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Test Bank Concepts Nursing Practice 1st Edition, Giddens
Concept 1: Development
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose
of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for
needs related to
a. anticipatory guidance.
b. lowrisk adolescents.
c. physical development.
d. sexual development.
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational.
3. The school nurse talking with a high school class about the difference between growth and
development would best describe growth as
a. processes by which early cells specialize.
b. psychosocial and cognitive changes.
c. qualitative changes associated with aging.
d. quantitative changes in size or weight.
4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it
a. can diagnose developmental disabilities.
b. identifies a need for physical therapy.
c. is a developmental screening tool.
d. provides a framework for health teaching.
5. To plan early intervention and care for an infant with Down syndrome, the nurse considers
knowledge of other physical development exemplars such as
a. cerebral palsy.
b. failure to thrive.
c. fetal alcohol syndrome.
6. To plan early intervention and care for a child with a developmental delay, the nurse would
consider knowledge of the concepts most significantly impacted by development, including
c. functional status.
7. A mother complains to the nurse at the pediatric clinic that her 4yearold child always talks to her
toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurses
best initial response is to
a. refer the child to a psychologist.
b. explain that playing make believe with dolls and people is normal at this age.
c. complete a developmental screening.
d. separate the child from the mother to get more information.
8. A 17yearold girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
a. have separation anxiety.
b. rebel against rules.
c. regress because of stress.
d. want to know everything.
Concept 2: Functional Ability
1. The nurse is assessing a patients functional ability. Which activities most closely match the
definition of functional ability?
a. Healthy individual, works outside the home, uses a cane, well groomed
b. Healthy individual, college educated, travels frequently, can balance a checkbook
c. Healthy individual, works out, reads well, cooks and cleans house
d. Healthy individual, volunteers at church, works part time, takes care of family and house
2. The nurse is assessing a patients functional performance. What assessment parameters will be
most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration assessment
d. Healthy individual, volunteers at church, works part time, takes care of family and house
3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the
patients functional ability. What question would be the most appropriate?
a. Are you able to shop for yourself?
b. Do you use a cane, walker, or wheelchair to ambulate?
c. Do you know what todays date is?
d. Were you sad or depressed more than once in the last 3 days?
4. The nurse is developing an interdisciplinary plan of care using the RoperLoganTierney Model of
Nursing for a patient who is currently unconscious. Which interventions would be most critical to
developing a plan of care for this patient?
a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature
5. The home care nurse is trying to determine the necessary services for a 65yearold patient who
was admitted to the home care service status after left knee replacement. Which tool(s) will assist
with this determination?
a. Minimum Data Set (MDS)
b. Functional Status Scale (FSS)
c. 24Hour Functional Ability Questionnaire (24hFAQ)
d. The Edmonton Functional Assessment Tool
6. The nurse is assessing a patients functional abilities and asks the patient, How would you rate
your ability to prepare a balanced meal? How would you rate your ability to balance a
checkbook? How would you rate your ability to keep track of your appointments? Which tool
would be indicated for the best results of this patients perception of their abilities?
a. Functional Activities Questionnaire (FAQ)
b. Mini Mental Status Exam (MMSE)
d. Performancebased functional measurement
Concept 3: Family Dynamics
1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions
and lack of family support for a patient would be to
a. enforce hospital visiting policies.
b. monitor the dysfunctional interactions.
c. notify the primary care provider.
d. role model appropriate support.
2. The nurse caring for a patient would identify a need for additional interventions related to family
a. extended family offers to help.
b. family members express concern.
c. the ill member demands attention.
d. memories are shared.
3. Jane and Janet have an established longterm relationship and are attending parenting classes in
anticipation of finalizing adoption of baby Joan. Jane and Janet would be considered which type of
d. Single parent
4. Critical Thinking: The nurse identifies the family with a child graduating from college as being in
the family life cycle of
a. single young adult leaving home.
b. new couple joins their families through marriage or living together.
c. families with young children.
d. launching children and moving on.
5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for
further teaching if the student responded that family assessment is used to gain an understanding of
c. political views.
6. The nurse planning to assess the structure of a family would which question?
a. Who lives with you?
b. Who does the grocery shopping?
c. Who provides support in your family?
d. How old are the members of your family?
