FUNDAMENTALS OF NURSING 10TH
EDITION POTTER PERRY TEST BANK
Fundamentals of Nursing 10th Edition Potter Perry Test Bank
Chapter 1. Nursing Today
MULTIPLE CHOICE
1. Contemporary nursing practice is based on knowledge generated through nursing theories.
Florence Nightingales theory introduced the concept that nursing care focuses on:
1
2
Psychological needs
A maximal level of wellness
3
Health maintenance and restoration
4
Interpersonal interactions with the client
ANS: 3
Florence Nightingale believed the role of the nurse was to put the clients body in the best state in
order to remain free of disease or to recover from disease.
Although Florence Nightingale may have addressed meeting the psychological needs of her
clients, it is not the focus of her theory. The goal of Nightingales theory is to facilitate the bodys
reparative processes by manipulating the clients environment.
Florence Nightingale thought the human body had reparative properties of its own if it was cared
for in a way to recover from disease. Her theory did not focus on achieving a maximal level of
wellness.
Florence Nightingale believed the nurse was in charge of the clients health. Although she
interacted with her clients by reading to them, her theory of nursing care did not focus upon
interpersonal interactions.
DIF: A REF: 2 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
2. Nursing education programs in the United States may seek voluntary accreditation by the
appropriate accrediting commission council of the:
1
National League for Nursing
2
American Nurses Association
3
Congress for Nursing Practice
International Council of Nurses
4
ANS: 1
The National League for Nursing (NLN) is the professional nursing organization concerned with
nursing education. The NLN provides accreditation to nursing programs that seek and meet the
NLN accreditation requirements.
The American Nurses Association (ANA) is concerned with the nursing profession and issues
affecting health care, including standards of care.
The Congress for Nursing Practice is the part of the ANA concerned with determining the legal
aspects of nursing practice, the public recognition of the importance of nursing, and the impact
of trends in health care on nursing practice.
The International Council of Nurses (ICN) is concerned about issues of health care and the
nursing profession, including the provision of an international power base for nurses.
DIF: A REF: 8 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
3. The minimum educational requirement for a nurse practitioner is:
1
Diploma in nursing
2
3
Masters in nursing
Doctorate in nursing
4
Baccalaureate in nursing
ANS: 2
A masters degree is nursing is required to become a nurse practitioner.
Diploma programs in nursing require 3 years of education after which the graduate may become
a registered nurse, but not a nurse practitioner.
Doctoral programs focus on the application of research findings to clinical practice. The doctoral
degree is beyond the masters degree.
The baccalaureate degree program generally requires 4 years of study in a college or university,
after which the graduate may become a registered nurse, not a nurse practitioner.
DIF: A REF: 8 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
4. A group that lobbies at the state and federal level for advancement of nursings role, economic
interest, and health care is the:
1
State Board of Nursing
2
American Nurses Association
3
American Hospital Association
4
National Student Nurses Association
ANS: 2
The American Nurses Association (ANA) hires lobbyists at the state and federal level to promote
the advancement of health care and the economic and general welfare of nurses.
State Boards of Nursing primarily focus on licensure of nurses within their own state.
The American Hospital Association does not focus on nurses economic issues and the
advancement of the role of nurses.
The National Student Nurses Association focuses on issues of importance for nursing students.
DIF: A REF: 8 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
5. A nurse moves from Seattle to Boston and begins working in a hospital. The most important
factor for the nurse to consider when moving to another state is the:
1
2
Massachusetts Nurse Practice Act
Standard for nursing practice in Boston
3
Clinical ladder of mobility in the new hospital
4
Requirement for continuing education units (CEU) in
Massachusetts
ANS: 1
Although most states have similar practice acts, each individual state has its own Nurse Practice
Act that regulates the licensure and practice of nursing within that state. Knowledge of the Nurse
Practice Act is necessary to provide safe and legal nursing care.
Standards of nursing practice are not specific to a city, but rather to the profession itself.
Although the clinical ladder of mobility may be of interest in regard to professional
advancement, it is not the most important factor when practicing nursing in another state.
Knowledge of the Nurse Practice Act in order to provide safe and legal nursing care is of higher
importance.
Regardless of where a nurse practices, the nurse should strive to remain current.
DIF: C REF: 8 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
6. A nurse is caring for a client who has chronic renal failure. The nurse states, We will do
everything possible to return you to the optimum level of self-care possible. In coordinating an
approach to best meet the needs of this client, the nurse is fulfilling the role of:
1
Manager
2
Educator
3
Counselor
Communicator
4
ANS: 1
The nurse, in caring for this client, will coordinate the activities of other members of the health
care team. This client may require the assistance of a nursing assistant to provide personal care
until the client is less fatigued. A nutritionist may be necessary for diet evaluation, planning, and
teaching. A nurse may provide education on the dialysis therapy and perform the skill necessary
until the client is able to do so independently.
The nurse may include patient teaching in the clients care, but more is required to meet the needs
of this client.
The nurse is not performing in the role of counselor.
Clear communication will be necessary for the client to understand self-care measures regarding
dialysis. The role of communicator does not, however, entirely meet the clients physical needs at
this time.
DIF: A REF: 10 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
7. Nurses have the opportunity to work in a wide variety of health care agencies around the
world. The practice setting where the majority of nurses continue to work is:
1
Acute care
2
3
Home care
Long-term care
4
Ambulatory care
ANS: 1
Most nurses provide direct client care in the hospital setting.
Although opportunities for providing patient care in the clients home are increasing, the majority
of nurses are not employed in this setting.
The majority of nurses do not work in nursing homes or extended care settings.
Significantly fewer nurses work in an ambulatory care setting.
DIF: A REF: 10 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
8. A client is receiving Dilantin to prevent seizure activity. To which allied health care
professional should the nurse refer this client in order to minimize the challenges this condition
creates?
1
Physical therapist
2
Physicians assistant
3
Respiratory therapist
4
Occupational therapist
ANS: 4
An occupational therapist is a person who provides assessment and intervention to ameliorate
physical and psychological deficits that interfere with the performance of activities and tasks of
living, including ones employment.
A physical therapist is responsible for the patients musculoskeletal system. A physical therapist
may use exercises as an intervention to improve a clients mobility.
A respiratory therapist provides treatment to preserve or improve pulmonary function.
A physicians assistant performs tasks usually done by physicians and works under the direction
of a supervising physician.
DIF: C OBJ: Analysis TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
9. The Goldmark Report concluded that:
1
Nursing roles and responsibilities required clarification
2
A theory-based curriculum was necessary for accreditation
3
Nursing education programs must be affiliated with
universities
4
Increased financial support should be provided for nursing
education
ANS: 4
In 1923 the Goldmark Report identified the need for increased financial support to universitybased schools of nursing.
The National Commission on Nursing and Nursing Education Report of 1965 recommended that
nursing roles and responsibilities be clarified in relation to other health care professionals.
In 1975 the National League for Nursing required theory-based curriculum for accreditation.
The Brown Report of 1948 concluded that all nursing education programs should be affiliated
with universities and should have their own budgets.
DIF: A REF: 3 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
10. In 1893 Lillian Wald and Mary Brewster made significant contributions to the nursing
profession through their work involving the:
1
Henry Street Settlement in New York
2
First training school in Toronto, Canada
3
Training school at Johns Hopkins in Baltimore
4
Development of the American Journal of Nursing
ANS: 1
In 1893 Lillian Wald and Mary Brewster opened the Henry Street Settlement, which was the first
community health service for the poor.
The first nurses training school in Canada was founded in St. Catherines, Ontario, in 1874.
In 1894 Isabel Hampton Robb was the first superintendent of the Johns Hopkins Training School
in Baltimore, Maryland.
Isabel Hampton Robb was one of the original founders of the American Journal of Nursing.
DIF: A REF: 3 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
11. To obtain a certification in a specialty area, the nurse will have to complete:
1
A request for state approval
2
3
A graduate degree in nursing
An examination and the minimum practice requirements
4
A general examination given to all nurses seeking certification
ANS: 3
Set minimum practice requirements are based on the certification the nurse is seeking. After
passing the initial examination, the nurse maintains certification by ongoing continuing
education and clinical or administrative practice.
Individual states do not grant certification by request. Certification in a specialty area requires
passing the examination for certification in that area and meeting minimum practice
requirements.
A masters degree in nursing is not required for certification in a specialty area.
A specialized examination is given according to the specific area of nursing practice in which
certification is being sought.
DIF: A REF: 9 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
12. In the ANA Standards of Professional Performance, which one of the following is a specific
measurement criterion for The nurses decisions and actions on behalf of clients are determined in
an ethical manner?
1
Acts as client advocate
2
Participates in the collection of client data
3
Seeks experiences to maintain clinical skills
4
Consults with appropriate health care providers
ANS: 1
As a client advocate, the nurse protects the clients human and legal rights and provides assistance
in asserting those rights if the need arises. Performing in the role of patient advocate fulfills a
measurement criterion for the professional performance standard of ethics.
Participating in data collection is a measurement criterion for the professional performance
standard of quality of practice.
The nurse who seeks experiences to maintain clinical skills is fulfilling a measurement criterion
for the professional performance standard of education.
Consulting with health care providers is a measurement criterion for the professional
performance standard of collaboration.
DIF: A REF: 7 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
13. In looking at the nineteenth century, the growth of professional nursing was stimulated by:
1
2
3
4
The Civil War
Federal legislation
Florence Nightingale
The womens suffrage movement
ANS: 1
The Civil War stimulated the growth of nursing in the United States. Nurses were in demand to
tend to the soldiers of the battlefield.
Throughout history, nurses and their professional organizations have lobbied for health care
legislation to meet the needs of clients. However, legislation was not responsible for the growth
of nursing in the nineteenth century.
Although Florence Nightingale had great impact on the practice of nursing, she was not the cause
for the growth of nursing in the United States during the nineteenth century.
The womens movement has encouraged nurses to seek greater autonomy and responsibility in
providing care, and has caused female clients to seek more control of their health and lives. The
womens movement was not responsible for the growth of nursing in the nineteenth century.
DIF: A REF: 3 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
14. Which of the following educational activities is an example of in-service education?
1
A workshop given at a nursing convention on malpractice
2
A program on new cardiac medications provided at a local
hospital
3
Credit courses in communication offered at the community
college
Noncredit courses on nursing issues available through the
internet
4
ANS: 2
An in-service education program is instruction or training provided by a health care agency or
institution for its employees.
A workshop at a nursing convention is an example of a continuing education program.
Credit courses at a college are examples of continuing education that could possibly by applied
toward furthering ones degree.
Noncredit courses offered via the internet are an example of a continuing education program.
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DIF: A REF: 8 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
15. Nurses need to be aware of current trends in the health care delivery system in order to
respond in educational preparation and practice. A major trend that is influencing nursing
practice today is:
1
Decreased client acuity
2
Increased hospital stays
3
Decreased emphasis on health promotion
4
Increased incidence of chronic disease processes
ANS: 4
In recent decades, there is a higher incidence of chronic, long-term illness.
With shortened hospital stays, client acuity has increased, not decreased.
Hospital stays have decreased, not increased. Lengths of stay have shortened with a trend toward
home care, and health promotion and illness prevention.
With increased public awareness and rising health care costs, greater emphasis has been placed
on health promotion and illness prevention.
DIF: A REF: 4 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
16. The nurse assists the client in a health promotion activity that also reduces the cost of health
care delivery when:
1
Administering medication
2
Treating a diabetic foot ulcer
3
Obtaining an operative consent
4
Discussing exercise and nutrition
ANS: 4
The nurse may educate the client in such areas as exercise, nutrition, and healthy lifestyles to
assist the client in health promotion and illness prevention.
By administering medication, the nurse is assisting to restore a person to health or maintain ones
health.
A nurse who treats a foot ulcer is assisting a client to restore their health, rather than promoting
healthy behaviors.
Obtaining an operative consent pertains to legal aspects of care and is not considered a health
promotion activity.
DIF: A REF: 5 OBJ: Comprehension
TOP: Nursing Process: Planning
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs
17. The nurse is best able to provide quality care that benefits both client and family by:
1
Incorporating caring into the practice
2
Making the client the center of the practice
3
Integrating the science and art of nursing into the practice
4
Being knowledgeable of the institutions standards of practice
ANS: 3
Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully
with compassion, caring, and a respect for each clients dignity and personhood. As a science,
nursing is based on a body of knowledge that is continually changing with new discoveries and
innovations. When you integrate the science and art of nursing into your practice, the quality of
care you provide to your clients is at a level of excellence that benefits clients and their families.
Caring is one part of the art of nursing.
While the client is the focus of nursing practice, this focus is not the main contributor to quality
care.
Standards of care provide guidelines for the delivery of client care. Awareness of the standards
does not guarantee quality care.
DIF: C REF: 2 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
18. Which of the following statements best reflects Nightingales nursing philosophy on health
maintenance and restoration?
1
Did all the clients eat a good breakfast?
2
What is the client rating his pain level after his medication?
3
Have any clients developed a nosocomial infection last
month?
Is anyone interested in volunteering to mentor our new
graduates?
4
ANS: 3
Florence Nightingale studied and implemented methods to improve battlefield sanitation, which
ultimately reduced illness, infection, and mortality (Cohen, 1984). Today nurses are active in
determining the best practices for skin care management, pain control, nutritional management,
and care of older adults. Infection control and its impact on disease prevention was a major
outcome of her contributions to nursing. Awareness of the connection between hospital-acquired
infections (nosocomial) and nursing practice is the best example of her nursing philosophy.
Nutritional management and its impact on client health, while important does not reflect the best
option offered.
Pain management while a vital client concern does not represent the best option offered
While volunteering is certainly reflected in Nightingales practice it is not the best option offered.
DIF: C REF: 2-3 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Disease Prevention
19. The twentieth century is recognized for which of the following nursing concepts?
1
Code of Nursing Ethics
2
Hospital-based nursing care
3
Specialized nursing textbooks were adopted.
4
Formalized university-based nursing education
ANS: 4
In the early twentieth century a movement toward a scientific, research-based defined body of
nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced
practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education
with universities.
In 1990 the American Nurses Association established the Center for Ethics and Human Rights.
Nursing in hospitals expanded in the late nineteenth century.
Isabel Hampton Robb helped found the Nurses Associated Alumnae of the United States and
Canada in 1896. This organization became the American Nurses Association (ANA) in 1911. She
authored many nursing textbooks, including Nursing: Its Principles and Practice for Hospital
and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907),
and was one of the original founders of theAmerican Journal of Nursing (AJN).
DIF: A REF: 4 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. The best example of the impact of the womens movement on health care is:
1
Improvement in breast cancer survival rates
2
Insurance coverage for well-woman check-ups
3
Women subjects to be included in all appropriate health
research projects
4
A single, teenage mother receiving Women, Infants, and
Children (WIC) benefits
ANS: 3
The womens movement brought about many changes in society as women increasingly
demanded economic, political, occupational, and educational equality. As a result, there is
greater sensitivity to the health care needs of women and the role of women in health care
research. There are emerging health care specialties dealing with the needs of women. These new
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specialties expand from the traditional obstetrical specialty and address issues ranging from wellwomens examinations, to oncological subspecialties, to the management of menopause. Because
of the prior lack of female subjects in biomedical research, the federal government now requires
studies to routinely include women in research, unless specific exception criteria are met. For
example, research focusing on management of prostatic cancer is an exception.
Improved survival rates for female-oriented cancers is evident because of emphasis being placed
on research.
While important, increased insurance coverage is not the best option available because this
action would be directly driven by research findings.
While important, increased federal funding for female-oriented benefits does not represent the
best option available because this action would be directly driven by research findings.
DIF: C REF: 4 OBJ: Analysis
TOP: Nursing Process: Comprehension
MSC: NCLEX test plan designation: Health Promotion and Maintenance
21. The human rights movement most directly impacts nursing practice because:
1
Nurses act as advocates for all clients
2
3
Clients require someone to focus on their needs
Caring for clients is the focus of nursing practice
4
Everyone deserves to be treated fairly and with respect
ANS: 1
Client advocacy is a nursing responsibility. The human rights movement changed the way
society views the rights of all of its members, including minorities, clients with terminal illness,
pregnant women, and older adults. Many groups have special health care needs, and nursing
responds by respecting the human rights of all clients and their right to quality care. Nurses
advocate the rights of all clients.
Clients do require someone to focus on their needs; advocacy is a responsibility of the nurse but
the concept of the nurse as an advocate was established well before the human rights movement.
Caring for clients is the focus of nursing practice, but caring physically and emotionally for a
client as a nursing responsibility was established well before the human rights movement.
Everyone deserves to be treated fairly and with respect. The realization of that truth was
impacted by the human rights movement; however, this option does not directly relate to nursing.
DIF: C REF: 4-5 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care
22. Nurses are caring for clients from a variety of cultures primarily as a result of:
1
Increased ease of travel and mobility
2
Political unrest in many foreign countries
3
Increased incidence of contagious diseases
4
Poor health care in underdeveloped countries
ANS: 1
Because the worlds population is more mobile, both immigration and travel have shown an
increase over the last decades. Nursing practice will require the management and delivery of care
for clients from many different cultures.
Although immigration to this country has been impacted by political strife in other countries, it is
not the primary factor in an increasingly culturally diverse client population.
Increased incidence of contagious diseases has little impact on the cultural diversity of the client
population.
Although poor health care services may contribute to some influx of foreign clients, it is not the
primary factor in an increasingly culturally diverse client population.
DIF: C REF: 5 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
23. Risk for injury during client transfer is minimized most effectively by:
1
Implementation of lift teams
2
Yearly personnel training sessions
3
Using mechanical lifts when possible
Use of evidence-based techniques
4
ANS: 4
Injuries to both caregiver and client occur during client transfer. The caregiver is at risk for
musculoskeletal injuries. The client is at risk for falls as well as musculoskeletal injuries. There
is a shift from ineffective, injury-prone client transfer techniques to evidence-based practices for
safe client handling.
The implementation of a lift team is directly supported by evidence-based research (EBR).
Yearly training sessions are important but the specific training is determined first by EBR.
The use of mechanical lifts is directly supported by evidence-based research (EBR).
DIF: C REF: 6 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Accident Prevention
MULTIPLE RESPONSE
1. Which of the following activities reflect the nurses role in health promotion and wellness?
(Select all that apply.)
1
2
3
4
Screening the local homeless population for head lice
Monitoring blood pressures at a community health fair
Organizing a foot race to benefit national cancer research
Consulting a teenage mother on breast-feeding techniques
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5
Providing literature on smoking cessation to client families
6
Presenting a nursing workshop on the care of diabetic ulcers
ANS: 1, 2, 4, 5
Nursing responds to this greater concern for health promotion by providing programs in the
community such as health fairs and wellness programs; educational programs for specific
diseases; and client and family teaching activities in hospitals, clinics, primary care facilities, and
other health care settings.
While admirable, organizing a benefit for cancer research is not an activity directed towards
health promotion and wellness but rather towards research that will benefit the population as a
whole rather than specific individuals.
Presenting a workshop on a specific nursing intervention is not an activity directed toward health
promotion and wellness but rather towards professional development of the nurses.
DIF: A REF: 5 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs
2. Changes in recent population demographics that have impacted the delivery of nursing care
include the following: (Select all that apply.)
1
2
Increased birth rates
Increased life expectancy
3
Decreasing rural population
4
Expanding urban settlement
5
Advances in medical modalities
Availability of free public education
6
ANS: 2, 3, 4
Demographic changes affect the population. Changes influencing health care in recent decades
include the population shift from rural areas to urban centers; the increased life span; the higher
incidence of chronic, long-term illness; and the increased incidence of diseases such as
alcoholism and lung cancer. Nursing responds to such changes by exploring new methods to
provide care, by changing educational emphases, and by establishing practice standards.
Recent birth rates have declined.
Advances in medical modalities and availability of free public education do not reflect changes
in population demographics but rather health care advances and social services.
Chapter 2. Health Care Delivery System
MULTIPLE CHOICE
1. Regulatory interventions were initiated to reduce the rise in health care costs. These
interventions include:
1
Prospective payment systems
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2
State limits on health care fees
3
Federal guidelines for treatment
Court review of insurance coverage
4
ANS: 1
As a means to reduce health care costs, in 1983 Congress established the prospective payment
system in which hospitals are reimbursed a set dollar amount for each diagnosis-related group,
regardless of the length of stay or use of services in the hospital.
State limits on health care fees have not been used nationwide to reduce health care costs.
Federal guidelines for treatment have not been used to reduce the cost of health care. Rather, the
focus has been on financial reimbursement.
Court review of insurance coverage has not been a primary intervention to lower health care
costs.
DIF: A REF: 16 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
2. Levels of prevention are used by the nurse to provide a framework or guide for nursing
interventions. Focus is based on the clients needs and the care or service that is provided. An
example of a true health promotion service is a(n):
1
Aerobic dance class
2
Immunization clinic
3
Diabetic support group
4
Smoking cessation clinic
ANS: 1
Examples of health promotion activities include exercise classes, prenatal care, well-baby care,
nutrition counseling, and family planning.
An immunization clinic is an example of an illness prevention service.
A diabetic support group may be an example of a rehabilitation service to adapt to a change in
lifestyle.
A smoking cessation clinic may be a part of rehabilitation or offered as an illness prevention
service.
DIF: A REF: 19 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
3. There are many types of health care delivery agencies. An example of a secondary level care
agency is a:
1
School
2
Nursing home
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3
Drug rehabilitation center
4
State-owned psychiatric hospital
ANS: 4
A state-owned psychiatric hospital is an example of the secondary level of care in which clients
who present with signs and symptoms of disease are diagnosed and treated.
A school is an example of preventive or primary care.
A nursing home is an example of continuing care.
A drug rehabilitation center is an example of restorative care.
DIF: A REF: 20 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
4. Which of the following fits within the occupational safety and health categories?
1
Noise exposure
2
3
Firearms safety
Swimming lessons
4
Motorcycle helmets
ANS: 1
Exposure to environmental hazards within the workplace, such as noise exposure, is one aspect
of occupational safety and health.
Firearms do not fit within the occupational safety and health category.
Swimming lessons do no fit within the occupational safety and health category.
Motorcycle helmets do not fit within the occupational safety and health category.
DIF: A REF: 20 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
5. A contractual agreement between a hospital and a corporation to pay the health care expenses
of the corporations employees is an example of a(n):
1
PPO
2
HMO
3
Private insurance
4
Third-party payment
ANS: 1
A preferred provider organization (PPO) is characterized by a contractual agreement between a
set of providers (e.g., hospitals, physicians, or clinics) and a purchaser (e.g., the corporations
insurance plan). Comprehensive health services are provided at a discount to the companies
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under contract. Enrollees are limited to a list of preferred hospitals, physicians, and providers. An
enrollee pays more out-of-pocket expenses for using a provider not on the list.
A Medicare HMO is the same as a managed care organization (all care provided by a primary
care physician) but designed to cover costs of senior citizens.
Private insurance is the traditional fee-for-service plan where payment is computed after services
are provided based on the number of services used.
Third-party payment is when an entity (other than the client or health care provider) reimburses
health care expenses. Third-party payers include insurance companies, governmental agencies,
and employers.
DIF: A REF: 18 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
6. The Medicaid insurance program is best described as:
1
Acute care hospital insurance for the older adult population
2
A funded health care program for older and disabled persons
3
A state-regulated health care program for persons of low
income
4
A fee-for-service insurance plan that supports preventive
health care
ANS: 3
Medicaid is a federally funded, state-operated program of medical assistance to people with low
incomes. Individual states determine eligibility and benefits.
This option describes Medicare.
This option describes Medicare Part A.
This option does not describe Medicaid.
DIF: A REF: 18 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
7. Quality health care is an innovative approach to delivering health care. The major factor for its
success is that it:
1
Focuses on the nursing process
2
Uses outcomes to manage client care
3
Is used exclusively in the acute care setting
4
Allows a high degree of flexibility delivering the care
ANS: 2
Health care providers are defining and measuring quality in terms of outcomes. An outcome is a
measure of what actually does or does not happen as a result of a process of care.
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The focus in quality health care is on the outcome, not the process.
Quality health care is not used exclusively in the acute care setting. It may be used in various
health care settings.
Because quality health care is based on achieving outcomes, it does not allow a high degree of
flexibility for the nurse in delivering care.
DIF: A REF: 27 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
8. Case management is one strategy for coordinating health care services. What best describes
this caregiving approach?
1
2
3
4
Continuity of care is the primary concern.
This focus of care may be more expensive.
The physician is the coordinator of client care.
It is designed to provide minimal to moderate levels of care.
ANS: 1
With the case management model of care, the case manager coordinates the efforts of all
disciplines to achieve the most efficient and appropriate plan of care. Continuity of care is of
primary importance.
If the efforts of all disciplines are well managed, repetition or delays may be avoided with a
resultant shortened hospital stay. Therefore this focus of care may not be more expensive.
The physician may or may not be the coordinator of client care. The case manager typically is a
nurse or social worker.
Case management is not entirely based on the level of care required.
DIF: A REF: 21 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care/
Case Management
9. The payment mechanism that Medicare uses within its health care financing is:
1
Capitation
2
Fixed payments
3
Direct contracting
4
Prospective payment
ANS: 2
Inpatient hospital services for Medicare clients are reimbursed a set amount for each DRG,
regardless of the clients length of stay or use of services in the hospital.
Capitation is the payment mechanism in which providers receive a fixed amount per enrollee of a
health care plan.
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The payment mechanism that Medicare uses is not direct contracting.
Medicare is not based on fixed payments, but rather on a set dollar amount according to the
DRG.
DIF: A REF: 27 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
10. A student nurse visiting a nurse-managed clinic should expect to see which of the following
services offered?
1
2
3
4
Physical therapy
Same-day surgery
Family support services
Ongoing psychiatric therapy
ANS: 3
Nurse-managed clinics focus on health promotion and health education, disease prevention,
chronic disease management, and support for self-care and caregivers.
Physical therapy is not typically offered in a nurse-managed clinic.
Same-day surgery is not offered in a nurse-managed clinic.
Psychiatric therapy is not offered in a nurse-managed clinic.
DIF: A REF: 21 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
11. A disabled client requiring restorative care should be referred to a(n):
1
Nursing home
2
Subacute care unit
3
Home health care agency
Ambulatory health center
4
ANS: 3
A home health care agency provides health services to individuals and families in their home to
promote, maintain, or restore health, or to maximize the level of independence while minimizing
the effects of disability and illness.
A nursing home is a long-term care setting in which clients receive 24-hour intermediate and
custodial care.
A subacute care unit is not the best referral for restorative care.
An ambulatory health center is not the best referral for restorative care.
DIF: A REF: 16 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
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12. Which of the following is an appropriate referral for an older client who requires some
assistance with daily activities within a partially protective environment?
1
2
3
4
Respite care
Extended care
Assisted living
Rehabilitative care
ANS: 3
The appropriate response is assisted living. A group of residents live together, each resident
having his or her own room, yet sharing dining and social activity areas.
Respite care is a service that provides short-term relief for persons providing home care to the ill
or disabled.
An extended care facility provides intermediate medical, nursing, or custodial care for clients
recovering from acute or chronic illness or disabilities.
Rehabilitative care includes physical, occupational and speech therapy, and social services to
help restore clients to their fullest ability.
DIF: A REF: 20 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
13. Discharge planning for clients begins:
1
After a diagnosis has been established
2
Once the long-term needs are identified
3
Upon admission to a health care facility
When the acute care therapies are completed
4
ANS: 3
Discharge planning should begin at the time of admission to the hospital, using the strengths and
resources of the client, providing resources to meet the clients limitations, and focusing on
improving the clients long-term outcomes.
The clients diagnosis does not have to be established before discharge planning can begin.
Discharge planning should include preparation for long-term needs of the client.
Acute care therapies may impact a clients discharge and should be a part of the plan from the
beginning.
DIF: A REF: 23 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
14. A client states that she does not understand managed care organization (MCO) health
insurance. The nurse responds most appropriately by explaining that the MCO:
1
Reimburses nursing home funding
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2
Focuses on health maintenance and primary care
3
Allows the individual to go to any physician that he desires
4
Requires a contractual agreement between the health provider
and clients employer
ANS: 2
In a managed care organization (MCO), a primary care physician provides all care and the focus
is on health maintenance and primary care.
Medicaid reimburses nursing home funding.
In a managed care organization, referral by the primary care physician is necessary for access to
specialists and for hospitalization.
A PPO is limited to a contractual agreement between a set of providers and one or more
purchasers.
DIF: A REF: 25 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
15. Which form of health care is of primary importance when dealing with managed care?
2
Health promotion
Disease prevention
3
Tertiary treatment
4
Secondary treatment
1
ANS: 1
If people stay healthy, the cost of medical care declines. Systems of managed care focus on
containing or reducing costs, increasing client satisfaction, and improving the health or
functional status of the individual (Sultz and Young, 2004). Health promotion: Activities that
develop human attitudes and behaviors to maintain or enhance well-being.
Disease prevention: Activities that protect people from becoming ill because of actual or
potential health threats.
Tertiary prevention: Care that prevents further progression of disease.
Secondary prevention: Early diagnosis and treatment of illness (e.g., screening for hypertension).
DIF: C REF: 21 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care
16. A nurse is consulting with a homeless family who has a 12-year-old disabled child. The nurse
suggests which of the following services to best assist with the childs health care needs?
1
2
Medicare
Medicaid
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3
Long-term care insurance
4
An extended care faculty
ANS: 2
Medicaid is a federally funded, state-operated program that provides (1) health insurance to lowincome families and (2) health assistance to low-income people with long-term care (LTC)
disabilities.
Chapter 3. Community-Based Nursing Practice
MULTIPLE CHOICE
1. The student nurse is investigating different types of practice settings. In looking at community
health nursing, the student recognizes that it:
1
Is the same as public health nursing
2
3
Focuses on the incidence of disease
Requires graduate-level educational preparation
4
Includes direct care and services to subpopulations
ANS: 4
Community health nursing strives to safeguard and improve the health of populations in the
community as well as providing direct care services to subpopulations within a community.
Public health nursing is concerned with trends and patterns influencing the incidence of disease
within populations. A community health nurse may be involved in direct client care for disease
within a community. Public health nursing focuses on the needs of populations. Community
health nursing has a broader focus, with an emphasis on the health of a community. The
community health nurse merges public health knowledge with nursing theory. The community
health nurse considers the needs of populations and is prepared to provide direct care services to
subpopulations within a community. Nurses who become expert in community health practice
may have advanced nursing degrees, yet the baccalaureate-prepared generalist also can become
quite competent in formulating and applying population-focused assessments and interventions.
DIF: A REF: 34 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. As a community health nurse assisting the client and family with nutritional needs the nurse
should first:
1
Identify for the client the best foods to buy
2
Purchase foods at the lowest cost for the client
3
Ask the client and family what they think they should eat
4
Provide information on stores with the most reasonable pricing
ANS: 3
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With the goal of helping clients assume responsibility for their own health care, the community
health nurse must assess a clients learning needs and readiness to learn within the context of the
individual, the systems the individual interacts with, and the resources available for support.
Asking the client about what foods he or she thinks should be eaten may help the nurse assess the
clients level of knowledge regarding nutrition as well as the clients food preferences. It also
enables the client to become a participant in his or her care. Telling the client what foods to buy
does not encourage the client to assume responsibility for managing his or her health care. The
nurse should first assess the resources available, and then encourage the client to do his or her
own shopping. Providing information on food sources and stores with reasonable pricing may be
appropriate after the nurse has determined what information the client requires to meet
nutritional needs.
DIF: C REF: 40 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
3. Which one of the following clients from a vulnerable population currently appears to be at the
greatest risk?
1
2
3
4
A physically abused client in a shelter
A schizophrenic client in outpatient therapy
An older adult taking medication for hypertension
A substance abuser who shares drug paraphernalia
ANS: 4
A client with substance abuse has health and socioeconomic problems. These clients frequently
may avoid health care for fear of judgmental attitudes by health care providers and concern over
being turned in to criminal authorities. An abused client in a shelter has sought protection so
currently should be at less risk. Although considered to be a member of a vulnerable population,
the older adult who takes medication for a chronic disease, such as hypertension, is taking
measures to maintain health. A schizophrenic client in outpatient therapy is currently at less risk
because he or she is receiving treatment.
DIF: C REF: 36 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. A client with a history of a gastrointestinal disorder eats a well-balanced diet that keeps his GI
symptoms suppressed. Which level of prevention corresponds to his dietary management?
1
Health promotion
2
Primary prevention
3
Tertiary prevention
4
Secondary prevention
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ANS: 3
The goal of tertiary prevention is to preclude further deterioration of physical and mental
function in a person who has an existing illness, and to have the client use whatever residual
function is available for maximum enjoyment of and participation in lifes activities. Health
promotion is aimed at reducing the incidence of disease and its impact on people. Primary
prevention is aimed at general health promotion.
Secondary prevention is aimed at early recognition and treatment of disease.
DIF: A REF: 37 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
5. Which of the following statements by the home health nurse best reflects client advocacy in
response to the clients concern over the expense of the therapy?
1
2
Have you considered the possibility of a renal transplant?
This peritoneal dialysis is less expensive than hemodialysis.
3
You must feel awful about this situation, but this is the best
course of treatment for you.
4
Lets call the regional dialysis center and explore options for
reducing the cost of your home dialysis.
ANS: 4
Calling the regional dialysis center and exploring options for reducing cost demonstrates the
nurse acting as client advocate by identifying and assisting the client in contacting the
appropriate agency for information and resources to meet the clients needs. Asking the client
whether he has considered renal transplantation does not demonstrate client advocacy. Pointing
out the difference in cost for dialysis in the home versus the hospital does not meet the clients
need to reduce the expenses of his therapy. The nurse is not demonstrating patient advocacy.
Telling the client that this is the best treatment for him does not address his financial concerns.
The nurse is not demonstrating patient advocacy with this response.
DIF: C REF: 40 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. In assessing the structure of the community in order to identify the needs of its population, the
nurse will focus on:
1
Collecting demographic data on age distribution
2
Visiting neighborhood schools to review health records
3
Interviewing clients to determine the cultural composition of
the subgroups
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4
Observing locations where services, such as water sanitation,
are provided
ANS: 4
When assessing the structure or locale of a community, the nurse should travel around the
neighborhood or community and observe its design; the location of services, such as water and
sanitation; and the locations where residents congregate. Collecting demographic data on age
distribution would be an assessment of the communitys population. Visiting neighborhood
schools to review health records is an example of assessing a social system within a community.
Interviewing clients to determine the cultural composition of subgroups is an example of
assessing the population within a community.
DIF: A REF: 41 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. To facilitate change within a community, the nurse working as an effective change agent
should:
1
Inform community members how to effectively manage their
health needs
2
Work with clients and groups to select alternative health care
sites and treatments
3
Formulate decisions for individual clients regarding their
health care options
4
Provide instruction in the way the community should address
health issues
ANS: 2
As a change agent, the nurse seeks to implement new and more effective approaches to
problems. The nurse creates change by working with and empowering individuals and their
families to solve problems or to become instrumental in changing aspects affecting their health
care. Telling community members how to manage their health care needs may meet resistance. It
also does not enable clients and their families to take responsibility for their health care. Making
decisions for clients does not enable individuals to assume responsibility for their health care
decisions. The community-based nurse acting as a change agent may be an excellent resource for
health information to members of the community. Ultimately; however, the community members
will take an active role to create change for themselves and will assume responsibility for their
health care decisions.
DIF: A REF: 39-40 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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8. The client is being discharged from an acute care facility following a total hip replacement.
She will need follow-up for her rehabilitation and exercise plan. In addition to a home health
care nurse, what referral should be discussed?
1
Dietitian
2
3
Social worker
Physical therapist
4
Respiratory therapist
ANS: 3
Directing clients to appropriate resources and improving continuity of care require the nurse to
know those resources well. A physical therapist is responsible for the clients movement system
and is likely to be needed following hip replacement surgery.
A social worker may or may not be necessary. A dietitian may or may not be necessary.
A respiratory therapist would not be necessary unless the client experienced a respiratory
complication or had a preexisting respiratory condition.
DIF: A OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
9. The nurse recognizes which of the following as the largest contributing factor for the rise in
the need and use of home care?
1
Government funding of the home care setting has increased
greatly.
2
Clients are more acutely ill when discharged from the acute
care facility.
There are 7 days/week services for the elderly in home care
agencies.
3
4
The existence of more single-income families has increased
the need for their elderly relatives to receive care in the home.
ANS: 2
Because hospital stays are being shortened to control health care costs, clients are returning
home more acutely ill. This is the largest contributing factor for the rise in the need and use of
home care. Government funding of home care is not the largest contributing factor for the rise in
the need and use of home care. There are 7 days/week services for the elderly in a variety of
settings, such as in acute care or long-term care, not just in the home care setting. Being able to
provide daily services for the elderly in the home care setting is not the largest contributing
factor for the rise in the need and use of home care. The existence of more single-income
families is not the largest contributing factor for the rise in the need and use of home care.
DIF: C REF: Chapter 2, 22 OBJ: Analysis
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. One of the overall goals of Healthy People 2010 is to:
1
Increase life expectancy
2
3
Decrease health care costs
Promote managed care organizations
4
Establish the credentials of service providers
ANS: 1
The overall goals of Healthy People 2010 are to increase the life expectancy and quality of life
and to eliminate health disparities. The initiative of Healthy People 2010 is to improve the
delivery of health care services to the general public. The overall goal did not focus on reducing
health care costs. Although managed care organizations may increase in number, this was not a
goal of the Healthy People 2010 initiative. Establishing the credentials of care providers was not
a goal of Healthy People 2010.
DIF: A REF: 33 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
11. When assessing members of a vulnerable population, the community health nurse should
realize that the primary need is to:
1
Provide culturally competent assessment.
2
Organize in your mind exactly what you need to ask.
3
Create a comfortable, nonthreatening environment.
4
Be alert for indications of mental and physical abuse.
ANS: 3
In order to be successful in assessing a member of a vulnerable population, the nurse must first
create an environment that is encourages the client to cooperate with and actively participate in
the assessment process While it is important that the nurse be cultural considerate of the client, it
is not the primary need of those offered as options.
