anxious. He states, “I’m just so tired of all these tests they are doing, and it’s so noisy here at night.” Mr. Arbor’s pulse is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following?
A. Turn on the television to provide distraction.
B. Ask the client if he would like to discuss his anxiety further.
C. Call the physician and obtain an order for an anti-anxiety medication for prn use.
D. Close the blinds, dim the lights, and ask the patient what other measures would help him rest.

Answer 54

D- these measures would most directly decrease the client’s sensory overload

Question 55

A culture has come back full of bacteria and fungi. What type of chain of infection is this?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 55

A- an infectious agent is a pathogen (bacteria, viruses, fungi, protozoa

Question 56

When inspecting a culture in a proper environment, the pathogens multiple. What type of chain of infection is this?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 56

B- reservoir is where pathogens live and multiple

Question 57

When assess a patient it is important to ensure to use proper PPE when dealing with bodily fluids. What type of infectious agent is this?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 57

F- portal of exit is anything via bodily fluids, coughing, sneezing, diarrhea, seeping wounds, tubes, IV lines

Question 58

Your patient discovers they have an STD. What was the chain of infection the patient received this disease from?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 58

C- contact can be direct or indirect (touching, sexual contact, contact with a fomite), droplet (coughing or sneezing), airborne (air conditioning and sweeping)

Question 59

When having an surgical procedure, it is important to make sure it is disinfected and cared for properly. What part of chain of infection can cause this?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 59

E- anything via eye, nares, mouth, vagina, cuts, scrapes, wounds, surgical sites, iv or drainage tube sites, bite from a vector

Question 60

Your patient has cancer, and very susceptible to everything due to a compromised immune system. What part of chain of infection is this?
A. infectious agent
B. reservoir
C. mode of transmission
D. susceptible host
E. portal of entry
F. Portal of exit

Answer 60

D- a person with inadequate defense (age, immune system, chronic illness, immune deficiency)

Question 61

What is the best ways to break the chain of infection?
A. hand washing
B. covering your mouth when coughing
C. changing clothes when you get home
D. keeping your hair pulled back

Answer 61

A- utilizing proper infection control

Question 62

Your patient has signs and symptoms of a disease, what stage of infection is this patient in?
A. incubation
B. prodromal
C. illness
D. decline
E. convalescence

Answer 62

C- illness is when signs and symptoms present

Question 63

When someone is on antibiotics, they must be on them for a minimum 24 hours before not being contagious anymore. What stage of infection is the patient trying to get past?
A. incubation
B. prodromal
C. illness
D. decline
E. convalescence

Answer 63

A- incubation is from time of infection until manifestations of symptoms; can infect others

Question 64

When you are getting the flu, your first symptom is a headache. What stage of infection is this?
A. incubation
B. prodromal
C. illness
D. decline
E. convalescence

Answer 64

B- appearance of vague symptoms- not all diseases have this stage

Question 65

You are completely fever free and return back to your normal health, what stage of infection are you currently in?
A. incubation
B. prodromal
C. illness
D. decline
E. convalescence

Answer 65

E- tissue repair, return to health

Question 66

Your patient is starting to feel slightly better, and getting more energy. What stage of infection is your patient in?
A. incubation
B. prodromal
C. illness
D. decline
E. convalescence

Answer 66

D- decline is the number of pathogens decline

Question 67

Your patient has a UTI, how would you classify this infection by location?
A. systemic
B. local
C. focused
D. familiar

Answer 67

B- local occurs in a limited region in the body

Question 68

Your patient has hepatitis B. How would you classify this infection by location?
A. systemic
B. local
C. focused
D. familiar

Answer 68

A- spread via blood or lymph, affects many regions

Question 69

Short answer What is medical sepsis?

Answer 69

a state of cleanliness that decreases the potential for the spread of infection/
maintaining a clean environment, clean hands, following CDC.

