Practice Questions for Final (Fundamentals: Potter and Perry 8th Edition)

1. When formulating a definition of “health,” the nurse should consider that health, within its current definition, is:
1. The absence of disease
2. A function of the physiological state
3. The ability to pursue activities of daily living
4. A state of well-being involving the whole person
A state of well-being involving the whole person
2. Which one of the following is the main, overarching goal for Healthy People 2010?
1. Reduction of health care costs
2. Elimination of health disparities
3. Investigation of substance abuse
4. Determination of acceptable morbidity rates
Elimination of health disparities
3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic?
1. “I would like you to perform this exercise once a day.”
2. “Your physician has left orders that you are to follow.”
3. “The laboratory tests reveal the need to reduce your daily percentage of fat intake.”
4. “Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels.”
“Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels.”
4. The client states, “Heart disease runs in our family. My blood pressure has always been high.” The nurse determines that this is an example of the client’s:
1. Risk factors
2. Active strategy
3. Health beliefs
4. Negative health behavior
Risk factors
5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage?
1. Action
2. Preparation
3. Maintenance
4. Contemplation
Contemplation
6. When assessing the external variables that influence a client’s health beliefs and practices, the nurse must consider his:
1. Income status
2. Religious practices
3. Educational background
4. Reaction to the heart disease
Income status
7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of:
1. Health promotion
2. Primary prevention
3. Tertiary prevention
4. Secondary prevention
Secondary prevention
8. Which of the following nursing activities is an example of tertiary level caregiving?
1. Teaching a client how to irrigate a new colostomy
2. Providing a class on hygiene for an elementary school class
3. Informing a client that her infant can be immunized at the health department
4. Arranging for a hospice nurse to visit with the family of a client with lung cancer
Arranging for a hospice nurse to visit with the family of a client with lung cancer
9. Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse?
1. Obesity
2. Sunbathing
3. Overcrowded housing
4. Industrial-based occupation
Sunbathing
10. In the Health Belief Model, the nurse recognizes that the focus is placed on the:
1. Basic human needs for survival
2. Functioning of the individual in all dimensions
3. Relationship of perceptions and compliance with therapy
4. Multidimensional nature of clients and their interaction with the environment
Relationship of perceptions and compliance with therapy
11. The client who recently received a kidney transplant is worried about her husband since he has taken over the physical tasks of running their home. The client is in the process of adapting to a change in:
1. Body image
2. Self-concept
3. Illness behavior
4. Family dynamics
Family dynamics
12. Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the client’s health status, the nurse will specifically look for:
1. Anxiety level present
2. Family remedies used
3. Location and type of occupation
4. Available health insurance coverage
Anxiety level present
13. A nurse understands that illness behavior means:
1. Each distinct illness will cause the client to behave in a specific manner
2. Nursing care provides interventions that are behavior oriented
3. The client’s behaviors will have a direct impact on his illness
4. When ill, a client’s perception of illness will result in unique behaviors
When ill, a client’s perception of illness will result in unique behaviors
14. A client tells the nurse that his illness is a result of his failure to “live a good life.” The nurse recognizes this statement as an example of the client’s:
1. Risk factor
2. Health belief
3. Illness behavior
4. Negative health behavior
Health belief
15. Which of the following client statements best relates to the third component of the Health Belief Model?
1. “My blood cholesterol is only a little high.”
2. “No one in my family is susceptible to the flu.”
3. “I’ll just avoid the food that causes the problem.”
4. “By losing weight my blood pressure may come down.”
“By losing weight my blood pressure may come down.”
16. The goal of Pender’s Health Promotion theory is best reflected in which of the following nursing interventions?
1. Suggesting the client experience a variety of exercise routines before settling on the one to adapt
2. Arranging for a client to attend a support group for individuals who also have severe burn scars
3. Playing soft, classical music when a client diagnosed with Alzheimer’s becomes physically agitated
4. Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care
Suggesting the client experience a variety of exercise routines before settling on the one to adapt
17. The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the client’s:
1. Emotional wellness
2. Developmental stage
3. Professed spirituality
4. Intellectual background
Intellectual background
18. The nurse is caring for a terminally ill client who recently immigrated to the United States. To provide quality end-of-life care, the nurse must initially:
1. Make every effort to involve the client and his family in the end-of-life care
2. Understand the client’s personal and cultural views regarding death and dying
3. Arrange for end-of-life care to be provided by personnel familiar with the client’s culture
4. Share the client’s concerns regarding the dying process with his interdisciplinary care team
Understand the client’s personal and cultural views regarding death and dying
19. Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu?
1. Staffing a flu immunization clinic at a senior citizen’s center
2. Providing flu prevention literature for distribution to visitors
3. Reminding client care personnel of the importance of the flu shot
4. Getting a drug manufacturer to donate flu vaccine for the homeless
Getting a drug manufacturer to donate flu vaccine for the homeless
20. The nurse can best discuss the impact of a known risk factor on a client’s health by stating:
1. “It doesn’t mean you’ll get the disease just that the odds are greater for you.”
2. “Now you know that the possibility is there, you can take steps to prevent it.”
3. “The risk factor can be managed by making a change in your lifestyle.”
4. “You’re lucky because you have the benefit of being able to do something about it.”
“It doesn’t mean you’ll get the disease just that the odds are greater for you.”
21. When caring for a client with a spouse and two adolescent children, the nurse knows that the family unit must first:
1. Be viewed as a client
2. Change traditional roles
3. Provide support for the ailing mother
4. Seek help to fulfill day-to-day needs
Be viewed as a client
22. The nurse observes signs of depression in a client who has been hospitalized for several weeks because of injuries sustained in an automobile accident. The client confirms his fears of never, “Being able to work and support my family as I did before.” The nurse’s initial intervention is to:
1. Offer to arrange for him to speak with the facility’s chaplain
2. Assure the client that physical therapy will help him tremendously
3. Revise his care plan to include interventions to assist him with coping
4. Tell his health care provider of his need for antidepressant medication
Revise his care plan to include interventions to assist him with coping
23. While discussing discharge plans for a client who recently experienced a stroke that resulted in right-sided weakness and communication problems, the daughter shares with the nurse that she has concerns regarding her role as caregiver. The most therapeutic response by the nurse is to:
1. Agree that her concerns are well-founded
2. Suggest that she consider home health aides
3. Offer to arrange for her to see the facility’s grief counselor
4. Provide her with information about a caregiver support group
Offer to arrange for her to see the facility’s grief counselor
1. Which of the following would be considered positive health behaviors for a 40-year-old client? (Select all that apply.)
1. Eating a low-fat, low-salt diet
2. Getting 6 to 8 hours of sleep nightly
3. Spending quality time with his children
4. Limiting his smoking to 3 cigarettes daily
5. Having his blood pressure checked regularly
6. Walking for 30 minutes several times a week
1. Eating a low-fat, low-salt diet
2. Getting 6 to 8 hours of sleep nightly
5. Having his blood pressure checked regularly
6. Walking for 30 minutes several times a week
2. Which of the following client behaviors are examples of active strategies of health promotion? (Select all that apply.)
1. Losing 10 pounds
2. Walking 1 mile each evening
3. Drinking vitamin D fortified milk
4. Driving a car equipped with airbags
5. Having regular blood pressure checks
6. Having a company-required hearing exam
1. Losing 10 pounds
2. Walking 1 mile each evening
5. Having regular blood pressure checks
1. The best way for a new graduate to demonstrate caring behavior towards the client is by:
1. Seeking assistance before attempting a new procedure
2. Attempting to do new treatments as quickly as possible
3. Informing the client when performing a treatment for the first time on an actual client
4. Avoiding situations with clients that may be uncomfortable for either the nurse or the client
Seeking assistance before attempting a new procedure
2. The nurse knows that according to Benner, caring is defined as a:
1. New consciousness and moral idea
2. Nurturing way of relating to a valued other
3. Person, event, project, or thing that matters to a person
4. Central, unifying, and dominant domain necessary for health and survival
Person, event, project, or thing that matters to a person
3. Which one of the following nursing activities is an example of Swanson’s “enabling” in the caring process?
1. Staying with the client before surgery
2. Performing a urinary catheterization skillfully
3. Assessing the client’s health history
4. Teaching the client how to inject fast-acting insulin
Teaching the client how to inject fast-acting insulin
4. Riemen’s study of nurses’ caring behaviors (1986) found which one of the following as a similarity between male and female clients’ perceptions of nursing caring behaviors?
1. Physical presence
2. Promotion of autonomy
3. Knowledge of injection technique
4. Speed in the completion of treatment
Physical presence
5. The nurse should realize that the most important aspect of knowing the client involves:
1. Establishing a relationship
2. Gathering assessment data
3. Treating discomforts quickly
4. Assuming the client’s emotional needs
Establishing a relationship
6. The nurse can best demonstrate caring behavior by:
1. Updates the family about the client’s condition
2. Asks to address the client by the client’s first name
3. Closes the door and covers the client during morning care
4. Shares with the client’s roommate that she is scheduled for tests
Closes the door and covers the client during morning care
7. To best improve the bathing care provided by a particular staff member, the nurse manager should:
1. Tell the staff member how to correctly give baths to clients
2. Provide the staff member with good resources to read on bathing clients
3. Ask another staff member to provide the unit’s bathing care in the afternoon
4. Assist and observe the staff member in the bathing care of a client on the unit
Assist and observe the staff member in the bathing care of a client on the unit
8. The nurse knows that a key element in Leininger’s theory of caring is that it includes:
1. Five categories of caring
2. Connectedness with others
3. Transcultural perspectives
4. Spiritual dimensions and healing
Transcultural perspectives
9. Caring enables a nurse to know the client and thereby focus on identifying the client’s specific needs. This ability is most typically impacted by a nurse’s:
1. Assessment skills
2. Sense of compassion
3. Clinical experience
4. Communication proficiency
Clinical experience
10. A client with chronic respiratory problems tells the nurse, “I haven’t felt this good in a long time.” The nurse realizes that the statement most reflects the client’s:
1. Willingness to share his feelings
2. Acceptance of his physical limitations
3. Personal definition of his individual health
4. Acknowledgment of his chronic health problems
Personal definition of his individual health
11. Which of the following statement’s best expresses the client’s definition of personal illness?
1. “I came to the emergency department when the pain got too bad to ignore.”
2. “I have arthritis, but I continue to enjoy knitting, embroidery and other needle work.”
3. “Sometimes my bad knee keeps me from the hiking, but I do it as much as I can.”
4. “It will be a terrible blow when my heart condition keeps me stuck in the house.”
“I came to the emergency department when the pain got too bad to ignore.”
12. Which of the following statements reflects the best understanding of cultural caring provided by professional nurses?
1. “Nurses must be open to learning the culture of our clients.”
2. “Nurses need to attend to clients in a culturally sensitive manner.”
3. “I care for my clients in ways that respect their culture and beliefs.”
4. “Culture caring means allowing the client the freedom to be himself.”
“I care for my clients in ways that respect their culture and beliefs.”
13. When facilities strive to improve client satisfaction, the area of primary focus should be:
1. Holistic client care
2. Caring nursing staff
3. Expert care providers
4. State-of-the-art technology
Caring nursing staff
14. The nurse observes a client scheduled for an invasive procedure crying while discussing the procedure with a family member. Which of the following therapeutic nursing interventions would be the most caring?
1. Arranging for the client’s clergy to visit
2. Inquiring, “Why is your sister crying?”
3. Providing a detailed explanation of the procedure
4. Offering to “sit and talk” if the client has any questions
Offering to “sit and talk” if the client has any questions
15. A client has confided to the nurse that she would prefer hospice care to receiving further radical treatment for terminal pancreatic cancer. The nurse observes that the client fails to share her wishes with her family during a discussion regarding future treatment plans. Ethically, the nurse should first:
1. Tell the family of the client’s expressed wishes
2. Privately ask the client if her wishes have changed
3. Inform the client’s health care provider of her wishes
4. Share with the client the importance of expressing her wishes
Privately ask the client if her wishes have changed
16. When the nurse offers to “just sit here with you” after a particularly painful procedure, a homeless client asks, “Why would you want to do that?” The nurse recognizes that the client most likely:
1. Prefers to be alone at this time
2. Does not have a need for companionship
3. Perceived the offer as being inappropriate
4. Finds it difficult to understand the nurse’s concern
Finds it difficult to understand the nurse’s concern
17. A client who is re-learning to walk asks the nurse, “to come with me today to physical therapy.” The nurse realizes that the client is most likely expressing:
1. A need for emotional support
2. A need for familiar companionship
3. An appreciation of the nurse’s caring
4. An interest in validating her progress
An appreciation of the nurse’s caring
18. Which of the following client reactions reflects the greatest positive response to the nurse’s use of caring touch in the form of a backrub?
1. The nurse observes the client smiling.
2. The client falls asleep shortly after the backrub.
3. The nurse feels the client’s back muscles relaxing.
4. The client tells his wife that, “the nurse is so nice.”
The nurse feels the client’s back muscles relaxing.
19. What is the single greatest factor that contributes to the struggle of today’s nurses to “know” the client?
1. Nursing shortage
2. High client acuity
3. Shorter hospital stays
4. Increasing client loads
High client acuity
20. Which of the following nurse-family interactions is most reflective of caring for the family?
1. Offering to arrange for a sleep chair for the family’s use
2. Notifying the family that the client has returned from surgery
3. Telling the family when the client’s surgeon will be on the unit
4. Always being available to spend time answering the family’s questions
Telling the family when the client’s surgeon will be on the unit
21. With which of the following interventions does the nurse best reflect caring by maintaining belief in a client?
1. Offering a client with cancer pain medication before a family visit
2. Explaining to a client what to expect during a bone marrow aspiration
3. Arranging for a burn client to talk with others who survived similar burns
4. Explaining to a client that he may select from a variety of entrees for dinner
Arranging for a burn client to talk with others who survived similar burns
22. Which of the following interventions made by a new graduate nurse reflects the best understanding of knowing her client?
1. Asking the client, “What do you need to be more comfortable?”
2. Offering the client’s family a sleeper chair for use in the client’s room
3. Providing an extra blanket for a client who often complains of being cold
4. Awakening the client for a phone call from her son who lives out of town
Asking the client, “What do you need to be more comfortable?”
23. The nurse is caring for a homeless client who recently emigrated from China. The client has a language barrier, and the hospital has been unsuccessful in locating any relatives. The health care provider is considering the option of placing the client on a respirator to manage a severe respiratory tract problem. To be a caring advocate for this client, the nurse must first:
1. Ask the hospital chaplain to arrange for appropriate religious support
2. Be sure that the client receives the best available care for his condition
3. Arrange for a Chinese interpreter to facilitate client-staff conversations
4. Become familiar with the Chinese culture’s attitudes regarding life support
Become familiar with the Chinese culture’s attitudes regarding life support
1. The best way for a new graduate to demonstrate caring behavior towards the client is by:
1. Seeking assistance before attempting a new procedure
2. Attempting to do new treatments as quickly as possible
3. Informing the client when performing a treatment for the first time on an actual client
4. Avoiding situations with clients that may be uncomfortable for either the nurse or the client
Seeking assistance before attempting a new procedure
2. The nurse knows that according to Benner, caring is defined as a:
1. New consciousness and moral idea
2. Nurturing way of relating to a valued other
3. Person, event, project, or thing that matters to a person
4. Central, unifying, and dominant domain necessary for health and survival
Person, event, project, or thing that matters to a person
3. Which one of the following nursing activities is an example of Swanson’s “enabling” in the caring process?
1. Staying with the client before surgery
2. Performing a urinary catheterization skillfully
3. Assessing the client’s health history
4. Teaching the client how to inject fast-acting insulin
Teaching the client how to inject fast-acting insulin
4. Riemen’s study of nurses’ caring behaviors (1986) found which one of the following as a similarity between male and female clients’ perceptions of nursing caring behaviors?
