Timby 8, 15, 30, 31 Concept 16, 17 Flashcards
1
Q
True or false
Nurses should primarily use verbal and visual methods of instruction to teach functionally illiterate clients
A
True
2
Q
True or false
Young adults prefer visualizations, stimulations, and other methods of participatory learning
A
True
3
Q
True or false
The use of gestures is preferable to the use of translators when neither the nurse nor the client speaks a compatible language
A
False
4
Q
True or false
Even if a client favors one domain, nurses can optimize learning by presenting information through a combination of teaching approaches
A
True
5
Q
True or false
A method of capturing the clients attention during teaching is to use the clients name frequently throughout the session
A
True
6
Q
The _______ domain of learning is demonstrated by processing information by listening or reading facts and descriptions
A
Cognitive
7
Q
________ is the study and practice of enhancing learning around older adults
A
Geragogy
8
Q
________ is the science of teaching children or those with cognitive ability comparable to children.
A
Pedagogy
9
Q
_______ illiterate clients generally posses minimal literacy skills.
A
Functionally
10
Q
The ________ domain is the realm of learning that focuses on learning by doing.
A
Psychomotor
11
Q
A nurse conducts a session on health teaching for diabetes management to a group of clients. What should be the nurse’s first step?
assessing the functional abilities of the clients who are supposed to attend the session
discussing the focus of the health education with other team members
including everyone who walks in the clinic during the session
preparing a study outline to guide the discussion in the given direction
A
assessing the functional abilities of the clients who are supposed to attend the session
12
Q
The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action?
Use a translating application for cellular phone to aid in communication.
Request other health care providers who speak the client’s language to care for the client.
Have family members translate.
Obtain a medical interpreter.
A
Obtain a medical interpreter
13
Q
A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client?
Provide an environment that promotes learning.
Divide information into manageable amounts.
Identify how long the education session will last.
Find out what the client wants to know.
A
Find out what the client wants to know
14
Q
A nurse educator is teaching a group of nurses about various aspects of care for clients who have experienced a stroke. What activity most clearly reflects the affective domain of learning?
having students demonstrate the correct technique for transferring a stroke client from a bed to a chair
having a person who had a stroke talk about her experiences as a client
asking students to differentiate the typical signs and symptoms of a left-sided stroke from those of a right-sided stroke
having students compare and contrast ischemic strokes from hemorrhagic strokes
A
having a person who had a stroke talk about her experiences as a client
15
Q
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
Interpersonal
Psychomotor
Cognitive
Affective
A
Cognitive
16
Q
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?
Provide less health teaching because of the language barrier.
Elongate the teaching session to be sure the client understands.
Request family members to serve as translators.
Talk with animation and vocal inflection to stimulate the client aurally.
A
Talk with animation and vocal inflection to stimulate the client aurally.
17
Q
The nurse determines that which client has accomplished the learning level of remembering according to Bloom’s taxonomy?
44-year-old who understands that all antibiotics must be taken to be free from infection, even if symptom relief comes sooner
22-year-old who has created a device to carry healthy food serving compartments
51-year-old who has a sprained wrist 6 months ago, who now has a sprained ankle, and knows to take anti-inflammatory medication
30-year-old who recalls the name of a medication the provider prescribed
A
30-year-old who recalls the name of a medication the provider prescribed
18
Q
An older adult client is advised to undergo a 12-lead electrocardiogram (ECG) assessment. The client seems to be anxious because this is the first time undergoing such a procedure. What explanation should the nurse provide to the client?
“The ECG electrodes are painless and will record electrical activity of the heart.”
“The procedure is short; it will take only 45 minutes to finish.”
“You should lie still when the ECG is recorded; otherwise, the recording may be wrong.”
“The ECG will give information about your heart to the doctor to guide treatment.”
A
“The ECG electrodes are painless and will record electrical activity of the heart.”
19
Q
The nurse is preparing to educate a client newly diagnosed with diabetes about various aspects of home management techniques to maintain control of blood glucose levels. When performing education, what actions should the nurse take when assessing the learning needs of the client? Select all that apply.
Determine whether the client has a support system in place to assist if necessary.
Ask the client what the client feels is the greatest learning need to manage diabetic care.
Ask the client what areas of weakness the client has that will prohibit learning.
Determine whether the client is ready to learn about the care of diabetes.
Determine the financial status of the client to be sure the client can afford care.
A
Determine whether the client has a support system in place to assist if necessary.,
Ask the client what the client feels is the greatest learning need to manage diabetic care.,
Determine whether the client is ready to learn about the care of diabetes.
20
Q
Following orthopedic surgery, a male client will be discharged home with supplies and instruction to inject himself daily with low molecular-weight heparin to prevent thrombosis. The nurse should be satisfied that the client has achieved the necessary learning for this skill when the client:
is able to explain the process for administering an injection correctly.
stops asking the nurse questions about the administration of the drug.
gives himself an injection of the drug using the correct technique.
states that he understands why the drug is necessary and how to inject it safely.
A
gives himself an injection of the drug using the correct technique.
