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WorksheetsExam 1: 1020
Total questions: 93
Worksheet time: 2hrs 33mins
In an effort to promote health, the home health nurse opens the client’s bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which individual?
Jean Watson
Jurgen Moltmann
Florence Nightingale
Patricia Benner
Which type of family would most likely be helpful in encouraging the client to experience a high level of wellness?
Controls feelings to avoid conflict
Teaches negotiation skills and independence
Encourages risk taking and adventure
Views themselves as helpless victims
An older client with genetic-linked anemia admits to not consuming a balanced diet, preferring carbohydrates to protein and vegetables. Which dimension of health can the nurse most likely influence by teaching and counseling this client?
Age-related changes
Genetic anemia
Eating habits
Gender-related issues
What type of loss is most common among patients who are hospitalized for complex health conditions?
Privacy
Dignity
Functional
Identity
An older client is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?
“What medications do you take at home?”
“Do you have any environmental, food, or drug allergies?”
“Do you have an advance directive?”
“What is the greatest concern you are dealing with today?”
When developing goals, which characteristic should the nurse keep in mind?
Realistic so that progress is recognized by the patient
Developed solely by the healthcare team
Developed without family input, to maintain confidentiality
Valued by the multidisciplinary care providers
Which nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended?
Administering medications according to schedule
Allowing flexible visitation by family and friends
Explaining treatment options in easy-to-understand terms
Providing a healing presence by listening and being attentive
Which statement best describes the health–illness continuum?
Health is the absence of disease; illness is the presence of disease.
Health and illness are along a continuum that cannot be divided
Health is remission of disease; illness is exacerbation of disease.
Health is not having illness; illness is not having health.
Which self-care action helps the body release growth hormone?
A healthy diet
Physical activity
Restful sleep
Comfortable room temperature
A client has been hospitalized for 6 weeks. Which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization?
Providing skin care every shift to prevent skin breakdown
Encouraging the patient to get up in a chair to eat meals
Assisting the patient to ambulate in the hallway for several minutes each day
Designating a corner of the patient’s room to display personal mementos
Which aspect of health is particularly valuable in helping a patient with a terminal illness maintain a sense of self?
Family relationships
Spirituality
Nutrition
Sleep and rest
An older client with an acute myocardial infarction signs the consent form for an angioplasty. Which illness behavior is this client demonstrating?
Sick role
Seeking professional care
Experiencing symptoms
Dependence on others
When preparing a room to receive a newly admitted patient, what should the nursing assistive personnel (NAP) do?
Mop the floor with an approved disinfecting solution.
Fold the top bed linens back to “open” the bed.
Hook up the suction machine and check to see that it is working.
Position the bed in its lowest position.
When transferring a patient from a hospital to a long-term care facility, which is most helpful in facilitating the patient’s planning and emotional adjustment?
Notify the patient and family as much in advance of the transfer as possible.
Send a complete copy of the patient’s medical records to the new facility.
Carefully coordinate the transfer with the long-term facility to keep it smooth.
Help arrange for transportation and accompany the patient to the transport vehicle.
The nurse suspects that an older client has an undiagnosed chronic health problem. What assessment findings did the nurse use to make this clinical decision? Select all that apply.
Stated that hip pain hurts more when it rains
Stopped walking at the mall because of the pain
Experienced left knee pain “off and on” for years
Altered living arrangements to avoid stair climbing
The nurse reviews the Neuman continuum of health in preparation for an in-service program on wellness for a group of community members. What should the nurse emphasize when using this continuum? Select all that apply.
Wellness occurs when more energy is generated than expended.
Health and illness are on a graduated spectrum that cannot be divided .
Health and illness are plotted on a health grid against the environment.
Illness or death occurs when more energy is expended than is generated.
Energy is displayed with wellness on one end and illness at the other end.
The nurse plans care for a client with an acute illness. What should the nurse keep in mind about the client’s developmental level when selecting interventions for this client? Select all that apply.
Age
Pain
Perception
Coping Ability
Family Support
The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. Which action is the most important for the nurse at this time?
Take an oral temperature with an electronic thermometer.
Take the blood pressure in the arm without an IV.
Count the client’s respiratory rate for 1 full minute.
Compare the left pedal pulse with the right pedal pulse.
The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?
Have the client take several deep breaths.
Request the client take a deep breath and cough.
Take the client’s blood pressure and apical pulse.
Count the client’s respiratory rate for 1 minute.
Which set of vital signs is within normal limits for a client at rest?
Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54
Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68
Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84
Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95
The nurse assesses a client’s vital signs. Which client situation should be reported to the primary care provider?