1. Physical presence
2. Promotion of autonomy
3. Knowledge of injection technique
4. Speed in the completion of treatment
Physical presence
5. The nurse should realize that the most important aspect of knowing the client involves:
1. Establishing a relationship
2. Gathering assessment data
3. Treating discomforts quickly
4. Assuming the client’s emotional needs
Establishing a relationship
6. The nurse can best demonstrate caring behavior by:
1. Updates the family about the client’s condition
2. Asks to address the client by the client’s first name
3. Closes the door and covers the client during morning care
4. Shares with the client’s roommate that she is scheduled for tests
Closes the door and covers the client during morning care
7. To best improve the bathing care provided by a particular staff member, the nurse manager should:
1. Tell the staff member how to correctly give baths to clients
2. Provide the staff member with good resources to read on bathing clients
3. Ask another staff member to provide the unit’s bathing care in the afternoon
4. Assist and observe the staff member in the bathing care of a client on the unit
Assist and observe the staff member in the bathing care of a client on the unit
8. The nurse knows that a key element in Leininger’s theory of caring is that it includes:
1. Five categories of caring
2. Connectedness with others
3. Transcultural perspectives
4. Spiritual dimensions and healing
Transcultural perspectives
9. Caring enables a nurse to know the client and thereby focus on identifying the client’s specific needs. This ability is most typically impacted by a nurse’s:
1. Assessment skills
2. Sense of compassion
3. Clinical experience
4. Communication proficiency
Clinical experience
10. A client with chronic respiratory problems tells the nurse, “I haven’t felt this good in a long time.” The nurse realizes that the statement most reflects the client’s:
1. Willingness to share his feelings
2. Acceptance of his physical limitations
3. Personal definition of his individual health
4. Acknowledgment of his chronic health problems
Personal definition of his individual health
11. Which of the following statement’s best expresses the client’s definition of personal illness?
1. “I came to the emergency department when the pain got too bad to ignore.”
2. “I have arthritis, but I continue to enjoy knitting, embroidery and other needle work.”
3. “Sometimes my bad knee keeps me from the hiking, but I do it as much as I can.”
4. “It will be a terrible blow when my heart condition keeps me stuck in the house.”
“I came to the emergency department when the pain got too bad to ignore.”
12. Which of the following statements reflects the best understanding of cultural caring provided by professional nurses?
1. “Nurses must be open to learning the culture of our clients.”
2. “Nurses need to attend to clients in a culturally sensitive manner.”
3. “I care for my clients in ways that respect their culture and beliefs.”
4. “Culture caring means allowing the client the freedom to be himself.”
“I care for my clients in ways that respect their culture and beliefs.”
13. When facilities strive to improve client satisfaction, the area of primary focus should be:
1. Holistic client care
2. Caring nursing staff
3. Expert care providers
4. State-of-the-art technology
Caring nursing staff
14. The nurse observes a client scheduled for an invasive procedure crying while discussing the procedure with a family member. Which of the following therapeutic nursing interventions would be the most caring?
1. Arranging for the client’s clergy to visit
2. Inquiring, “Why is your sister crying?”
3. Providing a detailed explanation of the procedure
4. Offering to “sit and talk” if the client has any questions
Offering to “sit and talk” if the client has any questions
15. A client has confided to the nurse that she would prefer hospice care to receiving further radical treatment for terminal pancreatic cancer. The nurse observes that the client fails to share her wishes with her family during a discussion regarding future treatment plans. Ethically, the nurse should first:
1. Tell the family of the client’s expressed wishes
2. Privately ask the client if her wishes have changed
3. Inform the client’s health care provider of her wishes
4. Share with the client the importance of expressing her wishes
Privately ask the client if her wishes have changed
16. When the nurse offers to “just sit here with you” after a particularly painful procedure, a homeless client asks, “Why would you want to do that?” The nurse recognizes that the client most likely:
1. Prefers to be alone at this time
2. Does not have a need for companionship
3. Perceived the offer as being inappropriate
4. Finds it difficult to understand the nurse’s concern
Finds it difficult to understand the nurse’s concern
17. A client who is re-learning to walk asks the nurse, “to come with me today to physical therapy.” The nurse realizes that the client is most likely expressing:
1. A need for emotional support
2. A need for familiar companionship
3. An appreciation of the nurse’s caring
4. An interest in validating her progress
An appreciation of the nurse’s caring
18. Which of the following client reactions reflects the greatest positive response to the nurse’s use of caring touch in the form of a backrub?
1. The nurse observes the client smiling.
2. The client falls asleep shortly after the backrub.
3. The nurse feels the client’s back muscles relaxing.
4. The client tells his wife that, “the nurse is so nice.”
The nurse feels the client’s back muscles relaxing.
19. What is the single greatest factor that contributes to the struggle of today’s nurses to “know” the client?
1. Nursing shortage
2. High client acuity
3. Shorter hospital stays
4. Increasing client loads
High client acuity
20. Which of the following nurse-family interactions is most reflective of caring for the family?
1. Offering to arrange for a sleep chair for the family’s use
2. Notifying the family that the client has returned from surgery
3. Telling the family when the client’s surgeon will be on the unit
4. Always being available to spend time answering the family’s questions
Telling the family when the client’s surgeon will be on the unit
21. With which of the following interventions does the nurse best reflect caring by maintaining belief in a client?
1. Offering a client with cancer pain medication before a family visit
2. Explaining to a client what to expect during a bone marrow aspiration
3. Arranging for a burn client to talk with others who survived similar burns
4. Explaining to a client that he may select from a variety of entrees for dinner
Arranging for a burn client to talk with others who survived similar burns
22. Which of the following interventions made by a new graduate nurse reflects the best understanding of knowing her client?
1. Asking the client, “What do you need to be more comfortable?”
2. Offering the client’s family a sleeper chair for use in the client’s room
3. Providing an extra blanket for a client who often complains of being cold
4. Awakening the client for a phone call from her son who lives out of town
Asking the client, “What do you need to be more comfortable?”
23. The nurse is caring for a homeless client who recently emigrated from China. The client has a language barrier, and the hospital has been unsuccessful in locating any relatives. The health care provider is considering the option of placing the client on a respirator to manage a severe respiratory tract problem. To be a caring advocate for this client, the nurse must first:
1. Ask the hospital chaplain to arrange for appropriate religious support
2. Be sure that the client receives the best available care for his condition
3. Arrange for a Chinese interpreter to facilitate client-staff conversations
4. Become familiar with the Chinese culture’s attitudes regarding life support
Become familiar with the Chinese culture’s attitudes regarding life support
1. A nurse who wants to apply a theory that relates to moral development should read more from the work of:
1. Gould
2. Freud
3. Erikson
4. Kohlberg
Kohlberg
2. The nurse using Erikson’s theory to assess a 20-year-old client’s developmental status expects to find which of the following behaviors?
1. Coping with physical and social losses
2. Enjoys participating in the community
3. Applying self to learning skills
4. Overcoming a sense of guilt or frustration
Enjoys participating in the community
3.The nurse recognizes that Freud’s theory approaches development by looking at:
1. Moral reasoning.
2. Logical maturity
3. Psychosexual aspects
4. Cognitive development
Psychosexual aspects
4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected by the nurse to exhibit which of the following behaviors?
1. Far-reaching problem-solving
2. Exploration of the environment
3. Cooperation and sharing with others
4. Thinking with the use of symbols and images
Thinking with the use of symbols and images
5. For an older adult client, an example of a common behavioral task or critical event is:
1. Selecting a mate
2. Rearing children
3. Finding a congenial social group
4. Adjusting to decreasing physical strength
Adjusting to decreasing physical strength
6. The nurse working in an adult medical clinic wishes to learn more about a developmental theory that focuses on the adult years. The nurse investigates different possibilities and selects the theory proposed by:
1. Gould
2. Piaget
3. Freud
4. Chess and Thomas
Gould
7. The nurse recognizes that which one of the following statements about growth and development is correct?
1. Development ends with adolescence.
2. Growth refers to qualitative events.
3. Developmental tasks are age-related achievements.
4. Cognitive theories focus on emotional development.
Developmental tasks are age-related achievements.
8. In Kohlberg’s Moral Development theory, an individual who reaches level II (conventional thought) is expected to exhibit:
1. Absolute obedience to authority
2. Reasoning based on personal gain
3. Personal internalization of other’s expectations
4. Self-chosen ethical principles, universality, and impartiality
Personal internalization of other’s expectations
9. According to Piaget, the infant is in the first period of development, which is characterized by:
1. Concrete operations
2. Preoperational thought
3. Sensorimotor intelligence
4. Identity versus role confusion
Sensorimotor intelligence
10. A child’s understanding of the concept of ice becoming water, Piaget’s stage of cognitive development, is seen in:
1. Sensorimotor
2. Preoperational
3. Formal operations
4. Concrete operations
Concrete operations
11. The nurse in a pediatric health care setting is using Kohlberg’s developmental theory. A child is evaluated as having reached level I, the preconventional level, if the child:
1. Makes sure that he or she is not late for school
2. Cleans the blackboards after school for the teacher
3. Runs for school council in order to change policies
4. Stays away from peer groups that harass other children
Makes sure that he or she is not late for school
12. In applying Gould’s developmental theory, the nurse anticipates that a client will have a greater concern for one’s health within the following theme and age-group:
1. First theme (20s)
2. Second theme (early 30s)
3. Fourth theme (40s)
4. Fifth theme (50s)
Fifth theme (50s)
13. The nurse is working with a new mother who will require surgery. The follow-up treatment will interfere with bonding. In applying Freud’s theory, the nurse recognizes that the stage of development that may be affected is the:
1. Oral stage
2. Anal stage
3. Phallic stage
4. Latent stage
Oral stage
14. In accordance with Erikson’s theory, it is expected by the nurse that a middle-aged adult client will be involved in the process of:
1. Developing a sense of identity
2. Searching for meaning in life
3. Enhancing one’s capability to love others
4. Expanding personal and social involvement
Expanding personal and social involvement
15. The primary purpose for the nurse to understand human growth and development is to be best able to:
1. Identify deviations from normal
2. Select effective nursing interventions
3. Be sensitive to age-appropriate needs
4. Enhance nurse-client communication
Identify deviations from normal
16. Which of the following should the nurse consider first when assessing the cognitive ability of an older adult?
1. A life-long bachelor
2. Orphaned at age 12
3. History of a chronic disease process
4. Recent immigration to the United States
Recent immigration to the United States
17. A nurse caring for a 78-year-old client recently diagnosed with pneumonia will find Erikson’s psychosocial development theory most helpful in determining:
1. Which needs the client will typically develop
2. Which coping mechanisms the client will likely use
3. How the client will respond to the respiratory problem
4. How the client and his family will adjust to the stressors
How the client will respond to the respiratory problem
18. As described by Freud, the nurse recognizes that a young adult best shows a well-developed superego when he:
1. Tells a friend that he’ll help him stop smoking
2. Returns a lost wallet to a stranger who dropped it
3. Arranges for a cab ride home after consuming alcohol
4. Has 10% of his salary automatically transferred to savings
Arranges for a cab ride home after consuming alcohol
19. A nurse is preparing to discharge an 11-month-old child after a hospitalization for a viral infection. The nurse uses anticipatory guidance most effectively when:
1. Encouraging the parents to limit visitors for 14 days
2. Providing the parents with written discharge instructions
3. Arranging the follow-up pediatrician appointment for the parents
4. Informing the parents that the child may cry when taken to daycare
Informing the parents that the child may cry when taken to daycare
20. Which of the following situations/statements best depicts Gould’s fourth theme of adult development?
1. “When I made that decision, I didn’t expect it to turn out like it did.”
2. “I have to take the opportunity to be my own boss and not rely on others.”
3. “I think you can do anything if only you have your health and good friends.”
4. “As much as I’d love to open my own shop, I just can’t take that kind of chance.”
“As much as I’d love to open my own shop, I just can’t take that kind of chance.”
21. The nurse is caring for an older adult client who has reported symptoms suggestive of depression. Which of the following questions asked by the nurse is most therapeutic in assessing the client’s perception of the impact depression has had on her life?
1. “What does it mean to be depressed?”
2. “How does being depressed make you feel?”
3. “Were you happy before becoming depressed?”
4. “What makes you think that you are depressed?”
“What does it mean to be depressed?”
22. The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piaget’s theory of cognitive development suggests that the nurse can help the child cope with the stressors of this hospital experience best by:
1. Arranging for the parents to be with the child until the anesthetic takes affect
2. Explaining the entire process with the child using age-appropriate language
3. Using play as a means of familiarizing the child with the events he will experience
4. Providing the child with a coloring book that shows the events he will be experiencing
Using play as a means of familiarizing the child with the events he will experience
23. Which of the following nursing responses is most therapeutic when made in response to a parent’s concern about her 3-year-old child’s tendency to “break the rules”?
1. “Just keep reminding her of the rules.”
2. “Daycare will help her learn to play fair.”
3. “She will begin to understand that concept in a year or so.”
4. “Add an age appropriate punishment for breaking the rules.”
“She will begin to understand that concept in a year or so.”
24. To help a comatose client’s family make a moral decision regarding the termination of life support, the nurse must first:
1. Refrain from expressing his/her personal beliefs concerning the life support issue
2. Provide the family with information regarding the process of terminating life support
3. Determine whether the client had expressed any written or oral wishes regarding the issue
4. Facilitate the family’s decision-making process by providing them with a quiet, private space for discussion
Refrain from expressing his/her personal beliefs concerning the life support issue
25. Which of the following best describes a nurse thinking at stage 5 of Kohlberg’s Moral Developmental Theory?
1. “The client has a right to decide whether or not to proceed with the treatment plan.”
2. “The hospital’s policies and procedures are excellent tools for making client oriented decisions.”
3. “It won’t be fair to expect to get every weekend and holiday off, so I’ll certainly work my share.”
4. “If you don’t keep client information confidential you could be terminated immediately.”
“The client has a right to decide whether or not to proceed with the treatment plan.”
26. Which of the following client statements made by an older adult best reflects an understanding of the decrease in physical strength and stamina in this developmental stage?
1. “I know I’m not as young as I use to be.”
2. “I just hire help with jobs I can’t do myself.”
3. “You get older you can’t do as much, that’s life.”
4. “I have to ask my son for help with the yard work.”
“I just hire help with jobs I can’t do myself.”
1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy?
1. Detection of fetal movement
2. Observation that the uterus is below the pubis
3. Confirmation of the desire to breast- or bottle-feed
4. Determination of the presence of morning sickness
Detection of fetal movement
2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit?
1. Moro
2. Startle
3. Babinski
4. Extrusion
Babinski
3. In evaluating an infant’s physical status and growth, the nurse expects to find:
1. Birth weight triples by 6 months
2. Anterior fontanel closes 4 to 8 weeks after birth
3. Chest circumference is larger than head circumference at 12 months
4. Birth height increases 1 inch each month for the first 6 months
Birth height increases 1 inch each month for the first 6 months
4. Upon evaluation of a 6-month-old infant’s developmental status, the nurse expects that the child at this age will be able to:
1. Completely roll over
2. Pull self to a standing position
3. Creep on all four extremities
4. Assume a sitting position independently
Completely roll over
5. For a 2-year-old child, cognitive development is characterized by:
1. Recognizing right and wrong
2. Initiating play with other children
3. Having a vocabulary of at least 1000 words
4. Using short sentences to express independence
Using short sentences to express independence
6. In planning nursing care for an 18-month-old child, the nurse should know that the predominant developmental characteristic of children this age is:
1. Parallel play
2. Peer pressure
3. Mutilation anxiety
4. Imaginary playmates
Parallel play
7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was admitted to the surgical center to have his tonsils removed to:
1. Perform his own preoperative hygienic care
2. Have alone time to relax before the procedure
3. Handle the equipment when taking his blood pressure
4. Have access to age-appropriate magazines and puzzles for diversion
Handle the equipment when taking his blood pressure
8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the correct response by the nurse?
1. “Your son is probably feeling neglected, and you should make an effort to spend more time with him.”
2. “This is common behavior that is expressed when the hospitalized child is stressed or anxious.”
3. “You may need to include discipline because children easily lose the ability to be toilet trained during hospitalization.”
4. “Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months.”