While organization to thought is important to the effective use of time needed for an assessment,
it is not the primary need of those offered as options. While vulnerable populations may be more
susceptible to both mental and physical abuse making observation for signs of abuse important, it
is not the primary need of those offered as options
DIF: C REF: 35 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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12. The nurse working in a free clinic often utilized by Hispanic immigrants is assessing a client
who reports a cough and malaise. The client is hearing impaired, speaks very little English and is
currently living in a homeless shelter. The nurses primary concerns should be the clients:
1
Language barrier
2
3
Risk for tuberculosis
Hearing impairment
4
Lack of health care resources
ANS: 2
Risk for tuberculosis presents the greatest risk since it is supported by the physical signs, is
highly contagious and a risk factor among the homeless and some immigrant populations. The
language barrier is a concern since it impacts the communication between the nurse and the
client but it is not the primary concern among the options offered. The clients hearing
impairment is a concern because it has an impact on the communication between the nurse and
the client but it is not the primary concern among the options offered. The clients lack of
insurance is a concern because it affects the treatment plan necessary for the clients recovery, but
it is not the primary concern among the options offered.
DIF: C REF: 36 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
13. A nurse is planning interventions for the clients of a homeless shelter. Which of the activities
represents a primary level intervention regarding sexually transmitted diseases?
1
HIV screening for all residents
2
Sex education for teenage residents
3
Treatment for residents diagnosed with AIDS
Gynecological referrals for female residences
4
ANS: 2
Primary level interventions are directed a preventing the disease. Educational programming is
generally considered a primary intervention. Screening a disease is generally considered a
secondary level intervention. Treatment of the disease is generally considered a tertiary level
intervention. Referrals are generally considered a secondary intervention.
DIF: A REF: 36 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. The nurse working in a free clinic is caring for a homeless client diagnosed with paranoid
schizophrenia who has reported that, I hurt my foot running away from them. It hurts so bad I
can hardly walk now. On assessment the nurse notices bruising on the clients back, arms, and
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thighs, a red rash on both neck and face, and poor personal hygiene, in addition to edema of the
left ankle. The nurse should first realize that this client is at risk for:
1
2
3
4
Physical abuse and assault
Drug addiction relating to pain
Communicable immune disorders
Hospitalization due to mental disorder
ANS: 1
When a client has a severe mental illness such as schizophrenia there are multiple health and
socioeconomic problems you will need to explore. Many clients with pervasive mental illnesses
are homeless or live in poverty. In addition, mentally ill clients are at greater risk of abuse and
assault. This clients reported foot injury and observable bruising support the possibility of abuse/
assault. While drug abuse may be a consideration, it does not represent the best option offered
for this item because there is not indication that the client is drug seeking. Contacting
communicable diseases is a risk factor for such a client but it does not represent the best option
offered for this item because there are several factors that may indicate abuse/assault.
Hospitalization may be required but it does not represent the best option offered for this item
because there is no indication that the client is experiencing a psychiatric crisis.
DIF: C REF: 37 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. A community nurse has identified a need for educational programming among the residents
of an assistive living facility dealing with osteoarthritis. The best example of such programming
is:
1
Planning the best exercise program for you.
2
Recognizing how arthritis has affected your life.
3
Proper self administration of antiinflammatory medication
Be an informed consumerdont fall for false arthritis cures.
4
ANS: 4
Thorough assessment and appropriate community based interventions provide an opportunity to
improve the lifestyle and quality of life of older adults in general. The focus is on broad-based
needs not specific client needs. Answer 4 offers information applicable to the entire resident
population diagnoses with osteoarthritis.
DIF: C REF: Chapter 2, 19 OBJ: Analysis
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
16. A homeless client has presented in the ED with a bacterial infection in a hand wound. The
nurse has cleansed and dressed the wound, and an initial dose of an antibiotic has been
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administered. The client will need the antibiotic prescription filled and a dressing change in 3
days. In order to ensure that the client will receive the appropriate follow-up care, the nurse must
first act as the clients:
1
Educator
2
3
Advocate
Caregiver
4
Counselor
ANS: 2
Client advocacy perhaps is more important today because of the confusion surrounding access to
health care services. Your clients often need someone to help them walk through the system,
identify where to go for services and tell them how to reach the individuals with the appropriate
authority, what services to request, and how to follow through with the information they
received. The role of the educator is to help the client assume responsibility for his or her own
health care. This client has been educated to the needs related to caring for the infection but
needs the nurse advocate to assist with facilitating the care. As caregiver, the nurse manages and
cares for the clients health. You apply the nursing process (see Unit III) in a critical thinking
approach to ensure appropriate, individualized nursing care for specific clients and their families.
This clients nursing care has been appropriated delivered and so that nursing role has been
fulfilled. A counselor assists clients in identifying and clarifying health problems and in choosing
appropriate courses of action to solve those problems. The client is first in need of assistance in
dealing with the obstacles to the care of the identified probleminfection.
DIF: C REF: 37-38 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. A nurse is discussing the need to use a specific cleansing agent when redressing an infected
hand. The client prefers using, plain old soap and water. The nurse knows that the primary factor
that will affect client compliance is:
1
The ease with which the client can use the special agent
2
The clients acceptance of the need for the specialized care
3
The availability and cost of the prescribed cleansing agent
4
The introduction of an incentive to prompt client to comply
ANS: 2
Client must perceive the innovation or change as more advantageous than other alternatives or
they will not make the change. Client education is essential in bringing about the change in
attitude necessary for change. While the client is more likely to adapt the change if it is perceived
as being easy, it is not the primary factor in achieving client compliance provided among the
options available because client compliance is primarily a result of the clients understanding of
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the need for change. While cost to the client is a factor, it is not the primary factor in achieving
client compliance provided among the options available since client compliance is primarily a
result of the clients understanding of the need for change. An incentive is sometimes necessary,
but it is not the primary factor in achieving client compliance provided among the options
available, because client compliance is primarily a result of the clients understanding of the need
for change.
DIF: C REF: 39 OBJ: Analysis
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
18. The nurse is assessing a client diagnosed with chronic bronchitis who has been experiencing
an increase in dyspnea. The client lives within 2 blocks of a factory that emits pollution into the
air. In light of this information, the nurse is primarily concerned with:
1
Performing a complete client health history and physical
assessment
2
Providing the client with assess to all the required breathing
treatments
3
Identifying a correlation between the pollution and the clients
increased dyspnea
4
Determining the availability of alternate housing for the client
away from the factory
ANS: 3
There may be many factors that are affecting the clients breathing. Determining the clients
exposure to the pollution and its affects of the clients breathing would be the nurses primary
concern for this client. The assessment and history is important but is not the best option
available regarding the effects of air pollution on the clients respirations.
The availability of required breathing treatments is important but it is not the best option
regarding the effects of air pollution of the clients respirations. It may be necessary for the client
to consider moving but only if it is determined that the pollution is responsible of the increase in
the dyspnea.
DIF: A REF: 40 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which of the following clients is a concern for the community health nurse? (Select all that
apply.)
1
The homeless woman with a history of congestive heart failure
2
The elderly gentleman who fell while disembarking from a bus
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3
The child of itinerant workers who has a developed asthma
4
A client diagnosed with HIV who recently lost her insurance
5
A 15-year-old who was injured while at a public swimming
pool
6
A retired service veteran who has a chronic psychiatric
disorder
ANS: 1, 3, 4
Community-based health care occurs outside traditional health care institutions, such as
hospitals. It provides services for acute and chronic conditions to individuals and families with in
the community (Stanhope and Lancaster, 2006). Some of these problems include an increase in
homeless and immigrant populations, an increase in sexually transmitted diseases,
underimmunization of infants and children, and life-threatening diseases (e.g., clients living with
HIV and other emerging infections). All of these clients possess risk factors that are community
based
DIF: C REF: 40 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. A nurse working with clients at or below the poverty level recognizes that the life expectancy
of these clients is lower than the general population because of: (select all that apply.)
1
Inadequate nutritional diets
2
High-risk work environments
3
Hazardous living environments
Addictive and abusive lifestyles
4
5
6
Predisposition to chronic diseases
Ineffective decision making abilities
ANS: 1, 2, 3, 4
People who live in poverty are more likely to live in hazardous environments, work at high-risk
jobs, eat less nutritious diets, abuse substances, and have multiple stressors in their life. When
researchers compared the life expectancies of European Americans and African-Americans, the
causes of the differences were related to low socioeconomic status rather than ethnicity.
Predisposition to chronic disease in part is genetic in nature and research has confirmed no such
link between poverty and chronic disease. Decision-making ability is not the only factor
affecting decision making. Poverty negatively affects the individuals ability to access recourses
and adds stressors such as finding shelter that can alter the decision-making process.
Chapter 4. Theoretical Foundations of Nursing Practice
MULTIPLE CHOICE
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1. In preparing to review different theories, the nurse reviews basic information to assist in
understanding the material. Theories are defined as:
1
2
Mental formulations of objects or events
Aspects of reality that can be consciously sensed
3
Statements that describe concepts or connect concepts
4
Concepts or propositions that project a systematic view of
phenomena
ANS: 4
A theory is a set of concepts, definitions, relationships, and assumptions that project a systematic
view of phenomena.
Mental formulations of objects or events are called concepts.
Aspects of reality that can be consciously sensed are called phenomena.
Statements that describe concepts or connect concepts are called assumptions.
DIF: A REF: 46 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. There are different types of theories that may be used by nurses seeking to study the basis of
nursing practice. When the goal of a theory is to speculate on why phenomena occur, it is termed
a:
1
Grand theory
2
Prescriptive theory
3
Descriptive theory
Middle range theory
4
ANS: 3
Descriptive theories describe phenomena, speculate on why phenomena occur, and describe the
consequences of phenomena.
Grand theories provide the structural framework for broad, abstract ideas about nursing.
Prescriptive theories address nursing interventions and predict the consequence of a specific
nursing intervention.
Middle range theories address specific phenomena or concepts and reflect practice.
DIF: A REF: 47 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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3. Which one of the four linkages of interest in the nursing paradigm refers to factors in the home
or school?
1
2
3
4
Person
Health
Nursing care
Environment
ANS: 4
Environment/situation includes all possible conditions affecting the client and the setting in
which health care needs occur, such as the home, school, workplace, or community.
Person refers to the recipient of nursing care, including individual clients, families, and the
community.
Health is the goal of nursing care.
Nursing care refers to the diagnosis and treatment of human responses to actual or potential
health problems (ANA, 1995).
DIF: A REF: 45 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. The nurse is working within a health care system that employs Neumans theory. A client is
having difficulty breathing and requires oxygen and medication. Within Neumans theory, the
nurse approaches the client to:
1
Achieve the 14 basic needs
2
Promote attainment of biological self-care requisites
3
Assist in physiological adaptation to internal changes
Strengthen the line of defenses at the secondary level of
prevention
4
ANS: 4
Neumans framework for practice included nursing actions as primary, secondary, or tertiary
levels of prevention in caring for clients holistically. Secondary prevention strengthens internal
defenses and resources by establishing priorities and treatment plans for identified symptoms.
In Hendersons theory, nurses help the client to perform 14 basic needs.
The goal of Orems theory is to promote attainment of self-care.
Roys theory focuses on adaptation.
DIF: A REF: 49 OBJ: Comprehension
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
5. Although there are similarities in the different nursing theories, there are key elements that
distinguish one from another. The emphasis of Jean Watsons conceptual model is that:
1
2
3
4
Self-care maintains wholeness
Stimuli disrupt an adaptive system
Subsystems exist in dynamic stability
Caring is central to the essence of nursing
ANS: 4
Like Benner and Wrubels theory, Watson emphasized caring in her theory. Watsons model is
designed around the caring process, assisting clients in attaining or maintaining health or in
dying peacefully. The key emphasis of her theory is that caring is the moral ideal: mind-bodysoul engagement with another.
Self-care is central to Orems theory.
The key emphasis of Roys theory is that stimuli disrupt an adaptive system.
The key emphasis of Johnsons theory is that subsystems exist in dynamic stability.
DIF: A REF: 50-51 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. A community health nurse is working with a variety of clients and decides to use a systems
theory approach to assist them to meet their health care needs. In using this approach, the nurse
focuses on the:
1
Hierarchy of the clients human needs
2
Clients interaction with the environment
3
Clients attitudes toward health behaviors
Response of the client to the process of growth and
development
4
ANS: 2
According to systems theory, a system is made up of parts that rely on one another, are
interrelated, share a common purpose, and together form a whole. A clients interaction with the
environment is an example of an open system. The nurse understands factors that change the
environment can also have an impact on the system.
Maslows hierarchy of human needs is an interdisciplinary theory useful in planning
individualized care.
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Determining a clients attitudes toward health behaviors follows a health-and-wellness theoretical
model.
Focusing on the response of a client to the process of growth and development is consistent with
developmental theories.
DIF: A REF: 47 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. While working on a postoperative unit, the nurse is applying the elements of the self-care
theory. The nurse who assists the client to manage or attain self-care in wound management is
using the theory developed by:
1
2
Imogene King
Dorothea Orem
3
Virginia Henderson
4
Florence Nightingale
ANS: 2
The goal of Orems theory is to help the client perform self-care.
The goal of Kings theory is to use communication to help the client reestablish positive
adaptation to the environment.
The goal of Hendersons theory is to work independently with other health care workers assisting
the client to gain independence as quickly as possible.
The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating
the clients environment.
DIF: A REF: 50 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
8. Martha Rogers theory has a framework for practice that includes the:
1
Manipulation of the clients environment
2
21 nursing problems within 4 major client needs
3
Seven categories of behavior and behavioral balance
4
Unitary human being in continuous interaction with the
environment
ANS: 4
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The framework for practice according to Martha Rogers theory is the unitary human
continuously changing and coexisting with the environment.
Nightingales theory includes manipulation of the clients environment (i.e., appropriate noise,
nutrition, hygiene, light, comfort, socialization, and hope) in the framework for practice.
Abdellahs nursing theory includes 21 nursing problems within 4 major client needs in the
framework for practice.
Johnsons theory includes seven categories of behavior and behavioral balance in the framework
for practice.
DIF: A REF: 50 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
9. The nurse plans to apply a theory that focused on stress reduction. A theory proposed by which
one of the following individuals should be selected?
1
2
3
4
Parse
Peplau
Neuman
Orlando
ANS: 3
Stress reduction is the goal of the systems model of nursing practice according to Neumans
theory.
Parses theory focuses on indivisible beings and the environment co-creating health.
Peplaus theory focuses on the interpersonal process as the maturing force for personality.
Orlandos theory focuses on the interpersonal process to alleviate distress.
DIF: A REF: 49 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. A similarity between the theories of Leininger and of Benner and Wrubel is:
1
Caring as a central focus
2
The clients adaptation to demands
3
An emphasis on the maximum level of wellness
4
Dynamic interpersonal communication
ANS: 1
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Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying
feature of nursing. Caring is also central to the theory of Benner and Wrubel, depicting personal
concern as an inherent feature of nursing practice.
The theories of Roy and Johnson focused on the clients adaptation to demands.
Neumans theory places emphasis on achieving a maximum level of wellness. Abdellahs theory
also addressed the person as a whole.
Kings theory and Peplaus theory share a similarity with a focus on interpersonal communication.
DIF: A REF: 50-51 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
11. The nurse is working with a client diagnosed with multiple sclerosis. The goal is that the
client will be capable of living independently. The nursing theory that best supports this clients
situation is:
1
2
3
4
Orems theory
Neumans theory
Abdellahs theory
Hendersons theory
ANS: 1
According to Orem, the goal of nursing is to increase the clients ability to independently meet
biological, psychological, developmental, or social needs.
Neumans theory is concerned with the whole person. According to Neuman, the focus of nursing
is on the variables affecting the clients response to a stressor.
Abdellahs theory emphasizes the delivery of nursing care for the whole person.
According to Henderson, nurses help clients to perform 14 basic needs.
DIF: A REF: 50 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
12. While the nurse realizes that the definition of health is unique to the client, the most universal
factor is that health is:
1
Dynamic and ever-changing
2
Affected and managed by the nurse
3
Determined by internal and external forces
4
Perceived and defined by the individual
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ANS: 1
Health has different meanings for each client, the clinical setting, and the health care profession
(see Chapter 6). Health is dynamic and continuously changing. Your challenge is to provide the
best possible care based on the clients level of health and health care needs at the time of care
delivery.
While the other options may be true, they are not universally true to all individuals because not
everyone is involved in a nurse-client relationship, wellness can be affected by internal factors,
external factors, or a combination of both, and not everyone is capable of perceiving and
defining their own wellness.
DIF: C REF: 45 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
13. Which of the following statements by the nurse best defines nursing diagnoses for a client?
1
It is the basis for a clients care plan.
2
It is what we nurses use to plan your care.
3
It is one of a set of standardized client oriented problems.
4
It is the way nurses identify what specific needs a client has.
ANS: 4
In medicine, physicians diagnose and treat disease. In contrast, nursing is the diagnosis and
treatment of human responses to actual or potential health problems (ANA, 2003). The scope of
nursing is broad. For example, a nurse does not medically diagnose the clients heart condition
but instead assesses the clients response to the disease and may develop nursing diagnoses of
fatigue, change in body image, and altered coping. From these nursing diagnoses, the nurse
creates an individualized plan of care for each of the clients health problems.
Although the other statements are correct, they are not the best options available because they do
not fully explain the function of a nursing diagnosis.
DIF: C REF: 45 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. The nurse is caring for a client newly diagnosed with type 2 diabetes mellitus. Which of the
following nursing interventions best reflects Orems nursing theory?
1
Arranging for a consult with a certified diabetic nurse educator
2
Demonstrating proper documentation of glucose testing results
3
Explaining the role of A1C values in the management of
glucose levels
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4
Preparing discharge teaching to reinforce proper finger-stick
technique
ANS: 4
If a nurse uses Orems theory in practice, the nurse assesses and interprets the data to determine
the clients self-care needs, self-care deficits, and self-care abilities in the management of a
disease. The theory then guides the design of individualized nursing interventions.
While the other interventions are appropriate and will ultimately affect effective client self-care/
management of the diabetes, they are not the correct option because they are not directly
involved in determining client self-care needs.
DIF: C REF: 50 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. Swansons theory of caring is best demonstrated when the nurse:
1
Demonstrates efficiency when performing ordered treatments
2
Offers to stay with the client during a painful bedside
procedure
3
Administers the clients pain medication promptly when
requested
Frequently updates a family regarding a clients status during
surgery
4
ANS: 2
Swansons theory of caring defines five components of caring: knowing, being with, doing for,
enabling, and maintaining belief. These components provide a foundation of knowledge for the
direction and delivery of caring nursing practice. This theory provides a basis for identifying and
testing nurse caring behaviors to determine if caring improves client health outcomes. Offering
to stay with the client is an intervention directly reflected of being with the client. Efficiency is a
component of caring but it is not the best option available because it is not exclusively directed
toward Swansons theory. Administering pain medication promptly reflects effective nursing care
as well as a clients right. It is a component of caring but it is not the best option available
because it is not exclusively directed towards Swansons theory. Effective nursing care and caring
for the family is important, but it is not the best option available because it is not directed
towards the client.
DIF: C REF: 46 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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16. Which of the following responses observed in a client recently diagnosed with lung cancer is
most directly addressed by the Neuman System Model?
1
The client asks for a consult with the hospital clergy.
2
The client is observed crying after his family has left for the
day.
3
The client asks for pictures of his children to be brought to
him in the hospital.
4
The client is heard saying, I trust my health team, and Ill do
what they suggest.
ANS: 2
Examples of phenomena of nursing include caring, self-care, and client responses to stress. In the
Neuman Systems Model (1995), phenomena include all client responses, environmental factors,
and nursing actions. Crying is reflective of a clients response to stress to a second level need
(Maslows) and so is directly related to Neumans model.
While consulting with clergy is reflective of a client need, it is higher on Maslows hierarchy and
so not the best option available.
While requesting family photos is reflective of a client need, it is higher on Maslows hierarchy
and so not the best option available.
The client stating that he/she will trust the health team is reflective of a client response, it is less
reflective of a need and so not the best option available.
DIF: C REF: 49 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. A client diagnosed with type 2 diabetes mellitus reports poor glucose control since starting
her new stressful job. The nurse uses Neumans theory to focus on the:
1
Identification of new stressors and improve dietary choices
2
Acquisition of appropriate interpersonal communication skills
3
Learning of effective coping methods and relaxation
techniques
4
Implementation of both aerobic and anaerobic exercise
routines
ANS: 1
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The Neuman Systems Model uses a systems approach to describe how clients deal with stressors
in their internal or external environments. Nurses using Neumans theory in practice focus their
care on client responses to the stressors (Meleis, 2006). For example, when a client takes on a
new role within their employment, they may react to the stress by eating an improper diet. In this
situation the nurse focuses on the client response to the stressors and designs interventions
related to improving nutritional intake, both actions directed towards improving glucose control.
While acquiring good interpersonal communication skills may help minimize the stress the client
is currently experiencing, it does not address identifying the source of the stress or the
management of the type 2 diabetes.
While acquiring effective coping and relaxation skills may help manage the stress the client is
currently experiencing, it does not address identifying the source of the stress or the management
of the type 2 diabetes.
While implementing effective exercise routines may help in the management of the type 2
diabetes, it does not address identifying the source of the stress or the thorough management of
the type 2 diabetes.
DIF: C REF: 46 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
18. The best example of an appropriate nursing assumption is:
1
Clients will make their needs and wants known to the staff
2
Clients require a quiet, darkened environment in which to
sleep
3
Prompt administration of pain medication is an expectation of
a postoperative client
4
A client recently diagnosed with cancer will want family
present when discussing treatment options
ANS: 3
Assumptions are the taken for granted statements that explain the nature of the concepts,
definitions, purpose, relationships, and structure of a theory (Meleis, 2006; Chinn and Kramer,
2004). It is a reasonable assumption that a client who recently underwent surgery would require
and expect prompt administration of medications to manage that pain.
Not all clients will openly communicate their needs/wants to the staff so this option is not the
best example offered.
While most clients will rest effectively in a quiet, darken environment, it is not required by all
clients so this option is not the best example offered.
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While many clients will want family present in this situation, not all will. Therefore this option is
not the best example offered because an incorrect assumption would result in a violation of a
clients right to privacy.
DIF: C REF: 46 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
19. An example of a nursing activity directed towards providing input to the nursing process is:
1
Assessing a client who has just reported being nauseated
2
Discussing various ways to increase calcium intake with a
client
3
Asking the client to identify when she would like to be
ambulated
4
Documenting a clients pain level 30 minutes after being
medicated
ANS: 1
Input for the nursing process is the data or information that comes from a clients assessment (i.e.,
how the client interacts with the environment and the clients physiological function).
This is an example of the nursing process content: the information about the nursing care for
clients with specific health care problems.
Feedback serves to inform a system about how it functions: how the client responds to the
intervention.
Output is the end product of a system and in the case of the nursing process it is whether the
clients health status improves or remains stable as a result of nursing care.
DIF: C REF: 47 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
20. The nurse realizes that which of the following stated client needs has the highest priority?
1
A clients reaction to facial scarring after an automobile
accident
2
A client who is crying hysterically upon hearing of her sons
death
A homeless clients fear that his belongings will be stolen while
he is hospitalized
3
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4
An asthmatic clients concern regarding the lack of insurance to
pay for her medications
ANS: 4
The second level of Maslows hierarchy includes safety and security needs, which involve
physical and psychological security. The clients concern about securing the medication needed to
minimize the potential for breathing problems has the highest priority of the options available.
The fourth level encompasses esteem and self-esteem needs, which involve self-confidence,
usefulness, achievement, and self-worth. Although important, a clients concern regarding her
appearance would not have priority over the other options available.
The third level contains love and belonging needs, including friendship, social relationships, and
sexual love. Although important, a clients reaction to the loss of a loved one does not have
priority over the other options available.
The second level of Maslows hierarchy includes safety and security needs, which involve
physical and psychological security. While the clients concern for the safety of his belongs is on
the same level, it does not take priority over the client whose concern relates to potential
breathing problems.
DIF: C REF: Chapter 6, 72 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
21. Which of the following statements best expresses the primary goal of nursing practice?
1
To identify client needs in order to facilitate improved health
and wellness
2
To tend to the physical and psychosocial needs of both the
client and his family
3
To provide effective, research-based nursing care specifically
tailored to each clients needs
To perform the required treatments and interventions directed
towards client recovery from illness
4
ANS: 3
Providing excellent, evidenced-based nursing care is an expectation for all nurses and the care
they provide.
Although other options are reflective of an appropriate nursing outcome, they are not the best
descriptions of nursings primary goal.
Chapter 5. Evidence-Based Practice
MULTIPLE CHOICE
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1. Which of the following research approaches is an example of an exploratory type of research?
1
Establishing facts and relationships of past events
2
3
Testing how well a program, practice, or policy is working
Refining a hypothesis on the relationships among phenomena
4
Portraying the characteristics of persons, situations, or groups
ANS: 3
An example of an exploratory type of research is to develop or refine a hypothesis about the
relationships among phenomena.
An example of a historical type of research is to establish facts and relationships concerning past
events.
An example of an evaluation type of research is to test how well a program, practice, or policy is
working.
An example of a descriptive type of research is to accurately portray characteristics of persons,
situations, or groups and the frequency with which certain events or characteristics occur.
PTS: 1 DIF: A REF: 62 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003,
may influence nursing research in the area of:
1
The cost of the study
2
Where the study may be published
3
What type of study may be conducted
4
How the data will be obtained and protected
ANS: 4
HIPAA regulations identify how protected health information of potential research subjects is to
be managed. The researcher must be able to ensure that the data will be protected and used only
by the researcher.
HIPAA regulations should not influence the area of cost in nursing research.
The focus of HIPAA regulations is not on where a study may be published.
HIPAA regulations should not influence the type of study conducted.
PTS: 1 DIF: A OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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3. The expected research role for the baccalaureate-prepared nurse is to:
1
Assume the role of a clinical expert
2
3
Acquire funding for research projects
Identify clinical nursing problems in practice
4
Develop methods of inquiry relevant to nursing
ANS: 3
Nurses with a baccalaureate degree are prepared to read research critically and use existing
standards to determine the readiness of the findings for clinical practice. They also participate in
research activities through identification of clinical problems in nursing practice.
Nurses with a masters degree assume the role of clinical expert and are able to create a climate in
which research-based change can be implemented into practice.
Doctorally-prepared nurses are responsible for acquiring funding for research from public and
private sources.
Doctorally-prepared nurses are prepared to design studies independently including the
development of methods of inquiry relevant to nursing.
PTS: 1 DIF: A REF: 55 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for
participation in her study, which of the following ethical principles that guide research is this
researcher using?
1
Informed consent
2
Freedom from harm
3
Protection of subjects
4
Confidentiality of subjects
ANS: 1
As a component of informed consent, research subjects are given full and complete information
about the purpose of the study, procedures, data collection, potential harm and benefits, and
alternative methods of treatment.
Research aspects such as minimizing the risk to participants, allowing reasonable risk to
participants in relation to anticipated benefits, and monitoring the research to ensure the safety of
participants follow the ethical standard of freedom from harm.
In the case of research, institutions have Health Information Portability and Accountability Act
(HIPAA) regulations that identify how protected health information of research subjects is to be
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managed. The nurse researcher who follows HIPAA guidelines is following the principle of
protection of subjects.
Confidentiality guarantees that any information provided by the subject will not be reported in
any manner that identifies the subject and will not be made accessible to people outside the
research team. Describing how confidentiality is maintained is a component of informed consent.
PTS: 1 DIF: A REF: 63 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. The nurse takes on ethical responsibilities when conducting research with human subjects.
Which of the following violates an ethical responsibility associated with informed consent?
1
2
Adhering to verbal and written agreements
Using data obtained before the initiation of the study
3
Explaining the possibility of unknown risks when appropriate
4
Providing alternatives, including the right of refusal and
standard practices
ANS: 2
Using data obtained before the initiation of the study would be a breach of privacy because the
participant has not yet given informed consent for use of those data.
Adhering to verbal and written agreements is central to informed consent and the implementation
of ethical research.
One component of informed consent is the inclusion of informing the research subject of the
potential harm and benefits. This would include the risks to the subject (including financial risks)
and the potential for no benefit.
Within the consent document, the researcher must outline alternative methods of treatment and
alternatives to participation, including the right to withdraw from the study at any given time.
PTS: 1 DIF: A REF: 63 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. Nurses need to become familiar with the elements of a research publication. A brief
explanation of the type of measurement to be used is found in which section of a study?
1
Results
2
Methods
3
Conclusion
Introduction
4
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ANS: 2
The methods section of a study includes the description of the sample (what or who was studied),
type of data collected, and the device or instrument used to measure empirical information.
The results section contains a description of the results obtained in the study, including
appropriate statistical tests used to analyze the data.
The conclusion consists of the author summarizing implications that can be drawn from the
study.
The introduction section presents the purpose, a summary of literature used to formulate the
study, and the hypothesis tested or the research questions posed.
PTS: 1 DIF: A REF: 59 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. After identifying the problem, the next step in the research process is to:
1
Select the population
2
3
Review the literature
Obtain approval to conduct the study
4
Identify the instrument to use for data analysis
ANS: 2
After identifying the problem, the next step in the research process is to review the literature to
determine what is known about the problem.
Following identification of the problem and review of the literature, the researcher will design
the study protocol. Selecting the population is a component of this phase of the research process.
Obtaining necessary approvals is part of conducting the study, which follows the design phase in
the research process.
Identifying the instrument to use for data analysis occurs during the process of designing the
study protocol. This step would occur during the study design phase of the research process after
problem identification and literature review have taken place.
PTS: 1 DIF: A REF: 58 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. A sample of orthopedic clients varies greatly in their requests for postsurgical analgesics.
Which type of nursing research would best examine a prospective group of clients in determining
what factors affect their alterations in comfort?
1
Historical research
2
Evaluation research
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3
Correlational research
4
Experimental research
ANS: 3
Correlational research explores the interrelationships among variables of interest (such as factors
affecting client comfort) without any active intervention by the researcher.
Historical research is designed to establish facts and relationships concerning past events. It
would not use prospective groups of clients.
Evaluation research tests how well a program, practice, or policy is working.
In experimental research, the investigator controls the study variable and randomly assigns
subjects to different conditions.
PTS: 1 DIF: A REF: 62 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. Which of the following research topics best lends itself to the experimental research process
method?
1
The effects of therapeutic touch on a geriatric client diagnosed
with Alzheimers disease
2
Prioritizing three nursing diagnoses for a newly admitted
client with diabetes mellitus
3
Employing humor as an intervention with clients who are
recovering from orthopedic surgery
4
Determining the blood pressure patterns of a client who
recently experienced a cerebrovascular accident (i.e., stroke)
ANS: 3
In experimental research, the investigator controls the study variable (use of humor) and
randomly assigns subjects to different conditions (those who receive humor as an intervention,
and those who do not).
The effect of therapeutic touch on a geriatric client with Alzheimers disease lends itself to the
nursing process as a nursing intervention to perhaps assist a client in meeting a goal of
preventing social isolation. To use the experimental research process, there would have to be
other clients involved (i.e., a group of clients with Alzheimers disease who receive therapeutic
touch, and a group of clients with Alzheimers disease who do not receive therapeutic touch) to
determine whether or not therapeutic touch had any effect.
Prioritizing nursing diagnoses for client care is an example of using the nursing process.
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Determining the blood pressure patterns of a client who recently had a cerebrovascular accident
is a part of the assessment phase of the nursing process. In contrast to an experimental research
study, no variable is being controlled by the nurse.
PTS: 1 DIF: A REF: 62 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. The nurse is looking at different strategies for learning and incorporating new information
into practice. A strategy that uses problem-solving is demonstrated by:
1
Repeatedly practicing vital signs until competence is achieved
2
Seeking information from the nurse manager on the clients
status
Reviewing Maslows hierarchy either in a textbook or on the
internet
3
4
Trying different types of colostomy dressings for maximum
therapeutic effect
ANS: 4
Trying various ways of resolving clients health care needs or evaluating health care products, as
in trying different types of colostomy dressings for maximum effect, is an example of the
problem-solving strategy for knowledge acquisition.
Practicing skills is an example of gaining experience to increase ones knowledge.
Information-seeking is a strategy used to obtain knowledge from experts in a particular field.
Reviewing Maslows hierarchy in a reference textbook or on the internet is another example of
acquiring knowledge through information-seeking.
PTS: 1 DIF: A REF: 55 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. A nurse researcher has completed a study involving the use of intravenous analgesics for
postsurgical discomfort. The description of the 16 clients used for the study would best be
written in which part of the research report?
1
Results section
2
Methods section
3
Discussion section
4
Introduction section
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ANS: 2
A description of the clients used is found in the methods section of the research study.
The results section contains a description of the results obtained in the study, including
appropriate statistical tests used to analyze the data.
The discussion section presents the authors interpretation of the results, including conclusions
and implications that can be drawn from the study.
The introductory section presents the purpose of the study, a summary of literature, and the
hypotheses tested or questions posed.
PTS: 1 DIF: A REF: 59 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. A nurse reads about a case study involving the potential positive effects of the early
stimulation of posthead-injury clients. Which of the following questions should be a priority
consideration before use of the research results?
1
What was the cost of the study?
2
3
Were ethical principles maintained?
Were the results of this study published in other journals?
4
Are the clients in the study similar to clients I work with?
ANS: 4
Determination of whether the subjects and environment in the study are similar to the clients for
whom the nurse provides care in the particular practice setting is necessary before research can
be considered for use in practice.
Although cost may be a consideration in determining the feasibility of applying research
findings, it is not the priority consideration for research utilization. The research findings would
first have to be applicable to the practice setting and client population.
Even though research may indicate ethical principles were maintained, it does not necessarily
mean that it is feasible to apply the findings in practice. For example, cost issues may limit the
use of research findings.
The number of journals that published the research results of the study should not be the priority
consideration in implementation of its findings. To judge the scientific worth of the study;
however, it is important to examine the amount of supportive evidence provided by other
scientific studies that have obtained similar results.
PTS: 1 DIF: C REF: 59 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. An example of a predictive type of question that a nurse might use for research is which of
the following?
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1
What creates an increase in stress levels?
2
3
How often does the stress reaction occur?
What does guided imagery mean to clients?
4
If guided imagery is used, will stress levels be reduced?
ANS: 4
Questioning whether stress will be reduced is an example of a predictive type of question
because it connects stress reduction with the use of guided imagery.
Asking what increases stress explores factors that impact a phenomenon. It is not a predictive
type of question.
Asking how often stress increases does not predict any outcome, but rather focuses on frequency
of a response, which could be used in data collection.
Asking what guided imagery means does not predict any type of outcome, but rather explores
meaning in order to gain understanding.
PTS: 1 DIF: A REF: 55 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. A nurse routinely uses therapeutic touch when caring for postoperative clients with incisional
pain. Occasionally a client will show reluctance when the intervention is offered. The nurses best
response in such a situation is to:
1
Research for alternative interventions that will be better
received by the client
2
Suggest that the client allow the intervention just once before
making a final decision
Respect the clients wishes and rely on pain medication to help
with managing the pain
3
4
Inform the client that the intervention has been found to be
effective during several research projects
ANS: 1
Evidence-based practice is a problem-solving approach to clinical practice that integrates the
conscientious use of best evidence in combination with a clinicians expertise and client
preferences and values in making decisions about client care. If the client is not receptive to an
intervention, the best nursing response is to search for an alternative evidence-based therapy that
the client will accept.
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Suggesting the client allow intervention once before making a decision may be considered as
long as there is no pressure placed on the client to accept the intervention, but it is not the best
option provided because there is no guarantee that the client will be receptive to the intervention,
and the problem regarding incisional pain would then go unaddressed.
Chapter 6. Health and Wellness
MULTIPLE CHOICE
1. When formulating a definition of health, the nurse should consider that health, within its
current definition, is:
1
2
3
4
The absence of disease
A function of the physiological state
The ability to pursue activities of daily living
A state of well-being involving the whole person
ANS: 4
When formulating a definition of health, a person should consider the total person, as well as the
environment in which the person lives. Health generally implies a state of well-being that is
ultimately defined in terms of the individual.
Health is considered to be more than merely the absence of disease.
The definition of health has broadened beyond the physiological state to include mental, social,
and spiritual well-being.
An individual who has the ability to pursue activities of daily living may not define himself or
herself as being healthy. Life conditions such as environment, diet, and lifestyle practices may
negatively impact ones health long before the person is unable to perform activities of daily
living.
DIF: A REF: 69 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. Which one of the following is the main, overarching goal for Healthy People 2010?
1
Reduction of health care costs
2
Elimination of health disparities
3
Investigation of substance abuse
Determination of acceptable morbidity rates
4
ANS: 2
Two overarching goals for Healthy People 2010 are (1) to increase quality and years of healthy
life and (2) to eliminate health disparities.
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Reducing health care costs was not a goal for Healthy People 2010.
Investigation of substance abuse was not one of the main, overarching goals for Healthy People
2010.
Determining acceptable morbidity rates was not one of the main, overarching goals for Healthy
People 2010.
DIF: A REF: 69 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors
that may influence the client, which of the following nursing responses is most therapeutic?
1
2
I would like you to perform this exercise once a day.
Your physician has left orders that you are to follow.
3
The laboratory tests reveal the need to reduce your daily
percentage of fat intake.
4
Adapting to a low-fat diet and increasing your activity will
help lower your blood glucose levels.
ANS: 4
Using a holistic approach involves consideration of all factors that may impact a clients level of
well-being in all dimensions, not just physical health. Factors such as diet and exercise can
influence ones level of health.
Directing the client to exercise does not address the many factors that may impact ones level of
health. This response does not facilitate the client in seeing the connection between lifestyle
choices and well-being.
Directing the client to follow physicians orders, though important, does not describe a holistic
approach of nursing care. A holistic approach may include a discussion of diet and exercise and
the effect these factors have on blood glucose level. The aim is for the client to take
responsibility for their health and choices that may impact their health.
