Test Bank Fundamentals Nursing 2nd Wilkinson
Chapter 1. Evolution of Nursing Thought and Action
1. What is the most influential factor that has shaped the nursing profession?
1) Physicians’ need for handmaidens
2) Societal need for health care outside the home
3) Military demand for nurses in the field
4) Germ theory influence on sanitation
2. Which of the following is an example of an illness prevention activity? Select all that apply.
1) Encouraging the use of a food diary
2) Joining a cancer support group
3) Administering immunization for HPV
4) Teaching a diabetic patient about his diet
3. Which of the following contributions of Florence Nightingale had an immediate impact on improving patients’ health?
1) Providing a clean environment
2) Improving nursing education
3) Changing the delivery of care in hospitals
4) Establishing nursing as a distinct profession
4. All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others?
1) Thinking and reasoning about the client’s care
2) Providing hands-on client care
3) Carrying out physician orders
4) Delegating to assistive personnel
5. Which statement pertaining to Benner’s practice model for clinical competence is true?
1) Progression through the stages is constant with most nurses reaching the proficient stage.
2) Progression through the stages involves continual development of thinking and technical skills.
3) The nurse must have experience in many areas before being considered an expert.
4) The nurse’s progress through the stages is determined by years of experience and skills.
6. Which of the following best explains why it is difficult for the profession to develop a definition of nursing?
1) There are too many different and conflicting images of nurses.
2) There are constant changes in health care and the activities of nurses.
3) There is disagreement among the different nursing organizations.
4) There are different education pathways and levels of practice.
7. Nurses have the potential to be very influential in shaping health care policy. Which of the following factors contributes most to nurses’ influence?
1) Nurses are the largest health professional group.
2) Nurses have a long history of serving the public.
3) Nurses have achieved some independence from physicians in recent years.
4) Political involvement has helped refute negative images portrayed in the media.
8. Nursing was described as a distinct occupation in the sacred books of which faith?
9. The American Red Cross was established by:
1) Louisa May Alcott.
2) Clara Barton.
3) Dorothea Dix.
4) Harriet Tubman.
10. Which of the following is the most important reason to develop a definition of nursing?
1) Recruit more informed people into the nursing profession
2) Evaluate the degree of role satisfaction
3) Dispel the stereotypical images of nurses and nursing
4) Differentiate nursing activities from those of other health professionals
Chapter 2. Critical Thinking & the Nursing Process
1. Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:
1) Requires reasoned thought.
2) Asks the questions “why” or “how”.
3) Is a hierarchical process.
4) Demands specialized thinking skills.
2. A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to:
1) Consider all the possible advantages and disadvantages.
2) Maintain an open mind about the proposed change.
3) Apply the nursing process to the situation.
4) Make a decision based on past experience with documentation.
3. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first?
3) Plan outcomes
4) Plan interventions
4. Which of the following is an example of theoretical knowledge?
1) A nurse uses sterile technique to catheterize a patient.
2) Room air has an oxygen concentration of 21%.
3) Glucose monitoring machines should be calibrated daily.
4) An irregular apical heart rate should be compared with the radial pulse.
5. Which of the following is an example of practical knowledge (assume all are true)?
1) The tricuspid valve is between the right atrium and ventricle of the heart.
2) The pancreas does not produce enough insulin in type 1 diabetes.
3) When assessing the abdomen, you should auscultate before palpating.
4) Research shows pain medication given intravenously acts faster than by other routes.
6. Which of the following is an example of self-knowledge? The nurse thinks, “I know that I:
1) Should take the client’s apical pulse for 1 minute before giving digoxin.”
2) Should follow the client’s wishes even though it is not what I would want.”
3) Have religious beliefs that may make it difficult to take care of some clients.”
4) Need to honor the client’s request not to discuss his health concern with the family.”
7. Which of the following is the most important reason for nurses to be critical thinkers?
1) Nurses need to follow policies and procedures.
2) Nurses work with other healthcare team members.
3) Nurses care for clients who have multiple health problems.
4) Nurses have to be flexible and work variable schedules.
8. The nurse administering pain medication every 4 hours is an example of which aspect of patient care?
1) Assessment data
2) Nursing diagnosis
3) Patient outcome
4) Nursing intervention
9. How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:
1) Terminology for the client’s disease or injury.
2) A part of the client’s medical diagnosis.
3) The client’s presenting signs and symptoms.
4) A client’s response to a health problem.
10. Which statement about the nursing process is correct?
1) It was developed from the ANA Standards of Care.
2) It is a problem-solving method to guide nursing activities.
3) It is a linear process with separate, distinct steps.
4) It involves care that only the nurse will give.
Chapter 3. Nursing Process: Assessment
1. What is the role of The Joint Commission in regard to patient assessment? The Joint Commission
1) States what assessments are collected by individuals with different credentials.
2) Regulates the time frames for when assessments should be completed.
3) Identifies how data are to be collected and documented.
4) Sets standards for what and when to assess the patient.
2. Which of the following is an example of data that should be validated?
1) The client weight measures 185 lbs at the clinic.
