Foundations of Health Assessment
Exam Answer Key
Course Introduction
Foundations of Health Assessment provides students with the essential knowledge and skills to conduct comprehensive and systematic health evaluations across the lifespan. The course emphasizes the integration of physical, psychological, social, and cultural factors in health assessment, focusing on the accurate collection and interpretation of health data through patient histories, physical examination techniques, and effective communication strategies. Students are introduced to normal versus abnormal findings, documentation practices, and critical thinking necessary for clinical decision-making, laying the groundwork for advanced practice and further clinical experiences in healthcare settings.
Recommended Textbook
Fundamentals of Nursing 8th Edition by Patricia A. Potter
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50 Chapters
1445 Verified Questions
1445 Flashcards
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Chapter 1: Nursing Today
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21 Verified Questions
21 Flashcards
Source URL: https://quizplus.com/quiz/25750
Sample Questions
Q1) The American Red Cross was founded by
A) Florence Nightingale.
B) Harriet Tubman.
C) Clara Barton.
D) Mary Mahoney.
Answer: C
Q2) Nurses working in the Henry Street Settlement in 1893 were among the first nurses to demonstrate autonomy in practice.This was because those nurses
A) Had no ability to work in the hospital setting.
B) Were required to use critical thinking skills.
C) Focused solely on healing the very ill.
D) Planned their care around research findings.
Answer: B
Q3) The first practicing nurse epidemiologist was
A) Florence Nightingale.
B) Mildred Montag.
C) Clara Barton.
D) Mary Agnes Snively.
Answer: A
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Page 3
Chapter 2: The Health Care Delivery System
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20 Flashcards
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Sample Questions
Q1) Primary health care focus includes
A) Individual health screenings.
B) Community health promotion programs.
C) Development of health policies.
D) Disease prevention in communities.
E) Discharge planning for individual patients.
Answer: B,C,D
Q2) Nurses who work in a skilled nursing facility need nursing expertise in which of the following areas?
A) Gerontological nursing
B) IV fluid management
C) Ventilator management
D) Depression/violent behavior management
E) Wound care management
Answer: A,B,C,E
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Chapter 3: Community-Based Nursing Practice
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Sample Questions
Q1) The patient is in the hospital with the diagnosis of early-onset Alzheimer's disease.Before the patient is discharged,the community-based nurse is making a visit to the patient's home,where he lives with his daughter and her family.A major focus of this visit will be to
A) Demonstrate caregiver techniques for providing care.
B) Stress to the family how difficult it will be to provide care at home.
C) Encourage the family to send the patient to an extended care facility.
D) Teach the family how to have the patient declared incompetent.
Answer: A
Q2) The student nurse is trying to determine what type of nurse she wants to be after graduation.In class,she states that community health nursing is probably not for her because community nursing focuses only on community issues such as preventing epidemics.The instructor's most appropriate response would be that community health nursing
A) Focuses on the health care of individuals, families, and groups in a community.
B) Focuses only on the health of a specific subgroup in a community.
C) Requires an advanced nursing degree, so the student need not worry.
D) Focuses only on maintaining the health of the community.
Answer: A
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Page 5
Chapter 4: Theoretical Foundations of Nursing Practice
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Sample Questions
Q1) The nurse is caring for a patient who is actively bleeding.The physician orders blood transfusions.The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order.The patient states that she is a Jehovah's Witness and does not want blood products.The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment.In doing so,the nurse is operating within which of the following theories?
A) Leininger's cultural care diversity and universality theory
B) Roy's adaptation theory
C) Watson's philosophy of transpersonal caring
D) Orem's self-care deficit theory
Q2) Nursing has its own body of knowledge that is both theoretical and practical.Which of the following is an example of theoretical knowledge?
A) Reflection on care experiences
B) Synthesis and integration of the art and science of nursing
C) Reflection on basic values and principles
D) Creating a narrow understanding of nursing practice
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Chapter 5: Evidence-Based Practice
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22 Flashcards
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Sample Questions
Q1) The first step in evidence-based practice is to ask a clinical question.In doing so,the nurse needs to realize that in researching interventions,the question
A) Is more important than its format.
B) Will lead you to hundreds of articles that must be read.
C) May be easier if in PICO format.
D) May be more useful the more general it is.
Q2) The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit.The nurse realizes that nursing research is important in that it is designed to
A) Enhance the nurse's chance at promotion.
B) Identify new knowledge.
C) Improve professional practice.
D) Enhance effective use of resources.
E) Lead to decreases in budget expenditures.
Q3) In collecting the best evidence,the gold standard for research is
A) The randomized controlled trial (RCT).
B) The peer-reviewed article.
C) Qualitative research.
D) The opinion of expert committees.
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Page 7
Chapter 6: Health and Wellness
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Sample Questions
Q1) The health care model that utilizes Maslow's hierarchy as its base is the _____ Model.
A) Health Belief
B) Health Promotion
C) Basic Human Needs
D) Holistic Health
Q2) The patient had a colostomy placed 1 week ago.When approached by the nurse,the patient and his wife refuse to talk about it and refuse to be taught about how to care for it.The nurse realizes that the patient and his wife are in which stage of adjustment?
A) Shock
B) Withdrawal
C) Acceptance
D) Rehabilitation
Q3) An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of
A) Increasing quality of life in America.