21
Q
A nurse is leading an education session on a cardiac care unit about rehabilitation for clients who have recently undergone heart surgery. Which statement by a participant most clearly indicates that learning has occurred?
“I’ve made a plan for changes that I’m going to make to my routines once I get home.”
“I really appreciated the fact that the nurse didn’t explain things too quickly or in too much detail.”
“I found that the class made a lot more sense to me than the pamphlets that I was given before my surgery.”
“I feel like the care team really understood what I was going through when I was in the hospital.”
A
“I’ve made a plan for changes that I’m going to make to my routines once I get home.”
22
Q
A client’s health education is delayed until the time the client is ready to be discharged from the health care facility. What is the probable outcome of this delay?
The nurse cannot perform any health education.
The client loses interest in the health education.
The client already has knowledge of health education.
The client is not satisfied with the education.
A
The client is not satisfied with the education
23
Q
When caring for a client with a throat infection, the nurse needs to ensure that the learning needs of the client are met. What is the first stage of the learning process for the client?
independent use of new learning
recognition of what has been taught
recall or description of information to others
explanation or application of information
A
recognition of what has been taught
24
Q
The nurse has completed teaching. Which client behavior demonstrates understanding within the psychomotor domain?
Provides return demonstration of use of inhaler.
Verbalizes key points of a brochure about diabetes that was read.
Provides a description of what appropriate wound healing should look like.
States “I feel comfortable using my walker.”
A
Provides return demonstration of use of inhaler.
25
At completion of the health teaching for a client, the nurse documents the details of the health teaching in the client's medical record. What can be determined by this documentation?
self-administration of medications
proof of compliance with teaching standards
client's response to the health teaching
dietary instructions for the client
proof of compliance with teaching standards
26
The nurse is readmitting a client who was discharged 1 week ago with complications from diabetes mellitus. The client states, "I really did not understand what I was supposed to do to care for myself from those papers that I was sent home with." What question will the nurse ask to promote the client's self-esteem?
"Do you have a problem with reading?"
"You understand that if you are not able to care for yourself, will you continue to be admitted?"
"How do you learn best and what can we do to provide you with that information?"
"What was so difficult about the discharge instructions?"
“How do you learn best and what can we do to provide you with that information?"
27
A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction?
The client is a passive learner.
The client is not interested.
The client has a short attention span.
The client belongs to a different culture.
The client belongs to a different culture.
28
The nurse is caring for a client with a migraine, who is admitted to the health care facility for observation. How can the nurse ensure that the client's learning needs are fulfilled?
Provide the client with adequate support materials.
Begin teaching as soon as possible after admission.
Provide tips to the client for applying knowledge.
Encourage client to self-administer the medications.
Begin teaching as soon as possible after admission.
29
Which documentation example best reflects the complexity of client teaching by the nurse?
"Told client to take antibiotic as ordered."
"Taught client about peak flows; client verbalized understanding."
"Client return demonstrated how to use glucometer."
"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."
“Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."
30
When preparing client teaching materials, how does the nurse best assess a client's preferred learning style?
Ask the client, "Do you learn best by observing, valuing, or doing?"
Determine client learning needs based on age and ability to hear effectively.
Provide teaching that works for the broadest base of clients.
Observe the client's behaviors.
Ask the client, "Do you learn best by observing, valuing, or doing?"
31
During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case?
Recall of the information being taught
Involvement in the education in an active way
Independent use of new learning
Repetition of information for memorization
Independent use of new learning
32
The community health nurse is teaching an 89-year-old community-dwelling client about the care of the client's venous leg ulcer. In light of this client's age, the nurse should make which adaptation to this client's education?
Test the client's comprehension in formal, rather than informal, ways.
Ensure that a friend or family member of the client is present during education.
Plan education sessions that are briefer than those intended for younger clients.
Perform education sessions that are dependent on technology.
Plan education sessions that are briefer than those intended for younger clients.
33
A nurse is conducting an education session with a client prior to the client's discharge. At the beginning of the session, the client was engaged with the material and had several questions. However, the client has stopped asking questions and is now rarely making eye contact with the nurse. How should the nurse best respond?
Bring the education session to a close and continue at a later time.
Emphasize the relevance of the teaching to the client's recovery.
Enlist the assistance of another nurse in the client education.
Ask the client why the client stopped caring about the material.
Bring the education session to a close and continue at a later time.
34
After teaching the client about a low-fat diet, which items selected by the client would indicate to the nurse that the client comprehends the nutritional teaching?
Egg white omelet with vegetables
Coffee with non-dairy creamer
Frozen hash browns with vegetables
Peanut-butter sandwich
Egg white omelet with vegetables
35
A 56-year-old woman with a diagnosis of breast cancer is receiving chemotherapy and has been experiencing debilitating nausea throughout the course of treatment. What nursing diagnosis should the nurse assign to this client's health problem?