“This is common behavior that is expressed when the hospitalized child is stressed or anxious.”
9. A 4½-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort?
1. “Please try to not move your leg and that will make it feel better.”
2. “I’ll give you a shot of medicine that will help take the pain away.”
3. “It’s okay if you need to cry. Would you like to hold your favorite doll?”
4. “Would you like to tell me now where you want me to give you your shot?”
“It’s okay if you need to cry. Would you like to hold your favorite doll?”
10. When teaching basic infant safety to the parents of a 3 month old, the nurse should emphasize:
1. Placing gates at stairways
2. Keeping bathroom doors closed
3. Giving large, hard teething biscuits
4. Removing feeding bibs at bedtime
Removing feeding bibs at bedtime
11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to:
1. Say Da-da
2. Smile responsively
3. Differentiate strangers
4. Play social peekaboo games
Smile responsively
12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that:
1. “The sex of the baby can be determined.”
2. “There is a fine hair that covers the body.”
3. “Fingers and toes are differentiated clearly.”
4. “The organ systems are beginning to develop.”
“The organ systems are beginning to develop.”
13. The nurse assists the family of a 9 year old with nutritional information. A recommended after-school snack for a child this age is:
1. Milk shakes
2. Potato chips
3. Plain popcorn
4. Bite-size candy
Plain popcorn
14. The elementary school nurse is responsible for evaluating each child’s overall physical development. During the school-age years, the nurse anticipates that:
1. The child’s body weight will almost triple
2. There will be few physical differences among children
3. The child will grow an average of 1 to 2 inches per year
4. Body fat will gradually increase, contributing to a heavier appearance
The child will grow an average of 1 to 2 inches per year
15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization?
1. Crayons and a coloring book
2. A 1000-piece puzzle to complete
3. A CD player with soothing CDs
4. A Nerf football to throw around the room
Crayons and a coloring book
16. Which one of the following statements is correct regarding the preadolescence developmental stage?
1. It appears 2 years earlier in boys than in girls.
2. Intimate feelings are confided in the parents.
3. Interest in the opposite sex is not a factor for this group.
4. It signals the development of secondary sex characteristics.
It signals the development of secondary sex characteristics.
17. The nurse is teaching parents about probable warning signs that a teenager is considering suicide and tells parents to be alert to:
1. An increase in appetite
2. A sudden interest in school activities
3. An unexplained increase in sleepiness
4. Talking about death and personal harm
Talking about death and personal harm
18. In order to obtain the most information, which of the following is the most appropriate question asked of a 14-year-old female who is visiting the county health center for “birth control help?”
1. “Have you told your parents that you are sexually active?”
2. “Are any of your friends participating in sexual behaviors?”
3. “What can you tell me about any of your past sexual activities?”
4. “Have you been physically protecting yourself with safe sex measures?”
“What can you tell me about any of your past sexual activities?”
1. A client thinks that she might be pregnant. Which first trimester physiological changes would most likely indicate this?
1. Amenorrhea and nausea
2. Braxton Hicks contractions
3. Increased urinary frequency
4. Edematous ankles and dyspnea
Amenorrhea and nausea
2. To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client:
1. “Have you ever been married?”
2. “Where do you currently work?”
3. “Has anyone ever taught you about contraception?”
4. “Who do you have for support during this pregnancy?”
“Who do you have for support during this pregnancy?”
3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?
1. Decreased hearing acuity
2. Decreased sense of smell
3. Decreased strength of abdominal muscles
4. Decreased function of the various cranial nerves
Decreased strength of abdominal muscles
4. A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial statement for the nurse to make in the assessment phase?
1. “How much weight have you lost over the past month?”
2. “Have you recently been experiencing menopausal symptoms?”
3. “Depression is something to expect at your age, and with assistance you will get better.”
4. “Your depression is somewhat uncommon. Can you tell me what has happened recently to cause it?”
“Have you recently been experiencing menopausal symptoms?”
5. The nurse, trying to promote positive health habits regarding stress management is aware of the external influences on young and middle adult clients. With this knowledge, the nurse recognizes that an effective strategy for this age-group is:
1. Teaching clients to abstain from all alcohol consumption
2. Demonstrating how to take an accurate blood pressure measurement
3. Determining an effective daily exercise schedule for stress reduction
4. Describing the types of medications commonly used for treating depression
Determining an effective daily exercise schedule for stress reduction
6. Individuals at the young adult point in their life are generally expected to, according to developmental patterns:
1. Continue physical growth
2. Experience severe illnesses
3. Ignore physical symptoms
4. Seek frequent medical care
Ignore physical symptoms
7. A nurse is preparing an education program on safety for a young adult group. Based on the major cause of mortality and morbidity for this age-group, the nurse should focus on:
1. Birth control
2. Automobile safety
3. Occupational hazards
4. Prevention of heart disease
Automobile safety
8. A nurse is working in the health office at a local college where most of the students are young adults. Being aware of the major concerns for this age-group, the nurse includes assessment of these clients’:
1. Current marital history status
2. Lifestyle and leisure activities
3. Experience with chronic disease
4. History of childhood accidents
Lifestyle and leisure activities
9. As an individual enters middle adulthood health problems generally become more prevalent. The middle adult may be influenced by chronic illness that results in:
1. Decreased health care tasks
2. Reinforcement of family roles
3. Changed sexual behavior habits
4. Improvement of family relationships
Changed sexual behavior habits
10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?
1. Palpable thyroid lobes
2. Decreased skin turgor
3. Reduced pupillary reaction
4. Increased range of joint motion
Decreased skin turgor
11. The nurse is alert to stressors that may have an influence on the young adult client. One example of a common stressor for this age-group is:
1. Occupational pursuits
2. Health-related matters
3. Coping with cognitive changes
4. Caring for the older adult parent
Occupational pursuits
12. A client who works in a dry cleaning establishment comes to the clinic for a regular check-up. Based on this information, the nurse assesses the client for:
1. Asbestosis
2. Dermatitis
3. Tendonitis
4. Raynaud’s phenomenon
Dermatitis
13. The nurse is completing a physical exam for a 45-year-old client who has come to the family practice office. In evaluating the observations made during the examination, the nurse recognizes that an expected finding for a client in this age-group is:
1. Hepatomegaly
2. Visual acuity below 20/50
3. An oral temperature of 39° C
4. Increased amount of skin turgor
Visual acuity below 20/50
14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the greatest financial impact on this family is caused by:
1. The ever-rising cost of living in the United States
2. The realization that a female earns 25% less than her male co-worker
3. Court-ordered child support is often times inadequate.
4. Daycare expenses are a strain on a single wage earner family
The realization that a female earns 25% less than her male co-worker
15. Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group?
1. Health screenings
2. Personal lifestyle assessment
3. Full body systems assessment
4. Cardiopulmonary focal assessment
Personal lifestyle assessment
16. Research has shown that certain postpartum factors negatively affect a woman’s general health status after pregnancy. Which of the following women has the greatest risk factor for poor postpartum health?
1. A mother with complaints of fatigue, loss of appetite, and insomnia
2. A practicing attorney who has reluctantly taken a 3-month maternity leave
3. A stay-at-home mom who gave birth 2 months ago and whose husband recently lost his job
4. A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas
A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas
17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with the parents of a newborn. Which of the following nursing actions would be most therapeutic regarding early detection of this postpartum condition?
1. Helping the couple understand the importance of social interaction with other adults
2. Providing the couple with a video that tells the story of a new mother’s experience with depression
3. Encouraging the couple to attend parenting classes designed to minimize the stressors of parenting an infant
4. Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression
Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression
18. Which of the following young adults is at greatest risk for experiencing death or injury?
1. An 18-year-old with a father who is an alcoholic
2. A 30-year-old who is a professional rodeo rider
3. A 20-year-old living in an urban housing project
4. A 26-year-old riding a motorcycle across the country
A 20-year-old living in an urban housing project
19. The most serious risk for death for a young adult living in rural poverty is:
1. Suicide
2. Homicide
3. Poor health maintenance practices
4. Family history of chronic illnesses
Suicide
20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his driver’s license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the client?
1. Use of illegal drugs
2. History of depression
3. Unprotected sexual experiences
4. Tendency toward violent behavior
Use of illegal drugs
21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the nurse shares with the client that in addition to physical symptoms of genital pain and discharge, sexually transmitted diseases:
1. Can lead to chronic illness and infertility
2. Are particularly common in young adults
3. Respond well to treatment when detected early
4. May be effectively controlled through the use of condoms
Are particularly common in young adults
22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult?
1. Alcohol and tobacco use
2. Ignoring seat belt and helmet laws
3. Unprotected sex with multiple partners
4. Poor nutrition and a lack of structured exercise
Alcohol and tobacco use
23. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults?
1. “Unprotected sex is just plain dangerous.”
2. “Everyone riding in my car wears a seatbelt.”
3. “I’m a vegetarian, but I eat nonanimal protein.”
4. “I’ve never smoked and I drink only occasionally.”
“I’ve never smoked and I drink only occasionally.”
26. Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults?
1. “I may want to have children someday, so I need to be careful.”
2. “Even though there are treatments for STDs, I don’t take chances.”
3. “There is certainly enough literature out there on the use of condoms.”
4. “Having unprotected sex with someone my age is very risky business.”
“Having unprotected sex with someone my age is very risky business.”
27. Which of the following statements made by a 27-year-old client shows the greatest need for further nursing assessment regarding the potential use of illegal drugs?
1. Whether you wear a helmet or not should be the choice of the motorcyclist.”
2. “I fractured my hand 3 years ago when I got so mad I hit a wall in my dorm room.”
3. “I like to drink a bit too much, and I lost my license once for drinking and driving.”
4. “My father suffered from depression when he lost his job, and he still takes medication for it.”
“I like to drink a bit too much, and I lost my license once for drinking and driving.”
28. Which of the following statements made by the parents of a newborn best reflects an understanding regarding the diagnosis of postpartum depression?
1. “I helped my sister when she was depressed after the birth of her second child.”
2. “I have a wonderfully supportive family who will be there if I start feeling depressed.”
3. “We’ve read over the literature, and I’ll be able to recognize any signs of depression in my wife.”
4. “Most new moms get a little depressed, but we will be sure to pay attention to any real indications of a problem.”
“We’ve read over the literature, and I’ll be able to recognize any signs of depression in my wife.”
29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester?
1. “Have you had any problems climbing steps?”
2. “Have you noticed any cramping in your abdomen?”
3. “Have you experienced any nausea in the morning?”
4. “Have you had any problems with shoes that don’t seem to fit?”
“Have you noticed any cramping in your abdomen?”
30. Which of the following client statements would be the best evidence that this young adult has adopted a positive strategy to promote his own personal emotional health?
1. “I drink alcohol only on special occasions and then moderately.”
2. “I run at least three times a week; it seems to help me stay relaxed.”
3. “I watch for the signs of depression since my mother experienced it.”
4. “I know stress can affect my blood pressure, so I have it taken regularly.”
“I run at least three times a week; it seems to help me stay relaxed.”
31. Which of the following client statements, made by a young adult regarding health promotion habits, reflects a need for further client education by the nurse?
1. “I go to the gym and work out 3 times a week with friends.”
2. “My dad has high cholesterol, so I have mine checked yearly.”
3. “Diabetes runs in my family, so I watch my carbohydrate intake.”
4. “I drink alcohol only on weekends, when it doesn’t interfere with work.”
“I drink alcohol only on weekends, when it doesn’t interfere with work.”
32. Which of the following nursing assessment questions is best directed toward determining the presence of a normal physiological change experienced by a middle-aged client?
1. “Any problems with your teeth or gums?”
2. “Any family history of thyroid problems?”
3. “Do you have a skin-moisturizing routine?”
4. “Are you having a problem with driving at night?”
“Do you have a skin-moisturizing routine?”
33. Which of the following nursing assessment questions is best directed toward determining the presence of an occupational hazard-related condition specific for a client working in a dry cleaning establishment?
1. “Do you have any problems with rashes or itching?”
2. “How long have you worked in the dry cleaning business?”
3. “Do you treat the minor burns you experience?”
4. “Do you drive the company van to make deliveries?”
“Do you have any problems with rashes or itching?”
34. Which of the following nursing assessment questions is best directed toward determining the presence of career stressors in a young adult?
1. “What do you do to relieve stress for yourself?”
2. “What is the most stressful part of your daily job?”
3. “Career-wise, where would you like to be in 2 years?”
4. “Do you miss much work as a result of injuries or illness?”
“What is the most stressful part of your daily job?”
35. Which of the following statements concerning health promotion habits made by a young adult best reflects an understanding regarding the primary cause of death and injury among that age group?
1. “Eating a healthy, low-fat diet is very important to me.”
2. “AIDS is nothing to mess with, so I always practice safe sex.”
3. “Regardless of what my friends say, I always wear a seat belt.”
4. “I enjoy mountain biking, but I always wear the right protection gear.”
“Regardless of what my friends say, I always wear a seat belt.”
1. A nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for individuals in this age-group. An expected finding for this client is:
1. Increased tactile responsiveness
2. Increased sensitivity to visual glare
3. Increased hearing acuity for higher tones
4. Increased thoracic expansion during ventilation
Increased sensitivity to visual glare
2. A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood pressure checked each shift. An appropriate response by the nurse as to why older clients often experience hypertension is because of:
1. Myocardial muscle damage
2. Reduction in physical activity
3. Ingestion of foods high in sodium
4. Accumulation of plaque on arterial walls
Accumulation of plaque on arterial walls
3. In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true?
1. Delirium is usually easily distinguished from irreversible dementia.
2. Therapeutic drug intoxication is a common cause of senile dementia.
3. Reversible systemic disorders are often implicated as a cause of delirium.
4. Cognitive deterioration is an inevitable outcome of the human aging process.
Reversible systemic disorders are often implicated as a cause of delirium.
4. A client has been recently diagnosed with Alzheimer’s disease. When teaching the family about the prognosis, the nurse must explain that:
1. Diet and exercise can slow the process considerably
2. Few clients live more than 3 years after the diagnosis
3. Many individuals can be cured if the diagnosis is made early
4. It usually progresses gradually with a deterioration of function
It usually progresses gradually with a deterioration of function
5. Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult?
1. 50% of older adults have two chronic health problems.
2. Cancer is the most common cause of death among older adults.
3. Nutritional needs for both younger and older adults are essentially the same.
4. Adults older than 65 comprise the greatest users of prescription medications.
Adults older than 65 comprise the greatest users of prescription medications.
6. The nurse is aware that the majority of older adults:
1. Live alone
2. Live in institutional settings
3. Are unable to care for themselves
4. Are actively involved in their community
Are actively involved in their community
7. The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility?
1. “Your shoulder pain is normal for your age.”
2. “Continue to exercise your joints regularly to your tolerance level.”
3. “Why don’t you begin walking 3 to 4 miles a day, and we’ll evaluate how you feel next week.”
4. “Don’t worry about taking that combination of medications since your doctor has prescribed them.”
“Continue to exercise your joints regularly to your tolerance level.”
8. A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying:
1. “Don’t worry about the medication’s name if you can identify it by its color and shape.”
2. “Unless you have severe side affects, don’t worry about the minor changes in the way you feel.”
3. “Feel free to ask your physician why you are receiving the medications that are prescribed for you.”
4. “Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications.”
“Feel free to ask your physician why you are receiving the medications that are prescribed for you.”
9. Which of the following behaviors shows the greatest risk to an older adult as they attempt to minimize the effects of the aging process?
