Module 1 Flashcards
(112 cards)
1
Q
- A young adult arrives in the emergency department (ED) with multiple abrasions after a motor vehicle accident and has an initial blood pressure (BP) of 180/98. Which of the following interventions should the nurse implement?
A. Discuss the need for hospital admission to control blood pressure.
B. Change the dressing on the abrasions and discuss the risks associated with hypertension.
C. Recheck the blood pressure before the client’s discharge from the ED.
D. Start an intravenous (IV) line to administer antihypertensive medications.
A
C. Recheck the blood pressure before the client’s discharge from the ED.
2
Q
- A hospitalized client who is usually well organized and calm is receiving diabetic teaching after being newly diagnosed with diabetes. The client is forgetful, irritable, and has poor concentration. Which action should the nurse take?
A. Ask the health care provider for a psychiatric referral.
B. Administer the PRN sedative medication every 4 hours.
C. Suggest the use of a home caregiver to the client’s family.
D. Plan to reinforce and repeat teaching about diabetes management.
A
D. Plan to reinforce and repeat teaching about diabetes management.
3
Q
3. The nurse is caring for a client who has been hospitalized following a heart attack and tells the nurse, “I didn’t sleep last night because I worried about missing work and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care? A. Anxiety B. Defensive coping C. Ineffective denial D. Risk prone-health behaviour
A
A. Anxiety
4
Q
4. The nurse is assisting with a breast biopsy for an alert client who has a lump in the right breast. Which relaxation technique will be best to use at this time? A. Massage B. Meditation C. Guided imagery D. Relaxation breathing
A
D. Relaxation breathing
5
Q
- The nurse is preparing a health-promotion session on meditation for older adults at a community centre. Which of the following points should the nurse include in the session?
A. Have clients bring earphones to the session.
B. Breathing pattern to slowly increase speed.
C. Allow a 10–20 minute time frame for meditation.
D. Practise two to three times per week.
A
C. Allow a 10–20 minute time frame for meditation.
6
Q
- When choosing music to help relax a client who is having a painful dressing change, which action is best for the nurse to take?
A. Use music composed by Mozart.
B. Ask the client about music preferences.
C. Select music that has 60–80 beats/minute.
D. Encourage the client to use music without words.
A
B. Ask the client about music preferences
7
Q
- The nurse is teaching a hospitalized client to use imagery as a relaxation technique. Which statement by the nurse is appropriate?
A. “Place your stress in the image of a form you can destroy.”
B. “Think of a place where you feel peaceful and comfortable.”
C. “Bring what you hear and sense in your present environment into your image of the scene.”
D. “If your scene is stressful to you, continue visualizing until you can overcome the distress.”
A
B. “Think of a place where you feel peaceful and comfortable.”
8
Q
- An overweight client who enjoys active outdoor activities develops arthritis in the knees. Which action by the nurse is most appropriate to assist the client in coping with the diagnosis?
A. Ask the client to discuss feelings about the diagnosis.
B. Have the client practise frequent relaxation breathing.
C. Educate the client on the use of imagery to decrease pain and decrease stress.
D. Encourage the client to think about how weight loss might improve symptoms.
A
D. Encourage the client to think about how weight loss might improve symptoms
9
Q
. The nurse is caring for a hospitalized client with diabetes who states to the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate?
A. “It is probably just coincidental that your blood sugars are high when you are ill.”
B. “Stressors such as illness cause the release of hormones that increase blood sugar.”
C. “Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.”
D. “Your diet is different here in the hospital than at home and that is the most likely cause of the increased glucose level.”
A
B. “Stressors such as illness cause the release of hormones that increase blood sugar.”
10
Q
Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized client? (Select all that apply.)
A. Assess for bradycardia.
B. Ask about gastrointestinal pain.
C. Observe for decreased appetite.
D. Check for elevated blood glucose levels.
E. Monitor for a decrease in respiratory rate.
A
B. Ask about gastrointestinal pain.
C. Observe for decreased appetite.
D. Check for elevated blood glucose levels.
11
Q
The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?
