Nursing Process and Critical Thinking
Final Test Solutions
Course Introduction
This course explores the systematic approach of the nursing process as a foundational framework for patient care, emphasizing critical thinking and clinical reasoning skills. Students will learn to assess, diagnose, plan, implement, and evaluate individualized care while integrating evidence-based practices. Through case studies, simulations, and real-world scenarios, learners will develop the ability to analyze complex patient situations, prioritize nursing interventions, and make informed decisions, ultimately fostering safe and effective patient outcomes across diverse healthcare settings.
Recommended Textbook
Kozier and Erbs Fundamentals of Nursing 10th Edition by Berman
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42 Chapters
1234 Verified Questions
1234 Flashcards
Source URL: https://quizplus.com/study-set/3913
Page 2
Chapter 11: Assessing
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28 Verified Questions
28 Flashcards
Source URL: https://quizplus.com/quiz/77919
Sample Questions
Q1) During an assessment interview,the client states that an elective surgical procedure will not be done because it does not fit into the client's life goals.Into which of Gordon's functional health patterns should the nurse identify this client's comment?
A)Cognitive/perceptual pattern
B)Coping/stress-tolerance pattern
C)Health-perception/health-management pattern
D)Value/belief pattern
Q2) During an initial interview,the client says "I don't understand why I have to have surgery;I'm really not that sick or in pain right now." How should the nurse respond to the client?
A)"It's OK to be worried.Surgery is a big step."
B)"What kind of questions do you have about your surgery?"
C)"I think these are things you should be asking your doctor."
D)"Have you had surgery before?"
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3
Chapter 12: Diagnosing
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family.Which data cluster did the nurse use to support this diagnosis?
A)The family visits different congregations,the parents have been reflecting on their own spiritual upbringings,and the children are questioning rituals of their friends and friends' families.
B)The children attend Sunday school classes,one parent always attends services with the children,and the parents attempt interaction with congregational activities.
C)The grandparents go to weekly services and have formal interaction with clergy.
D)The children have attended private,religious schools,and the parents are involved in the school's activities.
Q2) The nurse is preparing to write nursing diagnoses for a client.What should the nurse recall about the NANDA label?
A)Must contain three components
B)Describes the health problem for which nursing therapy is given
C)Helps define medical diagnoses for nursing
D)Promotes a taxonomy of nursing
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Chapter 13: Planning
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees)during feeding times.What should the nurse identify as the modifier in this intervention?
A)60 to 90 degrees during feeding times
B)Position in chair
C)Upright in a chair
D)Impaired swallowing
Q2) The nurse is devising a care plan for a client with complex health issues and current acute health problems.Which criteria should the nurse ensure is used when planning interventions for this client?
Standard Text: Select all that apply.
A)Congruent with the client's values,beliefs,and culture
B)Are within established standards of care
C)Based on scientific and medical knowledge
D)Achievable with the resources available
E)Must be safe and appropriate for the client's age
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Chapter 14: Implementing and Evaluating
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29 Verified Questions
29 Flashcards
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Sample Questions
Q1) A care area has been short staffed for the past month with a heavy client load and high acuity.The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned,returned,and stored in the appropriate areas.At what level should this care area be evaluated?
A)Management
B)Structure
C)Process
D)Outcome
Q2) The nurse is preparing to evaluate care provided to a client.What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process?
Standard Text: Select all that apply.
A)Effectively assessing the client's needs
B)Selecting the appropriate nursing diagnosis related to the client's needs
C)Collecting client-focused data with a specific need in mind
D)Evaluating by using assessment data to determine effective achievement of goals and outcomes
E)Basing evaluation on assessment data collected during the admission phase
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Chapter 15: Documenting and Reporting
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) The nurse administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?
A)Plan
B)Intervention
C)Evaluation
D)Progress notes
Q2) The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?
A)Subjective data
B)Objective data
C)Assessment
D)Planning
Q3) The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?
A)Lasix,20 mg,po bid
B)Lasix,20 mg tablet,twice daily
C)Lasix,20 mg by mouth,two times a day a day
D)Lasix,20 mg by mouth 8 AM and 2 PM
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Chapter 16: Health Promotion
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) The nurse is providing care within the total care context.What should the nurse consider when using this care approach?
