A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Quaternary prevention
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Quaternary prevention
A) “That’s fine. Exercise is bad for you anyway.”
B) “OK. I want you to walk 3 miles 4 times a week, and I’ll see you in 1 month.”
C) “I understand. Can you think of one reason why being more active would be helpful for you?”
D) “I’d like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day.”
A) “Walking is OK. I really think running is better.”
B) “Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?”
C) “Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables.”
D) “They probably aren’t walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good.”
A) Difficulty paying his bills
B) Seeing his pastor as a means of support
C) Family practice of not routinely seeing a health care provider
D) Stress from the divorce and the loss of a job
B) Safety and security
C) Love and belonging
B) Health belief
D) Health promotion
A) Health belief
B) Illness behavior
C) Health promotion
D) Illness prevention
A) Perceived threat of the disease
B) Likelihood of taking preventive health action
C) Analysis of perceived benefits of preventive action
D) Perceived susceptibility to the disease.
A) Care for the boy as she would any other patient
B) Ask the manager to talk with the father and keep him out of the unit
C) Have another nurse care for the boy because maybe that nurse will do better with the father
D) Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community
A) “I just don’t have any energy to get out of bed in the morning.”
B) “I’ve been attending church regularly with my wife since I got out of the hospital.”
C) “My wife has taken over paying the bills since I’ve been in the hospital.”
D) “I don’t go out very much because everyone stares at me.”
A) “I don’t have time to exercise because I have to work after school every night.”
B) “I’m worried about becoming overweight and getting diabetes because my father has diabetes.”
C) “The statistics of how many teenagers are overweight is scary.”
D) “I’ve decided to start a walking club at school for interested students.”
A) Sedentary lifestyle
B) Father died from CAD at age 50
C) History of hypertension
D) Eats diet high in sodium
E) Elevated cholesterol level
F) Age is 44 years
A) A home health care nurse visits a patient’s home to change a wound dressing.
B) A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked.
C) The school health nurse provides a program to the first-year students on healthy eating.
D) The patient attends cardiac rehabilitation sessions weekly.
A) She does not touch the patients either.
B) Touch is a type of verbal communication.
C) There is never a problem with using touch.
D) Touch forms a connection between nurse and patient.
A) Anticipating the patient’s cultural preferences
B) Determining the patient’s physician preference
C) Establishing an understanding of a specific patient
D) Gathering task-oriented information during assessment
A) Sharing feelings about the importance of having regular woman’s health examinations
B) Gaining an understanding of what a woman’s health examination means to the patient
C) Recognizing that the patient is modest; obtaining gendercongruent caregiver
D) Explaining the risk factors for cervical cancer
C) Doing for
D) Being with
A) “Spiritual care should be left to a professional.”
B) “You are correct, religion is a personal decision.”
C) “Nurses should not force their religious beliefs on patients.”
D) “Spiritual, mind, and body connections can affect health.”
A) Increasing the working hours of the staff
B) Increasing salary benefits of the staff
C) Creating a setting that allows flexibility and autonomy for staff
D) Encouraging increased input concerning nursing functions from physicians
A) Instilling hope and faith.
B) Forming a human-altruistic value system.
C) Cultural caring.
D) Being with.
A) Making health care decisions for patients.
B) Having family members provide a patient’s total personal hygiene.
C) Injecting the nurse’s perceptions about the level of care provided.
D) Asking permission before performing a procedure on a patient.
A) Become active participants in care.
B) Provide activities of daily living (ADLs).
C) Remove themselves from personal care.
D) Make health care decisions for the patient.
A) Incorporating the views of the physician.
B) Correcting any errors in the patient’s understanding.
C) Injecting the nurse’s personal views and statements.
D) Interpreting and understanding what the patient means.
A) The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room.
B) The nurse sits at the patient’s bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat.
C) The nurse listens to the patient’s story while sitting on the side of the bed and then summarizes the story.
D) The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.
A) Enables patients to care for self.
B) Provides personal care to a patient.
C) Conveys a closeness and a sense of caring.
D) Describes being in close contact with a patient.
A) Caring touch
B) Protective touch
C) Task-oriented touch
D) Interpersonal touch
A) Caring touch
B) Protective touch
C) Task-oriented touch
D) Interpersonal touch
A. Sustaining faith in one’s capacity to get through a situation
B. Striving to understand an event’s meaning for another person
C. Being emotionally there for another person
D. Providing for another as he or she would do for themselves.Knowing
A) Activate the fire alarm.
B) Confine the fire by closing all doors and windows.
C) Remove all patients in immediate danger.
D) Extinguish the fire by using the nearest fire extinguisher.
A) Give the child milk.
B) Give the child syrup of ipecac.
C) Call the poison control center.
D) Take the child to the emergency department.
A) Activity intolerance
B) Impaired bed mobility
C) Acute pain
D) Risk for falls
A) Home accidents
B) Physiological changes of aging
C) Poisoning and child abduction
D) Automobile accidents, suicide, and substance abuse
A) Insert a urinary catheter.
B) Leave a night light on in the bathroom.
C) Ask the physician to order a restraint.
D) Keep the bed in low position with upper and lower side rails up.
E) Assign a staff member to stay with the patient.
F) Provide scheduled toileting during the night shift.
G) Keep the pathway from the bed to the bathroom clear.
A) Contact the nursing supervisor.
B) Restrict the family’s visiting privileges.
C) Ask the family to stay with the patient.
D) Inform the family of the risks associated with side-rail use.
E) Thank the family for being conscientious and put the four rails up.
F) Discuss alternatives with the family that are appropriate for this patient.
___ 1. Explain what you plan to do.
___ 2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure.
___ 3. Determine that restraint alternatives fail to ensure patient’s safety.
___ 4. Identify the patient using proper identifier.
___ 5. Pad the patient’s wrist.
A) Begin cardiopulmonary respiration.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from injury.
A) A safe environment promotes patient activity.
B) Assessment focuses on environmental factors only.
C) Teaching home safety is difficult to do in the hospital setting.
D) Most accidents in the older adult are caused by lifestyle factors.
A) Place a bed alarm device on the bed.
B) Place the patient in a belt restraint.
C) Provide one-on-one observation of the patient.
D) Apply wrist restraints.
A) Smoking is prohibited around oxygen.
B) Demonstrate how to adjust the oxygen flow rate based on patient symptoms.
C) Do not use electrical equipment around oxygen.
D) Special precautions may be required when traveling with oxygen
A) Completing incident reports when appropriate
B) Completing incident reports for a near miss
C) Communicating product concerns to an immediate supervisor
D) Identifying the person responsible for an incident
A) Smokes a pack a day
B) Used a cane to walk at home
C) Takes antihypertensive and diuretics
D) History of recent fall
E) Neglect, spatial and perceptual abilities, impulsive
F) Requires assistance with activity, unsteady gait
G) IV line, urinary catheter
A) Prepare for an influx of patients
B) Contact the American Red Cross
C) Determine how to restore essential services
D) Evacuate patients per the disaster plan
A) Single parenthood.
B) Legal interventions.
C) Dual-income families.
D) Increased divorce rate.
B) Family function.
C) Family structure.
D) Economic stability.
A) Economic status
B) Chronic illness
D) Government-assisted day care
A) Nuclear family.
B) Blended family.
C) Extended family.
D) Alternative family
A) Family goals
B) Decision making
C) Methods of discipline
D) Impaired coping
A) Family meetings
B) Established family roles
C) Willingness to change in time of stress
D) Passive orientation to life
A) Resuming full-time work when spouse loses job
B) Arguing ways to deal with problems among siblings
C) Developing hobbies when children leave home
D) Placing blame on family members
A) Family members within a system.
B) Family process and relationships.
C) Family relational and transactional concepts.
D) Health needs of an individual member.
A) Family as context
B) Family as patient
C) Family as system
D) Family as structure
A) Cultural practices
B) Decision making
C) Rituals and celebrations
D) Neighborhood crime data
A) Diverse family relationship.
B) Blended family relationship.
C) Extended family relationship.
D) Alternative family relationship.
A) Health promotion activities
B) Acute care activities
C) Restorative care activities
D) Growth and development-care activities
A) Designing a nurturing family to raise children
B) Providing physical and emotional care for a family member
C) Establishing a safe physical environment for a family
D) Monitoring for side effects of illness and treatments
A) Logical reasoning.
C) Concrete thinking.
A) Slow to warm up.
A) A sense of guilt.