Viewing laboratory test results is a part of the nursing assessment. To approach the client
holistically, the nurse would need to also assess the clients diet and activity level.
DIF: C REF: 72 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. The client states, Heart disease runs in our family. My blood pressure has always been high.
The nurse determines that this is an example of the clients:
1
Risk factors
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2
Active strategy
3
Health beliefs
Negative health behavior
4
ANS: 1
Risk factors are anything that increases the vulnerability of an individual or group to an illness or
accident. This client is identifying the physical risk factor of genetic predisposition to heart
disease.
An example of an active strategy would be weight reduction or smoking cessation, where the
client is actively involved in measures to improve their present and future levels of wellness.
Health beliefs are a persons ideas, convictions, and attitudes about health and illness. An
example of a health belief would be if the client stated, Heart disease runs in our family. I know I
will have heart disease anyway, so why exercise?
A negative health behavior is a behavior that may negatively impact ones health. An example of
a negative health behavior would be consistently drinking alcohol in excess.
DIF: A REF: 77 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change
as a guide, the nurse recognizes that the client is most likely to begin to accept information on
diet changes and an exercise program during which stage?
1
Action
2
Preparation
3
Maintenance
4
Contemplation
ANS: 4
During the contemplation stage, the client is considering a change within the next 6 months. The
client may be ambivalent initially, but will more likely accept information as he or she develops
more belief in the value of change.
During the action stage, the client is actively engaged in strategies to change behavior.
During the preparation stage, the client is making small changes in preparation for a change in
the next month. At this point, the client believes advantages outweigh disadvantages in behavior
change.
During the maintenance stage, the client has sustained change over time.
DIF: A REF: 78 OBJ: Knowledge
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. When assessing the external variables that influence a clients health beliefs and practices, the
nurse must consider his:
1
2
3
4
Income status
Religious practices
Educational background
Reaction to the heart disease
ANS: 1
External variables influencing a persons health beliefs and practices include family practices,
cultural background, and socioeconomic factors, such as income. Economic variables may affect
a clients level of health by increasing the risk for disease and influencing how or at what point
the client enters the health care system. A persons compliance with the treatment to maintain or
improve health is also affected by economic status.
Religious practices are one way that people exercise spirituality. Spirituality is considered to be
an internal variable.
Educational background is an internal variable that can influence the health beliefs and practices
of a client.
An example of an internal variable that can influence health beliefs and practices of a client
includes emotional factors, such as the reaction to heart disease.
DIF: A REF: 74 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention,
the client is receiving care at the level of:
1
Health promotion
2
Primary prevention
3
Tertiary prevention
Secondary prevention
4
ANS: 4
The secondary prevention level focuses on early diagnosis and prompt treatment as well as
disability limitations. Adequate treatment for the electrolyte imbalance is sought to prevent
further complications.
Health promotion is a focus of the primary prevention level.
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The primary prevention level focuses on health promotion and specific protection measures such
as immunizations and personal hygiene.
The tertiary prevention level focuses on restoration and rehabilitation.
DIF: A REF: 75 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
8. Which of the following nursing activities is an example of tertiary level caregiving?
1
2
3
4
Teaching a client how to irrigate a new colostomy
Providing a class on hygiene for an elementary school class
Informing a client that her infant can be immunized at the
health department
Arranging for a hospice nurse to visit with the family of a
client with lung cancer
ANS: 4
Tertiary prevention occurs when a defect or disability is permanent and irreversible. Care of the
hospice nurse at this level aims to help the client and the clients family achieve as high a level of
functioning as possible despite the limitations caused by the cancer.
Teaching a client how to irrigate a new colostomy would be an example of secondary prevention.
If the colostomy is to be permanent, care may later move to the tertiary level of prevention.
Providing a class on hygiene for an elementary school class would be an example of the primary
level of prevention.
Informing a client about available immunizations would be an example of primary prevention.
DIF: A REF: 75-76 OBJ: Comprehension
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance
9. Which one of the following client assessment findings indicates a lifestyle risk factor to the
nurse?
1
Obesity
2
Sunbathing
3
Overcrowded housing
Industrial-based occupation
4
ANS: 2
Excessive sunbathing is a lifestyle risk factor for skin cancer.
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Obesity is a physiological risk factor.
Overcrowded housing is an environmental risk factor.
An industrial-based occupation is an environmental risk factor.
DIF: A REF: 77-78 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. In the Health Belief Model, the nurse recognizes that the focus is placed on the:
1
2
Basic human needs for survival
Functioning of the individual in all dimensions
3
Relationship of perceptions and compliance with therapy
4
Multidimensional nature of clients and their interaction with
the environment
ANS: 3
In the Health Belief Model, the nurse focuses on the relationship between a persons beliefs and
health behaviors. By focusing on the clients perceptions of health, the nurse is better able to
understand and predict how a client will comply with health care therapies.
Basic human needs for survival is a component of Maslows hierarchy of needs model.
The nurse who focuses on the functioning of the individual in all dimensions is following a
holistic health model.
In the health promotion model, the nurse focuses on the multidimensional nature of clients and
their interaction with the environment.
DIF: A REF: 70 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
11. The client who recently received a kidney transplant is worried about her husband since he
has taken over the physical tasks of running their home. The client is in the process of adapting
to a change in:
1
Body image
2
Self-concept
3
Illness behavior
4
Family dynamics
ANS: 4
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The effects of illness on the client and family have created a change in family dynamics. Family
dynamics is the process by which the family functions, makes decisions, gives support to
individual members, and copes with everyday changes and challenges.
Body image is the subjective concept of physical appearance. The client did not express concerns
regarding body image.
Self-concept is a mental self-image of strengths and weaknesses in all aspects of personality. The
client did not express a change in self-concept.
Illness behavior refers to how people monitor their bodies, define and interpret their symptoms,
take remedial actions, and use the health care system. The client did not express change in illness
behavior.
DIF: A REF: 81 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
12. Client assessment provides the nurse with necessary information for the development of an
effective plan of care. When determining the influence of an internal variable on the clients
health status, the nurse will specifically look for:
1
Anxiety level present
2
3
Family remedies used
Location and type of occupation
4
Available health insurance coverage
ANS: 1
Emotional factors, such as the clients degree of anxiety, is an internal variable that can influence
the clients health status.
An example of an external variable that can influence the clients health status is the use of family
remedies.
Socioeconomic factors, such as location and type of occupation, are external variables that can
influence the clients health status.
Available health insurance coverage is an example of an external socioeconomic factor that can
influence the clients health status.
DIF: C REF: 73-74 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
13. A nurse understands that illness behavior means:
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1
2
3
4
Each distinct illness will cause the client to behave in a
specific manner
Nursing care provides interventions that are behavior oriented
The clients behaviors will have a direct impact on his illness
When ill, a clients perception of illness will result in unique
behaviors
ANS: 4
Medical sociologists call the reaction to illness, illness behavior. Nurses who understand how
clients react to illness can minimize the effects of illness and assist clients and their families in
maintaining or returning to the highest level of functioning.
While the other options may be true, they do not define illness behavior.
DIF: A REF: 79 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. A client tells the nurse that his illness is a result of his failure to live a good life. The nurse
recognizes this statement as an example of the clients:
1
Risk factor
2
Health belief
3
Illness behavior
Negative health behavior
4
ANS: 2
Health beliefs are a persons ideas, convictions, and attitudes about health and illness.
A risk factor is any situation, habit, social or environmental condition, physiological or
psychological condition, developmental or intellectual condition, or spiritual or other variable
that increases the vulnerability of an individual or group to an illness or accident.
Illness behavior is the unique manner in which a client reacts to illness.
Negative health behaviors include practices actually or potentially harmful to health, such as
smoking, drug or alcohol abuse, poor diet, and refusal to take necessary medications.
DIF: A REF: 70 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. Which of the following client statements best relates to the third component of the Health
Belief Model?
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1
My blood cholesterol is only a little high.
2
3
No one in my family is susceptible to the flu.
Ill just avoid the food that causes the problem.
4
By losing weight my blood pressure may come down.
ANS: 4
The third componentthe likelihood that a person will take preventive actionresults from the
persons perception of the benefits of and barriers to taking action. Preventive action may include
lifestyle changes, increased adherence to medical therapies, or a search for medical advice or
treatment.
The second component is the individuals perception of the seriousness of the illness.
The first component of this model involves the individuals perception of susceptibility to an
illness.
Increased incidence of chronic disease processes.
DIF: C REF: 70 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
16. The goal of Penders Health Promotion theory is best reflected in which of the following
nursing interventions?
1
Suggesting the client experience a variety of exercise routines
before settling on the one to adapt
2
Arranging for a client to attend a support group for individuals
who also have severe burn scars
3
Playing soft, classical music when a client diagnosed with
Alzheimers becomes physically agitated
Providing a client with a history of stress-induced respiratory
problems with detailed explanations regarding her care
4
ANS: 1
Health-promoting behaviors should result in improved health, enhanced functional ability, and
better quality of life.
According to the Basic Human Needs model, certain human needs are more basic than others;
that is, some needs must be met before other needs (i.e., fulfilling the physiological needs before
the needs of love and belonging). Self-actualization is the highest expression of ones individual
potential and allows for continual discovery of self. Maslows model takes into account individual
experiences, always unique to the individual.
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Nurses using the holistic nursing model recognize the natural healing abilities of the body and
incorporate complementary and alternative interventions, such as music therapy, reminiscence,
relaxation therapy, therapeutic touch, and guided imagery, because they are effective,
economical, noninvasive, nonpharmacological complements to traditional medical care.
The holistic nursing model considers the emotional and spiritual well-being, as well as other
dimensions of an individual, as important aspects of physical wellness.
DIF: C REF: 71 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. The nurse knows that the greatest internal factor to consider when educating an adult client
concerning health promotion activities is the clients:
1
Emotional wellness
2
Developmental stage
3
Professed spirituality
4
Intellectual background
ANS: 4
A persons beliefs about health are shaped in part by the persons knowledge, lack of knowledge,
or incorrect information about body functions and illnesses; educational background; and past
experiences. These variables influence how a client thinks about health. In addition, cognitive
abilities shape the way a person thinks, including the ability to understand factors involved in
illness and to apply knowledge of health and illness to personal health practices. The clients
ability to understand and accept the importance of the teaching is the primary nursing
consideration.
The clients degree of stress, depression, or fear, for example, can influence health beliefs and
practices. The manner in which a person handles stress throughout each phase of life will
influence the way the person reacts to illness, but this option is not the best choice available.
A persons thought and behavior patterns change throughout life. The nurse must consider the
clients level of growth and development when using his or her health beliefs and practices as a
basis for planning care, but the client has been identified as being adult and so the developmental
stage has been determined.
Spirituality is reflected in how a person lives his or her life, including the values and beliefs
exercised, the relationships established with family and friends, and the ability to find hope and
meaning in life. However, this is not the best option available.
DIF: C REF: 23 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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18. The nurse is caring for a terminally ill client who recently immigrated to the United States.
To provide quality end-of-life care, the nurse must initially:
1
Make every effort to involve the client and his family in the
end-of-life care
2
Understand the clients personal and cultural views regarding
death and dying
3
Arrange for end-of-life care to be provided by personnel
familiar with the clients culture
4
Share the clients concerns regarding the dying process with his
interdisciplinary care team
ANS: 2
Differences in beliefs, values, and traditional health care practices are relevant when planning
end-of-life care. It is the nurses responsibility to become familiar with the clients personal and
cultural views so as to provide the most effective and appropriate end-of-life care.
While this is important, it is not the best available option because understanding the clients
cultural and personal views will facilitate all other offered options.
This may not be either practical or possible.
While this is important, it is not the best available option because understanding the clients
cultural and personal views will facilitate all other offered options.
DIF: C REF: 74 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
19. Which of the following nursing interventions is the best example of a primary care
prevention strategy regarding the flu?
1
Staffing a flu immunization clinic at a senior citizens center
2
Providing flu prevention literature for distribution to visitors
3
Reminding client care personnel of the importance of the flu
shot
4
Getting a drug manufacturer to donate flu vaccine for the
homeless
ANS: 4
Primary prevention is true prevention; it precedes disease or dysfunction and is applied to clients
considered physically and emotionally healthy. Primary prevention aimed at health promotion
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includes health education programs, immunizations, and physical and nutritional fitness
activities. This option is the best example because it facilitates the availability of a service to
clients to whom it might otherwise be unavailable.
This is a good example of primary care, but it is not the best one available because it facilitates a
service that is already available.
While this is an example of primary care, it is not the best because it does not ensure the
facilitation of the needed service.
While this is an example of primary care, it is not the best because it does not ensure the
facilitation of the needed service.
DIF: C REF: 75 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
20. The nurse can best discuss the impact of a known risk factor on a clients health by stating:
1
It doesnt mean youll get the disease just that the odds are
greater for you.
2
Now you know that the possibility is there, you can take steps
to prevent it.
3
The risk factor can be managed by making a change in your
lifestyle.
4
Youre lucky because you have the benefit of being able to do
something about it.
ANS: 1
The presence of risk factors does not mean that a disease will develop, but risk factors increase
the chances that the individual will experience a particular disease or dysfunction.
While this response is not incorrect, it does not address the impact of a risk factor on the clients
health.
This is not always true, and so it is not the best option.
This option minimizes the clients concern and does not address the impact of a risk factor on the
clients health.
DIF: C REF: 77 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
21. When caring for a client with a spouse and two adolescent children, the nurse knows that the
family unit must first:
1
Be viewed as a client
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2
Change traditional roles
3
Provide support for the ailing mother
Seek help to fulfill day-to-day needs
4
ANS: 1
The nurse must view the whole family as a client under stress, planning care to help the family
regain the maximal level of functioning and well-being.
While the illness of a family member requires role reassignment in order for the family to
continue to function, the initial focus is to be viewed as a unit in need of care.
While the family should provide support to the ailing member, the initial focus is to be viewed as
a unit in need of care.
Chapter 7. Caring in Nursing Practice
MULTIPLE CHOICE
1. The nurse recognizes that the client symptomatology typical of the acute cancer survival phase
includes:
1
Fear and anxiety
2
Despair and anger
3
Lethargy and alopecia
4
Dyspnea and tachycardia
ANS: 1
The acute survival phase starts with the diagnosis of cancer. Diagnostic and therapeutic efforts
dominate. Fear and anxiety are constant elements of this phase.
Despair and anger are more representative of the stages of grief and loss according to KblerRoss.
Extended survival is the period during which a client has ended the basic, rigorous course of
treatment and is dealing with the physical side effects of the treatment, such as lethargy and
alopecia.
Dyspnea and tachycardia may represent a clients unique individualized symptomatology but they
are not recognized as general signs of the acute phase.
DIF: A REF: 85 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
2. Since being treated for leukemia in her early twenties, a client has experienced bilateral
mastectomies and has been diagnosed with osteoporosis and hypothyroidism. This health history
best reflects the lifelong impact of:
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1
Cancer on a clients health and wellness
2
3
Cancer treatments on future health status
Specific cancers on the health status of survivors
4
Genetic susceptibility on the reoccurrence of cancer
ANS: 2
The impact of cancer treatment on future health status is the correct response. The increased risk
for developing a second cancer is due to cancer treatment, genetic or other susceptibility, or an
interaction between treatment and susceptibility. The risk for treatment related problems is
associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the
type, variety, and intensity of treatments used; and the age and underlying health status of the
client.
While cancer itself affects the clients immediate health and wellness status, it is secondary to the
long-term effects of the cancer treatments used.
Although some health effects are related to specific forms of cancer, this is not the best option
available because it is much less likely to be the cause of lifelong health issues.
While genetic predisposition is a factor in cancer development it is not the most likely factor
affecting lifelong health issues for the cancer survivor.
DIF: C REF: 86 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
3. In the geriatric population, the primary reason cancer is diagnosed in its later stage is:
1
Health care benefit coverage is often inadequate
2
Symptoms are often masked by the effects of aging
3
Clients are reluctant to seek help for the early symptoms
Symptoms are often attributed to the aging process
4
ANS: 4
Most cancer survivors (61%) are over the age of 65 (IOM, 2006). Often health care providers
wrongly attribute the symptoms of cancer or the symptoms from the side effects of treatment to
aging. This often leads to late diagnosis or a failure to provide aggressive and effective treatment
of symptoms.
While the geriatric population may have a problem with adequate health care coverage, it is not
the primary cause of delayed cancer diagnosis in that population.
While symptoms may be masked by the effects of aging, it is not the primary cause of delayed
cancer diagnosis in this population.
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While symptoms can be attributed to the aging process for individual geriatric clients, it is not
the primary cause of delayed cancer diagnosis in this population.
DIF: C REF: 86 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
4. Which of the following clients is most likely to experience cancer treatment-related problems
in the future?
1
2
3
4
A 73-year-old client with heart problems
An otherwise healthy 6-year-old child
A 25-year-old professional tennis player
A 39-year-old with a history of depression
ANS: 2
The risk for treatment-related problems is associated with the complexity of the cancer itself
(e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and
the age and underlying health status of the client. The 6-year-old child is at greatest risk because
the primary cancer occurred at such a young age and during a critical physiological
developmental stage.
Because the pivotal factors for cancer treatment-related problems are age and development, the
73-year-old with heart problems does not present the greatest risk.
Because the pivotal factors for cancer treatment related problems are age and development, 25year-old professional tennis players chronic health issues do not present the greatest risk.
While depression may have a negative health effect, a 39-year-old with a history of depression
does not present the greatest risk for cancer treatment related problems since the pivotal factors
are age and developmental stage.
DIF: C REF: 86-87 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
5. Eleven months after being treated for breast cancer, a client reports difficulty sleeping and the
associated fatigue while denying any other signs/symptoms. The nurse recognizes that the client
may be experiencing:
1
Situational depression
2
Normal remission symptoms
3
Post-traumatic stress disorder
Delayed effects of chemotherapy drugs
4
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ANS: 1
Survivors feelings of distress range along a continuum from sadness to disabling depression
(Vachon, 2006). The long-term presence of fatigue and sleep disturbances, for example, is often
associated with anxiety and depression in many cancer survivors (Barton-Burke, 2006).
Sleep disorders and fatigue would not necessarily be expected at this point in the remission stage.
Posttraumatic stress disorder (PTSD) is a psychiatric disorder characterized by an acute
emotional response to a traumatic event or situation. Cancer survivors experience symptoms of
PTSD (e.g., grief, nightmares, panic attacks, or fear) at a rate of 4% to 19%, as a result of their
diagnosis, treatment, or a past traumatic episode.
While chemotherapy drugs can produce side effects, sleep disorders are not a typical complaint.
DIF: C REF: 88 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
6. A client, who recently completed treatment for cancer, shares with the nurse that she is, a little
depressed, but I guess I will be OK. The foremost reason the nurse encourages the client to
discuss this situation with her primary health care provider is that the nurse realizes that:
1
The depression will not improve by itself
2
The medications can help resolve the depression
3
Depression can decrease the clients chances of recovery
4
The depression is a result of concerns about the cancer
reoccurring
ANS: 3
Research has associated depression with decreased cancer survivorship. A study conducted by
Brown and colleagues (2003) suggested that a cancer diagnosis and its effects predispose people
to distress, which if maintained over time will enhance disease progression.
While depression may not improve by itself, it is not the primary reason for the nurse to
encourage the client in cancer remission to seek medical advice. Chronic depression can
adversely affect the chances of long-term survivorship.
While medications can help resolve depression, it is not the primary reason for the nurse to
encourage the client in cancer remission to seek medical advice. Chronic depression can
adversely affect the chances of long-term survivorship.
While may be a result of concerns about the cancer reoccurring, it is not the primary reason for
the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression
can adversely affect the chances of long-term survivorship.
DIF: C REF: 87 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
7. The nurse knows that the primary factor affecting a cancer survivors quality of life is:
1
The clients precancer physical and mental health status
2
The presence of a strong support system
3
The quality and type of cancer treatment received
4
The type and number of cancer-related risk factors the client
possesses
ANS: 2
Mellon and colleagues (2006) interviewed cancer survivors and their family caregivers, finding
that two of the strongest predictors for cancer survivors quality of life (enjoyment of life) were
family stressors and social support.
Precancer physical and mental health status may affect the survivors physical recovery regarding
the treatment but not their quality of life (enjoyment of life).
The quality and type of cancer treatment received may affect the survivors chances of survival
but not their quality of life (enjoyment of life).
The type and number of cancer-related risk factors the client possesses may affect the survivors
chances of survival but not their quality of life (enjoyment of life).
DIF: C REF: 85-86 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
8. A client, who is a 7-year breast cancer survivor, tells the nurse, My husband will help me bathe
when he gets here. The nurse interprets this statement to mean that the client:
1
Is reluctant to have the staff see her chest scar
2
Prefers to protect her modesty and privacy
3
Has a healthy self-image regarding her husband
4
Is not comfortable with the care she is receiving
ANS: 3
Self-image and intimacy may be negatively affected after cancer surgery. It is a positive sign that
the client is comfortable having her husband perform this task for her.
Although the client may be reluctant to have staff see her chest scar, the clients history of cancer
surgery should direct you to the more related option.
While the client may prefer to protect her modesty and privacy, the clients history of cancer
surgery should direct you to the more related option.
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Although the client may not be comfortable with the care she is receiving, it is not as likely as
the other options and the clients history of cancer surgery should direct you to the more related
option.
DIF: C REF: 88 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
9. The nurse understands the primary focus of education for a client who has just received a
diagnosis of cancer is to:
1
Introduce self-care measures to support health
2
3
Discuss the management of treatment-related side effects
Reinforce the explanation of the risks of proposed treatments
4
Formulate long-term lifestyle changes to minimize risk factors
ANS: 3
When caring for clients with an initial diagnosis of cancer, the immediate focus of client
education should be the reinforcement of their health care providers explanations of the risks
related to their cancer as well as the benefits and risks related to the proposed treatment options.
This should then be followed by instructions on what they need to self-monitor (i.e., appetite and
weight, effects of fatigue and sleeplessness), and what to discuss with health care providers in the
future. Potential for treatment effects; such as pain, neuropathy, or cognitive change; also should
be addressed since clients are more likely to report their symptoms if they are educated on their
likelihood. Survivors need to learn how to manage problems related to persistent symptoms.
Because survivors are at an increased risk for developing a second cancer and/or chronic illness,
it is important to educate them about lifestyle behaviors that will improve the quality of their life.
While introducing self-care measures to support health is an appropriate topic for client
education, it should be addressed after the client is informed of the risks related to their cancer as
well as the benefits and risks related to the proposed treatment options.
Although discussing the management of treatment-related side effects is an appropriate topic for
client education, it should be addressed after the client is informed of the risks related to their
cancer as well as the benefits and risks related to the proposed treatment options.
While formulating long-term lifestyle changes to minimize risk factors is an appropriate topic for
client education, it should be addressed after the client is informed of the risks related to the
cancer as well as the benefits and risks related to the proposed treatment options.
DIF: C REF: 91 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. Which of the following assessment data best confirms the possibility of cognitive impairment
in a client with a diagnosis of lung cancer?
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1
Client is observed writing questions to ask his oncologist.
2
3
Client states, I seem to be a little more forgetful lately.
Clients wife states, I have to remind him of everything.
4
Client overheard asking son, Where did I put my glasses?
ANS: 2
Cognitive changes are a set of physical symptoms very common in survivors that develop from
their disease, treatment, the complications of treatment, underlying medical conditions, and
psychological responses to the diagnosis of cancer (Nail, 2006). Cognitive changes can occur
during all phases of the cancer experience, from small deficits in information processing to acute
delirium. Often the cognitive impairments survivors experience are not evident to someone else
but are apparent to the person experiencing them, especially in relation to work performance
with high cognitive demands (Anderson-Hanley and others, 2003). The clients personal
evaluation of his memory is the best indicator of cognitive impairment.
While writing down questions to ask the oncologist may be motivated by poor memory, it is not
uncommon for clients to prepare a list of questions before a meeting with their health care
provider.
Although the clients spouse reminding the client of things may indicate impaired cognitive
ability, it is not as strong an indicator as a statement from the client.
Although not being able to locate an item may indicate impaired memory, it is not uncommon for
individuals to misplace personal items.
DIF: C REF: 86-87 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
11. Which of the following cancer survivors is at greatest risk for post-treatment symptoms and
poor treatment outcomes?
1
An Asian dishwasher
2
A Hispanic truck driver
3
A Caucasian factory worker
4
An African-American carpenter
ANS: 1
There is evidence to suggest that survivors among racial and ethnic minorities and other
underserved populations have more post-treatment symptoms and poorer treatment outcomes
than Caucasians (CDC, 2004). The disparities in health among ethnic groups are related to a
complex interplay of economic, social, and cultural factors, with poverty being a key factor. The
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Asian dishwasher is both a member of a racial minority and likely the poorest paid of the
survivors.
While being a member of an ethnic group is a risk factor, a Hispanic truck driver is not likely to
be the poorest of the survivors.
The Caucasian factory worker has the least risk because he is not a member of an ethnic or racial
minority nor is there a likelihood of him being the poorest of the survivors.
While being a member of a racial minority is a risk factor, an African-American carpenter is not
likely to be the poorest of the survivors.
DIF: C REF: 85 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
12. When assessing cancer survivors regarding the stressors of cancer, the nurse should first ask
clients:
1
2
If they feel they are stressed by the cancer
How they believe cancer has affected their life
3
What they are doing to cope with the stress of having
experienced cancer
4
What assistance they need to successfully manage the stressors
of dealing with cancer
ANS: 2
As a nurse, learn to assess the many ways in which cancer affects the lives of clients who are
survivors. It is through their perception of how cancer impacts their lives, that therapeutic
nursing interventions can be implemented.
Clients may not be comfortable identifying themselves as being stressed. An open-ended
question regarding the effects of cancer on the clients life is likely to be more informative.
Asking a client what they are doing to cope with stress assumes the client is experiencing stress,
and it may be uncomfortable for the client to answer. An open-ended question regarding the
effects of cancer on the clients life is likely to be more informative.
Asking a client about assistance needed to manage stress assumes the client is experiencing
stress, and it may be uncomfortable for the client to answer. An open-ended question regarding
the effects of cancer on the clients life is likely to be more informative.
DIF: C REF: 91 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management
13. A 78-year-old woman presents at the emergency department with complaints of shortness of
breath. She has a history of radiation therapy for a lung mass 7 years ago. When the client asks
the nurse if it could be cancer again, the most therapeutic response would be:
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1
At your age, shortness of breath could be a result of any
number of things.
2
That is a possibility but it could also be a result of your
radiation therapy.
What makes you think that? Shortness of breath can have
many different causes.
3
4
I wouldnt jump to that conclusion. Lets just see what your
health care provider thinks.
ANS: 2
Cancer survivors are at increased risk for cancer (either a recurrence of the cancer for which they
were treated or a second cancer) and for a wide range of treatment-related problems (IOM,
2006).
While shortness of breath could be caused by many things, it does not address the clients concern
regarding reoccurring cancer.
While shortness of breath could be caused by many things, it does not address the clients concern
regarding reoccurring cancer.
Telling the client not to jump to conclusions minimizes the clients concern.
Chapter 8. Caring for Patients with Chronic Illness
MULTIPLE CHOICE
1. When caring for an older patient with hypertension who has been hospitalized after a transient
ischemic (TIA), which topic is the most important for the nurse to include in the discharge
teaching?
a.
Effect of atherosclerosis on blood vessels
b.
Mechanism of action of anticoagulant drug therapy
c.
Symptoms indicating that the patient should contact the health
care provider
d.
Impact of the patients family history on likelihood of
developing a serious stroke
ANS: C
One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient
needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to
take if these symptoms occur. The other information also may be included in patient teaching but
is not as essential in the patients self-management of the illness.
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DIF: Cognitive Level: Apply (application) REF: 63
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse performs a comprehensive geriatric assessment of a patient who is being assessed
for admission to an assisted living facility. Which question is the most important for the nurse to
ask?
a.
Have you had any recent infections?
b.
c.
How frequently do you see a doctor?
Do you have a history of heart disease?
d.
Are you able to prepare your own meals?
ANS: D
The patients functional abilities, rather than the presence of an acute or chronic illness, are more
useful in determining how well the patient might adapt to an assisted living situation. The other
questions will also provide helpful information but are not as useful in providing a basis for
determining patient needs or for developing interventions for the older patient.
DIF: Cognitive Level: Apply (application) REF: 71
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
3. An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is
alert and lives with a daughter who works during the day. During a clinic visit, the patient
verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy
being alone all day. Which nursing diagnosis should the nurse assign as the priority for this
patient?
a.
Risk for injury related to drug interactions
b.
Social isolation related to weakness and fatigue
c.
Compromised family coping related to the patients many care
needs
d.
Caregiver role strain related to need to adjust family
employment schedule
ANS: A
The patients age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. Problems with
social isolation, caregiver role strain, or compromised family coping are not physiologic
priorities. Drug-drug interactions could cause the most harm to the patient and is therefore the
priority.
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DIF: Cognitive Level: Apply (application) REF: 73-74
TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance
4. The nurse plans to complete a thorough assessment of an older patient. Which method should
the nurse use to gather the most complete information?
a.
Use a geriatric assessment instrument to evaluate the patient.
b.
Ask the patient to write down medical problems and
medications.
c.
Interview both the patient and the primary caregiver for the
patient.
d.
Review the patients medical record for a history of medical
problems.
ANS: A
The most complete information about the patient will be obtained through the use of an
assessment instrument specific to the geriatric population, which includes information about both
medical diagnoses and treatments and about functional health patterns and abilities. A review of
the medical record, interviews with the patient and caregiver, and written information by the
patient are all included in a comprehensive geriatric assessment.
DIF: Cognitive Level: Apply (application) REF: 71
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. An older patient is hospitalized with pneumonia. Which intervention should the nurse
implement to provide optimal care for this patient?
a.
Use a standardized geriatric nursing care plan.
b.
Minimize activity level during hospitalization.
c.
Plan for transfer to a long-term care facility upon discharge.
d.
Consider the preadmission functional abilities when setting
patient goals.
ANS: D
The plan of care for older adults should be individualized and based on the patients current
functional abilities. A standardized geriatric nursing care plan will not address individual patient
needs and strengths. A patients need for discharge to a long-term care facility is variable. Activity
level should be designed to allow the patient to retain functional abilities while hospitalized and
also to allow any additional rest needed for recovery from the acute process.
DIF: Cognitive Level: Apply (application) REF: 71
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TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should
the nurse plan to implement to best meet this patients needs?
a.
Suggest that the patient move to an urban area.
b.
Assess the patient for chronic diseases that are unique to rural
areas.
c.
Ensure transportation to appointments with the health care
provider.
d.
Obtain adequate medications for the patient to last for 4 to 6
months.
ANS: C
Transportation can be a barrier to accessing health services in rural areas. The patient living in a
rural area may lose the benefits of a familiar situation and social support by moving to an urban
area. There are no chronic diseases unique to rural areas. Because medications may change, the
nurse should help the patient plan for obtaining medications through alternate means such as the
mail or delivery services, not by purchasing large quantities of the medications.
DIF: Cognitive Level: Apply (application) REF: 66-67
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in
an older adult?
a.
Teach the patient to have all prescriptions filled at the same
pharmacy.
b.
Instruct the patient to avoid taking over-the-counter (OTC)
medications.
Make a schedule for the patient as a reminder of when to take
each medication.
c.
d.
Have the patient bring all medications, supplements, and herbs
to each appointment.
ANS: D
The most information about drug use and possible interactions is obtained when the patient
brings all prescribed medications, OTC medications, and supplements to every health care
appointment. The patient should discuss the use of any OTC medications with the health care
provider and obtain all prescribed medications from the same pharmacy, but use of supplements
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and herbal medications also need to be considered in order to prevent drug-drug interactions. Use
of a medication schedule will help the patient take medications as scheduled but will not prevent
drug-drug interactions.
DIF: Cognitive Level: Understand (comprehension) REF: 74
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation
stress syndrome. Which action should the nurse include in the plan of care?
a.
b.
Remind the patient that making changes is usually stressful.
Discuss the reason for the move to the facility with the patient.
c.
Restrict family visits until the patient is accustomed to the
facility.
d.
Have staff members write notes welcoming the patient to the
facility.
ANS: D
Having staff members write notes will make the patient feel more welcome and comfortable at
the long-term care facility. Discussing the reason for the move and reminding the patient that
change is usually stressful will not decrease the patients stress about the move. Family member
visits will decrease the patients sense of stress about the relocation.
DIF: Cognitive Level: Apply (application) REF: 70
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
9. An older patient complains of having no energy and feeling increasingly weak. The patient has
had a 12-pound weight loss over the last year. Which action should the nurse take initially?
a.
Ask the patient about daily dietary intake.
b.
Schedule regular range-of-motion exercise.
c.
Discuss long-term care placement with the patient.
Describe normal changes associated with aging to the patient.
d.
ANS: A
In a frail older patient, nutrition is frequently compromised, and the nurses initial action should
be to assess the patients nutritional status. Active range of motion may be helpful in improving
the patients strength and endurance, but nutritional assessment is the priority because the patient
has had a significant weight loss. The patient may be a candidate for long-term care placement,
but more assessment is needed before this can be determined. The patients assessment data are
not consistent with normal changes associated with aging.
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DIF: Cognitive Level: Apply (application) REF: 67
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. The nurse admits an acutely ill, older patient to the hospital. Which action should the nurse
take first?
a.
b.
Speak slowly and loudly while facing the patient.
Obtain a detailed medical history from the patient.
c.
Perform the physical assessment before interviewing the
patient.
d.
Ask a family member to go home and retrieve the patients
cane.
ANS: C
When a patient is acutely ill, the physical assessment should be accomplished first to detect any
physiologic changes that require immediate action. Not all older patients have hearing deficits,
and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring
the patient, much of the medical history can be obtained from medical records. After the initial
physical assessment to determine the patients current condition, then the nurse could ask
someone to obtain any assistive devices for the patient if applicable.
DIF: Cognitive Level: Apply (application) REF: 71
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital
with a chronic foot infection. Which intervention is the most appropriate for the nurse to include
in the discharge plan for this patient?
a.
Refer the patient to social services for further assessment.
b.
Teach the patient how to assess and care for the foot infection.
c.
Schedule the patient to return to outpatient services for foot
care.
d.
Give the patient written information about shelters and meal
sites.
ANS: A
An interdisciplinary approach, including social services, is needed when caring for homeless
older adults. Even with appropriate teaching, a homeless individual may not be able to maintain
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adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older
homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to
keep appointments for outpatient services because of factors such as fear of institutionalization
or lack of transportation.
DIF: Cognitive Level: Apply (application) REF: 67
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
12. The home health nurse cares for an older adult patient who lives alone and takes several
different prescribed medications for chronic health problems. Which intervention, if
implemented by the nurse, would best encourage medication compliance?
a.
b.
c.
d.
Use a marked pillbox to set up the patients medications.
Discuss the option of moving to an assisted living facility.
Remind the patient about the importance of taking
medications.
Visit the patient daily to administer the prescribed medications.
ANS: A
Because forgetting to take medications is a common cause of medication errors in older adults,
the use of medication reminder devices is helpful when older adults have multiple medications to
take. There is no indication that the patient needs to move to assisted living or that the patient
does not understand the importance of medication compliance. Home health care is not designed
for the patient who needs ongoing assistance with activities of daily living (ADLs) or
instrumental ADLs (IADLs).
DIF: Cognitive Level: Apply (application) REF: 65
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
13. The home health nurse visits an older patient with mild forgetfulness. The nurse is most
concerned if which information is obtained?
a.
The patient tells the nurse that a close friend recently died.
b.
The patient has lost 10 pounds (4.5 kg) during the last month.
c.
The patient is cared for by a daughter during the day and stays
with a son at night.
d.
The patients son uses a marked pillbox to set up the patients
medications weekly.
ANS: B
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A 10-pound weight loss may be an indication of elder neglect or depression and requires further
assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour
care are appropriate for this patient. It is not unusual that an 86-year-old would have friends who
have died.
DIF: Cognitive Level: Apply (application) REF: 67
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
14. Which statement, if made by an older adult patient, would be of most concern to the nurse?
a.
I prefer to manage my life without much help from other
people.
b.
I take three different medications for my heart and joint
problems.
c.
I dont go on daily walks anymore since I had pneumonia 3
months ago.
d.
I set up my medications in a marked pillbox so I dont forget to
take them.
ANS: C
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should
develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement is appropriate for independently living older adults. On average, an older adult
takes seven different medications so the use of three medications is not unusual for this patient.
The use of memory devices to assist with safe medication administration is recommended for
older adults.
DIF: Cognitive Level: Apply (application) REF: 73
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract
infection (UTI). Which action should the nurse take first?
a.
Palpate over the suprapubic area.
b.
Inspect for abdominal distention.
c.
Question the patient about hematuria.
Invite the patient to use the bathroom.
d.
ANS: D
Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse
should have the patient empty the bladder because bladder fullness or discomfort will distract
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from the patients ability to provide accurate information. The patient may seem disoriented if
distracted by pain or urgency. The physical assessment data are obtained after the patient is as
comfortable as possible.
DIF: Cognitive Level: Apply (application) REF: 71
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
16. Which patient is most likely to need long-term nursing care management?
b.
72-year-old who had a hip replacement after a fall at home
64-year-old who developed sepsis after a ruptured peptic ulcer
c.
76-year-old who had a cholecystectomy and bile duct drainage
d.
63-year-old with bilateral knee osteoarthritis who weighs 350
lb (159 kg)
a.
ANS: D
Osteoarthritis and obesity are chronic problems that will require planning for long-term
interventions such as physical therapy and nutrition counseling. The other patients have acute
problems that are not likely to require long-term management.
DIF: Cognitive Level: Apply (application) REF: 70
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
17. When completing an admission assessment on an older adult, the nurse gives the patient a
high fall risk score. Which action should the nurse take first?
a.
Use a bed alarm system on the patients bed.
b.
Administer the prescribed PRN sedative medication.
c.
