Multi Choice Exam 1

Question 1

Urinary retention is:

Answer 1

The inability to voluntary empty the bladder completely after voiding.

Question 2

While taking a health history from your client, a 53-year-old female, she discloses to you that she sometimes experiences urinary incontinence when she sneezes and laughs.
What would be the most appropriate response to this information?

Answer 2

Encourage the patient to perform pelvic floor muscle exercises.

Question 3

The nurse notes that a patient has had a black, tarry stool and recalls that a possible cause would be:

Answer 3

Gastrointestinal bleeding.

Question 4

A patient states that they are worried because they haven’t had a bowel movement each day.
The nurse’s best response concerning defecation patterns would be:

Answer 4

Check the usual elimination pattern.

Question 5

Which of the following statements regarding the ageing adult and abdominal assessment is true:

Answer 5

• Ageing influences bowel sounds
• Decreased abdominal tone
• Constipation due to dehydration

Question 6

What is anormal finding on palpation of the abdomen?

Answer 6

• No tenderness
• No muscle guarding
• No pulsations
• No large masses
• No pain

Question 7

During report the student nurse hears that a patient has ‘hepatomegaly’ and recognises that the term refers to:

Answer 7

Enlarged liver.

Question 8

When inspecting a client’s abdominal contour, the nurse observes the abdomen to be swollen and distended.
The nurse describes and documents this as:

Answer 8

Protuberant.

Question 9

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth.
The nurse knows that for her to move her hand to her mouth, she must perform the following movement:

Answer 9

Arm flexion.

Question 10

You are inspecting your client’s spinal symmetry and assessing their posture. You identify that the client has scoliosis.
This is:

Answer 10

Abdominal lateral curvature of the thoracic spine.

Question 11

The nurse is examining the ROM of a client’s shoulder.
Which of the following is a normal finding?

Answer 11

Full active and painless ROM of upper limbs.

Question 12

When using a mobile hoist with a dependent patient, identify the correct rule:

Answer 12

Perform a LITE assessment.

Question 13

You are caring for Mr Smith who has been admitted following a mechanical fall. You are reviewing his nursing care plan.
Which component of the care plan indicates that the patient’s problems have been appropriately described?

Answer 13

Nursing diagnosis.

Question 14

The older person’s tendency to take smaller steps with feet close together will most likely result in:

Answer 14

Falls risk, tripping hazard -due to imbalance.

Question 15

The most significant problem with restricted mobility is:

Answer 15

DVT: Deep Vein Thrombosis, pressure injuries, muscle atrophy.

Question 16

What is the prime purpose for maintaining a fluid imbalance chart for a hospitalised client?

Answer 16

Keeping an accurate record of input/output:
- Identifies any fluid loss/gain
- Identifies fluid imbalance
- And dehydration

Question 17

To ensure safe administration of medications the nurse must be aware of the seven rights of medication administration.
These are the right:

Answer 17

• Patient
• Dosage
• Medication
• Time
• Reason
• Route
• Documentation

Question 18

What is the term given to an unexpected effect of a medication?

Answer 18

Adverse effect..

Question 19

What should a nurse be familiar with when administering medications to patients?

Answer 19

The 7 rights of medication administration.

Question 20

While the nurse is administering the medication, the patient states, “This pill looks different to what I usually take.”
What is the correct practice in this situation?

Answer 20

Address the patient by name, tell patient you will check what the medication is. Double check patient case notes.

Question 21

A nurse administering medications has many responsibilities including knowledge of pharmacodynamics.
Pharmacodynamics is best described as:

Answer 21

The effect of the drug on the body.

Question 22

A prescription states that the nurse needs to administer a medication immediately.
What abbreviation would be used to stipulate this order?

Answer 22

STAT

Question 23

The prescription for a patient instructs the nurse to administer flucloxacillin 250 mg p.o QID.
How and when is the medication to be administered?

Answer 23

Per orally, four times a day.

Question 24

Mary Brown is 17 years old and presents with diagnosis of Type 1 Diabetes Mellitus.
Clinical manifestations associated with T1D include all the following, except?

Answer 24

• Obesity
• Recurrent infection
• BGL between 3.5-7.7

Question 25

Mirovascular complications of diabetes mellitus include damage to the kidney. This is called:

Answer 25

Diabetic nephropathy.

Question 26

Measures of glycosylated haemoglobin, such as HbA1c, monitor glucose control over a period of time, relative to the average life span of a RBC. This is normally:

Answer 26

120 days.