B) Prolonging healthy life in America.
C) Eliminating health disparities in America.
D) Promoting healthy behaviors.
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Page 8
Chapter 7: Caring in Nursing Practice
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Sample Questions
Q1) Caring is central to nursing practice,but technological advances for rapid diagnosis and treatment should lead the nurse to realize that
A) Technology has replaced caring as nurses' primary focus.
B) Technology and caring cannot coexist when related to patient care.
C) Technology becomes a powerful tool when it works with caring.
D) Caring is the essence of nursing and is isolated from technology.
Q2) The nurse is caring for a patient who has been sullen and quiet for the past three days.Suddenly,he says,"I'm really nervous about surgery tomorrow,but I'm more worried about how it will affect my family." What should the nurse do?
A) Assure the patient that everything will be all right and continue what she/he is doing.
B) Tell the patient that whatever happens is out of his control, so he shouldn't worry.
C) Stop what he/she is doing (if possible) and ask the patient to expand on his statement.
D) Contact hospital clergy to come and talk with the patient.
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Chapter 8: Caring for the Cancer Survivor
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Sample Questions
Q1) Which of the following are factors that help ease the psychological stress associated with having cancer?
A) Viewing cancer as a challenge
B) Female gender
C) Using problem-oriented coping processes
D) Social support system
E) Being younger
Q2) The nurse is caring for a patient who is undergoing chemotherapy and radiation for cancer.The patient says that he can't wait until the therapy is done so that he can feel stronger,and asks the nurse about the value of cancer screening when his course of therapy is over.The nurse should inform the patient that cancer screening
A) Should be done on an ongoing schedule.
B) Probably will not be needed because the patient has been cured.
C) Usually is not done even if recommended by the health care provider.
D) Is not something that the health care provider should recommend.
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10
Chapter 9: Culture and Ethnicity
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Sample Questions
Q1) In performing a cultural assessment,knowledge of a patient's country of origin and its history and ecological contexts is known as
A) Ethnohistory.
B) Biocultural history.
C) Social organization.
D) Religious and spiritual beliefs.
Q2) Care that includes the nurse learning about cultural issues involved in the patient's health care belief system and enable patients and families to achieve meaningful and supportive care is known as
A) Ethnocentrism.
B) Culturally competent care.
C) Cultural imposition.
D) Culturally congruent care.
Q3) In comparing American culture with Asian cultures,which of the following statements is true?
A) American culture supports collectivism.
B) Asian communication can be ambiguous.
C) American communication patterns downplay autonomy.
D) Asian communication is direct to avoid conflict.
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Page 11
Chapter 10: Caring for Families
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Sample Questions
Q1) The nurse is caring for an elderly woman and notices that she is not using her cane properly.Which of the following statements by the nurse would most likely elicit a positive response from the patient?
A) "You're doing that all wrong. Let me show you how to do it."
B) "I don't know who showed how to use the cane like that, but you're not doing it right. Let me show you again."
C) "You use the cane the way I did before I was shown a way to keep from tripping over it; do you mind if I show you?"
D) "I used to use the cane the same way you are using it: the wrong way. I'll show you the right way to do it."
Q2) Different approaches may be taken to family nursing practice.When the nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family,what is the best approach for the nurse to take?
A) Family as context
B) Family as patient
C) Family as system
D) Patient as individual
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Page 12
Chapter 11: Developmental Theories
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Sample Questions
Q1) A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home.When approaching this patient,which intervention should the nurse plan first?
A) Offer a reward for participation in all events.
B) Encourage the patient to attend all social events scheduled for the patients.
C) Allow the patient to incorporate personal belongings into her room.
D) Advise the patient of the importance of attending mandatory activities.
Q2) The nursing instructor will need to provide further instruction to the student who states
A) "Intellectual development is affected by cognitive processes."
B) "Socioemotional processes can influence an individual's growth and development."
C) "Breast development is an example of a change resulting from biological processes."
D) "An individual's biological processes determine physical characteristics and do not affect growth and development."
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13
Chapter 12: Conception Through Adolescence
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25 Flashcards
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Sample Questions
Q1) Immediate intervention is needed when the newborn exhibits
A) A soft, protuberant abdomen.
B) Molding.
C) Lack of reflexes.
D) Cyanotic hands and feet.
Q2) The nurse should instruct the parents of an adolescent about which of the following health concerns?
A) Signs of substance abuse
B) Suicide prevention
C) Safe sex practices
D) Pregnancy
E) Gonadotropic hormone stimulation
F) Voice changes
Q3) Which of these toys,if selected by the parent of a 10-month-old child,would indicate that the parent has a correct understanding of infant growth and development?
A) A game requiring two to four players
B) Electronic games
C) Small, plastic alphabet letters and magnets
D) Plastic stacking rings
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Page 14
Chapter 13: Young and Middle Adults
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20 Flashcards
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Sample Questions
Q1) When performing a thorough psychosocial assessment on a young adult,what must the nurse realize?
A) Having a job is the best way to relieve stress.
B) Although psychologically disturbing, stress does not lead to physical illness.
C) Change is inevitable and is not a factor in stress-related illness.
D) Psychosocial health is often related to job and family stress.
Q2) When choosing an appropriate topic for a young adult health fair,the nurse ranks which topic as least relevant?