Ask the health care provider to order a vest restraint.
Place the patient in a geri-chair near the nurses station.
d.
ANS: A
The use of the least restrictive restraint alternative is required. Physical or chemical restraints
may be necessary, but the nurses first action should be an alternative such as a bed alarm.
DIF: Cognitive Level: Apply (application) REF: 75
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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18. An older adult patient presents with a broken arm and visible scattered bruises healing at
different stages. Which action should the nurse take first?
a.
Notify an elder protective services agency about the possible
abuse.
b.
Make a referral for a home assessment visit by the home health
nurse.
c.
Have the family member stay in the waiting area while the
patient is assessed.
d.
Ask the patient how the injury occurred and observe the family
members reaction.
ANS: C
The initial action should be assessment and interviewing of the patient. The patient should be
interviewed alone because the patient will be unlikely to give accurate information if the abuser
is present. If abuse is occurring, the patient should not be discharged home for a later assessment
by a home health nurse. The nurse needs to collect and document data before notifying the elder
protective services agency.
DIF: Cognitive Level: Apply (application) REF: 68-69
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
19. The family of an older patient with chronic health problems and increasing weakness is
considering placement in a long-term care (LTC) facility. Which action by the nurse will be most
helpful in assisting the patient to make this transition?
a.
Have the family select a LTC facility that is relatively new.
b.
Obtain the patients input about the choice of a LTC facility.
c.
Ask that the patient be placed in a private room at the facility.
d.
Explain the reasons for the need to live in LTC to the patient.
ANS: B
The stress of relocation is likely to be less when the patient has input into the choice of the
facility. The age of the long-term care facility does not indicate a better fit for the patient or
better quality of care. Although some patients may prefer a private room, others may adjust
better when given a well-suited roommate. The patient should understand the reasons for the
move but will make the best adjustment when involved with the choice to move and the choice
of the facility.
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DIF: Cognitive Level: Apply (application) REF: 70
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
20. The nurse manages the care of older adults in an adult health day care center. Which
action can the nurse delegate to unlicensed assistive personnel (UAP)?
a.
Obtain information about food and medication allergies from
patients.
b.
Take blood pressures daily and document in individual patient
records.
c.
Choose social activities based on the individual patient needs
and desires.
d.
Teach family members how to cope with patients who are
cognitively impaired.
ANS: B
Measurement and documentation of vital signs are included in UAP education and scope of
practice. Obtaining patient health history, planning activities based on the patient assessment,
and patient education are all actions that require critical thinking and will be done by the
registered nurse.
DIF: Cognitive Level: Apply (application) REF: 72
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult
patient (select all that apply)?
a.
Observe for depression.
b.
Review laboratory results.
c.
Assess teeth and oral mucosa.
d.
Ask about transportation needs.
e.
Determine food likes and dislikes.
ANS: A, B, C, D
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor
protein intake or high-fat/cholesterol intake. Transportation impacts patients ability to shop for
groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may
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decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated
with malnutrition.
Chapter 9. Cultural Competence
MULTIPLE CHOICE
1. The nurse recognizes that ethnicity differs from race in that ethnicity:
1
2
Refers to subgroups within a race
Is a unique factor within a cultural group
3
Includes more than biological identification
4
Is the set of conflicting values between races
ANS: 3
Ethnicity refers to a shared identity related to social and cultural heritage, such as values,
language, geographical space, and racial characteristics. Race refers to biological attributes.
Subcultures refer to subgroups within a race. A variant cultural pattern is a unique factor within a
cultural group. Ethnocentrism is the root of biases and prejudices comprising beliefs and
attitudes associating negative permanent characteristics with people who are perceived to be
different from the valued group.
DIF: A REF: 107 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
2. Within transcultural nursing, sensitivity to social organization is the recognition of the clients:
1
Language usage
2
Status and expected role in the family
3
Definition of health and health practices
4
Psychological characteristics and coping mechanisms
ANS: 2
Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and
appropriate roles for their members. Sensitivity to social organization is the recognition of the
clients status and role in the family. Sensitivity to communication patterns would be the
recognition of the clients language usage. Culture is the framework used in defining social
phenomena such as when a person is considered to be healthy or in need of intervention. The
way an individual defines health and health practices needs to be understood by the nurse to best
meet the needs of the client. Sensitivity to social organization is not met by recognizing the
definition of health for an individual. Psychological characteristics and coping mechanisms may
be expressed in a variety of ways across cultures. Sensitivity to social organization is not
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demonstrated by the recognition of psychological characteristics and coping mechanisms of a
particular culture.
DIF: A REF: 116 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
3. Traditional Western medicine, in contrast to alternative therapy, uses:
1
2
Acupuncture
Herbal therapy
3
Spiritual advising
4
Medication administration
ANS: 4
Traditional Western medicine uses medication administration as a method of treatment.
Acupuncture is an alternative therapy often used in non-Western cultures such as the Chinese and
Southeast Asians. Herbal therapy is an alternative therapy often used in non-Western cultures,
but not in traditional Western medicine. Spiritual advising is not used in traditional Western
medicine, but it may be seen in the African-American cultural group.
DIF: A REF: 110 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
4. The nurse is completing an assessment of an Asian-American client. Recognizing that there
are commonly seen problems in individuals from this background, the nurse observes for
particular signs and symptoms of:
1
Hypertension
2
Tuberculosis
3
Diabetes mellitus
4
Lactose intolerance
ANS: 4
Lactose intolerance is frequently observed among Asians, Africans, and Hispanics. Hypertension
is commonly seen in African Americans. Aboriginal Canadians descended from native North
American Indians and living on reservations have a higher incidence of tuberculosis. Diabetes
mellitus is commonly seen among Ute, Pima, and Papago Indians.
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DIF: A REF: 116 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
5. The nurse recognizes the following as an appropriate strategy for communicating with clients
who are not fluent in English?
1
2
3
4
Speaking in a louder tone of voice
Incorporating hand gestures and pictures
Responding to the client by his or her first name
Interacting with an interpreter for all communication
ANS: 2
An appropriate strategy for communicating with clients who are not fluent in English is to
incorporate hand gestures and pictures. Speaking in a louder tone of voice will not help the client
understand the English language. Responding to the client by his or her first name may
demonstrate a lack of respect. The nurse should introduce him or herself and then request the
client to introduce himself or herself. An interpreter is not necessary for all communication.
However, an interpreter must be used for communicating to the client information about his or
her medical condition. It is not acceptable for family members to translate health care
information, but they can assist with ongoing interaction during the clients care.
DIF: A REF: 113 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
6. One aspect of a culture is invisible, or less observable, to others. A nurse wanting to develop
an awareness of the practices of different cultures within that community would have which of
the following as an example of this component?
1
Wearing an amulet or charm
2
Using prayer beads or candles
3
Using cotton garments for clothing
Believing in supernatural influences
4
ANS: 4
An example of an invisible (less observable) component of a culture is having a belief in
supernatural influences. An example of a visible (easily seen) component of culture is the
wearing of an amulet or charm. An example of a visible (easily seen) component of culture is
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using prayer beads or candles. Using cotton undergarments for clothing is a visible (easily seen)
component of culture.
DIF: A REF: 107 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
7. From culture to culture time often takes on different meanings. In exploring the relationship of
time to nursing interventions, the nurse should:
1
Avoid using set times to do procedures, if possible
2
Maintain the set times for treatments and inform the client of
the schedule
3
Maintain a flexible attitude when the client requests
procedures to be done at specific times
4
Encourage clients to set the times when they would like the
nurse to perform nursing care activities.
ANS: 3
Because time has different meanings from one culture to another, the nurse should maintain a
flexible attitude and not become emotionally upset when the client requests procedures to be
done at different times. When making appointments and referrals, anticipated barriers to time
adherence should be explored and managed with the client. For organizational purposes, nurses
should seek clients input and together the nurse and client may set a time to do procedures.
Maintaining set times for treatments and informing the client of the schedule do not take into
consideration the clients time orientation. Although the clients input should be sought, it is not
realistic to have clients set their own times for nursing care activities regardless of the schedule.
Some procedures may be required more frequently than the client would set, or the nurse may be
unable to meet the needs of several clients on the unit at the same time.
DIF: A REF: 118 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
8. The nurse recognizes that changes in demographics have an influence on health care delivery.
One of the expectations in the United States by the year 2020 is:
1
Growth of the European-American population
2
Increases in the Hispanic and Latino populations
3
Reduction of the African-American population by 50%
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4
Equal growth in the Hispanic-, Asian-, and African-American
populations
ANS: 2
By 2020 the population of Hispanic and Latino populations is predicted to triple. Population
projections beyond 2000 show Hispanics/Latinos, Asian-Americans, and African-Americans
outpacing the growth of white, European-descended groups. The African-American group is
projected to double by 2020. By 2020 the population of African Americans is predicted to double
and that of Asian Americans and Hispanics/Latinos to triple.
DIF: A REF: 107 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
9. While going through the process of acculturation a client will be:
1
Identifying with 2 or more cultures
2
Adapting to and adopting a new culture
3
Showing favor to the dominant culture
Socializing within their primary cultural group
4
ANS: 2
Acculturation is the process of adapting to and adopting a new culture. Biculturalism occurs
when an individual identifies equally with two or more cultures. Assimilation occurs when an
individual gives up his or her ethnic identity in favor of the dominant culture. Socialization into
ones primary culture as a child is known as enculturation.
DIF: A REF: 708 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
10. An example of a nurse imposing his/her own cultural beliefs on a client is evident in which of
the following examples?
1
2
3
Adaptation of the clients room to accommodate family
members
Seeking information on gender-congruent care for an Egyptian
client
Administering less potent pain medication to an outpatient
surgery client
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4
Encouraging family members to assist with the clients feeding
and hygiene care
ANS: 3
Holding back more potent pain medication for a client who had a minor procedure is an example
of a cultural imposition of the nurse on a client. Adaptation of the clients room to accommodate
extra family members is not an example of cultural imposition on a client, but rather is meeting
the clients need by providing culturally congruent care. Seeking information on gendercongruent care for an Egyptian client is an example of the desire to provide culturally congruent
care. Encouraging family to assist with the clients care is not an example of cultural imposition
on a client. Western culture tends to follow a pattern of caring that focuses on self-care and selfdetermination, whereas non-Western cultures typically have care provided by others.
DIF: A REF: 109 OBJ: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
11. Following a surgical procedure, an older Chinese woman refuses to perform the range of
motion and breathing exercises requested, in addition is hesitant to complete her hygienic care
and grooming. The nurse recognizes that this is most likely related to:
1
Dependence on health care providers for care
2
Reliance upon family members to assist with care
3
Lack of personal motivation to participate in self-care
4
Reluctance to cooperate with traditional Western medical
treatment
ANS: 2
Non-Western cultures traditionally rely heavily on family members to provide care. Although it
may be related to dependence on health care providers for care, it is not as likely because nonWestern cultures depend on family members to assist with care. While it may be related to lack
of personal motivation to participate in self-care, the clients behavior is more likely a result of
her cultural background rather than a lack of motivation. While the clients behavior may be a
result of reluctance to cooperate with Western medical treatments, it is more likely indicative of
her cultural dependence on family members.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
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12. When faced with a scenario where it is believed that a client from another cultural
background is using herbal remedies along with the prescribed medication to treat her arthritis.
The nurses first action should be to:
1
Educate the client concerning the danger of taking herbs and
the prescribed medication
2
Inquire of the client as to the reason for using herbal remedies
along with the prescribed medication
Ask the client to identify what herbal remedies are being used
along with the prescribed medications
3
4
Alert the physician to the clients use of herbal remedies in
addition to the prescribed medications
ANS: 3
Rather than first dismissing the practice as dangerous and incompatible with Western medicine,
practitioners need to investigate further whether the practice needs changing. Although educating
the client may be appropriate, this cannot be determined until the herb has been identified and it
is determined to be harmful in this situation. Asking the client why additional remedies are being
used may make the client feel defensive. The nurse needs to first determine what herbs are being
used. While alerting the physician is appropriate, it is not the first action to be taken by the nurse.
The nurse should initially determine what herbs are being used.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
13. Being cared for by a nurse of the opposite gender would be an especially important issue for
women from which of the following cultures?
1
Afghan
2
Filipino
3
Native American
4
African American
ANS: 1
Modesty is a strong value among Afghan and Arab women.
Modesty is not an especially important issue for Filipino women.
Modesty is not an especially important issue for Native American women.
Modesty is not an especially important issue for African American women.
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DIF: A REF: 109 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
14. An example of a culture where a male relative will regularly decline to observe the birth
process is:
1
2
Pakistani
Hispanic
3
Korean
4
Japanese
ANS: 1
Religious beliefs may prohibit the presence of males, including husbands, in the delivery room.
This may be observed among devout Muslims, Hindus, and Orthodox Jews. Hispanic men
typically do not have religious or cultural beliefs that would prohibit them from the delivery
room. Korean men typically do not have religious or cultural beliefs that would prohibit them
from the delivery room. Asian men typically do not have religious or cultural beliefs that would
prohibit them from the delivery room.
DIF: A REF: 111 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
15. The nurse observes a religious charm hanging from the wrist of a client being prepared for
surgery. The nurses best initial approach is to:
1
Remove the religious charm
2
Securely tape the charm in place
3
Ask the client to leave the charm with family members
4
Clarify whether the charm may remain in place during the
procedure
ANS: 4
The nurse should first determine if it is permissible for the item to remain in place during the
procedure. Removing the bracelet may create unnecessary stress for the client. Initially the nurse
should determine if removal is necessary. Taping the bracelet in place may be appropriate after
the nurse determines that the item may remain in place during the procedure. Asking the client to
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remove the item may create unnecessary stress for the client. Initially the nurse should determine
if removal is necessary.
DIF: B REF: 109 OBJ: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
16. The nurse recognizes that the family of a deceased Buddhist client will:
1
2
3
4
Bury before sundown
Decline viewing the body
Not move the body until it is cold
Select cremation rather than burial
ANS: 3
Some Buddhists may refuse to move the dead body after death because of their belief that the
spirit of the dead takes some time to leave the body. They define death as the absence of
consciousness and loss of body warmth. Among Orthodox Jews, the body is generally buried
before sundown. Some Asian Indians regard seeing the deceased as adding to the suffering of the
family. Hindus and Buddhists believe that the soul lives on and the dead body without the soul is
but an empty shell, and therefore may not want to see the body. Muslims prefer burial rather than
cremation.
DIF: A REF: 112-113 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity
17. A nurse that has the knowledge of the biocultural history of clients and aware that individuals
with a greater potential for and incidence of hypertension are:
1
Asians
2
Hispanics
3
Native Americans
African Americans
4
ANS: 4
Malignant hypertension is found more frequently in African Americans. Lactose intolerance is
frequently observed among Asians. Hispanics have a higher incidence of lactose intolerance.
Native Americans have a higher incidence of tuberculosis and diabetes mellitus.
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DIF: A REF: 117 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
18. There are cultural context of health and illness differences in comparing Western versus nonWestern cultures. The nurse is aware that in Western culture the overall treatment is:
1
2
3
4
Herbal
Holistic
Naturalistic
Specialty-specific
ANS: 4
The overall treatment in Western culture is specialty-specific. The treatment in some nonWestern cultures is herbal. The treatment in non-Western cultures is holistic in nature. Some nonWestern cultures use a naturalistic approach for the method of diagnosis.
DIF: A REF: 109 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
19. Regarding a client who is an Orthodox Jew and maintains a Kosher diet, the nurse will make
sure that the clients menu does not include:
1
Beef
2
Eggs
3
Milk
Shellfish
4
ANS: 4
Jewish clients who follow a Kosher diet will avoid meat from carnivores, pork products, and fish
without scales or fins. Therefore shellfish should not be included in the menu of a client who is
an Orthodox Jew and maintains a Kosher diet. Beef may be included in a Kosher diet. Eggs may
be included in a Kosher diet. Milk may be included in a Kosher diet.
DIF: A REF: 117 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
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20. For a client who is a Buddhist and maintains a traditional diet, the nurse will make sure that a
sufficient quantity of which of the following is included in the menu?
1
2
3
4
Beef
Milk
Fish
Vegetables
ANS: 4
Many Buddhists are vegetarians. The nurse should ensure that a sufficient quantity of vegetables
is included in the menu when caring for a Buddhist who maintains a traditional diet. Beef is not a
traditional component of a Buddhists diet. A sufficient quantity of milk is not necessary for the
traditional Buddhists diet. A sufficient quantity of fish is not necessary for the traditional
Buddhists diet.
DIF: A REF: 117 OBJ: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
21. Which of the following factors has the greatest impact on health care available to nonHispanic white minority groups in the United Sates?
1
Significant language barriers
2
Inappropriately high poverty rates
3
Genetically based disease processes
4
Mistrust of Western medical practices
ANS: 2
Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor. In
addition, Hispanics, African Americans, and some Asian subgroups are less likely than nonHispanic whites to have a high school education. In general, racial and ethnic minorities often
experience poorer access to care and lower quality of preventive, primary, and specialty care.
While language barriers may have an influence on the amount and type of health care services
available to and sought out by minority groups, it is poverty that has the greatest negative
influence. While genetically based disease processes may have an influence on the amount and
type of health care services available to and sought out by minority groups, it is poverty that has
the greatest negative influence. Although mistrust of Western medical practices may have an
influence on the amount and type of health care services available to and sought out by minority
groups, it is poverty that has the greatest negative influence.
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DIF: C REF: 107 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
22. The nurse who is attempting to practice in a culturally sensitive manner must first realize that
recognition of the visible signs of a clients culture:
1
2
Is essential to the establishment of a nurse-client relationship
Provides the basis for a sense of trust between client and nurse
3
Does not ensure understanding of the underlying cultural
beliefs
4
Has little impact on the nurses ability to provide therapeutic
care
ANS: 3
Culture has both visible (easily seen) and invisible (less observable) components. Nurses cannot
appreciate the meanings and beliefs associated with these artifacts without further assessment.
Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship because it conveys the nurses interest in the client as a person; it is not
essential to the relationship process. Recognition of visible signs of a clients culture will assist in
the formation of trust (a component of a therapeutic nurse-client relationship) because it conveys
the nurses interest in the client as a person; it is not essential to the trust-establishing process.
Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship, which is vital to the nurses ability to provide therapeutic care because it
conveys the nurses interest in the client as a person.
DIF: C REF: 107 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
23. Which of the following nursing interventions shows the greatest degree of culturally
competent nursing care for a Muslim female client?
1
Notifying the chaplain of the clients religious preference
2
Notifying staff that the clients bath will be done by her sister
3
Drawing the curtains around the clients bed during prayer time
Facilitating a dietary consult to meet the clients nutritional
concerns
4
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ANS: 2
Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that
ensure delivery of culturally congruent care. By arranging for the family to assume responsibility
for the clients hygiene, the nurse has shown a specific knowledge of the clients needs and acted
upon that need. The other options are not as specific or as directly related to nursing care as
notifying the staff that the clients bath will be done by her sister.
DIF: C REF: 109 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
24. A nursing care assistant fails to report in a timely manner a request for pain medication from
an African-American male client who is recovering from a stab wound. The nurses initial action
is to evaluate the care assistants:
1
Feelings regarding this particular client
2
3
Need for administrative disciplinary action
Understanding of the need for prompt reporting
4
Employment files for documentation of similar behavior
ANS: 1
Personal bias and prejudices when acted upon may interfere with the delivery of appropriate,
effective nursing care. While all the options are appropriate, the nurses initial action is to
determine the cause of the care assistants negligent behavior. Although all the options are
appropriate, the nurses initial action is to determine the cause of the care assistants negligent
behavior.
DIF: C REF: 109 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
25. An Arab woman arrives in the emergency department reporting vaginal bleeding. It is
determined that the client is 5 months pregnant with her second child and has had no prenatal
care. The nurse realizes that the most likely reason for this lack of health care is that the client:
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1
Cannot afford to seek health care
2
3
Views pregnancy as a normal life event
Typically relies on same-culture healers
4
Lacks an understanding of available services
ANS: 2
Culture is the context in which groups of people interpret and define their experiences relevant to
life transitions. This includes events such as birth, illness, and dying. It is the system of meanings
by which people make sense of their experiences. Culture is how others define social phenomena
such as when a person is healthy or requires intervention. Traditionally, in Arab culture,
pregnancy is not a medical condition but rather a normal life transition; hence, a pregnant woman
does not always go to a doctor unless she has a problem. While the other options may have been
a factor, the most likely cause is that the Arab culture views pregnancy as a normal life event and
care is sought only when a perceived problem exists.
DIF: C REF: 109 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
26. An Asian-American client will accept hygiene care from only family members. The cultural
origin of this behavior is most likely:
1
Valued privacy
2
Female modesty
3
Interdependency
Mistrust of strangers
4
ANS: 3
In collectivistic cultures that value group reliance and interdependence, such as traditional
Asians, Hispanics, and Africans, caring behaviors require actively providing physical and
psychosocial support for family or community members. While the other options may be
individualized factors, culturally the most likely origin is that of group reliance and
interdependency of the Asian culture.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
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27. An older Chinese client experienced a stroke that left him with right-sided weakness and now
refuses to participate in physical therapy until his son is present. The nurse should initially
interpret this behavior as:
1
A sign of post-stroke depression
2
3
An illustration of cultural collectivism
A response to the therapy-induced pain
4
An example of a healthy father-son relationship
ANS: 2
In collectivistic cultures that value group reliance and interdependence, such as traditional
Asians, Hispanics, and Africans, caring behaviors require actively providing physical and
psychosocial support for family or community members. The other options may be true;
however, the more likely interpretation is the clients cultural inclination toward group reliance
and family support systems.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
28. While assessing an older Vietnamese client, the nurse notes several oval-shaped reddened
areas on her back and arms. The clients daughter explains them to be the result of a traditional
healing practice called cupping. The nurses immediate reaction should be to:
1
Report the finding to the authorities to rule out physical abuse
2
Ask the daughter to explain the practice in detail
3
Notify the clients health care provider to see if treatment is
necessary
Document the assessment findings in the nursing notes
4
ANS: 2
Many Southeast-Asian cultures practice folk remedies such as coining, cupping, pinching, and
burning to relieve aches and pains and remove bad wind or noxious elements that cause illness.
These remedies leave peculiar visible markings on the skin in the form of ecchymosis,
superficial burns, strap marks, or local tenderness. Cultural ignorance causes a practitioner to call
authorities for suspicion of abuse. Nurses need to investigate to determine the details of the
practice in order to decide whether the practice needs to be changed. Consultation and
collaboration with herbalists and other naturalistic practitioners will prevent unnecessary distress
for the client. While reporting the finding to authorities should not be dismissed, the nurse should
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first discuss the practice with the daughter to learn more of the details regarding the practice. The
clients health care provider should be notified, however, the nurses assessment of the areas as
reddened areas suggests that other options may have priority. Documentation of the assessment
findings is certainly appropriate and is a nursing responsibility, but acquiring an explanation
from the daughter who is present would have priority.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
29. The nurse, caring for a comatose Muslim client who is dying, realizes that from a cultural
standpoint, the most therapeutic intervention is to:
1
Facilitate the clients peaceful, pain-controlled death
2
Become familiar with Muslim death and dying traditions
3
Approach the family to identify and discuss any needs that
exist
4
Arrange for a private room so the family can grieve
traditionally
ANS: 3
Be aware of religious and cultural preferences when helping clients and families prepare for
death. Facilitating the clients peaceful, pain-controlled death is an appropriate intervention; it is
not necessarily culturally oriented because nursing strives to facilitate a peaceful, pain-free death
for all clients. Becoming familiar with cultural tradition is therapeutic and would have priority if
the family were not present to be questioned directly regarding their needs. Arranging for a
private room may be a therapeutic intervention because most cultures would prefer some degree
of privacy when attending to the death of a loved one, but since the family is present the priority
intervention is the one that identifies their needs.
DIF: C REF: 112-113 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
30. A Hispanic client is diagnosed with inoperable brain cancer. The clients wife insists that any
discussion about treatment options be postponed until all local family members are present. The
nurse correctly views this as:
1
The familys attempt to facilitate a good death for the client
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2
An invasion of the clients right of confidentiality by the family
members
3
Appropriate because the cancer may have affected his
decision-making abilities
A cultural tradition that relieves the ill family member of the
burden of decision making
4
ANS: 4
In some cultures, the group assumes decision making for a family member in these situations and
is trusted to make the right decision for the individual. Indeed, some groups such as African
Americans, Asian Americans, and Hispanics expect their family to make decisions for them, and
family members prefer to protect the individual from unnecessary suffering by knowing the
reality of imminent death. These cultures value group interdependence and view individual
autonomy as an unnecessary burden for a loved one who is ill (Pacquiao, 2002, 2003a). The
means by which the family provides a good death is first established through the process of
group decision making. It may appear that the clients confidentiality is being invaded by a
member of the Western nursing profession; it is a cultural norm for members of many Hispanic
families. Although cancer may affect the clients abilities to make decisions, the origin of this
behavior is more likely the cultural tradition of group decision making among Hispanics.
DIF: C REF: 111 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
31. The nurse realizes that the primary goal of a cultural assessment is to:
1
Minimize client distress resulting from unmet cultural
expectations
2
Provide care that is in concert with the clients cultural
expectations
3
Identify cultural beliefs and traditions that are important to the
client
4
Blend Western nursing practice with the clients cultural
expectations
ANS: 2
The goal of cultural assessment is to gather significant information from the client that will
enable the nurse to implement culturally congruent care. Minimizing distress is an achieved
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outcome when the goal of culturally congruent care is met. Identifying beliefs and traditions is an
assessment goal that helps identify the criteria for individualized, culturally congruent care.
Blending Western nursing practice with cultural expectations will result in individualized,
culturally congruent care.
DIF: C REF: 108 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
32. The nurse caring for members of the Hispanic community recognizes which of the following
situations as the best reflection of the cultures view of family caring?
1
2
A husband calling each evening to tell his wife goodnight
Family members taking turns staying with the client at night
3
The daughter bringing her fathers favorite soup to the hospital
4
The eldest son sending a huge floral arrangement to the
hospital
ANS: 2
In collectivistic groups such as the Hispanic culture, the physical presence of loved ones with the
client demonstrates caring. While the other options show caring, it is not the best option
reflecting the Hispanic culture.
DIF: C REF: 110 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
33. A nurse caring for the Arab community observes a client crying. The woman was recently
informed that her radiation treatments may affect her ability to become pregnant. The nurse
recognizes that the client is most likely reacting to a cultural attitude regarding:
1
The importance of children to an Arab family
2
The Arab view that infertility is grounds for divorce
3
Infertility is a punishment for unholy living
The loss of status among other married Arab women
4
ANS: 2
Infertility in a woman is considered grounds for divorce and rejection among Arabs. Although
infertility is grounds for divorce in Arab cultures, it is not the best option for this question.
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Infertility as a punishment for unholy living may not be a generally accepted view, it is not the
best option for this question. While the loss of status among other married Arab women may be
true, it is not the best option for this question.
DIF: C REF: 111 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health
Promotion and Maintenance/Health and Wellness
34. The primary problem with using English-speaking children of immigrant families as
interpreters is that:
1
The adults may resent their dependence upon the child
2
The subjects discussed may be too disturbing to the child
3
Children can be easily distracted, thus making them unreliable
translators
4
There are concerns about the childs ability to convey
important information
ANS: 1
Assuming that children are ideal interpreters for their parents may in fact be an insult to the
authority of the elder who has to take directions from a child. Although the other options may be
true, it is not the primary reason for the concerns regarding using children as interpreters
Chapter 10. Family Dynamics
MULTIPLE CHOICE
1. Which of the following is a current trend in families or family living?
1
People marrying earlier
2
Reduction in the divorce rate
3
People having more children
4
More people choosing to live alone
ANS: 4
The number of people living alone is expanding rapidly and represents approximately 26% of all
households. People are marrying later, not earlier. The rate of divorce appears to have stabilized,
with approximately 55% of marriages ending in divorce. Couples are choosing to have fewer
children or none at all.
DIF: A REF: 122 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
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2. Of the following trends, which one represents the greatest current health care challenge to
nurses?
1
2
3
4
Homelessness
Single parent families
Alternative relationship patterns
Sandwiched or middle generation
ANS: 1
Homelessness is identified as one of the greatest health care challenges to nurses. The trend of
single parent families is not the greatest current health care challenge to nurses. The trend of
alternate relationship patterns is not the greatest current health care challenge to nurses. The
trend of a sandwiched or middle generation is not the greatest current health care challenge to
nurses.
DIF: A REF: 124 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
3. When working with families, the nurse may view the family as context or client. Which one of
the following examples demonstrates the view of the family as context?
1
The familys ability to support the clients dietary and
recreational needs
2
The clients ability to understand and manage his own personal
dietary needs
The familys demands on the client that are based on the clients
role performance
3
4
The adjustment of both the client and the family to changes in
diet and exercise
ANS: 2
When the nurse views the family as context, the primary focus is on the health and development
of an individual member existing within the clients family. The clients ability to understand and
manage his own dietary needs is an example of viewing the family as context. The familys
ability to support the clients dietary and recreational needs is an example of viewing the family
as client. The familys demands on the client based on his role performance is an example of
viewing the family as client. The adjustment of the client and family to changes in diet and
exercise is an example of viewing the family as system.
DIF: A REF: 128 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
4. What would a nurse expect to find in an assessment of a healthy family?
1
2
Change is viewed as detrimental to the family.
There is a passive response to most stressors.
3
The structure is flexible enough to adapt to crises.
4
Minimum influence is being exerted on the environment.
ANS: 3
A healthy family has a flexible structure that allows adaptable performance of tasks and
acceptance of help from outside the family system. The structure is flexible enough to allow
adaptability but not so flexible that the family lacks cohesiveness and a sense of stability. The
healthy family is able to integrate the need for stability with the need for growth and change. It
does not view change as detrimental to family processes. The healthy family demonstrates
control over the environment and does not passively respond to stressors. The healthy family
exerts influence on the immediate environment of home, neighborhood, and school.
DIF: A REF: 127 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
5. Initially, the nurse should begin by doing what in completing a clients family assessment?
1
Collecting health data from all the family members
2
Testing the familys ability to cope with normal stressors
3
Evaluating the familys interpersonal communication patterns
4
Determining the clients definition of familiar structure and
attitudes
ANS: 4
The nurse begins the family assessment by determining the clients definition of and attitude
toward family and the extent to which the family may be incorporated into nursing care. The
nurse also assesses family form and membership. Gathering health data from the family
members is not the starting point for a family assessment. Testing a familys ability to cope is not
where the nurse should begin a family assessment. Evaluating communication barriers would not
be an initial action of the nurse when completing a clients family assessment.
DIF: C REF: 126 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
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6. Post discharge, the client is returning to their home environment. In assisting the client with
that, specifically in implementing family-centered care, the nurse:
1
2
Provides personal beliefs regarding problem-solving
Assists the family members to assume dependent roles
3
Works with the client to accept responsibility for role in
discourse
4
Offers both client and family information about necessary selfcare abilities
ANS: 4
When implementing family-centered care, the nurse adopts the role of educator and offers
information about necessary self-care abilities. In family-centered care, the nurse guides the
family in problem solving without providing his/her own beliefs. In family-centered care, the
nurse assists clients to assume independent roles by increasing family members abilities in
certain areas. In family-centered care, the nurse guides the family in problem solving, not in
helping them accept blame.
DIF: A REF: 129 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
7. A client is unable to independently perform colostomy care due to arthritis. The nurse should
first:
1
Offer to assist the client to learn to manage the care
2
Arrange for home care services to care for the colostomy
3
Inquire as to family members who may be able to assist with
the care
Suggest that the client attend a colostomy self-help support
group
4
ANS: 3
The nurse should first find out if there is anyone else in the family or neighborhood who would
or could assist with the colostomy care. Informing the client that management of the colostomy
must be learned will not change the fact that the client has arthritis and needs assistance. The
nurse should first determine whether there is someone else who could perform the task. If not,
the nurse arranges for a home care service referral. A colostomy self-help support group may
provide emotional support, but it will not meet the clients need for assistance with colostomy
care.
DIF: C REF: 131 OBJ: Analysis
TOP: Nursing Process: Planning
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
8. The optimum goal of effective communication within the family, according to the nurse
observing the family members and their interaction, is:
1
2
3
4
Problem solving and psychological support
Role development of individual members
Socialization among individual members
Better financial conditions for the family
ANS: 1
The optimum goal of effective communication within the family is to be able to problem solve
and provide psychological support for its members. Role development is not the optimum goal of
effective communication within the family. Socialization among individual family members is
not the optimum goal of effective communication within the family. Improving financial
conditions for the family is not the optimum goal of effective communication within the family.
DIF: A REF: 129 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
9. Which of the following is a gerontological principle related to families?
1
Later-life families need not work on developmental tasks.
2
The caregivers are often not members of the clients family.
3
Role reversal is usually expected and well accepted by the
older client.
Support systems are likely to be different than those of
younger age-groups.
4
ANS: 4
It is true that social support systems for older adults are likely to be different from those for
clients in younger age-groups. Members of later-life families need to be working on
developmental tasks. Caregivers for older adults are usually either spouses or middle-age
children. Accepting shifting of generational roles is often difficult for the older client.
DIF: A REF: 125 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
10. In assessing the roles and power structure of a clients nuclear family, the nurse should
specifically ask the client:
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1
Who decides where to go on vacation?
2
3
What type of health care insurance do you have?
How many family members currently live in your home?
4
What types of social activities do you and your family enjoy?
ANS: 1
Asking, Who decides where to go on vacation? enables the nurse to determine the power
structure and patterning of roles and tasks of the family. Asking about health insurance does not
assess the roles and power structure of the family. Inquiring about family members living at
home may be used to help determine family form, not the power structure and roles of the
family. Asking about social activities may provide information on the interactive processes of the
family and how time is spent, but it does not assess the roles and power structure of the family.
DIF: C REF: 126 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
11. Needing assistance with daily living activities, an older adult with two grown children is
being discharged home. Although both children live nearby, the daughter is expressing concern
about handling her parents physical needs. The nurses initial response is to:
1
Work with the family on delegating responsibility
2
Suggest short-term nursing home placement to the client
3
Arrange for the client to remain hospitalized in the medical
center
Make decisions for the family on how to manage the care at
home
4
ANS: 1
The nurse must consider caregiver strain and work with the family on delegating responsibility.
Nursing home placement should not be the nurses initial response to caregiver strain. Arranging
for the client to remain in the medical center is not always feasible and does not address the
problem of caregiver strain. It should not be the nurses initial response in this situation. The
nurse should not make decisions for the family, but rather work with the family to problem solve.
DIF: C REF: 126 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
12. The nurse suspects that there is physical abuse present after visiting the client in the home. In
recognition of the pattern of family violence, the nurse knows that:
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1
Child abuse is declining in frequency
2
3
Spouses are the most frequent abusers
Mental illness is a major cause of abuse
4
Abuse is primarily seen in lower income families
ANS: 2
In recognition of the pattern of family violence, the nurse knows that spouses are the most
frequent abusers. Child abuse is increasing, not decreasing. Mental illness may increase the
incidence of abuse within a family, but is not a major cause of abuse. Emotional, physical, and
sexual abuse occurs across all social classes.
DIF: A REF: 124 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
13. The primary goal of family-centered nursing is to:
1
Promote the wellness of the family and its members
2
Implement appropriate care for the family and its members
3
Provide support and care for the family and its individual
members
4
Identify physical and emotional problems affecting the family
as a unit
ANS: 3
The goal of family-centered nursing care is to promote, support, and provide for the well-being
and health of the family and individual family members. While the other options are appropriate
goals, they are not the primary goal because promoting, supporting, and providing for the wellbeing and health of the family and individual family members will result in this option
DIF: C REF: 122 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
14. A nurse who is sensitive to the care of families recognizes that the term family is primarily
defined:
1
As individuals legally bound to the client
2
As people with biological connections to the client
3
In terms generally accepted by the majority of clients
By the client as individuals important to the client
4
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ANS: 4
A nurse can think of the family as a set of relationships that the client identifies as family or as a
network of individuals who influence each others lives. People related legally and biologically
may be criterion used to determine family. General terms may not be correct in todays diversified
world.
DIF: C REF: 122 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
15. The nurse is preparing a new mother for discharge when the woman shares that she is
worried about going back to work and its effects on my infant. The most therapeutic response by
the nurse is:
1
2
3
4
Do you want to go back to work?
Just be sure you have an excellent baby sitter.
There is no proof that working will harm your baby.
Can your husband share in the child care responsibilities?
ANS: 3
Balancing employment and family life creates a variety of challenges in terms of child care and
household work for both parents. There is no proof maternal employment is damaging for
children (Shpancer and others, 2006; Hill, 2005). Although the other options may be true or
attempt to offer a solution, they do not address her concerns regarding the effects on her child.
DIF: C REF: 123 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
16. The greatest risk to a child of adolescent parents comes from the:
1
Increased family stressors resulting in domestic violence
2
Lack of appropriate parenting resources and role models
3
Statically high potential for physical and emotional abuse
Parents inability to provide health care and economic support
4
ANS: 2
The greatest risk to a child of adolescent parents is derived from the parents strong potential to
lack good parenting skills. This inability can result in both physical and emotional harm.
Increased family stressors resulting in domestic violence and statically high potential for physical
and emotional abuse often result from poor parenting and coping skills. The parents inability to
provide health care and economic support is more likely in an adolescent-headed family resulting
from limited marketable skills.
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DIF: C REF: 123 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
17. Which of the following nursing statements has the greatest therapeutic value when
counseling a sandwich generation client caring for a chronically ill parent?
1
2
I can help you in finding assistance with the in-home care.
What is the most stressful aspect of caring for your parent?
3
Im sure your children love having grandmother in the house.
4
What do you do for relaxation now that your mom lives with
you?
ANS: 4
Assess for caregiver stress, such as tension in relationships with family and care recipient,
changes in level of health, changes in mood, and anxiety and depression. Asking the caregiver
about hobbies or other means of relaxation is a nonthreatening way to assess tension levels.