1. Increased cosmetic use
2. Refusing to share their actual ages
3. Spending less time with age-related peers
4. Refusing assistance with certain activities
Refusing assistance with certain activities
10. In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging?
1. Increased perspiration
2. Increased airway resistance
3. Increased salivary secretions
4. Increased pitch discrimination
Increased airway resistance
11. There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age:
1. Men have the greatest incidence of osteoporosis
2. Muscle fibers increase in size and become tighter
3. Weight-bearing exercise reduces the loss of bone mass
4. Muscle strength does not diminish as much as muscle mass
Weight-bearing exercise reduces the loss of bone mass
12. The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults:
1. Require institutional care
2. Have no social or family support
3. Are unable to afford any medical treatment
4. Are capable of taking charge of their own lives
Are capable of taking charge of their own lives
13. To assist older adults to meet their needs for sexuality, the nurse should recognize that the greatest impact on the sexuality of older adults is:
1. Therapeutic medications may alter sexual function
2. Sexual interest declines and then fades completely with age
3. Physiological changes do not adversely influence sexual activity
4. Prevention of sexually transmitted diseases is no longer an issue
Therapeutic medications may alter sexual function
14. The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in:
1. Fiber
2. Protein
3. Vitamin A
4. Refined sugars
Refined sugars
15. The nurse is presenting an information session on nutritional guidelines at a senior living center. Which of the following foods meets the recommended nutritional guidelines for older adults?
1. Grilled chicken
2. Hamburger and french fries
3. Hot dog with dill pickle relish
4. Baked potato with cheese and bacon bits
Grilled chicken
16. In the assessment of older-adult clients, it is often difficult to discriminate between delirium and dementia. Delirium is characterized by:
1. A slow progression
2. Lasting months to years
3. A normal state of alertness
4. Occurrences at twilight or darkness
Occurrences at twilight or darkness
17. Which of the following nursing questions is best directed towards the assessment of a normal finding regarding physiological changes in an older-adult client?
1. “Any difficulty driving at night?”
2. “Are you experiencing any loss of libido?”
3. “Do you see yourself as becoming forgetful”
4. “Have you had your cholesterol tested lately?”
“Any difficulty driving at night?”
18. Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult?
1. “I call a cab if I want to go out after dark.”
2. “I can’t help worrying about becoming forgetful.”
3. “I have my eyes checked regularly. Can’t afford to fall.”
4. “I really enjoy eating good vanilla ice cream, but I have cut way down.”
“I can’t help worrying about becoming forgetful.”
19. Which of the following statements made by a family member of a client recently diagnosed with Alzheimer’s disease is most reflective of an understanding of this disease process?
1. “Dad has always been a fighter; he’ll fight this too. He won’t give up.”
2. “We have an appointment with his care provider to see about medication therapy.”
3. “Good thing we found out about this early so steps can be taken to keep it from getting worse.”
4. “It usually progresses gradually so we are hoping it will be a while before his memory is gone.”
“We have an appointment with his care provider to see about medication therapy.”
20. The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group?
1. Suggest that he purchase an emergency in-home alert system.
2. Arrange for the client to receive meals delivered to his home daily.
3. Encourage the client to use a compartmentalized pill storage container for his daily medications.
4. Provide a written document describing the medications the client is currently prescribed.
Encourage the client to use a compartmentalized pill storage container for his daily medications.
21. An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications?
1. “I don’t seem to have problems with side effects, but I’ll let my doctor know if something happens.”
2. “I’m lucky since my daughter is really good about keeping up with my medications.”
3. “I’ll be sure to read the inserts and ask the pharmacist if I don’t understand something.”
4. “It shouldn’t be too hard to keep it straight since I don’t have any really serious health issues.”
“I’ll be sure to read the inserts and ask the pharmacist if I don’t understand something.”
22. Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse?
1. “I take all the pills ordered once a day at bedtime, so I’m less likely to forget them.”
2. “I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me.”
3. “The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet.”
4. “My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due.”
“I take all the pills ordered once a day at bedtime, so I’m less likely to forget them.”
23. Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the client’s adjustment to the aging process?
1. “I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it’s hard to even walk.”
2. “I’ve given my grandchildren money for college so they can live a better life than I had.”
3. “Growing old certainly presents all sorts of challenges. I wish I knew then what I know now.”
4. “As I age I’ve found its harder to do the things I love doing, but I guess it will all be over soon enough.”
“As I age I’ve found its harder to do the things I love doing, but I guess it will all be over soon enough.”
24. Which of the following statements made by a 75-year-old client shows the best understanding of how the aging process affects the musculoskeletal system?
1. “I drink milk and eat cheese to get my calcium.”
2. “I walk 1 mile everyday to strengthen my bones.”
3. “I wear sensible shoes so I won’t sprain an ankle.”
4. “At my age I might never fully recover from a hip fracture.”
“I walk 1 mile everyday to strengthen my bones.”
25. Which statement made by an older adult would reflect the best understanding of the nutritional requirements of individuals at this developmental stage?
1. “An apple a day is my motto; always has been.”
2. “I eat everything, but just a little a bit of things like sweets.”
3. “Fiber is more important than ever to my digestive system.”
4. “I don’t need the fat so I’ve taken to drinking protein shakes.”
“I eat everything, but just a little a bit of things like sweets.”
26. Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group?
1. “I can prepare grilled chicken at least 10 different, delicious ways.”
2. “When I entertain, I serve healthy foods like veggies and low-fat dip.”
3. “I know I need to eat nutritiously, and I have certainly been doing better.”
4. “I take seriously the suggestions my health team gives me on healthy eating.”
“When I entertain, I serve healthy foods like veggies and low-fat dip.”
27. Which of the following statements made by an older adult regarding sexuality would be of greatest concern for the nurse?
1. “Will this new medication affect my libido?”
2. “What can I do to help with vaginal dryness?”
3. “I really miss the intimacy my husband and I shared.”
4. “It’s so nice not to have to worry about an unwanted pregnancy.”
“It’s so nice not to have to worry about an unwanted pregnancy.”
28. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client?
1. Poor client compliance resulting from generalized diminished capacity
2. Inadequate health insurance coverage for the group as a whole
3. Insufficient research to provide a basis for effective geriatric health care
4. Preconceived assumptions regarding the lifestyles and attitudes of this group
Preconceived assumptions regarding the lifestyles and attitudes of this group
29. The nurse is preparing an educational program for members of the local senior center. Which of the following topics would present the greatest learning challenge for this developmental group?
1. Exercising arthritic joints
2. Tips for living with GERD
3. Importance of the human touch
4. Principles of heart-healthy eating
Importance of the human touch
30. When presenting information to the older adult, the client will be most likely to engage with the nurse in the learning process if:
1. Client feedback is encouraged and valued
2. Physical disabilities are accommodated for
3. The topic or information is valued by the learner
4. New knowledge is connected to knowledge already processed
The topic or information is valued by the learner
31. Of the following client statements made by an older adult client which best reflects an understanding the educational materials on nutrition presented by the nurse?
1. “I’ll keep this literature and read it again later.”
2. “I love rye bread. It’s good to know its high in fiber.”
3. “Nutrition and cooking has always been passions of mine.”
4. “Now I can see the connection between food and my health.”
“I love rye bread. It’s good to know its high in fiber.”
32. The nurse defines ageism most accurately as:
1. The undervaluing of individuals based on their age.
2. Perception of a person’s worth based on productivity
3. Biases directed towards individuals considered aged
4. Discrimination based on an individual’s increasing age
Discrimination based on an individual’s increasing age
33. Which of the following statements made by a nurse best reflects an understanding of the negative impact of ageism regarding client care?
1. “If I don’t value the older client, I will never be able to provide the care they are entitled too.”
2. “Everyone, regardless of age or position, always deserves effective, appropriate nursing care.”
3. “As a society we lose so much valuable wisdom and knowledge when we devalue our older members.”
4. “If older clients do not feel valued, they are less likely to seek the health care they need and deserve.”
“If I don’t value the older client, I will never be able to provide the care they are entitled too.”
34. Which of the following statements made by a nurse best reflects an understanding of the adaptation required of nursing to assure quality nursing care for the older adult client?
1. “Remember to ask the client when she prefers to have her bath.”
2. “I hope that I am that alert and interested in life when I’m her age.”
3. “My client is in her 90s, so I don’t expect her to respond to the therapy like a 50-year-old does.”
4. “I just finished reading a great article on caring for the client newly diagnosed with Alzheimer’s disease.”
“My client is in her 90s, so I don’t expect her to respond to the therapy like a 50-year-old does.”
35. Which of the following statements made by an older adult client best reflects a healthy adjustment to the aging process and its physical limitations?
1. “I use to run in marathons, but now I truly enjoy a 1 mile walk around the park.”
2. “I see friends my age just rocking on the porch. Not me; I want to stay physically active.”
3. “When I can’t get around like I do now, I’ll watch TV and catch up on my favorite programs.”
4. “I’ll miss working in my garden when the arthritis gets bad, but I’ll find something else to keep me busy.”
“I use to run in marathons, but now I truly enjoy a 1 mile walk around the park.”
36. Which of the following statements, made by the daughter of an older adult client concerning bring her mother home to live with her family, presents the greatest concern for the nurse?
1. “If this doesn’t work out, she can always go to live with my sister.”
2. “I don’t think she will react very well to me making decisions for her.”
3. “I’m afraid that mom will be depressed and really miss her home terribly.”
4. “My children will just have to adjust to having their grandmother with us.”
“I don’t think she will react very well to me making decisions for her.”
37. A nurse is caring for an older adult client preparing for discharge to a nursing center after having hip surgery. Which of the following nursing responses is most therapeutic when dealing with the client’s concern that she, “will never go back home”?
1. “What makes you think that this transfer to the nursing center will be permanent?”
2. “The reason for this transfer is only to support you while you continue to recuperate.”
3. “The decision to stay in the nursing center is yours to make. When you want to leave no one will stop you.”
4. “The nursing center is a lovely place with a wonderful staff of caring people. Just give it a chance. You may like it.”
“What makes you think that this transfer to the nursing center will be permanent?”
38. A nurse caring for older adults in an assistive living facility recognizes that a client’s quality of life needs are best determined by:
1. Excellent physical, social, and emotional nursing assessments
2. A working knowledge of this age-group’s developmental needs
3. A therapeutic nurse-client relationship that facilitates communication
4. The client’s ever-changing physical, emotional, and cognitive abilities
A therapeutic nurse-client relationship that facilitates communication
39. A nurse is preparing to perform an assessment on an older adult client newly admitted to a nursing center. Which of the following statements made by the nurse best reflects the unique needs of this client regarding the assessment process?
1. “I will be back after you are settled in and we can devote enough time to this assessment process.”
2. “We will need to move you to the examination room so that you will be comfortable during the assessment.”
3. “I have to perform an assessment as part of the admission process, is this a good time for you to help me with it?”
4. “Since this move has been both physical and emotionally stressful, I will make this assessment as concise and brief as possible.”
“I will be back after you are settled in and we can devote enough time to this assessment process.”
1. The nurse is preparing to present an educational program to residences of an assisted-living facility. Which teaching strategies would be most appropriate for the learning needs of this age-group? (Select all that apply.)
1. Speak in a slow but well-articulated manner.
2. Present a variety of ideas so as to have broad appeal.
3. Speak in soft, low voice so as to help the audience focus.
4. Small groups allow for more speaker-listener interaction.
5. End the program if there are signs of poor concentration or fatigue.
6. Present the material in a fast-paced manner to keep hold their attention.
1. Speak in a slow but well-articulated manner.
4. Small groups allow for more speaker-listener interaction.
5. End the program if there are signs of poor concentration or fatigue.
1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of:
1. A realistic goal
2. A compliant client
3. A negative evaluation
4. A nonmeasurable goal
A negative evaluation
2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be:
1. Goal met; client able to state three symptoms
2. Goal not met; client able to list three symptoms
3. Goal not met; client unable to list five symptoms
4. Goal partially met; client able to state three symptoms
Goal partially met; client able to state three symptoms
3. The nurse begins to auscultate the client’s lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of:
1. Performing a nursing assessment
2. Reorganizing the nursing diagnoses
3. Implementing nursing interventions
4. Critically analyzing client assessment data
Critically analyzing client assessment data
4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the client’s goal attainment?
1. “Client has no pain after ambulating.”
2. “Client has no manifestations of nausea while up in hall.”
3. “Client walked well and did not have any problem when up.”
4. “Client has no evidence of respiratory distress when ambulating.”
“Client has no evidence of respiratory distress when ambulating.”
5. When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should:
1. Redevelop the entire client care plan
2. Focus on changing the nursing diagnoses and goals
3. Perform a complete reassessment of all client factors
4. Add more nursing interventions from a standardized plan of care
Perform a complete reassessment of all client factors
6. Based on the following outcome criterion determined by the nurse: “Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic)” the nurse will evaluate the client’s ability to:
1. Assess the respiratory rate
2. Palpate the radial pulse
3. Review dietary habits
4. Inspect color of the skin
Palpate the radial pulse
7. The nurse has determined the following outcome for a client with a skin impairment: “Erythema will be reduced in 3 days.” Evaluation will specifically focus on:
1. Selection of appropriate wound care
2. Notation of the odor and color of drainage
3. Inspection of the color and condition of the area
4. Measurement of the diameter of the ulceration daily
Inspection of the color and condition of the area
8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client’s:
1. Respiratory rate
2. Complaint of chest pain
3. Lungs clear bilaterally on auscultation
4. Ability to perform incentive spirometry
Lungs clear bilaterally on auscultation
9. A client shares with the nurse that they have, “almost reached the goal of smoking only one-half pack of cigarettes a day.” The best example of a nursing intervention to correct this unmet outcome is:
1. Discuss with the client the desire to comply with the ordered therapy
2. Suggest that the client use another smoking cessation tool to achieve the goal
3. Reevaluate the time frame originally decided upon for achievement of the goal
4. Suggest that the strength of the prescribed nicotine patches be increased to 21 mg
Suggest that the strength of the prescribed nicotine patches be increased to 21 mg
10. The primary purpose of the nursing evaluation process is to:
1. Determine the effectiveness of the nursing care provided
2. Identify interventions that are ineffective in achieving client goals
3. Establish the progress the client is making towards health and wellness
4. Critique the nurse’s ability to implement appropriate nursing interventions
Determine the effectiveness of the nursing care provided
11. Which of the following statements best reflects a goal based on a clinical standard of practice?
1. Client will lose 10 pounds in 90 days.
2. Client will walk 30 feet with minimal assistance.
3. Client’s peripheral intravenous site will be free of redness.
4. Client’s chronic pain will be managed with oral medication by discharge.
Client’s peripheral intravenous site will be free of redness.
12. Which of the following outcomes best reflects a nurse-sensitive client outcome?
1. Client will consume 75% of all meals.
2. Client will perform personal hygiene daily.
3. Client will experience no falls during hospitalization.
4. Client will report lessened anxiety regarding surgical procedure.
Client will experience no falls during hospitalization.
13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the client’s understanding of the need for therapy?
1. Client agrees to test blood glucose levels 4 times a day.
2. Client records blood glucose levels for a 3-week period.
3. Client is observed testing his blood glucose level before breakfast.
4. Client is able to demonstrate the proper technique for performing a finger stick.
Client records blood glucose levels for a 3-week period.
14. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided?
1. “Pressure ulcer located on left heel has shown improvement.”
2. “Pressure ulcer located on left heel has responded to treatment.”
3. “Pressure ulcer on left heel is no longer producing purulent drainage.”
4. “Pressure ulcer on left heel has not enlarged in size within the last 24 hours.”
“Pressure ulcer on left heel is no longer producing purulent drainage.”
15. Which of the following statements made by a client’s family is the most reliable for use in the evaluation of a client’s outcome?
1. “Mom has been eating 90% of all of her meals since she’s been home.”
2. “My daughter is in much less pain now that she is going to physical therapy.”
3. “My husband has been less depressed since he’s been on that antidepressant pill.”
4. “Mom has been so much better since she’s been able to get up and walk by herself.”
“Mom has been eating 90% of all of her meals since she’s been home.”
16. A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process?
1. IV is discontinued.
2. Warm compress applied to IV site.
3. Site reinspected for presence of swelling.
4. IV site observed as having significant swelling.
Site reinspected for presence of swelling.
17. Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation?
1. “Do you feel confident in the use of your glucometer?”
2. “Have you been following your low carbohydrate diet?”
3. “Any questions regarding the tests you are scheduled for today?”
4. “May we review what we discussed earlier about your medications?”
“May we review what we discussed earlier about your medications?”
18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention?