7. Factors which would alert the nurse to negative/dysfunctional family dynamics include
a. aging of family members.
b. chronic illness of a family member.
c. disability of a family member.
d. intimate partner violence.
Concept 4: Culture
1. The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable
spasms, trembling, and shouting. It is important to identify manifestation of illness in order to
effectively treat a patient. The nurse identifies this as a culturebound syndrome called
a. shenjing sharo.
b. loco de la cabeza.
c. ataque de nervios.
2. Understanding cultural differences in health care is important because it will help the nurse to
understand the manner in which people decide on obtaining treatments and medical care. In
independent cultures an individual will
a. put himself first.
b. consult family members for advice.
c. ask for a second opinion.
d. travel great distances to receive the best care.
3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient
nodding yes to everything that is being said. With a better understanding of cultural interdependence
in selfconcept, a nurse should immediately
a. write everything down for the patient to refer to later.
b. prompt further to elicit additional questions or concerns.
c. call the recognized elder for this patient.
d. call the oldest male relative for help with decision making.
4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to
a. feminine attributes.
b. unequal gender.
c. fixed gender roles.
d. female inequality.
5. Mr. Giuseppe is a 60yearold Italian immigrant who presents for an annual physical. He is
counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination,
and pneumococcal vaccination. His reply is If it aint broke, dont try to fix it. Understanding that
respect for traditions and fulfilling obligations is important in developing a nursing plan of care. Mr.
Giuseppes cultural orientation is towards
a. short term.
b. long term.
c. leisurely term.
6. The emphasis on understanding cultural influence on health care is important because of
a. disability entitlements.
b. HIPAA requirements.
c. increasing global diversity.
d. litigious society.
7. What interrelated constructs facilitate a nurse to become culturally competent?
a. Cultural diversity, selfawareness, cultural skill, and cultural knowledge
b. Cultural desire, selfawareness, cultural knowledge, and cultural identity
c. Cultural desire, selfawareness, cultural knowledge, and cultural diversity
d. Cultural desire, selfawareness, cultural knowledge, and cultural skill
Concept 5: Motivation
1. The nurse is assessing a patients personal traits using the Influential Characteristics on
Motivation tool. What assessment parameters will be included in this assessment?
a. Developmental, cognitive, and educational levels; emotional readiness; actual or perceived
state of health or illness
b. Psychologic availability, readiness of health care system, and level of difficulty and ambiguity
c. Cultural expectations and customs and emotional ties such as love, intimacy, and sexual
d. Available human and physical resources and accessibility of health care facility
2. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is being
discharged on medications and given the Dietary Approaches to Stop Hypertension (DASH) diet to
follow. What statement by the patient signals to the nurse that the patient is motivated to learn?
a. I am sure the medications will help to bring down my blood pressure.
b. I cant wait to try the new recipes, and Im hopeful I will lose weight.
c. Do I really need to follow the diet and take medications?
d. I have my parents to blame for this. They both have high blood pressure.
3. The nurse is assessing intrinsic motivational levels of a patient who just had knee replacement
surgery. Which behaviors would indicate that the patient is intrinsically motivated?
a. Agrees to take blood thinners as prescribed because that is what the doctor prescribed
b. Verbalizes an understanding of taking blood thinners postop to reduce risk of clotting
c. Knows that exercise and physical therapy (PT) will help speed recovery
d. Enjoys exercise and PT, asks for pamphlets to learn about rehab techniques
4. The nurse is trying to help an obese diabetic patient who has 30 pounds to lose. The nurse is
setting weight loss goals that the patient will attain. Which goals would most likely cause an
increase in motivation in this patient?
a. Follow American Diabetic Diet, lose 2 pounds a week, and 20 pounds in 2 months.
b. Follow American Diabetic Diet, lose .5 pounds a week, and 5 pounds in 2 months.
c. Follow American Diabetic Diet, lose 1 pound a week, and 10 pounds in 2 months.
d. Follow American Diabetic Diet, lose 3 pounds a week, and 30 pounds in 2 months.
