The nurse is structuring activities that take a client's developmental stage into consideration. Which activities should the nurse include?

1. Implementing seizure precautions

2. Creating a schedule for daily wound care

3. Monitoring intake, output, and daily weights

4. Preparing newborn care classes for new parents

Answer: 

5. Scheduling instruction sessions on self-administration of insulin

4. Preparing newborn care classes for new parents

5. Scheduling instruction sessions on self-administration of insulin

The nurse is reviewing the Healthy People 2020 information which should the nurse identify as the foundation for this initiative?

1. Individual and community health are closely linked

2. The government is responsible for individual health

3. Businesses have no role in the health of the communities

4. Communities should expect local organizations to pay for healthcare

Answer: 1. Individual and community health are closely linked

The nurse reviews the progress of leading health indicators as identified by Healthy People 2020. Which indicator has been met?

1. Oral health

2. Mental health

3. Injury and violence

4. Environmental quality

5. Maternal, infant, and child health

Answer: 

3. Injury and violence

4. Environmental quality

5. Maternal, infant, and child health

The nurse on a college campus is implementing a health promotion activity by placing posters about proper handwashing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing?

1. Environmental control

2. Information dissemination

3. Health risk appraisal and wellness assessment

4. Lifestyle and behavior change

Answer: 2. Information dissemination

The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

1. Primary

2. Secondary

3. Tertiary

4. Community

Answer: 2. Secondary

The nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration?

1. Rest and exercise

2. Adjusting to physiologic changes and limitations

3. High obesity percentages

4. Safety promotion and injury prevention

Answer: 2. Adjusting to physiologic changes and limitations

The nurse is reviewing the principles of the Affordable Care Act with a client. What information should the nurse include when discussing the act with the client?

1. Individuals will be fined if they do not have health insurance.

2. Employers must offer health insurance if they meet identified requirements.

3. Insurance can be purchased through exchanges.

4. Individuals with preexisting health conditions cannot be denied health insurance coverage.

5. Health insurance is free.

Answer: 

2. Employers must offer health insurance if they meet identified requirements.

3. Insurance can be purchased through exchanges.

4. Individuals with preexisting health conditions cannot be denied health insurance coverage.

A nurse is especially competent in knowledge of the computerized charting system in a facility and is able to assume the team leader role on a regular basis. In which type of care delivery system is this nurse most likely providing care?

1. Primary nursing

2. Team nursing

3. Differentiated practice

4. Case method

Answer: 1. Primary nursing

A client learning how to manage asthma is instructed on the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior?

1. Competing preferences

2. Competing demands

3. Situational influences

4. Interpersonal influences

Answer: 1. Competing preferences

Before helping a client with smoking cessation, the nurse reviews the steps of the change process. In which order should the nurse expect the client to progress through the stages of health change behavior? Arrange the following stages in the correct order:

1. Preparation stage

2. Contemplation stage

3. Maintenance stage

4. Precontemplation stage

5. Termination stage

6. Action Stage

Answer: 4, 2, 1, 6, 3, 5

The nurse is reviewing changes occurring within the healthcare industry. What should the nurse identify as factors that have an effect on healthcare delivery?

1. Increased use of complementary and alternative medicine

2. More knowledgeable consumers

3. Increase in the number of older adults

4. Decrease in chronic disease

5. Technological advances

6. Economics

Answer: 

2. More knowledgeable consumers

3. Increase in the number of older adults

5. Technological advances

6. Economics

A client asks the nurse to explain the difference between an HMO and a PPO. What should the nurse include when responding to the client?

1. "You'll have good healthcare benefits, so don't worry."

2. "Both the HMO and PPO are covered by your employer, so it's really not your concern."

3. "Your PPO offered you a choice in your healthcare provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care."

4. "You really should be happy about the HMO. You'll pay little, if any, out-of-pocket expenses."

Answer: 3. "Your PPO offered you a choice in your healthcare provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care."

A client in the hospital is concerned about the cost of receiving hospitalized care. What should the nurse realize is causing the increase in the client's medical expenses?

1. Healthcare of the older adult

2. Number of uninsured population

3. Changes in birth rate over last 20 years

4. Cost of prescription drugs

5. State of inflation

6. Amount of diagnosed chronic illnesses

Answer: 

1. Healthcare of the older adult

2. Number of uninsured population

4. Cost of prescription drugs

5. State of inflation

6. Amount of diagnosed chronic illnesses

The nurse is reviewing sources of federal funding for healthcare services provided to clients. For which clients should the nurse recognize as most likely having healthcare paid through a federal funding source?

1. 35-year-old self-employed house painter

2. 72-year-old retired schoolteacher

3. 52-year-old nurse who runs the family farm

4. 29-year-old mentally challenged sheltered workshop employee

Answer: 

5. 40-year-old factory worker

2. 72-year-old retired schoolteacher

4. 29-year-old mentally challenged sheltered workshop employee

In order to comply with the U.S. Department of Health and Human Services' most current healthcare goals as stated in Healthy People 2030, what should the nurse do?

1. Plan a depression screening for senior citizens who regularly have lunch at the senior center.

2. Attend an educational in-service on the use of a new automated blood pressure monitor.

3. Advocate for psychiatric healthcare for those with no private insurance coverage.

4. Organize a park "cleanup day" to ensure the community's children have a safe place to play.

5. Counsel older clients regarding programs available to assist them to live in their homes independently.

Answer: 

1. Plan a depression screening for senior citizens who regularly have lunch at the senior center.

3. Advocate for psychiatric healthcare for those with no private insurance coverage.

4. Organize a park "cleanup day" to ensure the community's children have a safe place to play.

5. Counsel older clients regarding programs available to assist them to live in their homes independently.

The nurse is considering a position with a home health agency. What type of care should the nurse realize will be provided when working for this type of agency?

1. Providing ventilatory support

2. Completing a health and wellness visit

3. Instructing about care of a surgical wound

4. Providing intravenous antibiotics once a day

5. Teaching about medications for self-management of diabetes

Answer: 

3. Instructing about care of a surgical wound

4. Providing intravenous antibiotics once a day

5. Teaching about medications for self-management of diabetes

An older client with osteoarthritis lives alone, does not want to cook, and has been losing weight. What should the nurse recommend for this client?

1. See a psychiatrist because the client is depressed.

2. Check out joint replacement options for the osteoarthritis.

3. Start thinking about long-term care.

4. Consider moving to an assisted living facility.

Answer: 4. Consider moving to an assisted living facility.

A new graduate nurse is looking for employment and is hoping to find a facility that utilizes nursing personnel based on their educational preparation and skill set. In which type of facility should the new graduate apply for a position?

1. Patient-focused care

2. Functional method

3. Differentiated practice

4. Managed care

Answer: 3. Differentiated practice

Aclinic in a rural area depends primarily on the services of a nurse practitioner. Which legislation provided the opportunity for the nurse practitioner to have this position?

1. Medicare

2. Medicaid

3. Rural Health Clinics Act

4. National Health Planning and Resources Development Act

Answer: 3. Rural Health Clinics Act

The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination?