1. No additional pressure ulcers are noted over a 1-week period.
2. Client expresses a decrease in pressure ulcer related pain within 1 week.
3. The client’s pressure ulcer shows a decrease in size over a 1-week period.
4. The turning schedule is initiated to reflect appropriate positioning for a 1-week period.
The client’s pressure ulcer shows a decrease in size over a 1-week period.
19. Which of the following statements best defines quality improvement (performance improvement)?
1. The assessment of the delivery system responsible for the implementation of client-oriented interventions
2. Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions
3. High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers
4. An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client’s needs
An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client’s needs
20. The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure:
1. Effective use of both nursing time and resources
2. Delivery of both timely and relevant nursing care
3. Concrete evidence of successful outcome achievement
4. Minimal ineffective communication among the nursing staff
Delivery of both timely and relevant nursing care
21. Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: “Client will lose 10 pounds in 3 months?”
1. Interview the client to identify reasons why the goal was not met.
2. Assess the client for possible physical reasons for failure to lose the weight.
3. Discuss with the client whether they were truly motivated to lose the weight.
4. Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.
Interview the client to identify reasons why the goal was not met.
22. When a client goal is unmet, which of the following nursing actions is most appropriate?
1. Reevaluation of the original client goal
2. Selection of new but appropriate interventions
3. Evaluation of the client’s ability and motivation to be compliant
4. Repetition of the entire nursing process regarding the nursing diagnosis
Repetition of the entire nursing process regarding the nursing diagnosis
1. Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.)
1. Effective care
2. Delivery of care
3. Client satisfaction
4. Exceeding the standard of care
5. Identification of ‘missed’ client needs
6. Multidisciplinary approach to client care
1. Effective care
2. Delivery of care
3. Client satisfaction
4. Exceeding the standard of care
1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client’s environment. This involves the nurse:
1. Repositioning the client q2h
2. Removing clutter from the client’s room
3. Delegating ambulation of clients to the nursing assistant
4. Providing pain medication to the client before a dressing change
Removing clutter from the client’s room
2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?
1. Preventive measures
2. Assisting with ADLs
3. Preparing for special procedures
4. Compensation for adverse reactions
Compensation for adverse reactions
3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using?
1. Reassessing the client
2. Stating an expected outcome
3. Revising the nursing diagnosis
4. Modifying the nursing care plan
Modifying the nursing care plan
4. The nurse notes that a narcotic is to be administered “per epidural cath.” The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?
1. Seek assistance
2. Reassess the client
3. Use interpersonal skills
4. Critical decision making
Seek assistance
5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill?
1. Cognitive
2. Interactive
3. Psychomotor
4. Communication
Cognitive
6. An example of a cognitive nursing skill is:
1. Providing a soothing bed bath
2. Communicating with the client and family
3. Giving an injection to the client per the physician’s orders
4. Recognizing the potential complications of a blood transfusion
Recognizing the potential complications of a blood transfusion
7. An enterostomal nurse shows a client’s significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the client’s significant other, the nurse is using what type of nursing skill?
1. Affective
2. Cognitive
3. Interactive
4. Psychomotor
Psychomotor
8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?
1. Teaching
2. Counseling
3. Compensating for adverse reactions
4. Assisting with activities of daily living (ADLs)
Assisting with activities of daily living (ADLs)
9. The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is:
1. Administering analgesics
2. Restraining a violent client
3. Initiating stress-reduction therapy
4. Teaching the client how to take his/her pulse rate
Restraining a violent client
10. To provide optimum care, a nursing intervention should be based on:
1. An appropriate nursing diagnosis
2. Subjective and objective client data
3. Sound clinical judgment and knowledge
4. Identified physical and psychosocial needs of the client
Sound clinical judgment and knowledge
11. Which of the following interventions is the best example of an indirect intervention directed towards client safety?
1. Checking on a restrained client every 15 minutes
2. Performing hand hygiene between client contacts
3. Including the diagnosis at risk for injury related to falls to a client’s care plan
4. Turning on a night light to illuminate the path to the bathroom
Turning on a night light to illuminate the path to the bathroom
12. Which of the following interventions best reflects the nurse’s understanding of direct care interventions regarding a cognitively impaired client’s need for social interaction?
1. Arranging for the client to attend a “sing along” in the dayroom
2. Helping the client place a long distance telephone call to his daughter
3. Turning the client’s television on when his or her favorite program is playing
4. Talking about the client’s favorite sport’s team while redressing his or her wound
Talking about the client’s favorite sport’s team while redressing his or her wound
13. The primary reason for the establishment of standing orders is to:
1. Provide appropriate nursing autonomy in settings where client needs can change rapidly
2. Facilitate adequate care when direct contact with a primary health care provider is not immediately possible
3. Allow nurses to provide certain routine therapies without first notifying the primary health care provider
4. Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider
Provide appropriate nursing autonomy in settings where client needs can change rapidly
14. Which of the following statements best reflects the nurse’s understanding of the function of client reassessment?
1. “The client’s blood pressure is lower this morning than it was yesterday morning.”
2. “30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10.”
3. “Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx.”
4. “Since the client has been ambulating to the bedroom without difficulty, I’ll walk with him to the dayroom after dinner.”
“Since the client has been ambulating to the bedroom without difficulty, I’ll walk with him to the dayroom after dinner.”
15. Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?
1. “Clinical guidelines are so very helpful in providing the most up-to-date nursing care.”
2. “I’m sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols.”
3. “I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site.”
4. “I’m told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site.”
“I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site.”
16. The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:
1. Implement care that has its basis in evidence-based practice
2. Produce care plans that are specific to the individual client needs
3. Improve the standard of care provided to the clients cared for on that unit
4. Provide the staff on that unit with guidelines to ensure the delivery of quality care
Improve the standard of care provided to the clients cared for on that unit
17. Which of the following nursing actions is most likely a result of the nurse’s clinical experience?
1. Placing an immobile client on a turning schedule
2. Always assessing a client’s IV site before hanging a new bag of fluid
3. Requesting that the nursing assistant have vital signs recorded by 0815
4. Administering a pain medication 30 minutes before changing a burn dressing
Always assessing a client’s IV site before hanging a new bag of fluid
18. Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse’s mentor?
1. “Older clients with arthritis require additional time to complete to complete their own AM care.”
2. “My client’s wife says he loves chocolate milk so I will order his dietary supplement in chocolate.”
3. “My client just received some bad news regarding her tests. I’ll see if the chaplain can visit this evening.”
4. “Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars.”
“My client just received some bad news regarding her tests. I’ll see if the chaplain can visit this evening.”
19. A client reports to the nurse that the room is “too hot.” Which of the following nursing actions best reflects the nurse’s understanding of the therapeutic manipulation of the client’s environment?
1. Bringing a portable fan into the room
2. Assisting the client in the removal of excess clothing
3. Offering to ambulate the client into the visiting lounge
4. Closing the blinds to minimize the sunshine through the windows
Bringing a portable fan into the room
20. Which of the following statements made by a new graduate nurse regarding the modification of a client’s care plan requires immediate follow-up by the nurse’s preceptor?
1. “I will review the care plan before I do my charting.”
2. “The client prefers to bathe at night, so that’s what I’ll do.”
3. “I gave her a bed bath this morning, but she could really manage showering herself.”
4. “The order reads clear liquids, but I hear good bowel sounds and she’s really hungry.”
“The order reads clear liquids, but I hear good bowel sounds and she’s really hungry.”
21. Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse’s mentor?
1. “My LPN is really good with dressings, so I usually delegate them to her.”
2. “I always take the time to ambulate a post op client the first time out of bed.”
3. “I always try to help my nursing assistant with the clients who require a total bed bath.”
4. “I have my nursing assistant take and document all vital signs and intake and outputs.”
“I have my nursing assistant take and document all vital signs and intake and outputs.”
1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request?
1. Low priority
2. An unmet need
3. Intermediate priority
4. A safety and security need
Low priority
2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include:
1. Returning to sewing
2. Preventing ocular infection
3. Administering eye drops on time in the hospital
4. Performing independent hygienic care in the hospital
Returning to sewing
3. The nurse writes the following goal for a client who is hypertensive: “Client will maintain a blood pressure within acceptable limits.” Which of the following would be the most appropriate outcome criterion?
1. “Client will request pain medication as needed.”
2. “Client will experience no headache or dizziness.”
3. “Client will identify at least two things that cause stress.”
4. “Client will have a 7 AM blood pressure reading less than 140/90.”
“Client will have a 7 AM blood pressure reading less than 140/90.”
4. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?
1. Teaching a client to administer his or her insulin injection
2. Assisting a new mother with learning the art of breast-feeding
3. Notifying the nutritionist of a client’s specific dietary preferences
4. Administering a cleansing enema in preparation for radiological testing
Administering a cleansing enema in preparation for radiological testing
5. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement “Nurse will apply warm, wet soaks to the patient’s leg while awake” lacks which of the following components?
1. Method
2. Quantity
3. Frequency
4. Performing staff
Frequency
6. In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is:
1. “Client will describe activity restrictions.”
2. “Client will verbalize understanding of treatments.”
3. “Client will be ambulated in hallway 3 times each day.”
4. “Client’s respiratory rate will remain within 20 to 24 breaths per minute by 9/24.”
“Client’s respiratory rate will remain within 20 to 24 breaths per minute by 9/24.”
7. The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?
1. Nursing Kardex
2. Computerized care plan
3. Critical pathway
4. Standardized care plan
Critical pathway
8. The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved?
1.The problem area should be totally delegated to the consultant.
2. Consultation is often used when the exact problem remains unclear.
3. The problem area is identified by any member of the health care team.
4. Feelings about the problem should be described to the consultant by the nurse.
Consultation is often used when the exact problem remains unclear.
9. In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority?
1. Difficulty breathing
2. Financial problems
3. A nutritional deficit
4. An impending divorce
Difficulty breathing
10. The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following:
1. “Vital signs will return to within normal levels for a middle aged adult.”
2. “Nursing assistant will ambulate the client in the hallway 3 times each day.”
3. “Lungs will be clear to auscultation and respiratory rate will be 20/minute.”
4. “Output will be at least 100 mL/hour of clear yellow urine within 24 hours.”
“Output will be at least 100 mL/hour of clear yellow urine within 24 hours.”
11. In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is:
1. Realistic
2. Observable
3. Measurable
4. Client-centered
Realistic
12. Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse-initiated intervention is:
1. Providing client teaching
2. Administering medication
3. Ordering a liver CAT scan
4. Referring a client to physical therapy
Providing client teaching
13. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?
1. Taking vital signs
2. Providing support to a family
3. Changing a dressing 2 times each day
4. Measuring intake and output each shift
Changing a dressing 2 times each day
14. Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?
1. Maintaining regular bowel elimination
2. Promoting the health of the entire family
3. Managing severely restricted body movement
4. Restoring tissue integrity to areas damaged by friction
Restoring tissue integrity to areas damaged by friction
15. In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their:
1. Client outcomes
2. Client assessment
3. Nursing interventions
4. Multidisciplinary approach
Multidisciplinary approach
16. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:
1. Offer fluids to the client q2h
2. Observe the client’s respirations
3. Change the client’s dressing daily
4. Irrigate the nasogastric tube q2h with 30 ml normal saline
Irrigate the nasogastric tube q2h with 30 ml normal saline
17. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following:
1. “Take vital signs.”
2. “Refer client to a therapist.”
3. “Turn client as needed while in bed.”
4. “Apply two 4 × 4 dry gauze dressing pads tid.”
“Apply two 4 × 4 dry gauze dressing pads tid.”
18. Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the student’s care plan but not in the client’s record is:
1. Client outcomes
2. Nursing diagnoses
3. Scientific rationales
4. Nursing interventions
Scientific rationales
19. The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for:
1. Multidisciplinary communication
2. Quality assurance in the health care facility
3. Provision of a standardized format for client problems
4. Identification of the relationship of client problems and interventions
Identification of the relationship of client problems and interventions
20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based upon the established criteria is the following:
1. “Client will perform glucose measurements often.”
2. “Client will appear less anxious regarding diagnosis.”
3. “Urinary output will reach normal young adult levels.”
4. “Client will independently perform subcutaneous insulin injection by 8/31.”
“Client will independently perform subcutaneous insulin injection by 8/31.”
21. Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity?
1. Applying adequate clothing to ensure the client’s warmth
2. Providing sufficient quantities of an aloe-based skin lotion
3. Helping the client select her favorite foods from the menu form
4. Dressing the client’s feet in non-skid soled slippers when ambulating
Providing sufficient quantities of an aloe-based skin lotion
22. Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?
1. The client will show no systemic or local signs of infection by time of discharge from hospital.
2. The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA).
3. The client will demonstrate effective coughing and deep-breathing techniques within 2 hours of surgery.
4. The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.
The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.
23. Which of the following would be the most appropriate outcome criterion for the goal, “Client’s pain will be managed to within an acceptable level within 30 minutes of receiving pain medication.”
1. Client will deny presence of any pain or discomfort.
2. Client will rate pain at a level of 3 or less out of a possible 10.
3. Client will demonstrate ability to request pain medication as needed.
4. Client will identify two external factors that decrease presence of pain.
Client will rate pain at a level of 3 or less out of a possible 10.
24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?
1. Inventory of clothes and other personal belongings
2. Orientation to the nursing unit and individual room
3. Interview regarding medications currently being taken
4. Assessment of body systems for presurgery checklist
Orientation to the nursing unit and individual room
25. Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals?
1. Client will properly clean the hearing aid ear piece daily with soap and water.
2. Client will state 3 positive effects of wearing his hearing aid at follow-up appointment.
3. Client will wear hearing aid while awake to help improve his ability to understand instructions.
4. Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.
Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.
26. Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes?
1. “It gives the client something positive to strive towards.”
2. “They are statements of how the client’s behavior should change.”
3. “They are measurable criteria by which I can evaluation whether a goal has been achieved.”
4. “They provide the client with suggestions on how to achieve their long and short term goals.”
“They are measurable criteria by which I can evaluation whether a goal has been achieved.”
27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals?
1. “The client’s A1C levels will be 7 or below at the first testing date.”
2. “The client will experience no blood sugar readings below 60 mg/dL before first follow up visit.”
3. “The client will be visited weekly by home health nursing staff beginning 1 week after discharge.”
4. “The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit.”
“The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit.”
28. The expected outcome that best evaluates the presurgical goal of, “Client will understand purpose of coughing and deep breathing within 4 hours of returning to room” is:
1. Client will demonstrate proper technique for coughing and deep breathing
2. Client will cough and deep breathe every 1 hour while awake without staff prompting
3. Client is capable of restating the purpose of coughing and deep breathing in own words
4. Client’s lungs will be free of abnormal breath sounds within 1 hour of being returned to room
Client will cough and deep breathe every 1 hour while awake without staff prompting
29. Which of the following statements made by the nurse best reflects an understanding of the client’s role in goal setting?
1. “He knows what he needs better than anyone else.”
2. “When he sets the goals he is more likely to follow the plan.”
3. “He identifies the goals and then together we create the plan of action.”
4. “He is best suited to determine the level of effort he is capable of providing.”
“He is best suited to determine the level of effort he is capable of providing.”
30. A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?
1. “The client will certainly need frequent reorientation to the care plan goals.”
2. “I will restate the goals I’ve created for him regularly so as to win his compliance.”
3. “I’m not sure that his family will be able to support him with these goals but I will discuss it with them.”
4. “He seems very willing to work towards achieving his goals but his condition will certainly create barriers.”
“I will restate the goals I’ve created for him regularly so as to win his compliance.”
31. Which of the following goals best shows that the nurse understands the concept of a client-centered goal?
1. Client will consume at least 75% of each meal served.
2. ADLs will be completed before breakfast is served.
3. Pain will be managed so as to be rated at 3 or less out of 10.
4. Client will be transported to physical therapy by 9 AM daily.
Client will consume at least 75% of each meal served.
32. Which of the following client-centered goals best rest reflects singular focus?
1. Client will cough and deep breathe every hour while awake.
2. Client will be free of shoulder and elbow pain by discharge.
3. Client will adhere to a low-fat diet and lose 3 pounds in 30 days.
4. Client will ambulate to the bathroom for the purpose of showering daily.
Client will ambulate to the bathroom for the purpose of showering daily.
