Adult Health Nursing Exam Preparation Guide
Course Introduction
Adult Health Nursing focuses on the comprehensive care of adults experiencing acute and chronic health conditions across diverse healthcare settings. This course emphasizes the integration of evidence-based practice, clinical reasoning, and critical thinking in the assessment, planning, implementation, and evaluation of nursing interventions for adult patients. Students will explore common medical-surgical problems, disease processes, pharmacological therapies, and the promotion of health and wellness while developing skills in patient advocacy, collaboration with interdisciplinary teams, and culturally competent care. The course prepares students to manage complex patient needs, prioritize care, and support patients and their families during health transitions.
Recommended Textbook
Fundamentals of Nursing 8th Edition by Taylor
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45 Chapters
1562 Verified Questions
1562 Flashcards
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Page 2
Chapter 1: Introduction to Nursing
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Sample Questions
Q1) After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice?
A) Enrolling in an advanced degree program
B) Filing NCLEX results in the county of residence
C) Being licensed by the State Board of Nursing
D) Having a signed letter confirming graduation
Answer: C
Q2) A registered nurse adheres to the American Nurses Association's standard of professional performance by engaging in which of the following?
A) Assessment
B) Diagnosis
C) Evaluation
D) Collaboration
Answer: D
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Chapter 2: Theory, Research, and Evidence-Based Practice
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Sample Questions
Q1) A nursing instructor would like to study the effect peer tutoring has on student success. What is the independent variable?
A) Nursing student
B) Nursing education
C) Peer tutoring
D) Student success
Answer: C
Q2) A client undergoing chemotherapy for a brain tumor believes that having a good attitude will help in the healing process. This is an example of what type of knowledge?
A) Science
B) Philosophy
C) Process
D) Virtue
Answer: B
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Page 4
Chapter 3: Health, Illness, and Disparities
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Sample Questions
Q1) An elderly resident of a long-term care facility has developed diarrhea and dehydration as a result of exposure to clostridium difficile during a recent outbreak. The resident's primary care provider has consequently prescribed the antibiotic metronidazole (Flagyl). Which model of health promotion and illness prevention is most clearly evident in these events?
A) The Agent-Host-Environment Model
B) The Health-Illness Continuum
C) The Health Promotion Model
D) The Health Belief Model
Answer: A
Q2) A nurse is providing an educational event to a local group of disabled citizens. What would be important for the nurse to be aware of when planning this event?
A) The health promotion needs of the group the nurse is speaking to
B) What the disability of each person is
C) Wellness needs of each individual person
D) What the families want you to talk about
Answer: A
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Chapter 4: Health of the Individual, Family, and Community
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Sample Questions
Q1) When providing nursing care to a client, the nurse provides family-centered nursing care. What is one rationale for this nursing action?
A) The nurse does not want the client to feel lonely.
B) The client will be more compliant with medical instructions.
C) The family will be more willing to listen to instructions.
D) Illness in one family member affects all family members.
Q2) The nurse is planning interventions to promote the health of a family struggling with loss of energy and privacy for the parents. In which family stage is the family?
A) Family with young children
B) Family with adolescents and young adults
C) Family with middle-aged adults
D) Family with older adults
Q3) Which of the following groups involves all parts of a person's life and is concerned with meeting basic human needs to promote health?
A) Peers
B) Family
C) Community
D) Health care providers
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Chapter 5: Cultural Diversity
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Sample Questions
Q1) A father, mother, grandmother, and three school-aged children have immigrated to the United States from Thailand. Which member(s) of the family are likely to learn to speak English more rapidly?
A) Unemployed father
B) Stay-at-home mother
C) Grandmother
D) Children
Q2) The nurse is admitting a client from China to the medical-surgical unit with a diagnosis of cancer. While doing the client's assessments, the client speaks of her naturalistic beliefs related to health care and the importance of the yin/yang theory. Based on her cancer diagnoses, the idea that cancer is considered a cold illness in the culture, and her yin/yang beliefs, which meal will the patient most likely order for lunch?
A) Chicken noodle soup with crackers, fruit crisp, and hot tea
B) Turkey sandwich, small tossed salad, and iced tea
C) Chef's salad, bread, and water
D) Fruit smoothie and granola bar
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Chapter 6: Values, Ethics, and Advocacy
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Sample Questions
Q1) A nurse is concerned about the practice of routinely ordering a battery of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate source in handling this ethical dilemma would be which of the following?