1. Determine whether it is the right task.

2. Determine whether it is under the right circumstances.

3. Determine whether it is to the right person.

4. Determine the type of communication.

5. Determine whether there is enough time.

Answer: 

1. Determine whether it is the right task.

2. Determine whether it is under the right circumstances.

3. Determine whether it is to the right person.

4. Determine the type of communication.

The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role?

1. Self-confident

2. Skilled in teaching

3. Hesitant with decision making

4. Excellent communication skills

5. Effective utilization of resources

Answer: 

1. Self-confident

2. Skilled in teaching

4. Excellent communication skills

The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision?

1. Bathing a patient recovering from surgery

2. Weighing a patient who is prescribed diuretics

3. Discharge instruction teaching

4. Transferring and ambulating a client after hip replacement surgery

5. The care of an intravenous access device

Answer: 

3. Discharge instruction teaching

5. The care of an intravenous access device

The nurse is hired to provide care in a hospital that offers services in all specialty areas. How should the nurse categorize this type of healthcare facility?

1. General hospital

2. Specialty hospital

3. Long-term care hospital

4. Short-term care hospital

Answer: 1. General hospital

A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse?

1. Mentor

2. Manager

3. Team leader

4. Preceptor

Answer: 4. Preceptor

The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include?

1. Accomplish the goals of the organization.

2. Use the organization's resources efficiently.

3. Ensure effective client care.

4. Ensure compliance with regulatory standards.

5. Manage relationships.

Answer: 

1. Accomplish the goals of the organization.

2. Use the organization's resources efficiently.

3. Ensure effective client care.

4. Ensure compliance with regulatory standards.

The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility?

1. Effective utilization of resources

2. Communication to subordinates

3. Implementation of organizational goals and objectives

4. Problem solving

5. Managing the work team

Answer: 

1. Effective utilization of resources

3. Implementation of organizational goals and objectives

4. Problem solving

The nurse manager has the reputation of being an autocratic leader. Which statement by this manager would support that reputation?

1. "I'd like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit."

2. "I'm putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit."

3. "The new work schedule is posted for the next 6 weeks."

4. "I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front."

Answer: 3. "The new work schedule is posted for the next 6 weeks."

The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement this process?

1. Analyzing, classifying, and prioritizing risks

2. Evaluating and modifying risk reduction programs

3. Anticipating and seeking sources of risk

4. Developing a plan to avoid and manage risk

5. Gathering data that indicate success at avoiding or minimizing risk

Answer: 3, 1, 4, 5, 2

The nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting?

1. Planning

2. Organizing

3. Directing

4. Coordinating

Answer: 2. Organizing

A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management?

1. Authority

2. Responsibility

3. Coordination

4. Accountability

Answer: 4. Accountability

The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a healthcare provider?

1. Puckering of the skin

2. Flattening of the breast from the side view

3. Free movement of the breast over the chest wall

4. Symmetry of the nipples

5. Change in shape

Answer: 

1. Puckering of the skin

2. Flattening of the breast from the side view

5. Change in shape

While the nurse is measuring blood pressure, a male client lifts his hand and fondles the nurse's breast. What should the nurse do about this behavior?

1. Ignore the fondling.

2. Move the client's hand away.

3. Refocus the client on appropriate behavior.

4. Tell the client to stop performing the behavior.

5. Communicate that the behavior is not acceptable.

Answer: 

2. Move the client's hand away.

3. Refocus the client on appropriate behavior.

4. Tell the client to stop performing the behavior.

5. Communicate that the behavior is not acceptable.

After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the client's list caused the nurse to make this clinical decision?

1. Antibiotics

2. Antipyretics

3. Cardiotonics

4. Beta-blockers

5. Anticoagulants

Answer: 

3. Cardiotonics

4. Beta-blockers

When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes?

1. The respiratory rate can increase up to 40 breaths per minute.

2. Involuntary muscle spasms occur throughout the body.

3. The heart rate decreases to 20 beats below normal.

4. Systolic blood pressure can increase 20-30 mm Hg above normal.

5. Diastolic blood pressure can decrease 20-50 mm Hg below normal.

Answer: 

1. The respiratory rate can increase up to 40 breaths per minute.

2. Involuntary muscle spasms occur throughout the body.

4. Systolic blood pressure can increase 20-30 mm Hg above normal.

The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask?

1. "Do you have any difficulty with sexual desire and orgasm?"

2. "How often do you have sexual relations?"

3. "What type of contraception do you use?"

4. "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?"

Answer: 4. "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?"

During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity?

1. Intersex

2. Transgenderism

3. Homosexuality

4. Cross-dressing

Answer: 4. Cross-dressing

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format?

1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications.

2. Give the client accurate but concise information in regard to any sexual questions that might be asked.

3. State information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms.

4. Review current research literature associated with the sexual concerns of the client and partner.

Answer: 2. Give the client accurate but concise information in regard to any sexual questions that might be asked.

An older male client with an indwelling urinary catheter exposes the genitalia and fondles the penis. Which action should the nurse take?

1. Tell the client to stop touching the penis.

2. Assess the client's penis for irritation from the catheter.

3. Ask the client to keep the linens at waist level.

4. Collaborate with the physician regarding medications to control this behavior.

Answer: 2. Assess the client's penis for irritation from the catheter.

After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client?

1. Knowledge about sexual behavior

2. Reluctance to discuss sexual history

3. Utilization of birth control method that fits lifestyle

4. Statement that there are no issues with sexuality

5. Discussing sexual problems with healthcare provider

Answer: 

1. Knowledge about sexual behavior

3. Utilization of birth control method that fits lifestyle

5. Discussing sexual problems with healthcare provider

In discussion with adolescents, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice?

1. Infection is a much more precise term for the transmission that occurs.

2. The word disease may elicit guilt, shame, and fear in the client.

3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection.

4. These terms can be used interchangeably and there is no good rationale for using one over the other.

Answer: 2. The word disease may elicit guilt, shame, and fear in the client.

The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history?

1. "What are your erotic fantasies?"

2. "Are you currently sexually active?"

3. "Do you experience any pain with sexual interaction?"

4. "Do you have difficulty with sexual desire?"

5. "What do you like the best about having sex?"

Answer: 

2. "Are you currently sexually active?"

3. "Do you experience any pain with sexual interaction?"

4. "Do you have difficulty with sexual desire?"

A nurse colleague learns that a grandchild's day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept?

1. At this age, education regarding sexuality should come from parents.

2. Children are sexual beings from before birth.

3. Understanding the body and sexuality are a part of growth and development.

4. Sexual activity is beginning at earlier and earlier ages.

Answer: 1. At this age, education regarding sexuality should come from parents.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format?

1. Ask the physician for permission to discuss sexual topics with the client.

2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with sexual information.

3. Acknowledge the client's spoken and unspoken sexual concerns when providing care.

4. Document precertification for benefits from the client's insurance company regarding sexual teaching.

Answer: 3. Acknowledge the client's spoken and unspoken sexual concerns when providing care.

The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only?