A)The individualism of the client
B)Principles applicable to the client at this moment
C)Principles general to all clients of the same age and condition
D)The person's self-identity
Q2) A client has received a high score on the Life-Change Index.For which part of the client's assessment should the nurse use this information?
A)Life stress review
B)Social support systems review
C)Lifestyle assessment
D)Health beliefs review
Q3) Psychologic homeostasis is maintained by a variety of mechanisms.Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis?
A)A child who is used to getting ready for school alone
B)A teenager whose circle of friends includes single parents of the same age
C)An elderly person who has just moved to a long-term care facility
D)A young adult who is in a long-term relationship
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Page 8
Chapter 17: Health, Wellness, and Illness
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13 Verified Questions
13 Flashcards
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Sample Questions
Q1) During a home visit with a new community member,the nurse suspects that a client has a chronic illness.What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.
A)Experienced symptoms for 8 months
B)Has periods where the symptoms disappear
C)Altered activities of daily living because of the illness
D)Problem disappeared with over-the-counter medication
E)Symptoms appeared abruptly and disappeared after treatment
Q2) The nurse educator is reviewing internal variables that affect people's health status.On which variables is this nurse focusing?
Standard Text: Select all that aply.
A)Genetic makeup
B)Age
C)Developmental level
D)Environment
E)Spiritual and religious beliefs
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Chapter 18: Culture and Heritage
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29 Verified Questions
29 Flashcards
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Sample Questions
Q1) The nurse is concerned that many ethnically diverse clients are not receiving a consistently high level of health care within a community.What information should the nurse access to learn how to improve these clients' level of health care?
Standard Text: Select all that apply.
A)The National Partnership for Action to End Health Disparities website
B)The National Stakeholder Strategy for Achieving Health Equity goals
C)The Office of Minority Health's standards for cultural and linguistic programs
D)The National Center on Minority Health and Health Disparities mission statement
E)The Centers for Disease Control and Prevention website for employment opportunities
Q2) A client is the child of an African American father and Asian American mother.The client has been exposed to cultural foods,traditions,and customs from both parents throughout life.What term should the nurse use to describe this client's cultural development?
A)Diversity
B)Subculture
C)Multicultural
D)Cultural sensitivity
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Page 10
Chapter 19: Complementary and Alternative Healing
Modalities
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28 Verified Questions
28 Flashcards
Source URL: https://quizplus.com/quiz/77911
Sample Questions
Q1) The nurse is teaching a client regarding the use of herbal preparations.Which statements should the nurse include in this teaching?
Standard Text: Select all that apply.
A)"Echinacea might reduce the effectiveness of the immunosuppressant medications you've been prescribed since your transplant."
B)"Gingko could affect the results of your aspirin therapy."
C)"Ginger could be contraindicated because you are taking anticoagulant medications."
D)"With your history of glaucoma,I don't believe you should be supplementing with ginseng."
E)"St.John's wort is a safe supplement when being medicated for depression."
Q2) The nurse is preparing to assess a group of assigned clients with chronic illnesses who use essential oils.For which health problem should the nurse particularly assess the clients?
A)Hypertension
B)Cardiac problems
C)Asthma
D)Cancer
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Chapter 20: Concepts of Growth and Development
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) A young adult has never lived away from his parents and feels unable to make decisions on his own.According to Freud's theory of development,the nurse should suspect that this person would be fixated at which stage of development?
A)Phallic
B)Latency
C)Genital
D)Anal
Q2) The nurse notes that a 20-month-old child is lagging in stage 6 of Piaget's phases of cognitive development.Which activity did the nurse observe that indicates that this child is struggling at this stage?
A)The child wants the same toy to sleep with during naptime and bedtime.
B)The child merely watches as the other children pretend-play.
C)The child cries when the parents leave the unit.
D)The child does not cooperate with some of the treatments.
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Chapter 21: Promoting Health From Conception Through Adolescence
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25 Verified Questions
25 Flashcards
Source URL: https://quizplus.com/quiz/77909
Sample Questions
Q1) The nurse is preparing a teaching session for pregnant clients that reviews the fetal growth and development that occurs in the first 3 weeks post-conception.What should the nurse include in this teaching?
Standard Text: Select all that apply.
