Health Assessment for Nurses
Midterm Exam
Course Introduction
Health Assessment for Nurses is a foundational course designed to equip nursing students with the essential knowledge and skills necessary for comprehensive patient assessment across the lifespan. The course emphasizes the systematic collection of health data through patient interviews, health histories, physical examinations, and the use of diagnostic tools. Students will learn to identify normal versus abnormal findings, document assessments accurately, and apply clinical reasoning to formulate nursing care plans. By integrating theoretical knowledge with practical skills, this course prepares nurses to perform holistic health assessments and contribute to evidence-based clinical decision-making in diverse healthcare settings.
Recommended Textbook
Essentials for Nursing Practice 8th Edition by Potter
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39 Chapters
1000 Verified Questions
1000 Flashcards
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Page 2
Chapter 1: The Nursing Profession
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12 Verified Questions
12 Flashcards
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Sample Questions
Q1) A patient does not want the treatment that was prescribed.The nurse helps the patient talk to the primary health care provider and even talks to the primary health care provider when needed.The nurse is acting in which professional role?
A) Educator
B) Manager
C) Advocate
D) Provider of care
Answer: C
Q2) A nurse is an advanced practice registered nurse (APRN)who cares for geriatrics.This nurse is which type of advanced practice nurse?
A) Clinical nurse specialist
B) Nurse practitioner
C) Certified nurse-midwife
D) Certified registered nurse anesthetist
Answer: A
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Chapter 2: Health and Wellness
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36 Verified Questions
36 Flashcards
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Sample Questions
Q1) To determine a patient's external variables for health beliefs and practices,which area should the nurse assess?
A) Emotional factors
B) Intellectual background
C) Developmental stage
D) Socioeconomic factors
Answer: D
Q2) A patient is drinking milk that has been fortified with vitamin D.Which type of health promotion strategy is the patient using?
A) Active
B) Passive
C) Environmental
D) Sociological
Answer: B
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4
Chapter 3: The Health Care Delivery System
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) Which patient is most in need of discharge planning by the nurse?
A) A 29-year-old mother with strong family support who has a healthy newborn
B) A 59-year-old patient with an active lifestyle who has had an appendectomy
C) A 64-year-old patient with heart failure who has a limited income
D) A 56-year-old patient with a supporting spouse who has had a hysterectomy
Answer: C
Q2) A 78-year-old widow needs assistance with medications,housekeeping,and laundry,and would like to maintain independence.Which is the best option for the nurse to suggest?
A) Assisted living
B) Respite care
C) Nursing center
D) Rehabilitation center
Answer: A
Q3) Which patient is most suitable for admission into hospice?
A) A 63-year-old man with a fractured femur
B) A 45-year-old woman with terminal end-stage renal failure
C) A 14-year-old patient with leukemia that is in remission
D) A 78-year-old patient with dementia that wanders
Answer: B
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Chapter 4: Community-Based Nursing Practice
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12 Flashcards
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Sample Questions
Q1) A nurse in community-based practice needs a variety of skills and talents while rendering care to patients in the community.Which are competencies of the community health nurse? (Select all that apply.)
A) Case manager
B) Care giver
C) Educator
D) Advocate
E) Counselor
Q2) A nurse is practicing as a community health nurse.What is the primary focus of care for this nurse?
A) Providing care to subpopulations
B) Practicing care in existing services
C) Being a specialist in public health science
D) Having a case management certification
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6
Chapter 5: Legal Principles in Nursing
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30 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient who refuses to cooperate for a dressing change.The nurse tells the patient that he or she will tie the patient down if the patient does not hold still.Which action did the nurse commit?
A) Assault
B) Unintentional tort
C) Battery
D) Felony
Q2) A patient is confused and is attempting to get out of the hospital bed.The nurse is tired after working for more than 10 hours and is concerned for the patient's safety.What is the best action that the nurse should take to prevent the patient from harm?
A) Restrain the patient with wrist restraints.