1. Genitalia and breasts return to pre-excitement states.

2. There is a refractory period during which the body will not respond to sexual stimulation.

3. The heart rate returns to normal.

4. Possible sleepiness or intense relaxation may occur.

Answer: 2. There is a refractory period during which the body will not respond to sexual stimulation.

The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase?

1. The vagina dries.

2. The length of the vagina narrows and swells.

3. Erection of the clitoris occurs.

4. The breasts enlarge.

5. The uterus elevates.

Answer: 

3. Erection of the clitoris occurs.

4. The breasts enlarge.

5. The uterus elevates.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format?

1. Use information technology such as the Internet to obtain guidance suggestions for the client.

2. Use the technique of informal therapeutic groups to assist the client and partner.

3. Evaluate previous interventions and treatment for success.

4. Recommend intensive therapy with a qualified sex therapist.

Answer: 4. Recommend intensive therapy with a qualified sex therapist.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format?

1. Use the nurse's knowledge about how disease affects sexuality to offer specific suggestions for the client.

2. Focus interventions on explaining the somatic sexual difficulties and their treatment.

3. Offer the client a list of expected sexual side effects of drugs or treatments.

4. Identify any concerns the client has regarding attraction to the same sex.

Answer: 1. Use the nurse's knowledge about how disease affects sexuality to offer specific suggestions for the client.

The nurse enters the room and finds the adult client masturbating. What action should the nurse take?

1. Tell the client that masturbation is harmful to sexual well-being.

2. Say "excuse me" and leave the room.

3. Request that the client stop so that care can be provided.

4. Ask the client if there are any sexual concerns that should be discussed.

Answer: 2. Say "excuse me" and leave the room.

A female client being treated for candidiasis continues to have a white, cheesy discharge. What recommendation is necessary?

1. Referral to a surgeon for excision of infected tissue

2. Examination and treatment of sexual partner

3. Treatment with a stronger oral antibiotic

4. Routine douches with a topical antibiotic solution

Answer: 2. Examination and treatment of sexual partner

There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable?

1. A complete sexual history must be included in the admission history and physicals.

2. Sexual information should be pursued only if the client's chief complaint indicates possible sexual dysfunction.

3. Sexual assessment should be done by the physician and not repeated by the nurse.

4. The amount of sexual information taken will vary on a case-by-case basis.

Answer: 4. The amount of sexual information taken will vary on a case-by-case basis.

A high school student asks, "If alcohol causes erectile dysfunction, then why does pregnancy occur in events where alcohol is consumed?" The nurse should plan a response based on which concept?

1. Alcohol is a central nervous system depressant that affects judgment.

2. Erectile dysfunction only occurs after years of alcohol abuse.

3. Alcohol is a sexual stimulant.

4. Erectile dysfunction occurs only in men older than age 50.

Answer: 1. Alcohol is a central nervous system depressant that affects judgment.

A client who was recently unable to achieve an erection is concerned that a previous sexually transmitted infection will cause impotence. Which response should the nurse make?

1. Sexually transmitted infections may result in sexual problems in adults.

2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection.

3. An occasional incident like this is normal and common and there is no reason to be concerned.

4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.

Answer: 4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.

The 45-year-old married client reports having no interest in sex and has not had intercourse in 16 years. How should the nurse interpret this assessment data?

1. This couple is experiencing sexual dysfunction.

2. The lack of sexual desire has adversely affected the spouse.

3. If both partners share the same lack of desire, there is often not a problem.

4. This situation is so unnatural that some dysfunction is present.

Answer: 3. If both partners share the same lack of desire, there is often not a problem.

Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment?

1. "For some reason, I have more sexual desire than ever."

2. "I use water-soluble lubricant to treat my vaginal dryness."

3. "I am so glad that I don't need to worry about sex anymore."

4. "Sex certainly takes longer than it used to, but I'm getting used to that."

Answer: 3. "I am so glad that I don't need to worry about sex anymore."

The nurse is preparing for a pelvic physical examination of a client with vaginismus. What equipment should the nurse obtain for this examination?

1. Culture tubes to assess expected vaginal infection

2. Extra cleaning supplies to remove thick external secretions

3. Smaller-than-normal vaginal speculums

4. Equipment for preexamination douche

Answer: 3. Smaller-than-normal vaginal speculums

A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult?

1. Early menopause

2. Increased menstrual flow

3. Chronic urinary tract infection

4. Tendency for postpartum hemorrhage

Answer: 3. Chronic urinary tract infection

A research article the nurse is reading discusses the prevalence of androgyny in persons 20-30 years old. What should the nurse keep in mind when caring for clients who are androgynous?

1. They do not limit their behaviors to one gender over the other.

2. They are attracted to people of the same gender.

3. They often repress their sexual feelings.

4. They hold rigid stereotyped gender role expectations.

Answer: 1. They do not limit their behaviors to one gender over the other.

A client is concerned that an adult son who is homosexual will be going "to hell." Which should the nurse consider when responding to this client's comment?

1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved.

2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern.

3. What constitutes normal sexual expression varies among cultures and religions.

4. Sexual development is genetically determined and not affected by environment.

Answer: 3. What constitutes normal sexual expression varies among cultures and religions.

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident?

1. Ask the resident for advice in setting up an activity in the dayroom.

2. Keep the resident too busy to dwell in the past.

3. Don't allow the resident to talk about minor concerns.

4. Meet with the social worker to plan all of the client's care.

Answer: 1. Ask the resident for advice in setting up an activity in the dayroom.

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included?

1. If the baby awakens at night, let him cry for a few minutes before responding.

2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him.

3. Respond to the baby's needs promptly and consistently.

4. Use firm, loving discipline with the baby from the beginning.

Answer: 3. Respond to the baby's needs promptly and consistently.

A client had set the expected outcome: "At the next clinic visit, the client will report participation in three activities to increase self-esteem." Which action should the nurse take if the client is unable to meet the stated outcome?

1. Explore the possible reasons for not meeting the outcome.

2. Reevaluate the accuracy of the outcome statement.

3. Collaborate with the client to write a new expected outcome.

4. Identify new interventions to help the client achieve the outcome.

Answer: 1. Explore the possible reasons for not meeting the outcome.

The nurse is conducting a thorough psychosocial assessment of a client who reports fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment?

1. Take detailed notes to record client responses.

2. Ask as many questions as possible to explore all areas of concern.

3. Start the interview by asking a series of yes/no questions.

4. Investigate the client's culture prior to the interview.

Answer: 4. Investigate the client's culture prior to the interview.

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern?

1. "I hate my hair."

2. "Life is wonderful!"

3. "My hips are too big."

4. "I wish I had that nose job 2 years ago."

5. "It is awesome that I got that promotion at work."

Answer: 

1. "I hate my hair."

3. "My hips are too big."

4. "I wish I had that nose job 2 years ago."

The adolescent male client who weighs 100 lbs. is considering taking "some herbal stuff" to increase muscle mass and strength. Which should the nurse realize this statement indicates about the client?

