Lecture Exam 1 - Practice Questions
Taken from Fundamentals Success, 2nd Edition.
- 1.The nurse is assessing a patient who is experiencing prolonged stress. For which most serious complication should the nurse monitor the patient?
- A.
Altered sleeping
- B.
Impaired immunity
- C.
Increased muscle tension
- D.
Decreased intestinal persistalsis
- 2.The nurse gives a resident in a nursing home a choice about which color shirt to wear. What level need, according to Maslow's Hierarchy of Needs, has the nurse just met?
- A.
Physiologic
- B.
Self-esteem
- C.
Safety and Security
- D.
Love and Belonging
- 3.Freedom from which situation demonstrates a safety and security need in Maslow's Hierarchy of Needs?
- A.
Pain
- B.
Hunger
- C.
Ridicule
- D.
Loneliness
- 4.Which common physiologic changes associated with aging should the nurse assess for in an older adult? (Select all that apply.)
- A.
Increase in sebaceous gland activity
- B.
Deterioration of joint cartilage
- C.
Loss of social support system
- D.
Decreased hearing acuity
- E.
Increased need for sleep
- 5.A patient states, "Do you think I could have cancer?" The nurse responds, "What did the doctor tell you?" What interviewing approach did the nurse use?
- A.
Paraphrasing
- B.
Confrontation
- C.
Reflective technique
- D.
Open-ended question
- 6.The nurse plans to foster a therapeutic relationship with a patient. It is most important that the nurse:
- A.
Work on establishing a friendship with the patient
- B.
Use humor to defuse emotionally charged topics of discussion
- C.
Sympathize with the patient when the patient shares sad feelings
- D.
Demonstrate respect when discussion emotionally charged topics
- 7.A patient who is to receive nothing by mouth (NPO) in preparation for a bronchoscopy says, "I am worried about the test and I can't even have a drink of water." What is the best response by the nurse?
- A.
"Let's talk about your concerns regarding the test."
- B.
"I'll see if the doctor will let you have some ice chips."
- C.
"The doctor will review the results of the test as soon as possible."
- D.
"As soon as the test is over, I'll get you whatever you would like to drink."
- 8.A mother whose young daughter has died of leukemia is crying, and is unable to talk about her feelings. What is the best response by the nurse?
- A.
"Everyone will remember her because she was so cute. She was one of our favorites."
- B.
"As hard as this is, it is probably for the best because she was in a lot of pain."
- C.
"She put up the good fight but now she is out of pain and in heaven."
- D.
"I feel so sad. It can be hard to deal with such a precious loss."
- 9.The goals of therapeutic communication mainly should depend on the:
- A.
Environment in which communication takes place.
- B.
Role of the nurse in the particular clinical setting.
- C.
Skill level of the nurse in the situation.
- D.
Concerns of the patient.
- 10.A patient with chest pain is being admitted to the Emergency Department. When asked about next of kin, the patient states, "Don't bother calling my daughter, she's always too busy." What is the best response by the nurse?
- A.
"She might be upset if you don't call her."
- B.
"What does your daughter do that makes her so busy?"
- C.
"Is there someone else that you would like me to call for you?"
- D.
"I can't imagine that your daughter wouldn't want to know that you are sick."
- 11.Which are the most important nursing actions when speaking with an older adult who is hearing-impaired? Select all that apply.
- A.
Limit background noise.
- B.
Exaggerate lip movements.
- C.
Raise the pitch of your voice.
- D.
Stand directly in front of the patient while speaking.
- E.
Raise the volume of your voice while speaking directly toward the patient's good ear.
- 12.A patient with a colostomy wants to learn how to irrigate a newly created colostomy. The nurse provides this teaching by developing a therapeutic nurse-patient relationship and implementing teaching strategies. Identify statements that are included in the working phase of this therapeutic relationship. Select all that apply.
- A.
"How do you feel about doing this procedure?"
- B.
"Would you like to try to insert the cone yourself today?"
- C.
"You did a great job managing the instillation fluid today."
- D.
"I am here to help you learn how to irrigate your colostomy."
- E.
"I'll arrange for a home care nurse to visit you in your home when you are discharged."
- 13.When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?
- A.
Reassess the patient
- B.
Examine the 'r/t' factors
- C.
Analyze the 'secondary to' factors
- D.
Review the defining characteristics
- 14.The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
- A.
Diagnose if the patient is at risk for falls
- B.
Ensure that the patient's skin is intact
- C.
Establish a therapeutic relationship
- D.
Identify important data
- 15.The nurse comes to the conclusion that a patient's elevate temperature, pulse, and respirations are significant. What step of the nursing process is being used when the nurse comes to this conclusion?
- A.
Implementation
- B.
Assessment
- C.
Evaluation
- D.
Diagnosis
- 16.The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurately stated goal? "The patient will:
- A.
Be taught how to use a urinal when on bed rest."
- B.
Experience fewer incontinence episodes at night."
- C.
Be assisted on the toilet every two hours and whenever necessary."
- D.
Transfer independently and safely to a commode before discharge."
- 17.The nurse collects objective data when a hospitalized patient states:
- A.
"I am hungry."
- B.
"I feel very warm."
- C.
"I ate half my lunch."
- D.
I have the urge to urinate."
- 18.The nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? The patient will:
- A.
Have a lower temperature
- B.
Be given aspirin every eight hours prn
- C.
Be taught how to take an accurate temperature
- D.
Maintain fluid intake sufficient to prevent dehydration
- 19.The nurse collects data about a patient. Next, the nurse should:
- A.
Write a patient-centered goal
- B.
Formulate a nursing diagnosis
- C.
Design a plan of nursing interventions
- D.
Determine the significance of the information
- 20.The nurse understands that human responses can be classified as subjective or objective. Identify all those that are subjective.
- A.
Nausea
- B.
Jaundice
- C.
Dizziness
- D.
Diaphoresis
- E.
Hypotension
- 21.The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
- A.
Surgical creation of a colostomy
- B.
First-degree burn on the back
- C.
Puncture of the foot by a nail
- D.
Paper cut on the finger
- 22.A patient is positive for Clostridium difficile. The nurse should institute the isolation precaution known as:
- A.
Droplet
- B.
Contact
- C.
Reverse
- D.
Airborne
- 23.The nurse is concerned about a patient's ability to withstand exposure to pathogens. What blood component should the nurse monitor?
- A.
Platelets
- B.
Neutrophils
- C.
Hemoglobin
- D.
Erythrocytes
- 24.The nurse understands which primary (nonspecific) defense protects the body from infection?
- A.
Tears in the eyes
- B.
Alkalinity of gastric secretions
- C.
Bile in the gastrointestinal system
- D.
Moist environment of the epidermis
- 25.Which nursing action protects the patient from infection at the portal of entry?
- A.
Positioning an indwelling urine collection bag below the level of the patient's pelvis
- B.
Enclosing a urine specimen in a biohazardous transport bag
- C.
Wearing clean gloves when handling a patient's excretions
- D.
Handwashing after the removal of soiled protective gloves
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