Impaired Swallowing
Imbalanced Nutrition: Less Than Body Requirements
Self-care Deficit: Feeding
Risk for Aspiration
Imbalanced Nutrition: Less Than Body Requirements
36
A nurse is caring for a client with anorexia. What is the best evidence that the client is responding to the diet recommended by the dietitian?
The client's electrolytes are stable.
The client remains alert and talks about food.
The client is free of abdominal pain.
The client feels hungry.
The client feels hungry
37
An 84-year-old resident of a long-term care facility developed the early signs and symptoms of Alzheimer disease several months ago and has experienced a significant decline in food intake as the disease has progressed. What action should the nurse take in order to promote nutrition for this client?
Provide consistency in the time and place for eating each meal.
Eliminate spices and seasonings from the client's food whenever possible.
Provide the client with a minced or pureed diet that is easier to chew and swallow.
Provide a wide variety of new foods to increase the client's interest.
Provide consistency in the time and place for eating each meal.
38
Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2000 calories daily?
sodium less than 2000 mg
total fat less than 65 g
cholesterol greater than 300 mg
saturated fat greater than 20 mg
Total fat less than 65 g
39
A nurse is assessing a 70-year-old client with a reduced appetite. Which condition contributes to reduced appetite and reduced nutritional intake in older adults?
adverse medication effects
heart disease
arthritis
lack of digestive enzymes
Adverse medication effects
40
The nurse is caring for a client who wishes to include more antioxidant and anti-inflammatory foods in the diet. Which food(s) will the nurse recommend? Select all that apply.
red meat
pork products
cocoa
milk chocolate
blueberries
Cocoa, blueberries
41
A client underwent surgical repair of a hernia and has been ordered on a clear fluid diet for the first 24 hours following surgery. The client's family members are eager to help with recovery and have asked the nurse about permissible food items to bring for the client. Which item is acceptable at this point in the client's recovery?
orange juice
tomato juice
apple juice
drinkable yogurt
Apple juice
42
During a meeting with the school nurse, a 15-year-old girl has declared her intention to adopt a vegan diet. The nurse should conduct client education to ensure that the girl maintains an adequate intake of:
carbohydrates.
unsaturated fats.
vitamin C.
protein.
Protein
43
After a teaching session regarding dietary choices of carbohydrates, which client responses indicate correct understanding of the foods to limit in the diet? Select all that apply.
apple
rice
lean red meat
corn on the cob
wheat germ
Apple,
Rice,
Corn on the cob,
Wheat germ
44
The nurse is teaching an older adult client about different types of proteins that can be eaten. Which foods will the nurse identify as containing dietary protein? Select all that apply.
nuts
beans
poultry
butter
fish
Nuts,
Beans,
Poultry,
Fish
45
A nurse is caring for a client who has been prescribed a clear liquid diet. Which should the nurse teach the family to share with the client?
Ice cream
Cream soup
Pudding
Gelatin
Gelatin
46
A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?
"It does not matter which foods you eat, as long as you always make sure you get 2,400 calories."
"Can you share an example of what you ate yesterday?"
"Be sure to eat a large amount of carbohydrates so you can have energy."
"As long as you focus on protein intake, you will get the nutrition you need."
“Can you share an example of what you ate yesterday?"
47
The physician has asked the nurse to prepare a list of laboratory tests needed to assess an obese client's daily fat intake. Which test would the nurse include on the list?
serum albumin test
cholesterol level test
transferrin level test
complete blood count
Cholesterol level test
48
A nurse is collecting the objective data from a client during the physical assessment. What anthropometric data about the client is documented by the nurse?
estimated weight
clothing
height with shoes
body water
Clothing
49
A nurse observes that a client coughs and chokes when eating. What instructions should the nurse prepare for this client?
Tell the client to chew his food very thoroughly.
Instruct the client to avoid drinking beverages with meals.
Restrict milk and other dairy products in the diet.
Instruct the dietary department to prepare a liquid diet.
Tell the client to chew his food very throughly
50
A nurse is caring for a client diagnosed with high risk for cardiovascular disease. Which item should the nurse make sure is not on the client's dietary tray?
red meat
corn
eggs
fish
Red meat
51
A client is directed by the health care provider to increase omega fatty acids in daily meals. Which instruction should the nurse give the client?
Add spinach and sunflower seeds to your regular diet.
Add granola and bran to your diet.
Add low-fat milk and hazelnuts to your diet.
Add salmon, trout, and herring to your regular diet.
Add salmon, trout, and herring to your regular diet.
52
The nurse is caring for a client who is pregnant. Which nutrition education will the nurse provide?
Eliminate red meat and poultry from the diet.
Weight gain is not an issue since the client is pregnant.
Decrease intake of carbohydrates, such as grains.
More servings of milk daily will be required.
More servings of milk daily will be required.
53
A nurse is caring for a client reporting frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved?
carbonated beverages
boiled vegetables
fruit juices
warm milk
Fruit juices
54
A 77-year-old female client experienced a stroke several weeks ago that has left her with several motor and sensory deficits, including dysphagia. The client is receiving a diet with a modified texture that is easier to chew and swallow. What nursing action should the nurse perform in order to maintain this client's safety during feeding?