A)How the embryo has attached to the wall of the uterus
B)Development of the fetal membranes and the amniotic sac
C)How the embryo will be covered with a protective substance called vernix caseosa
D)How development of the fetal placenta has begun
E)How the embryo is covered with a soft,downy hair
Q2) The parents of a school-age child are concerned about the child learning right from wrong.In which order should the nurse instruct the parents of a school-age child that moral development will develop in their child?
Standard Text: Click and drag the options below to move them up or down.
A)Punishment and obedience
B)Law-and-order orientation
C)Instrumental-relativist orientation
D)"Good boy-nice girl" stage
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Page 13
Chapter 22: Promoting Health in Young and Middle-Aged
Adults
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19 Verified Questions
19 Flashcards
Source URL: https://quizplus.com/quiz/77908
Sample Questions
Q1) A nurse is working in a community of factory workers and is planning an educational session for wellness,targeting the young adult group.In order to address one of the health problems of this group,the nurse plans to:
A)help the group become more aware of marketing efforts by tobacco companies. AU: pls check--if this is correct answer,s/b "help the group become more aware of"?
B)tell this group that smoking is unacceptable.
C)make sure the group is aware of the increased risk of liver disease and cancer of the esophagus.
D)counsel the group regarding addiction.
Q2) The nurse is observing a group of young adults engaged in a discussion regarding work schedules over the holidays.What should the nurse realize that these adults will use to balance the emotional as well as logical side of the discussion?
A)Formal operational stage
B)Postformal thought process
C)Kohlberg's theory of moral development
D)Fowler's spiritual development theory
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Chapter 23: Promoting Health in Elders
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26 Verified Questions
26 Flashcards
Source URL: https://quizplus.com/quiz/77907
Sample Questions
Q1) A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care.When considering these supplies,what should the nurse recall?
A)Medicare will cover supplies,but only with a physician's written order.
B)Between insurance supplements and Medicare,the older client shouldn't have any difficulty with coverage.
C)Most clients in this age group live on a fixed income,and supplies used should be as economical as possible.
D)Clients have to be responsible for their own supplies.
Q2) When consulting Erikson's developmental theory,the nurse determines that which older adult will have the least difficulty being successful with the task of this stage?
A)A client who felt success through her children's accomplishments
B)A client who held his job and work status as the defining feature of his life
C)A client who maintained a balance between work and home
D)A client who planned to really enjoy life once she retired
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15
Chapter 24: Promoting Family Health
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18 Verified Questions
18 Flashcards
Source URL: https://quizplus.com/quiz/77906
Sample Questions
Q1) A nurse is conducting a family assessment as part of the process for services provided through the community.Which part of the assessment should provide the nurse with the best information in identifying existing or potential health problems?
A)Ecomap
B)Genogram
C)Cultural assessment
D)Family communication patterns
Q2) A family struggles with clear communication,and members of the family often seek the help of other systems for personal validation and gratification.What should the nurse identify as an appropriate nursing diagnosis for this family?
A)Altered Family Processes related to communication patterns
B)Impaired Verbal Communication related to inability to communicate
C)Ineffective Family Coping evidenced by assistance from outside sources
D)Knowledge Deficiency (communication patterns)related to dysfunctional patterns of communication
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Chapter 25: Caring
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28 Verified Questions
28 Flashcards
Source URL: https://quizplus.com/quiz/77905
Sample Questions
Q1) The nurse is identifying strategies to support a client's empowerment.What strategies should the nurse use?
Standard Text: Select all that apply.
A)Making it possible for the client diagnosed with mild Alzheimer's disease to continue to dance regularly,as it has always been a passion of hers
B)Being sure to polish the client's nails now that she is not able to do it herself,as it has always been important to her that she "have pretty hands"
C)Suggesting to a client's family members that they should insist that the client move into an assisted living facility so as to ensure her safety
D)Helping the client's family identify community support services that will make it possible for the client to remain in her own home
E)Encouraging the client to use a walker and stay indoors,"just in case she might fall"
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17
Chapter 26: Communicating
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22 Verified Questions
22 Flashcards
Source URL: https://quizplus.com/quiz/77904
Sample Questions
Q1) A nurse needs to evaluate the effectiveness of a teaching session with a client.Which approach would provide the best feedback?