A) The client's family
B) The admitting physician
C) The nurse in charge of the unit
D) The institutional ethics committee
Q2) A nurse working in a long-term care facility has an elderly male client who is very confused. What ethical dilemma is posed when using restraints in a long-term care setting?
A) It limits personal safety.
B) It increases confusion.
C) It threatens autonomy.
D) It prevents self-directed care.
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8
Chapter 7: Legal Dimensions of Nursing Practice
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Sample Questions
Q1) A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. What does the description of the client and his injuries represent as proof of malpractice?
A) Damages
B) Causation
C) Duty
D) Breach of duty
Q2) A nurse moves from Ohio to Missouri. Where can a copy of the Nurse Practice Act in Missouri be obtained?
A) Ohio State Board of Nursing
B) Missouri State Board of Nursing
C) Federal government nursing guidelines
D) National League for Nursing
Q3) A client is suing a nurse for malpractice. What is the term for the person bringing suit?
A) Plaintiff
B) Defendant
C) Litigator
D) Witness
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Chapter 8: The Health Care Delivery System
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Sample Questions
Q1) Health care is constantly changing and becoming more complex. Select the answers that describe clients as health care consumers today. Select all that apply.
A) They often have health information obtained from the Internet.
B) They prefer to control the decisions made about their own health care.
C) Most are less concerned about health care costs as long as they receive good care.
D) They express concern regarding access to care and the quality of service.
E) They have helped develop clients' rights and cost-containment measures.
Q2) Nurses who are employed in home care have a variety of responsibilities. Which of the following is one of those responsibilities?
A) Provide all care and services
B) Maintain a clean home environment
C) Advise clients on financial matters
D) Collaborate with other care providers
Q3) Which of the following phrases best describes hospitals today?
A) Focus on chronic illnesses
B) Focus on acute care needs
C) Primary care centers
D) Voluntary agencies
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Chapter 9: Care Coordination and Continuity
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Sample Questions
Q1) The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when ...
A) the client assists in developing the goals.
B) the physician develops the goals.
C) the nurse develops the goals.
D) the multidisciplinary team develops the goals.
Q2) Which of the following health care professionals prescribes home care and certifies the plan of care for the client?
A) Social worker
B) Discharge nurse
C) Home healthcare nurse
D) Physician
Q3) Which of the following is recommended to ensure safety for the home health care nurse?
A) Traveling with another nurse
B) Carrying a cell phone
C) Talking to family members
D) Refusing assignments
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11
Chapter 10: Blended Competencies
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Sample Questions
Q1) A student is asked to perform a skill for which he is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation?
A) Purpose of thinking
B) Adequacy of knowledge
C) Potential problems
D) Helpful resources
Q2) Which of the following groups developed standard language to increase the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses?
A) NANDA
B) NIC
C) NOC
D) HHCC (now CCC)
Q3) Which of the following is one example of a client benefit of using the nursing process?
A) Greater personal satisfaction
B) Decreased reliance on the nursing staff
C) Continuity of care
D) Decreased incidence of medical errors
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Page 12
Chapter 11: Assessing
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Sample Questions
Q1) A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make?
A) Number of rooms in the house
B) Safety of the immediate environment
C) Frequency of home visits to be made
D) Friendliness of the client and family
Q2) A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
A) "My leg hurts so bad. I can't stand it."
B) "Appears anxious and frightened."
C) "I am so sick; I am about to throw up."
D) "Unable to palpate femoral pulse in left leg."
Q3) Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
A) "Why didn't you go to the doctor when you began to have this pain?"
B) "Are you feeling better now than you did during the night?"
C) "Tell me more about what caused your pain."
D) "If I were you, I would not wait to get medical help next time."
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Chapter 12: Diagnosing
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Sample Questions
Q1) What is the nurse accountable for, according to the state nurse practice act?
A) Continuing education
B) Nursing diagnoses
C) Prescribing medications
D) Mentoring other nurses
Q2) A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
A) No problem
B) Possible problem
C) Actual problem
D) Clinical problem
Q3) A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?