B) Place the patient with a belt restraint in a chair.
C) Sedate the patient with medication.
D) Ask a family member to sit with the patient.
Q3) A patient died from suspicious circumstances.What should the nurse do next?
A) Notify the coroner.
B) Notify the newspaper.
C) Chart what the nurse thinks happened.
D) Chart opinions from the health care staff.
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Page 7
Chapter 6: Ethics
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19 Flashcards
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Sample Questions
Q1) The mother of a 45-year-old patient is a retired physician and requests to discuss the patient's plan of care with the nurse caring for the patient.What is the nurse's best response to this request?
A) "I will need to ask permission from my supervisor before I can share that information."
B) "I will show you the chart, just follow me and we can discuss your questions and concerns."
C) "I would suggest that you leave me out of your family problems. I am here to care for the patient."
D) "I will have to get the patient's permission before I can share that information."
Q2) A community health nurse states,"I wish we had just a portion of the dollars spent repairing atherosclerotic hearts to teach the community about cardiovascular risk factors." The nurse's statement stems from what philosophy?
A) Deontology
B) Feminist ethic
C) Utilitarianism
D) Ethics of care
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Chapter 7: Evidence-Based Practice
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19 Flashcards
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Sample Questions
Q1) A nurse is describing types of performance improvement models.Which information should the nurse include? (Select all that apply.)
A) Six Sigma
B) Balanced scorecard
C) Plan-Do-Study-Act
D) Root cause analysis
E) Human subjects committee
Q2) The quality improvement or performance improvement (QI/PI)process should begin at which level of nursing?
A) Staff nurse
B) Nurse manager
C) Nurse administrator
D) Advanced practice registered nurse
Q3) The nursing unit staff has used evidence-based practice to implement a practice change.What is the next step in the process the nursing staff should implement?
A) Review literature.
B) Engage companies.
C) Measure outcomes.
D) Ask a clinical question.
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Page 9
Chapter 8: Critical Thinking
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) A new registered nurse working for a busy unit of an acute care teaching hospital begins the shift with four patients.Which patient should the nurse attend to first?
A) Patient who needs assistance in ambulating the hall
B) Patient whose blood pressure suddenly drops and who passes out (faints)
C) Recovering stable surgical patient whose family has just arrived
D) Recovering patient who is resting quietly watching television
Q2) A nurse is teaching a group of nursing students about the nursing process.In which order should the nurse list the steps?
A) Assessment, diagnosis, planning, implementation, and evaluation
B) Diagnosis, assessment, planning, implementation, and evaluation
C) Planning, evaluation, diagnosis, implementation, and assessment
D) Evaluation, diagnosis, planning, implementation, and assessment
Q3) A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge.Which concept for a critical thinker is the nurse using?
A) Maturity
B) Analyticity
C) Systematicity
D) Inquisitiveness
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Chapter 9: Nursing Process
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33 Verified Questions
33 Flashcards
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Sample Questions
Q1) A postoperative patient is continuing to have incisional pain.As part of the nurse's assessment,the nurse notes that the patient is grimacing when he or she changes position.The patient's grimace can be useful in the assessment and can be described as which of the following?
A) Cue
B) Inference
C) Diagnosis
D) Health pattern
Q2) Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?
A) "Let us help you."
B) "Did you seek help when it first started?"
C) "Tell me about the problems you are having."
D) "Do you have a family history of this problem?"
Q3) A nurse is evaluating care for a patient.Which action should the nurse take?
A) Compares patient findings with the goals and outcomes
B) Determines if interventions were completed
C) Develops a nursing diagnosis
D) Writes a care plan
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Page 11
Chapter 10: Informatics and Documentation
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?
A) To invoice the nurse for reimbursement
B) To protect the patient in case of a malpractice suit
C) To ensure everyone is working toward a common goal of providing safe care
D) To contribute to a worldwide databank for trends in health care
Q2) A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night-Betty Smith,RN.The nurse is using which type of charting?