2) The client’s liver function test results are elevated.
3) The client’s blood pressure is 160/94 mm Hg; he states that is typical for him.
4) The client states she eats a low-sodium diet and later describes eating processed food.
3. Which of the following examples includes both objective and subjective data?
1) The client’s blood pressure is 132/68 and her heart rate is 88.
2) The client’s cholesterol is elevated, and he states he likes fried food.
3) The client states she has trouble sleeping and that she drinks coffee in the evening.
4) The client states he gets frequent headaches and that he takes aspirin for the pain.
4. The Joint Commission requires which type of assessment be performed on all patients?
1) Functional ability
5. Which of the following is an example of an ongoing assessment?
1) Taking the patient’s temperature 1 hour after giving acetaminophen (Tylenol)
2) Examining the patient’s mouth at the time she complains of a sore throat
3) Requesting the patient to rate intensity on a pain scale with the first perception of pain
4) Asking the patient in detail how he will return to his normal exercise activities
6. When should the nurse make systematic observations about a patient?
1) When the patient has specific complaints
2) With the first assessment of the shift
3) Each time the nurse gives medications to the patient
4) Each time the nurse interacts with the patient
7. Which of the following is an example of an open-ended question?
1) Have you had surgery before?
2) When was your last menstrual period?
3) What happens when you have a headache?
4) Do you have a family history of heart disease?
8. Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.)
1) Beginning with neutral topics
2) Individualizing your approach
3) Minimizing note taking
4) Using active listening
9. Which of the following is an example of the most basic motivation in Maslow’s Hierarchy of Needs?
1) Experiencing loving relationships
2) Having adequate housing
3) Receiving education
4) Living in a safe neighborhood
10. What makes a nursing history different from a medical history?
1) A nursing history focuses on the patient’s responses to the health problem.
2) The same information is gathered, the difference is in who obtains the information.
3) A nursing history is gathered using a specific format.
4) A medical history collects more in-depth information.
Chapter 4. Nursing Process: Diagnosis
1. Which of the following is an example of a problem that nurses can treat independently?
2. Which of the following is an example of a cluster of related cues?
1) Complains of nausea and stomach pain after eating
2) Has a productive cough and states stools are loose
3) Has a daily bowel movement and eats a high-fiber diet
4) Respiratory rate 20, heart rate 85, blood pressure 136/84
3. Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology:
1) Is the cause of the problem.
2) Cannot always be observed.
3) Directs nursing care.
4) Is an inference.
4. How does a risk nursing diagnosis differ from a possible nursing diagnosis?
1) A risk diagnosis is based on data about the patient.
2) A possible diagnosis is based on partial (or incomplete) data.
3) Nurses collect the data to support risk diagnoses.
4) A possible diagnosis becomes an actual diagnosis when symptoms develop.
5. Which of the following describes the difference between a collaborative problem and a medical diagnosis?
1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.
2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.
3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.
4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.
6. Which of the following is the best approach to validate a clinical inference?
1) Have another nurse evaluate it.
2) Have the physician evaluate it.
3) Have sufficient supportive data.
4) Have the client’s family confirm it.
7. What is wrong with the following diagnostic statement? “Impaired Physical Mobility related to laziness and not having appropriate shoes.” The statement is:
2) Too complex.
3) Legally questionable.
4) Without supportive data.
8. When making a diagnosis using NANDA, which of the following provides support for the diagnostic label you choose?
2) Related factors
3) Diagnostic label
4) Defining characteristics
9. Based only on Maslow’s Hierarchy of Needs, which nursing diagnosis should have the highest priority?
1) Self-Care Deficit
2) Risk for Aspiration
3) Impaired Physical Mobility
4) Disturbed Sensory Perception
10. Which of the following describes the most important use of nursing diagnosis (all statements are true)?
1) Differentiates the nurse’s role from that of the physician
2) Identifies a body of knowledge unique to nursing
3) Helps nursing develop a more professional image
4) Describes the client’s needs for nursing care
Chapter 5. Nursing Process: Planning Outcomes
1. For which patient would it be most important to perform a comprehensive discharge plan?
1) A teenager who is a first-time mother, single, and lives with her parents
2) An older adult who has had a stroke affecting the left side of his body and lives alone
3) A middle-aged man who has had outpatient surgery on his knee and requires crutches
4) A young woman who was admitted to the hospital for observation following an accident
2. The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful?
1) Start planning at admission
2) Involve the family members
3) Get patient input when making the plan
4) Involve the multidisciplinary team
3. What do initial, ongoing, and discharge planning have in common?
1) They are based on assessment and diagnosis.
2) They focus on the patient’s perception of his needs.
3) They require input from a multidisciplinary team.
4) They have specific timelines in which to be completed.
4. Which client has the greatest need for comprehensive discharge planning?
1) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter
2) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease
3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother
4) A woman who was just diagnosed with renal failure and has started peritoneal dialysis
5. Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans:
1) Apply to every patient on a particular unit.
2) Include both medical and nursing orders.
3) Specify patient outcomes for each day.