A) Unplanned pregnancies
B) Menopause and climacteric factors
C) Smoking cessation
D) Alcohol and drug use
Q3) What are the most common life events that occur during young adulthood?
A) Refining self-perception and ability for intimacy
B) Achievement and mastery of the surrounding world
C) Examination of life goals and relationships
D) Rejection of culture-bound definitions of health and illness
E) Women surrendering careers to raise families
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Chapter 14: Older Adults
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) A patient asks the nurse what the term polypharmacy means.The nurse defines this term as
A) Multiple side effects experienced when taking a medication.
B) The concurrent use of many medications.
C) The many adverse drug effects reported to the pharmacy.
D) The risks of medication effects due to aging.
Q2) Which teaching strategy is best to utilize with older adult patients?
A) Provide several topics of discussion at once to promote independence and making choices.
B) Avoid uncomfortable silences after questions by helping patients complete their statements.
C) Ask patients to recall past experiences that correspond with their interests.
D) Speak in a high pitch to help patients hear better.
Q3) One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use.One way to reduce the risks associated with medication usage is to
A) Periodically review the patient's list of medications.
B) Inform the patient that polypharmacy is to be avoided at all cost.
C) Be aware that medication is absorbed the same way regardless of patient age.
D) Focus only on prescribed medications.
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Page 16
Chapter 15: Critical Thinking in Nursing Practice
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20 Flashcards
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Sample Questions
Q1) What is the first component of the critical thinking model for clinical decision making?
A) Experience
B) Nursing process
C) Attitude
D) A scientific knowledge base
Q2) While caring for a hospitalized older adult female post hip surgery,the new graduate nurse is faced with the task of inserting an indwelling urinary catheter,which involves rotating the hip into a contraindicated position.The nurse exhibits critical thinking to perform this task by
A) Following textbook procedure.
B) Notifying the physician of the need for a urologist consult.
C) Adapting the positioning technique to the situation.
D) Postponing catheter insertion until the next shift.
Q3) The nursing student can best develop critical thinking skills by doing which of the following?
A) Studying 3 hours more each night
B) Actively participating in all clinical experiences
C) Interviewing staff nurses about their nursing experiences
D) Attending all open skills lab opportunities
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Chapter 16: Nursing Assessment
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Sample Questions
Q1) The nurse is assessing a patient with a hearing deficit.Where is the best place to conduct this interview?
A) The patient's room with the door closed
B) The waiting area with the television turned off
C) The patient's room before administration of pain medication
D) The patient's room while the occupational therapist is working on leg exercises
Q2) The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse
A) Completes a comprehensive database.
B) Identifies pertinent nursing diagnoses.
C) Intervenes based on patient goals and priorities of care.
D) Determines whether outcomes have been achieved.
Q3) While interviewing an older female patient of Asian descent,the nurse notices that the patient looks at the ground when answering questions.This nurse should
A) Notify the physician to recommend a psychological evaluation.
B) Consider cultural differences during this assessment.
C) Ask the patient to make eye contact to determine her affect.
D) Continue with the interview and document that the patient is depressed.
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18
Chapter 17: Nursing Diagnosis
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Sample Questions
Q1) A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture.The leg is stabilized in a full leg cast.Otherwise,the patient has no other major injuries,is in good health,and complains only of moderate discomfort.What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?
A) Posttrauma syndrome
B) Constipation
C) Urinary retention
D) Acute pain
Q2) Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
A) "What types of foods do you think caused your upset stomach?"
B) "How many bowel movements a day have you had?"
C) "Are you able to get to the bathroom in time?"
D) "What medications are you currently taking?"
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19
Chapter 18: Planning Nursing Care
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Sample Questions
Q1) The following statements are on a patient's nursing care plan.Which of the following statements is written as an outcome?
A) The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
B) The patient will demonstrate increased mobility in 2 days.
C) The patient will demonstrate increased tolerance to activity over the next month.
D) The patient will understand needed dietary changes by discharge.
Q2) A patient's plan of care includes the goal of increasing mobility this shift.As the patient is ambulating to the bathroom at the beginning of the shift,the patient suffers a fall.The nurse should revise the plan of care first by
A) Asking physical therapy to assist the patient because of the new injuries.
B) Disregarding all previous diagnoses and establishing a new plan of care.
C) Reassessing the patient.
D) Setting new priorities for the patient.
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Chapter 19: Implementing Nursing Care
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Sample Questions
Q1) The nurse is intervening for an identified nursing diagnosis of Risk for infection.Which direct care nursing intervention is most appropriate?
A) Teaching the family proper handwashing technique
B) Leaving side rails up at all times
C) Teaching the patient how to use crutches
D) Counseling the family on stress reduction techniques
Q2) Vital signs for a patient reveal a high blood pressure of 187/100.Orders state to notify the health care provider for diastolic blood pressure greater than 90.What is the nurse's first action?
A) Assess the patient for other symptoms or problems, and then notify the health care provider.
B) Review the most recent lab results for the patient's potassium level.
C) Follow the clinical protocol for a stroke.
D) Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
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21
Chapter 20: Evaluation
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Sample Questions
Q1) A nursing student asks her nursing instructor to describe the primary purpose of evaluation.Which of the following statements made by the nursing instructor is most accurate?