33. The nurse realizes that goals should be singular in focus primarily because:
1. The nurse will find it difficult to modify the plan of care if the goals are not met.
2. The client may not have the strength to accomplish multiply behavioral changes.
3. The client may have difficulty focusing on more than one behavioral modification at a time.
4. The nurse will find it difficult to identify appropriate interventions to address multiple behaviors.
The nurse will find it difficult to modify the plan of care if the goals are not met.
34. Which of the following goals concerning client anxiety is the best example of measurability?
1. Client will be less anxious by discharge.
2. Client will appear less anxious by discharge.
3. Client will report anxiety at less than 3 out of 5 by discharge.
4. Client pulse rate and blood pressure will be within normal limits by discharge.
Client will report anxiety at less than 3 out of 5 by discharge.
35. Which of the following goals best reflects measurability?
1. Client’s emotional state will be stable by time of discharge.
2. Client will experience normal sensations in feet by discharge.
3. Client will report being free of shoulder pain by discharge.
4. Client will have acceptable range of motion in elbow by discharge.
Client will report being free of shoulder pain by discharge.
36. When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider:
1. The institution’s policies and procedures
2. The state’s defined scope of nursing practice
3. The client’s physiological and psychological needs
4. The scientific rationale for the proposed nursing action
The state’s defined scope of nursing practice
37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to:
1. Facilitate the intervention in a timely manner
2. Evaluate the client’s response to the intervention
3. Possess the technical skills required to implement the intervention
4. Provide client education regarding the implementation of the intervention
Possess the technical skills required to implement the intervention
38. The primary function of a care plan is to provide:
1. The client with continuity of care
2. The staff with written client-centered nursing interventions
3. An established criteria for the evaluation of nursing outcomes
4. An organized means of exchanging information between caregivers
The client with continuity of care
1. Which of the following characteristics are considered guidelines for the writing of appropriate goals and outcomes? (Select all that apply.)
1. Singular
2. Realistic
3. Practical
4. Observable
5. Measurable
6. Meaningful
1. Singular
2. Realistic
4. Observable
5. Measurable
1. The nurse uses nursing diagnoses after completion of the client assessment, because they:
1. Are required for accreditation purposes
2. Identify the domain and focus of nursing
3. Assist the nurse to distinguish medical from nursing problems
4. Make all client problems become more quickly and easily resolved
Identify the domain and focus of nursing
2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client’s weight, the nurse also considers the age and height. This is an example of:
1. Defining the client problem
2. Recognizing gaps in data assessment
3. Comparing data with normal health patterns
4. Drawing conclusions about the client’s response
Comparing data with normal health patterns
3. Of the following statements, which one is an example of an appropriately written nursing diagnosis?
1. Acute pain related to left mastectomy
2. Impaired gas exchange related to altered blood gases
3. Deficient knowledge related to need for cardiac catheterization
4. Need for high protein diet related to alteration in client nutrition
Deficient knowledge related to need for cardiac catheterization
4. Of the following statements, which one is an example of an appropriately written nursing diagnosis?
1. Risk for change in body image related to cancer
2. Cardiac output decreased related to motor vehicle accident
3. Ineffective airway clearance related to increased secretions
4. Potential for injury related to improper teaching in the use of crutches
Ineffective airway clearance related to increased secretions
5. The nurse has diagnosed the client’s problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:
1. Poor fiber intake
2. Limited fluid intake
3. Total hip replacement
4. Lower abdominal discomfort
Total hip replacement
6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur?
1. Impaired gas exchange
2. Decreased cardiac output
3. Ineffective airway clearance
4. Impaired spontaneous ventilation
Impaired gas exchange
7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?
1. The diagnosis should identify a “cause and effect” relationship.
2. The diagnosis must remain constant during the client’s hospitalization.
3. The etiology of the diagnosis must be within the scope of the health care team’s practice.
4. The diagnosis should include the problem and the related contributing conditions.
The diagnosis should include the problem and the related contributing conditions.
8. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:
1. Validates the assessment information in the data base
2. Uses the NANDA International list of diagnoses as a primary source
3. Formulates a diagnosis too closely resembling a medical diagnosis
4. Distinguishes the nursing focus instead of other health care disciplines
Formulates a diagnosis too closely resembling a medical diagnosis
9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences.
1. “Altered speech”
2. “As evidenced by”
3. “Recent neurological disturbances”
4. “Inability to speak in complete sentences”
“Inability to speak in complete sentences”
10. The primary purpose of a nursing diagnosis, according to the nurses, is to:
1. Support the medical plan of care
2. Provide a standardized approach for all clients
3. Recognize the client’s response to an illness or situation
4. Offer the nurse’s subjective view of the client’s behaviors
Recognize the client’s response to an illness or situation
11. Which one of the following is an appropriate etiology for a nursing diagnosis?
1. Myocardial infarction
2. Cardiac catheterization
3. Abnormal blood gas levels
4. Increased airway secretions
Increased airway secretions
12. Which of the following is an appropriate etiology for a nursing diagnosis?
1. Incisional pain
2. Poor hygienic practices
3. Need to offer bedpan frequently
4. Inadequate prescription of medication
Incisional pain
13. Of the following statements, which one is an example of an appropriately written nursing diagnosis?
1. Diarrhea related to food intolerance
2. Alteration in comfort related to pain
3. Risk for impaired skin integrity related to poor hygiene habits
4. Potential complications related to insufficient vascular access
Diarrhea related to food intolerance
14. Of the following statements, which one is an example of an appropriately written nursing diagnosis?
1. Anxiety related to cardiac monitor
2. Pain related to difficulty ambulating
3. Chronic pain related to insufficient use of medication
4. Bedpan required frequently as a result of altered elimination pattern
Chronic pain related to insufficient use of medication
15. Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate.
1. Risk for injury
2. Excess fluid volume
3. Ineffective airway clearance
4. Impaired spontaneous ventilation
Ineffective airway clearance
16. Which one of the following is a NANDA International nursing diagnosis label?
1. Frequent urination
2. Coughing and dyspnea
3. Risk for impaired parenting
4. Abnormal hygienic care practices
Risk for impaired parenting
17. When asked to define “Nursing Diagnosis” the nurse’s best response is:
1. “It is the second step in the Nursing Process.”
2. “It is the process of defining a client’s problems.”
3. “It correlates a client’s problem with a condition a nurse is competent to treat.”
4. “It focuses care a licensed nurse can provide with the identified needs of a client.”
“It correlates a client’s problem with a condition a nurse is competent to treat.”
18. The nurse’s initial responsibility in the management of a client’s collaborative problem is to:
1. Monitor for changes
2. Advocate for the client
3. Implement interventions
4. Evaluate client outcomes
Monitor for changes
19. The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client’s anxiety regarding the procedure?
1. Assure the client that preoperative sedation will be administered.
2. Discuss the pre- and postprocedure care that will be provided.
3. Provide a detailed explanation of why the procedure is necessary.
4. Guarantee that family will be regularly updated during the procedure.
Discuss the pre- and postprocedure care that will be provided.
20. The nursing diagnosis of acute pain falls under which of the following comfort domain classifications?
1. Social comfort
2. Physical comfort
3. Interpersonal comfort
4. Environmental comfort
Physical comfort
21. When asked to define the purpose of diagnostic reasoning, the best nursing response is:
1. “Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis.”
2. “The diagnostic reasoning process flows from the assessment process and includes decision-making steps.”
3. “Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem.”
4. “Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis.”
“Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis.”
22. A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional?
1. “After defining the client’s symptomatology, eliminate those nursing diagnoses that are not supported by the database.”
2. “Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics.”
3. “After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable.”
4. “With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process.”
“After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable.”
23. A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, “what the diagnosis means.” Which of the following rationales best supports the nurse’s determination that the client has knowledge deficit rather than a readiness for enhanced knowledge?
1. The client initiated the question.
2. This is a new diagnosis for the client.
3. The client identified a lack of understanding.
4. Type 2 diabetes mellitus is a complicated disease process.
This is a new diagnosis for the client.
24. Which of the following responses best reflects an understanding of the purpose of the “related to” phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?
1. “To focus on the cause of the client’s needs”
2. “To identify the etiology of the client’s diagnosis”
3. “To provide for individualization of the nursing interventions”
4. “To communicate the client’s deficits to the nursing staff”
“To provide for individualization of the nursing interventions”
25. Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process?
1. Paternal family history of osteoarthritis has been reported.
2. Client is observed grimacing when walking to bathroom.
3. Right knee appears edematous when compared to left knee.
4. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.
Client is observed grimacing when walking to bathroom.
26. Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor?
1. “I can tell when my Hispanic clients are in pain.”
2. “Moaning is a classic sign of pain in most cultures.”
3. “All clients will tell you when they need pain medication.”
4. “Chronic pain is difficult to manage especially for the stoic individual.”
“All clients will tell you when they need pain medication.”
27. Which of the following statements best reflects the nurse’s understanding of the primary nursing-related purpose of a concept map?
1. To facilitate holistic nursing care
2. To provide visualization of the client’s health problems
3. To assist in the identification of client-oriented nursing diagnoses
4. To demonstrate the relationship between the client’s various health problems
To demonstrate the relationship between the client’s various health problems
28. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care?
1. “Concept maps help me see the whole client, not just individual health problems.”
2. “Concept maps can be easily edited to reflect a client’s ever changing health needs.”
3. “I need help organizing my assessment data and concept mapping is really good for that.”
4. “I like concept mapping because it helps me focus on how the disease processes affect the client.”
“Concept maps help me see the whole client, not just individual health problems.”
29. A client expresses concern over a scheduled intravenous pyelogram by stating, “I don’t know what to expect.” Which of the following nursing diagnoses is most appropriate for this client need?
1. Anxiety related to scheduled diagnostic testing
2. Knowledge deficit regarding need for diagnostic testing
3. Knowledge deficit related to need for intravenous pyelogram
4. Anxiety related to lack of knowledge concerning intravenous pyelogram
Anxiety related to lack of knowledge concerning intravenous pyelogram
1. Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.)
1. Client teaching related to health and wellness topics
2. Evaluation of client outcomes in regards to nursing care
3. Identification of patterns in the client’s health assessment data
4. Recognition of relationships among the client’s various health issues
5. Planning specialized nursing interventions to meet a client’s health needs
6. Facilitating assessment data collection through observation and communication
2. Evaluation of client outcomes in regards to nursing care
3. Identification of patterns in the client’s health assessment data
4. Recognition of relationships among the client’s various health issues
5. Planning specialized nursing interventions to meet a client’s health needs
1. A client interview consists of three phases. The nurse recognizes that those phases are:
1. Orientation, working, termination
2. Introduction, controlling, selection
3. Introduction, assessment, conclusion
4. Orientation, documentation, database
Orientation, working, termination
2. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about:
1. The onset and duration of his present breathing problem
2. His personal smoking, alcohol use, and exercise practices
3. Any extended family members who have diagnosed heart disease
4. Changes in other body systems that the client perceives as problematic
The onset and duration of his present breathing problem
3. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about:
1. A family history of heart problems
2. Medications currently being taken at home
3. Questions or concerns about hospitalization
4. The onset, severity, and duration of the chest pain
The onset, severity, and duration of the chest pain
4. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as:
1. Clustering data
2. Validating data
3. Peer reviewing
4. Problem statement
Clustering data
5. The client recently became febrile and stated he “felt hot.” The nurse takes the client’s temperature and finds it to be 38.2° C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data?
1. Pulse rate of 88 beats per minute
2. Blood pressure of 168/80 mm Hg
3. The statement regarding his feeling hot
4. The supported fact that he became febrile
The statement regarding his feeling hot
6. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning?
1. “Is your pain worse or better than it was an hour ago?”
2. “Do you believe that your nausea is from the new antibiotic?”
3. “What do you think has been causing your current depression?”
4. “What have you done to alleviate the side effects from your medications?”
“What do you think has been causing your current depression?”
7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories?
1. Family history
2. Psychosocial history
3. Biographical history
4. Environmental history
Psychosocial history
8. The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for:
1. Coordination with the physician’s visit
2. The time when the client’s family are visiting
3. Immediately before the client’s scheduled MRI testing
4. After the client has become comfortably oriented to the room
After the client has become comfortably oriented to the room
9. The nurse has completed an assessment and found that the client has “an activity and exercise abnormality.” This type of wording indicates that which of the following organizing formats has been used?
1. Review of systems
2. Nursing health history
3. Gordon’s functional health patterns
4. Biographical information database
Gordon’s functional health patterns
10. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data?
1. Pain in the left leg
2. Elevated blood pressure
3. Fear of impending surgery
4. Discomfort upon breathing
Elevated blood pressure
11. The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the:
1. Client
2. Physician
3. Family member
4. Experienced unit nurse
Client
12. The process of data collection should begin with the nurse performing a:
1. Physical exam
2. Client interview
3. Review of medical records
4. Discussion with other health team members
Client interview
13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the client’s health problem. To obtain these data most efficiently, the nurse should use:
1. Channeling
2. Open-ended questions
3. Closed-ended questions
4. Problem-seeking responses
Closed-ended questions
14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication?
1. “I understand how you must feel.”
2. “This medication is used to lower your blood pressure.”
3. “You appear anxious. You’re wringing your hands constantly.”
4. “Could you give me an example of how you handle stressors?”
“Could you give me an example of how you handle stressors?”
15. When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as:
1. Respiratory
2. Activity and exercise
3. Sleep and rest pattern
4. Self-care deficit: activities of daily living
Activity and exercise
16. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data?
1. “Client appears sleepy”
2. “No physical distress noted”
3. “Abdomen soft and non-tender”
4. “States feels anxious and tense”
“States feels anxious and tense”
17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time?
1. “Can you describe your pain?”
2. “Have you had this problem before?”
3. “What have you done to ease the pain?”
4. “When did your abdominal pain begin?”
“When did your abdominal pain begin?”
18. Which subjective assessment data are most supportive of a client’s diagnosis of anxiety?
1. Diaphoretic and cool skin
2. An apical pulse rate of 120 beats per minute
3. Reports “needing to leave now”
4. Claims “something is terribly wrong”
Claims “something is terribly wrong”
19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client’s depression?
1. “Have you ever felt this depressed before?”
2. “What do you believe is the cause of your depression?”
3. “What makes you feel that you are experiencing depression?”
4. “What can we do to make you comfortable while you are here?”
“What do you believe is the cause of your depression?”
20. Which of the following statements best reflects the nurse’s correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?
1. “I’m going to do the client’s history before his family leaves so they can help with the admission history questions.”
2. “You are scheduled for some x-rays, so I’d like to complete this admission history interview before you have to leave.”
3. “I have some questions to ask you regarding your admission history. I’ll be back once you are settled in and comfortable.”
4. “Please let me know when the blood lab is finished with the new client so I can complete his admission history interview.”
“I have some questions to ask you regarding your admission history. I’ll be back once you are settled in and comfortable.”
21. The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse?
1. “How long have you been dealing with GERD?”
2. “Are you currently taking any medications for your GERD?”
3. “Do you follow a particular diet to help manage your GERD?”
4. “Do you have any other gastrointestinal problems besides GERD?”
“Do you have any other gastrointestinal problems besides GERD?”
22. A new graduate nurse missed cues regarding the client’s emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is:
1. “That is why we perform assessments at least daily; so we can catch missed cues.”
2. “Everyone has missed cues; don’t be too hard on yourself and just keep trying.”
3. “You will be less likely to miss client cues as you acquire more experience with assessments.”
4. “The positive side to making this mistake is that you won’t miss those cues again in another client.”
“You will be less likely to miss client cues as you acquire more experience with assessments.”
23. The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain?
1. “What makes the pain worse?”
2. “When did you first notice the pain?”
3. “What do you do to lessen the pain?”
4. “Can you rate your pain using the pain scale that we’ve discussed?”
“Can you rate your pain using the pain scale that we’ve discussed?”