A)Client communication
B)Process recording
C)Therapeutic communication
D)Verbal communication
Q2) The nurse is communicating with an older client.Which actions demonstrate that the nurse understands the best approaches to communicate with this client?
Standard Text: Select all that apply.
A)Asking,"What can I do to make you feel safe?"
B)Observed intently listening to the client describe how being alone makes her feel
C)Offering to take the client "out for a walk"
D)Consistently arranging for the client to have her hair done
E)Managing to get a copy of the client's favorite magazine
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18
Chapter 27: Teaching
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39 Verified Questions
39 Flashcards
Source URL: https://quizplus.com/quiz/77903
Sample Questions
Q1) The nurse is documenting the teaching plan for a client.What should be included in this documentation?
Standard Text: Select all that apply.
A)Actual information to be taught
B)Teaching strategies to use
C)Skills to be taught
D)Amount of time needed to teach each topic
E)Vital signs before and after each teaching session
Q2) The nurse is utilizing humanistic theory when instructing a client.What will the nurse demonstrate when utilizing this theory?
Standard Text: Select all that apply.
A)Empathy
B)Encouraging the client to establish goals
C)Encouraging the client to participate in self-directed learning
D)Multisensory teaching strategies
E)Providing a physical environment conducive to learning
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19
Chapter 28: Delegating, Managing, and Leading
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department.This nurse will most likely have which title?
Standard Text: Select all that apply.
A)Supervisor
B)Nurse manager
C)Head nurse
D)Primary care nurse
E)Vice president
Q2) During a particularly heated staff meeting regarding staff assignments,the nurse manager makes this comment: "When you all can come to a decision,let me know and we'll move on from there." This leader is best identified as which of the following?
A)Democratic leader
B)Permissive leader
C)Bureaucratic leader
D)Situational leader
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Chapter 29: Vital Signs
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24 Verified Questions
24 Flashcards
Source URL: https://quizplus.com/quiz/77901
Sample Questions
Q1) When assessing a client's peripheral pulse,the health care provider is also assessing which of the following?
A)Depth
B)Rhythm
C)Sound
D)Stress
Q2) A client is unconscious and in respiratory distress after being in a motor vehicle crash.Which should the nurse realize as being a factor that caused a change in this client's respiratory rate?
A)Exercise
B)Increased intracranial pressure
C)Increased environmental temperature
D)Stress
Q3) Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the client's status?
A)Altered level of consciousness
B)Decreased urine output
C)Irregular radial pulse
D)Toes cool to touch
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Page 21
Chapter 30: Health Assessment
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29 Verified Questions
29 Flashcards
Source URL: https://quizplus.com/quiz/77900
Sample Questions
Q1) The nurse is planning a physical examination of a client following a head-to-toe format.In which order should the nurse conduct this assessment?
A)Head,upper extremities,abdomen,lower extremities
B)Neck,head,vital signs,chest and back
C)Lower extremities,abdomen,upper extremities,chest and back
D)Head,neck,lower extremities,abdomen
Q2) The nurse is assessing the peripheral vascular status of an older client.Which finding should the nurse consider as being normal for this client?
A)Easy to palpate upper extremity arteries
B)Easy to palpate lower extremity arteries
C)Reduction in the number of varicosities
D)Increase in diastolic blood pressure
Q3) The nurse is preparing a client for an abdominal examination.What should the nurse done before beginning the examination?
A)Ask the client to urinate.
B)Ask the client to drink 8 ounces of water.
C)Assess vital signs.
D)Assess heart rate.
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22
Chapter 31: Asepsis
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30 Verified Questions
30 Flashcards
Source URL: https://quizplus.com/quiz/77899
Sample Questions
Q1) The nurse is concerned that a break occurred in a sterile field.Which action occurred that caused this break?
A)Grasping the edge of the outermost flap and opening it away from oneself
B)Keeping objects on the field 1 inch from the edge
C)Keeping the sterile field in eyesight
D)Transferring a sterile object to a sterile field with a clean gloved hand
Q2) The nurse is preparing a presentation on standard precautions.Which statement should the nurse include in the presentation?
A)Cut the needle off a syringe after using it to give a client an injection.
B)Dispose of blood-contaminated materials in a biohazard container.
C)Gloves should not be worn for client care unless body fluids are seen.
D)Wear a mask when in direct contact with all clients.