Question 27

Three common complications of diabetes mellitus are:

Answer 27

- Retinopathy - Nephropathy - Neuropathy

Question 28

Which of the following statements regarding Type 1 Diabetes is true?

Answer 28

Auto immune disease in which the immune system has destroyed the insulin producing cells in the pancreas.

Question 29

A nurse assessing a person with Type 1 Diabetes and notices that they are confused, have cold and clammy skin and are complaining of feeling dizzy. These are symptoms of:

Answer 29

Hypoglycemia.

Question 30

A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for:

Answer 30

Cervical cancer.

Question 31

Which of the following is a bacterial sexually transmitted infection?

Answer 31

- Chlamydia - Gonorrhoea - Syphilis - Donovanosis

Question 32

An early sign/symptom of syphilis is:

Answer 32

Painless sore that can appear on genital, rectal, or vaginal area.

Question 33

You are providing education to a women's group on breast cancer. Identify the factor below that is incorrect:

Answer 33

- Wearing a bra - Men can't have breast cancer - Always hereditary - Healthy people can't get it

Question 34

The nurse is providing nutritional information to the mother of a 1-year-old child. Which of the following statements represents accurate information for this age group?

Answer 34

Breast milk, formula and a variety of solid food, purified fruit and vegetables. Avoid choking hazards and salty/sugary foods.

Question 35

Folate is a particularly important nutrient for which patient group?

Answer 35

- Pregnant women - Anaemic - Chrons - Rheumatic disease

Question 36

During the assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following; dry mucosa and deep vertical fissures in the tongue. The finding is reflective of:

Answer 36

Dehydration.

Question 37

A patient who has had a stroke is assessed by the nurse. The nursing diagnosis identified for the patient is: risk of aspiration related to dysphagia and left sided facial weakness. An appropriate technique for the nurse to use when assisting the patient to eat is to:

Answer 37

Position patient up in chair (90 degrees), pureed diet, pace feeding, food on unaffected side, several dry swallows to clear. Encourage throat clearing.

Question 38

The tissue that connects the tongue to the floor of the mouth is the:

Answer 38

Lingual frenulum.

Question 39

A 40yr old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding as well as other areas that have a white, cheesy coating. The nurse recognises that this abnormality is:

Answer 39

Candidas / Oral thrush

Question 40

An elderly patient, who has recently had a stroke, is assessed by the nurse as having a reddened area over the coccyx. To prevent this from progressing the nurse decides to:

Answer 40

Assess and monitor skin integrity, position change 2 hourly. Pressure relief aids, barrier cream, high protein, adequate fluids.

Question 41

What is the definition of debridement?

Answer 41

Facilitates the removal of dead or deviated tissue, metabolise waste, fibrin or foreign material form a wound.

Question 42

There are several instruments for assessing patients who are at risk of developing a pressure injury. The Braden Scale is commonly used. What risk factors are assessed using the Braden Scale?

Answer 42

Sensory perception, moisture, activity, mobility, nutrition, triction + shear

Question 43

The haemostasis phase of wound healing is characterised by:

Answer 43

Vasoconstriction, platelet plug formation, coagulation cascade.

Question 44

The nurse observes that the client's skin on their right elbow is reddened, with a small abrasion, representing partial-thickness loss of the dermis. Classify the stage of the pressure injury as:

Answer 44

Stage 2.

Question 45

The nurse uses a surgical aseptic technique when:

Answer 45

Wound dressing - elimination of micro organisms from the site of procedures.

Question 46

An effective question to assess orientation in a mental health assessment may include:

Answer 46

Name, time and place. Date, day, month. year. Age, DOB.

Question 47

You are caring for Mrs X and her daughter Jane phones accusing staff of physically abusing her mother. Jane is very angry and upset and you recognise that the situation needs to be de-escalated. What is an appropriate approach with Jane?

Answer 47

Active listening, paraphrasing, remain calm, empathetic responses.

Question 48

Delirium is characterised by:

Answer 48

Active listening, paraphrasing, remain calm, empathetic responses.

Question 49

The nurse is performing a lymph node assessment on a client who has been complaining of a sore throat. In palpating for the tonsillar lymph nodes the nurse must position the pads of their fingers in which position?

Answer 49

Below angle of the mandible, fingers positioned like a cats paw, pressing on side of neck for swelling / tendernes.

Question 50

Which symptoms are commonly associated with enlarged head and neck lymph nodes?

Answer 50

Headaches, malaise, difficulty swallowing, sore throat, flue like symptoms.