24. When following up on a client’s report of hip pain during an admission assessment, the most nursing conclusive observation would be:
1. The client tearing when being ambulated to the chair
2. A report from the ancillary staff that the client is reporting pain
3. The client observed grimacing when positioning self in the bed
4. Overhearing the client discuss hip pain with family on the phone
The client observed grimacing when positioning self in the bed
25. When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information?
1. A 50-year-old in the ED reporting chest pain
2. A 70-year-old admitted with fever of unknown origin
3. A 81-year-old receiving follow-up treatment for a hip replacement
4. A 22-year-old being treated at a clinic for a sexually transmitted disease
A 81-year-old receiving follow-up treatment for a hip replacement
26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse’s mentor?
1. Conducting the interview with the client’s boyfriend present
2. Stopping the interview to answer a page from the nursing station
3. Frequently checking the time while waiting for the client to answer
4. Heard asking the client, “Am I correct; you’ve rated your pain a 9 out of 10?”
Frequently checking the time while waiting for the client to answer
27. Which of the following assessment data provided by a client’s family will have the greatest impact on the client’s care while hospitalized?
1. “Mom falls asleep fastest with the television on.”
2. “Dad starts off the day with hot coffee; it regulates his bowels.”
3. “My wife’s sister died 4 months ago, and she is still grieving over her loss.”
4. “My husband doesn’t like to let people know his arthritis is bothering him.”
“My husband doesn’t like to let people know his arthritis is bothering him.”
28. What is the most appropriate method for the nurse to communicate a client’s wishes to the nurses on the next shift?
1. Document the request in the nursing notes.
2. Include the client’s request in the shift report.
3. Place instructions regarding the client’s wishes above the client’s bed.
4. Verbally inform the unit clerk of the client’s request.
Include the client’s request in the shift report.
29. While discussing a client’s medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation?
1. Note the allergy on the client’s Kardex.
2. Inform the provider of the client’s possible allergy.
3. Review the client’s medical record for confirmation of the allergy.
4. Tell the client to have all medications identified before taking them.
Review the client’s medical record for confirmation of the allergy.
30. The nurse realizes that in order to share information from a client’s medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:
1. Facilitate the exchange of information between appropriate parties
2. Minimize the opportunity for this information to be assessed inappropriately
3. Ensure the client’s right to have his medical information regarded as personal and confidential
4. Guarantee that the information will be shared with only those requiring it for client care purposes
Ensure the client’s right to have his medical information regarded as personal and confidential
31. The nurse recognizes that a client’s hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle?
1. Speaking slowly, clearly, and in a normal tone
2. Using various forms of nonverbal communication
3. Relying heavily on touch to convey caring and interest
4. Involving family in discussions concerning meeting client’s needs
Using various forms of nonverbal communication
32. Which of the following questions will provide the nurse with the best understanding of a terminally ill client’s spiritual needs?
1. “Do you have a religious preference?”
2. “Have you given thought to your spiritual needs?”
3. “Is there a particular clergy you would like to visit with?”
4. “Are there any spiritual needs you have that I may help with?”
“Are there any spiritual needs you have that I may help with?”
1. Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.)
1. “You’re answers will be kept confidential.”
2. “My name is Susan Smith and I’m a registered nurse.”
3. “We are here to make your hospitalization as pleasant as possible.”
4. “I need to ask you some questions that will help with planning your care.”
5. “Only those directly involved in your care will have access to this information.”
6. “If there is anything you need or help you require simply use your call bell and someone will be right in.”
1. “You’re answers will be kept confidential.”
2. “My name is Susan Smith and I’m a registered nurse.”
4. “I need to ask you some questions that will help with planning your care.”
5. “Only those directly involved in your care will have access to this information.”
2. The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.)
1. “My work environment would depress anyone.”
2. “It seems like almost anything can make me cry.”
3. “Being here away from my family makes me sad.”
4. “I just can’t seem to get excited about anything anymore.”
5. “The family always thought that my father was depressed.”
6. “I like winter because I can just cover up on the couch and sleep.”
4. “I just can’t seem to get excited about anything anymore.”
5. “The family always thought that my father was depressed.”
3. The goal of the orientation phase of a nursing interview is to: (select all that apply)
1. Initiate the nurse-client relationship
2. Begin identifying the client’s needs
3. Earn the trust and confidence of the client
4. Assume the decision role for the client
5. Welcome the client to the nursing unit
6. Gather the client’s demographic information
1. Initiate the nurse-client relationship
2. Begin identifying the client’s needs
3. Earn the trust and confidence of the client
1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student?
1. “Think about several interventions that you could use with this client.”
2. “Don’t draw subjective inferences about your client—be more objective.”
3. “Please think harder—there is a single solution for which I am looking.”
4. “Trust your feelings—don’t be concerned about trying to find a rationale to support your decision.”
“Think about several interventions that you could use with this client.”
2. The second component of critical thinking in the “critical thinking model” is:
1. Experience
2. Competencies
3. Specific knowledge
4. Diagnostic reasoning
Experience
3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is “not right” with the client and proceeds to take the vital signs. This is the nurse acting on:
1. Intuition
2. Reflection
3. Knowledge
4. Scientific methodology
Intuition
4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying?
1. Humility
2. Risk-taking
3. Accountability
4. Independent thinking
Risk-taking
5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of:
1. Inference
2. Management
3. Problem-solving
4. Diagnostic reasoning
Problem-solving
6. Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process?
1. “I believe that this client is getting depressed.”
2. “The client doesn’t look right to me; I think something is wrong.”
3. “The client’s husband told me that she is feeling very uncomfortable.”
4. “The client reports more pain than yesterday and her blood pressure is elevated.”
“The client reports more pain than yesterday and her blood pressure is elevated.”
7. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address?
1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
Implementation
8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who:
1. Has a documented blood pressure of 90/50
2. Was medicated for back pain 10 minutes ago
3. Has an order to be out of bed and ambulated
4. Requires instructions for wound care before discharge
Has a documented blood pressure of 90/50
9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is:
1. Giving medication at the time ordered
2. Following a procedure for catheterization step-by-step
3. Reviewing all clients’ medical records thoroughly
4. Discussing various alternative pain management techniques
Discussing various alternative pain management techniques
10. The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands?
1. Defining the problem
2. Making final decisions
3. Testing possible options
4. Considering consequences
Testing possible options
11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority?
1. Reporting client difficulties
2. Offering an alternative approach
3. Looking for a different treatment option
4. Sharing ideas about nursing interventions
Reporting client difficulties
12. Use of the intellectual standard of critical thinking implies that the nurse:
1. Questions the physician’s order
2. Recognizes conflicts of interest
3. Listens to both sides of the story
4. Approaches assessment logically
Approaches assessment logically
13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of:
1. Curiosity
2. Experience
3. Perseverance
4. Scientific knowledge
Experience
14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor?
1. “I feel it’s good practice to always have alternative interventions in mind.”
2. “I trust my feelings about a client’s needs since I work hard at knowing my client.”
3. “I always try to keep an open mind about what interventions my client will require.”
4. “I will wait until my assessment is completed before determining the client’s needs.”
“I trust my feelings about a client’s needs since I work hard at knowing my client.”
15. Which of the following is the best example of a nurse’s use of reflection?
1. The nurse places a client experiencing respiratory difficulties in a high-Fowler’s position.
2. The nurse calls the provider when a client reports feeling “chilled and achy” while having an oral temperature of 100.2° F.
3. While caring for a client with a history of asthma, the nurse assesses the client’s pulse oximetry reading when he “doesn’t sound right.”
4. A nurse tells a client; “When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time.”
A nurse tells a client; “When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time.”
16. Which of the following nursing situations best reflects accountability?
1. The nurse takes the oncology nursing certification examination.
2. The nurse files an incident report regarding a medication error.
3. The nurse assesses the client for the possible cause of his pain.
4. The nurse tells the client, “I don’t know but I will find out for you.”
The nurse files an incident report regarding a medication error.
17. Which of the following nursing actions is the best example of problem solving?
1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick
2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal
3. Trying several difficult wound dressings to determine which one the client can apply the most effectively
4. Calling for another pain medication order when the current drug results in the client experiencing nausea
Trying several difficult wound dressings to determine which one the client can apply the most effectively
18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment?
1. A new admission admitted for swelling in the right ankle and knee
2. A second day postoperative client who received pain medication 30 minutes ago
3. A client who the nursing assistant found crying in the bathroom
4. A client ready for discharge who requires a final assessment and documentation
A client who the nursing assistant found crying in the bathroom
19. Which of the following nursing interventions is the best example of the implementation step of the nursing process?
1. Determining that the client’s ankle edema is worse after he ambulates
2. Asking the client to rate his ankle pain after receiving oral pain medication
3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation
4. Crushing the client’s pain medication to facilitate easier swallowing and thus minimize the risk of choking
Crushing the client’s pain medication to facilitate easier swallowing and thus minimize the risk of choking
20. Which of the following nursing actions best reflects the consequence stage of the decision-making process?
1. Being physically present when a client is given the results of a tissue biopsy
2. Witnessing the client sign consent for surgery forms before cardiac surgery
3. The client is informed of the various treatments available for his condition.
4. The nurse explains to the client the risks of leaving the hospital against medical advice.
The nurse explains to the client the risks of leaving the hospital against medical advice.
21. The concept of nursing responsibility is best reflected in which of the following nursing actions?
1. Providing accurate and timely documentation regarding an incident resulting in a client fall
2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning
3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client
4. Referring to the institution’s policy manual when unsure of how to handle a client’s complaint regarding a social services consult
Referring to the institution’s policy manual when unsure of how to handle a client’s complaint regarding a social services consult
22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool?
1. Performing a head-to-toe assessment on a new admission
2. Placing a client experiencing shortness of breath on oxygen
3. Arbitrating a complaint between roommates over the television
4. Notifying a provider of a client’s allergy to an ordered medication
Placing a client experiencing shortness of breath on oxygen
23. The nurse is best demonstrating perseverance by:
1. Having a perfect attendance record
2. Completing a lengthy course on current chemotherapies
3. Repeatedly irrigating the nasogastric tube until it is patent
4. Sitting with a client until she is ready to discuss why she is crying
Sitting with a client until she is ready to discuss why she is crying
24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because:
1. The veteran nurse has a varied history of client care experiences
2. Critical thinking improves with experience, longevity, and interest
3. Today’s short hospital stays minimize the opportunity to develop critical thinking skills
4. New graduates often lack the self-confidence to take the risks often required of critical decision making
Critical thinking improves with experience, longevity, and interest
25. The primary factor that distinguishes a professional nurse’s care from care provided by ancillary nursing staff is:
1. Critical thinking
2. Years of education
3. Professional licensure
4. Complexity of the task
Critical thinking
26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response?
1. “A person with the educational background to solve problems.”
2. “A person who finds the problem and does what is best to fix it.”
3. “It’s someone who uses the scientific method to solve problems.”
4. “Someone who uses a system to work through and solve a problem.”
“A person who finds the problem and does what is best to fix it.”
27. Which of the following statements made by a new graduate nurse regarding a client’s care needs requires follow-up by the mentor?
1. “No one really enjoys being hospitalized.”
2. “Every client is offered a back rub at bedtime.”
3. “All post surgery clients are reluctant to ambulate.”
4. “I always spend extra time with new clients to help them relax.”
“All post surgery clients are reluctant to ambulate.”
28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care?
1. “I’m sure that friction and pressure have caused this problem.”
2. “Please be sure that her ankles are well padded when you place her in bed.”
3. “Do you have any suggestions on how we can minimize the pressure to her ankles?”
4. “It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour.”
“Do you have any suggestions on how we can minimize the pressure to her ankles?”
29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client’s care needs?
1. “That surgery is painful. I’ll get her pain medication ready.”
2. “She was sleeping when I checked 15 minutes ago. I’ll go back in right now.”
3. “I’ll be responsible for her PM care so I can spend some uninterrupted time with her.”
4. “A mastectomy is a blow to a woman’s self image. I’ll notify her provider that she is depressed.”
“She was sleeping when I checked 15 minutes ago. I’ll go back in right now.”
30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit’s nurse manager?
1. “Mary and I were comparing foot wound dressing techniques.”
2. “I’ve been caring for orthopedic clients for 10 years and I think I’ve seen it all.”
3. “I can’t believe that my client isn’t improving after 2 weeks of physical therapy.”
4. “I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.”
“I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.”
1. The scope of a client’s health problem is a result of which of the following factors? (Select all that apply.)
1. Religious beliefs
2. Life experiences
3. Lifestyle choices
4. Work environment
5. Family relationships
6. Educational background
2. Life experiences
3. Lifestyle choices
4. Work environment
5. Family relationships
1. Which of the following research approaches is an example of an exploratory type of research?
1. Establishing facts and relationships of past events
2. Testing how well a program, practice, or policy is working
3. Refining a hypothesis on the relationships among phenomena
4. Portraying the characteristics of persons, situations, or groups
Refining a hypothesis on the relationships among phenomena
2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003, may influence nursing research in the area of:
1. The cost of the study
2. Where the study may be published
3. What type of study may be conducted
4. How the data will be obtained and protected
How the data will be obtained and protected
3. The expected research role for the baccalaureate-prepared nurse is to:
1. Assume the role of a clinical expert
2. Acquire funding for research projects
3. Identify clinical nursing problems in practice
4. Develop methods of inquiry relevant to nursing
Identify clinical nursing problems in practice
4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for participation in her study, which of the following ethical principles that guide research is this researcher using?
1. Informed consent
2. Freedom from harm
3. Protection of subjects
4. Confidentiality of subjects
Informed consent
5. The nurse takes on ethical responsibilities when conducting research with human subjects. Which of the following violates an ethical responsibility associated with informed consent?
1. Adhering to verbal and written agreements
2. Using data obtained before the initiation of the study
3. Explaining the possibility of unknown risks when appropriate
4. Providing alternatives, including the right of refusal and standard practices
Using data obtained before the initiation of the study
6. Nurses need to become familiar with the elements of a research publication. A brief explanation of the type of measurement to be used is found in which section of a study?
1. Results
2. Methods
3. Conclusion
4. Introduction
Methods
7. After identifying the problem, the next step in the research process is to:
1. Select the population
2. Review the literature
3. Obtain approval to conduct the study
4. Identify the instrument to use for data analysis
Review the literature
8. A sample of orthopedic clients varies greatly in their requests for postsurgical analgesics. Which type of nursing research would best examine a prospective group of clients in determining what factors affect their alterations in comfort?
1. Historical research
2. Evaluation research
3. Correlational research
4. Experimental research
Correlational research
9. Which of the following research topics best lends itself to the experimental research process method?
1. The effects of therapeutic touch on a geriatric client diagnosed with Alzheimer’s disease
2. Prioritizing three nursing diagnoses for a newly admitted client with diabetes mellitus
3. Employing humor as an intervention with clients who are recovering from orthopedic surgery
4. Determining the blood pressure patterns of a client who recently experienced a cerebrovascular accident (i.e., stroke)
Employing humor as an intervention with clients who are recovering from orthopedic surgery
10. The nurse is looking at different strategies for learning and incorporating new information into practice. A strategy that uses problem-solving is demonstrated by:
1. Repeatedly practicing vital signs until competence is achieved
2. Seeking information from the nurse manager on the client’s status
3. Reviewing Maslow’s hierarchy either in a textbook or on the internet
4. Trying different types of colostomy dressings for maximum therapeutic effect
Trying different types of colostomy dressings for maximum therapeutic effect
11. A nurse researcher has completed a study involving the use of intravenous analgesics for postsurgical discomfort. The description of the 16 clients used for the study would best be written in which part of the research report?
1. Results section
2. Methods section
3. Discussion section
4. Introduction section
Methods section
12. A nurse reads about a case study involving the potential positive effects of the early stimulation of post-head-injury clients. Which of the following questions should be a priority consideration before use of the research results?
1. “What was the cost of the study?”
2. “Were ethical principles maintained?”
3. “Were the results of this study published in other journals?”
4. “Are the clients in the study similar to clients I work with?”