A) "During evaluation, you determine whether all nursing interventions were completed."
B) "During evaluation, you determine when to downsize staffing on nursing units."
C) "Nurses use evaluation to determine the effectiveness of nursing care."
D) "Evaluation eliminates unnecessary paperwork and care planning."
Q2) The nurse is caring for a patient who has an order to change a dressing twice a day,at 0600 and 1800.At 1400,the nurse notices that the dressing is saturated.What is the nurse's next action?
A) Wait and change the dressing at 1800 as ordered.
B) Revise the plan of care and change the dressing now.
C) Reassess the dressing and the wound in 1 hour.
D) Discontinue the plan of care.
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Chapter 21: Managing Patient Care
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Sample Questions
Q1) A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner.The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms several times looking for equipment and supplies.This nurse could benefit from practicing better _____ skills.
A) Clinical decision-making
B) Organizational
C) Evaluation
D) Interpersonal communication
Q2) In which nursing care model is the RN usually appointed the position of group leader?
A) Total patient care
B) Primary nursing
C) Team nursing
D) Case management
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23
Chapter 22: Ethics and Values
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Sample Questions
Q1) The nurse is caring for a severely ill patient with AIDS who now requires ventilator support.Which intervention is considered futile?
A) Administering the influenza vaccine
B) Providing oral care every 5 hours
C) Applying fentanyl patches prn for pain
D) Supporting the patient's lower extremities with pillows
Q2) The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children.Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause?
A) Responsibility
B) Advocacy
C) Confidentiality
D) Accountability
Q3) Which patient is most likely to have difficulty with the ethical concept of autonomy?
A) 18-year-old patient in labor
B) 35-year-old patient with appendicitis
C) 53-year-old patient with pancreatitis
D) 78-year-old patient with rheumatoid arthritis
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Chapter 23: Legal Implications in Nursing Practice
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Sample Questions
Q1) A recent immigrant who does not speak English is alert and requires hospitalization.What is the initial action that the nurse must take to enable informed consent to be obtained?
A) Ask a family member to translate what the nurse is saying.
B) Notify the health care provider that the patient doesn't speak English.
C) Request an official interpreter to explain the terms of consent.
D) Use hand gestures and medical equipment while explaining in English.
Q2) A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital.A full code was conducted without success.The patient had a urinary catheter,an intravenous line,an oxygen cannula,and a nasogastric tube.What question is priority for the nurse to ask the family before beginning postmortem care?
A) "Do you want to assist in bathing your loved one?"
B) "Is an autopsy going to be done?"
C) "To which funeral home do you want your loved one transported?"
D) "Do you want me to remove the lines and tubes before you see your loved one?"
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25
Chapter 24: Communication
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Sample Questions
Q1) The patient that will cause the greatest communication concerns for a nurse is the patient who is
A) Alert, has strong self-esteem, and is hungry.
B) Oriented, pain free, and blind.
C) Cooperative, depressed, and hard of hearing.
D) Dyspneic, has a tracheostomy, and is anxious.
Q2) A patient has trouble speaking words,and the patient's speech is garbled.Which nursing diagnosis is most appropriate for this patient?
A) Hopelessness
B) Impaired verbal communication
C) Hearing loss
D) Self-care deficit
Q3) A smiling patient angrily states,"I will not cough and deep breathe." How will the nurse interpret this finding?
A) The patient's personal space was violated.
B) The patient's affect is inappropriate.
C) The patient's vocabulary is poor.
D) The patient's denotative meaning is wrong.
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Chapter 25: Patient Education
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Sample Questions
Q1) Which action best indicates that learning has occurred?
A) A nurse presents information about diabetes.
B) A patient demonstrates how to inject insulin.
C) A family member listens to a lecture on diabetes.
D) A primary care provider hands a diabetes pamphlet to the patient.
Q2) While preparing a teaching plan,the nurse described what the learner will be able to accomplish after the teaching session.Which action did the nurse complete?
A) Developed learning objectives
B) Provided positive reinforcement
C) Implemented interpersonal communication
D) Presented facts and knowledge
Q3) A patient with heart failure is learning to reduce salt in the diet.When would be the best time for the nurse to address this topic?
A) At bedtime, when the patient is relaxed
B) At lunchtime while the nurse is preparing the food tray
C) At bath time, when the nurse is cleaning the patient
D) At medication time, when the nurse is administering patient medication
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Chapter 26: Documentation and Informatics
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Sample Questions
Q1) A nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?
A) The patient had a good day with no complaints.
B) The family is demanding and argumentative.
C) The patient has a new pain medication, Lortab.
D) The family is poor and had to go on welfare.
Q2) A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?
A) Patient went up and down stairs
B) Deficient knowledge regarding crutches
C) Demonstrated use of crutches
D) Used crutches with no difficulties
Q3) A nurse wants to reduce data entry errors on the computer system.Which behavior should the nurse implement?
A) Use the same password all the time.
B) Share password with only one other staff member.
C) Print out and review computer nursing notes at home.
D) Chart on the computer immediately after care is provided.
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Page 28
Chapter 27: Patient Safety
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Sample Questions
Q1) The patient presents to the clinic with a family member.The family member states that the patient has been wandering around the house and mumbling.What is the first assessment the nurse should do?
A) Ask the patient why she has been wandering around the house.