A. The blood pressure is 90/40 mm Hg.
B. Urine output is 30 mL over the last hour.
C. Oral fluid intake is 100 mL for the last 8 hours.
D. There is prolonged skin tenting over the sternum.
A
A. The blood pressure is 90/40 mm Hg.
12
Q
The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments should the nurse carefully monitor? A. Increased total urinary output B. Elevation of serum hematocrit C. Decreased serum sodium level D. Rapid and unexpected weight loss
A
C. Decreased serum sodium level
13
Q
. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client? A. Skin turgor B. Daily weight C. Presence of edema D. Hourly urine output
A
B. Daily weight
14
Q
. The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake?
A. In the late evening hours
B. If the oral mucosa feels dry
C. When the client feels thirsty
D. As soon as changes in level of consciousness (LOC) occur
A
B. If the oral mucosa feels dry
15
Q
. The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan? A. Personality changes B. Frequent loose stools C. Facial muscle spasms D. Lower extremity weakness
A
D. Lower extremity weakness
16
Q
. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective?
A. “I will try to drink at least eight glasses of water every day.”
B. “I will use a salt substitute to decrease my sodium intake.”
C. “I will increase my intake of potassium-containing foods.”
D. “I will drink apple juice instead of orange juice for breakfast.”
A
D. “I will drink apple juice instead of orange juice for breakfast.”
17
Q
The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing?
A. Restrict client’s oral free water intake.
B. Avoid use of electrolyte-containing drinks.
C. Infuse a solution of 5% dextrose in 0.45% saline.
D. Administer vasopressin (antidiuretic hormone, [ADH]).
A
A. Restrict client’s oral free water intake.
18
Q
- The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take?
A. Administer the KCl as a rapid IV bolus.
B. Infuse the KCl at a rate of 20 mEq/hour.
C. Give the KCl only through a central venous line.
D. Add no more than 40 mEq/L to a litre of IV fluid.
A
B. Infuse the KCl at a rate of 20 mEq/hour.
19
Q
9. The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client? A. Ventricular dysrhythmias B. Bradycardia C. Flatten T wave D. Prolonged P-R interval
A
D. Prolonged P-R interval
20
Q
The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following interpretations would the nurse document? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A
D. Respiratory alkalosis
21
Q
.The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement?
A. Notify the client’s health care provider.
B. Give the prescribed PRN lorazepam.
C. Start the prescribed PRN oxygen at 2–4 L/minute.
D. Encourage the client to take deep, slow breaths
A
A. Notify the client’s health care provider.
22
Q
The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness
A
b. Edema
23
Q
The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor? A. Lung sounds B. Urinary output C. Peripheral pulses D. Peripheral edema
A
A. Lung sounds
24
Q
The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client’s condition has improved? A. Hematocrit 28% B. Good skin turgor C. Absence of peripheral edema D. Blood pressure 110/72 mm Hg
A
C. Absence of peripheral edema
25
```
The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would the nurse document?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
```
A. Metabolic acidosis
26
The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications that the client has been taking at home, which of the following would be of most concern to the nurse?
A. Oral digoxin 0.25 mg daily
B. Ibuprofen 400 mg every 6 hours
C. Metoprolol 12.5 mg orally daily
D. Lantus insulin 24 U subcutaneously every evening
A. Oral digoxin 0.25 mg daily
27
The nurse is caring for a client with hypercalcemia. Which of the following actions would be included in the client’s nursing care plan?
A. Maintain the client on bed rest.
B. Auscultate lung sounds every 4 hours.
C. Monitor for Trousseau’s and Chvostek’s signs.
D. Encourage fluid intake up to 3 000 mL every day.
D. Encourage fluid intake up to 3 000 mL every day.
28
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The nurse is teaching a client with renal failure about a low phosphate diet. Which of the following foods would the nurse teach the client to restrict?