Ensure that there is a complete and functional suction system at the bedside.
Provide two larger meals each day rather than three smaller meals in order to prevent fatigue.
Encourage the client to hold her breath while she is attempting to swallow.
Position the head of the client's bed at a height of 30° to 45°.
Ensure that there is a complete and functional suction system at the bedside.
55
```
Which of the following terms best describes plant compounds that are thought to have health protecting qualities? Examples include lutein and lycopene.
A- macronutrients
B- organic nutrients
C- micronutrients
D- phytochemicals
```
D
56
The term malnutrition may be used to describe patients who consume an excessive quantity or quality of macronutrients or micronutrients.
A- true
B- false
True
57
An elderly individual who lives at a long term care facility is at less risk for nutritional deficits than an elderly patient who lives at home with a frail spouse.
A- true
B- false
False
58
Which of the following statements is true regarding vitamin D deficiency?
A- vitamin D deficiency is uncommon in African Americans because ethnic food choices include a variety of dairy products
B- vitamin D deficiency is not typically a concern for individuals following a vegan diet
C- vitamin D deficiency often leads to reduced calcium absorption, which affects bone health
D- vitamin D deficiency is associated with neurological damage
C- vitamin D deficiency often leads to reduced calcium absorption, which affects bone health
59
Which of the following conditions require increased caloric intake as a result of increased metabolic rates? Select all that apply
```
A- arthritis
B- severe burns
C- COPD
D- AIDS
E- hypothyroidism
```
B
C
D
60
```
The absorption of nutrients takes place in the intestinal tract. Which area of the intestine is the primary site for the absorption of water-soluble vitamins and proteins?
A- duodenum
B- jejunum
C- llueum
D- colon
```
B
61
```
Which of the following conditions is associated with vitamin C deficiency?
A- Kwashiorkor
B- marasmus
C- scurvy
D- pellagra
```
C- scurvy
62
```
The physician suspects a patient has iron deficiency anemia. Which of the following blood tests would assist with the diagnosis of anemia?
A- glucose level
B- hemoglobin level
C- lipid panel
D- electrolyte panel
```
B
63
```
For which would it be most important to monitor serum potassium levels?
A- COPD
B- CKD
C- a patient with pernicious anemia
D- a patient with diabetes mellitus
```
B
64
A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which primary nursing diagnosis? Select all that apply.
stress urinary incontinence
risk for infection
functional urinary incontinence
risk for impaired skin integrity
situational low self-esteem
risk for infection,
risk for impaired skin integrity,
situational low self-esteem
65
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?
loss of urine without any identifiable pattern or warning
need to void is perceived frequently, with short-lived ability to sustain control of flow
loss of urine control because a toilet is not accessible
loss of small amount of urine when intra-abdominal pressure rises
Loss of urine without any identifiable pattern or warning
66
A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?
Collect the entire urinary output.
Collect the first urine expelled.
After the initial stream is initiated, collect the sample.
Wait until the void is almost over to collect a specimen.
After the initial stream is initiated, collect the sample
67
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?
stress incontinence
functional incontinence
urge incontinence
reflex incontinence
Stress incontinence
68
The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?
Check electronic health record for medical order.
Gather equipment and supplies.
Explain the procedure to the client.
Assess urine characteristics.
Check electronic health record for medical order
69
Which instructions should the nurse give a client who needs to provide a urine sample for a pregnancy test?
Collect the first morning urine or urine that has been in the bladder for at least 4 hours.
Collect a specimen 2 hours after eating.
Collect a specimen just before retiring to bed at night.
Collect a specimen just before lunch if the urine has been in the bladder at least 2 hours.
Collect the first morning urine or urine that has been in the bladder for at least 4 hours
70
A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs continuous bladder irrigation. Which intervention should the nurse perform when providing continuous bladder irrigation?
Purge air from the tubing.
Empty the balloon with a syringe.
Clean the urinary meatus.
Place the sterile solution on the bed.
Purge air from tubing
71
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?
reflex
stress
urge
total
Stress
72
The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?
"Indwelling catheters do not hurt, and I will be careful placing it."
"This is what your health care provider has prescribed."
"This is the only option for catheterization."
"Let me talk to your health care provider about a condom catheter."
“Let me talk to your health care provider about a condom catheter”
73
A nurse has just completed the removal of a male client's Foley catheter the day after the client's orthopedic surgery. When providing health education after the removal of the catheter, what should the nurse communicate to the client?
the fact that mild incontinence and dribbling are to be expected for the 24 to 48 hours
the nurse's rationale for performing an intermittent catheterization if he has not voided in the next two hours
the importance of limiting fluid intake until his urine flow has returned to normal
the importance of saving the urine from his first few voids so the nurse may examine them
The importance of saving the urine from his first few voids so the nurse may examine them
74
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
strongly aromatic, amber
clear, dark amber
light yellow, clear
Cloudy, foul odor
75
When caring for a client at the health care facility, the nurse has to record the client's daily urinary output. Which would indicate a normal urine volume?