A) PIE documentation
B) SOAP documentation
C) Narrative charting
D) Charting by exception
Q3) Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?
A) "Sm. amt. of emesis."
B) "150 mL of cloudy dark yellow urine."
C) "Had a good day."
D) "Looks bad."
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Chapter 11: Communication
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) Which technique should the nurse use when providing information to a patient with a health literacy level of fifth grade?
A) Use the passive voice of language.
B) Present the most important information first.
C) Shift from subject to subject until the patient responds.
D) Explain using jargon so the patient will understand others on the health care team.
Q2) Which behavior by the nurse would be considered most professional?
A) Addressing a patient by "dear"
B) Wearing small earrings
C) Being task oriented
D) Avoiding troublesome patients
Q3) A 9-year-old patient who is hospitalized for bowel surgery appears very frightened.To appear less threatening to the child,which action should the nurse take?
A) Stand over the bed when talking to the patient.
B) Sit in a chair next to the bed when talking to the patient.
C) Maintain constant eye contact with the patient at all times.
D) Stay within 12 inches of the patient when talking to the patient.
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Chapter 12: Patient Education
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24 Flashcards
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Sample Questions
Q1) Which behavior by a new nurse will cause the nurse manager to intervene?
A) Initiates teaching of a patient
B) Uses discovery learning techniques with a patient
C) Assigns nursing assistive personnel to teach a patient
D) Implements the teach-back method to evaluate patient understanding
Q2) Which patient is the most likely to be motivated to learn?
A) A 23-year-old smoker being taught about weight control
B) A 45-year-old man being taught about importance of prostate cancer screening
C) A 63-year-old knee replacement patient being taught postsurgical knee rehabilitation
D) A 15-year-old girl being taught about safe sex
Q3) An 8-year-old boy has been diagnosed with diabetes.A nurse is teaching his mother how to plan meals that are appropriate for him.The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her.What type of teaching method did the nurse use?
A) Simulation
B) Role-play
C) Analogy
D) Demonstration
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Page 14
Chapter 13: Managing Patient Care
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient- and population-centered care that is safe,timely,efficient,effective,and equitable. Using a top-down communication strategy does not apply as a team approach,but is needed for interprofessional collaboration.
Q2) Which competencies should the nurse follow to be an effective team member in interprofessional collaboration? (Select all that apply.)
A) Work to maintain a climate of mutual respect.
B) Use your role specific knowledge to address health care needs.
C) Apply relationship-building values and principles of team dynamics.
D) Use a top-down communication strategy.
E) Support a team approach to the maintenance of health.
Q3) A staff nurse is caring for six patients and is working with nursing assistive personnel.Which task can the nurse safely delegate to the nursing assistive personnel?
A) Patient assessment
B) Patient discharge teaching
C) Patient bed bath
D) Patient medication administration
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Chapter 14: Infection Prevention and Control
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22 Verified Questions
22 Flashcards
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Sample Questions
Q1) The nurse has noticed slight redness when washing her hands.She is concerned about developing a latex allergy.To prevent this,the nurse should:
A) wear only powdered gloves to help protect her skin.
B) wear gloves constantly to decrease the number of handwashings.
C) apply only oil-based hand care products to her hands.
D) report to employee health services and/or seek immediate medical care.
Q2) The nurse and is very concerned about infection control in the Surgery Department.Recently she provided education to the surgery staff on ways to eliminate transient hand flora.The most precise description for this is hand:
A) hygiene.
B) washing.
C) antisepsis.
D) rub.
Q3) Which of the following situations is most likely to contribute to a health care-acquired infection?
A) A closed urinary drainage system
B) Use of aseptic technique during dressing changes
C) Foley catheter drainage bag touching the floor
D) Changing IV access site when site is red and warm
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Page 16
Chapter 15: Vital Signs
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) A 38-year-old postoperative patient is suddenly unresponsive but is still breathing.The nurse will use which site to assess the patient's pulse?