Q3) The nurse wants to protect a client from developing an infection.Which action should the nurse take to break a link in the chain of infection?
A)Cover the mouth and nose when sneezing.
B)Place contaminated linens in a paper bag.
C)Use personal protective equipment (PPE)sparingly.
D)Wear gloves at all times.
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23
Chapter 32: Safety
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33 Verified Questions
33 Flashcards
Source URL: https://quizplus.com/quiz/77898
Sample Questions
Q1) The nurse is identifying outcomes for an older client prone to injuries.Which outcome should the nurse identify as appropriate for this client?
A)The client will demonstrate an understanding of all limitations.
B)The client will establish a buddy system.
C)The client will make uninformed choices when addressing health issues.
D)The client will take his medication as desired.
Q2) A client is prescribed seizure precautions.The nurse places functioning oral suction equipment in the client's room for what reason?
A)Suctioning might be needed to prevent the aspiration of oral secretions.
B)The client has difficulty swallowing liquids.
C)There was a spare oral suction set up,and the nurse did not want to return it to the engineering department.
D)It helps when the client is brushing her teeth.
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24
Chapter 33: Hygiene
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34 Verified Questions
34 Flashcards
Source URL: https://quizplus.com/quiz/77897
Sample Questions
Q1) The nurse is reviewing assigned clients for morning care needs.Which situation could pose a threat to one client's personal hygiene?
A)A client has a newly formed ileostomy.
B)A client performs meticulous foot care.
C)A German client refuses to bathe everyday.
D)The room temperature is set at 72°F.
Q2) The nurse is making an occupied bed.Which step will provide comfort for the client during this linen change?
A)Allow for a toe pleat.
B)Place a bath blanket over the client.
C)Slide the mattress to the head of the bed.
D)Raise the side rail.
Q3) While providing a complete bed bath to a client,the nurse discovers abrasions along the client's back and upper buttock area.What should the nurse do to help this client?
A)Apply antiseptic spray to the abrasions.
B)Do not wash the client with soap.
C)Find assistance to help with the remainder of the bath.
D)Apply alcohol-free lotion to the abrasions.
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25
Chapter 34: Diagnostic Testing
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) A client is scheduled to have abdominal ascites fluid removed.What should the nurse instruct the client about this procedure?
A)A catheter will be inserted into the bladder.
B)A liver biopsy will be done.
C)An abdominal paracentesis will be done.
D)A thoracentesis will be done.
Q2) A client is scheduled for a nuclear imaging test.What should the nurse instruct the client about this test?
A)It is the use of a magnetic field to produce an image of a body part or organ.
B)A radioisotope will be injected to determine organ functioning as being either hot or cold.
C)It produces a three-dimensional image of an organ.
D)It is more sensitive than an x-ray image.
Q3) The nurse is teaching a client with heart failure about diagnostic tests.Which test should the nurse emphasize in this teaching?
A)BNP
B)CBC
C)LDH
D)PKU
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Page 26
Chapter 35: Medications
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46 Verified Questions
46 Flashcards
Source URL: https://quizplus.com/quiz/77895
Sample Questions
Q1) At which point of preparing medication from an ampule does the nurse anticipate using a filter needle?
A)Filter needles are not used for this preparation.
B)When drawing the medication from the ampule.
C)When administering the medication to the client.
D)Both for drawing up the medication and for administering the medication.
Q2) A client diagnosed with diabetes asks the nurse about reusing insulin syringes.Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills.The nurse also knows the client has financial difficulties.What instruction should the nurse give this client?
A)"The American Diabetes Association advises that syringes are for single use only."
B)"In order to save money,I advise you to reuse syringes up to three times or until the needle feels dull."
C)"Only people who practice good personal hygiene can reuse syringes."
D)"All clients are different,but I advise you to use a new syringe for each injection."
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Chapter 36: Skin Integrity and Wound Care
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34 Verified Questions
34 Flashcards
Source URL: https://quizplus.com/quiz/77894
Sample Questions
Q1) The UAP reports a small skin tear on the client's forearm that occurred during a routine turn.After assessing the wound the nurse should take which action?
A)Obtain a transparent dressing for the UAP to place on the wound.
B)Request a consult with the wound care nurse.
C)Cleanse the wound and apply a dressing.
D)Tell the UAP to reevaluate the wound in 20 minutes.