“Are the clients in the study similar to clients I work with?”
13. An example of a predictive type of question that a nurse might use for research is which of the following?
1. “What creates an increase in stress levels?”
2. “How often does the stress reaction occur?”
3. “What does guided imagery mean to clients?”
4. “If guided imagery is used, will stress levels be reduced?”
“If guided imagery is used, will stress levels be reduced?”
14. A nurse routinely uses therapeutic touch when caring for postoperative clients with incisional pain. Occasionally a client will show reluctance when the intervention is offered. The nurse’s best response in such a situation is to:
1. Research for alternative interventions that will be better received by the client
2. Suggest that the client allow the intervention just once before making a final decision
3. Respect the client’s wishes and rely on pain medication to help with managing the pain
4. Inform the client that the intervention has been found to be effective during several research projects
Research for alternative interventions that will be better received by the client
15. The dressing covering the pressure ulcer on a client’s heel frequently becomes loosened and requires repeated reinforcement. The nurse asks, “What can be done to improve the adhering properties of this type of dressing?” The nurse has just formulated a:
1. PICO-formatted question
2. Research question (hypothesis)
3. Problem-focused triggered question
4. Knowledge-focused triggered question
Problem-focused triggered question
1. The client has been informed that he can be discharged once he can irrigate his colostomy independently. The client requests the nurse to observe his irrigation technique. Which of the following learning motives is the client displaying?
1. Physical need
2. Social activity
3. Task mastery
4. Evaluation stance
Task mastery
2. An industrial nurse is planning to give an informative talk on hypertension to employees in honor of “heart month.” He plans to teach individuals how to take their blood pressure measurements. Which information is important for him to ask the planning committee before this presentation?
1. Ages of all employees involved
2. Names of employees who are married
3. Number of employees with high blood pressure
4. Type of room available and number of participants
Type of room available and number of participants
3. The nurse established the following objective for the client who was unable to void: The client’s intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indicated by the client:
1. Voiding at least 1000 mL during the shift
2. Verbalizing abdominal comfort without pressure
3. Having adequate fluid intake and urinary output
4. Drinking 240 mL of fluid five or six times during the shift
Drinking 240 mL of fluid five or six times during the shift
4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients. For a toddler, the nurse should use:
1. Role-playing
2. Problem-solving
3. Independent learning
4. Simple explanations and pictures
Simple explanations and pictures
5. The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is:
1. Telling
2. Trusting
3. Participating
4. Group teaching
Telling
6. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, “I will look at the wound four times a day and tell my surgeon if it looks red or swollen.” Her statement is an example of:
1. Attitudes
2. Application
3. Analysis
4. Evaluation
Application
7. The client continues to ask questions about a surgical wound. The client states, “I think I would like help the first time I look at my wound.” This is an example of:
1. Adaptation
2. Perception
3. Organizing
4. Guided response
Guided response
8. There are many factors are assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the:
1. Previous knowledge level of the client
2. Willingness of the client to want to learn the injection sites
3. Financial resources available to the client for the equipment
4. Intelligence and developmental level of the individual client
Willingness of the client to want to learn the injection sites
9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle of the lesson the client asks, “Why have my feet been swelling?” The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should follow?
1. Timing
2. Setting priorities
3. Building on existing knowledge
4. Organizing the teaching materials
Timing
10. Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is:
1. Client states side effects of a medication
2. Client responds appropriately to eye contact
3. Client independently plans an exercise program
4. Client demonstrates the proper use of a walking cane
Client demonstrates the proper use of a walking cane
11. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on:
1. Use of assistive devices, such as canes
2. Self-help devices for post-CVA clients
3. Stress management techniques for working parents
4. Environmental alterations for clients in wheelchairs
Stress management techniques for working parents
12. The nurse is evaluating the responses of clients to teaching sessions. An example of an evaluation of a client’s attainment of a cognitive skill is:
1. Client explains that the medication should be taken with meals
2. Client looks at the surgical incision without requiring prompting
3. Client uses crutches appropriately to move both up and down stairs
4. Client independently capable of dressing self after eating breakfast
Client explains that the medication should be taken with meals
13. The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time?
1. “I need to understand more about the reason for the colostomy.”
2. “I will find out more about that when the support group meets.”
3. “There’s no sense in showing me that now. I’m too sick right now.”
4. “Please be sure to tell me if I am completing all the steps correctly.”
“There’s no sense in showing me that now. I’m too sick right now.”
14. In planning to teach an older adult client, the nurse should incorporate which teaching method or principle into the plan?
1. Keep teaching sessions short.
2. Teach in the early morning or late evening.
3. Put as much as possible into each teaching session.
4. Focus on teaching a family member or caregiver instead.
Keep teaching sessions short.
15. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
1. Activity intolerance related to pain
2. Ineffective management of treatment regimen
3. Noncompliance with prescribed exercise plan
4. Knowledge deficit regarding impending surgery
Activity intolerance related to pain
16. There are a variety of teaching methodologies that may be utilized to meet the client’s needs. Which teaching method is best applied to a cognitive learning need?
1. Modeling of behavior
2. Discussion of feelings
3. Computer-assisted instruction
4. Demonstration of a procedure
Computer-assisted instruction
17. For a functionally illiterate client, the nurse particularly focuses on:
1. Using intricate analogies and examples
2. Avoiding lengthy return demonstrations
3. Incorporating familiar nonmedical terminology
4. Providing longer learning sessions with the client
Incorporating familiar nonmedical terminology
18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates evidence-based information. The nurse recognizes that evidence obtained about adult learners has identified that this group prefers:
1. Computer-assisted instruction
2. Traditional classroom settings
3. Long sessions with plenty of technical information
4. Interesting personal communication techniques
Interesting personal communication techniques
19. While teaching the client about management of his heart disease, a nurse might use a strategy that is implemented to promote learning in the affective domain such as:
1. Asking the client what he believes he needs to know about the diagnosis
2. Providing brochures both on current exercises and on nutrition guidelines
3. Encouraging the client to personally discuss his feelings about his health status
4. Having the client return-demonstrate self-measurement of his own blood pressure
Encouraging the client to personally discuss his feelings about his health status
20. The nurse is preparing to present a teaching session on skin protection for a group of older adults at a senior center. A principle that has been found to be most effective in teaching older adults is:
1. Moving the group along at a predetermined pace
2. Providing information in longer teaching sessions
3. Speaking very slowly and in a louder tone of voice
4. Beginning and ending each session with important information
Beginning and ending each session with important information
21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client diagnosed to be in the early stage of Alzheimer’s disease. The nurse best deals with the client’s cognitive deficits by:
1. Providing written material to supplement the discussion
2. Arranging for family to be present during the discussion
3. Presenting the material in two short but focused sessions
4. Requiring the client to restate the information in her own words
Arranging for family to be present during the discussion
22. The nurse recognizes that the client’s teaching plan is most directly driven by:
1. The client’s identified learning needs
2. The complexity of the client’s health needs
3. The client’s readiness and motivation to learn
4. The presence of cultural or physical barriers
The client’s identified learning needs
23. The nurse recognizes that the primary goal of a client’s teaching plan is to:
1. Facilitate a knowledge-based client decision-making process
2. Provide information that brings about informed client consent
3. Enhance the client’s sense of personal control regarding his or her health care
4. Therapeutically affect the client’s health, wellness, and independence
Therapeutically affect the client’s health, wellness, and independence
25. Which of the following teaching topics is an example of restoration of health?
1. Glucose monitoring at home
2. Living with rheumatoid arthritis
3. Stress management’s impact on depression
4. What to expect after hip replacement surgery
What to expect after hip replacement surgery
26. Which of the following actions is the primary nursing responsibility regarding client education?
1. Providing accurate, current, relevant information
2. Answering the client’s questions regarding health-related issues
3. Assessing the individual client’s readiness and motivation to learn
4. Identifying areas where clients are in need of educational information
Providing accurate, current, relevant information
27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for checking her blood glucose level four times a day, this is an example of:
1. Cognitive learning
2. Affective learning
3. Impaired learning
4. Psychomotor learning
Psychomotor learning
28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with the number of carbohydrates he is allowed for that meal, this is an example of:
1. Cognitive learning
2. Affective learning
3. Impaired learning
4. Psychomotor learning
Cognitive learning
29. Which of the following statement best reflects the nurse’s appropriate attention to a client’s need for self-efficacy?
1. “What can I do to help you lose the weight?”
2. “Are you really ready to start a regular exercise regimen?”
3. “After you watch me demonstrate this inhaler, you will have no problems using it at all.”
4. “Come on; with all the self-help products out there, you will be able to stop smoking.”
“After you watch me demonstrate this inhaler, you will have no problems using it at all.”
30. A client has been recently told that the primary cancer has metastasized, and the cancer is considered terminal. When the nurse offers to discuss palliative care options, the client replies, “I’m going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has been made.” The nurse recognizes this response as:
1. Anger
2. Disbelief
3. Bargaining
4. Acceptance
Disbelief
31. A client has been recently told that the primary cancer has metastasized and the cancer is considered terminal. When the nurse offers to discuss palliative care options the client replies, “I can’t understand why you all want to upset me by bringing the topic up. Now please just leave me alone.” The nurse recognizes this response as:
1. Anger
2. Disbelief
3. Bargaining
4. Acceptance
Anger
Which of the following is a current trend in families of family living?
1. People marrying earlier
2. Reduction in the divorce rate
3. People having more children
4. More people choosing to live alone
More people choosing to live alone
**Of the following trends, which one represents the greatest current health care challenge to nurses?
1. Homelessness
2. Single parent families
3. Alternative relationship patterns
4. “Sandwiched” or middle geration
Homelessness
When working with families, the nurse may view the family as context or client. Which one of the following examples demonstrates the view of the family as context?
1. The family’s ability to support the client’s dietary and recreational needs
2. The client’s ability to understand and manage his own personal dietary needs
3. The family’s demands on the client that are based on the client’s role performance
4. The adjustment of both the client and the family to changes in diet and exercise
The client’s ability to understand and manage his own personal dietary needs
**What would a nurse expect to find in an assessment of a healthy family?
1. Change is viewed as detrimental to the family
2. There is a passive response to most stressors
3. The structure is flexible enough to adapt to crises
4. Minimum influence is being exerted on the environment
The structure is flexible enough to adapt to crises
Initially, the nurse should begin by doing what in completing a client’s family assessment?
1. Collecting health data from all the family members
2. Testing the family’s ability to cope with normal stressors
3. Evaluating the family’s interpersonal communication patterns
4. Determining the client’s definition of familiar structure and attitudes
Determining the client’s definition of familiar structure and attitudes
**Post discharge, the client is returning to their home environment. In assisting the client with that, specifically in implementing family-centered care, the nurse:
1. Provides personal beliefs regarding problem-solving
2. Assists the family members to assume dependent roles
3. Works with the client to accept responsibility for role in discourse
4. Offers both client and family information about necessary self-care abilities
Offers both client and family information about necessary self-care abilities
**A client is unable to independently perform colostomy care due to arthritis. The nurse should first:
1. Offer to assist the client to learn to manage the care
2. Arrange for home care services to care for the colostomy
3. Inquire as to family members who may be able to assist with the care
4. Suggest that the client attend a colostomy self-help support group
Inquire as to family members who may be able to assist with the care
**The optimum goal of effective communication within the family, according to the nurse observing the family members and their interaction, is:
1. Problem solving and psychological support
2. Role development of individual members
3. Socialization among individual members
4. Better financial conditions for the family
Problem solving and psychological support
Which of the following is a gerontological principle related to families?
1. Later-life families need not work on developmental tasks.
2. The caregivers are often not members of the client’s family.
3. Role reversal is usually expected and well accepted by the older client.
4. Support systems are likely to be different than those of younger age-groups.
Support systems are likely to be different than those of younger age-groups.
**In assessing the roles and power structure of a client’s nuclear family, the nurse should specifically ask the client:
1. “Who decides where to go on vacation?”
2. “What type of health care insurance do you have?”
3. “How many family members currently live in your home?”
4. “What types of social activities do you and your family enjoy?”
“Who decides where to go on vacation?”
**Needing assistance with daily living activities, an older adult with two grown children is being discharged home. Although both children live nearby, the daughter is expressing concern about handling her parent’s physical needs. The nurse’s initial response is to:
1. Work with the family on delegating responsibility
2. Suggest short-term nursing home placement to the client
3. Arrange for the client to remain hospitalized in the medical center
4. Make decisions for the family on how to manage the care at home
Work with the family on delegating responsibility
The nurse suspects that there is physical abuse present after visiting the client in the home. In recognition of the pattern of family violence, the nurse knows that:
1. Child abuse is declining in frequency
2. Spouses are the most frequent abusers
3. Mental illness is a major cause of abuse
4. Abuse is primarily seen in lower income families
Spouses are the most frequent abusers
**The primary goal of family-centered nursing is to:
1. Promote the wellness of the family and its members
2. Implement appropriate care for the family and its members
3. Provide support and care for the family and its individual members
4. Identify physical and emotional problems affecting the family as a unit
Provide support and care for the family and its individual members
**A nurse who is sensitive to the care of families recognizes that the term “family” is primarily defined:
1. As individuals legally bound to the client
2. As people with biological connections to the client
3. In terms generally accepted by the majority of clients
4. By the client as individuals important to the client
By the client as individuals important to the client
The nurse is preparing a new mother for discharge when the woman shares that she is “worried about going back to work and its effects on my infant.” The most therapeutic response by the nurse is:
1. “Do you want to go back to work?”
2. “Just be sure you have an excellent baby sitter.”
3. “There is no proof that working will harm your baby.”
4. “Can your husband share in the child care reponsibilities?”
“There is no proof that working will harm your baby.”
The gratest risk to a child of adolescent parents comes from the:
1. Increased family stressors resulting in domestic violence
2. Lack of appropriate parenting resources and role models
3. Statically high potential for physical and emotional abuse
4. Parents inability to provide health care and economc support
Lack of appropriate parenting resources and role models
**Which of the following nursing statements has the greatest therapeutic value when counseling a “sandwich generation” client caring for a chronically ill parent?
1. “I can help you in finding assistance with the in-home care.”
2. “What is the most stressful aspect of caring for your parent?”
3. “I’m sure your children love having grandmother in the house.”
4. “What do you do for relaxation now that your mom lives with you?”
“What do you do for relaxation now that your mom lives with you?”
**The mother of a child receiving immunizations at a health clinic shares with the nurse that she and the child have not eaten today. Which of the following nursing interventions is best directed at impacting the immediate problem while being sensitive to the mother’s sense of self-worth?
1. Notifying family services of the problem
2. Taking both mother and child to the cafeteria
3. Informing the mother that she is eligible for food stamps
4. Providing her with contacts at the neighborhood food bank
Providing her with contacts at the neighborhood food bank
**The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest risk for:
1. Homelessness
2. School truancy
3. Family violence
4. Accident-related injuries
Family violence
**The most important impact that truthful, timely communication between the nurse and the family of a critically ill client has is on the family’s ability to:
1. Trust the nurse
2. Adjust to “bad news”
3. Be confident of the care the client is receiving
4. Make appropriate choices regarding client treatment
Trust the nurse
**When caring for a terminally ill client, the nurse must also assess the family, because the primary benefit will be:
1. Effective use of time and resources in the end-of-life care of the client
2. Appropriate attention to the cultrual beliefs and expectations of the family
3. Added information regarding the care needs and preferences of the client
4. The ability to respond effectively to the familly unit during the dying process
The ability to respond effectively to the familly unit during the dying process
When attempting to meet the needs of the family, the nurse recognizes the central concept of the theory of family developmental stages is that:
1. Over time all families progress through developmental stages
2. Needs differ as the family progresses through the various stages
3. While each family is unique, they all tend to progress through similar stages
4. The family will progress only when all the challenges of a particular stage are met
While each family is unique, they all tend to progress through similar stages
**The nurse can primarily affect the effectiveness of a family’s ability to cope with stress by encouraging:
1. Flexible roles
2. Distinct task assignment
3. Individual independence
4. Variable parenting models
Flexible roles

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