4) Help ensure that important interventions are not overlooked.
6. How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans:
1) Describe the care needed by patients in defined situations.
2) Include specific goals and nursing orders.
3) Become a part of the patient’s comprehensive care plan.
4) Usually describe ideal nursing care.
7. The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?
1) Validating conflicting data with the patient
2) Transcribing medical orders
3) Stating the frequency for ambulation
4) Performing a comprehensive assessment
8. Which of the following is the best example of an outcome statement? The patient will:
1) Use the incentive spirometer when awake.
2) Walk two times during day and evening shift.
3) Maintain an oxygen saturation above 92% while performing ADLs each morning.
4) Tolerate 10 sets of range-of-motion exercises with physical therapy.
9. How are critical pathways and standardized nursing care plans similar? Both:
1) Specify daily, or even hourly, outcomes and interventions.
2) Prescribe minimal care needed to meet recommended lengths of stay.
3) Describe care common to all patients with a certain condition or situation.
4) Emphasize medical problems and interventions.
10. How is NOC different from the Omaha System?
1) NOC can be used to write health restoration outcomes.
2) NOC can be used in all specialty and practice areas.
3) NOC can be used for individuals, families, or groups.
4) NOC formulates goals based on nursing diagnoses.
Chapter 6. Nursing Process: Planning Interventions
1. Which of the following nursing interventions is an indirect-care intervention?
1) Emotional support
4) Physical care
2. Which nursing intervention is considered an independent intervention?
1) Administering 1 liter of dextrose 5% in normal saline solution at 100 mL/hour
2) Encouraging the postoperative client to perform coughing and deep breathing exercises
3) Explaining his diet to the client; then communicating the teaching with the dietitian
4) Administering morphine sulfate 2 mg IV to the client with postoperative pain
3. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?
4. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not presently have any respiratory problems. The nurse’s teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing?
1) Health promotion
5. Which standardized intervention vocabulary was designed specifically for community health nurses?
1) Omaha System
2) Clinical Care Classification
3) Nursing Interventions Classification
4) International Classification for Nursing Practice
6. A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly-written nursing order for this patient?
1) 7/12/10 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN
2) By 7/12/10, uses incentive spirometer 10 times every hour while awake to 1000 mL
3) Incentive spirometer hourly while awake
4) Offer incentive spirometer to the client—J. Smith, RN
7. A newly diagnosed diabetic client is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?
1) Consulting the diabetic nurse educator for help with a teaching plan
2) Making arrangements for the client to join a diabetic support group
3) Demonstrating blood glucose monitoring and insulin administration to the client
4) Consulting with the dietician about the client’s dietary concerns
8. Which definition best describes a critical pathway?
1) Standardized plan of care for frequently occurring conditions
2) Systematically developed statement to assist practitioners and patients in decision making
3) Systematic review of clinical evidence for an intervention
4) Set of interrelated concepts that describes or explains something
9. A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations.Which nursing intervention should be listed first on the care plan?
1) Determine airway adequacy hourly and as needed
2) Administer oxygen as needed
3) Monitor arterial blood gas values
4) Place the client in a high Fowler’s position
10. Who is the primary decision maker when caring for healthy adult clients?
Chapter 7. Nursing Process: Implementation & Evaluation
1. A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?
1) Administer the medication as ordered.
2) Hold the medication and notify the physician.
3) Consult with a pharmacist before administering it.
4) Ask the patient’s RN for information about the medication.
2. Which task can be delegated to nursing assistive personnel (NAP)?
1) Turn and reposition the client every 2 hours.
2) Assess the client’s skin condition.
3) Change pressure ulcer dressings every shift.
4) Apply hydrocolloid dressing to the pressure ulcer.
3. The nurse has just finished documenting that he removed a patient’s nasogastric tube. Which is the next logical step in the nursing process?
4. Which nursing intervention is best individualized to meet the needs of a specific client?
1) Suction the client every 2 hours per unit policy.
2) Use incentive spirometry every hour while awake per postoperative protocols.
3) Institute swallowing precautions.
4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.
5. The physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?
1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
2) Gather the equipment and prepare it before informing the client about the procedure.
3) Obtain an order to restrain the client before inserting the urinary catheter.
4) Inform the physician that she cannot perform the procedure because the client is confused.
6. A patient underwent surgery 3 days ago for colorectal cancer. The patient’s critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed?
1) Postpone the teaching session until the patient is more receptive.
2) Follow the critical pathway for patient teaching
3) Administer a prescribed antidepressant and notify the physician.
4) Explain to the patient the importance of skin care around the ostomy site.
7. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
4) Critical thinking
8. Which intervention depends almost entirely on the client’s adhering to the therapy?
1) Inserting an intravenous catheter
2) Turning a client every 2 hours
3) Shortening a surgical drain
4) Following a low-fat, low-calorie diet
9. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
1) Teaching the client that he must lose weight to control his blood sugar
2) Informing the client he must exercise at least three times per week
3) Explaining to the client he must come to the diabetic clinic weekly
4) Determining the client’s main concerns about his diabetes
10. Which statement accurately describes delegation?
1) Transferring authority to another person to perform a task in a selected situation
2) Collaborating with other caregivers to make decisions, and plan care
3) Scheduling treatments and activities with other departments
4) Performing a planned intervention from a critical pathway
Chapter 8. Nursing Theory & Research
1. Which commonly accepted practice came out of the Framingham study? Use of:
1) Mammography in breast cancer screening
2) Colonoscopy in colon cancer screening
3) Pap testing in cervical cancer screening
4) Digital rectal examination in prostate cancer screening
2. Which theorist developed the nursing theory known as the Science of Human Caring?
1) Florence Nightingale
2) Patricia Benner
3) Jean Watson
4) Nola Pender
3. A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based upon her own experiences with pain. This mental image is known as a(n):
4. Hildegard Peplau was a nursing theorist whose major contribution to nursing was:
1) Transcultural nursing.
2) Health promotion.
3) Nurse–patient relationship.
4) Holistic comfort.
5. The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist?
1) Virginia Henderson
2) Imogene Rigdon
3) Katherine Kolcaba
4) Florence Nightingale
6. A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse if her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is utilizing the theory developed by which nurse theorist?
1) Betty Neuman
2) Dorothea Orem
3) Callista Roy
4) Madeline Leininger
7. According to Maslow’s Hierarchy of Needs, which patient need should the nurse address first?
1) Protecting the patient against falls
2) Protecting the patient from an abusive spouse
3) Promoting rest in the critically ill patient
4) Promoting self-esteem after a body image change
8. A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next?
1) Perform a literature review
2) Develop a conceptual framework
3) Formulate the hypothesis
4) Define the study variables
9. The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? The right
1) Not to be harmed.
2) To self-determination.
3) To full disclosure.
4) Of confidentiality.
10. After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow’s Hierarchy of Needs, cardiac rehabilitation most directly addresses which need?
1) Safety and security
Chapter 9. Development Through the Life Span
1. The nurse is providing prenatal counseling for a couple who is trying to become pregnant. The priority for the nurse is to include which of the following information?
1) Stages of growth and development of the fetus
2) Recommended schedule of visits to her health care provider
3) Recommended average weight gain during pregnancy
4) Healthy eating habits before and during pregnancy
2. Which of the following would indicate a 4-year-old child has successfully gone through Erikson’s Stage 3 (Initiative versus Guilt)? The child:
1) Refrains from hitting a friend.
2) Plays cooperatively with friends.
3) Is able to develop friendships.
4) Is able to express his feelings.
3. The nurse is preparing to assess a toddler. To make the assessment go smoothly, before examining the child the nurse should first:
1) Talk to the mother before talking to the child.
2) Ask the child about his favorite toy.
3) Get the child’s height and weight.
4) Ask the mother to undress the child.
4. According to Erikson, a behavior demonstrating an important psychosocial task for a toddler would be for the child to:
1) Act defiantly by refusing to hold mother’s hand while crossing the street.
2) Recognize it is wrong to take a toy away from someone else.
3) Be able to understand the concept of time in hours.
4) Express to his parents and playmates he does not like something.
5. A mother comes to the clinic with her infant for a newborn checkup at 1 week of age. The mother tells the nurse, “My baby looks yellow to me.” The nurse’s best response is:
1) “What type of detergent are you using to wash the baby clothes?”
2) “Is there a possibility you had hepatitis during your pregnancy?”
3) “The color is from the breakdown of maternal red blood cells.”
4) “There is a cream you can use to reduce the yellowing.”
6. A father brings his toddler to the clinic for well-child care. Which of the following would be most important for the nurse to assess?
1) How successful the child is with potty training
2) How the child acts when you enter the room
3) Whether the child is using eating utensils
4) Whether the home is child-proofed
7. Which comment made by a woman in her early fifties would be a cue indicating the need for further assessment for a problem?
1) “My skin is so dry I need to use lotion every day after I bathe.”
2) “I have episodes when I feel really hot even when others are not.”
3) “It’s getting harder to lift those big bags of dog food.”
4) “I have to write myself notes because I’m getting so forgetful.”
8. The nurse has instructed a group of parents on common adolescent behavior. Which comment by the parent would indicate the most urgent need for further discussion?
1) “I guess my daughter won’t be asking my opinion very much.”
2) “I’m really going to watch my daughter’s eating habits.”
3) “We are really going to have to think about rules we want to enforce after he gets his driver’s license.”
4) “We don’t keep alcohol in the house, so that’s at least one thing we don’t need to worry about.”
9. Which of the following would be the priority for most adolescents? Being:
1) A good student
2) Sexually active
3) Picked to be on the soccer team
4) Able to function independently
10. During adolescence, it would be most important to encourage the teen to eat plenty of:
2) Dairy products
Chapter 10. Experiencing Health & Illness
1. In an effort to promote health, the home health nurse opens the client’s bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people?