Q2) Multiple severely injured clients have arrived in the emergency department.On rapid assessment,the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage.The client is otherwise stable.What action should the nurse take?
A)Place a tourniquet above the wound.
B)Remove the dressing and place direct pressure on the wound.
C)Add an additional dressing to the wound without removing the original.
D)Remove the dressing and replace it with a new sterile dressing.
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Chapter 37: Perioperative Nursing
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34 Verified Questions
34 Flashcards
Source URL: https://quizplus.com/quiz/77893
Sample Questions
Q1) The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery.What did the nurse assess to make this clinical decision?
A)Abdominal distention present.
B)Gas pains present.
C)Client vomiting.
D)Bowel movement occurred 24 hours after resuming a normal diet.
Q2) The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite.The nurse should document that the client is in which operative phase?
A)Preoperative phase
B)Intraoperative phase
C)Postoperative phase
D)Perioperative phase
Q3) A client is scheduled for a cholecystectomy.The nurse realizes that the purpose for this surgery is
A)diagnostic.
B)palliative.
C)ablative.
D)constructive.
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Chapter 38: Sensory Perception
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26 Verified Questions
26 Flashcards
Source URL: https://quizplus.com/quiz/77892
Sample Questions
Q1) A client is hospitalized for treatment of a new disorder.While admitted,the client receives no telephone calls or visitors.The nurse should assess which aspect of the client's sensory-perception function?
A)Risk for sensory overload
B)Social support network
C)Mental status
D)Environment
Q2) The nurse is concerned that a client is not aware of being in the hospital.For what aspects of the sensory process should the nurse assess the client?
Standard Text: Select all that apply.
A)Speech
B)Stimuli
C)Receptor
D)Perception
E)Impulse conduction
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Chapter 39: Self-Concept
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Q1) The nurse and client had set the following expected outcome: "At the next clinic visit,the client will report participation in three activities to increase self-esteem." At today's visit,the client is unable to meet the stated outcome.What should be the nurse's next action?
A)Explore the possible reasons for not meeting the outcome.
B)Reevaluate the accuracy of the outcome statement.
C)Collaborate with the client to write a new expected outcome.
D)Identify new interventions to help the client achieve the outcome.
Q2) The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem.What should the nurse respond to the spouse?
A)"Most clients make quicker progress."
B)"Self-esteem work takes time and is not easily evaluated."
C)"What have you done to help the client with this work?"
D)"Do you think that the client is really trying?"
Q3) Which statement,made by the client,would indicate a "me-centered" self-concept?
A)"I couldn't stand to disappoint my parents."
B)"My sister is so much smarter than I am."
C)"My future is based on the decisions I make today."
D)"The world has always been against people like me."
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Page 31
Chapter 40: Sexuality
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Q1) The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus.What equipment should the nurse obtain for this examination?
A)Culture tubes to assess expected vaginal infection
B)Extra cleaning supplies to remove thick external secretions
C)Smaller-than-normal vaginal speculums
D)Equipment for preexamination douche
Q2) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction.Which action by the nurse best reflects the IT section of this format?
A)Use information technology such as the Internet to obtain guidance suggestions for the client.
B)Use the technique of informal therapeutic groups to assist the client and partner.
C)Evaluate previous interventions and treatment for success.
D)Recommend intensive therapy with a qualified sex therapist.
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Chapter 41: Spirituality
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Q1) The nurse caring for wheelchair-dependent residents of a long-term care environment has developed a care plan that includes taking the clients outside and assisting them in planting and maintaining a garden.What is the best rationale for this plan?
A)Accreditation agencies require that the residents have regular outings.
B)Keeping in touch with nature is a form of spiritual care.
C)Fresh vegetables from the garden are good sources of nutritional fiber.
D)Sunshine helps activate vitamin D.
Q2) The nurse is determining whether interventions to address the diagnosis of Spiritual Distress for a client newly diagnosed with a chronic illness have been effective.What outcome would indicate that interventions have been effective for this client?
A)The client has talked with the church priest twice during the hospitalization.
B)The client states that there is nothing that can be done spiritually to improve her current outlook on life.
C)The client plans to make an appointment with a psychologist after discharge.
D)The client thanks the nurse for trying to help improve her feelings.