A. Dairy products
B. High-fat foods
C. Fruits and juices
D. Green, leafy vegetables
```
A. Dairy products
29
The nurse is caring for a client in the outpatient clinic who has a decreased serum magnesium level. Which of the following assessment areas should the nurse include in the health history?
A. Daily alcohol intake
B. Intake of dietary protein
C. Multivitamin/mineral use
D. Use of over-the-counter (OTC) laxatives
A. Daily alcohol intake
30
The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client asks the nurse why a peripherally inserted central catheter must be inserted. Which of the following explanations is the basis for the nurse’s response?
A. The prescribed infusion can be given much more rapidly when the client has a central line.
B. There is a decreased risk for infection when 50% dextrose is infused through a central line.
C. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
D. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
C. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
31
Which of the following actions would the nurse include in the plan of care for a client who has a central venous access device (CVAD)?
A. Avoid using friction when cleaning around the CVAD insertion site.
B. Use the push–pause method to flush the CVAD after giving medications.
C. Obtain an order from the health care provider to change CVAD dressing.
D. Have the client turn the head toward the CAVD during injection cap changes.
B. Use the push–pause method to flush the CVAD after giving medications.
32
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The nurse is caring for a client who is receiving iso-osmolar continuous tube feedings who has developed nausea, vomiting, and tachycardia. Which of the following laboratory results is most important for the nurse to report to the health care provider?
A. K+ 3.4 mmol/L
B. Ca+2 1.95 mmol/L
C. Na+ 128 mmol/L
D. PO4–3 1.55 mmol/L
```
C. Na+ 128 mmol/L
33
The nurse is caring for a client who has been hospitalized for 2 days and is receiving normal saline IV at 100 mL/hour, has a nasogastric tube to low suction, and is NPO. Which of the following assessment findings by the nurse is the priority to report to the health care provider?
A. Serum sodium level of 138 mmol/L
B. Gradually decreasing level of consciousness (LOC)
C. Weight gain of 1 kg above the admission weight
D. Oral temperature of 37.8°C (100°F) with bibasilar lung crackles
B. Gradually decreasing level of consciousness (LOC)
34
```
The nurse is assessing a client with increased extracellular fluid (ECF) osmolality. Which of the following assessment areas is the priority assessment for the nurse to obtain?
A. Skin turgor
B. Heart sounds
C. Mental status
D. Capillary refill
```
C. Mental status
35
The nurse is caring for a client with renal failure and has been taking magnesium hydroxide suspension at home for indigestion. The client is somnolent and has decreased deep tendon reflexes. Which of the following actions should the nurse take first?
A. Notify the client’s health care provider.
B. Withhold the next scheduled dose of magnesium hydroxide.
C. Review the magnesium level on the client’s chart.
D. Check the chart for the most recent potassium level.
C. Review the magnesium level on the client’s chart.
36
The nurse is caring for a postoperative client who is receiving nasogastric suction and is anxious with incisional pain. The client’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which of the following actions should the nurse take first?
A. Discontinue the nasogastric suctions for a few hours.
B. Notify the health care provider about the ABG results.
C. Teach the client about the need to take slow, deep breaths.
D. Give the client the PRN morphine sulphate 4 mg intravenously
D. Give the client the PRN morphine sulphate 4 mg intravenously
37
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The nurse is caring for a client with a CVAD who suddenly develops chest pain, hypotension, and tachycardia. Which of the following positions should the nurse immediately put the client in?
A. Prone
B. High Fowler’s
C. Left lateral with head down
D. Sims
```
C. Left lateral with head down
38
Which assessment finding about a client who has a serum calcium level of 1.58 mmol/L is most important for the nurse to immediately report to the health care provider?
A. The client is experiencing laryngeal stridor.
B. The client complains of generalized fatigue.
C. The client’s bowels have not moved for 4 days.
D. The client has numbness and tingling of the lips.
A. The client is experiencing laryngeal stridor.
39
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The nurse is caring for a client postoperative after a thyroidectomy and the client states “I have a tingling feeling around my mouth.” Which of the following data is priority for the nurse to assess?
