1.
Which of the following nursing interventions promotes patient safety?
Correct Answer
D. All of the above
Explanation
All of the above nursing interventions promote patient safety. Assessing the patient's ability to ambulate and transfer from a bed to a chair ensures that the patient can move safely without the risk of falls or injuries. Demonstrating the signal system to the patient allows them to call for help in case of emergencies or when they need assistance. Checking that the patient is wearing their identification band helps to ensure that they receive the correct treatments and medications, minimizing the risk of errors.
2.
The nurse’s most important legal responsibility after a patient’s death in a hospital is:
Correct Answer
C. Labeling the corpse appropriately
Explanation
After a patient's death in a hospital, the nurse's most important legal responsibility is to label the corpse appropriately. This is crucial for maintaining accurate records and ensuring proper identification of the deceased individual. Proper labeling helps in preventing any confusion or mix-up during the subsequent processes such as transportation, autopsy, or funeral arrangements. It also aids in maintaining the chain of custody and complying with legal and regulatory requirements related to handling and disposition of deceased individuals.
3.
Which of the following patients is at greatest risk for developing pressure ulcers?
Correct Answer
B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
Explanation
The 88-year old incontinent patient with gastric cancer who is confined to his bed at home is at the greatest risk for developing pressure ulcers. This patient is at risk due to multiple factors: being elderly, having a medical condition (gastric cancer), being incontinent, and being confined to bed. Immobility, incontinence, and poor nutritional status are all risk factors for the development of pressure ulcers. Additionally, the patient's age and underlying medical condition may further compromise their skin integrity and ability to heal, increasing their risk for pressure ulcers.
4.
All of the following can cause tachycardia except:
Correct Answer
D. Parasympathetic nervous system stimulation
Explanation
Parasympathetic nervous system stimulation is not a cause of tachycardia. Tachycardia refers to an abnormally fast heart rate, typically above 100 beats per minute. Fever, exercise, and sympathetic nervous system stimulation can all lead to an increase in heart rate. However, parasympathetic nervous system stimulation, which is responsible for slowing down the heart rate, would not cause tachycardia.
5.
Fter 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?
Correct Answer
C. Muscle weakness
Explanation
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6.
Which of the following is the most common cause of dementia among elderly persons?
Correct Answer
D. Alzheimer’s disease
Explanation
Alzheimer's disease is the most common cause of dementia among elderly persons. It is a progressive brain disorder that affects memory, thinking, and behavior. It is characterized by the buildup of amyloid plaques and tau tangles in the brain, leading to the death of brain cells and a decline in cognitive function. Symptoms of Alzheimer's disease include memory loss, confusion, difficulty with language and problem-solving, and changes in mood and behavior. While Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis can also cause cognitive impairment, they are not as commonly associated with dementia as Alzheimer's disease.
7.
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
Correct Answer
C. Pedal
Explanation
The absence of the pedal pulse may not be a significant finding when a patient is admitted to the hospital because the pedal pulse refers to the pulse in the foot. In certain situations, such as when a patient has peripheral artery disease or is wearing compression stockings, the pedal pulse may not be easily palpable or may be weak. Therefore, its absence alone may not be a cause for concern, as there are other pulses that can be assessed to evaluate the patient's circulatory status.
8.
A prescribed amount of oxygen s needed for a patient with COPD to prevent:
Correct Answer
D. Inhibition of the respiratory hypoxic stimulus
Explanation
The correct answer is "Inhibition of the respiratory hypoxic stimulus". In patients with COPD, their respiratory drive is primarily stimulated by low oxygen levels in the blood. Therefore, if the patient receives too much supplemental oxygen, it can inhibit this hypoxic drive and lead to respiratory depression or hypoventilation. This is why it is important to carefully titrate the amount of oxygen given to COPD patients to avoid this potential complication.
9.
Which of the following vascular system changes results from aging?
Correct Answer
D. All of the above
Explanation
As a person ages, several changes occur in the vascular system. One of these changes is an increase in peripheral resistance of the blood vessels, which means that the blood vessels become narrower and it becomes more difficult for the blood to flow through them. Additionally, there is a decrease in blood flow, which further contributes to the reduced efficiency of the circulatory system. Lastly, the increased workload of the left ventricle is another consequence of aging, as it has to pump harder to compensate for the changes in the blood vessels. Therefore, all of the given options are correct and represent vascular system changes that result from aging.
10.
A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:
Correct Answer
A. Ineffective airway clearance related to thick, tenacious secretions.
Explanation
The patient's symptoms of shortness of breath, orthopnea, and thick, tenacious secretions indicate that their airway is not effectively clearing mucus. This is likely due to the thick secretions obstructing the airway, leading to difficulty in breathing. Therefore, the appropriate nursing diagnosis would be "Ineffective airway clearance related to thick, tenacious secretions." This diagnosis addresses the specific issue of the patient's airway being obstructed by the thick secretions and identifies it as the cause of their symptoms.
11.
The most common injury among elderly persons is:
Correct Answer
D. Hip fracture
Explanation
As people age, their bones become more fragile and prone to fractures. The hip is one of the most commonly affected areas in elderly individuals. Hip fractures can occur due to a fall or even a minor injury, and they can have serious consequences, leading to decreased mobility, increased dependence, and a higher risk of complications such as pneumonia or blood clots. Therefore, hip fractures are the most common injury among elderly persons.
12.
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
Correct Answer
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
Explanation
Increasing the patient's fluid intake can help to thin and loosen the secretions, making it easier for the patient to cough them up and improve gas exchange. This intervention can help to prevent further complications and promote better respiratory function.
13.