1. A strong need for admiration

2. Serious problems with logical thinking

3. Incongruence between reality and ideal self

4. The need for referral to a psychologist

Answer: 3. Incongruence between reality and ideal self

The nurse is determining a client's level of psychosocial development according to Erikson's stages. Place the developmental tasks in order according to Erikson's stages of psychosocial development.

1. Expressing one's own opinion

2. Guiding others

3. Asserting independence

4. Working well with others

Answer: 1, 4, 3, 2

The nurse with 25 years' experience is overheard saying, "I learn something new about nursing every day." What does this indicate about the nurse's self-awareness?

1. This nurse is not very self-aware.

2. The nurse's self-awareness is behind normal development.

3. Because this nurse has been a nurse for so long, self-awareness is no longer an important issue.

4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

Answer: 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses' self-concept along with information to use with clients. Why is the information for nurses important?

1. The nurse's self-concept is more important than the client's.

2. Poor self-concept is the number-one reason for nursing burnout

3. Nurses with positive self-concept are better able to help clients.

4. Nurses with poor self-concept are more likely to make errors.

Answer: 3. Nurses with positive self-concept are better able to help clients.

Which statement, made by the client, would indicate a "me-centered" self-concept?

1. "I couldn't stand to disappoint my parents."

2. "My sister is so much smarter than I am."

3. "My future is based on the decisions I make today."

4. "The world has always been against people like me."

Answer: 3. "My future is based on the decisions I make today."

A client asks what changes can be made to dietary intake to reduce the effects of stress. What changes should the nurse encourage the client to make?

1. Reduce sugar intake.

2. Eliminate excess salt.

3. Reduce caffeine intake.

4. Avoid vitamin supplements.

5. Follow a low-fat eating plan.

Answer: 

1. Reduce sugar intake.

2. Eliminate excess salt.

3. Reduce caffeine intake.

5. Follow a low-fat eating plan.

A client repeatedly tells the nurse that "all will be well" and "I'm fine" in response to learning of a health problem that requires immediate surgery. The nurse realizes that which diagnosis is appropriate for the client at this time?

1. Compromised Family Coping

2. Ineffective Coping

3. Disabled Family Coping

4. Defensive Coping

Answer: 4. Defensive Coping

The nurse is preparing to assess a client's stress and coping patterns. What will be included in this assessment?

1. Client's perception of stressors

2. Manifestations of stress

3. Employment status

4. Coping strategies

5. Weight changes

Answer: 

1. Client's perception of stressors

2. Manifestations of stress

4. Coping strategies

5. Weight changes

During a health interview, the nurse decides to focus the assessment questions on the middle-aged client's amount of stress. What information did the nurse use to make this clinical decision?

1. Caring for aging parents

2. Needing to wear glasses to read

3. Newly married

4. Choosing a career

5. Not having the same amount of stamina and energy

Answer: 

1. Caring for aging parents

2. Needing to wear glasses to read

5. Not having the same amount of stamina and energy

The adult daughter of an older client, who provides and pays for the client's care and needs, tells the nurse that her time is limited because of work responsibilities. The client complains that all the daughter ever does is work. What basic need is being affected by the daughter's stress?

1. Love and belonging

2. Self-actualization

3. Physiological

4. Self-esteem

Answer: 4. Self-esteem

While assessing a client's ability to cope after being diagnosed with a chronic illness, the client admits to an increase in drinking and smoking. The nurse recognizes the client is utilizing which type of coping strategy?

1. Short term

2. Long term

3. Adaptive

4. Effective

Answer: 1. Short term

The nurse identifies that a client is experiencing the resistance stage of general adaption syndrome. What did the nurse assess to make this clinical decision?

1. The client is unable to focus on activities and events.

2. The client is exhausted and spends time sleeping.

3. There is localized swelling and inflammation of the client's leg wound.

4. The client's capillary blood glucose level is 180 mg/dL.

Answer: 3. There is localized swelling and inflammation of the client's leg wound.

A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this client's behavior?

1. The parents may have been abusing this child.

2. The child is probably developmentally delayed secondary to multiple hospitalizations.

3. The child is reacting as a normal 2-year-old.

4. The child could be suffering from a clinical depression.

Answer: 3. The child is reacting as a normal 2-year-old.

The parents of an adolescent who has a history of depression are concerned because the physician has prescribed an SSRI antidepressant for their child. What information should the nurse use to formulate a response to these parents' concerns?

1. These medications are addictive and difficult to discontinue when the depressive incident is past.

2. It is difficult for adolescents to manage the dosage regimen for many of these drugs because they must be taken with a full meal.

3. There is an FDA warning regarding antidepressant use in adolescents and the increased risk of suicide.

4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3-4 days of the first dose.

Answer: 3. There is an FDA warning regarding antidepressant use in adolescents and the increased risk of suicide.

The assessment of a client undergoing testing for an anxiety disorder reveals an increased heart rate, an increased respiratory rate, a low-normal hematocrit, and a low blood sugar. Which finding is contrary to what could be explained by a normal response to anxiety?

1. The heart rate

2. The respiratory rate

3. The hematocrit

4. The blood sugar

Answer: 4. The blood sugar

The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the client's husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism?

1. Reaction formation

2. Rationalization

3. Regression

4. Reparation

Answer: 1. Reaction formation

A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What defense mechanism is this client exhibiting?

1. Compensation

2. Denial

3. Displacement

4. Identification

Answer: 2. Denial

A client tells the nurse about being laid off from work, the spouse wanting a divorce, and being ill with a chest cold for a month. What statement should the nurse make that reflects understanding of a client in crisis?

1. "Once you reach the crisis state, you may remain there for several months until you recover."

2. "People generally find it easier to work through a crisis if someone is working with them."

3. "Men often handle crisis better individually, whereas women do better with a counselor."

4. "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible."

Answer: 2. "People generally find it easier to work through a crisis if someone is working with them."

A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the nurse do in response to this outburst?

1. Call the charge nurse and refuse to take care of this client.

2. Apologize to the client for the unit rules but state they must be followed.

3. Tell the client that it is understandable about being upset but the no-smoking rule is not negotiable.

4. Tell the client to stop acting like a child and that such behavior will not be tolerated

Answer: 3. Tell the client that it is understandable about being upset but the no-smoking rule is not negotiable.

The nurse admits to being mildly anxious about an upcoming exam in graduate school. What is the likely result of this level of anxiety?

1. The nurse's perception and learning is enhanced.

2. The nurse's attention is focused solely on studying for the examination.

3. The nurse's only topic of conversation is the examination.

4. The nurse cannot talk about the examination without crying.

Answer: 1. The nurse's perception and learning is enhanced.

While caring for a client who is approaching death, the nurse notices the client's facial expression of extreme sadness. What should the nurse do?

1. Leave the client alone.

2. Provide physical care to increase comfort.

3. Acknowledge the client's expression and ask whether the client would like to talk about her feelings.

4. Offer to provide pain medication.

Answer: 3. Acknowledge the client's expression and ask whether the client would like to talk about her feelings.

A terminally ill client is demonstrating gurgling respirations. Which should the nurse realize is occurring with this client?