Decreased temperature after a period of diaphoresis
Decreased blood pressure (BP) after standing up
Increased heart rate after walking down the hall
Increased respiratory rate when the heart rate increases
Which client would probably have a higher than normal respiratory rate?
Recovering from surgery and receiving a narcotic analgesic
Recovering from surgery and lost a unit of blood intraoperatively
Lived at a high altitude and then moved to sea level
Exposed to the cold and is now hypothermic
When caring for a client with a fever, what should the nurse expect to be increased?
Urine output
Sensitivity to pain
Blood pressure
Respiratory rate
The nurse is teaching a client how to use a portable blood pressure device to monitor blood pressure at home. What is the most important action for the nurse to take?
Ask the client to demonstrate the use of the blood pressure device.
Explain the importance of frequent calibration of the device
Give the client a chart to record his blood pressure readings.
Provide written instructions of the information taught.
The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include?
“Be sure to put mittens on the baby.”
“Layer the infant’s clothing.”
“Place a cap on the infant’s head.”
“Put warm booties on the baby.”
In evaluating a client’s blood pressure for hypertension, what is the most important action for the nurse to take?
Use the same type of manometer each time.
Auscultate all five Korotkoff sounds.
Measure the blood pressure in both arms.
Monitor the blood pressure for a pattern.
Which information in a client’s health history might indicate a risk for primary hypertension?
Consumes a high-protein diet
Drinks three to four beers every day
Has a family history of kidney disease
Does not engage in physical exercise
The nurse provides client education regarding hypertension prevention and management. Which statement indicates that the client understands the instructions?
“I don’t have to worry if my blood pressure is high once in a while.”
“I guess I will have to make sure I don’t drink too much water.”
“I can lose some weight to help lower my blood pressure.”
“I will need to reduce the amount of milk and other dairy products I consume.”
For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit?
Recovering from abdominal surgery 2 hours ago
Experienced a fractured hip yesterday
Dehydrated from vomiting
History of heart and lung disease
Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range?
Oral temperature 100°F (37.8°C)
Respiratory rate 26 breaths/min and shallow
Apical heart rate 56 beats/min
Blood pressure 124/82 mm Hg
During a clinic interview, a client states experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement?
Ask the client when in the day dizziness occurs.
Help the client to assume a recumbent position.
Measure both heart rate and blood pressure with the client standing.
Measure vital signs with the client supine, sitting, and standing.
Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply
Blood pressure decreases less than heart rate and respiratory rate.
Respiratory rate remains fairly stable throughout a person’s life.
Blood pressure increases; heart rate and respiratory rate decline.
Men have higher blood pressure than women until after menopause.
Body temperature increases with aging.
Which findings are specific indicators of hypoxia? Select all that apply.
Feelings of anxiety
Crackles in the lung bases
Increased heart rate
Improved breathing in upright position
Cyanosis of the tongue
The nurse prepares a teaching session on blood pressure for a group of nursing students. What should the nurse explain can falsely elevate the blood pressure measurement? Select all that apply.
Cuff that is too wide
Cuff that is too narrow
Mild to moderate pain present
Measuring after the client smokes
Measuring after a client ambulates
Which nursing behavior indicates the highest potential for spreading infections among clients?
Disinfects dirty hands with antibacterial soap
Allows alcohol-based rub to dry for 10 seconds
Washes hands only when leaving each room
Uses cold water for medical asepsis
What is the most frequent cause of the spread of infection among institutionalized patients?
Airborne microbes from other patients
Contact with contaminated equipment
Hands of healthcare workers
Exposure from family members
Which activity is of highest priority for maintaining medical asepsis?
Washing hands
Donning gloves
Applying sterile drapes
Wearing a gown
What is a patient considered who is infected with a virus but who does not have any outward sign of the disease?
Pathogen
Fomite
Vector
Carrier
A patient is admitted to the hospital with tuberculosis. Which precaution must the nurse institute when caring for this patient?
Droplet
Airborne
Direct contact
Indirect contact
A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed?
Latent
Primary
Endogenous healthcare-related
Exogenous healthcare-related
A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. Currently the patient has a normal temperature. Which stage of infection is the patient most likely experiencing?
Incubation
Prodromal
Decline
Convalescence
A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?
Phagocytosis
Complement cascade
Inflammation
Immunity
What should the nurse consider for a patient who has a temperature of 101°F (38.3°C)?
Acetaminophen (Tylenol)
Increased fluids
Bedrest
Tepid bath
For which range of time must a nurse wash her hands before working in the operating room?
1 to 2 minutes
2 to 4 minutes
2 to 6 minutes
6 to 10 minutes
How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation?