A) Neither appendicitis nor acute pain
B) Both appendicitis and acute pain
C) Appendicitis
D) Acute pain
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Page 14
Chapter 13: Outcome Identification and Planning
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Sample Questions
Q1) The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention?
A) Teach client how to transfer from bed to chair and chair to bed.
B) Administer oxygen 4 L/min per nasal cannula.
C) Assist the client with coughing and deep breathing every hour.
D) Monitor intake and output every 2 hours.
Q2) What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
A) Problem statement
B) Defining characteristics
C) Etiology of the problem
D) Outcomes criteria
Q3) Which of the following groups of terms best describes a nurse-initiated intervention?
A) Dependent, physician-ordered, recovery
B) Autonomous, clinical judgment, client outcomes
C) Medical diagnosis, medication administration
D) Other health care providers, skill acquisition
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15
Chapter 14: Implementing
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Sample Questions
Q1) Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care?
A) Time management, communication, and establishing a support system.
B) Establishing a support system, a sense of humor, and self-awareness.
C) Self-awareness, preparation for crisis, and stress management.
D) A sense of humor, anticipation of loss, and developing negative body image.
Q2) What is the unique focus of nursing implementation?
A) Client response to health and illness
B) Client response to nursing diagnosis
C) Client compliance with treatment regimen
D) Client interview and physical assessment
Q3) A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse?
A) The UAP is responsible and accountable for his or her own actions.
B) Nurses do not have authority to delegate interventions.
C) The nurse transfers responsibility but is accountable for the outcome.
D) The UAP can function in an independent role for all interventions.
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Chapter 15: Evaluating
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Sample Questions
Q1) Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011."
Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate?
A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids"
B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate."
C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation."
D) "12/14/2011 Outcome met."
Q2) Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what?
A) Terminate the plan of care.
B) Modify the plan of care.
C) Continue the plan of care.
D) Re-evaluate the plan of care.
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Chapter 16: Documenting, Reporting, Conferring, and Using Informatics
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Sample Questions
Q1) A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?
A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired."
B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help."
C) "You seem to be impatient. The nurses work very hard and they do whatever they can."
D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."
Q2) A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?
A) Pay courtesy calls to staff members before attending the meeting.
B) Wait for the physicians to arrive before exchanging notes.
C) Avoid asking questions related to the medical record.
D) Come prepared with material required to take notes.
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Chapter 17: Developmental Concepts
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Sample Questions
Q1) The nursing student is visiting a middle school with an assignment to observe and visit with students while walking around with the school nurse. Then nursing student is interested to learn that some students seem to be rebelling against authority figures like teachers and parents. The nursing student recalls that, according to Erikson's theory, this is not abnormal behavior. To which stage of Erikson's theory does this behavior belong?
A) Identity versus role confusion
B) Industry versus inferiority
C) Initiative versus guilt
D) Autonomy versus shame
Q2) The nurse is working in the newborn nursery and observes neonates in various states of health and wellness. The nurse is aware that which of the following factors can affect fetal development? Choose all that apply.
A) Age of mother
B) Prenatal nutrition
C) Substance abuse by mother
D) Congenital vision deficit
E) Poor neonatal nutrition
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19
Chapter 18: Conception Through Young Adult
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Sample Questions
Q1) The nurse is providing education on childhood safety to a group of parents. In response to a question, the nurse relates that the major causes of death in toddlers include which of the following? Choose all that apply.
A) Infections
B) Childhood diseases
C) Drowning
D) Motor vehicle crashes
E) Accidents
Q2) A school nurse often observes adolescents challenging the decision making of their parents and teachers. Which of these developmental theorists relates this as an expected occurrence?
A) Piaget
B) Freud
C) Havighurst
D) Erikson
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Chapter 19: The Aging Adult
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Sample Questions
Q1) While providing hygiene care to a confused older adult client diagnosed with Alzheimer's disease, the nures is called to the nursing station. To ensure patient safety the nurse must do what?
A) Ask a family member to stay with him.
B) Cover him with a blanket for warmth.
C) Reattach the restraints.
D) Put side rails up before leaving the client.
Q2) A middle adult client requests visits by the hospital chaplain and reads the Bible each day while hospitalized for treatment of heart problems. What is the individual illustrating?