Offering to help find assistance infers a need for help that may insult the caregiver. Assuming the
caregiver is stressed or assuming the living situation is good may cause the caregiver to be
reluctant to discuss existing problems.
DIF: C REF: 133 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
18. The mother of a child receiving immunizations at a health clinic shares with the nurse that
she and the child have not eaten today. Which of the following nursing interventions is best
directed at impacting the immediate problem while being sensitive to the mothers sense of selfworth?
1
Notifying family services of the problem
2
Taking both mother and child to the cafeteria
3
Informing the mother that she is eligible for food stamps
4
Providing her with contacts at the neighborhood food bank
ANS: 4
When caring for these families, the nurse needs to be sensitive to the familys desire for
independence, but also help them with obtaining appropriate food, financial, and health care
resources. Notifying family services may become necessary, but attempts to provide the mother
with available means of assistance has priority. Taking them to the cafeteria would provide
immediate food but does not address future needs or show sensitivity to the mother. Informing
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the mother about local and state aid may become necessary, but it does not address the
immediate need, nor does it show sensitivity to the mother.
DIF: C REF: 124 OBJ: Analysis
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
19. The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest
risk for:
1
2
3
4
Homelessness
School truancy
Family violence
Accident-related injuries
ANS: 3
Factors such as alcohol and drug abuse increase the incidence of abuse within a family (Family
Violence Prevention Fund, 2006b). While the other options are possible, they are not the greatest
negative outcome.
DIF: C REF: 124 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
20. The most important impact that truthful, timely communication between the nurse and the
family of a critically ill client has is on the familys ability to:
1
Trust the nurse
2
Adjust to bad news
3
Be confident of the care the client is receiving
Make appropriate choices regarding client treatment
4
ANS: 1
Provide realistic assurance; giving false hope breaks the nurse-client trust. Being trustful of the
information provided by the nurse will aid in the adjustment to bad news. Trust is the basis for
confidence in the care being provided and for appropriate decision-making.
DIF: C REF: 125 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
21. When caring for a terminally ill client, the nurse must also assess the family, because the
primary benefit will be:
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1
Effective use of time and resources in the end-of-life care of
the client
2
Appropriate attention to the cultural beliefs and expectations
of the family
Added information regarding the care needs and preferences
of the client
3
4
The ability to respond effectively to the family unit during the
dying process
ANS: 4
The more you know about your clients family, how they interact with one another, their
strengths, and their weaknesses, the better. Each family approaches and copes with end-of-life
decisions differently. While the other responses may be true, they are not the primary benefit.
DIF: C REF: 125 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
22. When attempting to meet the needs of the family, the nurse recognizes the central concept of
the theory of family developmental stages is that:
1
Over time all families progress through developmental stages
2
Needs differ as the family progresses through the various
stages
3
While each family is unique, they all tend to progress through
similar stages
The family will progress only when all the challenges of a
particular stage are met
4
ANS: 3
Although families are far from identical to one another, they tend to go through certain stages.
Nursing care can be delivered based on the assumption that all families progress through similar
stages that present comparable challenges.
DIF: C REF: 125 OBJ: Analysis
TOP: Nursing Process: Assessment/Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Family Dynamics
23. The nurse can primarily affect the effectiveness of a familys ability to cope with stress by
encouraging:
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1
Flexible roles
2
3
Distinct task assignment
Individual independence
4
Variable parenting models
ANS: 1
A rigid structure specifically dictates who is able to accomplish a task, and may limit the number
of persons inside as well as outside the immediate family who can assume these tasks. Sharing
tasks allows for reassignment of tasks when the need arises.
A rigid structure specifically dictates who is able to accomplish a task, and may limit the number
of persons inside as well as outside the immediate family who can assume these tasks. Inability
to reassign the tasks will impact the familys ability to adjust to stressors.
Chapter 11. Developmental Theories
MULTIPLE CHOICE
1. A nurse who wants to apply a theory that relates to moral development should read more from
the work of:
1
Gould
2
Freud
3
Erikson
4
Kohlberg
ANS: 4
Kohlberg developed a theory on moral development. Gould developed a theory on psychosocial
development. Freud developed a theory on psychosexual development. Erikson developed a
theory on psychosocial development.
DIF: A REF: 144 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
2. The nurse using Eriksons theory to assess a 20-year-old clients developmental status expects
to find which of the following behaviors?
1
Coping with physical and social losses
2
Enjoys participating in the community
3
Applying self to learning skills
Overcoming a sense of guilt or frustration
4
ANS: 2
According to Erikson, the young adult is in the intimacy versus isolation stage of development.
This is the time in which the young adult can become fully participative in the community,
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enjoying adult freedom and responsibility. Coping with physical and social losses is found in
Eriksons integrity versus despair stage (old age) of development. Applying themselves to
learning productive skills is a consistent behavior found in Eriksons industry versus inferiority
stage (6 to 11 years) of development. According to Erikson, overcoming a sense of guilt or
frustration is in the initiative versus guilt stage (3 to 6 years) of development.
DIF: A REF: 140 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
3. The nurse recognizes that Freuds theory approaches development by looking at:
1
Moral reasoning.
2
3
Logical maturity
Psychosexual aspects
4
Cognitive development
ANS: 3
Freuds theory of personality development approaches development by looking at psychosexual
aspects. Kohlbergs theory approaches development by looking at moral reasoning. Goulds theory
approaches development by looking at logical maturity. Piagets theory approaches development
by looking at cognitive development.
DIF: A REF: 138 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected
by the nurse to exhibit which of the following behaviors?
1
Far-reaching problem-solving
2
Exploration of the environment
3
Cooperation and sharing with others
Thinking with the use of symbols and images
4
ANS: 4
According to Piaget, the preoperational child (age 2 to 7 years) is learning to think with the use
of symbols and mental images. Organization of thoughts and far-reaching problem-solving are
noted in Piagets formal operations (11 years to adulthood) stage of cognitive development.
According to Piaget, the child explores the environment in the sensorimotor stage (birth to 2
years) of cognitive development. Cooperation and sharing are seen in Piagets concrete operations
(age 7 to 11 years) stage of cognitive development.
DIF: A REF: 142 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
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5. For an older adult client, an example of a common behavioral task or critical event is:
1
Selecting a mate
2
3
Rearing children
Finding a congenial social group
4
Adjusting to decreasing physical strength
ANS: 4
A common behavioral task of the older adult client is adjusting to decreasing physical strength.
Selecting a mate is a developmental task commonly seen in the early adult. Rearing children is a
developmental task of the middle-early adult. Finding a congenial social group is a
developmental task of the middle-early adult.
DIF: A REF: 137 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
6. The nurse working in an adult medical clinic wishes to learn more about a developmental
theory that focuses on the adult years. The nurse investigates different possibilities and selects
the theory proposed by:
1
Gould
2
Piaget
3
Freud
4
Chess and Thomas
ANS: 1
Goulds theory of psychosocial development specifically focuses on the adult years. Piagets
theory focused on cognitive development throughout the life span. Freuds psychosexual theory
focused on personality development throughout the life span. The theory of Chess and Thomas
focused on development from childhood to early adulthood.
DIF: A REF: 142 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
7. The nurse recognizes that which one of the following statements about growth and
development is correct?
1
Development ends with adolescence.
2
Growth refers to qualitative events.
3
Developmental tasks are age-related achievements.
Cognitive theories focus on emotional development.
4
ANS: 3
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Developmental tasks are age-related achievements is a correct statement about growth and
development. Human growth and development are orderly, predictable processes beginning with
conception and continuing until death. Growth refers to quantitative events. Development refers
to qualitative events. Cognitive theories focus on reasoning and thinking processes.
DIF: A REF: 137 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
8. In Kohlbergs Moral Development theory, an individual who reaches level II (conventional
thought) is expected to exhibit:
1
2
Absolute obedience to authority
Reasoning based on personal gain
3
Personal internalization of others expectations
4
Self-chosen ethical principles, universality, and impartiality
ANS: 3
At level IIconventional thought, the person sees moral reasoning based on his or her own
personal internalization of societal and others expectations. In stage 1, the childs response to a
moral dilemma is in terms of absolute obedience to authority and rules. At level Ipreconventional
thoughtthe person reflects on moral reasoning based on personal gain. According to Kohlberg,
stage 6 is when a person has self-chosen ethical principles, universality, and impartiality.
DIF: A REF: 144 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
9. According to Piaget, the infant is in the first period of development, which is characterized by:
1
Concrete operations
2
Preoperational thought
3
Sensorimotor intelligence
Identity versus role confusion
4
ANS: 3
According to Piaget, the infant is in the first period of development, which is characterized by
sensorimotor intelligence. According to Piaget, children ages 7 to 11 are in the concrete
operations period of development, which is characterized by having the ability to perform mental
operations, while children ages 2 to 7 are in the preoperational period of development, which is
characterized by the child learning to think with the use of symbols and mental images. Identity
versus role confusion is a developmental stage (puberty) according to Erikson.
DIF: A REF: 142 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
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10. A childs understanding of the concept of ice becoming water, Piagets stage of cognitive
development, is seen in:
1
2
3
4
Sensorimotor
Preoperational
Formal operations
Concrete operations
ANS: 4
During Piagets concrete operations stage of cognitive development, the child is able to
understand that objects or quantities remain the same despite a change in their physical
appearance, such as when ice becomes water. During Piagets sensorimotor stage of cognitive
development, the child is exploring the environment but is unable to understand the concept of
ice becoming water. During Piagets preoperational stage of cognitive development, the child is
learning to think with the use of symbols and mental images but is not able to understand the
concept of ice becoming water. According to Piagets formal operations stage of cognitive
development, the individuals thinking moves to abstract and theoretical subjects.
DIF: A REF: 142-143 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
11. The nurse in a pediatric health care setting is using Kohlbergs developmental theory. A child
is evaluated as having reached level I, the preconventional level, if the child:
1
Makes sure that he or she is not late for school
2
Cleans the blackboards after school for the teacher
3
Runs for school council in order to change policies
Stays away from peer groups that harass other children
4
ANS: 1
According to Kohlbergs developmental theory of moral development, at level I, the
preconventional level, the childs reasoning is based on personal gain. The moral reason for
acting relates to the consequences the person believes will occur. The child who makes sure not
to be late for school may do so out of fear of punishment. Cleaning the blackboards after school
for the teacher is an example of Kohlbergs stage 3, good boy-nice girl orientation. The child
desires to win the teachers approval. Running for school council to change policies is an example
of Kohlbergs stage 5 social contract orientation. Staying away from gangs at school that harass
other children is an example of Kohlbergs stage 4 society-maintaining orientation.
DIF: A REF: 144 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
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12. In applying Goulds developmental theory, the nurse anticipates that a client will have a
greater concern for ones health within the following theme and age-group:
1
2
3
4
First theme (20s)
Second theme (early 30s)
Fourth theme (40s)
Fifth theme (50s)
ANS: 4
During the fifth theme (50s), Gould finds a realization of mortality with a concern for ones state
of health. During the first theme (20s), Gould finds individuals wanting to get away from their
parents. During the second theme (30s), Gould finds young adults working to accept who they
are and to accept their growing children as being unique and separate. During the fourth theme
(40s), Gould finds resignation and the belief that possibilities are limited.
DIF: A REF: 142 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
13. The nurse is working with a new mother who will require surgery. The follow-up treatment
will interfere with bonding. In applying Freuds theory, the nurse recognizes that the stage of
development that may be affected is the:
1
Oral stage
2
Anal stage
3
Phallic stage
Latent stage
4
ANS: 1
According to Freud, disruption in the physical or emotional availability of the parent for the
newborn (e.g., undergoing surgery) will affect the oral stage of development; the anal stage is
from 12 to 18 months to 3 years, when the child is toilet-training; the phallic stage is from 3 to 6
years of age, when the child becomes interested in the genital organs; and the latent stage is from
6 to 12 years, when the child represses sexual urges and channels them into productive activities
that are socially acceptable.
DIF: A REF: 138 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
14. In accordance with Eriksons theory, it is expected by the nurse that a middle-aged adult client
will be involved in the process of:
1
Developing a sense of identity
2
Searching for meaning in life
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3
Enhancing ones capability to love others
4
Expanding personal and social involvement
ANS: 4
In accordance with Eriksons theory, the middle-aged adult client is involved in the process of
expanding ones personal and social involvement. Middle-aged adults should be able to see
beyond their needs and accomplishments to the needs of society. Developing a sense of identity
is in accordance with Eriksons identity versus role confusion (puberty) stage of development.
Searching for meaning in life is in accordance with Eriksons integrity versus despair (old age)
stage of development. Enhancing ones capability to love others is in accordance with Eriksons
intimacy versus isolation (young adult) stage of development.
DIF: A REF: 140 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
15. The primary purpose for the nurse to understand human growth and development is to be
best able to:
1
Identify deviations from normal
2
3
Select effective nursing interventions
Be sensitive to age-appropriate needs
4
Enhance nurse-client communication
ANS: 1
Understanding normal growth and development helps nurses predict, prevent, and detect any
deviations from clients normal expected patterns. While being familiar with the characteristics of
the various stages of human growth and development and being able to apply that knowledge to
the individual client do have a positive impact on determining the most appropriate nursing
interventions, the primary purpose is to predict, prevent, and detect any deviations from the
clients normal expected patterns. Although being familiar with the characteristics of the various
stages of human growth and development and being able to apply that knowledge to the
individual client do have a positive impact on identifying age-appropriate needs, the primary
purpose is to predict, prevent, and detect any deviations from the clients normal expected
patterns. While being familiar with the characteristics of the various stages of human growth and
development and being able to apply that knowledge to the individual client do have a positive
impact on the nurses ability to communicate with the client in an appropriate manner, the
primary purpose is to predict, prevent, and detect any deviations from the clients normal
expected patterns.
DIF: C REF: 137 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
16. Which of the following should the nurse consider first when assessing the cognitive ability of
an older adult?
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1
A life-long bachelor
2
3
Orphaned at age 12
History of a chronic disease process
4
Recent immigration to the United States
ANS: 4
Cognitive processes comprise changes in intelligence, ability to understand and use language,
and the development of thinking that shapes an individuals attitudes, beliefs, and behaviors.
Recent immigration to the United States would present language and life experiences that should
be considered by the nurse. Socioemotional processes consist of the variations that occur in an
individuals personality, emotions, and relationships with others during their lifetime. Being a
bachelor and not having experienced a marital relationship should be considered by the nurse.
Socioemotional processes consist of the variations that occur in an individuals personality,
emotions, and relationships with others during their lifetime. Being orphaned at a young age
should be considered by the nurse. Biological processes produce changes in an individuals
physical growth and development. A chronic disease process should be considered by the nurse.
DIF: C REF: 142 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
17. A nurse caring for a 78-year-old client recently diagnosed with pneumonia will find Eriksons
psychosocial development theory most helpful in determining:
1
Which needs the client will typically develop
2
Which coping mechanisms the client will likely use
3
How the client will respond to the respiratory problem
4
How the client and his family will adjust to the stressors
ANS: 3
Developmental theories are important in helping nurses assess and treat a persons response to an
illness. Understanding and being able to apply the concepts of the theory will enable the nurse to
determine a variety of generalized information that will assist in providing appropriate nursing
care. The other options are only one area of information that is made available when applying
Eriksons psychosocial development theory.
DIF: C REF: 140 OBJ: Analysis
TOP: Nursing Process: Assessment/Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
18. As described by Freud, the nurse recognizes that a young adult best shows a well-developed
superego when he:
1
Tells a friend that hell help him stop smoking
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2
Returns a lost wallet to a stranger who dropped it
3
Arranges for a cab ride home after consuming alcohol
Has 10% of his salary automatically transferred to savings
4
ANS: 3
Components of the human personality develop through Freuds developmental stages. Freud
believed that the functions of these components regulate behavior. These components are the id,
the ego, and the superego. The superego performs regulating, restraining, and prohibiting actions.
Often referred to as the conscience, the superego is influenced by the standards of outside social
forces (i.e., the law). The ego represents the reality component mediating conflicts between the
environment and the forces of the id. The ego helps us judge reality accurately, regulate
impulses, and make good decisions.
DIF: C REF: 139 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
19. A nurse is preparing to discharge an 11-month-old child after a hospitalization for a viral
infection. The nurse uses anticipatory guidance most effectively when:
1
Encouraging the parents to limit visitors for 14 days
2
Providing the parents with written discharge instructions
3
Arranging the follow-up pediatrician appointment for the
parents
4
Informing the parents that the child may cry when taken to
daycare
ANS: 4
A nurses use of anticipatory guidance (derived from an understanding of the characteristics
shown by clients in the trust versus mistrust phase of development) will help parents cope with
the hospitalization of an infant and the infants behaviors when discharged to home. The childs
sense of trust may be challenged during hospitalization and may need support from parents when
returning home. Encouraging the parents to limit visitors for 14 days is more educational and
related to the childs physical recovery. Providing the parents with written discharge instructions
is more educational and designed to reinforce the information. Arranging the follow-up
pediatrician appointment for the parents is an action included in the discharge planning.
DIF: C REF: 139 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
20. Which of the following situations/statements best depicts Goulds fourth theme of adult
development?
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1
When I made that decision, I didnt expect it to turn out like it
did.
2
I have to take the opportunity to be my own boss and not rely
on others.
I think you can do anything if only you have your health and
good friends.
3
4
As much as Id love to open my own shop, I just cant take that
kind of chance.
ANS: 4
The fourth theme, identified in the 40s and called the die is cast, indicates resignation and the
belief that possibilities are limited. The personality is set. Individuals believe changes in career
are less likely to be successful. Parents are blamed for their lack of choices. Individuals face
regret for mistakes made with children. The second theme occurs during the early 30s and asks,
Is what I am the only way for me to be? This question occurs when young adults experience the
consequences of the decisions of their independence. Goulds development themes start when
individuals are in their 20s with, I have to get away from my parents. This is challenged in minor
ways before the end of high school but ends as young persons begin to live away from home.
The move away from parental influence is gradual as young adults establish themselves as
adults. During the 50s a decrease in negativism occurs. Gould finds a realization of mortality
with a concern for ones state of health.
DIF: C REF: 142 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
21. The nurse is caring for an older adult client who has reported symptoms suggestive of
depression. Which of the following questions asked by the nurse is most therapeutic in assessing
the clients perception of the impact depression has had on her life?
1
What does it mean to be depressed?
2
How does being depressed make you feel?
3
Were you happy before becoming depressed?
What makes you think that you are depressed?
4
ANS: 1
Understanding the older persons concept of depression assists nurses in explaining
complementary and alternative treatment measures. Asking how depression make the client feel
or whether the client was previously happy are best saved until the client defines depression and
is open to the possibility of being depressed. Asking what makes the client think they are
depressed could be interpreted as being somewhat threatening and may interfere with the clients
desire to talk about the situation.
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DIF: C REF: 141 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
22. The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piagets
theory of cognitive development suggests that the nurse can help the child cope with the stressors
of this hospital experience best by:
1
2
Arranging for the parents to be with the child until the
anesthetic takes affect
Explaining the entire process with the child using ageappropriate language
3
Using play as a means of familiarizing the child with the
events he will experience
4
Providing the child with a coloring book that shows the events
he will be experiencing
ANS: 3
Play becomes a primary means by which children foster their cognitive development and learn
about the world. Nursing interventions during this period will recognize the use of play as the
way the child understands the events taking place. You will assist parents in the use of play
materials such as thermometers, blood pressure equipment, and play needles that will allow
children to communicate feelings about health care procedures they experience. Arranging for
the parents to be with the child until the anesthetic takes affect may be an appropriate
intervention but it does not reflect effective care suggested by Piagets theory of cognitive
development. Explaining the entire process with the child using age-appropriate language would
be more appropriate for the older child. Providing the child with a coloring book that shows the
events he will be experiencing
DIF: C REF: 142 OBJ: Analysis
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
23. Which of the following nursing responses is most therapeutic when made in response to a
parents concern about her 3-year-old childs tendency to break the rules?
1
Just keep reminding her of the rules.
2
Daycare will help her learn to play fair.
3
She will begin to understand that concept in a year or so.
4
Add an age appropriate punishment for breaking the rules.
ANS: 3
The first stage, heteronomous morality, occurs between 4 and 7 years and is characterized by a
belief that rules are unchangeable and that when a rule is broken, there is imminent justice.
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Before that stage, the child is not able to fully understand rules or other moral issues. While
telling the client to keep reminding her of the rules may be useful, it does not help assure the
parent that the child is displaying normal, age-appropriate behavior. While socialization will
often have a positive effect on a childs sense of fair play, this option does not help assure the
parent that the child is displaying normal, age-appropriate behavior. The child is too young to
understand the concept that makes punishment effective in acquiring fair play.
DIF: C REF: 144 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
24. To help a comatose clients family make a moral decision regarding the termination of life
support, the nurse must first:
1
2
3
4
Refrain from expressing his/her personal beliefs concerning
the life support issue
Provide the family with information regarding the process of
terminating life support
Determine whether the client had expressed any written or oral
wishes regarding the issue
Facilitate the familys decision-making process by providing
them with a quiet, private space for discussion
ANS: 1
Nurses need to know their own moral reasoning level. Recognizing ones own moral
developmental level is essential in separating your own beliefs from others when helping clients
with their moral decision-making process. Information regarding the process of terminating life
support should be provided only after the family makes their decision or has asked for the
information. To not influence the family, the nurse must first refrain from interjecting any
personal feelings about the termination of life support measures.
DIF: C REF: 145 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
25. Which of the following best describes a nurse thinking at stage 5 of Kohlbergs Moral
Developmental Theory?
1
The client has a right to decide whether or not to proceed with
the treatment plan.
2
The hospitals policies and procedures are excellent tools for
making client oriented decisions.
It wont be fair to expect to get every weekend and holiday off,
so Ill certainly work my share.
3
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4
If you dont keep client information confidential you could be
terminated immediately.
ANS: 1
The individual also recognizes that different social groups have different values but believes that
all rational people would agree on basic rights, such as liberty and life. (Stage 5: Social Contract
Orientation). Moral decisions take into account societal perspectives. Right behavior is doing
ones duty, showing respect for authority, and maintaining the social order. (Stage 4:
SocietyMaintaining Orientation). The principles of justice require the individual to treat
everyone in an impartial manner, respecting the basic dignity of all people, and guides the
individual to base decisions on an equal respect for all. (Stage 6: Universal Ethical Principle
Orientation). Avoidance of punishment or the unquestioning deference to authority is the
characteristic motivation to behave. (Stage 1: Punishment and Obedience Orientation)
DIF: C REF: 144 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education
26. Which of the following client statements made by an older adult best reflects an
understanding of the decrease in physical strength and stamina in this developmental stage?
1
I know Im not as young as I use to be.
2
3
I just hire help with jobs I cant do myself.
You get older you cant do as much, thats life.
4
I have to ask my son for help with the yard work.
ANS: 2
A common behavioral task of the older adult client is adjusting to decreasing physical strength.
This option reflects the best adjustment because the client has developed a plan for coping.
While the other options appear to address the issue, they do not present any proof of the clients
healthy acceptance or adjustment to the decrease in physical strength and stamina.
Chapter 12. Conception Through Adolescence
MULTIPLE CHOICE
1. Which of the following data is the most important for the nurse to assess when caring for a
woman in her second trimester of pregnancy?
1
Detection of fetal movement
2
Observation that the uterus is below the pubis
3
Confirmation of the desire to breast- or bottle-feed
Determination of the presence of morning sickness
4
ANS: 1
During the second trimester, between 16 and 20 weeks gestation, the mother begins to feel fetal
movement. During the second trimester, the uterus should be above the level of the symphysis
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pubis. Confirmation of the desire to breast- or bottle-feed is more likely to take place during the
third trimester. Morning sickness is most likely to occur during the first trimester.
DIF: C REF: 151 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific
Assessments
2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month
well-baby visit?
1
2
Moro
Startle
3
Babinski
4
Extrusion
ANS: 3
The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is seen in
the newborn. The startle reflex is seen in the newborn. Before 6 months of age, the extrusion
reflex causes food to be pushed out of the mouth. It is normally present from birth to 4 months.
DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific
Assessments
3. In evaluating an infants physical status and growth, the nurse expects to find:
1
Birth weight triples by 6 months
2
Anterior fontanel closes 4 to 8 weeks after birth
3
Chest circumference is larger than head circumference at 12
months
Birth height increases 1 inch each month for the first 6 months
4
ANS: 4
Height increases an average of 1 inch during each of the first 6 months and inch the next 6
months. Birth weight doubles in approximately 5 months and triples by 12 months. The anterior
fontanel closes at about 12 to 18 months. The head and chest circumference are equal at 1 year of
age.
DIF: A REF: 155 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific
Assessments
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4. Upon evaluation of a 6-month-old infants developmental status, the nurse expects that the
child at this age will be able to:
1
2
3
4
Completely roll over
Pull self to a standing position
Creep on all four extremities
Assume a sitting position independently
ANS: 1
A 6-month-old infant is able to roll over. A 9-month-old infant is able to pull self to a standing
position, creep on all four extremities, and attain a sitting position independently.
DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
5. For a 2-year-old child, cognitive development is characterized by:
1
Recognizing right and wrong
2
Initiating play with other children
3
Having a vocabulary of at least 1000 words
Using short sentences to express independence
4
ANS: 4
A 2-year-old child uses short sentences to express independence and control, does not understand
the concepts of right and wrong, may engage in solitary play and begin to participate in parallel
play, may initiate play with other children, and has a vocabulary up to 300 words.
DIF: A REF: 159 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
6. In planning nursing care for an 18-month-old child, the nurse should know that the
predominant developmental characteristic of children this age is:
1
Parallel play
2
Peer pressure
3
Mutilation anxiety
Imaginary playmates
4
ANS: 1
During toddlerhood, the child begins to participate in parallel play, which is playing beside rather
than with another child. Peer pressure is seen with the school-age child. A fear of the preschool
child is bodily harm. The preschool child may have imaginary playmates.
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DIF: A REF: 159 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was
admitted to the surgical center to have his tonsils removed to:
1
2
Perform his own preoperative hygienic care
Have alone time to relax before the procedure
3
Handle the equipment when taking his blood pressure
4
Have access to age-appropriate magazines and puzzles for
diversion
ANS: 3
Preschool children may cooperate if they are allowed to manipulate the equipment. A preschooler
is unable to take responsibility for his or her own preoperative hygienic care.
Leaving the preschooler alone may increase the childs anxiety. Magazines and puzzles would be
more appropriate activities for the older child. The preschool child likes to engage in pretend
play, using their imagination and imitating adult behavior.
DIF: A REF: 160 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long
before hospitalization but now refuses to use the toilet. What is the correct response by the
nurse?
1
Your son is probably feeling neglected, and you should make
an effort to spend more time with him.
2
This is common behavior that is expressed when the
hospitalized child is stressed or anxious.
3
You may need to include discipline because children easily
lose the ability to be toilet trained during hospitalization.
Your son was probably not ready to be potty trained, and you
may want to continue the training for the next 6 months.
4
ANS: 2
During times of stress or illness, preschoolers may revert to bed-wetting or thumb-sucking and
want the parent to feed, dress, and hold them. Reassuring the parent that this is normal coping
behavior may help alleviate their concern. Reverting to a prior level of functioning, such as a
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child who was potty trained now refusing to use the toilet, does not indicate the child is feeling
neglected. The behavior demonstrates that the child is experiencing stress and this is a coping
behavior. Disciplining the child would not be a correct response. The child should be provided
with experiences he or she can master. Such successes help the child to return to their prior level
of independent functioning.
Reverting to a prior level of functioning, such as a child who was potty trained now refusing to
use the toilet, does not indicate the child was unready to be potty trained. The behavior more
likely demonstrates that the child is experiencing stress, and this is a coping behavior.
DIF: A REF: 161 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
9. A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the following
is the most appropriate nursing response to her alteration in comfort?
1
Please try to not move your leg and that will make it feel
better.
2
Ill give you a shot of medicine that will help take the pain
away.
3
Its okay if you need to cry. Would you like to hold your
favorite doll?
4
Would you like to tell me now where you want me to give you
your shot?
ANS: 3
Telling the child its okay to cry and hold a toy informs the child what they can do, and involves
an age-appropriate familiar toy to provide comfort. Telling the child not to move when they are
in pain is unlikely to be effective. A preschool child may have difficulty in understanding the
request. Telling the child they are going to get a shot may increase their anxiety, as they fear
bodily harm. If a child is allowed to determine the site for administration of an injection, specific
sites should be offered as choices. However, the nurse needs to avoid allowing procrastination by
the child.
DIF: A REF: 160 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
10. When teaching basic infant safety to the parents of a 3-month-old, the nurse should
emphasize:
1
Placing gates at stairways
2
Keeping bathroom doors closed
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3
Giving large, hard teething biscuits
4
Removing feeding bibs at bedtime
ANS: 4
Bibs should be removed at bedtime to avoid suffocation. Placing gates or fences at stairways is
an appropriate safety measure to prevent falls of the 8- to 12-month-old infant. Keeping
bathroom doors closed is an appropriate safety measure to prevent drowning of the 8- to 12month-old infant. Caution should be exercised when giving teething biscuits to a 4- to 7-monthold infant because large chunks may be broken off and aspirated. Teething biscuits are typically
not given to a 3-month-old.
DIF: A REF: 156 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse
informs the parents that the child will be able to:
1
Say Da-da
2
Smile responsively
3
Differentiate strangers
4
Play social peekaboo games
ANS: 2
Two- and 3-month-old infants begin to smile responsively rather than reflexively. By 1 year of
age, infants have two- or three-word vocabularies such as Da-da. By 8 months, most infants can
differentiate a stranger from a familiar person. By 9 months, infants play simple social games
such as patty-cake and peekaboo.
DIF: A REF: 155 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The
nurse responds correctly by telling the client that:
1
The sex of the baby can be determined.
2
3
There is a fine hair that covers the body.
Fingers and toes are differentiated clearly.
4
The organ systems are beginning to develop.
ANS: 4
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During the first trimester of pregnancy, the organ systems are beginning to develop. During the
second trimester of pregnancy, the sex of the fetus can be determined, and fine hair, called
lanugo, covers most of the body of the fetus. Also during the second trimester of pregnancy,
fingers and toes are differentiated.
DIF: A REF: 150 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific
Assessments
13. The nurse assists the family of a 9-year-old with nutritional information. A recommended
after-school snack for a child this age is:
1
2
Milk shakes
Potato chips
3
Plain popcorn
4
Bite-size candy
ANS: 3
Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate are
appropriate after-school snacks. Thick milk shakes would be high in fat and calories. There are
better food choices for after-school snacks. Potato chips should be discouraged as a snack
because they are high in fat and low in nutritional value. Candy bars should be discouraged as a
snack because they are high in fat and calories, are low in nutrition, and are cariogenic.
DIF: A REF: 168 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
14. The elementary school nurse is responsible for evaluating each childs overall physical
development. During the school-age years, the nurse anticipates that:
1
The childs body weight will almost triple
2
There will be few physical differences among children
3
The child will grow an average of 1 to 2 inches per year
Body fat will gradually increase, contributing to a heavier
appearance
4
ANS: 3
During the school-age years, the child will grow an average of 1 to 2 inches per year and gain an
average of 4 to 7 pounds a year. Many children double, not triple, their weight during these
middle childhood years. Growth accelerates at different times for different children. There will
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be many physical differences apparent among children at the end of middle childhood. The
school-age child appears slimmer as a result of changes in fat distribution and thickness.
DIF: A REF: 164 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
15. A 6-year-old is hospitalized for asthma. Which of the following activities would be
appropriate to help this child resolve the crisis of hospitalization?
1
2
3
4
Crayons and a coloring book
A 1000-piece puzzle to complete
A CD player with soothing CDs
A Nerf football to throw around the room
ANS: 1
Providing a 6-year-old with crayons and a book to color in would be an age-appropriate activity
to help the child with the crisis of hospitalization. Painting, drawing, playing computer games,
and making models allow children to practice and improve newly refined skills. A 1000-piece
puzzle would be too much for a 6-year-old to complete. A CD player with soothing CDs would
not be an age-appropriate activity for a 6-year-old. Throwing a Nerf football around the room
may not be appropriate for a hospitalized child with asthma.
DIF: A REF: 164 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
16. Which one of the following statements is correct regarding the preadolescence developmental
stage?
1
It appears 2 years earlier in boys than in girls.
2
Intimate feelings are confided in the parents.
3
Interest in the opposite sex is not a factor for this group.
It signals the development of secondary sex characteristics.
4
ANS: 4
The preadolescence developmental stage (puberty) signals the development of secondary sex
characteristics. Physical changes often begin 2 years earlier in girls than in boys. Preadolescents
usually develop best friends with whom they share intimate feelings. New interest in the opposite
sex develops in the preadolescence developmental stage.
DIF: A REF: 167 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
17. The nurse is teaching parents about probable warning signs that a teenager is considering
suicide and tells parents to be alert to:
1
2
3
4
An increase in appetite
A sudden interest in school activities
An unexplained increase in sleepiness
Talking about death and personal harm
ANS: 4
A warning sign that a teenager is considering suicide includes verbalization of suicidal thoughts.
Appetite disturbances, usually a decrease in appetite, may be a warning sign that a teenager is
considering suicide. A decrease in school performance and loss of initiative are possible warning
signs that a teenager is considering suicide. Sleep disturbances, such as the inability to sleep, are
a warning sign for suicide.
DIF: A REF: 172 OBJ: Knowledge
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
18. In order to obtain the most information, which of the following is the most appropriate
question asked of a 14-year-old female who is visiting the county health center for birth control
help?
1
Have you told your parents that you are sexually active?
2
Are any of your friends participating in sexual behaviors?
3
What can you tell me about any of your past sexual activities?
Have you been physically protecting yourself with safe sex
measures?
4
ANS: 3
The nurse can be proactive by using the interview process and open-ended questions such as this
one, to identify risk factors in the adolescent. Once identified, the risk factors should lead to
strategies for prevention. Inquiring what the client has told parents does not obtain the most
information. Asking about friends activities does not address the individual and does not obtain
the most information about the health behaviors of the client. Asking whether the client is having
safe sex may be answered with a yes or no response and therefore does not obtain the most
information.
Chapter 13. Young and Middle Adults
MULTIPLE CHOICE
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1. A client thinks that she might be pregnant. Which first trimester physiological changes would
most likely indicate this?
1
2
3
4
Amenorrhea and nausea
Braxton Hicks contractions
Increased urinary frequency
Edematous ankles and dyspnea
ANS: 1
Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first
trimester. Braxton Hicks contractions are noted during the second trimester of pregnancy.
Increased urinary frequency is commonly seen in the third trimester of pregnancy. Edematous
ankles and dyspnea may be experienced during the third trimester of pregnancy.
DIF: A REF: 183 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/Reduction of Risk Potential/Specific Systems
Assessment
2. To determine how the client, who is a single parent of three children, will be able to cope with
the current pregnancy, the nurse should ask the client:
1
Have you ever been married?
2
Where do you currently work?
3
Has anyone ever taught you about contraception?
4
Who do you have for support during this pregnancy?
ANS: 4
This could be a situational crisis for a single-parent family. The nurse should assess
environmental and familial factors, including support systems and coping mechanisms
commonly used. Asking the client whether she has ever been married does not assess her ability
to cope with the pregnancy. Asking the client where she works may help determine if there are
any environmental factors that may place her pregnancy at risk, but it does not assess her ability
to cope with the pregnancy. This would not be the most opportune time to discuss contraception
with the client and may convey a message of disapproval. Nor does asking the client about
contraception assess her ability to cope with the pregnancy.
DIF: B REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management
3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will
most likely find that the client of this age is experiencing which one of the following
physiological changes related to normal aging?
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1
Decreased hearing acuity
2
3
Decreased sense of smell
Decreased strength of abdominal muscles
4
Decreased function of the various cranial nerves
ANS: 3
A physiological change related to normal aging in the middle adult would be decreased strength
of abdominal muscles. The middle adult should have normal auditory structures and acuity. The
middle adult should have a normal sense of smell. The middle adult should have normal
functioning of the cranial nerves.
DIF: A REF: 185 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/
Specific Systems Assessment
4. A 49-year-old client is experiencing problems with depression. She has come to the clinic
showing signs of malnutrition and fatigue. Which of the following is the best initial statement for
the nurse to make in the assessment phase?
1
How much weight have you lost over the past month?
2
Have you recently been experiencing menopausal symptoms?
3
Depression is something to expect at your age, and with
assistance you will get better.
Your depression is somewhat uncommon. Can you tell me
what has happened recently to cause it?
4
ANS: 2
Mood changes and depression are common phenomena during menopause, and this client is in
the expected age range to be experiencing menopause. Asking the client about weight loss may
be an indication to verify depression; however, it is not the best initial response. Depression is
not something to expect, although it can occur. Depression is not uncommon during menopause.
DIF: C REF: 186 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management
5. The nurse, trying to promote positive health habits regarding stress management is aware of
the external influences on young and middle adult clients. With this knowledge, the nurse
recognizes that an effective strategy for this age-group is:
1
Teaching clients to abstain from all alcohol consumption
2
Demonstrating how to take an accurate blood pressure
measurement
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3
Determining an effective daily exercise schedule for stress
reduction
4
Describing the types of medications commonly used for
treating depression
ANS: 3
Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young
and middle adults. Exercise is a positive health habit for this age-group. Clients do not have to
abstain from all alcohol consumption. Teaching clients to abstain from excessive alcohol
consumption is important, but it is not a proactive positive health habit to help reduce stress.
Monitoring ones blood pressure may be important, but it is not a proactive positive health habit
to help reduce stress. Teaching clients about types of medication used for treating depression
does not help the client develop positive health habits for reducing stress.
DIF: A REF: 182 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices
6. Individuals at the young adult point in their life are generally expected to, according to
developmental patterns:
1
Continue physical growth
2
3
Experience severe illnesses
Ignore physical symptoms
4
Seek frequent medical care
ANS: 3
Young adults generally are quite active, experience severe illnesses less commonly than older
age-groups, tend to ignore physical symptoms, and often postpone seeking health care. Young
adults generally do not continue their physical growth. Young adults experience severe illnesses
less commonly than older age-groups. Young adults often postpone seeking health care.