The most common psychogenic disorder among elderly person is:
Correct Answer
A. Depression
Explanation
Depression is the most common psychogenic disorder among elderly individuals. It is characterized by symptoms such as sleep disturbances, inability to concentrate, and decreased appetite. Depression can have a significant impact on the overall well-being and quality of life of elderly individuals. It is important to recognize and address depression in this population as it can often be overlooked or mistaken for normal aging. Treatment options, including therapy and medication, can help alleviate symptoms and improve the mental health of elderly individuals affected by depression.
14.
When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
Correct Answer
A. Protect the patient from injury
Explanation
In the terminal stages of lung cancer, when a patient starts to lose consciousness, protecting the patient from injury becomes a major nursing priority. This is because loss of consciousness can lead to a loss of control over body movements, making the patient more prone to accidents or falls. By ensuring a safe environment and taking measures to prevent injuries, nurses can help maintain the patient's overall well-being and minimize any potential harm.
15.
The most common deficiency seen in alcoholics is:
Correct Answer
A. Thiamine
Explanation
Thiamine deficiency is the most common deficiency seen in alcoholics. Alcohol interferes with the absorption, storage, and utilization of thiamine in the body. Thiamine is an essential B vitamin that plays a crucial role in energy metabolism and the functioning of the nervous system. Chronic alcohol consumption can lead to a decrease in thiamine levels, which can result in a condition called Wernicke-Korsakoff syndrome, characterized by neurological symptoms such as confusion, memory loss, and coordination problems. Therefore, alcoholics are at a higher risk of thiamine deficiency compared to other vitamin deficiencies.
16.
A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
Correct Answer
C. Accompany the patient for his walk.
Explanation
The patient had surgery for head and neck cancer, which can have significant effects on balance and vision. Even though the nurse notes that the patient is steady on his feet and his vision is unaffected, it is still important to accompany the patient for his walk. This is a precautionary measure to ensure the patient's safety and provide support if any issues arise during ambulation. Consulting a physical therapist may also be beneficial, but the immediate action would be to accompany the patient for his walk.
17.
Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:
Correct Answer
D. “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”
Explanation
The correct answer is the best response because it shows empathy and understanding towards Mrs. Lim's emotions. It acknowledges the difficulty she is experiencing and offers reassurance that her hair will grow back after completing chemotherapy. This response shows support and compassion, providing Mrs. Lim with the emotional comfort she needs in that moment.
18.
Palpating the midclavicular line is the correct technique for assessing
Correct Answer
D. Apical pulse
Explanation
Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is the heartbeat that is felt at the apex of the heart, which is located in the fifth intercostal space at the midclavicular line. By palpating this area, healthcare professionals can accurately assess the rate, rhythm, and strength of the heartbeat. This technique allows for a more accurate assessment of the heart's function and can help identify any abnormalities or irregularities in the pulse.
19.
Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
Correct Answer
D. Side rails are a reminder to a patient not to get out of bed
Explanation
The correct answer is "Side rails are a reminder to a patient not to get out of bed." This conclusion is based on the fact that despite the use of side rails, 40% of patients still fall out of bed. This suggests that side rails alone are not enough to prevent falls, but they serve as a visual reminder to patients to stay in bed and not attempt to get out.
20.
Before rigor mortis occurs, the nurse is responsible for:
Correct Answer
B. Placing one pillow under the body’s head and shoulders
Explanation
Placing one pillow under the body's head and shoulders is the correct answer because it helps to maintain proper body alignment and prevent pooling of blood in the head and neck area. This position also allows for a more natural and comfortable appearance of the deceased. Providing a complete bath and dressing change, removing the body's clothing and wrapping the body in a shroud, or allowing the body to relax normally are not tasks that are typically performed before rigor mortis occurs.
21.
Which of the following statement is incorrect about a patient with dysphagia?
Correct Answer
C. The patient should always feed himself
Explanation
The statement "The patient should always feed himself" is incorrect because a patient with dysphagia may require assistance with feeding. Dysphagia can make swallowing difficult and increase the risk of choking or aspiration. Therefore, it is important for the nurse or caregiver to assist the patient with feeding, ensuring that the food is prepared appropriately and that the patient is in a safe position during the process.
22.
An additional Vitamin C is required during all of the following periods except:
Correct Answer
B. Young adulthood
Explanation
During young adulthood, the body is typically in its prime and able to meet its nutritional needs through a balanced diet. Infancy, childhood, and pregnancy, on the other hand, are periods of rapid growth and development where additional vitamin C is crucial. Vitamin C is essential for healthy immune function, collagen synthesis, and iron absorption, making it particularly important during these stages. Therefore, young adulthood does not require additional vitamin C supplementation compared to the other mentioned periods.
23.
Which of the following statement is incorrect about a patient with dysphagia?
Correct Answer
C. The patient should always feed himself
Explanation
The statement "The patient should always feed himself" is incorrect. Patients with dysphagia may have difficulty swallowing and may require assistance with feeding. The nurse should assess the patient's ability to swallow safely and provide the necessary support and assistance during meal times to prevent choking or aspiration.
24.
Examples of patients suffering from impaired awareness include all of the following except:
Correct Answer
C. A patient who cannot care for himself at home
Explanation
A patient who cannot care for himself at home may not necessarily have impaired awareness. Impaired awareness refers to a lack of understanding or recognition of one's own condition or situation. While a patient who cannot care for himself at home may have physical limitations or disabilities, it does not necessarily mean that they have impaired awareness.
25.
Certain substances increase the amount of urine produced. These include:
Correct Answer
A. Caffeine-containing drinks, such as coffee and cola.
Explanation
Caffeine-containing drinks, such as coffee and cola, increase the amount of urine produced. Caffeine is a diuretic, which means it promotes urine production by increasing the blood flow to the kidneys and inhibiting the reabsorption of water. This results in more urine being produced and expelled from the body.