Place the tray in a specially marked trash can inside the patient’s room.
Place the tray in a special isolation bag held by a second healthcare worker at the patient’s door.
Return the tray with a note to dietary services so it can be cleaned and reused for the next meal.
Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.
To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands?
When fingers feel sticky
After 5 to 10 seconds
When leaving the client’s room
Once fingers and hands feel dry
A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient?
Contact
Protective
Droplet
Airborne
The nurse is removing personal protective equipment (PPE). Which item should be removed first?
Gown
Gloves
Face shield
Hair covering
In which situation would using standard precautions be adequate? Select all that apply
Interviewing a client with a productive cough
Helping a client to perform his own hygiene care
Aiding a client to ambulate after surgery
Inserting a peripheral intravenous catheter
Emptying a urine collection bag
Which action protects the body against infection? Select all that apply.
Eating a healthy, well-balanced diet
Being an older adult or an infant
Engaging in leisure activities three times a week
Exercising for 30 minutes 5 days a week
Receiving recommended immunizations
The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. Which NAP action indicates that teaching has been effective? Select all that apply.
Uses a paper towel to turn off the fauce
Holds fingertips below the wrists while rinsing off the soap
Removes all rings and watch before washing hands
Cleans underneath each fingernail
Rubs hands vigorously for 20 seconds
Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply.
Virus
Bacterial spores
Yeast
Mold
Protozoa
A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply.
Question the order because the patient must remain in isolation.
Place an N-95 respirator mask on the patient and transport him to the test.
Place a surgical mask on the patient and transport him to CT lab.
Notify the CT department about precautions prior to transport.
A client informs the nurse that he has quit smoking because his father died of lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which behavior?
Healthy living
Health promotion
Wellness behaviors
Health protection
Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults?
Liver damage
Unintentional death
Tobacco use
Obesity
A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving?
Primary prevention
Secondary prevention
Tertiary prevention
Health promotion
Which individuals should receive annual lipid screening?
All overweight children
All adults aged 20 years and older
Persons with total cholesterol greater than 150 mg/dL
Persons with HDL less than 40 mg/dL
A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which trait is she demonstrating that is linked to health and healing?
Invincibility
Hardiness
Baseline strength
Vulnerability
After completing a health assessment, the nurse determines that a patient is at risk for heart disease. What did the nurse assess to make this clinical determination?
Large thighs
Low water intake
Abdominal obesity
Cares for young children
A client with a BMI of 29 asks what can be done to help in losing weight. What should the nurse recommend to this client?
Enjoy food.
Eat more whole grains.
Eat one meatless meal a week.
Replace sugary beverages with diet soda.
What does the World Health Organization’s definition of the health include? Select all that apply.
Absence of disease
Physical well-being
Mental well-being
Social well-being
Financial security
Which are goals for Healthy People 2020? Select all that apply
Eliminate health disparities among various groups.
Decrease the cost of healthcare related to tobacco use.
Increase the quality and years of healthy life.
Decrease the number of inpatient days annually.
Promote healthy development for people in all stages of life.
Health promotion programs assist a person to advance toward optimal health. Which activity might such programs include? Select all that apply.
Disseminating information
Changing lifestyle and behavior
Prescribing medications to treat underlying disorders
Environmental control programs
Wellness appraisal programs
Which action demonstrates how nurses promote health? Select all that apply.
Role modeling
Educating patients and families
Counseling
Providing support
Providing direct care
A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain?
Acute
Chronic
Intractable
Neuropathic
How should the nurse classify pain that a patient with lung cancer is experiencing?
Radiating
Deep somatic
Visceral
Referred
A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?
Psychogenic
Phantom
Referred
Radiating
The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?
Blood pressure 160/82 mm Hg
Temperature 100.6°F
Heart rate 80 beats/min
Oxygen saturation 95%
A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?
Metabolic alkalosis
Pneumothorax
Pneumonia
Hemothorax
After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take?
Use nonpharmacological therapy while waiting 3 more hours before the next dose.
Administer an additional 800-mg oral dose of ibuprofen right away.
Do nothing because the patient’s facial expression indicates he is comfortable.
Notify the prescriber that the current pain management plan is ineffective.
The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan?
Place the cold pack directly on the skin over the ankle.
Apply the cold pack to the ankle for 30 minutes at a time.
Check the skin frequently for extreme redness.
Keep the cold pack in place for at least 24 hours.
A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do?
Notify the prescriber immediately.
Take the medication with food.
Take the medication with 8 ounces of water.
Take the medication before bedtime.
A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication?
Monitor the patient’s respiratory status.
Auscultate the patient’s heart sounds.