1) Jean Watson
2) Jurgen Moltmann
3) Florence Nightingale
4) Robert Louis Stevenson
2. Which of the following is known to be a healthy strategy for coping with stress?
1) Performing meaningful work
2) Consuming simple carbohydrates
3) Drinking three glasses of red wine each day
4) Weight training
3. Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who:
1) Controls feelings in order to avoid conflict.
2) Teaches negotiation skills and independence.
3) Encourages risk-taking and adventure.
4) Views themselves as helpless victims.
4. The client is a 76-year-old man who is experiencing chronic illness. He has a genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him?
1) Age-related changes
2) Genetic anemia
3) Eating habits
4) Gender-related issues
5. What type of loss is most common among patients who are hospitalized for complex health conditions?
6. A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?
1) “What medications do you take at home?”
2) “Do you have any environmental, food, or drug allergies?”
3) “Do you have an advance directive?”
4) “What is the greatest concern you are dealing with today?”
7. When developing goals, which guideline should the nurse keep in mind? Goals should be:
1) Realistic so that progress is recognized by the patient
2) Developed solely by the healthcare team
3) Developed without family input, to maintain confidentiality
4) Valued by the multidisciplinary care providers
8. Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended?
1) Administering her medications according to schedule
2) Allowing flexible visitation by her family and friends
3) Explaining treatment options in terms she can understand
4) Providing a healing presence by listening and being attentive
9. Which statement best describes the health–illness continuum?
1) Health is the absence of disease; illness is the presence of disease.
2) Health and illness are along a continuum that cannot be divided.
3) Health is remission of disease; illness is exacerbation of disease.
4) Health is not having illness; illness is not having health.
10. Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?
1) A healthy diet
2) Physical activity
3) Restful sleep
4) Comfortable room temperature
11. A client has been hospitalized for 6 weeks. All of the following interventions are good ones; but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization?
1) Providing skin care every shift to prevent skin breakdown
2) Encouraging the patient to get up in a chair to eat meals
3) Assisting the patient to ambulate in the hallway for several minutes each day
4) Designating a corner of the patient’s room to display personal mementos
Chapter 11. Psychosocial Health & Illness
1. Which of the following is considered a strength of the nursing profession?
1) Biomedical focus
2) Psychosocial focus
3) Biopsychosocial focus
4) Physical focus
2. A homeless patient is admitted with an infected leg wound. According to Maslow’s Hierarchy of Needs, which nursing intervention meets one of his basic physiological needs?
1) Providing the patient with a dinner tray
2) Administering antibiotics as prescribed
3) Irrigating a wound with normal saline solution
4) Encouraging the patient to express his feelings
3. Which of the following can the nurse assess using Erik Erikson’s theory?
1) Moral development
2) Developmental tasks
3) Social identity
4. Which statement best describes self-concept? An individual’s:
1) Understanding of how other’s perceive him.
2) Evaluation of himself.
3) Overall view of himself.
4) Perspective of his role in society.
5. The nurse is teaching a group of parents about growth and development. Which of the following statements by a parent would indicate correct understanding of self-concept? Self-concept stabilizes during:
6. A 13-year-old patient is admitted to the hospital. There is no medical restriction on visitation. To help maintain the patient’s social identity while hospitalized, it is most important for the nurse to encourage visits by:
7. Which response by the patient demonstrates an internal locus of control?
1) “My blood sugar wouldn’t be out of control if my wife prepared better foods.”
2) “I knew I shouldn’t have come to this hospital; I’d be better if I hadn’t.”
3) “God must be getting even with me for my past behavior.”
4) “I’m just glad to be alive; the accident could’ve been a lot worse.”
8. The nurse is caring for a group of patients on the medical-surgical unit. Which patient is most likely to experience the most difficulty in adapting to a change in body image? The patient:
1) Who suffered a traumatic amputation of the left leg in an industrial accident.
2) With hypothyroidism who has coarse, dry, thinning hair, and weight gain.
3) Who is obese and who underwent gastric bypass surgery.
4) With peripheral vascular disease who required a wound graft.
9. Which individual is most likely to have a positive body image?
1) Child who has been deaf since birth
2) Child who was born with cystic fibrosis
3) Adolescent of average appearance who had an appendectomy
4) Adult born with a spinal defect and associated paralysis of the lower body
10. A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following?
1) Role strain
2) Interpersonal role conflict
3) Role performance
4) Interrole conflict
Chapter 12. The Family
1. A 12-year-old patient’s mother recently married a man who has a 13-year-old daughter. The nurse recognizes that the patient belongs to which type of family?
2. A 65-year-old patient is admitted to the hospital with heart failure. The patient’s best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene?
1) Involve the friend and children in the patient’s care, discharge planning, and home care.
2) Encourage the friend to wait until discharge to provide care for the patient at home.
3) Explain to the friend that for confidentiality reasons she cannot be involved in the patient’s care.
4) Encourage liberal visiting hours by the friend and the patient’s children.
3. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed child-bearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing?