A) Apical artery
B) Radial artery
C) Carotid artery
D) Brachial artery
Q2) The nurse has assessed the need to check the patient for orthostatic hypotension.Conditions that would cause the nurse to be concerned about this would be which of the following? (Select all that apply.)
A) Dehydration
B) Obesity
C) Recent blood loss
D) Cigarette smoking
E) Prolonged bed rest
Q3) What is the difference between systolic and diastolic pressure?
A) Diastolic pressure
B) Pulse pressure
C) Hypertension
D) Systolic pressure
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Page 17
Chapter 16: Health Assessment and Physical Examination
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33 Verified Questions
33 Flashcards
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Sample Questions
Q1) An older adult African-American woman has gone to the clinic where a RN volunteers twice a week.She is a diabetic and has some skin breakdown on the calf of her right leg.Her skin is very darkly pigmented.To best examine the patient's skin,the nurse should use which of the following?
A) Halogen lighting
B) Artificial warming to increase room temperature
C) Natural sunlight
D) Air conditioning to lower room temperature
Q2) An adolescent is examined and told that she has a sexually transmitted disease (STI).The patient is shocked and states,"How can that be.I would know if I had a problem down there wouldn't I?" What is the most appropriate response by the nurse?
A) "You should have known. It's pretty hard to miss."
B) "Usually STIs show up within 2 to 3 days of exposure."
C) "If you'd like, we can teach you some self-examination techniques."
D) "It's just bad luck. We'll clear this up and that will be the end of it."
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18
Chapter 17: Administering Medications
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Sample Questions
Q1) The health care provider orders pain medication to be given to a patient when the patient needs it to control pain.What is this called?
A) PRN order
B) Standing order
C) One-time order
D) STAT order
Q2) A nurse is caring for a patient with kidney disease.The nurse needs to make more focused assessments when administering medications to this patient because the patient may experience problems with the process of:
A) excretion.
B) absorption.
C) distribution.
D) metabolism.
Q3) Which of the following patients is most at risk for theophylline toxicity due to decreased biotransformation ability?
A) A 45-year-old man with renal insufficiency
B) A 59-year-old man with chronic obstructive airway disease
C) A 53-year-old woman who smokes and has asthma
D) A 49-year-old woman with chronic obstructive airway disease and hepatitis
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Page 19
Chapter 18: Fluid,Electrolyte,and Acid-Base Balances
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32 Flashcards
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Sample Questions
Q1) A nurse is mentoring a new nurse who is learning to start IVs.The nurse tells the new nurse that in case the patient needs subsequent venipuncture sites,the best place to initially start an IV is the:
A) antecubital vein of the patient's nondominant arm.
B) most appropriate distal vein on the nondominant arm.
C) most appropriate proximal vein available on either arm.
D) antecubital vein of the patient's dominant arm.
Q2) During a clinical rotation at an orthopedic unit,a nursing student is caring for a 67-year-old patient who has undergone a knee replacement.The patient is complaining of pain at the IV site.The nursing student assesses the site and finds that the site is cool and pale.The student stops the IV and reports the situation to the nurse.What does the nursing student suspect?
A) Phlebitis
B) Infiltration
C) Thrombophlebitis
D) Local inflammation
Q3) Yesterday morning the patient weighed 169.4 lb (77 kg).This morning the patient weighs 171.6 lb (78 kg).The nurse determines that the patient has gained _____ liter(s)of fluid.
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Page 20
Chapter 19: Caring in Nursing Practice
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Sample Questions
Q1) Which of the following would indicate that the nurse has established a level of mutual problem solving?
A) The nurse helps the patient develop questions to ask the health care provider.
B) The nurse tells the patient what needs to be done to resolve health problems.
C) The nurse is seen as the authority when it comes to health care issues.
D) The nurse excludes the family from health discussions to protect privacy.
Q2) The ANA,National League for Nursing,AONE,and American Association of Colleges of Nursing recommend strategies to reverse the current nursing shortage.A number of the strategies have potential for creating work environments that enable nurses to demonstrate more caring behaviors.Which of the following provisions is advocated to create a more desirable work environment?