Check blood pressure in supine and sitting positions.
Monitor the patient for psychological drug dependence.
A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use?
Caution the patient against combining acetaminophen with alcohol.
Explain that acetaminophen increases the risk for bleeding.
Advise taking acetaminophen with meals to prevent gastric irritation.
Explain that physical dependence may occur with long-term oral use.
Which side effects associated with opioid use may improve after taking a few doses of the drug?
Constipation
Drowsiness
Dry mouth
Difficulty with urination
Which pain management task can be safely delegated to nursing assistive personnel (NAP)?
Assessing the quality and intensity of the patient’s pain
Evaluating the effectiveness of pain medication
Providing a therapeutic back massage
Administering an oral dose of acetaminophen
An older adult receiving hospice care has dementia as a result of metastasis to the brain and bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed?
Experiences less pain than in earlier stages of cancer
Cannot communicate the character of his pain effectively
Recalls pain at a later time than when it occurs
Relies on caregiver to provide pain relief without asking
What is typically the most reliable indicator of pain?
Patient’s self-report
Past medical history
Description by caregiver(s)
Behavioral cues
A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale would be appropriate to use with this patient? Select all that apply.
Visual analog
Numerical rating
Wong-Baker FACES rating
Simple descriptor
Revised Faces Pain Scale
A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction by the nurse might help relieve the patient’s constipation? Select all that apply.
“Be sure the amount of fruit, vegetables, and fiber in your diet is adequate.”
“Drink at least eight 8-ounce glasses of water each day.”
“Avoid using stool softeners because they may become habit forming.”
“Increase your exercise routine to include 1 hour of exercise a day.”
“Take a laxative every day.”
Nursing assistive personnel (NAP) ask why so many clients seem to be complaining of pain. What should the nurse emphasize to the NAP about pain? Select all that apply.
Pain is subjective.
Pain is measured objectively.
Pain is whatever the client says it is.
Pain exists when the client says it does.
Your expectations of clients’ pain are influenced by individual values.
The nurse notes that clients have different thresholds and levels of pain that are not consistent with the health problem or condition. What should the nurse remember about influencers of pain? Select all that apply.
Age
Culture
Emotions
Previous experiences
Socioeconomic status
What will a person who is deprived of REM sleep for several nights in succession usually experience?
Extended NREM sleep
Paradoxical sleep
REM rebound
Insomnia
Which factor has the greatest positive effect on sleep quality?
Sleeping hours in synchrony with circadian rhythm
Sleeping in a quiet environment
Spending additional time in stage NIII of the sleep cycle
Napping frequently during the day hours
Which patient teaching would be most therapeutic for someone with sleep disturbance?
Give yourself at least 60 minutes to fall asleep.
Avoid eating carbohydrates before going to sleep.
Catch up on sleep by napping or sleeping in when possible.
Do not go to bed feeling upset about a conflict.
A client becomes confused when aroused so the nurse can provide a treatment. Which stage of sleep was this client most likely experiencing?
NREM 1
NREM 2
NREM 3
REM
Which is a pattern of waking behavior that appears during sleep?
Parasomnias
Dyssomnias
Insomnia
Hypersomnia
During which developmental stage does a person tend to need the most hours of sleep?
Toddler
Adolescence
Middle adulthood
Older adulthood
The nurse prepares to provide a client with a back massage during evening care. What action should the nurse take before providing this intervention?
Provide a warm cup of tea.
Provide a prescribed sleeping aid.
Check the skin for reddened areas or skin breakdown.
Encourage the client to sit in a chair for a short time before the massage.
Which factor is known to affect sleep? Select all that apply..
Age
Environment
Lifestyle
State of health
A mother is concerned about a 7-year-old child having nocturnal enuresis three to four times a week. What should the nurse respond to this mother? Select all that apply.
“Your daughter’s bladder is still developing at this point in her life.”
“Be patient; most children outgrow enuresis.”
“Wake your daughter every 4 hours to use the bathroom.”
“You might consider purchasing protective pads for the bed.”
“Try a bed alarm to wake her when she starts wetting the bed at night.”
The patient is diagnosed with obstructive sleep apnea. What should the nurse expect to assess in this patient? Select all that apply.
Bruxism
Enuresis
Daytime fatigue
Snoring
Drooling
A middle-aged client is overwhelmed with work and says, “Sleep is optional.” What should the nurse explain about the importance of sleep to this client’s physical, mental, and spiritual health? Select all that apply.
Sleep impacts learning.
Sleep and illness are not related.
Sleep reduces stress and anxiety.
Sleep regulates energy metabolism.
Sleep affects almost every tissue in the body.