B) Introduce self and ask the patient her name.
C) Take the patient's blood pressure, pulse, temperature, and respiratory rate.
D) Immediately do a complete head-to-toe neurologic assessment.
Q2) The home health nurse is caring for a patient in the home who is using an electrical infusion device.While visiting the patient,the nurse smells smoke and notices an electrical fire started by this device.The nurse uses the fire extinguisher and fights the fire when
A) All occupants have left the home.
B) Fire department has been called.
C) Fire is confined to one room.
D) An exit route is available.
E) The correct extinguisher is available.
F) The nurse thinks she can use the fire extinguisher.
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Page 29
Chapter 28: Infection Prevention and Control
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Sample Questions
Q1) The nurse is admitting a patient with an infectious disease process.What question would be appropriate for a nurse to ask this patient?
A) "Do you have a chronic disease, and how long have you had it?"
B) "Do you have any children living in the home?"
C) "What is your marital status-single, married, or divorced?"
D) "Do you have any cultural or religious beliefs that will influence your care?"
Q2) The nurse is caring for a patient who becomes nauseated and vomits without warning.The nurse has contaminated hands.The nurse's best next step is to
A) Clean hands with wipes from the bedside table.
B) Wash hands with an antimicrobial soap and water.
C) Use an alcohol-based waterless hand gel.
D) Instruct the patient to wash his face and hands.
Q3) Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response?
A) Rest, ice, compression, and elevation
B) Turn, cough, and deep breathe
C) Orient to date, time, and place
D) Passive range-of-motion exercises
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Chapter 29: Vital Signs
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46 Verified Questions
46 Flashcards
Source URL: https://quizplus.com/quiz/25778
Sample Questions
Q1) When assessing the temperature of newborns and children,the nurse decides to utilize a temporal artery thermometer.Why is this preferable to methods used for adults?
A) It is accurate even when the forehead is covered with hair.
B) It is not affected by skin moisture.
C) It reflects rapid changes in radiant temperature.
D) There is no risk of injury to patient or nurse.
Q2) Which artery is the most appropriate for assessing the pulse of a small child?
A) Radial
B) Femoral
C) Brachial
D) Ulnar
Q3) The physician order reads "Lopressor (metoprolol)50 mg PO daily.Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66.The nurse does not give the medication and
A) Does not tell the patient what the blood pressure is.
B) Documents only what the blood pressure was.
C) Documents that the medication was not given owing to low blood pressure.
D) Does not need to inform the health care provider that the medication was held.
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Chapter 30: Health Assessment and Physical Examination
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40 Verified Questions
40 Flashcards
Source URL: https://quizplus.com/quiz/25779
Sample Questions
Q1) During a routine pediatric history and physical,the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual.They state that the infant was yellow when born,and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history,the nurse determines that it is especially important to perform a focused _____ examination.
A) Cardiac
B) Respiratory
C) Ophthalmic
D) Hearing acuity
Q2) The school nurse is assessing the tympanic membranes of a 3-year-old child.Which of the following demonstrates proper technique?
A) Using an inverted otoscope grip while pulling the auricle downward
B) Pulling the auricle upward and backward
C) Holding the handle of the otoscope between the thumb and index finger while the child lies on the weight scale
D) Using an inverted otoscope grip while pulling the auricle upward
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Chapter 31: Medication Administration
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50 Verified Questions
50 Flashcards
Source URL: https://quizplus.com/quiz/25780
Sample Questions
Q1) A patient is to receive medication through a nasogastric tube.What is the most important nursing action to ensure effective absorption?
A) Thoroughly shake the medication before administering.
B) After all medications are administered, flush tube with 15 to 30 mL of water.
C) Position patient in the supine position for 30 minutes.
D) Clamp suction for 30 to 60 minutes after medication administration.
Q2) The nurse knows that an idiosyncratic event with the stimulant pseudoephedrine (Sudafed)is occurring when the patient
A) Experiences blurred vision while driving.
B) Falls asleep during daily activities.
C) Presents with a pruritus rash.
D) Develops xerostomia.
Q3) A 64-year-old quadriplegic patient needs an IM injection of antibiotic.What is the best site for the administration?
A) Deltoid
B) Dorsal gluteal
C) Ventrogluteal
D) Vastus lateralis
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33
Chapter 32: Complementary and Alternative Therapies
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20 Verified Questions
20 Flashcards
Source URL: https://quizplus.com/quiz/25781
Sample Questions
Q1) Which medication could cause an abnormal drug interaction in a patient taking an antidepressant medication?
A) Digoxin
B) Aspirin
C) Chamomile
D) Ginger
Q2) An acquaintance of a nurse asks for a nonmedical approach for excessive worry and work stress.The most appropriate CAM therapy that the nurse can recommend is
A) Meditation
B) Ayurvedic herbs
C) Acupuncture
D) Chiropractic therapy
Q3) The complementary and alternative therapy that is known to alter immune function is which of the following?
A) Biofeedback
B) Imagery
C) Breath work
D) Acupuncture
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Chapter 33: Self-Concept
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20 Flashcards
Source URL: https://quizplus.com/quiz/25782
Sample Questions
Q1) The nurse can assist the patient in becoming more self-aware by using which technique?