1. Status is improving

2. Increase in pain

3. Attempting to talk

4. Nearing death

Answer: 3. Attempting to talk

The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time?

1. Encourage the client to resume normal activities.

2. Use therapeutic communication techniques.

3. Offer choices that promote client autonomy.

4. Provide information about community resources or support groups.

5. Acknowledge the grief of the client.

Answer: 

2. Use therapeutic communication techniques.

3. Offer choices that promote client autonomy.

4. Provide information about community resources or support groups.

5. Acknowledge the grief of the client.

The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed which of the following?

1. The client's denying the son's death

2. Depression

3. Sudden weight loss because of not eating

4. Crying

5. Verbalizing the desire to not live anymore

Answer: 

1. The client's denying the son's death

2. Depression

3. Sudden weight loss because of not eating

5. Verbalizing the desire to not live anymore

The spouse of a deceased client is working through the stages of grief. If the nurse applies Kübler-Ross's stages of grief to this situation, the spouse would progress through the stages in which order?

1. Depression

2. Anger

3. Acceptance

4. Bargaining

5. Denial

Answer: 5, 2, 4, 1, 3

A client with terminal lung cancer complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client?

1. Move the client to a room closer to the nurse's desk for closer observation.

2. Help the client assume a position lying on the right side.

3. Place a fan in the room to move air around the client.

4. Change the client's oxygen therapy to a nonrebreathing mask.

5. Elevate the head of the client's bed to a Fowler position.

6. Consider use of a p.r.n. morphine sulfate order.

Answer: 

3. Place a fan in the room to move air around the client.

5. Elevate the head of the client's bed to a Fowler position.

6. Consider use of a p.r.n. morphine sulfate order.

The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurse's best action according to these wishes?

1. Arrange an encounter with the client and tell him the truth.

2. Change the subject when the client asks about his impending death.

3. Tell the family that the patient has the right to know that he is dying.

4. Talk to the family about the situation and their concerns.

Answer: 4. Talk to the family about the situation and their concerns.

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness does not believe the diagnosis and that there must have been a mistake with testing. What should be the nurse's first step in assisting this family?

1. Provide structure and continuity to promote feelings of security.

2. Examine the nurse's own feelings to ensure denial is not shared.

3. Offer spiritual support.

4. Allow the family to express sadness.

Answer: 2. Examine the nurse's own feelings to ensure denial is not shared.

A client with end-stage renal disease refuses to talk about dying with the spouse, who also refuses to discuss death with the client. What will be the outcomes of this situation?

1. Client has dignity

2. Client has privacy

3. Client can finalize affairs

4. Client can plan own funeral

5. Client burdened with no one to confide in

Answer: 

1. Client has dignity

2. Client has privacy

5. Client burdened with no one to confide in

During a bath, the client suddenly says, "I am not going to get well. I think I am going to die." What response given by the nurse is most appropriate?

1. "Let's think of something more cheerful."

2. "You are doing so well; don't talk like that."

3. "What makes you think you are dying?"

4. "Whatever is meant to be will happen."

Answer: 3. "What makes you think you are dying?"

A client who was having an affair is upset and cannot sleep since learning of her partner's death. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief?

1. Abbreviated

2. Chronic

3. Disenfranchised

4. External

Answer: 3. Disenfranchised

The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death?

1. Toddlers perceive death as irreversible and unnatural.

2. Preschool children view death as a spiritual release.

3. At about age 9, children begin to understand that death is inevitable.

4. Adolescents tend to have better outcomes than adults after a loss.

Answer: 3. At about age 9, children begin to understand that death is inevitable.

The nurse is engaging in an activity to develop spiritual self-awareness. What activities can aid the nurse in achieving this goal?

1. Write a will.

2. Complete an advance directive form.

3. Explore personal end-of-life issues.

4. Create a personal loss history.

5. List significant values.

Answer: 

3. Explore personal end-of-life issues.

4. Create a personal loss history.

5. List significant values.

The nurse determines that a middle-aged client has developed spiritually. What client statement caused the nurse to come to this conclusion?

1. "I listen to and learn from others who talk about beliefs in God or a Supreme Being."

2. "The tales in the Bible are real to me."

3. "I attend service with my friends on most Sundays."

4. "I attend the same church as my parents and follow the customs of my culture."

Answer: 1. "I listen to and learn from others who talk about beliefs in God or a Supreme Being."

The nurse is caring for an older client with end-stage renal disease. What actions should the nurse take to support this client's spiritual development?

1. Support the client to have hope for a cure.

2. Suggest the client view losses as liberations.

3. Encourage the client to reminisce about life events.

4. Ask open-ended questions about the client's life purpose.

5. Remind the client that time is running out to make any life changes.

Answer: 

2. Suggest the client view losses as liberations.

3. Encourage the client to reminisce about life events.

4. Ask open-ended questions about the client's life purpose.

The nurse is caring for a 5-year-old child. How can the nurse best support the spiritual development of this client?

1. Ask the child who God is.

2. Listen to the child's routine bedtime prayer.

3. Encourage the child to pray before each meal.

4. Bring a Bible storybook in to read to the child at bedtime.

Answer: 2. Listen to the child's routine bedtime prayer.

The nurse has never been particularly religious or spiritual and is unaccustomed to praying but holds no strong feeling against prayer. Which action should the nurse take when asked to pray with a client and family?

1. Try to ensure assignment to clients who are unlikely to request prayer.

2. Arrange to have a coworker substitute for the nurse in these prayer situations.

3. Memorize two or three short, formal prayers to use when prayer is requested.

4. Just stand silently at the bedside and let others in the room do the praying.

Answer: 3. Memorize two or three short, formal prayers to use when prayer is requested.

The nurse caring for wheelchair-dependent residents of a long-term care environment has developed a care plan that includes taking the clients outside and assisting them in planting and maintaining a garden. What is the best rationale for this plan?

1. Accreditation agencies require that the residents have regular outings.

2. Keeping in touch with nature is a form of spiritual care.

3. Fresh vegetables from the garden are good sources of nutritional fiber.

4. Sunshine helps activate vitamin D.

Answer: 2. Keeping in touch with nature is a form of spiritual care.

A client says that a treatment plan is against religious beliefs. Which nursing diagnosis problem statement should the nurse identify as appropriate for this client?

1. Ineffective Coping

2. Decisional Conflict

3. Impaired Religiosity

4. Anxiety

Answer: 2. Decisional Conflict

During labor, it becomes apparent that the male infant will survive only a short time after birth. Because this baby's parents are Catholic, what planning should the nurse consider?

1. Arrange to have the baby circumcised immediately after birth.

2. Ask the hospital chaplain to be present in the delivery room.

3. Ask the nursing supervisor to find a Catholic nurse to attend the birth.

4. Consider emergency transport of the mother to a Catholic

Answer: 2. Ask the hospital chaplain to be present in the delivery room.

A client who is devoutly Jewish is hospitalized during Yom Kippur and wants to fast. How should the nurse respond to this wish?