5. The nurse is working with the interprofessional team to develop a plan of care for a patient who
had a myocardial infarction 5 days ago and is about to go home. The team has decided to focus in
home rehabilitation on medications, regaining strength, and losing weight. What interventions will
be in the initial plan of care if this patient is motivated by power?
a. Develop a plan of exercise and weight loss that is assertive and entails beating the previous
b. Develop a plan of exercise and weight loss that is slow and gradually increases.
c. Develop a plan of exercise and weight loss that enacts consequences if the plan is not followed.
d. Develop a plan of exercise and weight loss that involves rewards and positive reinforcement
from the health care team.
6. A patient expresses a strong interest in returning to their work, family, and hobbies after having a
stroke. Which theory type would the nurse use to develop a plan of care for the best results of this
patients motivation style?
7. The nurse is assessing a patients readiness to be discharged. What is the most appropriate
question for the nurse to ask to determine the patients learning needs before planning teaching
a. What are your hobbies and occupation?
b. What do you need to know before you go home from the hospital?
c. Do you have any cultural or religious beliefs that you would like incorporated into your plan
d. What were your grades and learning style when you were in school?
Concept 6: Adherence
1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a
collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse
is planning teaching for the patient, which is the most important initial learning goal?
a. The patient will select the type of learning materials they prefer.
b. The patient will verbalize an understanding of the importance of following the regimen.
c. The patient will demonstrate coping skills needed to manage hypertension.
d. The patient will verbalize the side effects of treatment.
2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the
patient can explain the information but fails to take the medications as prescribed. The nurses next
action would be to
a. reeducate the patient, because learning did not occur because the patients behavior did not
b. assess the patients perception and attitude towards the risks associated with not taking their
c. take full responsibility for helping the patient make dietary changes.
d. ask the provider to prescribe a different medication, because the patient does not want to take
3. A diabetic patient presents to the diabetes clinic with A levels of 7.5%. The nurse has met this
1c patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which
teaching strategy by the nurse is most likely to be effective?
a. Provide information on the importance of blood glucose control in maintenance of longterm
health and evaluate how the patient has been following the prescribed regime.
b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask
what strategies they have tried thus far.
c. Refer the patient to a certified diabetic educator, because the educator is an expert on
management of diabetes complications.
d. Have the patient explain what medications they are on and what diet they should be following.
4. The nurse is assessing a newly diagnosed diabetic, and the patients readiness to learn about
glucose monitoring. Before planning teaching activities, which approach would be most effective?
a. Assist the patient with longterm goals and plan teaching according to these goals.
b. Provide the patient with all the latest research from the Internet on glucose monitoring.
c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer.
d. Assist the patient in developing realistic shortterm goals.
5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with
blood glucose monitoring. Which statement by the patient would indicate to the nurse that the
patient is not motivated and will most likely not comply?
a. I do not like to test my sugar, but I do it because my wife nags me.
b. I forget to check my sugar once in a while.
c. I dont see or feel any different when I do keep my blood sugars under control.
d. I have no idea what the signs of low blood sugar are.
6. The nurse is doing discharge teaching on a patient who has peripheral vascular disease and has
poor circulation to the feet. Which learning goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will understand the rationale for proper foot care after instruction.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will post reminder stickers on their calendar to check feet every day and record
scheduled appointments with podiatrist.
7. A patient with hypertension is prescribed a lowsodium diet. The patients teaching plan includes
this goal: The patient will select a 2gram sodium diet from the hospital menu for the next 3 days.
Which intervention would be most effective at increasing the patients compliance with the diet?
a. Check the sodium content of the patients menu choices over the next 3 days.
b. Ask the patient to identify which foods on the hospital menus are high in sodium.
c. Have the patient list favorite foods that are high in sodium and foods that could be substituted
for these favorites.
d. Compare the patients sodium intake over the next 3 days with the sodium intake before the
teaching was implemented.
8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be
sure the patient can function in accomplishing daily activities independently. What is the nurses
a. Determine if the patient has had home visits before and if the experience was positive.
b. Check the patients ability to bathe without any assistance the next day.
c. Have the patient demonstrate the learned skills at the end of the teaching session.
d. Arrange a physical therapy visit before the patient is discharged from the hospital.