A) Setting up an appointment to allow the patient to vent
B) Allowing the patient to openly explore thoughts and feelings
C) Assisting the patient to physically punch a pillow when upset
D) Providing materials for the patient to write complaint letters
Q2) A nurse who grimaces when seeing a patient's colostomy opening while changing the colostomy bag is most likely to have what effect on the patient?
A) Assist recovery by using honest communication.
B) Motivate the patient to increase physical activity.
C) Promote development of a negative body image.
D) Develop a kind nickname for the colostomy opening.
Q3) The nurse in an addictions clinic is working with a patient on priority setting before the patient's discharge from residential treatment.An appropriate priority for a patient at this clinic would be
A) Identifying local self-help groups before being discharged from the program.
B) Staying away from all triggers that cause substance abuse.
C) Stating a plan to never be tempted by illicit substances after discharge.
D) Identifying personal areas of weakness to grow stronger.
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Page 35
Chapter 34: Sexuality
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23 Verified Questions
23 Flashcards
Source URL: https://quizplus.com/quiz/25783
Sample Questions
Q1) A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment.The patient tells the nurse,"I feel happier,but my sex drive is gone." Which nursing diagnosis has the highest priority?
A) Sexual dysfunction
B) Ineffective coping
C) Deficient knowledge about contraception
D) Risk for self-directed violence
Q2) A patient who had an ostomy placed 1 month ago states that he is feeling depressed and does not want to participate in sexual activities anymore because he is afraid that his partner is not physically attracted to him.Which nursing intervention will be most effective in helping this patient resume sexual activity?
A) Reassure the patient that lots of people resume sex the same week the ostomy is placed.
B) Inform the patient about a support group for people with ostomies.
C) Teach the patient about intimate activities that can be done to incorporate the ostomy.
D) Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy.
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Page 36
Chapter 35: Spiritual Health
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20 Verified Questions
20 Flashcards
Source URL: https://quizplus.com/quiz/25784
Sample Questions
Q1) The nurse is caring for a patient who has been diagnosed with a terminal illness.The patient states,"I just don't feel like going to work.I have no energy,and I can't eat or sleep." The patient shows no interest in taking part in his care.The nurse should
A) Not be concerned about self-harm because the patient has not indicated any desire toward suicide.
B) Ignore individual patient goals until the current crisis is over.
C) Encourage the patient to purchase over-the-counter sleep aids to help him sleep.
D) Assess the potential for suicide and make appropriate referrals.
Q2) The nurse is caring for a patient who is in the final stages of his terminal disease.The patient is very weak but refuses to use a bedpan,and wants to get up to use the bedside commode.What should the nurse do?
A) Explain to the patient that he is too weak and needs to use the bedpan.
B) Insert a rectal tube so that the patient no longer needs to actively defecate.
C) Enlist assistance from family members if possible and assist the patient to get up.
D) Put the patient on a bedpan and stay with him until he is finished.
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Chapter 36: The Experience of Loss, death, and Grief
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24 Verified Questions
24 Flashcards
Source URL: https://quizplus.com/quiz/25785
Sample Questions
Q1) After the anticipated demise of a chronically ill patient,the unit nurse is found crying in the staff lounge.The best response to her crying colleague would be
A) "It is normal to feel this way. Give yourself some time to mourn."
B) "Your other patients still need you, so hurry back to them."
C) "You're being a bad role model to the unit's nursing students."
D) "Why don't you take a sedative to cope?"
Q2) Validation of a dying person's life would be demonstrated by which nursing action?
A) Taking pictures of visitors
B) Calling the organ donation coordinator
C) Listening to family stories about the person
D) Providing quiet visiting time
Q3) The palliative team's primary obligation to a patient in severe pain includes which of the following?
A) Supporting the patient's nurse in her grief
B) Providing postmortem care for the patient
C) Teaching the patient the stages of grief
D) Enhancing the patient's quality of life
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Chapter 37: Stress and Coping
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20 Flashcards
Source URL: https://quizplus.com/quiz/25786
Sample Questions
Q1) A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares,fear of going to sleep,repeated vivid memories of the sexual assault,and inability to feel much emotion.The nurse recognizes the signs and symptoms of which medical problem?
A) General adaptation syndrome
B) Posttraumatic stress disorder
C) Developmental crisis
D) Alarm reaction
Q2) A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor.The senior student reports that the freshman is crying and is not adjusting to college life.The clinic nurse recognizes this as a combination of situational and maturational stress factors.The best comment to the senior student would be
A) "I'd better call 911 because your friend is suicidal."
B) "Give her this list of university and community resources."
C) "You must make an appointment for the student to obtain medications."
D) "I'd recommend you help the student pack her bags to go home."
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Chapter 38: Activity and Exercise
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30 Verified Questions
30 Flashcards
Source URL: https://quizplus.com/quiz/25787
Sample Questions
Q1) The nurse is developing a plan of care for a patient diagnosed with activity intolerance.Of the following strategies,which has the best chance of maintaining patient compliance?
A) Performing 20 minutes of aerobic exercise daily with 10 minute warm-up and cool-down periods
B) Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity
C) Instructing the patient on the evils of not exercising, and getting her to take responsibility for her current health status
D) Arranging for the patient to join a gym that she will have to pay, for so that she does not need to depend on insurance
Q2) The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance.In doing so,the nurse should
A) Plan for 20 minutes of continuous aerobic activity and increase as tolerated.