1. Support the client's desires to the extent possible.

2. Remind the client that most religions excuse persons who are ill from fasting.

3. Attempt to convince the client to ignore the tradition due to illness.

4. Tell the client that the physician must make this decision.

Answer: 1. Support the client's desires to the extent possible.

During assessment, the client says that it has been "a long time" since she has thought very much about religion. The nurse caring for this client has a strong belief in God and the healing power of prayer. What action should be taken by the nurse?

1. Mention the nurse's belief and offer to pray with the client for forgiveness.

2. Tell the client that the nurse will pray for her often.

3. Ask the client if there are any spiritual needs with which the staff can assist.

4. Refer the client for spiritual counseling.

Answer: 3. Ask the client if there are any spiritual needs with which the staff can assist.

A client who is facing a final life-saving surgery asks the nurse to stay and pray until the surgery begins. In which ways should the nurse demonstrate presencing with this client?

1. Adjusting the intravenous infusion

2. Talking with the client about the surgery

3. Sitting next to the client in the holding area

4. Praying with the client for divine intervention

5. Focusing on the client and fulfilling his needs

Answer: 

4. Praying with the client for divine intervention

5. Focusing on the client and fulfilling his needs

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion?

1. Enrolled in online classes

2. Raising two children ages 4 and 8

3. Experiences chronic pain from sciatica

4. Attends religious services every Sunday and Wednesday

5. Works one steady job at night and another part time in the late afternoon

Answer: 

1. Enrolled in online classes

2. Raising two children ages 4 and 8

3. Experiences chronic pain from sciatica

5. Works one steady job at night and another part time in the late afternoon

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision?

1. Is wide awake around 3:00 am

2. Takes a nap after lunch every day

3. Returns to sleep after using the bathroom

4. Goes to sleep before 9:00 pm most evenings

5. Wakes up and looks at the clock every hour

Answer: 

1. Is wide awake around 3:00 am

2. Takes a nap after lunch every day

4. Goes to sleep before 9:00 pm most evenings

5. Wakes up and looks at the clock every hour

A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep?

1. Illness

2. Stimulant

3. Diet

4. Lifestyle

Answer: 1. Illness

The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent?

1. Provide hot chocolate prior to bedtime.

2. Limit or eliminate television.

3. Engage in a physical activity before bedtime.

4. Play a computer game before bedtime.

Answer: 2. Limit or eliminate television.

A client who appeared to be asleep denies sleeping and wants the television to remain on. Which stage of NREM sleep is the client demonstrating?

1. 4

2. 3

3. 2

4. 1

Answer: 3. 2

A hospital committee is tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful?

1. Turn off all overhead lights on the unit and use nightlights and flashlights.

2. Establish a time at which radios and televisions should be turned off or down.

3. Discontinue use of the paging system after 2100.

4. Conduct nursing reports in the hallway.

5. Open curtains between beds in semiprivate rooms.

Answer: 

2. Establish a time at which radios and televisions should be turned off or down.

3. Discontinue use of the paging system after 2100.

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem?

1. Have the child walk around in the room when night terrors occur.

2. The next morning, ask the child to describe the event.

3. Have the child empty the bladder prior to going to bed.

4. Use an additional pillow behind the child's head at night.

Answer: 3. Have the child empty the bladder prior to going to bed.

A client with stiffness and muscle tension in the back declines the offer of a back rub. What action should the nurse take?

1. Encourage the client to accept the back rub, saying how much it will relax the back muscles.

2. Document that the client is noncompliant with the nursing plan of care.

3. Accept the declination but tell the client to call if one is desired later.

4. Instruct assistive personnel to rub the client's back while assisting to change into a clean gown.

Answer: 3. Accept the declination but tell the client to call if one is desired later.

A client questions why a medication that is used to treat Parkinson disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do?

1. Contact the physician.

2. Assure the client that medications used to treat Parkinson disease are also used to treat PLMD.

3. Tell the client not to take the medication because there is most likely an error.

4. Check with the pharmacy to make sure the correct medication has been provided to the client.

Answer: 2. Assure the client that medications used to treat Parkinson disease are also used to treat PLMD.

A client reports difficulty sleeping. Which environmental intervention should the nurse recommend?

1. Play soft music throughout the night.

2. Keep a television on in the bedroom.

3. Provide white noise with a fan.

4. Play a talk radio station.

Answer: 3. Provide white noise with a fan.

The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful?

1. Maintain a regular bedtime and wake-up time for all days of the week.

2. If bedtime is delayed on one night, go to bed that much earlier the next night.

3. If daytime drowsiness occurs, go to bed earlier that night.

4. Sleep at least 1 hour later on mornings you don't have to go to work.

Answer: 1. Maintain a regular bedtime and wake-up time for all days of the week.

A client complains of not being able to stay awake during the day even after sleeping throughout the night. What should the nurse suggestion to this client?

1. Go to your physician for a physical examination.

2. Go to a mental health professional for evaluation of possible depression.

3. Purchase an over-the-counter sleep aid to deepen nighttime sleep.

4. Drink more caffeinated beverages in the daytime to stay awake

Answer: 1. Go to your physician for a physical examination.

An older client reports going to sleep easily but waking up a few hours later and unable to go back to sleep. What nursing action would help promote rest and sleep in this client?

1. Have the client develop a bedtime ritual of quiet music and a glass of wine.

2. Encourage the client to avoid taking pain medication prior to sleep.

3. Evaluate if the client perceives sleeplessness to be a serious problem.

4. Have the client perform moderate exercises before bedtime.

Answer: 3. Evaluate if the client perceives sleeplessness to be a serious problem.

A client is prescribed an intravenous infusion to be started. Which should the nurse ensure is included when documenting the starting of this infusion?

1. Type, length, and gauge of the catheter

2. Questions the client asked about the infusion

3. Length of time the current infusion bag will last

4. Medications that are to be changed to the intravenous route

Answer: 1. Type, length, and gauge of the catheter

Assistive personnel (AP) is caring for a client with an intravenous infusion. Which action should the nurse take if the AP reports that the infusion bag is empty?

1. Direct the AP to cap the infusion

2. Ask the AP to turn the infusion off

3. Provide a new intravenous infusion bag

4. Provide the AP with a new infusion bag

Answer: 3. Provide a new intravenous infusion bag

The nurse assigns assistive personnel (UAP) morning care for a client with an intravenous infusion. Which finding should the nurse remind the UAP to report to the nurse?

1. Client's breath sounds slide

2. Rate of the intravenous infusion

3. Leaking of fluid around the catheter site

4. Amount of fluid remaining in the infusion bag

Answer: 3. Leaking of fluid around the catheter site

A client reports taking multiple doses of antacids every day. For which health problem should this client be assessed?

1. Acidosis

2. Alkalosis

3. Hyperkalemia

4. Hyponatremia

Answer: 1. Acidosis

A client reports rarely feeling thirsty. Which parameter should be evaluated in this client?

1. Status of osmotic pressure

2. Vascular volume

3. Presence of angiotensin

4. Urine output

5. Body weight

Answer: 

1. Status of osmotic pressure

2. Vascular volume

3. Presence of angiotensin

A client with a significant loss of blood after a motor-vehicle accident has a low urine output. Which hormones should the nurse suspect are influencing the client's fluid balance?

