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
Correct Answer
B. Impaired immunityExplanation
Difficulty sleeping is a common adaptation to prolonged stress, but is not life threatening.
Impaired immunity is a serious threat caused by prolonged periods of stress.
Increased muscle tension is a physiologic indicator of stress, but is not as serious a concern as one other option offered.
Constipation is a concern, but is not as serious as one of the other options offered.Rate this question:
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- 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
Correct Answer
B. Self-esteemExplanation
Choosing which color shirt to wear provides the person with the opportunity to make a choice and supports feelings of independence, competence, and self-respect, which all contribute to and provide self-esteem.
Physiologic needs are related to breathing, eating, resting, etc.
Safety and security needs relate to feeling protected in the physiologic and interpersonal realms.
Love and belonging needs relate to giving and receiving affection, etc.Rate this question:
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- 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
Correct Answer
A. PainExplanation
According to Maslow, freedom from pain is considered a safety and security need.
Freedom from hunger is considered a first-level, physiologic need.
Freedom from ridicule is associated with self-esteem needs.
Freedom from loneliness is associated with love and belonging needs.Rate this question:
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- 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
Correct Answer(s)
B. Deterioration of joint cartilage
D. Decreased hearing acuityExplanation
Sebaceous gland activity decreases with age, leading to dry, cracked skin.
Older adults generally experience a deterioration of the hyaline cartilage surface of joints, limiting joint motion.
Loss of social support system is a psychosocial, not a physiologic, change commonly experienced by older adults.
Hearing acuity decreases with age.
Older adults have the same need for sleep as younger adults -- they just may not sleep as well as they age.Rate this question:
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- 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
Correct Answer
D. Open-ended questionExplanation
Paraphrasing is restating the patient's basic message in similar words.
Confrontation is challenging a patient's statements or behaviors.
Reflection is referring back to the basic feelings underlying the patient's statement.
This open-ended question invites the patient to elaborate on the expressed thoughts with more than a one or two word response.Rate this question:
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- 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
Correct Answer
D. Demonstrate respect when discussion emotionally charged topicsExplanation
Nurses should be friendly, but not establish a friendship, with a patient -- the nurse should maintain a professional relationship.
Humor may be viewed as minimizing the concerns or frivolous, and could be a barrier to communication.
Sympathy denotes pity, which should be avoided. The nurse should empathize, not sympathize, with the patient.
Emotionally charged topics should be approached with respectful, sincere interactions that are accepting and nonjudgmental, which will promote further discussion.Rate this question:
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- 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."
Correct Answer
A. "Let's talk about your concerns regarding the test."Explanation
The best response encourages the patient to explore their concerns -- verbalization of concerns, validation of feelings, and patient teaching may help reduce anxiety.
Ice chips are contraindicated because of the risk of aspiration.
Fluid and food are not permitted after this test until gag reflex returns.
Saying the doctor will review ASAP ignores both the patient's concerns and addresses a completely different issue.Rate this question:
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- 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."
Correct Answer
D. "I feel so sad. It can be hard to deal with such a precious loss."Explanation
The first response focuses on the nurse, not on the mother.
The second response minimizes the mother's loss, and focuses on the pain of the child which may increase the mother's grief.
The third response minimizes the loss and focuses on the pain of the child, and the mother may not believe in heaven.
The correct response expresses empathy in its first sentence, and the second part focuses on feelings surrounding loss and provides the patient an opportunity to verbalize. Both of these are therapeutic responses to the situation.Rate this question:
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- 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.
Correct Answer
D. Concerns of the patient.Explanation
The patient and significant others and their needs are always the focus of nursing interventions, including the goals of communication.
Although environment may enhance or be a barrier, it does not determine the goals of communication.
The role of a nurse in a particular setting does not dictate the goals of communication.
Although the interviewing skills of the nurse may determine the effectiveness of the communication, it does not determine its goals.Rate this question:
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- 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."
Correct Answer
C. "Is there someone else that you would like me to call for you?"Explanation
This response lets the patient know that the message has been heard and moves forward to meet the need to notify a significant other of the patient's situation.
The first response puts the patient on the defensive and will jeopardize the nurse-patient relationship.
The second response requires the patient to rationalize the daughter's behavior and focuses on information that is not significant at this time.
The last response provides false reassurance. Only the daughter can convey this message.Rate this question:
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- 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.
Correct Answer(s)
A. Limit background noise.
D. Stand directly in front of the patient while speaking.Explanation
Limiting competing stimuli promotes reception of verbal messages.
Standing directly in front of the patient focuses the patient's attention on the nurse; a hearing-impaired receiver must be aware that a message is being sent before the message can be received and decoded.
Exaggerating lip movements can be demeaning and ineffective.
Raising the pitch of voice is not helpful, because hearing loss in older persons typically involves loss of perception of high pitched sounds.
Raising the volume of your voice is demeaning and can be viewed as aggressive.Rate this question:
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- 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."
Correct Answer(s)
B. "Would you like to try to insert the cone yourself today?"
C. "You did a great job managing the instillation fluid today."Explanation
The first statement is therapeutic but is part of the orientation phase, not the working phase.
The two correct options are therapeutic, are part of the working phase. Asking the patient to insert the cone involves completing interventions that address expected outcomes (learning how to irrigate the colostomy.) The second statement provides feedback and encouragement.
Stating you are there to help the patient learn how to irrigate the colostomy is part of the orientation phase.
Arranging the home care nurse reflects the termination phase of the therapeutic relationship.Rate this question:
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- 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
Correct Answer
D. Review the defining characteristicsExplanation
The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
If a thorough assessment is completed initially, a reassessment should not be necessary.