B) Perform 6-minute walks at the patient's pace at least 2 times a day.
C) Instruct the patient that he should not take his beta blocker medication on exercise days.
D) Encourage a high-calorie diet to plan for extra calorie expenditure.
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Page 40
Chapter 39: Hygiene
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) The patient is complaining of an inability to clear his nasal passages.The nurse instructs the patient to
A) Blow his nose forcefully to clear the passage.
B) Insert a cotton-tipped applicator as far as possible.
C) Apply gentle suction using a pediatric bulb suction device.
D) Use a dry washcloth to absorb secretions.
Q2) The nurse is providing perineal care to an uncircumcised male patient.When providing such care,the nurse should
A) Leave the foreskin alone because there is little chance of infection.
B) Retract the foreskin for cleansing and allow it to return on its own.
C) Retract the foreskin and keep retracted.
D) Retract the foreskin and return it to its natural position when done.
Q3) When providing basic eye care,the nurse
A) Cleanses the eye with soap and water.
B) Applies pressure directly to the eyeball.
C) Cleanses from inner canthus to outer canthus.
D) Provides less frequent care to unconscious patients.
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Chapter 40: Oxygenation
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48 Flashcards
Source URL: https://quizplus.com/quiz/25789
Sample Questions
Q1) The structure that is responsible for returning oxygenated blood to the heart is the
A) Pulmonary artery.
B) Pulmonary vein.
C) Superior vena cava.
D) Inferior vena cava.
Q2) A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
A) Decreased tidal volumes.
B) Increased perfusion.
C) Increased use of accessory muscles.
D) Decreased hemoglobin.
Q3) A patient has inadequate stroke volume related to decreased preload.The nurse anticipates
A) Placing the patient on oxygen monitoring.
B) Administering vasodilators.
C) Verifying that the blood consent form has been signed.
D) Preparing the patient for dialysis.
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Chapter 41: Fluid, electrolyte, and Acid-Base Balance
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45 Verified Questions
45 Flashcards
Source URL: https://quizplus.com/quiz/25790
Sample Questions
Q1) The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration.What is the most effective nursing intervention for monitoring both of these patients?
A) Weigh the patients every morning before breakfast.
B) Ask the patients to record their intake and output.
C) Measure the patients' blood pressure every 4 hours.
D) Assess the patients for edema in extremities.
Q2) A patient informs the nurse that he has the type of diabetes that does not require insulin.The nurse advises the patient to make which dietary change?
A) Drink plenty of fluids throughout the day to stay hydrated.
B) Avoid food high in acid to avoid metabolic acidosis.
C) Reduce the quantity of carbohydrates ingested to lower blood sugar.
D) Include a serving of dairy in each meal to elevate calcium levels.
Q3) The nurse would not expect full compensation to occur for which acid-base imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
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Page 43
Chapter 42: Sleep
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30 Verified Questions
30 Flashcards
Source URL: https://quizplus.com/quiz/25791
Sample Questions
Q1) A patient has received a nursing diagnosis of sleep deprivation.Which of the following statements by the patient would indicate that outcomes are being met?
A) "I wake up only once a night to go the bathroom."
B) "I feel rested when I wake up in the morning."
C) "I go to sleep within 30 minutes of lying down."
D) "I only take a 20-minute nap during the day."
Q2) The patient shares with the nurse the vivid,full color dreams experienced by the patient last night.These data would indicate that the patient has reached what stage of sleep?
A) Stage 1 NREM
B) Stage 2 NREM
C) Stage 3 NREM
D) REM
Q3) The nurse assigns a nursing diagnosis of ineffective breathing pattern.Which of the following sleep conditions would support this diagnosis?
A) Insomnia
B) Narcolepsy
C) Obstructive sleep apnea
D) Sleep deprivation
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Chapter 43: Pain Management
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35 Verified Questions
35 Flashcards
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Sample Questions
Q1) A nurse has brought the patient his scheduled pain medication.The patient asks the nurse to wait to give pain medication until the time for the dressing change,which is 2 hours away.Which response by the nurse is most therapeutic?
A) "This medication will still be providing you relief at the time of your dressing change."
B) "OK, swallow this pain pill, and I will return in a minute to fill your wound."
C) "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"
D) "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."
Q2) A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand.What does type of pain does the nurse document that the patient has?
A) Visceral pain
B) Somatic pain
C) Peripherally generated pain
D) Centrally generated pain
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45
Chapter 44: Nutrition
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45 Verified Questions
45 Flashcards
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Sample Questions
Q1) The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours.The most likely cause of the diarrhea would be
A) Clostridium difficile.
B) Antibiotic therapy.
C) Formula intolerance.
D) Bacterial contamination.
Q2) When teaching a patient about current dietary guidelines for the general population,the nurse explains referenced daily intakes (RDIs)and daily reference values (DRVs),otherwise known as daily values.In providing this information,the nurse understands that daily values
A) Have replaced recommended daily allowances (RDAs).
B) Have provided a more understandable format of RDAs for the public.
C) Are based on percentages of a diet consisting of 1200 kcal/day.
D) Are not usually easy to find computer experience is required.
Q3) In measuring the effectiveness of nutritional interventions,the nurse should
A) Expect results to occur rapidly.