1) Family launching young adults
2) Postparental family
3) Family with frail elderly
4) Family with teenagers and young adults
4. A 13-year-old girl is admitted to the adolescent unit with acute leukemia. The patient has a support system that includes her brother, sister, mother, father, and grandmother as well as members of her local community. Which component of her support system is considered a suprasystem?
1) The community
2) The parents
3) Her mother
4) Her sister
5. The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge?
1) Importance of quitting smoking
2) Availability of community resources
3) Adherence to a low-fat diet
4) Importance of physical exercise
6. Which factor is related to the increased risk of acquiring polio in the United States after the disease was thought to be eradicated?
1) Lack of health insurance
3) Reduced compliance with vaccinations
4) Drug resistance
7. Which question helps the nurse to assess family structure?
1) Where does your family live?
2) How are family decisions made?
3) With which religious affiliation is your family associated?
4) What is your ethnic background?
8. Which family member is most likely to be disabled?
1) 60-year-old African American male
2) 65-year-old Asian male
3) 70-year-old Caucasian female
4) 75-year-old Native American female
Chapter 13. Culture & Ethnicity
1. North American health care culture typically reflects which culture?
2) European American
4) African American
2. A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? He may:
1) Believe in taboos against narcotic use to relieve pain.
2) Expect immediate treatment for relief of pain.
3) Endure pain longer and report it less frequently than some patients do.
4) Use herbal teas, heat application, and prayers to manage his pain.
3. The nurse is caring for a 42-year-old, Chinese-American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patient’s discharge?
1) Ethnic background
2) Family support
4) Health care coverage
4. A patient who came from Central America is admitted with diabetes mellitus. The nurse is collecting biographical information. Which information provided by the patient represents his ethnicity?
5. A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing:
6. Which of the following is considered a “practice” (as opposed to a belief or value)?
1) Always drinking water after exercise
2) Thinking often about cleanliness
3) Emphasis on success
4) Maintaining youth
7. The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the:
1) Practices of the patient’s ethnic group.
2) Patient’s individual cultural beliefs.
3) Values of her own culture.
4) Spanish-speaking community.
8. The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present-oriented?
1) “I know I need to lose weight; I’ll have to begin an exercise program right away.”
2) “If I change my diet and begin exercising, maybe I can control my blood pressure without medications.”
3) “I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult.”
4) “I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke.”
9. A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of “Pain related to reluctance to take medication secondary to cultural beliefs.” If the cultural archetype is true for this particular patient, this probably means that the patient views pain as:
1) A punishment for immoral behavior.
2) A part of life.
3) Best treated with herbal teas and prayer.
4) A virtue and a matter of family honor.
10. The physician prescribes metoprolol tartrate (a beta blocker) for an African American patient with hypertension. Based on the patient’s ethnicity, the nurse should monitor the effectiveness of therapy closely, because:
1) Higher doses of the drug may be needed to be effective.
2) More gastrointestinal side effects occur with this group.
3) Flushing and palpitations are common among African Americans.
4) Rebound hypotension commonly occurs in this group.
Chapter 14. Spirituality
Which statement best describes theology?
1) Discussions and theories related to God and His relation to the world
2) Doctrines about the human soul and its relation to eternal life
3) A life-long journey involving accumulation of experience and understanding
4) Codes of conduct that integrate beliefs and values
2. Which of the following is considered a religious denomination within the tradition of Christianity?
3. Which factor is held in common by many of the world religions?
1) Strict health code, including dietary laws
2) Belief that one must submit to a god or gods
3) Rules prohibiting alcohol consumption
4) Sacred writings that reveal the nature of the Supreme Being
4. A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best?
1) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse.
2) Explore with the patient her beliefs and determine which might have caused her to make this statement.
3) Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender.
4) Comply with the patient’s request and assign a female nurse to care for the patient.
5. A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patient’s religious affiliation, which of the following actions should the nurse take?
1) Administer the medication as prescribed.
2) Hold the medication until after Yom Kippur.
3) Explain the importance of taking the medication despite the holiday.
4) Ask the physician to change the route of administration.
6. The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patient’s religion, for which religious practice should she expect to notify the hospital chaplain?
1) Anointing of Sick
4) Sacrament of Reconciliation
7. Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with:
4) Jehovah’s Witness.
8. Which special consideration may the nurse need to make when caring for a female Rastafarian patient?
1) Allow the patient to wear her own clothing.
2) Provide a diet that is caffeine-free.
3) Allow the patient to wear jewelry with religious symbols.
4) Provide free-flowing water for bathing.
9. What is the most effective action by the nurse when delivering spiritual care to a patient of the same religion as the nurse?
1) Understanding that the patient shares the same beliefs
2) Striving to meet the patient’s spiritual needs independently
3) Explaining her own religious beliefs to the patient
4) Developing a greater awareness of her own spirituality
10. A patient prays, “God, be with me during this surgery and help me safely through it so I can be with my wife and children again.” Which type of prayer is the patient utilizing?
Chapter 15. Loss, Grief, & Dying
1. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing?