Question 70

Select all that apply:
When you have contact precautions, what should you as a nurse be wearing?
A. mask
B. shoe covers
C. hair cover
D. goggles
E. gown
F. face shield
G. gloves

Answer 70

E and G- mask is optional

Question 71

Select all that apply:
When you have droplet precautions, what should you as a nurse be wearing?
A. mask
B. shoe covers
C. hair cover
D. goggles
E. gown
F. face shield
G. gloves

Answer 71

gown, gloves, mask, eye protections- within 3 feet of client

Question 72

Select all that apply:
When you have airborne precautions, what should you as a nurse be wearing?
A. mask
B. shoe covers
C. hair cover
D. goggles
E. gown
F. face shield
G. gloves

Answer 72

A, G, F, E
same as those for contact except special room, special mask, and mask for patient when transporting

Question 73

The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement:

A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. No precautions

Answer 73

C

Question 74

Which action violates a principle that is key to proper hand washing at the bedside?

A. Using the soap provided by the agency.
B. Shaking your hands dry over the sink.
C. Using warm, not very hot water.
D. Washing your hands for 1 min.

Answer 74

B

Question 75

When preparing the field for a sterile dressing change, the nurse accidentally sneezes over the sterile field and packaged items. The nurse knows the next correct step is to:
A. Discard all materials from the sterile field and prepare a new sterile field.
B. Remove the sterile gloves and gown and reapply new ones.
C. Remove items that have visible moisture or droplets on them.
D. Continue with preparation knowing no sterile items were opened yet.

Answer 75

A

Question 76

The nurse is changing a patient’s sterile dressing. The following actions demonstrate appropriate sterile technique. Select all that apply.

A. Touching clean gown with sterile gloves.
B. Having sterile field in visual field at all times.
C. nspecting packaging for damage and moisture.
D. Using sterile gloves to position the 1-inch edging on the sterile packaging.

Answer 76

A,B,C,D

Question 77

What is the most important thing to do when you are done with a patient?
A. writing it down on paper
B. report off
C. hand off
D. documentation

Answer 77

D- if you didn’t document it, it didn’t happen

Question 78

What is it called when you compare findings
A. data
B. analyze
C. research
D. results

Answer 78

A- compare findings

Question 79

What is it called when the nursing practice has changed and is linked to improve outcomes?
A. data
B. analyze
C. research
D. results

Answer 79

B

Question 80

You are looking at data that is evidence based? What is this called?
A. data
B. analyze
C. research
D. results

Answer 80

D

Question 81

The student nurse has earned “A’s” in all of her prerequisite courses. For the first exam in a nursing course, she earns a “D” and now feels that she may not be smart enough to become a nurse. What type of “loss” is the student experiencing?
A. Actual
B. External
C. Physical
D. Perceived

Answer 81

D- not felt of seen by others

Question 82

When a patient has an undesired change or removal of a value object person or situation, what are they experiencing?
A. end of life care
B. death
C. loss
D. grief

Answer 82

C

Question 83

Your patient experiences a physical, psychological, and spiritual responses to a loss, what are they experiencing?
A. end of life care
B. death
C. loss
D. grief

Answer 83

D

Question 84

A young woman’s fiancé died in a car accident one month prior to their wedding day. Since his death, she has become sexually promiscuous. What type of grief, if any, is the woman displaying?
A. Chronic
B. Disenfranchised
C. Masked
D. No grief

Answer 84

C

Question 85

Your 55-year-old patient was just informed that she has metastatic pancreatic cancer and has 4 months to live. After the provider leaves, she says to you, “I don’t want my family to know. But they have to know. Please don’t tell them. Please tell me what to do, help me.” What is your best response?
A. “I know this is difficult for you. Take time to think about it.”
B. “You should get a second opinion before you alarm your family.”
C. “Let me hold your hand to make you feel better.”
D. “Tell me how you are feeling right now.”

Answer 85

D

Question 86

The client is dying of cancer and can no longer swallow. The son states to the nurse, “You MUST give dad some water, he always drank a lot of water.” The nurse’s best response is
A. “You sound very upset. Tell me more about your dad.”
B. “Your father is dying from cancer and water will not stop this process.”
C. “Research shows that withholding oral fluids decreases edema.”
D. “I will call the provider and get a prescription to insert a nasogastric tube for the water.”

Answer 86

A