3,500 mL/day
350 mL/day
200 mL/day
2,000 mL/day
2000 mL/day
76
An adult client has scheduled a visit to the clinic because the client has been experiencing polyuria for several months, a problem that has been getting worse in recent weeks. The nurse should recognize the need for assessments related to what health problem?
functional incontinence
kidney failure
diabetes mellitus
urinary tract infection
Diabetes mellitus
77
A nurse is caring for a client with urinary incontinence. When providing continence training to the client, what should the nurse tell the client about the Crede maneuver?
Perform isometric exercise to improve the ability to retain urine.
Bend forward and apply hand pressure over the bladder.
Relax the urinary sphincter in response to physical stimulation.
Massage lightly or tap the skin above the pubic area.
Bend forward and apply hand pressure over the bladder.
78
When caring for a client at the health care facility, the nurse has to record the client's urinary volume. Which amount would indicate a normal urinary volume?
200 mL/day
3,500 mL/day
350 mL/day
2,000 mL/day
2,000 mL/day
79
Preliminary laboratory results of a client's urine culture suggest that the sample was contaminated. A clean-catch specimen has consequently been recommended. Why is a clean-catch specimen preferable to a randomly voided specimen?
The osmolarity of urine from the middle of a void is higher than that from the initial and final urine.
A clean-catch specimen is more accurate because it is collected after the initial urine stream has cleansed the urinary structures.
Microorganisms in the bladder are most prevalent in the last urine that is produced during a void.
A clean-catch specimen allows the simultaneous examination of urine that has recently contacted the ureters, bladder, and urethra.
A clean-catch specimen is more accurate because it is collected after the initial urine stream has cleansed the urinary structures.
80
A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced?
total
reflex
urge
stress
Total
81
A nurse is examining the urine specimen of a dehydrated client. What is a characteristic odor of the urine voided by a dehydrated client?
foul
aromatic
pungent
strong
Strong
82
A hospital nurse has been caring for a female client since 0700 and the time is now 1430. The nurse notes that the client has not voided to this point in the shift. How can the nurse begin to determine whether the client is failing to produce urine or is retaining urine in her bladder?
Inspect the client's bed sheets and gown for indications of urinary incontinence.
Question the client about her fluid intake since the previous evening.
Inspect the client's abdomen for indications of distention.
Check the client's skin turgor and mucous membranes for signs of dehydration.
Inspect the clients abdomen for indications of distention
83
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?
Keep muscles contracted for at least 30 seconds.
Tighten the internal muscles used to prevent or interrupt urination.
Relax muscles for at least 1 minute between contractions.
Perform these exercises 10 times daily for 1 month.
Tighten the internal muscles used to prevent or interrupt urination
84
A nurse is caring for a female client who has been experiencing urinary retention for several hours. The client's primary care provider has ordered the insertion of a Foley catheter and the nurse is currently performing this aseptic procedure. The nurse has inserted the catheter and urine has just begun to flow. How should the nurse inflate the balloon that will anchor the catheter in place?
Withdraw the catheter 1½ to 2 in. (4 to 5 cm) and the inflate the balloon.
Advance the catheter until gentle resistance is felt and then inflate the balloon.
Hold the catheter in place and gently inflate the balloon.
Advance the catheter ½ to 1 in. (1.25 to 2.5 cm) and then inflate the balloon.
Advance the catheter ½ to 1 in. (1.25 to 2.5 cm) and then inflate the balloon.
85
A client is not having a bowel movement daily. The client perceives being constipated. Which assessment data is the nurse likely to collect from this client? Select all that apply.
daily intake of 6 servings of raw fruits and vegetables
oozing, liquid stool
using laxatives several times daily
bowel movements occur every third day
chronic purging
Using laxatives several times daily,
| Chronic purging
86
A 56-year-old client tells the nurse that he has been experiencing intermittent constipation and changes in the size and consistency of his stool in recent months. During the assessment interview, the nurse learns that the client has been maintaining consistent levels of exercise, fiber intake, nutrition and fluid intake, and has not previously been prone to constipation. The nurse should recognize the need for this client to be assessed for:
colorectal cancer.
Crohn disease.
ulcerative colitis.
anal fistula.
Colorectal cancer
87
A nurse is caring for a client with an ostomy pouch. Which are the major points to reinforce when preparing the client who is to be discharged?
"Slowly add foods that are difficult to digest, such as nuts, slowly back into your diet."
"Change the pouch every 4 to 7 days."
"What questions do you have about sexuality and your stoma?"
"Keep the skin around the stoma clean to prevent irritation."
"You should empty the pouch when it is one-third to one-half full."
ALL answers are correct
88
A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?
distends rectum and irritates local tissue
distends rectum and moistens stool
lubricates and softens stool
irritates local tissue
Lubricates and softens stool
89
The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?
Heart rate of 88 beats/min
Temperature of 99°F (37.2°C)
Skin turgor response of 6 seconds
Blood pressure of 120/70 mm Hg
Skin turgor response of 6 seconds
90
A nurse inserts a rectal suppository into a middle-age female client. The client says that she has an urge to expel the suppository instantly. Which action should the nurse perform?