A. An elevated serum potassium level
B. The presence of Chvostek’s sign
C. A decreased thyroid hormone level
D. Bleeding on the client’s dressing
```
B. The presence of Chvostek’s sign
40
An older adult woman took a prescription medicine to help her to sleep; however, she felt restless all night and did not sleep at all. The nurse recognizes that this woman has experienced which type of reaction or effect?
a. Allergic reaction
b. Idiosyncratic reaction
c. Mutagenic effect
d. Synergistic effect
b. Idiosyncratic reaction
41
. While caring for a patient with cirrhosis or hepatitis, the nurse knows that abnormalities in which phase of pharmacokinetics may occur?
a. Absorption
b. Distribution
c. Metabolism
d. Excretion
c. Metabolism
42
A patient who has advanced cancer is receiving opioid medcations around the clock to “keep him comfortable” as he nears the end of his life. Which term best describes this type of therapy?
a. Palliative therapy
b. Maintenance therapy
c. Supportive therapy
d. Supplemental therapy
a. Palliative therapy
43
The nurse is giving medications to a patient in heart failure. The intravenous route is chosen instead of the intramuscularlar route. Which patient factor most influences the decision about which route to use?
a. Altered biliary function
b. Increased glomerular filtration
c. Reduced liver metabolism
d. Diminished circulation
d. Diminished circulation
44
A patient has just received a prescription for an entericoated stool softener. When teaching the patient, the nurse should include which statement?
a. “Take the tablet with 60 to 90 mL of orange juice.”
b. “Avoid taking all other medications with any enteric- coated tablet.”
c. “Crush the tablet before swallowing if you have problems with swallowing.”
d. “Be sure to swallow the tablet whole without chewing it.”
d. “Be sure to swallow the tablet whole without chewing it.”
45
1. Which action by the nurse is most appropriate for the patient receiving an infusion of packed red blood cells?
A. Flush the IV line with normal saline before the blood is added to the infusion.
B. Flush the IV line with dextrose before the blood is added to the infusion.
C. Check the patient’s vital signs once the infusion is completed.
D. Anticipate that flushed skin and fever are expected reactions to a blood transfusion.
A. Flush the IV line with normal saline before the blood is added to the infusion
46
2. When preparing an IV solution that contains potassium, what would be a contraindication prior to administering potassium intravenously?
a. Diarrhea
b. Serum sodium level of 145 mmol/L
c. Serum potassium of 5.6 mmol/L
d. Dehydration
c. Serum potassium of 5.6 mmol/L
47
3. A patient is about to receive an albumin infusion. What comorbidity of the patient would be most concerning for the nurse prior to initiating the infusion?
a. Acute liver failure
b. Heart failure
c. Severe burns
d. Fluid-volume deficit
b. Heart failure
48
4. The nurse is preparing an infusion for a patient who has a deficiency in clotting factors. Which type of infusion is most appropriate for this patient?
a. Albumin 5%
b. Packed red blood cells
c. Whole blood
d. Fresh frozen plasma
d. Fresh frozen plasma
49
5. While monitoring a patient who is receiving an infusion of a crystalloid solution, the nurse should monitor for which potential adverse event?
a. Bradycardia
b. Hypotension
c. Decreased skin turgor
d. Fluid overload
d. Fluid overload
50
The nurse is administering an IV solution that contains potassium chloride to a patient in the Critical Care Unit who has a severely decreased serum potassium level. Which action(s) by the nurse is/are appropriate? (Select all that apply.)
a. Administer the potassium by slow IV bolus.
b. Administer the potassium at a rate no faster than 20 mmol/hr.
c. Monitor the patient’s cardiac rhythm with a heart monitor.
d. Use an infusion pump for the administration of IV potassium chloride.
e. Administer the potassium IV push.
b. Administer the potassium at a rate no faster than 20 mmol/hr.
c. Monitor the patient’s cardiac rhythm with a heart monitor.
d. Use an infusion pump for the administration of IV potassium chloride.