B) Not be concerned with physical measures such as weight.
C) Expect to maintain a course of action regardless of changes in condition.
D) Evaluate outcomes according to the patient's expectations and goals.
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Page 46
Chapter 45: Urinary Elimination
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44 Flashcards
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Sample Questions
Q1) The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be
A) Cloudy.
B) Discolored.
C) Sweet smelling.
D) Painful.
Q2) The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis?
A) Renal ultrasound
B) Bladder scan
C) KUB x-ray
D) Intravenous pyelogram
Q3) Upon palpation,the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate.The nurse should follow up by asking
A) "When was the last time you voided?"
B) "Do you lose urine when you cough or sneeze?"
C) "Have you noticed any change in your urination patterns?"
D) "Do you have a fever or chills?"
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Chapter 46: Bowel Elimination
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40 Verified Questions
40 Flashcards
Source URL: https://quizplus.com/quiz/25795
Sample Questions
Q1) The nurse administers a cathartic to a patient.The nurse determines that the cathartic has had a therapeutic effect when the patient
A) Has a decreased level of anxiety.
B) Experiences pain relief.
C) Has a bowel movement.
D) Passes flatulence.
Q2) A nurse is educating a patient on how to irrigate an ostomy bag.Which statement by the patient indicates the need for further instruction?
A) "I can use a fleet enema to save money because it contains the same irrigation solution."
B) "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl."
C) "I should never attempt to reach into my stoma to remove fecal material."
D) "Using warm tap water will reduce cramping and discomfort during the procedure."
Q3) The nurse should question which order?
A) A normal saline enema to be repeated every 4 hours until stool is produced
B) A hypertonic solution enema with a patient with fluid volume excess
C) A Kayexalate enema for a patient with hypokalemia
D) An oil retention enema for a patient using mineral oil laxatives
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Chapter 47: Mobility and Immobility
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48 Flashcards
Source URL: https://quizplus.com/quiz/25796
Sample Questions
Q1) The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to
A) Be ineffective in reducing injury.
B) Be cost neutral in budgeting.
C) Enhance recruitment.
D) Decrease retention rates.
Q2) The nurse needs to reposition a 300-lb patient.Which of the following strategies is most likely to prevent back injury?
A) Turn the patient alone using the lift pad and applying pillows.
B) Put the bed in Trendelenburg and pull from the head of the bed.
C) Assess and obtain the number of people needed to help.
D) Bend at the waist and pull the lift pad using the arms.
Q3) Joints are the connections between bones.The joint that is freely movable is known as the _____ joint.
A) Synostotic
B) Cartilaginous
C) Fibrous
D) Synovial
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Page 49
Chapter 48: Skin Integrity and Wound Care
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) The nurse is completing a skin assessment on a medical-surgical patient.Which nursing assessment questions should be included in a skin integrity assessment?
A) "Can you easily change your position?"
B) "Do you have sensitivity to heat or cold?"
C) "How often do you need to use the toilet?"
D) "Is movement painful?"
E) "What medications do you take?"
F) "Have you ever fallen?"
Q2) The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection.The patient is unconscious and bedridden.The nurse is completing the plan of care and is writing goals for the patient.What is the best goal for this patient?
A) The patient's family will demonstrate specific care of the wound site.
B) The patient will state what to look for with regard to an infection.
C) The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.
D) The patient's family members will wash their hands when visiting the patient.
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Chapter 49: Sensory Alterations
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29 Verified Questions
29 Flashcards
Source URL: https://quizplus.com/quiz/25798
Sample Questions
Q1) What is the involuntary motion of retracting the body from painful stimuli?
A) Sensation
B) Reception
C) Perception
D) Reaction
Q2) The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location.Which nursing intervention would be effective in orienting a patient with neurological deficit?
A) Assessing the patient's level of consciousness and documenting every 4 hours
B) Keeping a day-by-day calendar at the patient's bedside and having the patient manage it
C) Placing a patient observer in the patient's room for safety
D) Informing the patient that she cannot be discharged unless she is awake, alert, and oriented
Q3) Which of the following sensory changes are normal with aging?
A) Impaired night vision
B) Difficulty hearing low pitch
C) Increase in taste discrimination
D) Heightened sense of smell
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Chapter 50: Care of Surgical Patients
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45 Flashcards
Source URL: https://quizplus.com/quiz/25799
Sample Questions
Q1) The nurse is caring for a postoperative patient who has had a carpel tunnel repair.The patient has a temperature of 97° F and is shivering.Which of the following is the best reason for this condition?
A) The patient is dressed only in a gown.
B) Anesthesia lowers metabolism.
C) The surgical suite has laminar flow.
D) The open body cavity contributed to heat loss.
Q2) The nurse is preparing to assist the patient in using the incentive spirometer.Which nursing intervention should the nurse provide first?
A) Perform hand hygiene.
B) Place in reverse Trendelenburg position.
C) Explain use of the mouthpiece.
D) Instruct the patient to inhale slowly.
Q3) The nurse is preparing a patient for surgery.Aims of assessment before surgery include
A) Establishing a patient's baseline of normal function.
B) Planning for care after the procedure.
C) Educating the patient and family about the procedure.
D) Gathering appropriate equipment for the patient's needs.
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