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Chapter 42: Stress and Coping
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Q1) A newly hospitalized client is demonstrating anxiety and stress.What intervention can the nurse plan to help this client?
A)Explain all procedures in detail before performing them.
B)Let the client make the majority of decisions about the plan of care.
C)Control the environment of healing.
D)Demonstrate staff competence by using multiple nurses for care.
Q2) A 2-year-old client,who has had multiple hospitalizations for treatment of a congenital disorder,is lying curled in bed holding a stuffed animal and will not interact with the parents.What should the nurse identify as causing this client's behavior?
A)The parents may have been abusing this child.
B)The child is probably developmentally delayed secondary to multiple hospitalizations.
C)The child is reacting as a normal 2-year-old.
D)The child could be suffering from a clinical depression.
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Chapter 43: Loss, Grieving, and Death
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Q1) During a home visit,an older male client tells the nurse that his wife died 3 years ago.What did the nurse observe as an indication that this client is experiencing complicated grief?
A)The client has an album of photographs of his wife open on the living room table.
B)He tells the nurse that his wife was an awful cook and that he has eaten better meals since she died.
C)He indicates that he sends his laundry out to be done because he had never figured out how the washer works.
D)He shows the nurse his wife's craft room that remains just as she left it before she died.
Q2) The nurse is caring for a client whose family does not want to tell him that he is dying.What is the nurse's best action according to these wishes?
A)Arrange an encounter with the client and tell him the truth.
B)Change the subject when the client asks about his impending death.
C)Tell the family that the patient has the right to know that he is dying.
D)Talk to the family about the situation and their concerns.
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Chapter 44: Rest
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Q1) The nurse is teaching a client on the use of a cane.What should the nurse include in this teaching?
Standard Text: Select all that apply.
A)Hold the cane on the weaker side of the body.
B)Move the cane forward while the body weight is between both legs.
C)The length of the cane should permit the elbow to be fully extended.
D)Move the weaker leg forward while the weight is between the cane and the stronger leg.
E)Move the stronger leg forward while the weight is between the cane and the weaker leg.
Q2) The client who is bed-bound complains of abdominal pain.Bowel sounds are present.What action should be taken by the nurse?
A)Percuss for flatness over the liver.
B)Palpate for bladder fullness.
C)Use the p.r.n.order to medicate the client with an antacid.
D)Inspect the sacral area for edema.
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Chapter 45: Activity and Exercise
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Q1) The client reports difficulty sleeping.Which environmental intervention should the nurse recommend?
A)Play soft music throughout the night.
B)Keep a television on in the bedroom.
C)Provide white noise with a fan.
D)Play a talk radio station.
Q2) A client reports the need to urinate during the night and then not being able to fall back asleep.The nurse should document this assessment finding as which factor that influences sleep?
A)Illness
B)Stimulant
C)Diet
D)Lifestyle
Q3) The nurse is admitting a critically ill client to the intensive care unit.What should the nurse ask regarding this client's sleep history?
A)No questions should be asked.
B)"When do you usually go to sleep?"
C)"Do you have any problems with sleeping?"
D)"What are your bedtime rituals?"
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Page 37
Chapter 46: Pain Management
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Q1) After receiving medication for mild pain,the client states that the pain is getting worse.What should the nurse plan to do for this client?
A)Administer another dose of a nonopioid medication.
B)Administer an opioid for severe pain.
C)Administer an opioid for moderate pain.
D)Administer two doses of an opioid for moderate pain.
Q2) A client recovering from a left below-the-knee amputation is experiencing left foot pain.The nurse realizes the client is experiencing which type of pain?
A)Phantom limb pain
B)Acute pain
C)Chronic pain
D)Narcotic-induced pain
Q3) A client's pain level is assessed as being severe.Which intervention would be the most applicable for the client at this time?
A)Provide NSAID medication as prescribed.
B)Coach the client with guided imagery.
C)Suggest the client read or watch television until the pain subsides.
D)Provide opioid analgesic as prescribed.
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Chapter 47: Nutrition
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Q1) The nurse is instructing a client on foods that are considered complete proteins.What will the nurse include in these instructions?
Standard Text: Select all that apply.
A)Meat
B)Gelatin
C)Eggs
D)Chicken
E)Fish
Q2) The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories.How should the client interpret the food label to decide if a food is low in calories?