A) Provide nurses with autonomy over their practice.
B) Increase the rigor in the work environment structure.
C) Increase the availability of technology.
D) Stress the cost-effectiveness of health care.
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Chapter 20: Cultural Awareness
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Sample Questions
Q1) Health care regulatory agencies,national think tanks,and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication,patient safety and quality,and patient-centered care.Some examples of such organizational policies and practices include which of the following? (Select all that apply.)
A) Instituting a requirement for all staff to be trained in cultural competence
B) Maintaining the traditional description of family in written policies
C) Enforcing strict visitation policies and practices
D) Ensuring that persons who are deaf or speak limited English have access to an interpreter
E) Embedding health literacy principles in written and verbal communication
Q2) A nurse is in the process of admitting an ethnically diverse patient.To plan culturally competent care,what must the nurse do? (Select all that apply.)
A) Assume that cultural processes are the same within a social group.
B) Conduct a systematic cultural assessment.
C) Communicate effectively.
D) Negotiate world view differences.
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Page 22
Chapter 21: Spiritual Health
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Sample Questions
Q1) Interventions a nurse can use to establish presence with a patient include which of the following? (Select all that apply.)
A) Giving attention
B) Answering questions
C) Listening
D) Administering medication
E) Speaking with the family
Q2) A nurse is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery.To help this patient cope with this experience,what is the best thing for the nurse to do?
A) Recommend that the patient not discuss the experience with family.
B) Assume that the near death experience was a positive experience.
C) Explain that people who have not had that experience will not understand.
D) Explore what happened with the patient.
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23
Chapter 22: Growth and Development
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Sample Questions
Q1) A pregnant teenager asks the clinic nurse why she cannot smoke during the first trimester.Remembering growth and development,what is the nurse's best response?
A) "Smoking is a bad habit, but it probably won't affect the baby."
B) "Smoking may affect organ systems that are beginning to develop."
C) "Smoking will only affect the baby in the third trimester."
D) "Smoking mothers usually produce overweight babies"
Q2) A student nurse who works in a pediatric clinic is assisting with an assessment on a young child who is not yet walking.She knows that it is considered a delayed gross motor ability if the child does not walk by _____ months.
A) 16
B) 18
C) 20
D) 22
Q3) Polypharmacy is:
A) the use of unprescribed medication for recreational use.
B) the prescription, use, or administration of more medications than are needed.
C) very rare in older adults.
D) rarely a problem as long as the medications are taken together.
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Chapter 23: Self-Concept and Sexuality
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Sample Questions
Q1) The patient is a 66-year-old patient who has been admitted to the hospital for a transient ischemic attack (TIA).Her health care provider has told her that she should consider retiring from her high-stress position as a hospital administrator.The patient is distraught over this suggestion.The nurse caring for her recognizes the most likely cause of distress is a result of a change in which of the following?
A) Body image
B) Role performance
C) Self-esteem
D) Identity
Q2) The student nurse is discussing her 4-year-old patient with her nursing instructor.The instructor asks her about how Erikson's Developmental Tasks have an impact on a 4-year-old child's self-concept and sexuality.What is the best response?
A) "Mike identifies with his father."
B) "Mike likes to help dress himself."
C) "Mike is aware that he is too small to play football."
D) "Mike is looking forward to going to college when he gets bigger."
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25
Chapter 24: Family Context in Nursing
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Sample Questions
Q1) The nurse is admitting a 45-year-old patient and asks about her family.The patient states that she lives with her daughter and son-in-law.The nurse knows that this is an example of which of the following family forms?
A) Nuclear
B) Extended
C) Blended
D) Alternate pattern relationship
Q2) A student nurse is working on a community health project with her peers.One of the concerns in her community is the rise in homelessness resulting from the economy.The student nurse understands that which of the following is true?
A) Almost all homeless families are made up of single-parent families.