51
After completing an initial assessment of a patient, the nurse has charted that his respirations
are 18 breaths per minute and his pulse is 58 beats per minute. These types of data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
a. Objective
52
. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
c. Subjective
53
. The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
a. Database
b. Admitting data
c. Financial statement
d. Discharge summary
a. Database
54
When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present
c. Validate the data by asking a coworker to listen to the breath sounds.
55
The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, with less experience, are more likely to base
their decisions on:
a. Intuition
b. Clear-cut rules
c. Articles in journals
d. Advice from supervisors
b. Clear-cut rules
56
Expert nurses assess and make decisions through the use of:
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
a. Critical thinking
57
The nurse is reviewing information about evidence-informed practice (EIP). Which statement best reflects EIP?
a. EIP relies on tradition for support of best practices.
b. EIP is simply the use of best practice techniques for the treatment of patients.
c. EIP emphasizes the use of best and most appropriate evidence with clinician
expertise and patient preference.
d. The patient’s own preferences are not important in EIP.
c. EIP emphasizes the use of best and most appropriate evidence with clinician
expertise and patient preference.
58
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Patient newly diagnosed with diabetes needing diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
d. Individual with shortness of breath and respiratory distress
59
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant data from irrelevant data
b. Clustering related cues
60
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
a. Nursing
61
. The nursing process is a sequential method of problem solving that nurses use and includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
62
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
a. Breathing, pain, and sleep
63
What step of the nursing process includes data collection through health history, physical examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
d. Assessment
64
What is an important concept when undertaking a life-cycle approach to health assessment?
a. Consideration of the patient’s cultural view of health
b. Being responsive to the patient’s gestures to build a relationship
c. Acknowledgement of the effect of poverty on health
d. Awareness of age-specific developmental factors
d. Awareness of age-specific developmental factors
65
The nurse identifies priorities and assesses risk factors with a generally healthy individual to:
a. Identify patterns to discover missing information.
b. Determine areas for health promotion and disease prevention.
c. Distinguish normal from abnormal findings.
d. Determine treatment for a medical diagnosis.
b. Determine areas for health promotion and disease prevention.
66
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
a. Patient’s history of allergies.
b. Patient’s use of medications at home.
c. Last menstrual period 1 month ago.
d. 2 x 5 cm scar on the right lower forearm.
d. 2 x 5 cm scar on the right lower forearm.
67
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of database is most appropriate to collect in this setting?
a. A follow-up database to evaluate changes at appropriate intervals
b. An episodic database because of the continuing, complex medical problems of this patient
c. A complete health database because of the nurse’s primary responsibility for
monitoring the patient’s health
d. An emergency database because of the need to collect information and make
accurate diagnoses rapidly
c. A complete health database because of the nurse’s primary responsibility for
monitoring the patient’s health
68
Which situation is most appropriate during which the nurse collects episodic or
problem-centred data?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital for surgery the next day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
69
A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
a. Collect a follow-up database and then check her blood pressure.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was
documented 2 months ago.
d. Obtain a complete health history before checking her blood pressure because much
of her history information may have changed.
a. Collect a follow-up database and then check her blood pressure.
70
. A patient is brought by ambulance to the emergency department with multiple injuries
received in an automobile accident. The patient is alert and cooperative, but his injuries are
quite severe. How would the nurse proceed with data collection?
a. Collect history information first and then perform the physical examination and institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the
patient is transferred to the intensive care unit.
b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
71
A 38-year-old patient who is a recent refugee from Syria is attending the clinic for an initial examination. A potential intervention the nurse will implement is:
a. Cognitive assessment.
b. Fall risk screening.
c. Fasting glucose test.
d. Tuberculin skin test
d. Tuberculin skin test
72
During a clinical examination of a 68-year-old patient, the nurse will:
a. Remind the patient use medication wisely.
b. Perform a tuberculin skin test.
c. Discuss body image and dieting.
d. Helping the consumer choose a healthier lifestyle.
a. Remind the patient use medication wisely.