9. When assessing a 22yearold male patient, the nurse learns that he smokes a pack of cigarettes
daily. The patient tells the nurse, I enjoy smoking and have no plans to quit. Which nursing
diagnosis is most appropriate?
a. Health Seeking Behaviors related to cigarette use
b. Ineffective Health Maintenance related to tobacco use
c. Readiness for Enhanced SelfHealth Management related to smoking
d. Deficient Knowledge related to longterm effects of cigarette smoking
10. A 73yearold male patient is seen in the home setting for a routine physical. The nurse notes
which behavior as the most reassuring sign that the patient has been following the treatment plan for
the diagnoses of hypertension, diabetes, and hyperlipidemia?
a. The patient has a list of glucose readings for the past 10 days.
b. The patient has a list of medications along with newly refilled meds.
c. The patient has a list of all foods and beverages for a 3day period.
d. The patient verbalizes the side effects of all his medications.
Concept 7: Fluid and Electrolyte Balance
1. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question
which doctors order?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day
2. The nurse assessed four patients at the beginning of the shift. Which finding should the nurse
report most urgently to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvosteks sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
3. The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which
assessment finding should cause the nurse to hold the IV solution and contact the physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58
4. At changeofshift report, the nurse learns the medical diagnoses for four patients. Which patient
should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland
5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings
should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness
6. The patient with which diagnosis should have the highest priority for teaching regarding foods
that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal disease
d. Adrenal insufficiency
7. The patients laboratory report today indicates severe hypokalemia, and the nurse has notified the
physician. Nursing assessment indicates that heart rhythm is regular. What is the most important
nursing intervention for this patient now?
a. Raise bed side rails due to potential decreased level of consciousness and confusion.
b. Examine sacral area and patients heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg muscles.
Concept 8: Acid-Base Balance
1. The patient had diarrhea for 5 days and developed an acidbase imbalance. Which statement
would indicate that the nurses teaching about the acidbase imbalance has been effective?
a. To prevent another problem, I should eat less sodium during diarrhea.
b. My blood became too acid because I lost some base in the diarrhea fluid.
c. Diarrhea removes fluid from the body, so I should drink more ice water.
d. I should try to slow my breathing so my acids and bases will be balanced.
2. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute
upper respiratory infection. Which blood gas values should the nurse expect to see?
a. pH high, PaCO2 high, HCO3 high
b. pH low, PaCO2 low, HCO3 low
c. pH low, PaCO2 high, HCO3 high
d. pH low, PaCO2 high, HCO3 normal
3. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most
important for the nurse to assess in order to detect development of the acidbase imbalance for
which the patient has highest risk?
a. Urine output and color
b. Level of consciousness
c. Heart rate and blood pressure
d. Lung sounds in lung bases
4. The nurse is making a home visit to a child who has a chronic disease. Which finding has the
greatest implication for acidbase aspects of this patients care?
a. Urine output is very small today.
b. Whites of the eyes appear more yellow.
c. Skin around the mouth is very chapped.
d. Skin is sweaty under three blankets.
5. The nurse has telephone messages from four patients who requested information and assistance.
Which one should the nurse refer to a social worker or community agency first?
a. Is there a place that I can dispose of my unused morphine pills?
b. I want to lose at least 20 pounds without getting sick this time.
c. I think I have asthma because I cough when dogs are near.
d. I ran out of money and am cutting my insulin dose in half.
Concept 9: Thermoregulation
1. The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is
a. large for gestational age.
b. low birth weight.
c. born at term.
d. well nourished.
2. A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be
complaining about temperatures. The nurses best response is that older people have a diminished
ability to regulate body temperature because of
a. active sweat glands.
b. increased circulation.
c. peripheral vasoconstriction.
d. slower metabolic rates.
3. The nurse admitting a patient to the emergency department on a very hot summer day would
suspect hyperthermia when the patient demonstrates
a. decreased respirations.
b. low pulse rate.
c. red, sweaty skin.
d. slow capillary refill.
4. The priority nursing intervention for a patient suspected to be hypothermic would be to
a. assess vital signs.
b. hydrate with intravenous (IV) fluids.
c. provide a warm blanket.
d. remove wet clothes.
5. Strategies to include in a community program for senior citizens related to dealing with cold
winter temperatures would include
a. avoiding hot beverages.
b. shopping at an indoor mall.
c. using a fan at low speed.
d. walking slowly in the park.