B) A poor sense of self.
C) Feelings of inferiority.
A) Trust versus mistrust
B) Initiative versus guilt
C) Industry versus inferiority
D) Autonomy versus sense of shame and doubt
A) Object permanence.
B) Sensorimotor play.
D) Magical thinking.
A) Allowing the child to watch another child undergoing the same procedure
B) Showing the child pictures of what he or she will experience
C) Talking to the child in simple terms about what will happen
D) Preparing the child through play with a doll and toy medical equipment
A) Conventional reasoning
B) Formal operations
C) Integrity versus despair
D) Postformal thought
A) Encouraging him to explore new roles.
B) Encouraging relocation to a new city.
C) Explaining the need to simplify life.
D) Encouraging him to adopt a new pet.
A) Using building blocks to determine how houses are constructed
B) Writing a story about a clown who wants to leave the circus
C) Drawing pictures of a family using stick figures
D) Writing an essay about patriotism
A) Imaginary audience.
B) False-belief syndrome.
C) Personal fable.
D) Personal absorption syndrome.
A) Imaginary audience.
B) False-belief syndrome.
C) Personal fable.
D) Sense of invulnerability
A) Cognitive development
B) Activity theory
C) Selective optimization with compensation
D) Formal operations
A) He is in one of the later developmental periods, concerned with reviewing his life.
B) He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives.
C) He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships.
D) It is difficult to determine Dave’s developmental stage since most people report overall satisfaction with their lives in all stages
A) Instrumental relativist orientation
B) Social contract orientation
C) Society-maintaining orientation
D) Universal ethical principle orientation
A) Nutrition, stress, and mother’s age.
B) Prematurity, stress, and mother’s age.
C) Nutrition, mother’s age, and fetal infections.
D) Fetal infections, prematurity, and placenta previa.
A) “I can start giving her whole milk at about 12 months.”
B) “I can continue to breastfeed for another 6 months.”
C) “I’ve started giving her plenty of fruit juice as a way to increase her vitamin intake.”
D) “I can start giving her solid food now.”
A) Provision of adult supervision.
B) Educational level of the parent
C) Physical health of the child
D) Developmental level of the child
A) Always give several choices.
B) Set few limits to allow for open expression.
C) Use noninvasive methods when possible.
D) Gain cooperation before attempting treatment.
A) “I won’t use a pacifier to help my baby sleep.”
B) “I’ll be sure my baby does not spend any time on her abdomen.”
C) “I’ll place my baby on her back for sleep.”
D) “I’ll be sure to keep my baby’s room cold.”
A) Roll from abdomen to back
B) Move from prone to sitting unassisted
C) Sit upright without support
D) Turn completely over
A) Provide more attention.
B) Reduce opportunities for a “no” answer.
C) Be consistent with punishment.
D) Provide opportunities for the toddler to make decisions.
A) Be alert to clues to their emotional state.
B) Ask closed-ended questions to get straight answers.
C) Avoid looking for meaning behind adolescents’ words or actions.
D) Avoid discussing sensitive issues such sex and drugs.
A) Boys and girls play equally with each other.
B) Peer influence is not yet an important factor to the child.
C) They like to play games with rigid rules.
D) Children frequently have “best friends.”
A) Indicative of extreme stress
B) Representative of his cognitive development
C) Suggestive of excessive discipline at home
D) Indicative of his developing sense of inferiority
A) Provide nutritious snacks.
B) Offer rewards for eating at mealtimes.
C) Avoid snacks so she is hungry at mealtime.
D) Explain to her firmly why eating at mealtime is important.
A) Explain hospital routines such as meal times to her.
B) Use terms such as “honey” and “dear” to show a caring attitude.
C) Explain when her parents can visit and why siblings cannot come to see her.
D) Since she is young, orient her parents to her room and hospital facility.
A) Concentrate on the child only rather than the family since it is the child’s responsibility.
B) Consider the use of medications to suppress the appetite.
C) First plan for weight loss through dieting and then add activity as tolerated.
D) Plan food intake to allow for growth
A) Contact her parents to alert them of her need for birth control.
B) Refer her to a primary health care provider to obtain a prescription for birth control.
C) Counsel her on safe sex practices.
D) Ask her to have her partner come to the clinic for STI testing.
A) She has just broken up with her boyfriend and time will heal all.
B) You will need to observe her over time to see if symptoms persist.
C) School may be too difficult for her right now.
D) She may be at increased risk for suicide.
A) Instructing him to return in 2 years.
B) Instructing him in secondary prevention.
C) Instructing him in health promotion activities.
D) Implementing primary prevention with vaccines
D) Family history
D) Lay doula
C) Substitute parents.
D) Alternative family structure.
C) Family history.
D) Personal hygiene habits.
C) Health education
D) Stress management techniques.
A) Outpatient referral.
B) Counseling technique.
C) Health promotion activity.
D) Stress-management technique.
A) Cardiovascular disease
C) Sexually transmitted infection
D) Iron deficiency anemia
A) The sandwich generation.
B) The millennial generation.
C) Generation X.
D) Generation Y.
A) Alcohol abuse
D) Drug use
D) Herpes zoster
A) Routine screening and diagnostic tests
B) Unprotected sexual activity
C) Regular exercise
D) Excess alcohol consumption
A) The medical course of the illness
B) The prognosis for the patient
C) Coping mechanisms of the patient and family
D) The need for community and social services
A) The woman works in an executive position that is very demanding.
B) The woman works out at the corporate gym at 5 am two mornings per week
C) The woman says that she has little time to prepare meals at home and eats out at least four nights a week.
D) The woman says that she tries to eat “low cholesterol” foods to help lose weight.
A) Tell the student that temporary confusion is normal and simply requires reorientation
B) Tell the student to increase the patient’s fluid intake since the urine is concentrated
C) Tell the student that her assessment findings are normal for an older adult
D) Tell the student that he will notify the physician of the findings
A) The center should be clean, and rooms should look like a hospital room.
B) There should be adequate staffing on all shifts.
C) Social activities should be available for all residents.
D) Three meals should be served daily with a set menu and serving schedule.
E) Family involvement in care planning and assisting with physical care is necessary.
A) When the sexual partner passes away, the survivor no longer feels sexual.
B) A decrease in an older adult’s libido occurs.
C) Any outward expression of sexuality suggests that the older adult is having a developmental problem.
D) All older adults, whether healthy or frail, need to express sexual feelings.
A) The need to touch and be touched is decreased.
B) The sexual preferences of older adults are not as diverse.
C) Physical changes usually do not affect sexual functioning.
D) Frequency and opportunities for sexual activity may decline.
A) Speak loudly so the patient can hear you.
B) Sit facing the patient so he is able to watch your lip movements and facial expressions.
C) Present one idea or concept at a time.
D) Send a written copy of the instructions home with him and tell him to have the family review them.
E) Include the family caregiver in the teaching session
A) Spicy and bland foods.
B) Salty, sour, and bitter tastes.
C) Hot and cold food temperatures.
D) Moist and dry food preparations.
A) Decreased bone density in the vertebrae and hips.
B) Increased risk for pathological stress fractures in the hips.
C) Changes in the configuration of the spine that affect the lungs and thorax.
D) Calcification of the bony tissues of the long bones such as in the legs and arm
A) The loss of his work role
B) The risk of social isolation
C) A determination if the wife will need to start working
D) How the wife expects household tasks to be divided in the home in retirement
E) The age the patient chose to retire
A) Taking two medications for hypertension
B) Taking a total of eight different medications during the day.
C) Having one physician who reviews all medications
D) Patient’s health history
E) Involvement of the caregiver in assisting with medication administration
B) Liver failure.
B) Validation therapy
C) Reality orientation
D) Body image interventions
A) Presence of a chronic disease
B) Impaired vision
C) Residence design
D) Blood pressure
E) Leg weakness
F) Exercise history
A) Rebound hypertension
B) Orthostatic hypotension
C) Dysfunctional proprioception.
D) Central nervous system rebound hypotension
A) Call for assistance.
B) Allow patient to sit down.
C) Take patient’s blood pressure and pulse.
D) Continue to ambulate patient to build endurance.
E) If patient begins to faint, allow him to slide against the nurse’s leg to the floor.
A) Giving a patient information on exercise
B) Providing information to the patient when the patient is ready to change behavior
C) Explaining the importance of exercise when a patient is diagnosed with a chronic disease such as diabetes
D) Following up with instructions after the health care provider tells a patient to begin an exercise program
A) Keep the knees in a locked position.