A) Midlife transition
B) Support of the rights of others
C) Fear for the future
D) Trust in spiritual strength
Q3) Which aging theory describes a chemical reaction that produces damage to the DNA and cell death?
A) Genetic theory
B) Immunity theory
C) Cross-linkage theory
D) Free radical theory
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Chapter 20: Communicator
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Sample Questions
Q1) The nurse has engaged the services of an interpreter when interviewing a client who speaks a language that the nurse does not understand. The interpreter is functioning in which role during the communication process?
A) Sender
B) Encoder
C) Receiver
D) Communication channel
Q2) The nurse is caring for a client who speaks Chinese, and the nurse does not speak Chinese. An appropriate approach for communication with this client includes what?
A) Using a caring voice and repeating messages frequently
B) Speaking directly and loudly to the client
C) Avoiding the use of gesture or play-acting
D) Writing messages for the client and offering him a dictionary for translation.
Q3) Why is communication important to the "assessing" step of the nursing process?
A) The major focus of assessing is to gather information.
B) Assessing is primarily focused on physical findings.
C) Assessing involves only nonverbal cues.
D) Written information is rarely used in assessment.
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Chapter 21: Teacher and Counselor
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Q1) At completion of the health education for a client, the nurse documents the details of the health education in the client's medical record. What can be determined by this documentation?
A) Proof of compliance with education standards
B) Client's response to the health education
C) Self-administration of medications
D) Dietary instructions for the client
Q2) When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which category does the client fall into?
A) Motivation
B) Attention and concentration
C) Learning readiness
D) Learning needs
Q3) Which of the following is an essential component of the definition of learning?
A) Increases self-esteem
B) Decreases stress
C) Can be measured
D) Cannot be measured
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Page 23
Chapter 22: Nurse Leader, Manager, and Care Coordinator
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Sample Questions
Q1) Which of the following nursing care tasks is acceptable for a graduate nurse to delegate to unlicensed assistive personnel (UAP)?
A) Assisting a client with ambulation
B) Evaluation of nursing care delivered to a client
C) Initial and ongoing assessments
D) Development of a client teaching plan
Q2) What type of leadership can a graduate nurse working in a magnet hospital expect?
A) Democratic
B) Autocratic
C) Situational
D) Quantum
Q3) A student nurse has just graduated with a baccalaureate degree in nursing. What type of nursing leadership will this nurse be expected to provide?
A) Nursing care of the individual client
B) Demonstration of selected critical skills
C) Ability to be a follower rather than a leader
D) Nursing care of groups of clients
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24
Chapter 23: Asepsis and Infection Control
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Q1) A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure?
A) Use sterile gloves to handle the entire drape surface.
B) Fold the lower edges of the drape over the sterile-gloved hands.
C) Touch only the outer two inches of the drape when not wearing sterile gloves.
D) When reaching over the drape do not allow clothing to touch the drape.
Q2) A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?
A) Nosocomial
B) Viral
C) Iatrogenic
D) Antimicrobial
Q3) Which of the following is an example of the body's defense against infection?
A) Racial characteristics
B) Body shape and size
C) Immune response
D) Level of susceptibility
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Page 25
Chapter 24: Vital Signs
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Q1) A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?
A) Hyperventilation
B) Hypoventilation
C) Dyspnea
D) Apnea
Q2) An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?
A) Assess the client's temperature by axilla.
B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client's temperature.
D) Take the client's temperature rectally.
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Chapter 25: Health Assessment
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Q1) During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. What nerve is being tested by this action?
A) Cranial nerve I
B) Cranial nerves II and III
C) Cranial nerve VII
D) Cranial nerve VIII
Q2) A nurse is performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure?
A) Taking vital signs
B) Palpating the integument
C) Identifying risk factors for altered health
D) Assessing the head and neck
Q3) What is one purpose of documentation of the health assessment?
A) To identify the nurse's role in health care
B) To identify actual and potential health problems
C) To expand nursing knowledge and skills
D) To provide a basis for evidence-based nursing
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Chapter 26: Safety, Security, and Emergency Preparedness
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Q1) A client arrives at the emergency department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed to the anthrax bacillus. What category of medications will be administered?
A) Antimicrobials
B) Narcotics
C) Antihistamines
D) Antacids
Q2) Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls?
A) Keep bed in the high position.
B) Keep side rails up at all times.