6. During orientation to an emergency department, the nurse educator would be concerned if the new
nurse listed which of the following as a risk factor for impaired thermoregulation?
a. Impaired cognition
b. Occupational exposure
c. Physical agility
d. Temperature extremes
7. The most appropriate measure for a nurse to use in assessing core body temperature when there
are suspected problems with thermoregulation is a(n)
a. oral thermometer.
b. rectal thermometer.
c. temporal thermometer scan.
d. tympanic membrane sensor.
8. The nurse planning care for a patient with hypothermia would consider knowledge of similar
a. heat exhaustion.
b. heat stroke.
Concept 10: Cellular Regulation
1. The nurse would incorporate which of the following into the plan of care as a primary prevention
strategy for reduction of the risk for cancer?
a. Yearly mammography for women aged 40 years and older
b. Using skin protection during sun exposure while at the beach
c. Colonoscopy at age 50 and every 10 years as followup
d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over
2. While collecting a health history on a patient admitted for colon cancer, which of the following
questions would be a priority to ask this patient?
a. Have you noticed any blood in your stool?
b. Have you been experiencing nausea?
c. Do you have back pain?
d. Have you noticed any swelling in your abdomen?
3. While planning care for a patient experiencing fatigue due to chemotherapy, which of the
following is the most appropriate nursing intervention?
a. Prioritization and administration of nursing care throughout the day
b. Completing all nursing care in the morning so the patient can rest the remainder of the day
c. Completing all nursing care in the evening when the patient is more rested
d. Limiting visitors, thus promoting the maximal amount of hours for sleep
4. The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse
would monitor for which of the following clinical manifestations that could indicate a potentially
d. Mild temperature elevation
5. While the nurse is obtaining the health history of a 75yearold female patient, which of the
following has the greatest implication for the development of cancer?
a. Being a 75yearold woman
b. Family history of hypertension
c. Cigarette smoking as a teenager
d. Advancing age
6. In caring for a patient following lobectomy for lung cancer, which of the following should the
nurse include in the plan of care?
a. Position the patient on the operative side only.
b. Avoid administering narcotic pain medications.
c. Keep the patient on strict bed rest.
d. Instruct the patient to cough and deep breathe.
7. A female patient complains of a scab that just wont heal under her left breast. During your conversation, she also
mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurses next steps?
a. Continue to conduct a symptom analysis to better understand the patients symptoms and concerns.
b. End the appointment and tell the patient to use skin protection during sun exposure.
c. Suggest further testing with a cancer specialist and provide the appropriate literature.
d. Tell her to put a bandage on the scab and set a followup appointment in one week.
Concept 11: Intracranial Regulation
1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?
a. Aligning the neck with the body
b. Clustering many nursing activities
c. Elevating the head of the bed 30 degrees
d. Providing stool softeners or laxatives as ordered
2. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be
a. change in level of consciousness.
b. inability to focus visually.
c. loss of primitive reflexes.
d. unequal pupil size.
3. When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes,
a. hypertension, and bradycardia.
b. hypertension, and tachycardia.
c. hypotension, and bradycardia.
d. hypotension, and tachycardia.
4. Components of the GCS the nurse would use to assess a patient after a head injury include
a. blood pressure.
b. cranial nerve function.
c. head circumference.
d. verbal responsiveness.
5. Primary prevention strategies to reduce the occurrence of head injuries would include
a. blood pressure control.
b. smoking cessation.
c. maintaining a healthy weight.
d. violence prevention.
6. The nurse preparing to care for a patient after a suspected stroke would question an order for a(n)
c. osmotic diuretic.
7. After shunt procedure, the nurse would monitor the patients neurologic status by using the
c. National Institutes of Health Stroke Scale.
d. Monro-Kellie doctrine.
Concept 12: Glucose Regulation
1. The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin?
a. Furosemide (Lasix)
b. Dicumarol (Bishydroxycoumarin)
c. Reserpine (Serpasil)
d. Cimetidine (Tagamet)
2. When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl?
a. Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity.
b. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.
c. Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP.
d. The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.