B) Bend at the waist to maintain a center of gravity.
C) Maintain a wide base of support.
D) Hold objects away from the body for improved leverage.
B) Older adults
D) Young children
A) An increase in obesity
B) An increase in heart disease
C) Higher computer literacy
D) Improved school attendance and grades
A) “As long as we use proper body mechanics, no one will get hurt.”
B) “The patient only weighs 125 lb. You don’t need my assistance.”
C) “Call the lift-team for additional assistance.”
D) “The two of us can easily lift the patient.”
A) Use a transfer board.
B) Obtain a stand assist device.
C) Implement a three-person carry.
D) Use the ceiling-mounted lift.
A) A modified two-point gait. The affected leg is advanced between the crutches to the stairs.
B) A modified three-point gait. The unaffected leg is advanced between the crutches to the stairs.
C) A swing-through gait.
D) A modified four-point gait. Both legs advance between the crutches to the stairs.
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
A) Disturbed thought processes
B) Impaired skin integrity
C) Disturbed body image
D) Risk for activity intolerance
A) Notify nurse if patient reports pain before, during, or after exercise.
B) Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise.
C) Notify nurse of vital sign values.
D) Evaluate the patient’s ability to use crutches properly.
E) Prepare the patient for exercise by assisting in dressing and putting on shoes.
A) For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is divided between the cane and the stronger leg.
B) A person’s cane length is equal to the distance between the elbow and the floor.
C) Canes provide less support than a walker and are less stable.
D) The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.
A) Pulmonary rehabilitation provides a safe environment for monitoring your progress.
B) You have to participate or you will be back in the hospital.
C) Tell me more about your concerns with going to pulmonary rehabilitation.
D) The staff at our pulmonary rehabilitation facility are professionals and will not cause you any harm.
A) B/P = 128/84
B) Respirations 26 per minute on room air
C) HR 114
D) Crackles heard on auscultation
E) Pain reported as 3 on scale of 0 to 10 after medication
A) Call the health care provider to report this change in condition.
B) Give the patient a paper bag to breathe into to decrease her anxiety.
C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
D) Explain that this is normal after such trauma and administer the ordered pain medication.
A) Prevent varicose veins.
B) Prevent muscular atrophy.
C) Ensure joint mobility and prevent contractures.
D) Promote venous return to the heart.
A) “I usually go swimming with my family at the YMCA 3 times a week.”
B) “I need to ask my doctor if I should have a bone mineral density check this year.”
C) “If I don’t drink milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet.”
D) “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. “
A) 1-year-old child with a hernia repair.
B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
C) 51-year-old woman following a thyroidectomy.
D) 38-year-old woman undergoing a hysterectomy.
A) Chronic pain
B) Impaired skin integrity
C) Risk for ineffective cerebral tissue perfusion
D) Risk for activity intolerance
A) Pale yellow urine
B) Unilateral neglect
C) Slight movement noted on the R side
D) Coffee ground-like aspirate from the feeding tube
A) The rubber mat in the walk-in shower
B) The three-legged stool on wheels in the kitchen
C) The braided throw rugs in the entry hallway and between the bedroom and bathroom
D) The night-lights in the hallways, bedroom, and bathroom
E) The cordless phone next to the patient’s bed
A) Cream of broccoli soup with whole wheat crackers and tapioca for dessert
B) Hamburger on soft roll with a side salad and an apple for dessert
C) Low-fat turkey chili with sour cream and fresh pears for dessert
D) Chicken salad on toast with tomato and lettuce and honey bun for dessert
A) Patient’s weight
B) Patient’s level of cooperation
C) Patient’s ability to assist
D) Presence of medical equipment
E) 24-hour calorie intake
A) The adductors muscles are weakened as a result of immobility.
B) The muscle fibers become shortened because of disuse.
C) The calcium-to-phosphorus ratio becomes disrupted.
D) There is a deficiency in vitamin D.
A) Repositioning patient every 1 to 2 hours while awake
B) Using an objective, valid scale to assess patient’s risk for pressure ulcer development
C) Using a device to relieve pressure when patient is seated in chair
D) Teaching patient how to shift weight at regular intervals while sitting in a chair
E) A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
A) The patient is 5 feet 6 inches and weighs 120 lbs.
B) The patient speaks and understands English.
C) The patient received an injection of morphine 30 minutes ago for pain.
D) You feel comfortable handling a patient of his size and with his level of cooperation
A) “Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you.”
B) “Would you like me to walk on your right side so you feel more secure?”
C) “Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side.”
D) “By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.
A) Maintain serum level of calcium.
B) Maintain independence with activities of daily living (ADLs).
C) Reduce supplemental sources of vitamin D.
D) Reverse bone loss through dietary manipulation.
A) Finish the bath quickly
B) Help the patient return to bed
C) Leave the patient alone to rest in the chair at the sink for a few minutes
D) Instruct the patient to take deep breaths and try to relax
A) Allow the patient to perform as much of the care as possible.
B) Start by washing the face.
C) Try an alternative to traditional bathing such as the “bag bath.”
D) Use restraints to prevent the patient from injuring self or the nurse.
A) Thoroughly brushing all tooth and oral surfaces
B) Preventing aspiration
C) Controlling mouth odor
D) Applying local antiseptic such as chlorhexidine
A) Finding a female nurse to help the patient
B) Convincing the patient that he will work quickly and provide as much privacy as possible
C) Skipping hygiene care for the day except for the parts that the patient can complete independently
D) Asking the patient if she prefers a family member assist with the care
A) Explain to the patient that, because of her symptoms, you need to observe the perineal area.
B) Insist that you are supposed to complete the care.
C) Honor the patient’s request to complete her own perineal care to avoid any embarrassment.
D) Ask the patient if a family member can complete the care instead.
A) Remove dentures overnight once a week while they soak in a cleansing bath.
B) Do not wear damaged or poorly fitting dentures.
C) Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth.
D) See dentist regularly.
E) Rinse dentures after meals.
F) Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.
A) Decreasing frequency of oral hygiene
B) Applying water-soluble moisturizing gel on the oral mucosa
C) Encouraging intake of soft foods
D) Using commercial mouthwash
A) A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10
B) A patient who prefers a bath in the evening when his wife visits and can help him
C) A patient who is experiencing frequent incontinent diarrheal stools
D) A patient who has just returned from diagnostic testing and complains of being very fatigued
B) Reverse Trendelenburg’s.
A) Used clean gloves.
B) Did not retract the foreskin before cleansing.
C) Used the clean portion of washcloth for each cleansing wipe.
D) Used a circular motion to cleanse from urinary meatus outward.
A) Decrease the chance of infection.
B) Help remove dry, flaky skin.
C) Prevent skin trauma.
D) Stimulate venous return.
A) Checking frequently for soiling
B) Washing the perineal area with strong soap and water
C) Placing the call light within easy reach
D) Keeping a pad under the patient
A) Avoid cleaning the feet until an order from the health care provider is received.
B) Wash the feet with lukewarm water and then dry well.
C) Apply moisturizing lotion to the feet, especially between the toes.
D) File the toenails straight across.
A) Bathe twice a week.
B) Rinse well after using soap.
C) Use hot water for bathing.
D) Drink plenty of fluids.
A) Room temperature is overly warm.
B) Room door is open to the hallway.
C) Television volume is too loud.
D) Strong odor of urine is detected.
A) I need to stop eating red meat.
B) I will increase the servings of fruit juice to four a day.
C) I will make sure that I eat a balanced diet and exercise regularly.
D) I will not eat so many dark green vegetables and eat more yellow vegetables.
A) Sit the patient upright in a chair.
B) Give liquids at the end of the meal.
C) Place food in the strong side of the mouth.
D) Provide thin foods to make it easier to swallow.
E) Feed the patient slowly, allowing time to chew and swallow.
F) Encourage patient to lie down to rest for 30 minutes after eating.
A) Raise head of bed to 90 degrees
B) Turn patient to left lateral decubitus position
C) Notify health care provider immediately
D) Have patient perform the Valsalva maneuver
A) Placing an order for x-ray film examination to check position
B) Confirming the distal mark on the feeding tube after taping
C) Testing the pH of the gastric contents and observing the color
D) Auscultating over the gastric area as air is injected into the tube
D) Helicobacter pylori
A) Gastric pH of 4.0 during placement check
B) Weight gain of 1 pound over the course of a week
C) Active bowel sounds in the four abdominal quadrants
D) Gastric residual aspirate of 350 mL for the second consecutive time
A) A 55-year-old obese man recently diagnosed with diabetes mellitus
B) A recently widowed 76-year-old woman recovering from a mild stroke
C) A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery
D) A 46-year-old man recovering at home following coronary artery bypass surgery
A) I’ll continue to use formula for the baby until he is a least a year old.