C) Apply restraints to all confused clients.
D) Lock wheels on beds and wheelchairs.
Q3) What age group is most vulnerable to toxic fumes or asphyxiation?
A) Young children
B) Adolescents
C) Toung adults
D) Middle adults
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Chapter 27: Complementary and Alternative Therapies
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Sample Questions
Q1) Which essential oil can be used during aromatherapy to treat nausea?
A) Lavender
B) Garlic
C) Parsley
D) Peppermint
Q2) A client interested in acupuncture asks a nurse, "Just exactly what does it do?" What would the nurse explain?
A) "Acupuncture is based on a philosophy of laying on of hands."
B) "I don't think it does anything, so I don't know anything about it."
C) "It uses a manual process of adjusting the spine."
D) "It changes the flow of energy and helps healing."
Q3) Which of the following would be the least consistent as a reason for the use of complementary and alternative medicine (CAM)?
A) Increasing numbers of acute conditions
B) Dissatisfaction with conventional medicine
C) Difficulty meeting rising health care costs
D) Growth of culturally diverse groups
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Chapter 28: Medications
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Sample Questions
Q1) A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?
A) To prevent absorption in the mouth
B) To prevent absorption in the esophagus
C) To facilitate absorption in the stomach
D) To prevent gastric irritation
Q2) A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges?
A) All needles for parenteral injection are the same gauge.
B) The gauge will depend on the length of the needle.
C) Ask the client what size needle is preferred.
D) Gauges range from 18 to 30, with 18 being the largest.
Q3) What would a nurse instruct a client to do after administration of a sublingual medication?
A) "Take a big drink of water and swallow the pill."
B) "Try not to swallow while the pill dissolves."
C) "Swallow frequently to get the best benefit."
D) "Chew the pill so it will dissolve faster."
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Page 30
Chapter 29: Perioperative Nursing
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Sample Questions
Q1) A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight?
A) Risk for Aspiration
B) Risk for Imbalanced Body Temperature
C) Risk for Infection
D) Risk for Falls
Q2) Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs?
A) Assess abdominal distention, especially if bowel sounds are audible or are low pitched.
B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake.
C) Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods.
D) Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery.
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Chapter 30: Hygiene
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Sample Questions
Q1) The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother?
A) "That's not good. Use a Q-tip or your finger instead."
B) "You really like to keep your child clean. Good for you!"
C) "That is dangerous; you might puncture the eardrum."
D) "Show me exactly how you use the hairpin."
Q2) The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care?
A) Apply moisture barriers to the skin of the perineal area.
B) Provide excessive hydration to the skin of the perineal area.
C) Wash the perineal area frequently with soap and water.
D) Aggressively cleanse the perineal area with a washcloth or towel.
Q3) A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do?
A) Provide total physical hygiene, including perineal care.
B) Provide total physical hygiene, excluding hair care.
C) Provide supplies and orient to the bathroom.
D) Provide supplies and assist with hard-to-reach areas.
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Chapter 31: Skin Integrity and Wound Care
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Sample Questions
Q1) A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record?
A) A clean separation of skin and tissue with a smooth, even edge
B) A separation of skin and tissue in which the edges are torn and irregular
C) A wound in which the surface layers of skin are scraped away
D) A shallow crater in which skin or mucous membrane is missing
Q2) A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected?
A) Full-thickness skin loss
B) Skin pallor
C) Blister formation
D) Eschar formation
Q3) When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?
A) Perform hand hygiene.
B) Insert a swab into the wound at 90 degrees.
C) Measure the width of the wound with a disposable ruler.
D) Assess the condition of the visible wound bed.
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Page 33
Chapter 32: Activity
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Sample Questions
Q1) Which of the following activities is normally acquired in the toddler years? Select all that apply.
A) Rolling over
B) Pulling to a standing position
C) Walking
D) Running
E) Jumping
Q2) A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?
A) Every hour
B) Every two hours
C) Every four hours
D) Every shift
Q3) The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?
A) Sitting up
B) Lying prone
C) Lying flat
D) Lying flat with feet raised slightly
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Page 34
Chapter 33: Rest and Sleep
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Sample Questions
Q1) A nurse educates a young couple on putting their newborn on his back to sleep. What is the rationale for this information?