1. Aldosterone

2. Angiotensin

3. Antidiuretic hormone

4. Estrogen

5. Progesterone

Answer: 

1. Aldosterone

2. Angiotensin

3. Antidiuretic hormone

A client being mechanically ventilated has an arterial blood gas analysis that indicates respiratory acidosis. Which change in ventilator settings should the nurse anticipate?

1. Decrease in oxygen delivery

2. Decreased tidal volume of each breath

3. Increased respiratory rate

4. Increase in humidification of inspired air

Answer: 3. Increased respiratory rate

The client has been placed on a 1200-mL oral fluid restriction. In which way should the nurse plan for this restriction?

1. Allow 600 mL from 7:00-3:00, 400 mL from 3:00-11:00, and 200 mL from 11:00-7:00.

2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow.

3. Offer the client softer, cold foods such as sherbet and custard.

4. Remove fluids from diet trays and offer them only between meals.

Answer: 1. Allow 600 mL from 7:00-3:00, 400 mL from 3:00-11:00, and 200 mL from 11:00-7:00.

The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement?

1. Add 20 mEq of KCL to 1,000 mL of IV fluid

2. 10 mEq KCL IV over 1-2 minutes

3. Dilute 20 mEq KCL in 3 mL of NS and give IV push

4. 10 mEq KCL SQ

Answer: 1. Add 20 mEq of KCL to 1,000 mL of IV fluid

A client has experienced a narcotic overdose. What acid-base imbalance should the nurse expect to observe in this client?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Answer: 1. Respiratory acidosis

A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client?

1. pH 7.30; PaCO2 50; HCO3 27

2. pH 7.47; PaCO2 43; HCO3 28

3. pH 7.43; PaCO2 50; HCO3 28

4. pH 7.47; PaCO2 30; HCO3 23

Answer: 2. pH 7.47; PaCO2 43; HCO3 28

A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid-base imbalance should the nurse expect to assess in this client?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Answer: 3. Metabolic acidosis

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? Record your answer, rounding to the nearest whole number

Answer: 50 drops

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken?

1. Refigure the rate of the IV.

2. Infuse the remaining IV fluid before hanging a new bag.

3. Discard the remaining IV fluid and hang a new bag.

4. Discontinue the IV site and restart an IV in the opposite hand.

Answer: 3. Discard the remaining IV fluid and hang a new bag.

The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr? Record your answer, rounding to the nearest whole number

Answer: 150 mL

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information?

1. On the packaging of the tubing

2. In the charting from the nurse who started the infusion

3. In the drug reference book

4. On the roller clamp of the tubing

Answer: 1. On the packaging of the tubing

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother?

1. Have the infant be seen by a physician.

2. Give the infant at least 2 ounces of juice every 2 hours.

3. Measure the infant's urine output for 24 hours.

Answer: 1. Have the infant be seen by a physician.

The nurse suspects that a client's body is attempting to correct an acid-base imbalance. How will this imbalance be corrected?

1. Slow but efficient respiratory regulation will occur.

2. Primary regulation is through GI system losses.

3. Kidney regulation is powerfully effective.

4. The cardiovascular system is the major buffer.

Answer: 3. Kidney regulation is powerfully effective.

The nurse provides a client with a back massage. Which information should the nurse omit when documenting the care provided to this client?

1. Client fell asleep

2. Client reports feeling relaxed

3. Client reports pain level 3 on a scale from 1 to 10

4. Client talked with family on the telephone during the massage

Answer: 4. Client talked with family on the telephone during the massage

The nurse is assigning tasks for evening care. Which client should the nurse assign assistive personnel (AP) to provide a back massage?

1. Client with spontaneous fractures

2. Client receiving high-dose heparin

3. Client recovering from back surgery

4. Client with moderate pain asking for help

Answer: 4. Client with moderate pain asking for help

A client is receiving opioid-sparing pain management. Which should the nurse consider to enhance the effectiveness for the client?

1. Massage

2. Turning and repositioning

3. Range-of-motion exercises

4. Deep breathing and coughing

Answer: 1. Massage

A client with severe pain is prescribed two medications from different classes to be given orally and topically. Which is an advantage of this approach to pain management?

1. Lowest costly to the client

2. Less time-consuming to provide

3. Eliminating the need for opioids

4. Reduces the development of chronic pain

Answer: 3. Eliminating the need for opioids

The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client?

1. Secure all tubing connections with gauze.

2. Apply tape over all injection ports on the tubing.

3. Cleanse the insertion site with alcohol swabs once a day.

4. Label the tubing, infusion bag, and pump with the word "epidural."

5. Post a sign above the client's bed indicating that an epidural is being used.

Answer: 

2. Apply tape over all injection ports on the tubing.

4. Label the tubing, infusion bag, and pump with the word "epidural."

5. Post a sign above the client's bed indicating that an epidural is being used.

The healthcare provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client?

1. Oxymorphone (Opana)

2. Hydrocodone (Vicodin)

3. Oxycodone (OxyContin)

4. Morphine sulfate (morphine)

5. Hydromorphone hydrochloride (Dilaudid)

Answer: 

1. Oxymorphone (Opana)

3. Oxycodone (OxyContin)

4. Morphine sulfate (morphine)

5. Hydromorphone hydrochloride (Dilaudid)

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the client's pain was influenced by which type of distraction?

1. Visual

2. Tactile

3. Intellectual

4. Behavioral

Answer: 1. Visual

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client?

1. Apply ice to the knee over the cast.

2. Rub the knee of the noncasted leg.

3. Apply heat to the knee over the cast.

4. Rub the foot of the casted extremity.

Answer: 2. Rub the knee of the noncasted leg.

The nurse wants to assign back rubs to assistive personnel (AP). Which should the nurse determine before making the assignments?

1. Whether unlicensed assistive personnel know how to perform a back rub

2. Whether there any clients who have intravenous fluids infusing

3. Whether there any clients who should not have a back rub performed

4. Whether there any clients who are prescribed to take nothing by mouth

5. Whether there any clients who do not want a back rub done by unlicensed assistive personnel

Answer: 

1. Whether unlicensed assistive personnel know how to perform a back rub

3. Whether there any clients who should not have a back rub performed

5. Whether there any clients who do not want a back rub done by unlicensed assistive personnel

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage?

1. Supine

2. Fowler

3. Trendelenburg

4. Prone

5. Side-lying

Answer: 

4. Prone

5. Side-lying

The nurse is preparing to massage a client's back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage.

1. Move the hands down the sides of the back.

2. Pour lotion into the palms of the hands to warm the lotion.

3. Massage the areas over the right and left iliac crests.

4. Move the hands up the center of the back.

5. With the palms, massage the sacral area with smooth, circular strokes.

6. Move the hands to the scapulae and massage this region using circular strokes.

Answer: 2, 5, 4, 6, 1, 3

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions?