B) I’ll make sure that I purchase iron-fortified formula.
C) I’ll start feeding the baby cereal at 4 months.
D) I’m going to alternate formula with whole milk starting next month
A) Avoid grapefruit and grapefruit juice, which impair drug absorption.
B) Increase the amount of carbohydrates for energy.
C) Take a multivitamin that includes vitamin D for bone health.
D) Cheese and eggs are good sources of protein.
E) Limit fluids to decrease the risk of edema.
A) Fastens the tube to the gown with tape.
B) Places the patient supine while giving a bath.
C) Performs oral care for the patient.
D) Elevates the head of the bed 45 degrees.
A) TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range.
B) The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely.
C) Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN.
D) Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention.
A) Affective domain
B) Cognitive domain
C) Attentional domain
D) Psychomotor domain
A) When there are visitors in the room
B) When the patient’s pain medications are working
C) Just before lunch, when the patient is most awake and alert
D) When the patient is talking about current stressors in his or her life
A) Teach the patient’s spouse
B) Focus on knowledge the patient will need in a few weeks
C) Provide only the information that the patient needs to go home
D) Convince the patient that learning about her health is necessary
A) Provide information using a lecture
B) Use simple words to promote understanding
C) Develop topics for discussion that require problem solving
D) Complete an extensive literature search focusing on eating disorders
A) The patient will verbalize the steps involved in breast self-examination within 1 week.
B) The nurse will explain the importance of performing breast self-examination once a month.
C) The patient will perform breast self-examination correctly on herself before the end of the teaching session.
D) The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society.
A) Telling approach
B) Selling approach
C) Entrusting approach
D) Participating approach
A) Role play
C) An analogy
D) A demonstration
A) Speaks loudly.
B) Presents the information once.
C) Expects the patient to understand the information quickly.
D) Allows the patient time to express himself or herself and ask questions.
A) Describing difficulties a family member has had in taking insulin
B) Expressing the importance of learning the skill correctly
C) Being able to see and understand the markings on the syringe
D) Having the dexterity needed to prepare and inject the medication
C) Group instruction
D) One-on-one discussion
A) How to use an inhaler during an asthma attack
B) The need to avoid people who smoke to prevent asthma attacks
C) Where to purchase a medical alert bracelet that says she has asthma
D) The importance of maintaining a healthy diet and exercising regularly
B) Restoring health
C) Coping with impaired function
D) Health promotion and illness prevention
A) A teaching plan.
B) A learning objective.
C) Reinforcement of content.
D) Enhancing the children’s self-efficacy.
A) Avoid rushing when charting an entry.
B) Use correction fluid to remove the entry.
C) Draw a single line through the statement and initial it.
D) Enter only objective and factual information about the patient.
A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report.
B) Gives a newly ordered medication before entering the order in the patient’s medical record.
C) Reads the orders back to the health care provider after receiving them and verifies their accuracy.
D) Asks the preceptor to listen in on the phone conversation.
A) The patient has a defiant attitude and is demanding his test results.
B) The patient appears to be upset with his nurse because he wants his test results immediately.
C) The patient is demanding and complains frequently about his doctor.
D) The patient stated that he felt frustrated by the lack of information he received regarding his tests
A) HIPAA allows all hospital staff access to your medical record.
B) HIPAA limits the information that is documented in your medical record.
C) HIPAA provides you with greater control over your personal health care information.
D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
A) State that only her family may read the record.
B) Indicate that she has the right to read her record.
C) Tell her that she is not allowed to read her record.
D) Explain that only health care workers have access to her record.
A) Patient walked up and down hallway with assistance, tolerated well.
B) Patient up, out of bed, walked down hallway and back to room, tolerated well.
C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.
D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.
B. “The pain increases every time I try to turn on my left side.”
C. Acute pain related to tissue injury from surgical incision.
D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.S
A) Information technology.
B) Electronic health record.
C) Personal health information.
D) Administrative information system.
A) The patient’s name, age, and admitting diagnosis
B) Allergies to food and medications
C) Your evaluation that the patient is “needy”
D) How much the patient ate for breakfast
E) That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
A) Documented medication given by another nursing student.
B) Included the date and time of all entries in the chart.
C) Stood with his back against the wall while documenting on the computer.
D) Signed all documentation electronically.
A) “CPOE reduces transcription errors.”
B) “CPOE reduces the time necessary for health care providers to write orders.”
C) “Health care providers can write orders from any computer that has Internet access.”
D) “CPOE reduces the time nurses use to communicate with health care providers.”
A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged.
B) You need to use words the patients can understand when writing the directions.
C) The form needs to be given to patients in a sealed envelope to protect their health information.
D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
A) Electronic health record
B) Clinical documentation
C) Clinical decision support system
D) Computerized physician order entry
A) The nurses forgot to document on the pulmonary system.
B) The nurses were charting by exception.
C) The computer is not working correctly.
D) The physician does not have authorization to view the nursing assessment.
A) Rip several times and place in a standard trash can
B) Place in the patient’s paper-based chart
C) Place in a secure canister marked for shredding
D) Burn the documents
A) Temperature: 37°C (98.6°F)
B) Radial pulse: 112
C) Respiratory rate: 24
D) Oxygen saturation: 96%
E) Blood pressure: 134/78
A) 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
B) 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72
C) 63-year-old man with venous ulcers from diabetes, temperature 37.3°C (99.1°F), HR 84
D) 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
A) Heart rate
B) Presence of diaphoresis
C) Smoking history
D) Respiratory rate
E) Recent bowel movement
F) Blood pressure in right arm
G) Patient’s normal temperature
H) Blood pressure in distal extremity
A) Right antecubital and tympanic membrane
B) Right popliteal and right axillae
C) Left antecubital and oral
D) Left popliteal and temporal artery
A) Activity order
B) Medication list
C) Baseline vital signs
D) Patient’s perception of dyspnea
A) Dietary habits
B) Medication list
C) Exercise regimen
D) Age, weight, and height
A) 96/40 mm Hg
B) 110/66 mm Hg
C) 130/70 mm Hg
D) 156/82 mm Hg
A) Nail polish attracts microorganisms and contaminates the finger sensor.
B) Nail polish increases oxygen saturation.
C) Nail polish interferes with sensor function.
D) Nail polish creates excessive heat in sensor probe.
A) Usual range of circadian rhythm measurements
B) Sustained fever pattern
C) Intermittent fever pattern
D) Resolving fever pattern
A) Request that the nursing assistant repeat the pulse check
B) Call for a stat electrocardiogram (ECG)
C) Assess the patient’s apical pulse and evidence of a pulse deficit
D) Prepare to administer cardiac-stimulating medications
A) A healthy professional tennis player
B) A patient admitted with hypothermia
C) A patient with a fever of 39.4°C (103°F)
D) A 90-year-old male taking beta blockers
A) Patient just admitted with four rib fractures
B) Woman who is 9 months’ pregnant
C) Adult who has consumed alcoholic beverages
D) Adolescent awaking from sleep
A) 120/80, 118/78, 124/82
B) 128/84, 124/86, 128/88
C) 148/82, 148/78, 134/86
D) 154/78, 118/76, 126/84
A) Right arm BP: 120/80
B) Radial pulse rate: 72 and irregular
C) Temporal temperature: 37.4°C (99.3°F)
D) Respiratory rate: 28
E) Oxygen saturation: 99%
A) Assess the patient’s apical pulse to obtain the heart rate.
B) Obtain the heart rate from right and left radial sites.
C) Obtain the heart rate using the oximeter probe.
D) Perform a complete assessment of all pulses.
A) Appearance and behavior
B) Measurement of vital signs
C) Observing specific body systems
D) Conducting a detailed health history
A) Place the palm of the hand on the child’s back.
B) Lightly touch the child’s forehead with the fingertips.
C) Place the back of your hand against the child’s forehead and then on the back of the neck.
D) Use the pads of your fingers and press against the child’s neck and over the thorax.