3. The nurse associates which assessment finding in the diabetic patient with decreasing renal function?
a. Ketone bodies in the urine during acidosis
b. Glucose in the urine during hyperglycemia
c. Protein in the urine during a random urinalysis
d. White blood cells in the urine during a random urinalysis
4. What is the nurses best response about developing diabetes to the patient whose father has type 1 diabetes mellitus?
a. You have a greater susceptibility for development of the disease because of your family history.
b. Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes.
c. Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.
d. Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.
5. The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?
a. Young white man
b. Middle-aged African-American man
c. Young African-American woman
d. Middle-aged Native American woman
6. A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis?
a. Oral temperature of 38.9 Celsius
b. Severe orthostatic hypotension
c. Increased rate and depth of respiration
d. Extremity tremors followed by seizure activity
Concept 13: Nutrition
1. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?
a. The patients son uses a marked pillbox to set up the patients medications weekly.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
c. The patient is cared for by a daughter during the day and stays with a son at night.
d. The patient tells the nurse that a close friend recently died.
2. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient?
a. Your weight is within normal limits. Continue maintaining with current lifestyle choices.
b. You are a little overweight. Cut down on calories and increase your activity, and you should be fine.
c. You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery.
d. You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.
3. Critical Thinking: The nurse is doing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient?
a. regular diet
b. low sodium diet
c. pureed diet
d. low sugar diet
4. During a nutritional assessment, the nurse calculates that a female patients BMI is 27. The nurse would advise the patient to follow which of these recommendations?
a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.
b. This measurement indicates that the patient is underweight and will need to take measures to gain weight.
c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery.
d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.
5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
a. Food diary
b. Calorie count
c. Comprehensive diet history
d. 24-hour recall
6. Critical Thinking: During a physical examination, the nurse notes that the patients skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
a. Vitamin C
b. Vitamin B
c. Essential fatty acid
7. Critical Thinking: During a physical examination, the nurse notes that the patients skin is dry and flaking, with patches of eczema, and suspects a nutritional deficiency. What additional data would the nurse expect to find to confirm the suspicion?
a. Hair loss and hair that is easily removed from the scalp
b. Inflammation of the tongue and fissured tongue
c. Inflammation of peripheral nerves and numbness and tingling in extremities
d. Fissures and inflammation of the mouth
Concept 14: Elimination
1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patients daughter asks the nurse why this is happening. The best response by the nurse is:
a. The patient is angry about the dementia diagnosis.
b. The patient is losing sphincter control due to the dementia.
c. The patient forgets where the bathroom is located due to the dementia.
d. The patient wants to leave the hospital.
2. You are caring for a patient who has suffered a spinal cord injury. You are concerned about the patients elimination status. As the nurse, your primary concern is to
a. speak with the patients family about food choices.
b. establish a bowel and bladder program for the patient.
c. speak with the patient about past elimination habits.
d. establish a bedtime ritual for the patient.
3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?
a. Large intestine
c. Small intestine
4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. The best response from the nurse would be which of the following?
a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.
b. Some people have a slower bowel than others, and this is nothing to be concerned about.
c. The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.
d. Bowel peristalsis is slow because you are not walking. Get more exercise during the day.
5. A primary prevention tool used for colon cancer screening is
a. abdominal x-rays.
b. blood, urea, and nitrogen (BUN) testing.
c. serum electrolytes.
d. occult blood testing.
Concept 15: Perfusion
1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student states, Central perfusion
a. is monitored only by the physician.
b. involves the entire body.
c. is decreased with hypertension.
d. is toxic to the cardiac system.
2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease could have happened to them. The nurses best response is Hypertension
a. happens to everyone sooner or later. Dont be concerned about it.
b. can happen from eating a poor diet, so change what you are eating.
c. can happen from arterial changes that impede the blood flow.
d. happens when people do not exercise, so you should walk every day.
3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best response would be, The sinoatrial node
a. provides the heart with the stimulation to beat in a normal rhythm.
b. protects the heart from atherosclerotic changes.
c. provides the heart with oxygenated blood.
d. protects the heart from infection.
4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. The nurses primary concern is to monitor for
a. mental alertness.
d. reaction to medications.
5. A patients serum electrolytes are being monitored. The nurse notices that the potassium level
is low. The nurse knows that the patient should be observed for
a. tissue ischemia.
b. brain malformations.
c. intestinal blockage.
d. cardiac dysthymia.