1. Massage

2. Acupressure

3. Self-hypnosis

4. Exercise

5. Nutritional supplements

Answer: 

1. Massage

2. Acupressure

3. Self-hypnosis

4. Exercise

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control?

1. Body

2. Mind

3. Social interactions class

4. Spirit

Answer: 3. Social interactions class

A client has been taking medication for back pain for several months and has seen several different healthcare providers in efforts to receive pain medication. Which should the nurse suspect the client is exhibiting?

1. Tolerance

2. Addiction

3. Physical dependence

4. Pseudoaddiction

Answer: 1. Tolerance

A client experiencing pain after surgery believes something is wrong because the pain is so severe. What is the best response for the nurse to make to the client?

1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel."

2. "That could be so."

3. "Taking pain medication for many years has made the medication ineffective now."

4. "Are you sure the pain is as bad as you are saying it is?"

Answer: 1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel."

A client's pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time?

1. Provide NSAID medication as prescribed.

2. Coach the client with guided imagery.

3. Suggest the client read or watch television until the pain subsides.

4. Provide opioid analgesic as prescribed.

Answer: 4. Provide opioid analgesic as prescribed.

From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time?

1. Anxiety

2. Hopelessness

3. Ineffective Health Maintenance

4. Insomnia

5. Impaired Physical Mobility

Answer: 

3. Ineffective Health Maintenance

4. Insomnia

5. Impaired Physical Mobility

A client is complaining of having the same type of pain prior to being diagnosed with cancer. The nurse realizes that which process will influence this client's perception of pain?

1. Transmission

2. Modulation

3. Perception

4. Transduction

Answer: 3. Perception

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

1. Pulse rate: 80

2. Respiratory rate: 8.

3. Blood pressure: 120/80

4. Pain rating of 4 on scale of 1 to 10

Answer: 2. Respiratory rate: 8.

The client scheduled to undergo minor surgery states, "The physician will not give me pain medication after surgery because my surgery is only minor." What is the best response by the nurse?

1. "You can experience pain after minor surgery, so you can have pain medication."

2. "You are correct. The physician will not order any pain medication."

3. "You are correct. I will need to teach you nonpharmacologic pain relief measures."

4. "You can only have about half the dose because your surgery is minor."

Answer: 1. "You can experience pain after minor surgery, so you can have pain medication."

The client taking an opioid is experiencing pruritus. Which medication should the nurse expect the physician to prescribe?

1. Naloxone hydrochloride (Narcan)

2. Acetaminophen (Tylenol)

3. Diphenhydramine hydrochloride (Benadryl)

4. Normal saline

Answer: 3. Diphenhydramine hydrochloride (Benadryl)

The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication?

1. Gastrointestinal (GI) distress

2. Shakiness

3. Tremors

4. Rash

Answer: 1. Gastrointestinal (GI) distress

The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant?

1. FLACC scale

2. Wong-Baker FACES

3. Visual analog scale

4. Numeric rating scale

Answer: 1. FLACC scale

Which behavior that Jane exhibits supports her subjective report of acute pain?

A) Constant foot tapping.

B) Excessive blinking.

C) Limited eye contact.

D) Frequent guarding.

Answer: D) Frequent guarding.

To assess the severity of Jane's pain, the nurse asks which question?

A) "On a scale of 0 to 10, how would you rate your pain?"

B) "What word best describes the pain you are experiencing?"

C) "What actions do you take to relieve the pain?"

D) "What do you fear most about your pain?"

Answer: A) "On a scale of 0 to 10, how would you rate your pain?"

Which information, obtained by the nurse, is most likely to influence Jane's perception of her pain?

A) Jane's younger child is an infant, who feeds every three hours.

B) Jane's four-year-old enjoys being the "big brother" to his baby sister.

C) Jane was a first-grade teacher before having children, but now stays home.

D) Jane's parents live in the same neighborhood and often help with the children.

Answer: A) Jane's younger child is an infant, who feeds every three hours.

Respiratory rate regulation can be regulated easily by what type of anesthesia?

Answer: General anesthesia

What is the goal of the postoperative phase?

Answer: Assist the client to achieve optimal health status

What preoperative test is performed for all female clients of child bearing age?

Answer: Pregnancy test

What are the 4 priority assessments completed by the nurse for the postoperative client admitted to their nursing unit?

Answer: Assessing the client's response to surgery, performing interventions to facilitate healing and prevent complications, teaching and providing support to the client and support people and planning for home care

The unconscious client should be placed in what position in the postanesthesia stage?

Answer: On the side, with the face slightly down

Briefly describe the beginning & end of the 3 phases of surgery.

Answer: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating room. The intraoperative phase begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit. The postoperative begins with the admission of the client to the PACU or PAR and ends when healing is complete

Planning for home care begins in preoperative stage- what assessment planning should this include?

Answer: Assessment of the client's, family's and significant other's abilities and resources for care, financial resources and the need for referrals and home health services

What is an effective preoperative teaching tool with children?

Answer: Play

For what procedures is conscious sedation utilized?

Answer: Endoscopies, incision and drainage of abscesses, and balloon angioplasty

What 9 assessments are included in a preoperative assessment ?

Answer: Purpose, degree of urgency, degree of risk, age, general health, nutritional status, obstructive sleep apnea, medications, and mental status

What is a reliable test confirming N/G tube placement test performed by nurses on the nursing unit?

Answer: X-ray

What is the purpose of a surgical skin prep?

Answer: Remove soil and reduce the microbial count

A client recovering from surgery has antiembolic stockings applied. Which should the nurse document about this procedure?

1. Type of surgery

2. Name of the surgeon

3. Orientation of the client

4. Time when the stockings were applied

Answer: 4. Time when the stockings were applied

Assistive personnel (AP) responds when a client recovering from surgery calls for help. Which should the AP do when the client has accidentally removed the nasogastric tube?

1. Reinsert the tube

2. Suction the client's mouth

3. Empty the suction cannister

4. Notify the nurse immediately

Answer: 4. Notify the nurse immediately

The nurse is concerned that an older client is developing a postoperative infection. What did the nurse assess to make this clinical determination?

1. Fever

2. Confusion

3. Tachycardia

4. Inflammation

Answer: 2. Confusion

The surgical team conducts a final verification of the correct client, procedure, and site. In which way should the nurse document this validation?

1. SBAR

2. Time-out

3. SOAPIE note

4. Hand-off communication

Answer: 2. Time-out

A client is having a surgical procedure. At which time does the postoperative phase begin?

1. When healing is complete

2. When the decision to have surgery is made

3. With admission to the postanesthesia care unit

4. When the client is transferred to the operating table

Answer: 3. With admission to the postanesthesia care unit

A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this client's degree of risk for this major surgical procedure?

1. Age

2. Medications

3. General health

4. Blood pressure

5. Nutritional status

Answer: 

1. Age

2. Medications

3. General health

5. Nutritional status

The nurse is completing a preoperative assessment with a client. What should this assessment include?

1. Current health status

2. Allergies

3. Current medications

4. Mental status

5. Respiratory rate

Answer: 

1. Current health status

2. Allergies

3. Current medications

4. Mental status