B) Children in homeless families are usually in good health.
C) Families with children are the fastest growing segment of the homeless population.
D) Children in homeless families have no way to attend school so are illiterate.
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Chapter 25: Stress and Coping
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Sample Questions
Q1) The student nurse was late for clinical rounds because she had to change the tire on her car.She is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the medication that she is preparing.The student nurse is very frustrated,becomes tearful,and states,"I can't seem to crush this tablet correctly." This reaction to the instructor is most likely a result of what ego-defense mechanism?
A) Compensation
B) Displacement
C) Denial
D) Dissociation
Q2) A patient telephones a crisis intervention hotline.The nurse assigned to this center assesses that the patient is experiencing a crisis.What is the most appropriate action for the nurse to take?
A) Take control of the situation and tell the patient what needs to be done.
B) Define the problem at hand and ensure that the patient is safe.
C) Ask the patient how he would like to handle the crisis and follow through.
D) Ask the patient to list all of his problems and prioritize which to deal with first.
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Chapter 26: Loss and Grief
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Sample Questions
Q1) A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered.The nurse identifies that this patient is experiencing the second stage of Kübler-Ross' stages of dying.What is the second stage?
A) Anger
B) Denial
C) Bargaining
D) Acceptance
E) Depression
Q2) The patient's home has been demolished by a tornado.The patient's spouse and child were killed and the spouse is in need of a leg amputation.The nurse realizes that which of the following is true?
A) The patient will deal with his losses using usual coping strategies.
B) A patient's normal coping strategies are always adequate.
C) Patients usually seek new strategies to deal with loss.
D) At the end of life, people still rely on the usual coping strategies.
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Chapter 27: Exercise and Activity
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Sample Questions
Q1) Which of the following actions are effective in reducing friction when repositioning a patient in bed? (Select all that apply.)
A) Lifting rather than pushing
B) Pushing the patient up in bed
C) Asking the patient to bend his or her knees and lift the hips when moving up in bed
D) Asking the patient to lie still as you reposition him or her; even when the patient offers to help
E) The use of a draw sheet
F) The use of a transfer board
Q2) Which of the following trouble points are common in the side-lying position? (Select all that apply.)
A) Lack of support for the feet
B) Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles
C) Adduction of the shoulder and hip joints
D) Hyperextension of the neck
E) Spinal curves out of normal alignment
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Chapter 28: Safety
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Sample Questions
Q1) Of the following,who is most at risk for accidental poisoning?
A) Supervised 16-month-old toddler eating dry cereal in the highchair
B) Unsupervised 2-month-old infant left near a closed bottle of prescription medication
C) Unsupervised 4-year-old child playing dress-up with mother's makeup
D) Supervised 6-year-old child playing with watercolor paints
Q2) A nurse is giving anticipatory guidance to the mother of a 10-month-old child.The nurse is focusing on providing a safe environment for the child.Which of the following is the best statement regarding childhood safety?
A) "The car seat should be placed in a forward-facing position."
B) "The majority of deaths in children between the ages of 1 and 3 years old are caused by contagious diseases."
C) "Injuries are a major cause of death during infancy, especially for children 6 to 12 months old."
D) "Measles causes more deaths in children younger than 5 years old than all other diseases combined."
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Chapter 29: Hygiene
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Sample Questions
Q1) An unconscious patient requires mouth care every 2 hours.Before attempting mouth care,the nurse should first do which of the following?
A) Assess the patient for a gag reflex.
B) Position the patient in a prone position.
C) Have an operational suction machine nearby.
D) Retract the upper and lower teeth with a padded tongue blade.
Q2) A nurse who works for a pediatric clinic is preparing a 13-year-old patient with strep throat for the health care provider.Which of the following is the most important patient teaching information to prevent re-infection?
A) "Replace your toothbrush."
B) "Floss thoroughly after each meal."
C) "Store your toothbrush with a toothbrush cover."
D) "Gargle with antiseptic mouthwash."