A) Respiratory rate: 14
B) Pain reported when palpating posterior lower thorax
C) Thorax rising and falling symmetrically for right and left lungs
D) Vesicular breath sounds heard with auscultation of peripheral lung fields
A) Avoid sunbathing between 3 PM and 7 PM.
B) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
C) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown.
D) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor
A) Applying adhesive tape to anchor a nasogastric tube
B) Inserting a rubber Foley catheter into the patient’s bladder
C) Providing oral hygiene using a standard toothbrush and toothpaste
D) Giving an injection using plastic syringes with rubbercoated plungers
E) Applying a transparent wound dressing
A) Palpation of a femoral pulse with a heart rate of 76
B) Auscultation of a heart murmur over the left thorax
C) Identification of mild bruising at the catheter insertion site
D) Palpation of a right dorsalis pedis pulse with strength of +1
A) Buccal mucosa is moist and dark pink.
B) Respiratory rate is 18, rhythm is even.
C) Retropharyngeal lymph nodes are enlarged and firm.
D) Inspection with a tongue depressor on the posterior tongue causes gagging.
A) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
B) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee
C) When there is poor arterial blood flow, the leg is generally warm to the touch.
D) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
A) Supine with both arms overhead with palms upward
B) Sitting with hands clasped just above the umbilicus
C) Supine with the right arm abducted and hand under the head and neck
D) Lying on the right side, adducting the right arm on the side of the body
A) The aorta can be felt using deep palpation in the upper abdomen near the midline.
B) The patient should be sitting to best determine the contour and shape of the abdomen.
C) Always wear gloves when palpating the skin on the patient’s abdomen.
D) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.
A) “The testes are normally round and feel smooth and rubbery.”
B) “The best time to do a testicular self-examination is before your bath or shower.”
C) “Perform a testicular self-examination weekly to detect signs of testicular cancer.”
D) “Since you are over 40 years old, you are in the highest risk group for testicular cancer.”
A) Patient was not able to flex arm at shoulder.
B) Extension of right arm is limited.
C) Patient’s abduction of right arm was limited to 100 degrees.
D) Internal rotation of right arm is limited to less than 90 degrees.
A) “Tell me where you are.”
B) “What can you tell me about your illness?”
C) “Repeat these numbers back to me: 7…5…8.”
D) “What does this mean: ‘A stitch in time saves nine? ‘ “
A) VII — Facial
B) V — Trigeminal
C) XII — Hypoglossal
D) XI— Spinal accessory
A) Inspect the lips and mucous membranes to determine if they are moist.
B) Pinch the skin on the back of the hand to see if the skin tents.
C) Check the patient’s pulse and blood pressure.
D) Weigh the patient daily.
A) “What’s the special occasion?”
B) “You must be feeling better today.”
C) “This is the first time I have seen you look this good.”
D) “I see that you’ve combed your hair and put on makeup.”
A) Promote active socialization with other patients
B) Role play to increase assertiveness skills
C) Focus on identifying strengths and accomplishments
D) Encourage journaling of underlying feelings
A) Asking questions is attention-seeking behavior.
B) Inability to make decisions reflects a self-concept issue.
C) Dependence on staff must be stopped immediately.
D) Indecisiveness is aimed at testing how the staff reacts.
A) Remain with the patient until he or she stops crying.
B) Tell the patient that is not true and that every person has a purpose in life.
C) Review recent behaviors or accomplishments that demonstrate skill ability.
D) Reassure the patient that you know how he is feeling and that things will get better.
A) Patients need support in dealing with the loss of a body part.
B) The patient’s family should take the lead role in providing support.
C) The nurse should explain that breast tissue is not essential to life.
D) The patient should focus on the cure of the cancer rather than loss of the breast.
A) Attitude and behaviors of relatives providing care
B) Caring behaviors of the nurse and health care team
C) Level of education, economic status, and living conditions
D) Adjustment to role change, loss of loved ones, and physical energy
A) Offer independent decision-making opportunities
B) Review previously successful coping strategies
C) Provide a quiet environment with minimal stimuli
D) Support a dependent role throughout treatment
The nurse is assessing the patient’s:
C) Body image.
D) Role performance.
A) Helping the patient define her problems clearly
B) Allowing the patient to openly explore thoughts and feelings
C) Reframing the patient’s thoughts and feelings in a more positive way
D) Have family members assume more responsibility during times of stress
A) Form a sense of identity.
B) Create intimate relationships.
C) Separate from parents and live independently.
D) Achieve positive self-esteem through experimentation.
A) Acute confusion.
B) Disturbed body image.
C) Chronic low self-esteem.
D) Situational low self-esteem.
A) Assurance of sexual intimacy.
B) Preservation of self-esteem.
C) Expanded socialization.
D) Increase in monthly income.
A) Intimacy versus Isolation.
B) Autonomy versus Shame and Doubt.
C) Generativity versus Self-Absorption.
D) Ego Integrity versus Despair.
A) Self-care deficit, toileting
B) Deficient knowledge regarding resources for the visually impaired
C) Disturbed body image
D) Risk for situational low self-esteem
A) Increase his self-esteem with mastery of a new skill.
B) Accept changes in his appearance and physical endurance.
C) Experience success in role transitions and increased responsibilities.
D) Appreciate his body appearance and function
A) “A vaccine is available to reduce infection from certain types of human papillomavirus.”
B) “I should be screened for an STI after I am with a new partner.”
C) “I know I’ m not infected if I don’t have any symptoms such as discharge or sores.”
D) “A viral infection such as herpes or human papillomavirus cannot be treated with antibiotics.”
A) Refer the patient to a sexual counselor
B) Tell the patient about the safe house for women
C) Ask the patient to describe how she got the bruises
D) Report the abuse immediately to the proper authorities
A) Should be tested for human immunodeficiency virus (HIV).
B) May have a sexually transmitted infection (STI) such as chlamydia.
C) Is experiencing normal signs of pregnancy.
D) Needs education on proper perineal hygiene.
A) Clarifying personal values related to sexuality
B) Role playing discussion of sexual concerns with another nurse
C) Attending a conference to enhance knowledge about sexuality
D) Avoiding a discussion of sexual concerns until after completing new nurse orientation
A) Older adults are usually not part of a sexual minority group.
B) Older adults sometimes do not reveal intimate details.
C) Older men and women lose their interest in sex.
D) Older adults in nursing homes do not usually participate in sexual activity.
A) Expectations about behavior by men or women in the culture.
B) Higher percentages of lesbian, gay, bisexual, or transgender individuals in the culture.
C) Genetic predisposition to the disease in the culture
D) Communication patterns and language practiced by the culture.
A) Encourage regular screenings in all sexually active individuals.
B) Provide information about contraception options.
C) Administer prescribed antibiotics for human papillomavirus (HPV) or genital herpes outbreaks.
D) Ask all patients if they are experiencing any symptoms.
A) How often he or she has sexual intercourse.
B) To disrobe in preparation for the physical assessment.
C) For permission to discuss sexual issues.
D) For specific examples of sexual practices and problems.
A) Condoms or diaphragms must be used with each sexual encounter.
B) Hormonal methods offer little protection against sexually transmitted infections (STIs).
C) Barrier methods offer some protection against STIs.
D) Sterilization is an effective option that she should consider.
A) Genital discharge and dyspareunia.
B) Painful menstrual cycles.
C) Infertility and pelvic inflammatory disease.
D) Genital warts.
A) “I can use any kind of lubricant such as lotions or baby oil.”
B) “Before using the condom, I should check the package for damage or expiration.”
C) “I need to use a condom to help reduce the risk of sexually transmitted infections.”
D) “A good place to store condoms is in the bathroom so they don’t dry out.”
A) How do you and your wife/husband feel about intimacy?
B) Do you have sex with men, women, or both?
C) Are you heterosexual or homosexual?
D) What is your sexual orientation?
A) A personal issue such as this is best addressed by the male physician during the examination.
B) Erectile dysfunction affects most men over the age of 50.
C) The patient needs to be screened for sexually transmitted infections (STIs).
D) Antidepressant medication may be affecting his sexual functioning.
A) It’s normal for me to take longer to reach an orgasm.
B) I might experience chest pain or shortness of breath during intercourse.
C) It’s normal for me to lose interest in sexual relationships.
D) I won’t need to be concerned about contraception or sexually transmitted infections because of my age.
A) Prevent you from being involved in contact sports.
B) Only create health problems if they are located in the nipples or genital area.
C) Increase your risk for infection at the site and in the body.