Ask the client to remain still in the Sims' position.
Avoid placing the suppository within the stool.
Ask the client to contract the gluteal muscles.
Ask the client to take several slow, deep breaths.
Ask the client to contract the gluteal muscles
91
A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?
soap and water
hypertonic saline
tap water
mineral oil
Mineral oil
92
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?
prone
Sims
supine
semi-Fowler's
Sims
93
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?
a diet consisting of whole grains, seeds, and nuts
a diet lacking in glucose and water
a diet lacking in fruits and vegetables
a diet lacking in meat and poultry products
A diet lacking in fruits and vegetables
94
A nurse is caring for a client with diarrhea. Which intervention can help provide relief to a client with diarrhea?
Help the client lie flat in a supine position.
Offer solid foods such as vegetables and beans.
Encourage a clear liquid diet.
Tell the client to avoid bananas and apples.
Encourage a clear liquid diet
95
A 71-year-old woman sought care because of recurrent constipation. The client stated that she had tried an array of pharmacologic and dietary approaches to managing her problem, yet it persisted. The nurse suggested that the woman keep a "stool diary" for a few weeks and this documented the fact that the woman typically has six to seven formed bowel movements each week. What type of constipation is this client most likely experiencing?
secondary constipation
iatrogenic constipation
primary constipation
pseudoconstipation
Pseudoconstipation
96
A nurse is caring for a client with diabetes who has iatrogenic constipation. What is the major reason for iatrogenic constipation?
prolonged use of narcotics
pathologic disorder
inadequate intake of fiber
overuse of abuse laxatives
Prolonged use of narcotics
97
The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?
Use water and mild soap.
Use alcohol-based sanitizer.
Use water only.
Use mineral oil.
Use water and mild soap
98
A client had a colostomy created several weeks ago as part of a treatment regimen for colon cancer. The client has lately been experiencing the passage of hard, dry stool that is difficult to pass through the stoma and into the appliance. The nurse should consider which intervention?
provision of a low-bulk, low-fluid diet
irrigation of the client's ostomy
removal of the client's ostomy bag for an hour at a time, several times daily
abdominal massage to stimulate peristalsis
Irrigation of the clients ostomy
99
An older adult resident of a long-term care home has been experiencing diarrhea for the past two days as a result of an influenza outbreak at the facility. The nurse at the care home should be aware that older adults who experience diarrhea are at increased risk of what health problem?
anal fissures
electrolyte imbalances
small bowel obstruction
peripheral and pulmonary edema
Electrolyte imbalances
100
A client diagnosed with colorectal cancer reports constipation to the nurse. Which teaching will the nurse provide to help the client identify sign(s) or symptom(s) of constipation? Select all that apply.
You may experience pain on defecation.
Your abdomen will feel empty.
You will feel less thirsty.
You will urinate less often or not at all.
Watch for liquid bowel movements after days with none.
You may experience pain on defecation.,
You will urinate less often or not at all.,
Watch for liquid bowel movements after days with none.
101
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?
"This test will help determine whether you have an infectious process in the intestines."
"This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer."
"This will determine what foods you are allergic to that affect digestion and elimination."
"This test detects heme, an iron compound in blood within the stool."
“This test detects heme, an iron compound in blood within the stool."
102
A hospitalized client has been experiencing abdominal pain in recent days and has developed a noticeably distended and firm abdomen. The client states feeling constipated, but a review of the client's medical record reveals that the client has had several episodes of diarrhea over the past 72 hours. How should the nurse best interpret these events?
The client may have diverticulosis in which the walls of the intestines are weakened and bulging.
The client may have a fecal impaction in which liquid stool bypasses the impacted stool.
The client may be misinterpreting gas accumulation as stool accumulation.
The client may have sphincter incompetence between the stomach and small intestine.
The client may have a fecal impaction in which liquid stool bypasses the impacted stool
103
The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.
black
light brown
yellow
clay colored
dark brown
Light brown,
| Dark brown
104
A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?
Will includes a pat of butter with eggs for breakfast.
Plans to eat 4 ounces of protein 3 times per day.
Will include fish one to two times per week.
Plans to eat a snack of fruit twice per day.
Plans to eat a snack of fruit twice per day
105
The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient?
Eat foods high in fiber.
Drink six to eight glasses of noncaffeinated fluids daily.
Visit the urologist once yearly.
Exercise in the morning and evening.
Drink six to eight glasses of non caffeinated fluids daily
106
The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement?
The patient must remain in the restraints all day.
The patient needs to be toileted to maintain a regular toileting schedule.
The patient needs to be provided with adult briefs for incontinence.
The patient will use the call bell when he or she feels the urge to void.
The patient needs to be toileted to maintain a regular toileting schedule
107
The nurse is caring for a patient with a colostomy of the ascending colon. What would the nurse expect of the stool in the colostomy device?
Stool would have flecks of blood.
Stool would be formed.