73
The nurse has implemented actions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individual’s condition and compare actual outcomes with expected
outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.
c. Evaluate the individual’s condition and compare actual outcomes with expected
outcomes.
74
Which statement best describes an experienced nurse? An experienced nurse is one who:
a. Has little experience with a specified population and uses rules to guide performance.
b. Takes a linear approach to the nursing process.wh
c. Is focused only on a patient’s disease.
d. Understands a patient’s situation as a whole, rather than a list of tasks, and recognizes the long-term goals for the patient.
d. Understands a patient’s situation as a whole, rather than a list of tasks, and recognizes the long-term goals for the patient.
75
The nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis?
(Select all that apply.)
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
a. Inspiratory wheezes noted in left lower lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
76
When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects? (Select all that apply.)
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
e. New confusion and forgetfulness
c. Abnormal laboratory values
d. Severely abnormal vital signs
e. New confusion and forgetfulness
77
What is the purpose of a nursing diagnosis? (Select all that apply.)
a. To evaluate the cause of disease
b. To evaluate a patient’s response to treatment
c. To determine the need to initiate supportive measures
d. To order specific diagnostic tests
e. To determine the need for health education
b. To evaluate a patient’s response to treatment
c. To determine the need to initiate supportive measures
e. To determine the need for health education
78
Which of the following are social determinants of health with potential to influence a patient’s health? (Select all that apply.)
a. Poverty
b. Poor research studies
c. Unaffordable housing
d. Lack of education
e. Poor nursing skills
a. Poverty
c. Unaffordable housing
d. Lack of education
79
The nurse wants to take a relational approach in her nursing practice. The nurse needs to: (Select all that apply.)
a. Identify unit policies and procedures
b. Identify and manage personal assumptions.
c. Promote the use of best practice guidelines.
d. Determine what is important to patients in the context of their situations.
e. Form decisions based on prevalent stereotyping
b. Identify and manage personal assumptions.
| d. Determine what is important to patients in the context of their situations.
80
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
a. To provide an opportunity for interaction between the patient and the nurse
b. To provide a form for obtaining the patient’s biographic information
c. To document the normal and abnormal findings of a physical assessment
d. To provide a database of subjective information about the patient’s past and
current health
d. To provide a database of subjective information about the patient’s past and
current health
81
When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient:
a. Has a history of drug abuse and therefore is not reliable.
b. Provided consistent information and therefore is reliable.
c. Smiled throughout interview and therefore is assumed reliable.
d. Would not answer therefore is not reliable.
b. Provided consistent information and therefore is reliable.
82
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the past 24 hours. How would the nurse best document his reason for seeking care?
a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
b. J.M. came into the clinic complaining of having black stools for the past 24 hours.
c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it
checked.
d. J.M. is a 59-year-old man who states that he has been having “black stools” for the
past 24 hours.
d. J.M. is a 59-year-old man who states that he has been having “black stools” for the
past 24 hours.
83
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?
a. “Can you point to where it hurts?”
b. “We’ll talk more about that later in the interview.”
c. “What have you had to eat in the past 24 hours?”
d. “Have you ever had any surgeries on your abdomen?”
a. “Can you point to where it hurts?”
84
A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which
would be the nurse’s appropriate response to the woman’s statement?
a. “How does your family react to your pain?”
b. “The pain must be terrible. You probably pinched a nerve.”
c. “I’ve had back pain myself, and it can be excruciating.”
d. “How would you say the pain affects your ability to do your daily activities?”
d. “How would you say the pain affects your ability to do your daily activities?”
85
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
a. Patient denies usual childhood illnesses.
b. Patient states he was a “very healthy” child.
c. Patient states his sister had measles, but he did not.
d. Patient denies having had measles, mumps, rubella, chickenpox, pertussis, and
strep throat.
d. Patient denies having had measles, mumps, rubella, chickenpox, pertussis, and
strep throat.