D) Be a safe and important way of establishing your personality.
D) Instilling hope.
This patient most likely is an:
B) Life satisfaction.
C) Fellowship and community.
D) Connectedness with his family and co-workers.
A) “I planted a tree at church in my husband’s honor.”
B) “I have been unable to talk with my children lately.”
C) “My friends think that I need to go to a grief support group.”
D) “I believe that someday I’ll meet my husband in heaven.”
A) Praying with the patient
B) Giving pain medications before a painful procedure
C) Telling a patient that it is time to take a bath before family arrive to visit
D) Making the patient’s bed following hospital protocol
E) Helping a patient see positive aspects related to a chronic illness
A) Answer the patient’s questions
B) Help the patient get into a comfortable position
C) Select a teaching environment that is free from distractions
D) Encourage the patient to meditate for 10 to 20 minutes 2 times a day
A) Teaching the patient how to use guided imagery
B) Encouraging the family to visit the patient frequently
C) Taking the patient’s vital signs every time the nurse visits
D) Teaching the patient how to manage pain and take pain medications
E) Helping the patient put significant photographs in a scrapbook for the family
A) What gives your life meaning?
B) Which aspects of your spirituality would you like to discuss right now?
C) Who do you consider to be the most important person in your life at this time?
D) How do you feel about the accomplishments you’ve made in your life so far?
A) Which church do you attend?
B) Which sports do you like to play?
C) Are there any foods you cannot eat?
D) In which church activities do you participate?
A) Apple sauce
B) Cheese and crackers
C) Spaghetti with meat sauce
D) Tossed salad with ranch dressing
A) The patients may not be on time for their appointments.
B) The patients most likely do not trust the doctors and nurses.
C) The patients probably are not comfortable if they have to remove their undergarments.
D) Terminally ill patients probably want to receive the sacrament, the anointing of the sick.
A) “I have nothing to live for now.”
B) “What will happen to my wife when I die?”
C) “How much longer do I have to live?”
D) “I need to go to church and pray for a miracle.”
A) Encourage the patient to meditate 2 to 3 times a week.
B) The patient will set up a time to speak to a close friend in 1 week.
C) Encourage the patient to phone his brother and set up a time to go out for dinner.
D) The patient will experience greater connections with family members in 2 months.
A) Specially educated personnel make requests.
B) Requests are usually made by the nurse caring for the patient at the time of death.
C) Only patients who have given prior instruction regarding donation become donors.
D) Professionals need to be very selective in whom they ask for organ and tissue donation.
C) Spiritual distress
D) Complicated grieving
A) Encourage the family member to think more positively about the patient’s new therapy
B) Avoid the discussion because it has to do with medical, not nursing, diagnoses
C) Initiate a discussion about advance directives with the patient, family, and health care team
D) Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present
A) Practice honesty with everyone, telling patients about their illness, even if the news is not good.
B) Ask family members if they prefer to help with the care of the body after death.
C) Provide postmortem care at the time of death to relieve family members of this difficult job.
D) Value patient self-determination, understanding that each person makes his or her own decisions.
A) Younger patients are usually less talkative about their diagnosis.
B) All patients benefit by talking about their feelings with another person.
C) Avoid discussing illness-related topics with quiet patients.
D) Remain alert for signals that the patient wants to discuss his illness.
1. Bathe the body of the deceased.
2. Collect any needed specimens.
3. Remove all tubes and indwelling lines.
4. Position the body for family visit/viewing.
5. Speak to the family members about their possible participation.
6. Confirm that request for organ/tissue donation and/or autopsy has been made.
7. Notify a support person (e.g., spiritual care provider, bereavement specialist) for the family.
8. Accurately tag the body, indicating the identity of the deceased and safety issues regarding infection control.
9. Elevate the head of the bed.
Positioning the head of the bed first helps prevent pooling of blood in the face during all of the other preparations. Find out if there are medical or legal considerations (specimens, autopsy, or tissue donation) before beginning so you do not have to disrupt your care of the person once you have started. Notify a support person for the family while you make other preparations. Invite the family early so you do not violate any cultural or spiritual rituals by beginning your care too early. Once ready to work with the body, remove drains before bathing the body in the event that there is leakage or soiling of the bed on removal. Arrange the person for viewing and transport to the morgue as the last step.
B) Anticipatory grief
C) Dysfunctional grief
D) Yearning and searching
A) Learning not to take losses so seriously.
B) Limiting involvement with patients who are grieving.
C) Maintaining life balance and reflecting on the meaning of your work.
D) Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to care for these patients.
A) Locating the patient’s clothing
B) Providing culturally and religiously sensitive care in body preparation
C) Transporting the body to the morgue as soon as possible to prevent body decomposition
D) Providing all postmortem care to protect the family of the deceased from having to see the body
A) Help the patient identify the tasks to be accomplished during his or her grief.
B) Encourage people to recognize stages of grieving in anticipation of what is to come.
C) Listen carefully to a person’s story of how his or her grief experience is unfolding.
D) Offer general grief timelines to help the person know when a phase will pass.
A) “Learning to accept that you can’t perform some activities anymore will bring you more acceptance and peace.”
B) “Which activities are most important to you, and how can you continue to do them?”
C) “People in your life want to help you with things; allow them to do what they want for you.”
D) “Spending more of your time resting or reading will conserve your energy.”
A) Hospice and palliative care are the same thing.
B) Palliative care is for any patient, any time, any disease, in any setting.
C) Palliative care strategies are primarily designed to treat the patient’s illness.
D) Palliative care interventions relieve the symptoms of illness and treatment.
A) Use family members and physician orders as primary resources for prioritizing your actions.
B) Address the nursing diagnosis that most affects the medical diagnosis.
C) Ask the patient to identify the most distressing symptom and first address that diagnosis.
D) Use nursing knowledge to address the problem that is the underlying cause of other diagnoses.
A) Older adults have usually sustained many losses in life, which influence the current loss.
B) Older adults with a poor memory experience grief less intensely.
C) Older adults generally handle loss better because they have more experience with it.
D) Social support is less important because an older adult’s circle of friends has become smaller.
A) Results in neurophysiological response.
B) Reduces body temperature
C) Causes a person to be hypervigilant
D) Reduces level of consciousness to conserve energy.
A) Posttraumatic stress disorder
B) Rising hormone levels
C) Chronic illness
D) Return of vital signs to normal
PTSD originates with a person’s experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The car accident is the traumatic event
A) A situational crisis.
B) A maturational crisis.
C) An adventitious crisis.
D) A developmental crisis.
A) How is this flood affecting your life?
B) Since your husband has died, what have you been doing in the evening when you feel lonely?
C) How is having diabetes affecting your life?
D) I know this must be hard for you. Let me tell you what might help.
A) Loss of autonomy caused by health problems
B) Physical appearance, family, friends, and school
C) Self-esteem issues, changing family structure
D) Search for identity with peer groups and separating from family
A) “Tell me who I can call to help you.”
B) “Tell me what bothers you the most about this experience.”
C) “I’ll contact someone who can help get you temporary housing.”
D) “I’ll sit with you until other family members can come help you get settled.”
A) The amount of family support
B) A 3-day diet recall
C) A thorough physical assessment
D) Threats to safety in her home
A) “Don’t be sad. People live with cancer every day.”
B) “Have you thought about how you are going to tell your family?”
C) “Would you like for me to sit down with you for a few minutes so you can talk about this?”
D) “I know another patient whose colon cancer was cured by surgery
A) “Are you thinking of suicide?”
B) “You’ve been doing a good job raising your children. You can do it!”
C) “Is there someone who can help you?”
D) “You have so much to live for.”
A) “I’m going to learn to drive a car so I can be more independent.”
B) “My sister says she feels better when she goes shopping, so I’ll go shopping.”
C) “I’ve always felt better when I go for a long walk. I’ll do that when I get home.”
D) “I’ m going to attend a support group to learn more about multiple sclerosis.”
A) “Let’s talk about something cheerful.”
B) “Do other members of your family have diabetes?”
C) “I can tell that you feel stressed to learn that you have diabetes.”
D) With silence.
A) Nurses who feel stress usually pass the stress along to their patients.
B) A nurse who feels stress is ineffective as a nurse and should not be working.
C) Nurses who talk about feeling stress are unprofessional and should calm down.
D) Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.
A) After 2 weeks when the child’s pneumonia begins to improve
B) After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks
C) After 1 month when the child goes home and the mother gets help from a food pantry
D) After 6 months when the child is back in school
A) Susceptible host.