A) Prone position increases the risk for sudden infant death syndrome.
B) Prone position decreases the risk for sudden infant death syndrome.
C) Supine position may alter the size and shape of the infant's head.
D) Supine position makes changing diapers and feeding difficult.
Q2) The client is a male who states his wife complains that his snoring awakens her at night. The spouse is present. To obtain further data, the nurse asks the spouse what?
A) "How loud is his snoring?"
B) "Is there silence after snoring which then is followed with a snort?"
C) "How long does he snore each night?"
D) "How often are you awakened at night due to his loud snoring?"
Q3) Which of the following is the most common sleep disorder?
A) Hypersomnia
B) Parasomnia
C) Insomnia
D) Dyssomnia
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Page 35
Chapter 34: Comfort and Pain Management
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Sample Questions
Q1) A client who has breast cancer is said to be in remission. What does this term signify?
A) The client is experiencing symptoms of the disease.
B) The client has end-stage cancer.
C) The client is experiencing unremitting pain.
D) The disease is present but the client is not experiencing symptoms.
Q2) A client has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate?
A) Psychogenic pain
B) Neuropathic pain
C) Cutaneous pain
D) Visceral pain
Q3) A nurse is assessing a mentally challenged, adult client who is in pain after a fall. Which of the following scales should the nurse use to assess the client's pain?
A) Pain Assessment in Advanced Dementia (PAINAD)
B) Wong-Baker Faces scale
C) Linear Scale
D) Numeric Scale
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Chapter 35: Nutrition
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Q1) A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant?
A) Solid foods after the first month
B) No solid foods until age 1 year
C) Bottle feeding with cow's milk
D) Breast-feeding or formula with iron
Q2) To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following?
A) Eliminate high-fiber foods
B) Eat foods high in folic acid
C) Consume saturated fats
D) Consume milk products in the last trimester
Q3) A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance?
A) Milk
B) Eggs
C) Oatmeal
D) Nuts
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Chapter 36: Urinary Elimination
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Sample Questions
Q1) The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client?
A) Risk for activity intolerance
B) Risk for impaired skin integrity
C) Risk for infection
D) Risk for falls
Q2) A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill?
A) Deflate the balloon by aspirating the fluid.
B) Ask the client to take several deep breaths.
C) Tell the client burning may initially occur.
D) Wash hands and put on gloves.
Q3) A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine?
A) Compare the amount of output with intake.
B) Use a clean measuring cup for each voiding.
C) Tell the client to wash the urethra before voiding.
D) Wear gloves when handling a client's urine.
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Page 38
Chapter 37: Bowel Elimination
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Sample Questions
Q1) A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client?
A) "Just give it a few more days and you should be fine."
B) "Well, that shouldn't happen. Let me recommend a good laxative for you."
C) "When you increase fiber in your diet, you also need to increase liquids."
D) "I will tell the doctor you are having problems; maybe he can help."
Q2) Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?
A) Hard, formed
B) Black, tarry
C) Soft, watery
D) Dry, odorous
Q3) A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?
A) It is painful to sit on a bedpan.
B) The position does not facilitate downward pressure.
C) The position encourages the Valsalva maneuver.
D) The cause is unknown and requires further study.
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Chapter 38: Oxygenation and Perfusion
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Q1) An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?
A) Inspiration and expiration
B) Only on inspiration
C) Only on expiration
D) When coughing
Q2) The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of
A) Atelectasis
B) Bronchospasm
C) Croup
D) Epiglottitis
Q3) Which of the following diseases may result in decreased lung compliance?
A) Emphysema
B) Appendicitis
C) Acne
D) Chronic diarrhea
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Chapter 39: Fluid, Electrolyte, and Acid-Base Balance
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Sample Questions
Q1) Which client would be the most likely candidate for the administration of total parenteral nutrition?
A) A client with severe pancreatitis
B) A client with a myocardial infarction
C) A client with hepatitis B
D) A client with mild malnutrition
Q2) Cross-matching of blood is ordered for a client before major surgery. What does this process do?
A) Determines compatibility between blood specimens
B) Determines a person's blood type
C) Predicts the amount of needed blood replacement
D) Specifies the donor and the recipient of the blood
Q3) A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the client when accessing the vein?