86
A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
a. P-6, B-4, (S)Ab-2
b. Grav 6, Term 4, (S)Ab-2, Living 4
c. Patient has had four living babies
d. Patient has been pregnant six times
b. Grav 6, Term 4, (S)Ab-2, Living 4
87
A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best
response to this information?
a. “Are you allergic to any other drugs?”
b. “How often have you received penicillin?”
c. “I’ll write your allergy on your chart so you won’t receive any penicillin.”
d. “Describe what happens to you when you take penicillin.”
d. “Describe what happens to you when you take penicillin.”
88
The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
a. Emphysema
b. Head trauma
c. Mental illness
d. Fractured bones
c. Mental illness
89
The review of systems section provides the nurse with:
a. Physical findings related to each system
b. Information regarding health promotion practices
c. An opportunity to teach the patient medical terms
d. Information necessary for the nurse to diagnose the patient’s medical problem
b. Information regarding health promotion practices
90
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin?
a. Skin appears dry.
b. No lesions are obvious.
c. Patient denies any colour change.
d. Lesion is noted on the lateral aspect of the right arm.
c. Patient denies any colour change.
91
The nurse is obtaining the history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
a. “Do you perform testicular self-examinations?”
b. “Have you ever noticed any pain in your testicles?”
c. “Have you had any problems with passing urine?
d. “Do you have any history diseases?”
a. “Do you perform testicular self-examinations?”
92
Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
a. “I broke my right leg in a car accident 2 weeks ago.”
b. “The pain is decreasing, but I still need to take acetaminophen.”
c. “I check the colour of my toes every evening just like I was taught.”
d. “I’m able to transfer myself from the wheelchair to the bed without help.”
d. “I’m able to transfer myself from the wheelchair to the bed without help.”
93
In response to a question about stress, a 39-year-old woman tells the nurse that her husband and her mother both died in the past year. Which response by the nurse is most appropriate?
a. “This has been a difficult year for you.”
b. “I don’t know how anyone could handle that much stress in 1 year!”
c. “What did you do to cope with the loss of both your husband and your mother?”
d. “That is a lot of stress; now let’s go on to the next section of your history.”
c. “What did you do to cope with the loss of both your husband and your mother?”
94
In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
a. This information is necessary to determine the patient’s reliability.
b. Alcohol can interact with all medications and can make some diseases worse.
c. The nurse needs to be able to teach the patient about the dangers of alcohol use.
d. This information is not necessary unless a drinking problem is obvious.
b. Alcohol can interact with all medications and can make some diseases worse.
95
The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?
a. “Maybe she is just teething.”
b. “I will check her ear for an ear infection.”
c. “Are you sure she is really having pain?”
d. “Describe what she is doing to indicate she is having pain.”
d. “Describe what she is doing to indicate she is having pain.”
96
During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram?
a. List of diseases present in a person’s near relatives
b. Graphic family tree that uses symbols to depict the gender, relationship, and age of
immediate family members
c. Drawing that depicts the patient’s family members up to five generations back
d. Description of the health of a person’s children and grandchildren
b. Graphic family tree that uses symbols to depict the gender, relationship, and age of
97
A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which
information should the nurse collect before this procedure?
a. Child’s birth weight
b. Age at which he crawled
c. Whether the child has had measles
d. Child’s reactions to previous hospitalizations
d. Child’s reactions to previous hospitalizations
98
As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at age 15 months. What recommendation should the nurse make?
a. No further MMR
b. MMR vaccination needs to be repeated at ages 4 years through 6 years.
c. MMR immunization needs to be repeated every 4 years until age 21 years.
d. A recommendation cannot be made until the physician is consulted.
b. MMR vaccination needs to be repeated at ages 4 years through 6 years.