B) Communicable disease.
C) Port of entry to a host.
D) Port of exit from the reservoir.
A) Exposure to another patient’s cough
B) Sharing equipment among patients
C) Disposing of soiled linen in a shared linen bag
D) Contact with a health care worker’s hands
A) Illness stage
C) Prodromal stage
D) Incubation period
A) Hand hygiene
B) Wearing gloves
C) Placing patients in isolation
D) Providing private rooms for patients
A) Wear gloves before eating or handling food.
B) Place any soiled materials into a bag and double bag it.
C) Have the family member check with the doctor about need for immunization.
D) Perform hand hygiene after care and/or handling contaminated equipment or material.
A) Provide a dark, quiet room to calm the patient.
B) Reduce the level of precautions to keep the patient from becoming angry.
C) Explain the reasons for isolation procedures and provide meaningful stimulation.
D) Limit family and other caregiver visits to reduce the risk of spreading the infection.
A) The patient’s hygiene is poor.
B) The nurse is assisting with medication administration.
C) The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis.
D) Blood or body fluids may get on the nurse’s clothing from a task that he or she plans to perform.
A) Leave the gloves on to administer the medication.
B) Remove gloves and administer the medication.
C) Remove gloves and perform hand hygiene before administering the medication.
D) Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient’s room.
A) Below elbows.
B) Above elbows.
C) At a 45-degree angle.
D) In a comfortable position
A) Use an autoclave.
B) Use boiling water.
C) Use ethylene oxide gas.
D) Use chemicals for disinfection.
A) It keeps an incontinent patient’s skin dry.
B) It can get caught in the linens or equipment.
C) It obstructs the normal flushing action of urine flow.
D) It allows the patient to remain hydrated without having to urinate.
A) Untie top, then bottom mask strings and remove from face.
B) Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side.
C) Remove gloves.
D) Remove eyewear or goggles.
E) Perform hand hygiene.
A) Wash them with soap and water.
B) Use an alcohol-based hand cleaner.
C) Rinse them and use the alcohol-based hand cleaner.
D) Wipe them with a paper towel.
A) Notify the health care provider and use surgical technique to change the dressing.
B) Reassure the patient and recheck the wound later.
C) Notify the health care provider and support the patient’s fluid and nutritional needs.
D) Alert the patient and caregivers to the presence of an infection to ensure care after discharge.
A) When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action.
B) Fluid flows in the direction of gravity.
C) A sterile field becomes contaminated by prolonged exposure to air.
D) None of the principles were violated.
A. If a seizure occurs, turn the patient on his side after placing an airway in his mouth
B. Hold the patient firmly during the seizure so he does not bump his head
C. Pad the siderails of the patient’s bed to provide a cushion in case of seizures
D. If a seizure occurs, stay with him while watching his ability to breathe
A. When the patient experiences an aura, right before the seizure begins
B. During the most active part of the seizure so the airway stays open
C. As soon as the seizure is over
D. During the postictal period if the dentures are loose
A. Perform a complete head-to-toe assessment
B. Place a cervical collar on the patient
C. Use at least three people to put him back in bed
D. Contact the physician for further orders
A. “Please explain to the patient why the restraints are needed.”
B. “Let me know if the skin under the restraints is becoming red.”
C. “If the patient promises to behave appropriately, release the restraints.”
D. “If the patient continues to be combative, we can add a vest restraint.”
A. Remove one hand and one leg restraint at the same time
B. Remove the upper extremity restraints at the same time, then the lower ones
C. Remove one restraint at a time with another staff member present
D. Remove all of the restraints at the same time with another staff member present
A. “The radiation reduces the flow of saliva.”
B. “The radiation causes the mucous lining of the mouth to become thin.”
C. “It would be best to discuss this with your radiation oncologist.”
D. “How have you been managing the dryness you’re having?”
A. Rinse two to three times a day with an alcohol-based mouthwash and use a water- based mouth moisturizer afterward.
B. Rinse your mouth before and after meals and at bedtime with salt water and apply a moisturizing gel on the lips if needed.
C. Brush your teeth gently before each meal with water and suck on mints to help soothe your mouth.
D. Floss your teeth gently each day after applying an oral lubricant to the mouth and use a Vaseline-based lip gel as needed.
A. Whether any patients have diabetes
B. Whether any patients have a tendency to bleed
C. Whether any patients need assistance with walking
D. Whether any patients have family members present
A. Trim the toenails after soaking them for 10 minutes.
B. Ask the physician for a referral to a podiatrist.
C. Let the patient trim his own toenails.
D. Ask the patient’s wife if she will trim his toenails.
A. A horizontal fold was placed in the linens near the patient’s feet while making an occupied bed.
B. The patient’s eyes were wiped from the outer to the inner canthus.
C. The perineum was cleaned from the front to the back.
D. The nursing assistive personnel put on gloves before washing a patient’s hair.
A. “As long as we use proper body mechanics, no one will get hurt.”
B. “Because the patient weighs only 100 pounds, you can handle the transfer yourselves.”
C. “Please find the slide board for us to use.”
D. “Which one of you wants to be at the patient’s head?”A patient with a proprioceptive disorder is being assessed for his ability to walk. Which nursing diagnosis would be the primary one on which to base his care?
A. Activity intolerance
B. Risk for injury
C. Chronic pain
D. Nutrition: less than body requirements
A. Rocking the patient back and forth before standing
B. Flexing the patient’s hips to a 90-degree angle
C. Moving the patient to the edge of the bed
D. Placing the patient’s hands around his neck
A. “Why haven’t you been using the stockings?”
B. “You know you’re subject to developing blood clots.”
C. “How many pairs of stockings do you have?”
D. “Have you noticed a change in your hands?”
A. “You should wear shoes with the same size heel.”
B. “Try to wear the same shoes for stability and safety.”
C. “If you change heel sizes, the crutches may need adjusting.”
D. “Wearing shoes with different heel sizes is fine as long as you’re comfortable.”
A. On the patient’s left side
B. On the patient’s right side
C. Slightly in front of the patient and on the patient’s left side
D. Slightly behind the patient’s right side
A. “Use the walker’s handgrips to give you leverage.”
B. “Get close to the edge of the chair.”
C. “Rock yourself several times to get up.”
D. “Use the arms of the chair to push up to the walker.”
A. Check the functioning of the CPM machine.
B. Perform skin care on the affected extremity.
C. Pad the hard surfaces of the CPM machine.
D. Assess the skin on both lower extremities.
B. Vitamin C
D. Vitamin B12
A. The foods to eat to reduce his blood glucose levels
B. The need to increase his daily protein intake
C. The health risks related to extreme obesity
D. The need to add a few pounds, but slowly
A. Open food and beverage containers, cut food and position tray so he can reach it
B. Prepare the items on the tray, then watch the patient’s ability to feed himself and assist as needed
C. Leave the tray where the patient can reach it, which allows the patient to be totally independent
D. Sit with the patient and feed him after opening and preparing the food on the tray
A. A jelly sandwich
B. Graham crackers with peanut butter
D. Apple slices
A. A Hindu patient receives a baked potato, mixed vegetables, dinner roll, and salad
B. An Orthodox Jew received a grilled cheese sandwich, French fries, coleslaw, and applesauce
C. A Muslim patient receives baked ham, scalloped potatoes, mixed fruit, and garlic bread
D. A Southeast Asian patient receives baked chicken, rice, corn, and a fruit salad,
A. The nurse pulled back quickly with the 20-mL syringe watching for facial grimacing
B. The nurse placed the patient supine with the bed elevated at least 30 degrees while checking placement
C. The nurse pulled the syringe plunger slowly to obtain 10 mL of gastric juice at least an hour after medications were given
D. The nurse flushed the tube with 60 mL of air through the syringe while watching for abdominal distention
A. Stop the continual tube feeding
B. Elevate the head of the bed
C. Auscultate the patient’s lungs
D. Notify the physician
A. Auscultating the lungs
B. Checking the skin turgor
C. Weighing the patient
D. Checking for bowel sounds
A. Check the current laboratory values
B. Check for signs of fluid retention
C. Slow the rate of the tube feeding by 20%
D. Ask the patient how he feels
A. If the formula or medications contain sorbitol
B. If the patient has a history of a latex allergy
C. The patency of the enteral feeding tube
D. A complete assessment of the gastrointestinal system
A. SBAR documentation
B. Charting by exception
C. Focus charting
D. PIE documentation
A. The majority of the documentation provides subjective data.
B. The nurse’s hunches are included in case a sudden change occurs in the patient’s condition.
C. The documentation contains only objective data.
D. The documentation reflects individualized care based on assessment data.
A. A Foley catheter needed to be inserted because the patient could not void.
B. The patient’s fever dropped dramatically and sooner than expected.
C. The patient had to be taken back to surgery.
D. The patient’s family has been visiting frequently.
A. When less than standard patient care has been provided
B. To document an injury to a patient or visitor
C. To identify potential risks in new treatments
D. To document when an adverse situation almost occurred in care
A. “Too much morphine was given; being monitored frequently and is stable; family at bedside and has been told of situation.”