A) Discomfort
B) Pain
C) Minor bleeding
D) Infection
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Chapter 40: Self-Concept
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Q1) What might a nurse ask during a health history to assess personal identity?
A) "Tell me how your illness has affected you in your job."
B) "Tell me what you do for fun and what you do for work."
C) "How do you believe others see you? Why do you believe that?"
D) "How would you describe yourself to others?"
Q2) The wife of an older adult man has recently died. The couple was married for 32 years. What part of the man's self-concept may be influenced by this loss?
A) Ideal self
B) Global self
C) Body image
D) False self
Q3) A nurse who works on the pediatric unit wants to help a child cope with the loss of a leg in a hunting accident. What would the nurse implement to help the child express feelings?
A) Support from other family members
B) Television cartoons
C) Story books
D) Dolls or animals
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Chapter 41: Stress and Adaptation
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Sample Questions
Q1) Which of the following illnesses has been associated with long-term stress?
A) Bacterial infections
B) Cardiovascular disease
C) Renal disease
D) Fractures
Q2) The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system?
A) Blood sugar of 65 mg/dL
B) Heart rate of 102 beats/minute
C) Increased bowel sounds
D) Cool, clammy skin
Q3) When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?
A) Change jobs.
B) Avoid people who dump tasks on him.
C) Take control of the situation.
D) Avoid doing petty jobs.
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Chapter 42: Loss, Grief, and Dying
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Sample Questions
Q1) Which of the following is an example of a perceived loss?
A) A client mourns the loss of his amputated leg.
B) A client grieves for the loss of his wife to cancer.
C) An older client grieves for the loss of his independence.
D) A client grieves for the loss of his job.
Q2) Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief?
A) Socioeconomic factors
B) Cultural influences
C) Religious influences
D) Cause of death
Q3) Which of the following statements is typical of the first stage of grieving described by Engel?
A) "No, not me."
B) "Why me?"
C) "My husband was the best man in the world."
D) "The funeral service helped me survive."
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44
Chapter 43: Sensory Functioning
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Q1) What type of cognitive responses might a nurse assess in a client with sensory deprivation?
A) Uncoordinated movements, altered sense of smell
B) Decreased attention span, difficulty problem solving
C) Apathy, depression
D) Rapid mood changes, anxiety
Q2) The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply.
A) Make sure he wears his hearing aid.
B) Speak in a lower tone of voice.
C) Speak so he can observe your lip movement.
D) Keep his environment clear of clutter.
E) Orient to person, place, and time frequently
Q3) Which of the following best describes a stimulus?
A) A sense organ that receives a message and converts it into a nerve impulse
B) Conduction along a nerve pathway from the receptor to the brain
C) Reception and translation of an impulse into a sensation
D) An act or agent that initiates a response by the nervous system
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Page 45
Chapter 44: Sexuality
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Sample Questions
Q1) After instructing the male client on the performance of a testicular examination, the nurse instructs the client to perform the examination how often?
A) Monthly
B) Weekly
C) Bi-monthly
D) Bi-yearly
Q2) When conducting a class on sexuality with teenagers, the nurse includes that sexuality is which of the following?
A) External appearance of one's genitalia as male or female
B) Male or female internal organ structure and function
C) How one experiences maleness or femaleness physically, emotionally, and mentally
D) The pleasure experienced during sexual activity
Q3) A heterosexual couple enjoys both anal and vaginal intercourse. What may result from these sexual activities?
A) Feelings of guilt and shame
B) Vaginal infections
C) Damage to the vagina
D) Penile infections
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Chapter 45: Spirituality
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Q1) A nurse is preparing a client's room to accommodate a visit from a spiritual counselor. Which of the following is a recommended practice?
A) Dim or turn off the lights.
B) Place a candle on the bedside table.
C) Remove any unnecessary equipment.
D) Place a cross on the bedside table.
Q2) A client verbalizes to a mental health counselor that his life is meaningless since his wife divorced him and that he no longer wants to live. What nursing diagnosis, resulting from his spiritual distress, would be appropriate?
A) Sexual Dysfunction
B) Fear
C) Powerlessness
D) Risk for Self-Directed Violence
Q3) Which of the following health care practices may be influenced by a young woman's religion?
A) Yearly mammograms
B) Annual physicals
C) Birth-control measures
D) Health assessments
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Page 47