6. A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, Perfusion
a. is a normal function of the body, and I dont have to be concerned about it.
b. is monitored by the physician, and I just follow orders.
c. is monitored by vital signs and capillary refill.
d. varies as a person ages, so I would expect changes in the body.
7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment?
a. Blood pressure above the normal range
b. Bounding pedal pulses
c. Night blindness
d. Reflux disease
Concept 16: Gas Exchange
1. The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient
a. with a blood glucose of 350 mg/dL
b. who has been on anticoagulants for 10 days
c. with a hemoglobin of 8.5 g/dL
d. with a heart rate of 100 beats/min and blood pressure of 100/60
2. The nurse is reviewing the patients arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient?
a. Disorientation and tremors
b. Tachycardia and decreased blood pressure
c. Increased anxiety and irritability
d. Hyperventilation and lethargy
3. The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with
a. peripheral arterial disease of the lower extremities
b. chronic obstructive pulmonary disease (COPD)
c. chronic asthma
d. severe anemia secondary to chemotherapy
4. The nurse is assessing a patients differential white blood cell count. What implications would this test have on evaluating the adequacy of a patients gas exchange?
a. An elevation of the total white cell count indicates generalized inflammation.
b. Eosinophil count will assist to identify the presence of a respiratory infection.
c. White cell count will differentiate types of respiratory bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic infection.
5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A patient with
a. chronic lung disease with increased carbon dioxide retention
b. acute anxiety, hyperventilation, and decreased carbon dioxide retention
c. decreased cardiac output with increased serum lactic acid production
d. gastric drainage with increased removal of gastric acid
6. Which patient would the nurse identify as being at an increased risk for altered transport of oxygen? A patient with
a. hemoglobin level of 8.0
b. bronchoconstriction and mucus
c. peripheral arterial disease
d. decreased thoracic expansion
7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk?
a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.
8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention?
a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease
Concept 17: Clotting
1. Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)?
a. An INR (international normalize ratio) of 1.8
b. An INR of 4.8
c. A partial thromboplastin time (APTT) level of 25 seconds
d. An APTT level of 35 seconds
2. Which statement by a patient indicates additional teaching is required about the medication warfarin?
a. I will continue my diabetic diet and restrict sugar.
b. I will increase the intake of green, leafy vegetables for a more healthful diet.
c. I will restrict the intake of foods high in vitamin C.
d. I will increase the amount of protein in my diet to protect my kidneys.
3. A patient states that his/her legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patients lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patients legs?
b. Crossed at the knee
c. Slightly bent with a pillow under the knees
d. Dependent position
4. The nurse would expect to administer an anticoagulant to a patient following which surgery?
a. Hip replacement
c. Abdominal aorta aneurism (AAA) repair
5. A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions?
a. Use a standard safety razor for shaving.
b. Use a soft bristle toothbrush.
c. Have aggressive dental care immediately to prevent dental caries.
d. Do not eat fresh fruit.
6. Which of the following patients would the nurse anticipate the collaborative treatment of regular phlebotomies?
Concept 18: Reproduction
1. A female college student is planning to become sexually active. She is considering birth control options and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in preventing pregnancy, which option should be given the strongest consideration?
a. Intrauterine device
b. Coitus interruptus
c. Natural family planning
d. Oral contraceptive pills
2. The RN at the Preconception Counseling Clinic takes a male history for infertility evaluation. Which finding has the greatest implication for this patients care?
a. Practice of nightly masturbation
b. Primary anovulation
c. High testosterone levels
d. Impotence due to alcohol ingestion
3. Many females experience problems achieving and maintaining a pregnancy. The ER nursing assessment of a childbearingage female shows back pain, elevated blood pressure, and leaking of clear fluid from the vagina. Maternal-fetal complications described above are most often associated with which child-bearing stage?
b. First trimester
c. Second-third trimester
4. The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked weed in the remote past, and is a social drinker. Which action should the nurse first take?
a. Strongly advise immediate tobacco cessation
b. Elimination of all caffeinated beverages
c. Serum and urine testing for drug use and alcohol use
d. Referral to a 12-step program
5. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit. She asks the nurse why she has never been able to get pregnant. Which response is best?
a. Circulating estrogen contributes to secondary sex characteristics.
b. Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility.
c. Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer.
d. The corona radiata is preventing fertilization of the ovum.