Stool would be loose.
Stool would be dark.
Stool would be loose
108
A patient with a history of cardiac problems talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagus nerve and cause bradycardia. Which physiological function is the nurse explaining?
Eupnea
Tachypnea
First-degree heart block
Valsalva maneuver
Valsalva maneuver
109
The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? (Select all that apply.)
Select all that apply.
```
Eat fruit twice daily.
Increase fiber in the diet.
Drink six to eight glasses of noncaffeinated fluids daily.
Exercise daily.
Void when the urge is felt.
```
Drink six to eight glasses of non caffeinated fluids daily
Void when the urge is felt
110
The home health nurse is caring for a patient experiencing constipation. The patient asks the nurse how to prevent constipation. Which recommendations should the nurse include in their answer to the patient? (Select all that apply.)
Select all that apply.
```
Avoid eating fruits with seeds.
Defecate when the urge is felt.
Increase fiber in the diet.
Increase activity or exercise.
Drink at least 1500 mL of water per day.
```
Defecate when the urge is felt
Increase fiber in the diet
Increase activity or exercise
Drink at least 1500 mL of water per day
111
The nurse is working with a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency?
A Caucasian female who is 39 weeks gestation
An Asian female diagnosed with hypoglycemia
A Hispanic female who has a BMI of 24.1
An African-American female who is breastfeeding
An African-American female who is breastfeeding
112
The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which supplement may be prescribed to prevent deficiency?
Omega-3 fatty acids
Vitamin D
Vitamin C
Vitamin B12
Vitamin B12
113
Appropriate approaches used by the long-term care nurse to reinforce patient education for a 73 year old who has just been diagnosed with diabetes include which of the following? (Select all that apply.)
Select all that apply.
Remind the patient that a lot of damage has already occurred.
Avoid discussion of the patient’s favorite foods.
Encourage the patient’s family to participate in teaching sessions.
Schedule a visit by another resident who is diabetic.
Demonstrate food choices using food photographs.
Ask the patient about past experiences with lifestyle changes.
114
A home health nurse is caring for a 79-year-old male patient suspected of being malnourished. Which findings support this suspicion? (Select all that apply.)
Select all that apply.
```
Prealbumin level of 16 mg/dL
Weight loss of 6% since last month’s visit
Hematocrit level of 50%
Waist-to-hip ratio of 1.0
Body mass index (BMI) of 17
Hemoglobin level of 8.2 g/dL
```
Weight loss of 6% since last month’s visit
Body mass index of 17
Hemoglobin level of 8.2 g/dL
115
A person of Northern heritage is at an increased risk for which of the following? (Select all that apply.)
Select all that apply.
```
Celiac disease
Type 2 diabetes
Metabolic syndrome
Hypertension
Type 1 diabetes
Vitamin C deficiency
```
Celiac disease
Type 1 diabetes
116
True or false
| The physical characteristics of urine include its volume, color, clarity, and odor
True
117
True or false
| Oliguria means greater than normal urinary volume
False
118
True or false
| Residual urine that remains in the bladder after voiding can support the growth of microorganisms, leading to infection
True
119
True or false
| A sign of urinary retention is a progressively distending bladder
True
120
True or false
| Diabetes mellitus is a common disorder associated with dysuria
False
121
An abnormal urinary elimination pattern characterized by absence of urine or a volume of 100 mL or less in 24 hours is termed as ______
Anuria
122
A seat like container that is used to collect urine or stool is called a _____
Bedpan
123
The act of applying or inserting a hollow tube inside the bladder or externally about the urinary meatus is called ______
Catheterization
124
______ means the inability to control either urinary or bowel elimination
Incontinence
125
A ______ is a urinary diversion that discharges urine from an opening on the abdomen
Urostomy
126
Elimination refers to the excretion of waste products. In the human body, waste products are eliminated through which of the following organs? (Select all that apply)
```
A-Skin
B-Kidneys
C-Lungs
D-Intestines
E-Liver
```
A
B
C
D
127
The term micturition means urine
True
False
True
128
```
What is the most common cause of urinary elimination discomfort?
A- a urinary blockage
B- a urinary tract infection
C- dehydration
D- a kidney stone
```
B
129
Which of the following patients is least likely to experience altered urinary or bowel elimination functioning?
A- an elderly adult with alzheimer disease
B- a young adult with a spinal cord injury following an automobile accident
C- a middle aged adult with crohn disease
D- a young adult with asthma
D- a young adult with asthma
130
The main functional unit of the kidneys is the _____
Nephron
131
```
A middle aged woman complains of small amounts of urinary leakage when she coughs or sneezes. Which of the following types of urinary incontinence is this woman most likely experiencing?
A- urge
B- overflow
C- stress
D- functional
```
C- stress
132
Which of the following statements are true regarding bowel function and elimination? (Select all that apply)
A- constipation is defined as the difficult passage of hard, dry stool
B- narcotic pain medication and anesthesia contribute to postoperative stool retention
C- oozing of liquid stool may indicate a bowel impaction
D- a common side effect of diuretic medications is loose stools
E- increased intake of dietary fiber contributes to stool retention
A
B
C
133
A patient is diagnosed with multiple renal calculi. Which procedure does the nurse anticipate will be performed to treat this condition?