DIF: A REF: 178 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development
7. A nurse is preparing an education program on safety for a young adult group. Based on the
major cause of mortality and morbidity for this age-group, the nurse should focus on:
1
Birth control
2
3
Automobile safety
Occupational hazards
4
Prevention of heart disease
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ANS: 2
Violence is the greatest cause of mortality and morbidity in the young adult population. Deaths
and injury from motor vehicle accidents are significant among this age-group. Unplanned
pregnancies may be a source of stress but is not the major cause of mortality and morbidity in the
young adult population. Exposure to work-related hazards or agents may cause diseases and
cancer, but it is not the major cause of mortality and morbidity in this age-group. Developing
healthy habits to prevent heart disease later in life is important, but heart disease is not the
leading cause of mortality and morbidity for the young adult.
DIF: A REF: 181 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development/Lifestyle Choices
8. A nurse is working in the health office at a local college where most of the students are young
adults. Being aware of the major concerns for this age-group, the nurse includes assessment of
these clients:
1
Current marital history status
2
Lifestyle and leisure activities
3
Experience with chronic disease
4
History of childhood accidents
ANS: 2
The young adult client may benefit from a personal lifestyle assessment to help identify habits
that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases.
Assessing a clients marital status does not offer much information about the clients health or risk
for future illnesses. Assessing a clients experience with chronic disease is less appropriate for
this age-group. Assessing the clients history of childhood accidents does not offer much
information about the clients current health or risk for future illnesses.
DIF: A REF: 179 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development/Lifestyle Choices
9. As an individual enters middle adulthood health problems generally become more prevalent.
The middle adult may be influenced by chronic illness that results in:
1
Decreased health care tasks
2
Reinforcement of family roles
3
Changed sexual behavior habits
Improvement of family relationships
4
ANS: 3
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A few examples of the problems experienced by clients who develop debilitating chronic illness
during adulthood include role reversal, changes in sexual behavior, and alterations in self-image.
Chronic illness would result in increased health care tasks. Family roles are often changed with
chronic illness, not reinforced. Strained family relationships may result from chronic illness.
DIF: A REF: 186 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development
10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will
most likely find that the client of this age is experiencing which one of the following
physiological changes related to normal aging?
1
2
Palpable thyroid lobes
Decreased skin turgor
3
Reduced pupillary reaction
4
Increased range of joint motion
ANS: 2
There is a slow, progressive decrease in skin turgor in the middle adult. The thyroid lobes should
not be palpable in the middle adult. Pupillary reaction to light and accommodation should not
change in the middle adult. A normal change in the middle adult is a decreased range of joint
motion.
DIF: A REF: 221 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development
11. The nurse is alert to stressors that may have an influence on the young adult client. One
example of a common stressor for this age-group is:
1
Occupational pursuits
2
Health-related matters
3
Coping with cognitive changes
4
Caring for the older adult parent
ANS: 1
A common stressor for the young adult is job stress. Health-related matters are not common
stressors for the young adult. Coping with cognitive changes is not a common stressor for the
young adult. Caring for older adult parents is more often seen with the middle adult, not the
young adult.
DIF: A REF: 182-183 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Psychosocial Integrity/Stress Management
12. A client who works in a dry cleaning establishment comes to the clinic for a regular checkup. Based on this information, the nurse assesses the client for:
1
2
3
4
Asbestosis
Dermatitis
Tendonitis
Raynauds phenomenon
ANS: 2
Persons who work in dry cleaning establishments are exposed to solvents that may cause
dermatitis or liver disease. Asbestosis is more likely to be found as an occupational hazard for
automobile workers and insulators. Tendonitis may result from repetitive wrist motion as seen in
office computer workers. Raynauds phenomenon may result from vibration as seen with
jackhammer operators.
DIF: C REF: 182 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/
Specific Systems Assessment
13. The nurse is completing a physical exam for a 45-year-old client who has come to the family
practice office. In evaluating the observations made during the examination, the nurse recognizes
that an expected finding for a client in this age-group is:
1
Hepatomegaly
2
Visual acuity below 20/50
3
An oral temperature of 39 C
4
Increased amount of skin turgor
ANS: 2
The visual acuity tested by the Snellen chart should be less than 20/50. Hepatomegaly is not an
expected finding and would be considered abnormal. Oral temperature should be 36.1 to 37.6 C.
The expected finding would be a slow, progressive decrease in skin turgor.
DIF: A REF: 221 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/
Specific Systems Assessment
14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the
greatest financial impact on this family is caused by:
1
The ever-rising cost of living in the United States
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2
3
4
The realization that a female earns 25% less than her male coworker
Court-ordered child support is often times inadequate.
Daycare expenses are a strain on a single wage earner family
ANS: 2
According to the AFL-CIO (2004) workers union, women in the United States are paid 76 cents
for every dollar men receive for comparable work. This fact has an all-encompassing effect on
the single-parent household. The cost of living is rising; it is not unique to the single mother.
While court-ordered support often is inadequate, it does not have the impact that earning power
has on the family income. While daycare expenses can be a strain, does not have the impact that
earning power has on the family income.
DIF: C REF: 178 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Dynamics
15. Because young adults are less likely to experience serious illness, which of the following
nursing interventions is most effective in determining risk for illness in this age-group?
1
Health screenings
2
Personal lifestyle assessment
3
Full body systems assessment
4
Cardiopulmonary focal assessment
ANS: 2
A personal lifestyle assessment (see Chapter 6) helps nurses and clients identify habits that
increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Health
screening helps detect the presence of disease processes. Full body systems assessment would
determine deviation from normal but not necessarily identify risk for illness. Cardiopulmonary
focal assessment would determine deviation from normal but not necessarily identify risk for
illness.
DIF: B REF: 178 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury;
Physiological Integrity/Specific System Assessment
16. Research has shown that certain postpartum factors negatively affect a womans general
health status after pregnancy. Which of the following women has the greatest risk factor for poor
postpartum health?
1
A mother with complaints of fatigue, loss of appetite, and
insomnia
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2
A practicing attorney who has reluctantly taken a 3-month
maternity leave
3
A stay-at-home mom who gave birth 2 months ago and whose
husband recently lost his job
A mother of a 3-week-old and a 2-year-old whose military
husband is currently deployed overseas
4
ANS: 4
Postpartum stress and depression have significant effects on postpartum womens health. In
addition, a lack of social support can affect womens health adversely. This woman is the most
likely mother to be experiencing depression and economic stressors as well as a lack of support.
While fatigue, loss of appetite, and insomnia may be reflective of depression, there are no
indications of the other high-risk factors. While this woman may be experiencing anxiety over
being away from her career for 3 months, there is no indication of the other risk factors. While
this mother may well be at risk for depression and possible financial stressors, there is no
indication of a lack of support.
DIF: C REF: 180 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems
17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with
the parents of a newborn. Which of the following nursing actions would be most therapeutic
regarding early detection of this postpartum condition?
1
Helping the couple understand the importance of social
interaction with other adults
2
Providing the couple with a video that tells the story of a new
mothers experience with depression
3
Encouraging the couple to attend parenting classes designed to
minimize the stressors of parenting an infant
4
Having a discussion with the father in which he identifies the
signs and symptoms of postpartum depression
ANS: 4
Educating both new mothers and their families regarding the signs and symptoms of postpartum
stress and depression will facilitate early detection and treatment of the condition. While
preventing social isolation is important to the prevention of generalized depression, it has little
impact on detecting the signs and symptoms of the condition. While the video may be
informative it is not the most therapeutic option because it lacks interaction between the nurse
and the clients. While Option 3 is appropriate in regard to minimizing the risk of developing
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depression stemming from postpartum stressors, it does not directly impact the identification of
the signs and symptoms of the condition.
DIF: C REF: 180 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems;
Psychosocial Integrity/Stress Management/Crisis Intervention
18. Which of the following young adults is at greatest risk for experiencing death or injury?
1
2
An 18-year-old with a father who is an alcoholic
A 30-year-old who is a professional rodeo rider
3
A 20-year-old living in an urban housing project
4
A 26-year-old riding a motorcycle across the country
ANS: 3
Violence is the greatest cause of mortality and morbidity in the young adult population. Factors
that predispose individuals to violence, injury, or death include poverty, family breakdown, child
abuse and neglect, repeated exposure to violence, and ready access to guns. This option
represents an individual who most likely is both poor and exposed to an environment of repeated
violent acts. While Option 1 represents a potential for physical and mental abuse, it does not
present the level of potential violence existing in Option 3. While Option 2 represents a potential
for physical injury and possible death, it does not present the level of potential violence existing
in Option 3. While Option 4 represents a potential for physical injury and possible death, it does
not present the level of potential violence existing in Option 3.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury
19. The most serious risk for death for a young adult living in rural poverty is:
1
Suicide
2
Homicide
3
Poor health maintenance practices
4
Family history of chronic illnesses
ANS: 1
A young adult is more likely to die of self-inflicted injury when living at or below the poverty
level when no other risk factors (i.e., a violent environment, drug abuse, etc.) are present. In
2002 the death rate (per 100,000 population) for 25- to 34-year-olds in the United States caused
by homicide was 11.2; the death rate caused by accidents was 31.5; and the death rate caused by
suicide was 12.6 (U.S. Department of Health and Human Services [USDHHS]).
DIF: C REF: 13 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management/Crisis
Intervention
20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his
drivers license because of an arrest for driving under the influence of alcohol. This admission
should prompt the nurse to discuss which of the following in detail with the client?
1
2
Use of illegal drugs
History of depression
3
Unprotected sexual experiences
4
Tendency toward violent behavior
ANS: 1
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly
conduct are reasons for you to investigate the possibility of drug abuse more carefully. A history
of depression is not necessarily a risk factor for illegal drug abuse. Unprotected sex is not
necessarily a risk factor for illegal drug abuse. A tendency toward violent behavior is not
necessarily a risk factor for illegal abuse.
DIF: C REF: 181 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors;
Psychosocial Integrity/Chemical Dependency
21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the
nurse shares with the client that in addition to physical symptoms of genital pain and discharge,
sexually transmitted diseases:
1
Can lead to chronic illness and infertility
2
Are particularly common in young adults
3
Respond well to treatment when detected early
May be effectively controlled through the use of condoms
4
ANS: 2
Sexually transmitted diseases (STDs) remain a major public health problem for sexually active
persons, with almost half of all new infections occurring in men and women younger than 24
years of age (USDHHS, CDC, 2004). While Option 1 is true, it is vitally important that the nurse
first share the high probability of contracting a STD to a sexually active young adult who
practices unprotected sex. While some STDs respond well to early treatment, some, such as
genital herpes and human immunodeficiency virus (HIV), can only be managed because no cure
is currently available. While Option 4 may be true, it is vitally important that the nurse first share
the high probability of contracting a STD in a sexually active young adult who practices
unprotected sex.
DIF: C REF: 181 OBJ: Analysis
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the
young adult?
1
2
3
4
Alcohol and tobacco use
Ignoring seat belt and helmet laws
Unprotected sex with multiple partners
Poor nutrition and a lack of structured exercise
ANS: 1
Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic
illnesses or disabilities during their middle or older adult years. While ignoring seat belt and
helmet laws represents a risk factor for injury or death it is not directly related to chronic illness.
While unprotected or multiple-partner sex option does represent a risk factor for chronic disease
in the form of STDs, the greater risk comes from alcohol and tobacco use. While poor nutrition
and lack of exercise do represent risk factors for chronic disease such as heart disease and
obesity, the greater risk comes from alcohol and tobacco use.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
23. Which of the following client responses shows the best understanding regarding the
management of risk factors for chronic illness among young adults?
1
Unprotected sex is just plain dangerous.
2
Everyone riding in my car wears a seatbelt.
3
Im a vegetarian, but I eat nonanimal protein.
Ive never smoked and I drink only occasionally.
4
ANS: 4
Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in middle
and older adult years. While Option 1 shows an understanding of the risk factor for chronic
disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While Option
2 shows an understanding of the risk factor for injury and death caused by vehicular accidents, it
is not directly related to chronic illness.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
24. Which of the following lifestyle choices poses the greatest risk for chronic illness to the
young adult?
1
Alcohol and tobacco use
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2
Ignoring seat belt and helmet laws
3
Unprotected sex with multiple partners
Poor nutrition and a lack of structured exercise
4
ANS: 1
Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic
illnesses or disabilities during their middle or older adult years.
DIF: C REF: 180-181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
25. Which of the following client responses shows the best understanding regarding the
management of risk factors for chronic illness among young adults?
2
Unprotected sex is just plain dangerous.
Everyone riding in my car wears a seat belt.
3
Im a vegetarian, but I eat non-animal protein.
4
Ive never smoked, and I drink only occasionally.
1
ANS: 4
Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in their
middle and older adult years.
DIF: C REF: 180-181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
26. Which of the following client responses shows the best understanding regarding the
management of risk factors for acquiring a sexually transmitted disease (STD) among young
adults?
1
I may want to have children someday, so I need to be careful.
2
Even though there are treatments for STDs, I dont take
chances.
There is certainly enough literature out there on the use of
condoms.
3
4
Having unprotected sex with someone my age is very risky
business.
ANS: 4
Sexually transmitted diseases (STDs) remain a major public health problem for sexually active
persons, with almost half of all new infections occurring in men and women younger than 24
years of age (USDHHS, CDC, 2004).
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While it is true that some STDs can result in infertility, this option doesnt show the greatest
understanding since it focuses on only one outcome.
While some STDs respond well to early treatment, some STDs, such as genital herpes and
human immunodeficiency virus (HIV), can only be managed since a cure is not currently
available.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: : Health Promotion and Maintenance/High Risk Behaviors
27. Which of the following statements made by a 27-year-old client shows the greatest need for
further nursing assessment regarding the potential use of illegal drugs?
1
Whether you wear a helmet or not should be the choice of the
motorcyclist.
2
I fractured my hand 3 years ago when I got so mad I hit a wall
in my dorm room.
3
I like to drink a bit too much, and I lost my license once for
drinking and driving.
4
My father suffered from depression when he lost his job, and
he still takes medication for it.
ANS: 3
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly
conduct are reasons for you to investigate the possibility of drug abuse more carefully.
A tendency toward high-risk behavior such as extreme sports or not using safety equipment is
not necessarily a risk factor for illegal drug use.
A tendency toward violent behavior is not necessarily a risk factor for illegal drug abuse.
A family history of depression is not necessarily a risk factor for illegal drug abuse.
DIF: C REF: 181 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors
28. Which of the following statements made by the parents of a newborn best reflects an
understanding regarding the diagnosis of postpartum depression?
1
I helped my sister when she was depressed after the birth of
her second child.
2
I have a wonderfully supportive family who will be there if I
start feeling depressed.
3
Weve read over the literature, and Ill be able to recognize any
signs of depression in my wife.
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4
Most new moms get a little depressed, but we will be sure to
pay attention to any real indications of a problem.
ANS: 3
Having someone in close contact with the new mom available to assess her for possible signs of
postpartum depression shows both an understanding of the condition as well as a desire to
manage it if it occurs.
DIF: C REF: 180 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Family Systems;
Psychosocial Integrity/Stress Management/Crisis Intervention
29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy
most likely observed in the second trimester?
1
Have you had any problems climbing steps?
2
Have you noticed any cramping in your abdomen?
3
Have you experienced any nausea in the morning?
Have you had any problems with shoes that dont seem to fit?
4
ANS: 2
Braxton-Hicks contractions are noted during the second trimester of pregnancy.
Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy.
Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first
trimester. Edematous ankles and dyspnea may be experienced during the third trimester of
pregnancy.
DIF: C REF: 183 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Ante/Intra/Postpartum
and Newborn Care; Physiological Integrity/ Reduction of Risk Potential/Specific Systems
Assessment
30. Which of the following client statements would be the best evidence that this young adult has
adopted a positive strategy to promote his own personal emotional health?
1
I drink alcohol only on special occasions and then moderately.
2
I run at least three times a week; it seems to help me stay
relaxed.
3
I watch for the signs of depression since my mother
experienced it.
4
I know stress can affect my blood pressure, so I have it taken
regularly.
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ANS: 2
Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young
and middle adults. Exercise is a positive emotional health habit for this age group.
Drinking alcohol in moderation is certainly a positive health habit, but it does not have the
strongest impact on emotional health of the available options.
DIF: C REF: 181 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices;
Psychosocial Integrity/Coping Mechanisms
31. Which of the following client statements, made by a young adult regarding health promotion
habits, reflects a need for further client education by the nurse?
1
2
I go to the gym and work out 3 times a week with friends.
My dad has high cholesterol, so I have mine checked yearly.
3
Diabetes runs in my family, so I watch my carbohydrate
intake.
4
I drink alcohol only on weekends, when it doesnt interfere
with work.
ANS: 4
The correct answer reflects a poor understanding of alcohol abuse. The primary criterion for
healthy alcohol consumption is not drinking only when it will not affect work. Further education
regarding responsible alcohol consumption and alcoholism is appropriate. The other options
reflect a good understanding of health promotion habits.
DIF: C REF: 181 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices;
Psychosocial Integrity/Coping Mechanisms
32. Which of the following nursing assessment questions is best directed toward determining the
presence of a normal physiological change experienced by a middle-aged client?
1
Any problems with your teeth or gums?
2
Any family history of thyroid problems?
3
Do you have a skin-moisturizing routine?
Are you having a problem with driving at night?
4
ANS: 3
There is a slow, progressive decrease in skin turgor in the middle-aged adult.
Dental problems are not a normal physiological change seen in the middle-aged adult.
Thyroid problems are not a normal physiological change seen in the middle-aged adult.
Night blindness is not a normal physiological change seen in the middle-aged adult.
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DIF: C REF: 185 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development
33. Which of the following nursing assessment questions is best directed toward determining the
presence of an occupational hazard-related condition specific for a client working in a dry
cleaning establishment?
1
2
Do you have any problems with rashes or itching?
How long have you worked in the dry cleaning business?
3
Do you treat the minor burns you experience?
4
Do you drive the company van to make deliveries?
ANS: 1
Persons who work in dry cleaning establishments are exposed to solvents that may cause
dermatitis or liver disease. While asking about the length of time employed is an appropriate
assessment question, it is not directed toward identifying a response to any specific risk factor.
While burns may be a risk factor for those working in the dry cleaning industry, the risk is not as
specific as assessing for contact dermatitis.
While automobile accident-related injuries may be a risk factor in this case, the risk is not as
specific as assessing for contact dermatitis.
DIF: C REF: 182 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/ Reduction of Risk Potential/
Specific Systems Assessment
34. Which of the following nursing assessment questions is best directed toward determining the
presence of career stressors in a young adult?
1
What do you do to relieve stress for yourself?
2
What is the most stressful part of your daily job?
3
Career-wise, where would you like to be in 2 years?
Do you miss much work as a result of injuries or illness?
4
ANS: 2
The correct option is an open-ended question that encourages the client to identify and discuss
work-related stressors, which are a major source of stress for this age group.
DIF: C REF: 182-183 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Psychosocial Integrity/Stress Management
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35. Which of the following statements concerning health promotion habits made by a young
adult best reflects an understanding regarding the primary cause of death and injury among that
age group?
1
Eating a healthy, low-fat diet is very important to me.
2
AIDS is nothing to mess with, so I always practice safe sex.
Regardless of what my friends say, I always wear a seat belt.
3
4
I enjoy mountain biking, but I always wear the right protection
gear.
ANS: 3
Deaths and injury from motor vehicle accidents are significant among this age group.
Developing healthy habits to prevent heart disease later in life is important, but heart disease is
not the leading cause of mortality and morbidity for the young adult.
Sexually transmitted diseases are a risk factor for this age group, but they do not represent the
greatest risk for death and injury.
An injury related to occupation and recreation is a risk factor, but it is not the major cause of
mortality and morbidity in this age group.
Chapter 14. Older Adults
MULTIPLE CHOICE
1. A nurse is performing a physical examination on an older-adult client in an assisted living
facility. On completion of the examination, the nurse compares the results to findings expected
for individuals in this age-group. An expected finding for this client is:
1
Increased tactile responsiveness
2
Increased sensitivity to visual glare
3
Increased hearing acuity for higher tones
Increased thoracic expansion during ventilation
4
ANS: 2
A common physiological change in the older-adult client is an increased sensitivity to glare.
Increased tactile responsiveness would not be an expected finding in the older-adult client. An
expected physiological change in the older adult-client is a loss of hearing acuity for highfrequency tones (presbycusis). The older adult has decreased thoracic expansion during
ventilation because of musculoskeletal changes.
DIF: A REF: 198 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Integrity/System Specific Assessment
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2. A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood
pressure checked each shift. An appropriate response by the nurse as to why older clients often
experience hypertension is because of:
1
Myocardial muscle damage
2
3
Reduction in physical activity
Ingestion of foods high in sodium
4
Accumulation of plaque on arterial walls
ANS: 4
Although hypertension is not a normal physiological change of aging, older adults often
experience hypertension because of vascular changes and accumulation of plaque on arterial
walls, both of which reduce contractility. Vascular changes include thickening of vessel walls,
narrowing of vessel lumen, and loss of vessel elasticity. Myocardial damage is not the reason for
older adults commonly experiencing hypertension. Hypertension is not caused by a reduction in
physical activity. Older adults with hypertension should be counseled on limiting fat and salt in
their diet. However, ingestion of processed foods high in salt is not the reason why older clients
often experience hypertension.
DIF: A REF: 199 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems
3. In reviewing changes in the older adult, the nurse recognizes that which of the following
statements related to cognitive functioning in the older client is true?
1
Delirium is usually easily distinguished from irreversible
dementia.
2
Therapeutic drug intoxication is a common cause of senile
dementia.
Reversible systemic disorders are often implicated as a cause
of delirium.
3
4
Cognitive deterioration is an inevitable outcome of the human
aging process.
ANS: 3
Delirium is a potentially reversible cognitive impairment that is often due to a physiological
cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumors,
cerebrovascular infection, or hemorrhage. Delirium is not always easily distinguishable from
irreversible dementia. Because of the close resemblance between delirium and dementia, the
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presence of delirium must be ruled out whenever dementia is suspected. The cause of senile
dementia (e.g., Alzheimers disease) is not known. Medications and drug effects can cause
delirium. Dementia is not an inevitable outcome of aging.
DIF: A REF: 202 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
4. A client has been recently diagnosed with Alzheimers disease. When teaching the family about
the prognosis, the nurse must explain that:
1
Diet and exercise can slow the process considerably
2
Few clients live more than 3 years after the diagnosis
3
Many individuals can be cured if the diagnosis is made early
4
It usually progresses gradually with a deterioration of function
ANS: 4
Alzheimers disease usually progresses gradually with a deterioration in function. Medications,
not diet and exercise, can slow the process of Alzheimers disease considerably. Clients may live
years after the diagnosis of Alzheimers disease. There is no cure for Alzheimers disease but
medications can be given to slow the progression of symptoms.
DIF: A REF: 202 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems
5. Which of the following statements accurately reflects data that the nurse should use in
planning care to meet the needs of the older adult?
1
50% of older adults have two chronic health problems.
2
Cancer is the most common cause of death among older
adults.
Nutritional needs for both younger and older adults are
essentially the same.
3
4
Adults older than 65 comprise the greatest users of
prescription medications.
ANS: 4
This is a true statement. Approximately two thirds of older adults use prescription and
nonprescription drugs with one third of all prescriptions being written for older adults.
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Approximately 90% of adults older than 65 have at least one chronic health condition.
Approximately 70% of older adults have multiple chronic conditions with arthritis, hypertension,
heart disease, vision impairment, and diabetes mellitus being the most common in
noninstitutionalized older adults. Heart disease is the leading cause of death in older adults.
Nutritional needs of older adults are affected by their levels of activity and by clinical conditions.
DIF: A REF: 209 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
6. The nurse is aware that the majority of older adults:
1
2
Live alone
Live in institutional settings
3
Are unable to care for themselves
4
Are actively involved in their community
ANS: 4
The majority of adults are indeed active within their community. The majority of older adults
live with a spouse or have other living arrangements such as living with a family member. Most
older adults live in noninstitutional settings. Most older adults are able to care for themselves.
DIF: A REF: 193 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process
7. The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which
of the following statements made by the nurse is the most therapeutic regarding their mobility?
1
Your shoulder pain is normal for your age.
2
Continue to exercise your joints regularly to your tolerance
level.
3
Why dont you begin walking 3 to 4 miles a day, and well
evaluate how you feel next week.
Dont worry about taking that combination of medications
since your doctor has prescribed them.
4
ANS: 2
Clients in the older adult age group should be advised to exercise their joints regularly to their
level of tolerance. Shoulder pain is not a normal finding in the older adult. It may indicate a
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condition such as arthritis. Exercise programs should begin conservatively and progress slowly.
Periodic and thorough review of all medications being used is important to restrict the number of
medications used to the fewest necessary. Concurrent use of medications increases the risk for
adverse reactions.
DIF: A REF: 207-208 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
8. A long-term care facility sponsors a discussion group on the administration of medications.
The participants have a number of questions concerning their medications. The nurse responds
most appropriately by saying:
1
2
Dont worry about the medications name if you can identify it
by its color and shape.
Unless you have severe side affects, dont worry about the
minor changes in the way you feel.
3
Feel free to ask your physician why you are receiving the
medications that are prescribed for you.
4
Remember that the hepatic system is primarily responsible for
the pharmacotherapeutics of your medications.
ANS: 3
The nurse should encourage the older adult to question the physician and/or pharmacist about all
prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all
drugs being taken, when and how to take them, and the desirable and undesirable effects of the
drugs. The nurse should teach the client how to avoid adverse side effects and to report them to
their care provider if they occur. If the client is disturbed by minor side effects, it could be an
indication of beginning drug toxicity. Another possibility is that the client may become
noncompliant with their medication because they dislike how the side effects make them feel.
The hepatic system is not the only system responsible for the pharmacotherapeutics of
medication. Older adults are at risk for adverse reactions because of age-related changes in the
absorption, distribution, metabolism, and excretion of drugs. Changes in the GI system may
affect absorption, distribution may be affected by changes in body composition and by reduced
serum albumin levels, and changes in kidney functioning may impair excretion.
DIF: A REF: 209 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Pharmacological Therapies
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9. Which of the following behaviors shows the greatest risk to an older adult as they attempt to
minimize the effects of the aging process?
1
2
3
4
Increased cosmetic use
Refusing to share their actual ages
Spending less time with age-related peers
Refusing assistance with certain activities
ANS: 4
Some older adults may deny functional declines associated with aging and refuse to ask for
assistance with tasks that place their safety at great risk. Some older adults find it difficult to
accept themselves as aging and attempt to conceal physical evidence of aging with cosmetics.
Older adults who find it difficult to accept themselves as aging may understate their age when
asked. Spending more time with other older adults is indicative of the older adults acceptance of
personal aging. Those who find it difficult to accept themselves as aging may avoid activities
designed to benefit older adults, such as senior citizens centers and senior health promotion
activities.
DIF: C REF: 195 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process
10. In performing a physical assessment for an older adult, the nurse anticipates finding which of
the following normal physiological changes of aging?
1
Increased perspiration
2
Increased airway resistance
3
Increased salivary secretions
Increased pitch discrimination
4
ANS: 2
Normal physiological changes of aging include increased airway resistance in the older adult.
The older adult would be expected to have decreased perspiration and drier skin as they
experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The
older adult would be expected to have a decrease in saliva. A normal physiological change of the
older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis).
DIF: A REF: 199 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
11. There are factors that influence the musculoskeletal system associated with aging. The nurse
recognizes that with age:
1
2
3
4
Men have the greatest incidence of osteoporosis
Muscle fibers increase in size and become tighter
Weight-bearing exercise reduces the loss of bone mass
Muscle strength does not diminish as much as muscle mass
ANS: 3
Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as
those who are inactive. Postmenopausal women have a greater problem with osteoporosis than
older men. Muscle fibers are reduced in size with aging. Muscle strength diminishes in
proportion to the decline in muscle mass.
DIF: A REF: 207-208 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
12. The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the
majority of older adults:
1
Require institutional care
2
Have no social or family support
3
Are unable to afford any medical treatment
Are capable of taking charge of their own lives
4
ANS: 4
The majority of older adults are interested in their health and are capable of taking charge of their
lives. Most older adults do not require institutional care. The majority of older adults have social
or family support. Most older adults live with a spouse or have other living arrangements, such
as living with a family member. Most older adults receive Social Security benefits and are able to
afford medical treatment.
DIF: A REF: 93 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process
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13. To assist older adults to meet their needs for sexuality, the nurse should recognize that the
greatest impact on the sexuality of older adults is:
1
2
Therapeutic medications may alter sexual function
Sexual interest declines and then fades completely with age
3
Physiological changes do not adversely influence sexual
activity
4
Prevention of sexually transmitted diseases is no longer an
issue
ANS: 1
Many older adults use prescription medications that depress sexual activity, such as
antihypertensives, antidepressants, sedatives, or hypnotics. Some drugs increase libido in older
adults. For example, phenothiazines increase sexual desire in women, and levodopa has a similar
effect in men. It is a common misconception that older adults are not interested in sex. The older
adults libido does not decrease, although frequency of sexual activity may decline. Physiological
changes may have an adverse influence on sexual activity. The older man may experience
decreased firmness in his erection, a decreased need for ejaculation with orgasm, or a longer
recovery period between episodes of intercourse. The older woman may experience vaginal
dryness. Information about the prevention of sexually transmitted diseases should be included
when appropriate.
DIF: A REF: 203-204 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
14. The nurse is presenting an information session on nutritional guidelines at a senior living
center. Incorporated into the discussion are the recommendations for nutritional intake for
individuals of this age-group, which include a reduction in:
1
Fiber
2
Protein
3
Vitamin A
Refined sugars
4
ANS: 4
Good nutrition for older adults includes a limited intake of refined sugars. Fiber should not be
reduced as it has benefits of aiding bowel elimination and lowering cholesterol. Protein should
not be reduced. Protein intake may be lower than recommended if older adults have reduced
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financial resources or limited access to grocery stores. Difficulty chewing meat may also limit
protein intake. Vitamin A does not need to be reduced in the older adult. Vitamin intake may be
less than recommended if shopping for fresh fruits and vegetables is difficult.
DIF: A REF: 207 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
15. The nurse is presenting an information session on nutritional guidelines at a senior living
center. Which of the following foods meets the recommended nutritional guidelines for older
adults?
1
Grilled chicken
2
3
Hamburger and french fries
Hot dog with dill pickle relish
4
Baked potato with cheese and bacon bits
ANS: 1
Grilled chicken would be a good source of protein that is also low in fat. A hamburger and french
fries are high in fat content and calories, making them a less desirable food choice. A hot dog
with pickle relish is high in fat and sodium. Good nutrition for the older adult includes a limited
intake of fat and salt. A baked potato with cheese and bacon bits is higher in calories and fat. A
plain baked potato would be a healthier food choice.
DIF: A REF: 207 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
16. In the assessment of older-adult clients, it is often difficult to discriminate between delirium
and dementia. Delirium is characterized by:
1
A slow progression
2
Lasting months to years
3
A normal state of alertness
4
Occurrences at twilight or darkness
ANS: 4
Delirium is characterized by short, diurnal fluctuations in symptoms and is worse at night, in
darkness, and on awakening. Delirium has an abrupt onset. Dementia has a slow progression.
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Delirium lasts hours to less than 1 month, seldom longer. Dementia may last months to years.
Delirium is characterized by fluctuating alertness; the client may be lethargic or hypervigilant.
Alertness is generally normal with dementia.
DIF: A REF: 202 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
17. Which of the following nursing questions is best directed towards the assessment of a normal
finding regarding physiological changes in an older-adult client?
1
Any difficulty driving at night?
2
Are you experiencing any loss of libido?
3
Do you see yourself as becoming forgetful
4
Have you had your cholesterol tested lately?
ANS: 1
A common physiological change in the older-adult client is an increased sensitivity to glare,
which makes night driving difficult. Decreased sexual drive is not a normal physiological change
of aging. Memory loss is not a normal physiological change of aging. Hyperlipidemia is not a
normal physiological change of aging, nor should it be monitored only by the older adult.
DIF: C REF: 198 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process;
Physiological Integrity/System Specific Assessment
18. Which of the following responses by an older-adult client is most reflective of a need for
further education by the nurse regarding the physiological changes associated with the older
adult?
1
I call a cab if I want to go out after dark.
2
I cant help worrying about becoming forgetful.
3
I have my eyes checked regularly. Cant afford to fall.
I really enjoy eating good vanilla ice cream, but I have cut way
down.
4
ANS: 2
Although some forgetfulness is accepted, memory loss is not a normal physiological change of
aging. This expressed fear requires further education by the nurse so as to help eliminate the
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clients concerns. A common physiological change in the older-adult client is an increased
sensitivity to glare, which makes night driving difficult. A common physiological change in the
older-adult client is an alteration in visual acuity, which would require regular vision check-ups.
Hyperlipidemia is a concern regarding cardiac health and should be considered by the older
adult.
DIF: C REF: 201 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process;
Physiological Integrity/System Specific Assessment
19. Which of the following statements made by a family member of a client recently diagnosed
with Alzheimers disease is most reflective of an understanding of this disease process?
1
Dad has always been a fighter; hell fight this too. He wont
give up.
2
We have an appointment with his care provider to see about
medication therapy.
3
Good thing we found out about this early so steps can be taken
to keep it from getting worse.
4
It usually progresses gradually so we are hoping it will be a
while before his memory is gone.
ANS: 2
Medications can slow the process of Alzheimers disease considerably when prescribed
appropriately. There is no cure for Alzheimers disease. This option suggests that the family
member still clings to the hope that there is a cure. Alzheimers disease usually progresses
gradually with a deterioration in function, but medications can be given to slow the progression
of symptoms, not halt them. Although Alzheimers disease usually progresses gradually with a
deterioration in function with some clients living years after the diagnosis of Alzheimers disease,
this option does not reflect the best understanding because no mention of management is made.
DIF: C REF: 202 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems;
Psychosocial Integrity/Sensory Perception Alterations
20. The nurse is planning client education for an older adult being prepared for discharge home
after hospitalization for a cardiac problem. Which nursing action addresses the most commonly
determined need for this age-group?
1
Suggest that he purchase an emergency in-home alert system.
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2
Arrange for the client to receive meals delivered to his home
daily.
3
Encourage the client to use a compartmentalized pill storage
container for his daily medications.
Provide a written document describing the medications the
client is currently prescribed.
4
ANS: 3
Approximately two thirds of older adults use prescription and nonprescription drugs with one
third of all prescriptions being written for older adults. A system that allows the client to sort his
medication for daily dosage would help minimize the risk of overdosing as well as missing
ordered medications. While this option addresses the risk of injury in the home, it does not
address the greatest need experienced by this age-groupthe risk of overmedication or
undermedication of prescribed drugs. While this option does address the clients nutritional needs,
it does not address the greatest need experienced by this age-groupthe risk of over- or undermedication of prescribed drugs. Although this option does address the clients need to monitor the
medications he is prescribed, it does not address the greatest need experienced by this agegroupthe risk of overmedication or undermedication of prescribed drugs on a daily basis.
DIF: C REF: 209 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe,
Effective Care Environment/Safety Promotion/Safe Home Environment
21. An assisted living facility has provided its clients with an educational program on safe
administration of prescribed medications. Which statement made by an older-adult client reflects
the best understanding of safe self-administration of medications?
1
I dont seem to have problems with side effects, but Ill let my
doctor know if something happens.
2
Im lucky since my daughter is really good about keeping up
with my medications.
3
Ill be sure to read the inserts and ask the pharmacist if I dont
understand something.
4
It shouldnt be too hard to keep it straight since I dont have any
really serious health issues.
ANS: 3
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This option reflects an understanding of the importance to understand the various aspects of the
medication and its effects on the client. The older adult should be encouraged to question the
physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. Although this
option reflects an understanding of potential risk for side effects, it is not the best option because
it focuses on only one aspect of self-medication. This option appears to have the client delegating
responsibility to the daughter. This option appears to have the client minimizing the importance
of informed self-administration.
DIF: C REF: 209 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Pharmacological Therapies
22. Which of the following client statements regarding self-medication administration by an
older-adult client requires follow-up teaching by the nurse?
1
I take all the pills ordered once a day at bedtime, so Im less
likely to forget them.
2
I have one pill that needs cut in half. I am going to ask the
pharmacist to do that for me.
3
The pharmacist said to keep my pills away from the sunlight,
so I put them inside the kitchen cabinet.
4
My daughter comes over each morning and puts my pills into
a container that sorts them by the time they are due.
ANS: 1
There may be a concern regarding drug interactions if all the medications are taken at the same
time. The nurse should have a discussion with the client to determine if this practice is
appropriate. This option shows the clients willingness to deal with this issue effectively and
safely. This option shows an appropriate intervention for keeping the pills out of sunlight. This
option shows an appropriate intervention for dealing with multiple medication schedules.
DIF: C REF: 209 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe
and Effective Care Environment/Safety Promotion/Safe Home Environment
23. Which of the following statements made by an older-adult client poses the greatest concern
for the nurse conducting an assessment regarding the clients adjustment to the aging process?
1
I use to enjoy dancing and jogging so much, but now I have
arthritis in my knees so that its hard to even walk.
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2
Ive given my grandchildren money for college so they can live
a better life than I had.
3
Growing old certainly presents all sorts of challenges. I wish I
knew then what I know now.
As I age Ive found its harder to do the things I love doing, but
I guess it will all be over soon enough.
4
ANS: 4
This option should give the nurse concern over the clients possible depression because there are
indications of possible suicide. This option does reflect regret over the inability to do the things
previously enjoyed and the presence of a painful condition, but it does not present the
seriousness of other available options. This option does reflect regret regarding life situations,
but it does not present the seriousness of other available options. This option does reflect regret
over the perceived changes, but it does not present the seriousness of other available options.
DIF: C REF: 209-210 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Psychosocial Integrity/Coping Mechanisms
24. Which of the following statements made by a 75-year-old client shows the best
understanding of how the aging process affects the musculoskeletal system?