To establish which of the two diagnoses is most appropriate is not dependent upon identifying the factors that contributed to (also known as the etiology or r/t) the nursing diagnosis. These factors are identified after the problem statement is identified.
To establish which of the two nursing diagnoses is most appropriate is not dependent up on 'secondary to' factors; these are medical conditions that precipitate the 'r/t' factors.Rate this question:
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- 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
Correct Answer
D. Identify important dataExplanation
Identifying important data is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped into meaningful clusters before a nursing diagnosis can be made.
A nursing admission assessment does include assessments of the skin, risk for falls, and establishes a therapeutic relationship, these are only single components of the assessment and not the primary purpose.Rate this question:
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- 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
Correct Answer
D. DiagnosisExplanation
During the diagnosis step, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of the nursing diagnosis; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority.
During implementation, planned nursing care is delivered.
During assessment, data may be gathered, but the manipulation of the data is done during a different step.
During evaluation, actual outcomes are compared with expected outcomes, which reflect attainment or nonattainment of the goal.Rate this question:
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- 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."
Correct Answer
D. Transfer independently and safely to a commode before discharge."Explanation
This goal is correctly worded because it is patient-centered, measurable, realistic, and includes a time-frame. The word 'independently' indicates that no help is needed, and the word 'safely' indicates that no injury will occur. The time frame is 'before discharge'.
Teaching to use a urinal is not a goal; it is an action the nurse must implement to help a patient achieve a goal.
The statement about fewer incontinence episodes is inappropriate because it is not specific, measurable, and has no time frame.
Being assisted on the toilet is not a goal; it is an action the nurse plans to implement in order to help the patient achieve a goal.Rate this question:
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- 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."
Correct Answer
C. "I ate half my lunch."Explanation
In a hospital setting, the amount of food a patient ate can be objectively verified.
The other responses are subjective.Rate this question:
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- 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
Correct Answer
D. Maintain fluid intake sufficient to prevent dehydrationExplanation
A goal must be patient-centered, specific, be measurable, and have a time-frame.
A "lower" temperature is not specific, measurable, or objective.
Giving aspirin is an action the nurse plans to implement, not a goal.
Teaching the patient is an action the nurse plans to implement, not a goal.
Maintaining fluid intake sufficient to prevent dehydration is a well-written goal: 'sufficient' and 'dehydration' are based on generally accepted criteria against which to measure the patient's actual outcome. The word 'maintain' connotes continuity, which is a time frame.Rate this question:
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- 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
Correct Answer
D. Determine the significance of the informationExplanation
After data are collected, they are clustered to determine their significance.
Once the data have been clustered, the nurse makes inferences and then formulates a nursing diagnosis. After making the nursing diagnosis, nursing care is planned.Rate this question:
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- 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
Correct Answer(s)
A. Nausea
C. DizzinessExplanation
Jaundice, excessive sweating, and abnormally low blood pressure can be observed, measured, or otherwise verified. Only nausea and dizziness are subjective; they cannot be measured by the nurse directly.Rate this question:
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- 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
Correct Answer
C. Puncture of the foot by a nailExplanation
Of all the options, a puncture wound on the foot by a nail has the greatest risk for a wound infection. A nail is a solid object that has the potential of introducing pathogens into a deep wound that can trap them under the surface of the skin, a favorable environment for multiplication.
Surgery is conducted using a sterile technique, and preoperative techniques are used for colostomy procedure that helps reduce the number of organisms that have the potential to cause infection.
There is no break in the skin in a first-degree burn; therefore, less risk of infection than in another option.
Paper generally is not heavily soiled and the wound edges are approximated. This is less of a risk than another option.Rate this question:
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- 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
Correct Answer
B. ContactExplanation
Contact precautions are used for patients who have an illness transmitted by direct contact, for example GI, skin or wound infections: Hep A, herpes simplex, C. diff or E. coli colonization, Shigella, impetigo, scabies, pediculosis, syncytial virus, parainfluenza...
Droplet precautions are for patients who have an illness transmitted by particle droplets larger than 5 microns; mumps, pneumonia, diphtheria, Mycoplasma PNE, pertussis, pnemonic plague...
Reverse isolation precaution are to protect immunocompromised patients from additional infection(s). Also known as neutropenic precautions.
Airborne precautions are used for patients who have an illness transmitted by airborne droplet smaller than 5 microns; varicella, rubeola, TB...Rate this question:
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- 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
Correct Answer
B. NeutrophilsExplanation
Neutrophils are the most numerous white blood cell and are a primary defense against infection because they ingest and destroy microorganisms. When the WBC count is low, it indicates a compromised ability to fight infection. The rest of the options are unrelated to ability to fight infection.
Erythrocytes are for oxygen transport (w/ hemoglobin).
Platelets are for clotting.
Hemoglobin transports oxygen.Rate this question:
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- 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
Correct Answer
A. Tears in the eyesExplanation
Tears flush the eyes of microorganisms and debris and are a primary (nonspecific) defense.
Gastric secretions are acidic, not alkaline.
Bile helps emulsify fats and is not involved in protecting the body from infection.
A dry, NOT moist, epidermis is a primary (nonspecific) defense.Rate this question:
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- 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
Correct Answer
A. Positioning an indwelling urine collection bag below the level of the patient's pelvisExplanation
The positioning of the urine collection bag is an action designed to prevent backflow and reduces the risk of introducing pathogens into the bladder.
Enclosing the urine specimen is a method of controlling the reservoir.
Wearing clean gloves is an example of controlling the mode of transmission.
Washing hands in this case is an example of controlling the mode of transmission.Rate this question:
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