Q3) A bedridden patient with long hair may experience problems with matting.What is the most appropriate nursing action?
A) Cut the matted hair away.
B) Braid the hair to reduce the tangles.
C) Use a thick, commercial product to grease the hair.
D) Keep the hair dry by applying powder every morning.
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Page 31
Chapter 30: Oxygenation
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Sample Questions
Q1) A patient on the surgical unit is 1 day postoperative for surgery to remove stomach cancer.In addition to the physiological stress this patient has undergone,the nurse recognizes that this patient will have to deal with the psychological stress of finding out that the cancer has metastasized to the liver.Which physiological change would the nurse expect to see as a response to stress?
A) Decreased heart rate
B) Increased hemoptysis output
C) Increased respiratory rate
D) Decreased cardiac output
Q2) The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations.The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves.The rate is 116 beats per minute and regular.The nurse identifies this rhythm as which of the following?
A) Sinus bradycardia
B) Ventricular tachycardia
C) Sinus tachycardia
D) Normal sinus rhythm
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Chapter 31: Sleep
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Sample Questions
Q1) A patient has been hospitalized with pneumonia.The patient has had some difficulty sleeping while in the hospital.The patient would like to avoid taking medication for sleep because there have been problems with sleeping pills in the past.Which action by the nursing assistant personnel will cause the nurse to intervene?
A) Encouraging the patient to void before bedtime
B) Offering to give the patient a backrub
C) Giving the patient an extra blanket when cold
D) Providing a warm cup of hot cocoa before bedtime
Q2) A patient has returned from back surgery.The family has brought in the patient's continuous positive airway pressure (CPAP)machine.What is the best rationale for allowing the patient to use the CPAP machine at night?
A) It will keep the patient in deep levels of REM, which will decrease the need for pain medication.
B) It will help decrease hospital noise that will keep the patient awake.
C) The patient needs ventilator support owing to the increased chance of postoperative respiratory complications.
D) The patient needs to follow the same bedtime routine to promote a safe environment for sleep.
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Page 33
Chapter 32: Pain Management
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Sample Questions
Q1) Pain impulses are sent to the brain,where the central nervous extracts information regarding location,duration and quality of the pain impulse.What is this process?
A) Transduction
B) Transmission
C) Perception
D) Modulation
Q2) A graduate nurse is working for a diabetes unit.The nurse manager has prepared a very thorough orientation,which includes check-offs for taking vital signs.The nurse manager has informed the graduate nurse that their hospital has adopted the Joint Commission's pain standard and that they will be assessing five vital signs.The graduate nurse knows that the fifth vital sign is which of the following?
A) Arterial blood gasses
B) Blood sugar
C) Blood pressure
D) Pain
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Chapter 33: Nutrition
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Sample Questions
Q1) A patient with head trauma is scheduled for a gastrostomy tube to be inserted.The spouse asks the nurse why an intravenous (IV)cannot be used.What is the nurse's best response?
A) "The gastrostomy tube will allow us to give medications as well as feedings."
B) "Research has shown that a gastrostomy tube is safer for patients and maintains function of the gut."
C) "It will be more expensive in the long run to use a gastrostomy tube than an IV."
D) "The gastrostomy placement is noninvasive, and the patient will be more content being fed through the stomach."
Q2) The nurse who works on the oncology unit understands the importance of nutrition and the disease process.Which patient should the nurse be most concerned about from a nutritional standpoint?
A) A patient with cervical cancer
B) A patient with liver cancer
C) A patient with prostate cancer
D) A patient with colon cancer
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Chapter 34: Urinary Elimination
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Sample Questions
Q1) A patient with a Foley catheter needs a urine sample for culture and sensitivity.What is the most appropriate action for the nurse to take?
A) Disconnect the drainage tube from the catheter.
B) Open the drainage bag and withdraw urine.
C) Withdraw urine from the closed system drainage bag.
D) Insert a sterile blunt cannula in the catheter port to withdraw urine.