6. An obstetric multipara with triplets is placed on bed rest at 24 weeks gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This is an example of
a. antenatal diagnostics.
b. primary prevention.
c. secondary prevention.
d. tertiary prevention.
7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patients plan of care?
a. Electrical power lines are a potential hazard to the woman and her fetus.
b. Living near an oil field may mean the water supply is polluted.
c. Alcohol exposure should be avoided during pregnancy due to teratogenicity.
d. Eating sweets may cause gestational diabetes or miscarriage.
Concept 19: Sexuality
1. A 55-year-old male patient postmyocardial infarction (MI) queries the nurse caring for him whether he will be healthy enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and beta-blockers. While health teaching, the nurse understands that the three phases of the four-stage model of the human sexual response cycle that are of concern for this patient include
a. excitement, plateau, and orgasmic.
b. plateau, orgasmic, and resolution.
c. excitement, orgasmic, and resolution.
d. arousal, excitement, and plateau.
2. In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality, it is important for the nurse working in either a primary care or hospital setting to be cognizant that some groups of patients will have an increased risk for problems related to the concept of sexual health. Which patient is most at risk for sexual abuse?
a. A recently divorced 50-year-old woman
b. A Hispanic teenage girl
c. A 30-year-old African-American male
d. An individual with intellectual or developmental disabilities
3. A thorough assessment of sexual health includes laboratory and other diagnostic procedures. Tests are ordered at the providers discretion based upon gender and lifestyle of the patient. A 37-year-old heterosexual African-American man has come for his annual health screening. Which test must the nurse ensure is ordered for this patient?
a. Human papilloma virus (HPV)
b. Prostate-specific antigen (PSA)
d. Venereal disease research laboratory (VDRL)
4. Primary strategies are those that are implemented in order to avoid the development of disease. These strategies can be either population-based or individually-based. As a school nurse, you are developing a curriculum for a junior human sexuality class. In order to provide the most up-to-date information, you are aware that the single most effective primary prevention strategy for preventing sexually transmitted diseases is
a. a vaccine to prevent HPV infection.
b. HIV screening.
c. education directed at high-risk behaviors.
d. the male condom.
5. Symptoms of sexual dysfunction and altered body image often coexist with prolapse of the female reproductive organs. Nursing care requires a great deal of sensitivity, because many women are embarrassed by their condition. Your patient is a 44-year-old married woman who is complaining of painful intercourse and incontinence. Clinical evaluation reveals that the patient has a cystocele. Which treatment option is most appropriate for this patient?
a. Pelvic floor training
b. Vaginal pessaries
c. Surgical correction
d. Lifestyle changes
6. Preventing infection remains the most effective way of reducing the adverse consequences of sexually transmitted infections, in particular those that are not readily curable. Nurses are often able to reassure the patient enough to open dialog regarding possible exposure, testing, and treatment options. When assessing high-risk behaviors, which question specifically identifies a blood-related risk?
a. Have you ever received donor semen, eggs, or transplanted tissue?
b. Have you ever exchanged sex for drugs, money, or shelter?
c. How do you protect yourself from HIV and sexually transmitted infections?
d. Have you ever injected drugs using shared equipment?
Concept 20: Immunity
1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patients discharge planning?
a. The mechanisms of the inflammatory response
b. Basic infection control techniques
c. The importance of wearing a face mask in public
d. Limiting contact with the general population
2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the childs growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for
a. primary immunodeficiency.
b. secondary immunodeficiency.
3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if
a. his immune system is functioning properly.
b. he is properly vaccinated.
c. he has an infection.
d. the suppressor T-cells in his body are activated.
4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following?
a. My body will treat the new kidney like my original kidney.
b. I will have to make sure that I avoid being around people.
c. The medications that I take will help prevent my body from attacking my new kidney.
d. My body will only have a problem with my new kidney if the donor is not directly related to me.
5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patients respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n)
a. suppressed immune response.
b. hyperimmune response.
c. allergic reaction.
d. anaphylactic reaction.
6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to
a. eradicate the disease.
b. enhance immune response.
c. control inflammation.
d. manage pain.
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