99
In obtaining a review of systems on a “healthy” 7-year-old girl, the nurse knows that it would be important to include the:
a. Last glaucoma examination
b. Frequency of breast self-examinations
c. Date of her last electrocardiogram
d. Limitations related to her involvement in sports activities
d. Limitations related to her involvement in sports activities
100
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system for the child, what part of the assessment is being performed?
a. Family history
b. Review of systems
c. Functional assessment
d. Reason for seeking care
c. Functional assessment
101
The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
a. Obstetric history
b. Childhood illnesses
c. General health for the past 20 years
d. Current health promotion activities
d. Current health promotion activities
102
The nurse is performing a review of systems on a 76-year-old patient. Which of these
statements is correct for this situation?
a. The questions asked are identical for all ages.
b. The interviewer will start incorporating different questions for patients 70 years of
age and older.
c. Questions that are reflective of the normal effects of aging are added.
d. At this age, a review of systems is not necessary—the focus should be on current
problems.
c. Questions that are reflective of the normal effects of aging are added.
103
A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:
a. “Can you tell me what they look like?”
b. “Don’t worry about it. You are only taking two medications.”
c. “How long have you been taking each of the pills?”
d. “Would you have a family member bring in your medications?”
d. “Would you have a family member bring in your medications?”
104
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
a. “Do you wear glasses?”
b. “Are you able to dress yourself?”
c. “Do you have any thyroid problems?”
d. “How many times a day do you have a bowel movement?”
b. “Are you able to dress yourself?”
105
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of the functional assessment?
a. The functional assessment assesses how the individual is coping with life at home.
b. It determines how children are meeting developmental milestones.
c. The functional assessment can identify any problems with memory the individual
may be experiencing.
d. It helps determine how a person is managing day-to-day activities.
d. It helps determine how a person is managing day-to-day activities.
106
The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
a. Chest pain
b. Clammy skin
c. Serum potassium level at 4.2 mEq/L
d. Body temperature of 100 F
a. Chest pain
107
A patient is describing his symptoms to the nurse. Which of these statements reflects a
description of the setting of his symptoms?
a. “It is a sharp, burning pain in my stomach.”
b. “I also have the sweats and nausea when I feel this pain.”
c. “I think this pain is telling me that something is wrong with me.”
d. “This pain happens every time I sit down to use the computer.”
d. “This pain happens every time I sit down to use the computer.”
108
During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating?
a. The patient is an alcoholic.
b. The patient is annoyed at the questions.
c. The patient should be thoroughly examined for possible alcohol withdrawal
symptoms.
d. The nurse should suspect alcohol abuse and continue with a more thorough
substance abuse assessment.
d. The nurse should suspect alcohol abuse and continue with a more thorough
substance abuse assessment.
109
The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
a. “Do you believe in God?”
b. “Are you a part of any religious or spiritual group?”
c. “Do you consider yourself to be a religious or spiritual person?”
d. “How does your religious faith influence the way you think about your health?”
b. “Are you a part of any religious or spiritual group?”
110
The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
a. “Please stay during the interview; you can answer for her if she does not know the
answer.”
b. “It would help to interview the three of you together.”
c. “While I interview your daughter, will you please stay in the room and complete
these family health history questionnaires?”
d. “While I interview your daughter, will you step out to the waiting room and
complete these family health history questionnaires?”
d. “While I interview your daughter, will you step out to the waiting room and
complete these family health history questionnaires?”
111
The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the
critical characteristics of symptoms that should be assessed? (Select all that apply.)
a. “Where is the headache pain?”
b. “Did you have these headaches as a child?”
c. “On a scale of 1 to 10, how bad is the pain?”
d. “How often do the headaches occur?”
e. “What makes the headaches feel better?”
f. “Do you have any family history of headaches?
a. “Where is the headache pain?”
c. “On a scale of 1 to 10, how bad is the pain?”
d. “How often do the headaches occur?”
e. “What makes the headaches feel better?”
112
The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? (Select all that apply.)
a. “How much junk food does your child eat?”
b. “How many teeth has he lost, and when did he lose them?”
c. “Is he able to tie his shoelaces?”
d. “Does he take children’s vitamins?”
e. “Can he tell time?”
f. “Does he have any food allergies?”
b. “How many teeth has he lost, and when did he lose them?”
c. “Is he able to tie his shoelaces?”
e. “Can he tell time?”