1) Environmental loss
2) Internal loss
3) Perceived loss
4) Psychological loss
2. According to William Worden, which task in the grieving process takes longest to achieve?
1) Realizing that the loved one is gone
2) Experiencing the pain from the loss
3) Adjusting to the environment without the deceased
4) Investing emotional energy
3. What emotional response is typical during the Rando’s confrontation phase of the grieving process?
1) Anger and bargaining
2) Shock with disbelief
4) Emotional upset
4. An elderly man lost his wife a year ago to cardiovascular disease. During a health care visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate?
1) Shock and numbness
2) Yearning and searching
3) Disorganization and despair
5. Which patient is at most risk for experiencing difficult grieving?
1) The middle-aged woman whose grandmother died of advanced Parkinson’s disease
2) A young adult with three small children whose wife died suddenly in an accident
3) The middle-aged person whose spouse suffered chronic, painful death
4) The older adult whose spouse died of complications of chronic renal disease
6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six martinis every night before going to bed. Which type of grief does this best illustrate?
7. According to the Uniform Determination of Death Act, which bodily function must be lost to declare death?
2) Brain stem function
3) Cephalic reflexes
4) Spontaneous respirations
8. A patient’s wife tells the nurse that she wants to be with her husband when he dies. The patient’s respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best?
1) “Certainly, go ahead; your husband will most likely hold on until you return.”
2) “Your husband could live for days or a few hours; you should do whatever you are comfortable with.”
3) “You need to take care of yourself; go home and shower, and I’ll stay at his bedside while you are gone.”
4) “Don’t worry. Your husband is in good hands; I’ll look out for him.”
9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur:
1) 1 to 3 months before death
2) 1 to 2 weeks before death
3) Days to hours before death
4) Moments before death
10. Which intervention takes priority for the patient receiving hospice care?
1) Turning and repositioning the patient every 2 hours
2) Assisting the patient out of bed into a chair twice a day
3) Administering pain medication to keep the patient comfortable
4) Providing the patient with small frequent meals
Chapter 16. Documenting & Reporting
1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?
1) Study the discharge plan.
2) Check the graphic data for vital signs.
3) Examine the history and physical.
4) Look for an advance directive.
2. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?
1) It involves a cooperative spirit among various disciplines.
2) The system requires diligence in maintaining a current problem list.
3) Data may be fragmented and scattered throughout the chart.
4) It allows the nurse to provide information in a unorganized manner.
3. The patient’s medical record contains the following documentation:
06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge intravenous catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN
Which type of charting has the nurse used?
4. The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE:
1) Reduces the time nurses spend charting
2) Addresses the patient’s concerns holistically
3) Establishes an ongoing care plan from admission
4) Is most useful when constructing a timeline of events
5. A patient is admitted to the emergency department with a stroke. After being stabilized, the patient’s needs are best met if the nurse documents a care plan that provides for:
1) Acute interventions.
2) Patient teaching.
3) Discharge needs.
4) Family health data.
6. The patient’s health record contains the following provider’s order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient’s response to the medication, where would he look?
1) In the progress notes
2) On the graphic record
3) In the narrative notes
4) On the MAR
7. A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication?
1) Every hour around-the-clock
2) Immediately after taking off the order
3) As needed, but not more than once per hour
4) 1 hour after the last administered dose
8. The nurse administers heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document?
1) Injection site
2) Previous site of administration
3) Patient response to medication
4) Heart rate prior to administration
9. A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement?
2) Rheumatoid arthritis
3) Postoperative colon resection
4) Follow all three plans
10. The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?
1) 09/02/10 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN
2) 09/02/10 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN
3) 09/02/10 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN
4) 09/02/10 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN
Chapter 17. Measuring Vital Signs
1. A client’s vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 118/76. Four hours later the client’s oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client’s heart rate would be how many beats per minute?
2. The nurse is assessing vital signs for a client after surgical procedure on the left leg and has intravenous (IV) fluids running. It would be most important for the nurse to:
1) Compare the left pedal pulse with the right pedal pulse.
2) Count the client’s respiratory rate for 1 full minute.
3) Take the blood pressure in the arm without an IV.
4) Take an oral temperature with an electronic thermometer.
3. The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?
1) Have the client take several deep breaths.
2) Request the client take a deep breath and cough.
3) Take the client’s blood pressure and apical pulse.
4) Count the client’s respiratory rate for 1 minute.
4. Which of the following sets of vital signs are all within normal limits for patients at rest?
1) Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54
2) Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68
3) Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84
4) Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95
5. The nurse assesses the following changes in a client’s vital signs. Which client situation should be reported to the primary care provider?
1) Decreased blood pressure (BP) after standing up
2) Decreased temperature after a period of diaphoresis
3) Increased heart rate after walking down the hall
4) Increased respiratory rate when the heart rate increases
6. The client’s temperature is 101.1°F. Which is the correct conversion to centigrade?
7. The client has had a fever, ranging from 99.8°F orally to 103°F orally over the last 24 hours. The client’s fever would be classified as:
8. A client’s vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 124/78. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the client’s respiratory rate to be:
9. Which one of the following clients would probably have a higher than normal respiratory rate? A client who has:
1) Had surgery and is receiving a narcotic analgesic.