Q2) Patients with urinary incontinence are unable to completely empty their bladder.The nurse can assist a patient to void by using which of the following methods? (Select all that apply.)
A) Completing manual bladder compression
B) Having the patient assume the normal position for voiding
C) Telling the patient to void only when he or she has the urge
D) Pressing down on the right and left flanks of the patient
E) Running water in the sink
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Chapter 35: Bowel Elimination
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Sample Questions
Q1) A patient will be undergoing abdominal surgeries,which will most likely result in an ostomy.The patient asks the nurse,"What will the stool from my ostomy look like?" What is the best answer?
A) "Your stools won't change from what they currently are."
B) "The consistency of your stools will be very soft."
C) "The consistency of your stools will be liquid."
D) "The consistency of your stools will depend on the location of stoma (ostomy)."
Q2) The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized following surgery.The nurse recognizes that this condition most likely a result of which of the following?
A) Diarrhea
B) Flatulence
C) Fecal impaction
D) The Valsalva maneuver
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Chapter 36: Immobility
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Sample Questions
Q1) An elderly nursing home resident fell 2 weeks ago and has been on bed rest.The patient has become increasingly fatigued during activities of daily living (ADLs).The family is concerned about the patient's declining condition.The best explanation that the nurse can give the family is that the patient's fatigue is caused by which of the following?
A) Decreased muscle endurance caused by immobility
B) Advanced age
C) Increased metabolism
D) Urinary stasis
Q2) Which patient is most at risk for developing a urinary tract infection?
A) Teenage comatose patient on a ventilator lying supine
B) Middle-age adult after abdominal surgery sitting in a chair
C) Elderly adult with Alzheimer disease who is wandering at night
D) Middle-age adult postcardiac catheterization being discharged home
Q3) Nurses implement therapeutic immobilization for patients to achieve which result?
A) Reducing pain
B) Restraining an unstable patient in bed
C) Increasing active movement of the body
D) Strengthening joints and muscles
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Chapter 37: Skin Integrity and Wound Care
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Q1) On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale? (Select all that apply.)
A) Mobility
B) Nutrition
C) Infection
D) Friction and shear
E) Sensory perception
Q2) Which patient is best suited for heat therapy?
A) A patient with low back pain
B) A patient with suspected appendicitis
C) A patient with first-degree burn
D) A patient with active bleeding
Q3) The nurse is caring for a patient with a necrotic hip wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?
A) Dry gauze
B) Transparent film
C) Hydrogel
D) Hydrocolloid
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Chapter 38: Sensory Alterations
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Q1) A home care nurse is conducting a home assessment.The nurse is looking for the presence of sensory alterations.Factors to assess include if any changes have occurred in which of the following? (Select all that apply.)
A) Activities of ADLs
B) Health promotion
C) Has person had visitors
D) Is person wearing hearing aids and glasses
E) Ability to follow a conversation
Q2) A 16-year-old mother and her newborn come into the clinic for a routine checkup.The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age.The nurse hits a buzzer and the baby turns toward the sound.The nurse assures the mother that the baby can hear because the baby:
A) was discharged from the hospital without any known problems.
B) is producing ear wax.
C) responds to loud noises.
D) is too long young to determine any type of hearing loss.
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Chapter 39: Surgical Patient
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Sample Questions
Q1) A 56-year-old nondiabetic patient is undergoing orthopedic surgery.The perioperative nurse is monitoring the blood glucose level.What is the main rationale for monitoring his blood glucose level during surgery?
A) She does not want the patient to develop an embolism.
B) Research shows a strong relationship between wound infections and hyperglycemia.
C) She knows that normal glucose levels promote platelet production.
D) She is monitoring to prevent embolism.
Q2) A patient is awaiting surgery.The nurse's best rationale for assessing vital signs is to do which of the following?
A) Assess the patient's anxiety level.
B) Determine the patient's basal temperature.
C) Establish a baseline for vital signs comparisons.
D) Assess for any changes that may indicate infection.
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