A- nephrectomy
B- transrethral resection of the prostate
C- urinary diversion
D- lithotripsy
D
134
```
A patient arrives at the clinic with complaints of urinary burning and frequency. The health care provider suspects the patient has a UTI. Which diagnostic test will the nurse prepare the patient for?
A- renal function test
B- urinalysis and urine culture (UA/UC)
C- occult blood test
D- kidney biopsy
```
B- UA/UC
135
```
The nurse is performing a physical assessment on a patient diagnosed with an acute episode of inflammatory bowel disorder. Upon auscultation of the patients abdomen, which of the following does the nurse expect to note?
A- absent bowel sounds
B- abdominal tenderness
C- hyperactive bowel sounds
D- abdominal distinction
```
C- hyperactive bowel sounds
136
A 78 years old women who lives alone has been admitted to the hospital with a diagnosis of failure to thrive. Assessment revels that the women has malnutrition, a problem related to her lack of finances, transportation, and a social support network. Malnutrition is defined as:
A- a body mass index that is in the lowest third of the American population.
B- a condition related to a chronic lack of sufficient nutrients
C- excessive consumption of fats and sugars accompanied by inadequate vegetables.
D- a condition in which the body is unable to adequately metabolize nutrients
B
137
The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardio metabolic syndrome?
A- 23 year old with ankle fracture and anxiety
B- 36 years old with obesity who smokes
C- 44 year old with hypertension and under nutrition
D- 59 years old with lupus who exercises three times weekly
B
138
```
When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? (Select all that apply)
A- cholesterol level
B- lipoprotein level
C- triglyceride level
D- BUN
E- creatinine
F- CBC with differential
```
A
B
C
139
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
A- allow the client privacy during mealtime
B- delegate feeding assistance to the CNA
C- assess when the client generally eats meals
D- contact the healthcare provider to prescribe an appetite stimulant
C
140
A post surgical client has been admitted to the unit with an indwelling urinary catheter that was inserted in the operating room and which is scheduled for removal the following morning. How can the nurse best avoid backflow or urine into the clients bladder and subsequent infection?
A- ensure that the collection bag is always lower than the clients bladder
B- irrigate the catheter if clots or pus are viable in the tubing or collection bag
C- ensure that the contents of the collection bag do not exceed 50 percent of capacity
D- position the client in a high Fowler position unless contraindicated
A
141
```
A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?
A- urge
B- total
C- reflux
D- functional
```
D
142
```
A nurse is assessing and documenting the eating habits of a client with repeated reports of flats. Which food item produces gas that could lead to flatus?
A- chicken
B- apples
C- cabbage
D- fish
```
C
143
When caring for a client with fetal incontinence, the nurse provides an absorbent pad to protect clothing and bed linens. The nurse knows that fecal incontinence is the result of:
A- nature and amount of food consumed
B- drinking and smoking habits of client
C- neurological changes that impair muscle activity
D- social and emotional setting of client
C
144
A nurse is caring for a client with Alzheimer’s diseases. What action should the nurse perform when feeding a client with Alzheimer’s disease?
A- guide the hand with the food to the clients mouth if necessary
B- use the analogy of a clock when describing the location of food
C- describe the benefits of nutrition in simple terms
D- have the client watch television during meals
A
145
True or false
| Essential amino acids are protein components manufactured within the body
False
146
True or false
| Protein complementation helps a person to acquire all essential amino acids from non animal sources
True
147
True or false
| Trans fats are saturated fats that have been altered to be solid at room temperature
True
148
True or false
| BMI is calculated using height and waist ratio
False
149
True or false
| Plant sources contain incomplete proteins
True
150
The process by which the body obtains nutrients from food is known as_____
Absorption
151
A ________ is the amount of heat that raises the temperature of 1 gram of water degree centigrade
Calorie
152
People who rely exclusively on plant sources for protein are called _______
Vegans
153
———-data are measurements pertaining to body size and composition
Anthropometric data
154
_________ or bleaching is the discharge of gas from the stomach through the mouth
Eructation
155
True or false
| Increased peristaltic activity is termed the gastrocolic reflux
True
156
True or false
| Chronic purging eventually weakens digestive tract
False
157
True or false
| Fecal impactions result from retained barium from an intestinal x-ray
True
158
Eating beans aids the expelling of intestinal gas
False
159
Medications to reduce fever are available in suppository form
True
160
__________ means the rhythmic contractions of intestinal smooth muscle that facilitate defecation
Peristalsis
161
Fecal ____ occurs when a large, hardened mass of stool interferes with defecation
Impaction
162
A _____ is inserted into a body cavity such as the rectum.
Suppository
163
A_____ enema uses a solution held within the large intestine for a specified period, usually at least 30 minutes
Retention
164
A _____ ostomy is also referred to as a knock pouch
Continent