A)The product label will state "lighter" or "reduced calories."
B)The Nutrition Facts label will have the letter "L" located in the lower right corner.
C)Nutritional labeling on the product will indicate less than 40 calories per serving.
D)The product will contain no more than 11% fat.
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Chapter 48: Urinary Elimination
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Q1) Which intervention would the nurse plan to help a client prevent a urinary tract infection?
A)Encourage the use of bubble baths.
B)Have the client increase sugar in the diet.
C)Instruct the client to empty the bladder completely.
D)Wipe from back to front.
Q2) The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP).Which task should the nurse before delegating to this level of health care provider?
A)Measuring intake and output
B)Assessing vital signs for clients who are clinically stable
C)Performing complete morning care for a client recovering from a stroke
D)Inserting a urinary catheter into a client
Q3) Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate?
A)The client will avoid bladder distention.
B)The client will maintain fluid imbalance.
C)The client will remain free of skin breakdown.
D)The client will voice increased discomfort.
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Chapter 49: Fecal Elimination
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Q1) A client has a bowel movement of hard,dry,but formed stool.The nurse associates these characteristics with
A)bowel incontinence.
B)constipation.
C)diarrhea.
D)fecal impaction.
Q2) The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work.Which response should the nurse make to explain why this practice should be changed?
A)"If you continue to ignore the urge to defecate,the urge is ultimately lost."
B)"It is best to suppress the urge rather than suffer embarrassment at work."
C)"This is a common practice,and it will strengthen the reflex later."
D)"You will get the urge later;don't worry."
Q3) A client has received an oil retention enema.The nurse should instruct the client that the enema will take effect within
A)1 to 3 hours.
B)10 to 20 minutes.
C)5 to 10 minutes.
D)10 to 15 minutes.
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Page 41
Chapter 50: Oxygenation
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Q1) The nurse has completed nasopharyngeal suctioning of a client.What should the nurse document about this procedure?
Standard Text: Select all that apply.
A)Amount,consistency,color,and odor of sputum
B)Amount of sterile solution used to flush the catheter
C)Lung sounds before the procedure
D)Lung sounds after the procedure
E)Oxygen saturation after the procedure
Q2) A client is concerned about maintaining a healthy respiratory system.What should the nurse instruct the client to do to promote a healthy respiratory status?
Standard Text: Select all that apply.
A)Use pursed-lip breathing.
B)Exercise regularly.
C)Do not smoke.
D)Breathe through the nose.
E)Breathe through the mouth.
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Chapter 51: Circulation
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Q1) A client has a long history of hypertension and has developed heart failure.The nurse should anticipate giving medications for which purpose?
A)To increase preload
B)To decrease afterload
C)To decrease contractility
D)To decrease cardiac output
Q2) After a cardiac catheterization,an infant is diagnosed with a malformation of the mitral valve.The nurse will monitor the client for the development of a problem associated with the delivery of
A)oxygenated blood to the body.
B)deoxygenated blood to the lung.
C)oxygenated blood to the right atrium.
D)deoxygenated blood to the left ventricle.
Q3) The post-myocardial infarction client asks the nurse about return to exercise.What information should the nurse give this client?
A)It is better to exercise when it is cold.
B)Environmental temperatures have little impact on cardiac function.
C)Avoid exercise when the weather is hot or cold.
D)Hot temperatures increase peripheral blood vessel contraction.
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Page 43
Chapter 52: Fluid, Electrolyte, and Acid-Base Balance
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Q1) After obtaining a unit of packed red blood cells for a client,the nurse learns the client needed to leave the care area for an emergency x-ray.What action should the nurse take?
A)Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the client's room to initiate immediately after the client returns.
B)Place the blood in the unit refrigerator until the client returns.
C)Return the blood to the laboratory blood bank until the client returns.
D)Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.
Q2) The nurse is preparing to discontinue a client's intravenous infusion.Which actions should the nurse take when removing the catheter from the vein?
Standard Text: Select all that apply.
A)Pull the catheter out in line with the vein
B)Apply pressure to the site while removing the catheter.
C)Pull the catheter out at an angle perpendicular to the vein.
D)Bend the client's elbow if bleeding at the site persists after removal.
E)Apply pressure to the site after the catheter is removed for 2 to 3 minutes.
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