2) Had surgery and lost a unit of blood intraoperatively.
3) Lived at a high altitude and then moved to sea level.
4) Been exposed to the cold and is now hypothermic.
10. For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose:
1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84.
2) Oral temperature is 97.9°F in the morning and 99.8°F in the evening.
3) Heart rate was 76 beats/minute before eating and 88 beats/minute after eating.
4) Respiratory rate is 16 breaths/minute when standing and 18 when lying down.
Chapter 18. Communication & Therapeutic Relationships
1. Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?
1) Small group
2. During admission to the unit, a patient states, “I’m not worried about the results of my tests. I’m sure I’ll be all right.” As he observes the patient, the nurse notes that the patient is shaky, tearful, and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following goals is most appropriate for the nurse to establish when returning to the patient? Patient will
1) Explain the reason for his incongruent statements.
2) Engage in diversional activities to cope with stress.
3) Express his concerns to his primary care provider.
4) Discuss his concerns and fears with the nurse.
3. The nurse is preparing a patient for a computed tomography scan of the abdomen. Which statement by the nurse is best (all contain correct information)?
1) “You will need to remain NPO for the 8 hours prior to your CT scan.”
2) “You cannot have anything to eat or drink for 8 hours before your test.”
3) “You will need to be NPO and drink this contrast media before your test.”
4) “You may need to void before you go down to the department for your CT scan.”
4. The nurse is assigned to the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient?
1) Middle-aged woman just diagnosed with terminal lung cancer
2) Middle-aged man experiencing the acute phase of myocardial infarction
3) Older adult admitted with dehydration with a history of dementia
4) Young adult recovering from surgery who will be discharged tomorrow
5. The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful?
1) “This was a good idea to form a group; I’ve been wanting to get to know some of the people from the other shifts.”
2) “It really helps me to share feelings about how hard it is to see pain and suffering every day.”
3) “I now have a group to help me when I need to work through situations at home causing personal stress.”
4) “It’s nice to have a chance to get away from the unit and talk on a regular basis.”
6. A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient?
1) Impaired Communication
2) Readiness for Enhanced Communication
3) Impaired Verbal Communication
4) Sensory Alteration
7. A young adult with an episode of acute asthma comes to the Emergency Department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that patient is disoriented to time and place. Which nursing diagnosis is probably most suitable for this patient?
1) Chronic Confusion
2) Acute Confusion
3) Impaired Verbal Communication
4) Readiness for Enhanced Communication
8. A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient?
1) Uses alternative methods of communication
2) Communicates effectively using a translator
3) Interprets messages accurately
4) Follows commands when asked
9. Which intervention by the nurse helps to establish a trusting nurse–patient relationship?
1) Avoiding topics that may provoke emotional responses from the patient
2) Listening to the patient while performing care activities
3) Performing care interventions quietly without explanation
4) Greeting the patient by name whenever entering the patient’s room
10. A physician tells a patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach, but responds by saying, “I’ll do whatever you think I should do.” Which communication style is this patient using?
3) Passive aggressive
Chapter 19. Health Assessment: Performing a Physical Examination
1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient?
1) Have the mother remain outside the room.
2) Ask the mother to remove the infant’s clothing and diaper.
3) Weigh the infant with the diaper only.
4) Place the infant supine on the scale with his knees extended.
2. Where should the nurse assess skin color changes in the dark-skinned patient?
2) Any exposed area
3) Oral mucosa
4) Palms of the hands
3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is something wrong with my baby?” Which response by the nurse is best?
1) “I’ll ask the physician to look at the spot.”
2) “Those spots are quite common and typically fade with time.”
3) “You may want a plastic surgeon to look at that.”
4) “That spot is benign so it’s nothing you need to worry about.”
4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower legs. Which condition does this finding suggest?
1) Venous insufficiency
3) Arterial insufficiency
5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler’s diarrhea?
6. A female patient has excessive facial hair. The nurse should document this finding as:
7. The nurse should assess skin temperature by using the:
1) Dorsum of the hand.
2) Pad of the fingertip.
3) Palm of the hand.
4) Dorsum of the wrist.
8. While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of:
1) Fungal infection.
2) Poor circulation.
3) Iron deficiency.
4) Long-term hypoxia.
9. A 6-week-old infant is brought to the pediatrician’s office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest:
1) The baby has been lying in the same position for several hours a day.
2) A disorder associated with excessive growth hormone.
3) An accumulation of excessive cerebrospinal fluid.
4) Temporomandibular joint syndrome.
10. The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest:
4) Macular degeneration.
Chapter 20. Promoting Asepsis & Preventing Infection
1. Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalized patients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining medical asepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the disease is considered a:
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact
6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing?
8. The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?
1) Closing the patient’s door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?
2) Complement cascade
10. The patient suddenly develops hives, shortness of breath, and wheezing after receiving an antibiotic. Which antibody is primarily responsible for this patient’s response?
AND MUCH MORE