1
I drink milk and eat cheese to get my calcium.
2
I walk 1 mile everyday to strengthen my bones.
3
I wear sensible shoes so I wont sprain an ankle.
4
At my age I might never fully recover from a hip fracture.
ANS: 2
Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as
those who are inactive. Walking regularly shows that this client has an understanding of and the
disciple to work on health promotion habits for a healthy musculoskeletal system. While this
option shows an understanding regarding osteoporosis and the need for calcium, it is not the best
option because it focuses on only one aspect of musculoskeletal health. This option focuses only
on safety measures, and so it is not the best option. While this option shows an understanding
regarding the seriousness of a hip fracture for someone of older age, it is not the best option
because it focuses on only one aspect of musculoskeletal health.
DIF: C REF: 208 OBJ: Analysis
TOP: Nursing Process: Evaluation
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MSC: Process/Health Promotion Programs; Physiological Adaptation/Alteration in Body
Systems
25. Which statement made by an older adult would reflect the best understanding of the
nutritional requirements of individuals at this developmental stage?
1
2
3
4
An apple a day is my motto; always has been.
I eat everything, but just a little a bit of things like sweets.
Fiber is more important than ever to my digestive system.
I dont need the fat so Ive taken to drinking protein shakes.
ANS: 2
Good nutrition for older adults includes a balanced diet with limited intake of refined sugars.
This is not the best option because it focuses on only one aspect of nutrition. This option is not
the best choice because it focuses on only one aspect of nutrition. This is not the best option
because it focuses on only one aspect of nutrition.
DIF: C REF: 207 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health
Promotion Programs
26. Which statement made by an older adult would reflect the best understanding of the
nutritional guidelines for this age-group?
1
I can prepare grilled chicken at least 10 different, delicious
ways.
2
When I entertain, I serve healthy foods like veggies and lowfat dip.
3
I know I need to eat nutritiously, and I have certainly been
doing better.
I take seriously the suggestions my health team gives me on
healthy eating.
4
ANS: 2
This option shows an understanding of healthy eating as well as a commitment to incorporating
this knowledge into everyday living. While this is a good option, it is not as encompassing
regarding knowledge and commitment as other options. This option leaves some doubt as to how
committed the client really is to nutritional eating. While this is a good option, it is not as
encompassing regarding knowledge and commitment as other options.
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DIF: C REF: 207 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health
Promotion Programs
27. Which of the following statements made by an older adult regarding sexuality would be of
greatest concern for the nurse?
1
2
3
4
Will this new medication affect my libido?
What can I do to help with vaginal dryness?
I really miss the intimacy my husband and I shared.
Its so nice not to have to worry about an unwanted pregnancy.
ANS: 4
This option infers that the client is sexually active and not using protection because there is no
longer a possibility of conception. Information about the prevention of sexually transmitted
diseases should be included when appropriate because there is a growing number of older adults
contracting STDs. Many older adults use prescription medications that depress sexual activity,
such as antihypertensives, antidepressants, sedatives, or hypnotics. This question requires further
education but the statement does not arouse concern regarding the clients safe sex practices.
Physiological changes may have an adverse influence on sexual activity. The older woman may
experience vaginal dryness. This question requires further education, but the statement does not
arouse concern regarding the clients safe sex practices. It is a common misconception that older
adults are not interested in sex. This statement would require further discussion to assess the
degree of distress the situation is causing the client, but the statement does not arouse concern
regarding the clients safe sex practices.
DIF: C REF: 203-204 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
28. Of the following options, which is the greatest barrier to providing quality health care to the
older-adult client?
1
Poor client compliance resulting from generalized diminished
capacity
2
Inadequate health insurance coverage for the group as a whole
3
Insufficient research to provide a basis for effective geriatric
health care
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4
Preconceived assumptions regarding the lifestyles and
attitudes of this group
ANS: 4
Despite ongoing research in the field of gerontology, myths and stereotypes about older adults
persist. These include false ideas about the physical and psychosocial characteristics and
lifestyles of older adults. However, when health care providers hold negative stereotypes about
aging, those stereotypes negatively affect the quality of the care. While there may be poor
compliance related to diminished physical and cognitive capacity, it is not the primary barrier to
effective care of this developmental group. While there are numbers of the older-adult population
who are underinsured, it is not the primary barrier to effective care of this developmental group.
A lack of research regarding the unique needs of this age-group is not the primary barrier to
providing effective care.
DIF: C REF: 93 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
29. The nurse is preparing an educational program for members of the local senior center. Which
of the following topics would present the greatest learning challenge for this developmental
group?
1
Exercising arthritic joints
2
Tips for living with GERD
3
Importance of the human touch
Principles of heart-healthy eating
4
ANS: 3
Of the available topics, Importance of the human touch is possibly the most abstract in nature.
Older adults are lifelong learners, but concrete rather than abstract material appears to be a better
choice for the learning style of most older adults. This option is concrete in nature and so a better
choice for the learning style of most older adults. This option is concrete in nature and so a better
choice for the learning style of most older adults. This option is concrete in nature and so a better
choice for the learning style of most older adults.
DIF: C REF: 210 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health
Promotion Programs
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30. When presenting information to the older adult, the client will be most likely to engage with
the nurse in the learning process if:
1
2
3
4
Client feedback is encouraged and valued
Physical disabilities are accommodated for
The topic or information is valued by the learner
New knowledge is connected to knowledge already processed
ANS: 3
The older adult learner will be more interested and willing to participate actively in the learning
if they have been given the opportunity to determine the values of the information to them
personally.
DIF: C REF: 193 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
31. Of the following client statements made by an older adult client which best reflects an
understanding the educational materials on nutrition presented by the nurse?
1
Ill keep this literature and read it again later.
2
I love rye bread. Its good to know its high in fiber.
3
Nutrition and cooking has always been passions of mine.
4
Now I can see the connection between food and my health.
ANS: 2
The correct option shows the client making a connection between a type of food, its nutritional
value, and its impact on personal health
DIF: C REF: 193 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process;
Physiological Adaptation/Alteration in Body Systems
32. The nurse defines ageism most accurately as:
1
The undervaluing of individuals based on their age.
2
Perception of a persons worth based on productivity
3
Biases directed towards individuals considered aged
Discrimination based on an individuals increasing age
4
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ANS: 4
The correct option best describes ageism since it identifies discrimination towards a person based
solely on the persons age. Devaluing is one aspect of ageism but this option failed to identify
discrimination as the goal. While perception of a persons worth is a criteria used to judge, it is
not the most complete description of the term. Bias and discrimination are the outcomes of
ageism.
DIF: C REF: 207 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process
33. Which of the following statements made by a nurse best reflects an understanding of the
negative impact of ageism regarding client care?
1
If I dont value the older client, I will never be able to provide
the care they are entitled too.
2
Everyone, regardless of age or position, always deserves
effective, appropriate nursing care.
As a society we lose so much valuable wisdom and knowledge
when we devalue our older members.
3
4
If older clients do not feel valued, they are less likely to seek
the health care they need and deserve.
ANS: 1
According to experts in the field of gerontology, unopposed ageism has the potential to
undermine the self-confidence of older adults, limit their access to care, and distort caregivers
understanding of the uniqueness of each older adult. Health care providers must be free of such
an unethical attitude so that client care will never be compromised. This is a truism that is not
specific to ageism
Chapter 15. Critical Thinking in Nursing Practice
MULTIPLE CHOICE
1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse
educator to a nursing student?
1
Think about several interventions that you could use with this
client.
2
Dont draw subjective inferences about your clientbe more
objective.
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3
Please think harderthere is a single solution for which I am
looking.
4
Trust your feelingsdont be concerned about trying to find a
rationale to support your decision.
ANS: 1
The nurse educator is asking the student to synthesize critical thinking skills by encouraging the
student to examine alternatives to meet the clients unique needs within the context of the nursing
process. Drawing inferences is a specific critical thinking competency used in diagnostic
reasoning. The educator who tells the student not to draw inferences is not allowing the student
to practice competencies necessary for specific critical thinking in clinical situations. The critical
thinker will look beyond a single solution to a problem. Intuition develops as ones clinical
experience increases. The nursing student should examine
rationales in order to make good decisions.
DIF: C REF: 216 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The second component of critical thinking in the critical thinking model is:
1
2
Experience
Competencies
3
Specific knowledge
4
Diagnostic reasoning
ANS: 1
Experience is the second component of critical thinking in the critical thinking model. The third
component of the critical thinking model is competencies. Specific knowledge base is the first
component of the critical thinking model. Diagnostic reasoning is a specific critical thinking
competency in clinical situations.
DIF: A REF: 222 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The nurse enters the room of a client who has a history of heart disease. On looking at the
client, the nurse feels that something is not right with the client and proceeds to take the vital
signs. This is the nurse acting on:
1
Intuition
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2
Reflection
3
Knowledge
Scientific methodology
4
ANS: 1
Intuition is an inner sensing that something is so, as in this example. Reflection is the process of
purposefully thinking back or recalling a situation to discover its purpose or meaning.
Knowledge of the nurse includes information and theory from the basic sciences, humanities,
behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or
verifying that a set of facts agrees with reality.
DIF: A OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her
surgical unit are nervous about using her instrument. If the nurse manager continues to
implement the new strategy, which of the following critical thinking attitudes is she portraying?
1
Humility
2
Risk-taking
3
Accountability
4
Independent thinking
ANS: 2
This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to
take risks in trying different approaches to solving problems. Humility is a critical thinking
attitude in which a person admits what they do not know and tries to acquire the knowledge
needed to make proper decisions. To be accountable means to be answerable for the outcomes of
your actions. To think independently, one questions others ways of interpreting knowledge and
looks for rational and logical answers to problems.
DIF: A REF: 224 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. The nurse is working with a client who has recently had a colostomy and is having difficulty
using the provided supplies. The nurse works with the client to see which alternative supplies are
easier for the client to use. This is an example of the critical thinking strategy of:
1
Inference
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2
Management
3
Problem-solving
Diagnostic reasoning
4
ANS: 3
This is an example of the critical thinking strategy of problem-solving. The nurse gathers
information from the client and combines that information with what the nurse already knows
about ostomy care to find a solution. Effective problem-solving involves the examination of
alternatives. Inference is the process of drawing conclusions. Management is not a critical
thinking strategy. Diagnostic reasoning is a process of determining a clients health status after
the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the
client.
DIF: A REF: 219 OBJ: Comprehension
TOP: Nursing Process: Assessment/Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. Which of the following is an example of a nurses statement that reflects using the scientific
method in the nursing process?
1
2
3
4
I believe that this client is getting depressed.
The client doesnt look right to me; I think something is wrong.
The clients husband told me that she is feeling very
uncomfortable.
The client reports more pain than yesterday and her blood
pressure is elevated.
ANS: 4
Reporting more pain than yesterday and elevated blood pressure reflects using the scientific
method in the nursing process. The nurse identified a problem of pain, hypothesized that it was
greater than the day before, and collected data to evaluate its reality. Believing the client is
depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects
information gathering, which may be used in diagnostic reasoning.
DIF: A REF: 218 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she
has previously been providing her orthopedic client. Which step of the nursing process does this
address?
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1
Assessment
2
3
Nursing diagnosis
Planning
4
Implementation
ANS: 4
Taking appropriate action demonstrates the implementation step of the nursing process.
Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse
critically examines and analyzes the data, and identifies the clients response to a problem. The
nurse may then determine priorities. Planning involves establishing goals and expected outcomes
of care.
DIF: A REF: 221 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the
nurse needs to determine which postoperative client should be seen first. Of the following, the
nurse should go to see the client who:
1
Has a documented blood pressure of 90/50
2
Was medicated for back pain 10 minutes ago
3
Has an order to be out of bed and ambulated
Requires instructions for wound care before discharge
4
ANS: 1
The nurse prioritizes actions and determines to see this client first because of a lower than
normal blood pressure for a postoperative patient. This nurse is using scientifically and practicebased criteria for making clinical judgment. This is an example of following standards. The nurse
uses criteria such as the clinical condition of the client, Maslows hierarchy of needs, and risks
involved in treatment delays to determine which clients have the greatest priority for care.
In answers 2 through 4, the client is not reported to be having any problems and therefore is not
the priority.
DIF: C REF: 221 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordination/Setting
Priorities
9. There are a variety of levels of critical thinking. An example of critical thinking at the complex
level is:
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1
Giving medication at the time ordered
2
3
Following a procedure for catheterization step-by-step
Reviewing all clients medical records thoroughly
4
Discussing various alternative pain management techniques
ANS: 4
Discussing alternative pain management techniques is an example of critical thinking at the
complex level. The nurse analyzes and examines alternatives more independently. Giving
medication at the time ordered is an example of the basic level of critical thinking. Following a
procedure step-by-step is an example of the basic level of critical thinking. Reviewing the clients
medical records thoroughly is an example of gathering data and may be used in evaluation of a
clients care.
DIF: C REF: 218 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. The nurse is deciding on the type of dressing to use for a client. Which step of the decisionmaking process is being used when the nurse observes the absorbency of different dressing
brands?
1
Defining the problem
2
Making final decisions
3
Testing possible options
4
Considering consequences
ANS: 3
The nurse who observes the absorbency of different brands of dressing is demonstrating testing
of possible options. This is not an example of defining the problem. The nurse has not yet made a
final decision. The nurse is not examining pros and cons, and therefore is not considering
consequences.
DIF: A REF: 219 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which one of the following examples demonstrates the critical thinking attitude of
responsibility and authority?
1
Reporting client difficulties
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2
Offering an alternative approach
3
Looking for a different treatment option
Sharing ideas about nursing interventions
4
ANS: 1
Reporting client difficulties demonstrates the critical thinking attitude of responsibility and
authority. Asking for help if uncertain and following standards of practice also demonstrate the
critical thinking attitudes of responsibility and authority. Offering an alternative approach would
demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option
demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions
demonstrates the critical thinking attitude of thinking independently.
DIF: A REF: 223 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. Use of the intellectual standard of critical thinking implies that the nurse:
2
Questions the physicians order
Recognizes conflicts of interest
3
Listens to both sides of the story
4
Approaches assessment logically
1
ANS: 4
Use of the intellectual standard of critical thinking implies that the nurse approaches assessment
logically and consistently. Questioning the physicians order is an example of the critical thinking
attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking
attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude
of fairness.
DIF: A REF: 225 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. A client requires urinary catheterization but has difficulty keeping her legs in the usual
position needed for this procedure. The nurse has worked for many years and adapts the
procedure to allow the client to lie on her side. This action is based on the critical thinking
element of:
1
Curiosity
2
Experience
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3
Perseverance
4
Scientific knowledge
ANS: 2
Having worked for many years and being able to adapt a procedure to meet the clients needs is
an example of the second component of the critical thinking modelexperience. Curiosity is a
critical thinking attitude where the nurse asks why, and continues to learn more about the client
to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the
nurse does not readily accept the easy answer but does look further to find necessary information
and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science.
It may be acquired through education, such as coursework, or by reading nursing literature to
remain current in nursing science.
DIF: A REF: 222 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. Which of the following statements made by a nursing student concerning the use of critical
thinking and client care requires follow-up by the nursing instructor?
1
I feel its good practice to always have alternative interventions
in mind.
2
I trust my feelings about a clients needs since I work hard at
knowing my client.
3
I always try to keep an open mind about what interventions my
client will require.
4
I will wait until my assessment is completed before
determining the clients needs.
ANS: 2
Intuition develops as ones clinical experience increases. The nursing instructor should instruct
the student to examine rationales in order to make good decisions regarding client needs. The
instructor would encourage the student to examine alternatives to meet the clients unique needs,
so this statement would not require follow-up. Basing client care on identified client needs is the
appropriate use of critical thinking, and so would not require follow-up. Basing client care on
client needs identified by thorough nursing assessments is the appropriate use of critical thinking,
and so would not require follow-up.
DIF: C OBJ: Analysis TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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15. Which of the following is the best example of a nurses use of reflection?
1
The nurse places a client experiencing respiratory difficulties
in a high-Fowlers position.
2
The nurse calls the provider when a client reports feeling
chilled and achy while having an oral temperature of 100.2 F.
While caring for a client with a history of asthma, the nurse
assesses the clients pulse oximetry reading when he doesnt
sound right.
3
4
A nurse tells a client; When you refused to go to physical
therapy earlier today I believe you were upset about something
else besides the appointment time.
ANS: 4
Reflection is the process of purposefully thinking back or recalling a situation to discover its
purpose or meaning. Knowledge of the nurse includes information and theory from the basic
sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to
seeking the truth or verifying that a set of facts agrees with reality. Intuition is an inner sensing
that something is so, as in this example.
DIF: C REF: 226 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. Which of the following nursing situations best reflects accountability?
1
The nurse takes the oncology nursing certification
examination.
2
The nurse files an incident report regarding a medication error.
3
The nurse assesses the client for the possible cause of his pain.
The nurse tells the client, I dont know but I will find out for
you.
4
ANS: 2
To be accountable means to be answerable for the outcomes of your actions. Answer 2 is an
example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in
trying different approaches to solving problems. To think independently, one questions others
ways of interpreting knowledge and looks for rational and logical answers to problems. Humility
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is a critical thinking attitude where a person admits what they do not know and tries to acquire
the knowledge needed to make proper decisions.
DIF: C REF: 224 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which of the following nursing actions is the best example of problem solving?
1
Requesting the IV team to start an antibiotic drip on a client
with a history of being a difficult stick
2
Offering to call the kitchen to provide an alternate breakfast
for a client who does not like cooked cereal
3
Trying several difficult wound dressings to determine which
one the client can apply the most effectively
4
Calling for another pain medication order when the current
drug results in the client experiencing nausea
ANS: 3
This is an example of the critical thinking strategy of problem solving. The nurse gathers
information by using several different products and then uses this information to determine
which will work best for the client. Effective problem solving involves the examination of
alternatives. While requesting the IV team solves a problem, there is little critical thinking
needed because it would be understood that the IV team would be called under these
circumstances. Although calling the kitchen solves a problem, there is little critical thinking
needed because it would be understood that the kitchen would be called under these
circumstances. Calling for another pain medication order solves a problem, but there is little
critical thinking needed because it would be understood that the provider would be called for a
new drug order under these circumstances.
DIF: C REF: 219 OBJ: Analysis
TOP: Nursing Process: Assessment/Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. Which of the following clients should be prioritized with the most urgent need for a nursing
assessment?
1
A new admission admitted for swelling in the right ankle and
knee
2
A second day postoperative client who received pain
medication 30 minutes ago
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3
A client who the nursing assistant found crying in the
bathroom
4
A client ready for discharge who requires a final assessment
and documentation
ANS: 3
This client has an acute need that requires the nurses attention. The facility has a policy regarding
the amount of time available in which to complete such an assessment and this client is in no
acute distress, so the assessment does not have priority. While a pain assessment is required to
evaluate the effectiveness of pain medication, it does not the have the priority of the other
presented options. This client has no acute problems and so the assessment does not have the
priority of some of the other options.
DIF: C REF: 221 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following nursing interventions is the best example of the implementation step
of the nursing process?
1
Determining that the clients ankle edema is worse after he
ambulates
2
Asking the client to rate his ankle pain after receiving oral pain
medication
Arranging for the client to receive pain medication 30 minutes
before his ordered ambulation
3
4
Crushing the clients pain medication to facilitate easier
swallowing and thus minimize the risk of choking
ANS: 4
Taking appropriate action demonstrates the implementation step of the nursing process.
Assessment involves the gathering of data. Assessment involves the gathering of data. Planning
involves establishing goals and expected outcomes of care.
DIF: C REF: 221 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following nursing actions best reflects the consequence stage of the decisionmaking process?
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1
Being physically present when a client is given the results of a
tissue biopsy
2
Witnessing the client sign consent for surgery forms before
cardiac surgery
The client is informed of the various treatments available for
his condition.
3
4
The nurse explains to the client the risks of leaving the
hospital against medical advice.
ANS: 4
The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being
physically present is not an example of defining the problem. Witnessing the client sign consent
is an example of a final decision. In Answer 3 the client is being given various options.
DIF: C REF: 219 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. The concept of nursing responsibility is best reflected in which of the following nursing
actions?
1
Providing accurate and timely documentation regarding an
incident resulting in a client fall
2
Suggesting that a client might prefer taking a particular
medication at bedtime instead of in the morning
3
Posting a note on the unit Kardex how to best apply a dressing
to a skin wound on a particular client
Referring to the institutions policy manual when unsure of
how to handle a clients complaint regarding a social services
consult
4
ANS: 4
Asking for help if uncertain and following standards of practice best demonstrate the critical
thinking attitudes of responsibility because failure to do so could result in client injury. Reporting
client difficulties demonstrates the critical thinking attitude of responsibility but is not the best
option of those available because it would not result in client injury/harm. Offering an alternative
approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about
nursing interventions best demonstrates the critical thinking attitude of thinking independently.
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DIF: C REF: 224 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. Which of the following situations is the best example of a nurse using intellectual standards
as a critical thinking tool?
1
2
Performing a head-to-toe assessment on a new admission
Placing a client experiencing shortness of breath on oxygen
3
Arbitrating a complaint between roommates over the
television
4
Notifying a provider of a clients allergy to an ordered
medication
ANS: 2
Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care
logically, consistently, and appropriately. This option reflects the use of such standards in a
situation that addresses client distress. While performing a head-to-toe assessment is an example
of intellectual standards, it is not the best example because it does not involve a clients
immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude
of fairness. Notifying a provider of a clients allergy is an example of nursing responsibility.
DIF: C REF: 225 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The nurse is best demonstrating perseverance by:
1
Having a perfect attendance record
2
Completing a lengthy course on current chemotherapies
3
Repeatedly irrigating the nasogastric tube until it is patent
Sitting with a client until she is ready to discuss why she is
crying
4
ANS: 4
Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy
answer but does look further to find necessary information and appropriate solutions. While
perfect attendance shows a nurses willingness to complete the work responsibilities regardless of
barriers, it is a better representation of responsibility. While completing a course on current
chemotherapies shows the nurses willingness to pursue knowledge, it is more representative of
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the acquiring of scientific knowledge to remain current in nursing science. While repeatedly
irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is
appropriate, it is a better representation of possessing knowledge of the procedure.
DIF: C REF: 224 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. With regards to client care, the most likely reason that a veteran nurse tends to be a more
skillful critical thinker than a new graduate nurse is because:
1
The veteran nurse has a varied history of client care
experiences
2
Critical thinking improves with experience, longevity, and
interest
3
Todays short hospital stays minimize the opportunity to
develop critical thinking skills
4
New graduates often lack the self-confidence to take the risks
often required of critical decision making
ANS: 2
Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a
process acquired only through experience, commitment, and an active curiosity toward learning.
While experience is a factor in the development of critical thinking skills, it is not the only factor.
While having extended periods of time with clients has a positive effect on the development of
critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a
negative effect on the development of critical thinking skills, it is not the primary or sole factor.
DIF: C REF: 216 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. The primary factor that distinguishes a professional nurses care from care provided by
ancillary nursing staff is:
1
Critical thinking
2
Years of education
3
Professional licensure
4
Complexity of the task
ANS: 1
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Clinical decision making separates professional nurses from technical personnel. While advanced
education is a distinction, the primary factor regarding client care is the professional nurse is
responsible for actions that require critical thinking decision making. Although licensure is a
distinction, the primary factor regarding client care is the professional nurse is responsible for
actions that require critical thinking decision making. 4. While complexity is a distinction, the
primary factor regarding client care is that the professional nurse is responsible for actions that
require critical thinking decision making.
DIF: C REF: 216 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of
the following represents the best response?
1
2
A person with the educational background to solve problems.
A person who finds the problem and does what is best to fix it.
3
Its someone who uses the scientific method to solve problems.
4
Someone who uses a system to work through and solve a
problem.
ANS: 2
A critical thinker considers what is important in a situation, imagines and explores alternatives,
considers ethical principles, and then makes informed decisions. Educational background may
have an impact on critical thinking but it is not the primary or sole factor to consider. Although
the scientific method is often used in critical thinking it is neither the only method nor the sole
factor to consider. While an orderly method is used in critical thinking, it is not the only factor to
consider.
DIF: C REF: 216 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. Which of the following statements made by a new graduate nurse regarding a clients care
needs requires follow-up by the mentor?
1
No one really enjoys being hospitalized.
2
Every client is offered a back rub at bedtime.
3
All post surgery clients are reluctant to ambulate.
4
I always spend extra time with new clients to help them relax.
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ANS: 3
Because no two clients respond exactly alike to similar health problems, you always have to
observe each client closely in order to make critically sound decisions regarding that clients
needs. Answer 1 does not require follow-up because even if it is not true, it does not have an
impact on the nurses perception of the clients care needs. Answer 2 does not require follow-up
because it is a nursing action that should be offered to all clients at bedtime.
Answer 4 does not require follow-up because it is a nursing action that should be offered to all
clients.
DIF: C REF: 216 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which
of the following statements by the nurse best reflects critical thinking regarding client care?
1
Im sure that friction and pressure have caused this problem.
2
Please be sure that her ankles are well padded when you place
her in bed.
3
Do you have any suggestions on how we can minimize the
pressure to her ankles?
4
It was an ineffective turning schedule that allowed this to
happen so now we will reposition every hour.
ANS: 3
Nurses who apply critical thinking in their work focus on options for solving problems and
making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff
input regarding interventions shows critical thinking. While Answer 1 may be true, it is
knowledge or experience, not critical thinking, that brought about this conclusion. Although
Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical
thinking, that brought about this conclusion. While Answer 4 may be true and an example of an
appropriate intervention, it is knowledge or experience, not critical thinking, that brought about
this conclusion.
DIF: C REF: 217 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant
reports that the client is crying. Which of the following responses by the nurse best reflects the
use of analysis regarding this clients care needs?
1
That surgery is painful. Ill get her pain medication ready.
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2
She was sleeping when I checked 15 minutes ago. Ill go back
in right now.
3
Ill be responsible for her PM care so I can spend some
uninterrupted time with her.
A mastectomy is a blow to a womans self image. Ill notify her
provider that she is depressed.
4
ANS: 2
Analysis requires being opened-minded as you look at information about a client. Do not make
careless assumptions. Do the data reveal what you believe is true, or are there other options?
Although pain may be the cause of this clients tears, there are other possible reasons, so making
an assumption is not appropriate. Although Answer 3 shows the nurses intention to analyze the
clients needs, the delay is not appropriate. While the client may be experiencing some
depression, there are other possible reasons for the tears and so the nurse should not assume.
DIF: C REF: 217 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. Which of the following statements made by a nurse regarding personal reflection related to
client care requires follow-up by the units nurse manager?
1
Mary and I were comparing foot wound dressing techniques.
2
Ive been caring for orthopedic clients for 10 years and I think
Ive seen it all.
3
I cant believe that my client isnt improving after 2 weeks of
physical therapy.
4
I always wean my orthopedic surgery clients onto oral pain
medication on postoperative day 4.
ANS: 4
Reflect on your experiences. Identify the ways you can improve your own performance. This
option presents a rigid attitude concerning client pain needs. Answer 1 needs follow-up because
it shows a willingness to explore others opinions. Answer 2 requires no follow-up because it does
not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because
it does not reflect an inflexible attitude toward client care needs.
DIF: C REF: 217 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. The scope of a clients health problem is a result of which of the following factors? (Select all
that apply.)
1
2
3
Religious beliefs
Life experiences
4
Lifestyle choices
Work environment
5
Family relationships
6
Educational background
ANS: 2, 3, 4, 5
Each clients problems are unique and a product of many factors, including the clients physical
health, lifestyle, culture, relationship with family and friends, living environment, and
experiences.
Chapter 16. Nursing Assessment
MULTIPLE CHOICE
1. A client interview consists of three phases. The nurse recognizes that those phases are:
1
2
3
4
Orientation, working, termination
Introduction, controlling, selection
Introduction, assessment, conclusion
Orientation, documentation, database
ANS: 4
The three phases of an interview are orientation, working, and termination.
DIF: A REF: 236 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. During the admission history, the client states that he has trouble breathing at night. In
obtaining data for a problem-oriented database, the nurse should first question the client about:
1
2
The onset and duration of his present breathing problem
His personal smoking, alcohol use, and exercise practices
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3
Any extended family members who have diagnosed heart
disease
4
Changes in other body systems that the client perceives as
problematic
ANS: 1
A clients database originates with the clients perception of a symptom or health problem. If an
illness is present, the nurse gathers essential and relevant data about the nature and onset of
symptoms. The problem-seeking technique takes the information provided in the clients story to
more fully describe and identify the clients specific problems. Habits and lifestyle patterns such
as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not
the first question the nurse should ask when obtaining data for a problem-oriented database after
the client reports having a health problem. Information regarding family history, such as
members who had heart disease, may be obtained in an admission history. However, if a client
reports a problem, the nurse should first follow-up with questions relevant to the nature and onset
of symptoms. The nurse may inquire about changes in other body systems during an admission
history; however, if the client reports a problem, the nurse should first follow-up using a
problem-oriented approach. This would include asking specific questions about the clients health
problem, such as the nature and onset of symptoms.
DIF: A REF: 237 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
3. The nurse begins the assessment of a client that has come to the emergency department
experiencing chest pain by asking the client about:
1
A family history of heart problems
2
3
Medications currently being taken at home
Questions or concerns about hospitalization
4
The onset, severity, and duration of the chest pain
ANS: 4
If a client comes to the emergency department with chest pain, the nurse should first ask the
client about the onset, severity, and duration of the chest pain. In an emergency situation, the
clients current health problem becomes the priority assessment. Initially, the nurse should not ask
questions regarding family history. Gathering data about the problem currently affecting the
client has greater priority. Asking the client about medications taken at home is appropriate, but
not at this time. The priority is to assess the symptoms the client is experiencing. Asking the
client about concerns regarding hospitalization is not the priority.
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DIF: A REF: 241 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. A nurse seeks to organize the data obtained from the client in a logical manner. The
organizational method that identifies relationships between factors and symptoms in the database
is known as:
1
2
Clustering data
Validating data
3
Peer reviewing
4
Problem statement
ANS: 1
Clustering data means the nurse organizes the information obtained into meaningful clusters. A
cluster is a set of signs or symptoms grouped together in a logical order. When clustering data,
the nurse identifies relationships between factors and symptoms. Validating data means to
compare the data obtained with another source to ensure its accuracy. Peer review is the
evaluation of the quality of the work effort of an individual by his or her peers. After validating
data and clustering data, the nurse may formulate a problem statement, usually in the form of a
nursing diagnosis.
DIF: A REF: 234 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
5. The client recently became febrile and stated he felt hot. The nurse takes the clients
temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute, and his
blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data?
1
Pulse rate of 88 beats per minute
2
Blood pressure of 168/80 mm Hg
3
The statement regarding his feeling hot
The supported fact that he became febrile
4
ANS: 3
Subjective data are clients perceptions about their health problems. The statement by the client
regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is
an example of objective data. Objective data are observations or measurements made by the data
collector. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is
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an example of objective data. Becoming febrile can be determined by measurement, and
therefore is an example of objective data.
DIF: A REF: 234 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. The nurse decides to interview the client using the open-ended question technique. Which of
the following statements reflects this type of questioning?
1
2
Is your pain worse or better than it was an hour ago?
Do you believe that your nausea is from the new antibiotic?
3
What do you think has been causing your current depression?
4
What have you done to alleviate the side effects from your
medications?
ANS: 3
An open-ended question prompts the client to describe a situation in more than one or two
words. This option demonstrates the open-ended question technique. This question limits the
clients answers to one or two words. It is an example of a closed-ended question. The question in
this option limits the clients answer to one or two words such as yes or no. It is an example of a
closed-ended question. This option only requires a few words to form an answer. It does not use
the open-ended question technique.
DIF: A REF: 239 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he
just lost his job. Job loss best fits into which of the following categories?
1
Family history
2
Psychosocial history
3
Biographical history
4
Environmental history
ANS: 2
The psychosocial history reveals the clients support system, if there are any recent losses or
stressful events, and how the individual copes with such stressors. The loss of a job would fit the
psychosocial history category. Family history is used to obtain data about immediate and blood
relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It
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also provides information about the family itself. The biographical history provides factual
demographic data about the client. The environmental history provides data about the clients
home and working environments.
DIF: A REF: 241 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
8. The nurse is going to perform the admission history for a newly admitted client on the medical
unit. The optimum time for completion of the history is planned for:
1
Coordination with the physicians visit
2
3
The time when the clients family are visiting
Immediately before the clients scheduled MRI testing
4
After the client has become comfortably oriented to the room
ANS: 4
Completion of the admission history is scheduled for a time when interruptions by other staff or
visiting family members are minimal. The nurse should create an environment where the client
feels comfortable. Conducting the admission history after the clients orientation to the room and
completion of lunch would be optimum because the client will not be distracted by hunger, and
the interview will less likely be interrupted. The admission history should be scheduled for a
time when interruptions by other staff are minimal. During the physicians visit would not be an
optimum time. The nurse should provide an environment private enough to allow the client to be
comfortable when providing personal information. Inclusion of family members should be left
up to the client to decide. Information obtained should remain confidential. Immediately before a
clients testing would not be an optimum time for obtaining a nursing history. The client may feel
more anxious about the upcoming test, impeding communication, and there may not be sufficient
time allowed to gather all of the information.
DIF: A REF: 236 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
9. The nurse has completed an assessment and found that the client has an activity and exercise
abnormality. This type of wording indicates that which of the following organizing formats has
been used?
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1
Review of systems
2
3
Nursing health history
Gordons functional health patterns
4
Biographical information database
ANS: 3
Utilizing Gordons functional health patterns format, the nurse organizes information and makes
an assessment identifying functional patterns (client strengths) and dysfunctional patterns (such
as an activity and exercise abnormality). The review of systems is a systematic method for
collecting data on all body systems. The nurse asks the client about the normal functioning of
each body system and any noted changes. A nursing health history is broader and includes
information about the clients current level of wellness, a review of body systems, family and
health history, sociocultural history, spiritual health, and mental and emotional reactions to
illness. A biographical information database provides factual demographic data about the client,
such as age, address, occupation, marital status, etc.
DIF: A REF: 233 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. After visiting with the client, the nurse documents the assessment data. Both objective and
subjective information has been obtained during the assessment. Which of the following is
classified as objective data?
1
Pain in the left leg
2
Elevated blood pressure
3
Fear of impending surgery
Discomfort upon breathing
4
ANS: 2
Objective data are observations or measurements made by the data collector, such as a blood
pressure reading. Subjective data are clients perceptions about their health problems, such as
pain. Fear of surgery would be subjective data because it is the clients perception and not
something the data collector can measure. Subjective data are clients perceptions about their
health problems, such as discomfort during breathing. A respiratory rate would be an example of
objective data.
DIF: A REF: 234 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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11. The primary source of information when completing an assessment of a client that is alert
and oriented as he is admitted to the medical center for diagnostic testing is the:
1
2
3
4
Client
Physician
Family member
Experienced unit nurse
ANS: 1
A client is usually the best source of information. The client who is oriented and answers
questions appropriately can provide the most accurate information about health care needs,
lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of
daily living. The physician may have knowledge of the clients medical problem, but the client is
the primary source of information for completing an assessment. Family members can be
interviewed as primary sources of information about infants or children or critically ill, mentally
handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources
of information and can confirm findings provided by the client. The client in this situation is
capable of being the primary source of information. An experienced nurse on the unit may offer
insight into a clients health care needs and care, but is not the primary source of information
when completing a client assessment.
DIF: A REF: 234 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
12. The process of data collection should begin with the nurse performing a:
1
Physical exam
2
Client interview
3
Review of medical records
Discussion with other health team members
4
ANS: 2
The first step in establishing the database is to collect subjective information by interviewing the
client. The physical examination follows the client interview so that data can be verified. A
review of medical records is not the first step the nurse should take in the process of data
collection. The medical record is a valuable tool for checking the consistency and congruency of
personal observations made during the client interview. Discussion with other health team
members may provide additional information and be used to relay information, but is not the first
step in the process of data collection.
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DIF: A REF: 236 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
13. During an interview, the nurse needs to obtain specific information about the signs and
symptoms of the clients health problem. To obtain these data most efficiently, the nurse should
use:
1
2
Channeling
Open-ended questions
3
Closed-ended questions
4
Problem-seeking responses
ANS: 3
Using closed-ended questions helps the nurse to acquire specific information about health
problems such as symptoms, precipitating factors, or relief measures in an efficient manner.
Channeling is where the nurse uses active listening techniques, such as all right, go on, or uhhuh, to indicate the nurse has heard what the client said and encourage the client to elaborate
further. Using open-ended questions prompts the client to describe a situation in more than one
or two words. Because it allows the client the opportunity to tell their story and reveal what is
important to them, it is not the most efficient method of obtaining specific information regarding
a clients signs and symptoms of a health problem. In problem-seeking technique, the nurse takes
the information provided in the clients story to more fully describe and identify the clients
specific problems. Using closed-ended questions would be the most efficient method for
obtaining specific information about the signs and symptoms of a clients health problem.
DIF: A REF: 239 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. The nurse is conducting an interview with the client and wants to clarify information that the
client has shared. Which response by the nurse is an example of the clarifying technique of
communication?
1
I understand how you must feel.
2
This medication is used to lower your blood pressure.
3
You appear anxious. Youre wringing your hands constantly.
Could you give me an example of how you handle stressors?
4
ANS: 4
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In this option, the nurse is seeking further clarification of information by asking the client to
provide an example. Clarification helps the nurse to gain accurate understanding of a clients
situation. This is not an example of clarifying information. This response provides information.
The nurse is not using the clarifying technique of communication. In this option the nurse
describes his or her observations. It does not seek clarification.