B. “Incident report filed after patient received too much pain medication and had decreased respirations; is resting quietly; doctor notified.”
C. “Dilaudid 1 mg IV caused RR 8, BP 100/68, P 70 afterward; being monitored q15 min—see graphic for VS; MD notified.”
D. “Sleeping deeply and snoring after receiving narcotic IV; VS stable; nailbeds pink, oxygen ready if needed; supervisor notified.”
A. Dry the axilla before placing the thermometer probe.
B. Hold the thermometer probe in place.
C. Place the patient in a supine position.
D. Check that the patient has not had anything to eat or drink recently.
A. Obtain a different thermometer.
B. Check for the presence of cerumen.
C. Document the temperature assessed.
D. Record the average between the two readings.
A. The patient is assessed while flat, supine, and quiet.
B. The patient’s head is elevated based on the patient’s desire.
C. The nurse tells the patient when to begin breathing for the assessment.
D. The nurse holds the patient’s wrist while counting respirations.
A. “Just relax while I put the cuff on your arm.”
B. “This is painless and will take just a minute.”
C. “The cuff can go over your thin silk sleeve.”
D. “Please uncross your legs while I do this.”
A. The patient with a constant tremor
B. The diabetic patient with hyperglycemia
C. The feverish patient who is shivering
D. The patient with an irregular heart rate
A. A small dark mole looks the same.
B. A smooth, flat mole has gotten larger since his weight gain.
C. A small black mole is beginning to ooze.
D. A raised mole has regular borders.
A. Cardiac and respiratory status
B. Prior and current health history
C. Pain level and current medications
D. Overall appearance and behavior
A. Move through the assessment as quickly as possible.
B. Ask closed-ended questions to conserve the patient’s energy.
C. Elevate the head of the patient’s bed for comfort.
D. Count the respirations for 15 seconds and multiply by 4.
B. Consensual response
C. Equality of pupils
D. Shape of the pupils
A. Count the apical heart rate for 30 seconds, and then the radial pulse for the next 30 seconds.
B. Count the apical pulse for 60 seconds, and then wait 5 minutes and count the radial pulse for 60 seconds.
C. Count the apical rate for 60 seconds while another nurse counts the radial pulse at the same time.
D. Count the radial pulse for the first 30 seconds, and then the apical rate for the last 30 seconds.
A. Assess the patient’s respiratory rate more often
B. Add humidification to the nasal cannula
C. Elevate the patient’s head to at least 45 degrees
D. Encourage use of the incentive spirometer
A. “The alveoli need to be kept inflated to provide for better gas exchange, which the mask will do.”
B. “CPAP uses a nose mask that pushes air in at a constant pressure to keep your airway open.”
C. “You really need to ask your doctor since she’s the one who ordered it.”
D. “Your oxygen level drops when you’re sleeping, and CPAP will keep the level up.”
A. Arterial blood gases
B. A chest radiograph
C. A pulmonary function test
D. A pulse oximeter reading
A. Performing mouth care at least four times a day
B. Repositioning the patient every 2 to 3 hours
C. Assessing lung sounds every 4 hours
D. Performing range of motion exercises three times a day
A. The patient was coughing
B. The patient became disconnected from the ventilator
C. There is a leak in the ventilator circuit
D. The patient’s anxiety is increasing
A. “This gives him extra oxygen before his tube is suctioned.”
B. “This maneuver compensates for the anticipated suction-induced hypercarbia.”
C. “What are your concerns regarding the procedure?”
D. “It helps prevent the lungs from collapsing while he is being suctioned.”
A. Whether the patient has been sick within the past 3 months
B. Whether the patient has ever had the procedure done before
C. Whether the patient has any environmental allergies such as allergies to dust or grasses
D. Whether the patient has an allergy to shellfish
A. Evaluation of the patient’s risk for aspiration by a speech pathologist
B. Measurement of the patient’s arterial blood gases by respiratory care
C. Determination of the status of the patient’s lung sounds
D. Review of how long the patient has had his artificial airway
A. Assessed the skin on the patient’s neck for redness and intactness
B. Cut the old tracheostomy ties on the side after securing the new ones first
C. Had the patient cough and deep breathe before removing the old tie
D. Moved the pilot balloon to the side where the tracheostomy ties were cut
A. Elevating the patient’s head of the bed to 45 degrees
B. Hyperoxygenating the patient
C. Placing sterile normal saline into the endotracheal tube
D. Checking the patient’s oxygen saturation
A. Support the family as they experience their grief and loss.
B. Before beginning the care, explain the sounds the expired patient may make
C. Help the family members put on the appropriate personal protective equipment
D. Allow the family members to do only those activities they are comfortable with
protected from the deceased patient’s body fluids. All of the answers are correct;
however, only option 3 deals with the physical wellbeing of the family members. All
of the other options deal with the psychological aspects. Page 416
A. Reposition the patient after giving him a backrub.
B. Turn out all the lights after telling him where he is.
C. Suction the patient’s mouth, then perform mouth care.
D. Raise the head of the bed after changing all the linens.
A. Place a rolled towel under the chin
B. Tape the jaw closed using paper tape
C. Use roll gauze around the head and jaw
D. Place a cervical collar on the patient
jaw position so the dentures remain in place. The jaw muscles weaken after death and the dentures could move. Check to ensure this is allowed by the beliefs of the family. Page 416
A. Decrease the amount of oral fluid given
B. Monitor the oxygen saturation every four hours
C. Reposition the patient into semi-Fowler’s
D. Place the patient on his side with his neck hyperextended
A. “Put socks on and a light blanket over the legs and feet.”
B. “You can use a heating pad as long as it’s on the lowest setting.”
C. “Do you have an electric blanket instead of a heating pad?”
D. “Ask you family member what he wants done.”
A. Document the care provided.
B. Check for new orders.
C. Restock the patient’s supplies.
D. Perform hand hygiene.
A. Perform hand hygiene.
B. Place the container in the agency’s biohazard bag.
C. Document the collection in the patient’s record.
D. Open the patient’s curtains.
A. Check for new orders.
B. Place a dab of petroleum-based lotion on his hands.
C. Apply clean gloves.
D. Perform hand hygiene.
A. The nurse wears a mask while talking to the patient from the doorway.
B. The nurse wears a gown and mask when taking supplies into the room.
C. The nurse wears a mask while checking the patient’s temperature.
D. The nurse wears gloves and a gown while moving the patient up in bed.
A. Mask, goggles, gloves, then gown
B. Gloves, goggles, gown, then mask
C. Gloves, gown, goggles, then mask
D. Gown, gloves, mask, then goggles
A. Rub petroleum jelly on his hands to provide a barrier between his hands and the gloves.
B. Put a pair of synthetic gloves on before donning the latex sterile gloves.
C. Use a larger pair of sterile gloves so they are not as tight.
D. Rinse his hands with cold water before putting on the sterile gloves.
A. “Are you having any difficulty breathing?”
B. “Are you having any chest discomfort?”
C. “Do you have any food allergies?”
D. “Have you ever felt this way before?”
A. Ask another nurse to change the dressing.
B. Wear a gown and mask when changing the dressing.
C. Perform hand hygiene for a longer time before putting on sterile gloves.
D. Ask the patient if it is all right with him if he changes the dressing.
A. Position the patient using as many pillows as needed.
B. Open the sterile supplies for the nurse to decrease the length of the procedure.
C. Give the patient a backrub during the procedure to distract him.
D. Place the patient in a position that is comfortable during the dressing change.
A. The sterile gloves are kept above waist level.
B. The over-bed table is positioned before any of the supplies are opened.
C. The nurse pours the bottle of cleaning solution with the palm facing the label.
D. The sterile glove package is dry and intact but water stained.