DIF: A REF: 239 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. When clustering data according to functional health patterns, the nurse determines that the
client is only able to ambulate short distances without becoming fatigued and requires rest
periods during morning care. The health pattern that requires intervention is identified by the
nurse as:
1
2
Respiratory
Activity and exercise
3
Sleep and rest pattern
4
Self-care deficit: activities of daily living
ANS: 2
Using the functional health pattern format, the nurse clusters data that pertain to a functional
health category. Fatigue upon ambulating short distances and requiring frequent periods of rest
are examples of data belonging to the category of activity and exercise. Respiratory would be
found in a systems approach of health assessment, not a functional health pattern assessment.
The functional health pattern category of sleep and rest would focus more on the number of
hours of sleep the client obtains, use of sleep aids, and any difficulties associated with sleep.
Self-care deficit: activities of daily living would include such aspects as bathing, feeding, and
dressing self. The symptoms described would be clustered more accurately under the functional
health pattern category of activity and exercise.
DIF: A REF: 233 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
16. After visiting with the client, the nurse documents the assessment data. Both objective and
subjective information have been obtained during the assessment. Which of the following is
classified as subjective data?
1
Client appears sleepy
2
No physical distress noted
3
Abdomen soft and non-tender
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4
States feels anxious and tense
ANS: 4
Subjective data are clients perceptions about their health problems. Feeling anxious and tense is
information that only the client can provide. Objective data are observations or measurements
made by the data collector. In this example, the data collector is making the observation that the
client appears sleepy. No physical distress noted is an example of objective data because it is an
observation made by the data collector. Abdomen soft and non-tender is an example of objective
data because it is an observation made by the data collector, not a clients perception.
DIF: A REF: 234 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the
following questions asked by the nurse has priority at this time?
1
Can you describe your pain?
2
3
Have you had this problem before?
What have you done to ease the pain?
4
When did your abdominal pain begin?
ANS: 4
If a client presents to the emergency department with pain, the nurse should first ask the client
about the onset, severity, and duration of the pain. In an emergency situation, the clients current
health problem becomes the priority assessment. Gathering data about the problem currently
affecting the client has greater priority, but a description of the pain does not have priority over
onset. Asking the client about medical history is appropriate but not at this time. The priority is
to assess the symptoms the client is experiencing. Gathering data about the problem currently
affecting the client has greater priority, but attempted self-treatment does not have priority over
onset.
DIF: C REF: 236-237 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
18. Which subjective assessment data are most supportive of a clients diagnosis of anxiety?
1
Diaphoretic and cool skin
2
An apical pulse rate of 120 beats per minute
3
Reports needing to leave now
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4
Claims something is terribly wrong
ANS: 4
Subjective data are clients perceptions about their health problems. The statement by the client
regarding his sense of impending doom is the best example of subjective data regarding his
anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of
objective data. Objective data are observations or measurements made by the data collector. A
pulse rate is an example of objective data. Objective data are observations or measurements
made by the data collector. While a client statement regarding the need to leave the hospital is
subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending
doom.
DIF: C REF: 241 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following questions asked by the nurse during the assessment process is best
directed towards gathering information regarding the clients depression?
1
Have you ever felt this depressed before?
2
3
What do you believe is the cause of your depression?
What makes you feel that you are experiencing depression?
4
What can we do to make you comfortable while you are here?
ANS: 2
This option is an open-ended question that encourages the client to express his insight regarding
his condition. This option is a closed-ended question requiring only a yes or no response and so
provides minimal information regarding the clients condition. While this is an open-ended
question, it is not the best option because it is not directed towards assessment of the clients
current complaint. While this is an open-ended question, it is not the best option because it is
directed at the clients comfort, not towards assessing his current complaint.
DIF: C REF: 234 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following statements best reflects the nurses correct understanding of the
importance of selecting the optimum time for interviewing a client newly admitted to the unit?
1
Im going to do the clients history before his family leaves so
they can help with the admission history questions.
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2
You are scheduled for some x-rays, so Id like to complete this
admission history interview before you have to leave.
3
I have some questions to ask you regarding your admission
history. Ill be back once you are settled in and comfortable.
Please let me know when the blood lab is finished with the
new client so I can complete his admission history interview.
4
ANS: 3
Completion of the admission history is scheduled for a time when interruptions by other staff or
visiting family members are minimal. The nurse should create an environment where the client
feels comfortable and the clients orientation to the room is completed. While this may be
appropriate if the client requires help with answering the questions, it is not the best option
because family and visitors can be distracting and may represent a confidentiality problem.
While the history must be taken within a specific time period, rushing to complete it before the
client goes to radiology is not appropriate. The interview requires the clients attention and
cooperation. Attempting to complete it immediately after a treatment or other intervention would
not be the best choice of time.
DIF: C REF: 239 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. The nurse is conducting an admissions history interview with a client who has a history of
gastroesophageal reflux disease (GERD). Which of the following questions shows the best
example of relevant questioning by the nurse?
2
How long have you been dealing with GERD?
Are you currently taking any medications for your GERD?
3
Do you follow a particular diet to help manage your GERD?
4
Do you have any other gastrointestinal problems besides
GERD?
1
ANS: 4
The nurse should ask relevant questions and collect relevant history and physical assessment data
related to the clients presenting health care needs in order to produce the most inclusive,
effective nursing care plan. The questions How long have you been dealing with GERD? and Are
you currently taking any medications for your GERD? as well as Do you follow a particular diet
to help manage your GERD? are directed towards the GERD itself and not towards conditions
that might be related to the presence of GERD.
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DIF: C REF: 236 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. A new graduate nurse missed cues regarding the clients emotional state at the time of
admission. The most therapeutic response to the nurse by her mentor is:
1
That is why we perform assessments at least daily; so we can
catch missed cues.
2
Everyone has missed cues; dont be too hard on yourself and
just keep trying.
3
You will be less likely to miss client cues as you acquire more
experience with assessments.
4
The positive side to making this mistake is that you wont miss
those cues again in another client.
ANS: 3
It is possible to miss important cues when you conduct an initial overview. However, always try
to interpret cues from the client to know how in-depth to make your assessment. Remember,
thinking is human and imperfect. You will acquire appropriate thinking processes in the conduct
of assessment, but expect to make mistakes in missing important cues. While this may be true, it
is not the most therapeutic option because it does not address the issue personally for the new
graduate. While this is true, it is not the most therapeutic option because it does not offer a
reason for the omission. While this may be true, it is not the most therapeutic option because it
does not address the issue personally for the new graduate.
DIF: C REF: 240-241 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The nurse is performing a problem-focused assessment when the client reports pain in his left
shoulder. Which of the following nursing questions has priority when determining the nature of
the pain?
1
What makes the pain worse?
2
When did you first notice the pain?
3
What do you do to lessen the pain?
4
Can you rate your pain using the pain scale that weve
discussed?
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ANS: 4
Once you complete the assessment, you thoroughly analyze the extent and nature of the clients
problem so you are able to later develop a care plan. Identifying the degree of pain the client is
experiencing has priority over the other options. While this option is an appropriate pain
assessment question, it is more directed towards identifying contributing factors than the
characteristics (nature) of the pain. While this option is an appropriate pain assessment question
regarding the nature of the pain, it does not have priority over the degree of pain because that
represents an issue that requires immediate intervention. While this option is an appropriate pain
assessment question, it is more directed towards identifying effective self-treatment rather than
the characteristics (nature) of the pain.
DIF: C REF: 236 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. When following up on a clients report of hip pain during an admission assessment, the most
nursing conclusive observation would be:
1
2
The client tearing when being ambulated to the chair
A report from the ancillary staff that the client is reporting pain
3
The client observed grimacing when positioning self in the bed
4
Overhearing the client discuss hip pain with family on the
phone
ANS: 3
This option where the client was observed grimacing describes nonverbal actions that are
associated with pain when the client is unaware of being observed and so represents the most
conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to
the chair, the ancillary staffs report of the clients pain as well as overhearing the client discuss
hip pain may well be an observation of pain, but they are not the most conclusive of the options
because the client is aware of being observed.
DIF: C REF: 240 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. When obtaining subjective assessment data, the nurse recognizes which of the following
client scenarios as being the most likely to produce accurate, credible information?
1
A 50-year-old in the ED reporting chest pain
2
A 70-year-old admitted with fever of unknown origin
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3
A 81-year-old receiving follow-up treatment for a hip
replacement
4
A 22-year-old being treated at a clinic for a sexually
transmitted disease
ANS: 3
This option where the 81-year-old is receiving follow-up treatment for a hip replacement
presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other
emotion/factor that would inhibit the free communication of subjective symptom data. The 50year-old client is experiencing pain; this is likely to inhibit the communication process. The 70year-old client is febrile; this could interfere with the communication process, especially for an
older adult because it may cause confusion and the 22-year-old client may be experiencing guilt
and/or embarrassment; both may interfere with the communication process.
DIF: C REF: 234 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. A nurse is observed conducting an assessment interview for a newly admitted client. Which
of the following would require immediate follow-up by the nurses mentor?
1
Conducting the interview with the clients boyfriend present
2
Stopping the interview to answer a page from the nursing
station
3
Frequently checking the time while waiting for the client to
answer
4
Heard asking the client, Am I correct; youve rated your pain a
9 out of 10?
ANS: 3
Clients are less likely to fully reveal the nature of their health care problems when nurses show
little interest, appear rushed, or are easily distracted by activities around them. As long as the
nurse had the clients permission, this would not require follow-up. While interrupting an
assessment is not recommended, a page is an example of an acceptable exception and so this
would not require follow-up. If the nurse were confirming the information, it would not require
follow-up. If the mentor felt the nurse was questioning the validity of clients pain rating, a
follow-up would be appropriate because a clients pain rating should not be questioned.
DIF: C dm 234 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. Which of the following assessment data provided by a clients family will have the greatest
impact on the clients care while hospitalized?
1
2
Mom falls asleep fastest with the television on.
Dad starts off the day with hot coffee; it regulates his bowels.
3
My wifes sister died 4 months ago, and she is still grieving
over her loss.
4
My husband doesnt like to let people know his arthritis is
bothering him.
ANS: 4
Family and friends can make important observations about the clients health status, changes, and
needs that can affect the way care is delivered. Being aware of the clients reluctance to discuss
his pain will impact the frequency and way his pain is assessed. While this information will
affect the way the staff prepares the client for sleep, it does not have priority over pain
assessment. While this information will allow the staff to meet the clients morning coffee need, it
does not have priority over pain assessment. While this information will affect the way the staff
address the clients emotional needs, it does not have priority over pain assessment.
DIF: C dm 237 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. What is the most appropriate method for the nurse to communicate a clients wishes to the
nurses on the next shift?
1
Document the request in the nursing notes.
2
Include the clients request in the shift report.
3
Place instructions regarding the clients wishes above the
clients bed.
4
Verbally inform the unit clerk of the clients request.
ANS: 2
In the acute care setting, the change-of-shift report is the way for nurses from one shift to
communicate information to nurses on the next shift Documenting the request in the nursing
notes is not appropriate for inclusion in the nursing notes because it does not reflect information
regarding the clients condition, response to treatment, or current health status. Placing the
instructions regarding the clients wishes above the bed is not appropriate because there is no
guarantee that staff will see the posting, but more importantly there are confidentiality issues
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being ignored. While verbally informing the unit clerk of the clients request may result in the
clients wishes being respected, it is not the most effective option.
DIF: C dm 234-235 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
29. While discussing a clients medication history, the client tells the nurse that she thinks she is
allergic to a particular type of medication. Which of the following nursing actions has priority in
this situation?
1
Note the allergy on the clients Kardex.
2
Inform the provider of the clients possible allergy.
3
Review the clients medical record for confirmation of the
allergy.
4
Tell the client to have all medications identified before taking
them.
ANS: 3
The medical record is a valuable tool for checking the consistency and similarities of personal
observations. Information such as a history of allergic reactions would be found in the medical
record. Noting the allergy on the clients Kardex would be appropriate only after the allergy is
confirmed; although if there was true concern, a notation of a possible allergy should be noted on
the medication record. Informing the provider of the clients possible allergy would be
appropriate after the medical record was reviewed and no mention of the allergy was confirmed
or denied. While telling the client to have all medications identified before taking them is a
safety measure appropriate for all clients, it is not the priority in this situation.
DIF: C dm 235 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. The nurse realizes that in order to share information from a clients medical record with
another facility, the client must provide written consent. The primary reason for this requirement
is to:
1
Facilitate the exchange of information between appropriate
parties
2
Minimize the opportunity for this information to be assessed
inappropriately
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3
Ensure the clients right to have his medical information
regarded as personal and confidential
4
Guarantee that the information will be shared with only those
requiring it for client care purposes
ANS: 3
Educational, military, and employment records may contain significant health care information.
You need written permission from the client or guardian to access or transfer the records. Any
information you obtain is confidential, and you treat it as part of the clients legal medical record.
This process recognizes the clients right to confidentiality. The other three options, facilitating
the exchange of information, ensuring the clients rights to have his medical information regarded
as personal and confidential as well as guaranteeing the sharing of information will be only when
required for client care purposes are outcomes of the process but not the primary reason for the
consent.
DIF: C dm 235-236 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
31. The nurse recognizes that a clients hearing deficits impact the development of the nurseclient relationship. Which of the following has the greatest impact on minimizing this obstacle?
1
2
Speaking slowly, clearly, and in a normal tone
Using various forms of nonverbal communication
3
Relying heavily on touch to convey caring and interest
4
Involving family in discussions concerning meeting clients
needs
ANS: 2
When a client has limited hearing or visual deficits, it becomes more important for a nurse to use
nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly
and in a normal tone may make verbal communication more effective, but it will not have the
greatest positive impact of the offered options. Relying heavily on touch is only one form of
nonverbal communication that can positively impact the development of the relationship. While
involving family in discussions may help in the identification of client needs, it does not
necessarily have positive impact on developing a healthy nurse-client relationship.
DIF: C dm 236 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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32. Which of the following questions will provide the nurse with the best understanding of a
terminally ill clients spiritual needs?
1
2
3
4
Do you have a religious preference?
Have you given thought to your spiritual needs?
Is there a particular clergy you would like to visit with?
Are there any spiritual needs you have that I may help with?
ANS: 4
In asking if there are any spiritual needs that the client might need help with, you collect
information about life goals, values, and religious practices; part of a clients spirituality. This
option provides the client with an opportunity to discuss his needs if indeed he has any while
reaffirming the nurses wish to meet his needs. Asking simply is a client has a religious preference
is a closed-ended question and provides little encouragement to discuss spiritual needs. While
asking if the client has given thought to their spiritual needs provides an opportunity to discuss
any client needs, it does not allow for the nurse to be of help with attending to these needs.
Inquiring about a particular clergy is a closed-ended question and provides little encouragement
to discuss spiritual needs.
DIF: C dm 237 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following statements made by the nurse should be included in the orientation
phase of a nursing interview? (Select all that apply.)
1
Youre answers will be kept confidential.
2
My name is Susan Smith and Im a registered nurse.
3
We are here to make your hospitalization as pleasant as
possible.
I need to ask you some questions that will help with planning
your care.
4
5
6
Only those directly involved in your care will have access to
this information.
If there is anything you need or help you require simply use
your call bell and someone will be right in.
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ANS: 1, 2, 4, 5
The orientation phase begins with you introducing yourself and your position and explaining the
purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing
history or for a focused assessment) and assure them that any information obtained will remain
confidential and will be used only by health care professionals.
The statements We are here to make your hospitalization as pleasant as possible and I need to ask
you some questions that will help with planning your care are more appropriate for the
termination phase.
DIF: C dm 241 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse has determined that the assessment data have resulted in a strong inference that the
client is suffering from depression. Which of the following client responses to nursing questions
best supports the possibility of depression? (Select all that apply.)
1
2
My work environment would depress anyone.
It seems like almost anything can make me cry.
3
Being here away from my family makes me sad.
4
I just cant seem to get excited about anything anymore.
5
The family always thought that my father was depressed.
6
I like winter because I can just cover up on the couch and
sleep.
ANS: 4, 5
I just cant seem to get excited about anything anymore and The family always thought that my
father was depressed. Remember to always have supporting cues before you make an inference.
These options relate a broad lack of interest in life and a family history of depression. While
mentioning My work environment would depress anyone as a depressing situation, this option
does not infer personal depression. While mentioning It seems like almost anything can make me
cry as a potential sign of depression, this option is not a strong inference because crying can be a
result of other emotions. While mentioning Being here away from my family makes me sad
notes sadness, this option describes a normal reaction to being separated from loved ones. While
mentioning I like winter because I can just cover up on the couch and sleep shows withdrawal
behaviors, this option is not a strong inference because winter often evokes stay-at-home
tendencies in people.
DIF: C dm 241 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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3. The goal of the orientation phase of a nursing interview is to: (select all that apply)
1
Initiate the nurse-client relationship
2
Begin identifying the clients needs
Earn the trust and confidence of the client
3
4
5
Assume the decision role for the client
Welcome the client to the nursing unit
6
Gather the clients demographic information
ANS: 1, 2, 3
Initiating the nurse-client relationship, beginning to identify the clients needs and earning the
clients trust and confidence. During the orientation phase you establish trust and confidence with
a client. One important goal for the initial interview is to make the foundation for understanding
the clients primary needs. Another is to begin a relationship that allows the client to become an
active partner in decisions about care. As the orientation phase proceeds, the client should begin
to feel more comfortable speaking with you so the necessary information can be obtained.
Assuming the decision role isnt correct as the client should be involved in all care decisions;
assuming this role is not appropriate. While welcoming the client to the nursing unit is an
expected outcome of the orientation phase of the interview process, it is not a goal. While
gathering the clients demographic information is an expected outcome of the orientation phase of
the interview process, it is not a goal.
Chapter 17. Nursing Diagnosis
MULTIPLE CHOICE
1. The nurse uses nursing diagnoses after completion of the client assessment, because they:
1
Are required for accreditation purposes
2
Identify the domain and focus of nursing
3
Assist the nurse to distinguish medical from nursing problems
4
Make all client problems become more quickly and easily
resolved
ANS: 2
After completing the client assessment, the nurse develops nursing diagnoses based on the data
obtained. Nursing diagnoses distinguish the nurses role from that of the physician, and nursing
diagnoses help nurses to focus on the role of nursing in client care. Although most state nurse
practice acts include nursing diagnosis as part of the domain of nursing practice, nursing
diagnoses are not required for accreditation purposes. Medical problems are identified with
medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the clients
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actual or potential response to a health problem that the nurse is licensed and competent to treat.
Nursing diagnoses distinguish the nurses role from that of the physician. Nursing diagnoses may
facilitate communication among health professionals, but they do not necessarily allow all client
problems to become more quickly and easily resolved.
DIF: A dm 248 OBJ: Knowledge
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the
clients weight, the nurse also considers the age and height. This is an example of:
1
2
3
4
Defining the client problem
Recognizing gaps in data assessment
Comparing data with normal health patterns
Drawing conclusions about the clients response
ANS: 3
The nurse uses scientific knowledge and experience to analyze and interpret data collected about
the client. This includes comparing the data with norms. The nurse is comparing data to
determine if there is a problem. A problem has not yet been identified. The nurse is not
recognizing gaps in data assessment. An example of a gap in data assessment would be if the
clients weight had not been measured. The nurse has not drawn a conclusion about the clients
response. The nurse must first compare the data with normal health problems to be able to arrive
at a conclusion.
DIF: A dm 249 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
3. Of the following statements, which one is an example of an appropriately written nursing
diagnosis?
1
Acute pain related to left mastectomy
2
Impaired gas exchange related to altered blood gases
3
Deficient knowledge related to need for cardiac catheterization
4
Need for high protein diet related to alteration in client
nutrition
ANS: 3
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This nursing diagnosis is written correctly. It defines a problem and its etiology. In this case the
problem is the clients response to a diagnostic test. A medical diagnosis should not be recorded
as the etiology because nursing interventions cannot change the medical diagnosis. It would be
appropriate to state acute pain related to impaired skin integrity secondary to mastectomy
incision. This nursing diagnosis is written incorrectly because it uses supportive data of the
problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It
identifies the clients goal rather than the problem. It could be reworded as imbalanced nutrition:
less than body requirements related to inadequate protein intake.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. Of the following statements, which one is an example of an appropriately written nursing
diagnosis?
1
2
Risk for change in body image related to cancer
Cardiac output decreased related to motor vehicle accident
3
Ineffective airway clearance related to increased secretions
4
Potential for injury related to improper teaching in the use of
crutches
ANS: 3
Ineffective airway clearance related to increased secretions is written appropriately. It identifies a
problem using a NANDA International diagnostic statement and connects it to its etiology. Risk
for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for
the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly.
The etiology is not treatable. Potential for injury related to improper teaching in the use of
crutches is written incorrectly. It identifies the nurses problem, not the clients.
DIF: A dm 250 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
5. The nurse has diagnosed the clients problem as altered elimination. From the database the
nurse identifies all the following as appropriate etiologies for this diagnosis except:
1
Poor fiber intake
2
Limited fluid intake
3
Total hip replacement
4
Lower abdominal discomfort
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ANS: 3
Total hip replacement because the medical diagnosis requires medical interventions, it is legally
inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the clients
response, such as decreased mobility. The nurse should be able to provide nursing interventions
that will treat the etiology. Poor fiber intake would be an appropriate etiology for the problem of
altered elimination. Limited fluid intake would be an appropriate etiology for the nursing
diagnosis of altered elimination. Lower abdominal discomfort is an appropriate etiology for the
nursing diagnosis of altered elimination.
DIF: A dm 248 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of
the following is an appropriate diagnostic label for this problem, should it occur?
1
2
Impaired gas exchange
Decreased cardiac output
3
Ineffective airway clearance
4
Impaired spontaneous ventilation
ANS: 1
A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support
the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for
ineffective airway clearance. Increased tenacious sputum production would be a possible
etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an
appropriate diagnostic label for atelectasis.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. The nurse recognizes that which one of the following statements is true with regard to the
formulation of nursing diagnoses?
1
The diagnosis should identify a cause and effect relationship.
2
The diagnosis must remain constant during the clients
hospitalization.
The etiology of the diagnosis must be within the scope of the
health care teams practice.
3
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4
The diagnosis should include the problem and the related
contributing conditions.
ANS: 4
The diagnosis should include the problem and the related contributing conditions is a true
statement. Related factors are causative or other contributing conditions that have influenced the
clients actual or potential response to the health problem and can be changed by nursing
interventions. The nursing diagnosis does not identify a cause and effect relationship; rather, it
indicates that the etiology contributes to or is associated with the clients problem. The nursing
diagnosis does not have to remain constant during the clients hospitalization. It should change
according to changes in the patient. The etiology or cause of the nursing diagnosis must be
within the domain of nursing practice and a condition that responds to nursing interventions, not
those of the entire health care team.
DIF: A dm 253 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
8. A diagnostic error can influence the application of the nursing care plan. A likely source for a
nursing diagnosis error is if the nurse:
1
Validates the assessment information in the data base
2
Uses the NANDA International list of diagnoses as a primary
source
3
Formulates a diagnosis too closely resembling a medical
diagnosis
Distinguishes the nursing focus instead of other health care
disciplines
4
ANS: 3
A nursing diagnosis should identify the clients response, not the medical diagnosis. Because the
medical diagnosis requires medical interventions, it is legally inadvisable to include it in the
nursing diagnosis. A nurse should validate assessment data for accuracy and understanding.
Using the NANDA International list of diagnoses as a source helps to ensure accuracy. One
purpose the nursing diagnosis serves is to distinguish the nurses role from that of the physician.
Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses
promote understanding between nurses regarding clients health problems.
DIF: A dm 248 OBJ: Knowledge
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related
to recent neurological disturbance, as evidenced by inability to speak in complete sentences.
1
2
3
4
Altered speech
As evidenced by
Recent neurological disturbances
Inability to speak in complete sentences
ANS: 4
Defining characteristics are assessment findings that support the nursing diagnosis. In this
example, the inability to speak in complete sentences supports the nursing diagnosis of altered
speech. Altered speech is the diagnostic label identifying the problem. As evidenced by is a
connecting statement for the problem and the defining characteristics. Recent neurological
disturbances is the etiology.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. The primary purpose of a nursing diagnosis, according to the nurses, is to:
1
Support the medical plan of care
2
Provide a standardized approach for all clients
3
Recognize the clients response to an illness or situation
4
Offer the nurses subjective view of the clients behaviors
ANS: 3
The primary purpose of a nursing diagnosis is to recognize the clients response to an illness or
situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions
to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical
plan of care. Although nursing diagnoses may facilitate communication, it does not mean they
provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the
clients needs. The primary purpose of nursing diagnoses is not to offer the nurses subjective view
of the clients behaviors. Nursing diagnoses are based on subjective and objective client data and
should not include the nurses personal beliefs and values.
DIF: A dm 248 OBJ: Knowledge
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
11. Which one of the following is an appropriate etiology for a nursing diagnosis?
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1
Myocardial infarction
2
3
Cardiac catheterization
Abnormal blood gas levels
4
Increased airway secretions
ANS: 4
Increased airway secretions is a condition that responds to nursing interventions and therefore
would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an
appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing
interventions will not alter the medical diagnosis of myocardial infarction. Cardiac
catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing
diagnosis. Rather, the clients response to the procedure would be the area of nursing concern.
Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because
it is not a causative factor, but rather it is a defining characteristic of a problem.
DIF: A REF: 253-254 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
12. Which of the following is an appropriate etiology for a nursing diagnosis?
1
Incisional pain
2
Poor hygienic practices
3
Need to offer bedpan frequently
Inadequate prescription of medication
4
ANS: 1
Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies
the cause of a clients response to a health problem, and a condition that a nurse can treat or
manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis
because it insinuates a nurses prejudicial judgment. Need to offer bedpan frequently is not an
appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate
prescription of medication by the physician is not an appropriate etiology because it identifies the
nurses problem, not the clients problem. The nursing diagnosis should center attention on client
needs.
DIF: A dm 253-254 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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13. Of the following statements, which one is an example of an appropriately written nursing
diagnosis?
1
2
3
4
Diarrhea related to food intolerance
Alteration in comfort related to pain
Risk for impaired skin integrity related to poor hygiene habits
Potential complications related to insufficient vascular access
ANS: 1
Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a
problem related to an etiology, and it is a condition that nursing interventions can treat or
manage. Alteration in comfort related to pain is not written correctly because it is a circular
statement. It would be appropriate to state ineffective breathing pattern related to incisional pain.
Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it
uses a nurses prejudicial judgment. It would be more appropriate and professional to state risk
for impaired skin integrity related to knowledge about perineal care. Potential complications
related to insufficient vascular access is not written appropriately because it identifies a nursing
problem, not a clients problem. It would be appropriate to state risk for infection related to
presence of invasive lines.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. Of the following statements, which one is an example of an appropriately written nursing
diagnosis?
1
Anxiety related to cardiac monitor
2
Pain related to difficulty ambulating
3
Chronic pain related to insufficient use of medication
4
Bedpan required frequently as a result of altered elimination
pattern
ANS: 3
Chronic pain related to insufficient use of medication is an example of an appropriately written
nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing
interventions can be directed at treating or managing the behavior of insufficient medication use.
Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment
rather than the clients response to the equipment. It would be appropriate to state deficient
knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not
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written correctly. What could be a defining characteristic is used as an etiology. This nursing
diagnosis could be rewritten more appropriately as impaired mobility related to pain as
evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label and could be
rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of
altered elimination pattern is written incorrectly because it identifies a nursing intervention, not
the clients problem. It could be reworded as diarrhea related to food intolerance.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. Based on the following information, what would the nurse identify as the most appropriate
nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and
variable respiratory rate.
1
Risk for injury
2
3
Excess fluid volume
Ineffective airway clearance
4
Impaired spontaneous ventilation
ANS: 3
The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and
variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance.
Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does
not support the diagnostic label of excess fluid volume. There would be other defining
characteristics such as edema, weight gain, and an elevated blood pressure. Impaired
spontaneous ventilation does not most accurately describe impaired spontaneous ventilation.
Other characteristics, such as apnea, would better support the diagnostic label of impaired
spontaneous ventilation.
DIF: A dm 252 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
16. Which one of the following is a NANDA International nursing diagnosis label?
1
Frequent urination
2
Coughing and dyspnea
3
Risk for impaired parenting
Abnormal hygienic care practices
4
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ANS: 3
Frequent urination is a symptom, not a NANDA International nursing diagnosis label.
Coughing and dyspnea are symptoms, not a NANDA International nursing diagnosis label.
Risk for impaired parenting is a NANDA International nursing diagnosis label.
Abnormal hygienic care practices is not a NANDA International nursing diagnosis label. It
incorrectly implies a nurses prejudicial judgment.
DIF: A dm 251 OBJ: Knowledge
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. When asked to define Nursing Diagnosis the nurses best response is:
1
It is the second step in the Nursing Process.
2
It is the process of defining a clients problems.
3
It correlates a clients problem with a condition a nurse is
competent to treat.
4
It focuses care a licensed nurse can provide with the identified
needs of a client.
ANS: 3
It correlates a clients problem with a condition a nurse is competent to treat is a statement that
describes the clients actual or potential response to a health problem that the nurse is licensed
and competent to treat. Although It is the second step in the Nursing Process is true, it does not
define the term. Although It is the process of defining a clients problems is true, is does not
address the nursing aspect of the term. Although It focuses care a licensed nurse can provide with
the identified needs of a client is true, the focus is not primarily on care.
DIF: C dm 248 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
18. The nurses initial responsibility in the management of a clients collaborative problem is to:
1
Monitor for changes
2
Advocate for the client
3
Implement interventions
4
Evaluate client outcomes
ANS: 1
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Nurses initially monitor to detect the onset of changes in a clients status. Although advocating for
the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement
interventions is not the initial responsibility. Evaluate client outcomes is not the initial
responsibility.
DIF: C dm 248 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
19. The nurse has identified deficient knowledge regarding surgery for a client who is scheduled
for an outpatient procedure. Which of the following instructional topics will best minimize the
clients anxiety regarding the procedure?
1
2
Assure the client that preoperative sedation will be
administered.
Discuss the pre- and postprocedure care that will be provided.
3
Provide a detailed explanation of why the procedure is
necessary.
4
Guarantee that family will be regularly updated during the
procedure.
ANS: 2
A nursing diagnosis focuses on a clients actual or potential response to a health problem rather
than on the physiological event, complications, or disease. In the case of the diagnosis deficient
knowledge regarding surgery, the nurse will best minimize anxiety by providing information
regarding pre- and postoperative routines so as to facilitate the client in formulating realistic
expectations. Although the other options are appropriate, they are limited in scope and do not
have as much impact on anxiety.
DIF: C dm 249 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
20. The nursing diagnosis of acute pain falls under which of the following comfort domain
classifications?
1
Social comfort
2
Physical comfort
3
Interpersonal comfort
Environmental comfort
4
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ANS: 2
There are only three classifications for the comfort domain. Acute pain is a physiological
response and so is classified as a physical comfort problem. Impaired verbal communication is
considered a social comfort issue, while at risk for poisoning would be considered an
environmental comfort issue.
DIF: A dm 251 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
21. When asked to define the purpose of diagnostic reasoning, the best nursing response is:
1
Diagnostic reasoning is the foundation of the second step of
the nursing process; Nursing Diagnosis.
2
The diagnostic reasoning process flows from the assessment
process and includes decision-making steps.
3
Diagnostic reasoning includes data clustering, identifying
client needs and formulating the diagnosis or problem.
4
Diagnostic reasoning involves using the assessment collected
on a specific client to logically arrive at an appropriate nursing
diagnosis.
ANS: 4
Diagnostic reasoning is a process of using the assessment data gathered about a client to
logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do
not describe purpose but rather identify outcomes of diagnostic reasoning.
DIF: C dm 253 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
22. A nursing student expresses some confusion about identifying the appropriate nursing
diagnosis for a specific client. Which of the following responses by the clinical instructor is most
instructional?
1
After defining the clients symptomatology, eliminate those
nursing diagnoses that are not supported by the database.
2
Assess your client and then select the nursing diagnosis that
has the greatest number of observable defining characteristics.
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3
After assessing the client, compare their symptoms carefully to
the defining characteristic of the nursing diagnosis in order to
support or eliminate it as applicable.
4
With experience you will become skilled at identifying the
defining characteristics of a nursing diagnosis in your client.
Until that time use a nursing diagnosis book to help in the
selection process.
ANS: 3
After assessing the client, always examine the defining characteristics in your database carefully
to support or eliminate a nursing diagnosis. Although the other options are correct, they do not
provide as concise an explanation as after assessing the client, compare their symptoms carefully
to the defining characteristic of the nursing diagnosis in order to support or eliminate it as
applicable.
DIF: C dm 252 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
23. A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, what the
diagnosis means. Which of the following rationales best supports the nurses determination that
the client has knowledge deficit rather than a readiness for enhanced knowledge?
1
2
The client initiated the question.
This is a new diagnosis for the client.
3
The client identified a lack of understanding.
4
Type 2 diabetes mellitus is a complicated disease process.
ANS: 2
Although all the options are accurate, this is a new diagnosis for the client best reflects the need
for knowledge because the client had no previous experience with the condition and so had a true
knowledge deficit.
DIF: C dm 252 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
24. Which of the following responses best reflects an understanding of the purpose of the related
to phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?
1
To focus on the cause of the clients needs
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2
To identify the etiology of the clients diagnosis
3
To provide for individualization of the nursing interventions
To communicate the clients deficits to the nursing staff
4
ANS: 3
The inclusion of the related to phrase requires you to use critical thinking skills to individualize
the nursing diagnosis and then select personalized nursing interventions. Although the other
options are not incorrect, they do not reflect the best understanding of the purpose of the phrase,
To provide for individualization of the nursing interventions is the correct answer.
DIF: C dm 253 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
25. Which of the following assessment findings best supports the nursing diagnosis of pain in
right knee joint related to degenerative process?
2
Paternal family history of osteoarthritis has been reported.
Client is observed grimacing when walking to bathroom.
3
Right knee appears edematous when compared to left knee.
4
Client rated the pain felt after walking at a 6 on a scale of 1 to
10.
1
ANS: 2
To collect complete, relevant, and correct assessment data it helps to identify assessment
activities that produce specific kinds of data. When possible, the nurse should collect objective
data because they are often more supportive than subjective data. Observation of the clients
response to the use of the affected joint is the most supportive of the options.
DIF: C dm 254 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
26. Which of the following statements made by a nursing student regarding the cultural
characteristics of pain requires immediate follow-up by the clinical instructor?
1
I can tell when my Hispanic clients are in pain.
2
Moaning is a classic sign of pain in most cultures.
3
All clients will tell you when they need pain medication.
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4
Chronic pain is difficult to manage especially for the stoic
individual.
ANS: 3
Nurses who are not familiar with how a particular culture or developmental group expresses pain
can often miss the objective signs or assume there is a lack of pain when familiar signs are
absent. Being culturally and developmentally aware and sensitive will improve your accuracy in
making nursing diagnoses. All clients will tell you when they need pain medication is the correct
answer.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
27. Which of the following statements best reflects the nurses understanding of the primary
nursing-related purpose of a concept map?
1
To facilitate holistic nursing care
2
To provide visualization of the clients health problems
3
To assist in the identification of client-oriented nursing
diagnoses
To demonstrate the relationship between the clients various
health problems
4
ANS: 4
Concept mapping is one way to graphically represent the connections between concepts and
ideas that are related to a central subject (e.g., the clients health problems). Although the other
options are correct, they do not provide the best understanding of the purpose of concept
mapping in nursing practice as well as to demonstrate the relationship between the clients
various health problems.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
28. Which of the following statements made by the nurse reflects the best understanding of the
usefulness of a concept map to client care?
1
Concept maps help me see the whole client, not just individual
health problems.
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2
Concept maps can be easily edited to reflect a clients ever
changing health needs.
3
I need help organizing my assessment data and concept
mapping is really good for that.
I like concept mapping because it helps me focus on how the
disease processes affect the client.
4
ANS: 1
The advantage of a concept map is its central focus on the client rather than the clients disease or
health alteration, thus concept maps help me see the whole client, not just individual health
problems is the correct answer.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
29. A client expresses concern over a scheduled intravenous pyelogram by stating, I dont know
what to expect. Which of the following nursing diagnoses is most appropriate for this client
need?
2
Anxiety related to scheduled diagnostic testing
Knowledge deficit regarding need for diagnostic testing
3
Knowledge deficit related to need for intravenous pyelogram
4
Anxiety related to lack of knowledge concerning intravenous
pyelogram
1
ANS: 4
Identify the problem caused by the treatment or diagnostic study rather than the treatment or
study itself. The client need, identified by the statement, is not related to the necessity for the test
but concern over a lack of knowledge about what to expect before, during, and after the test. The
remaining options fail to identify a client need.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
30. Which of the following assessment findings best supports the nursing diagnosis of Pain in
right knee joint related to degenerative process?
1
Paternal family history of osteoarthritis reported
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2
Client observed grimacing when walking to bathroom.
3
Right knee appears edematous when compared to left knee
Client rated the pain felt after walking at a 6 on a scale of 1-10
4
ANS: 2
To collect complete, relevant, and correct assessment data it helps to identify assessment
activities that produce specific kinds of data. When possible, the nurse should collect objective
data, because it is often more supportive than subjective data. Observation of the clients response
to the use of the affected joint is the most supportive of the options.
DIF: C dm 254 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
31. Which of the following statements best reflects the nurses understanding of the primary
nursing related purpose of a concept map?
2
To facilitate holistic nursing care
To provide visualization of the clients health problems
3
Assist in the identification of client-oriented nursing diagnoses
4
Demonstrate the relationship between the clients various
health problems
1
ANS: 4
Concept mapping is one way to graphically represent the connections between concepts and
ideas that are related to a central subject (e.g., the clients health problems). While the other
options are correct they do not provide the best understanding of the purpose of concept mapping
in nursing practice.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
32. Which of the following statements made by the nurse reflects the best understanding of the
usefulness of a concept mapping to client care?
1
Concept maps help me see the whole client, not just individual
health problems
2
Concept maps can be easily edited to reflect a clients everchanging health needs.
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3
I need help organizing my assessment data and concept
mapping is really good for that.
4
I like concept mapping because it helps me focus on how the
disease processes affect the client
ANS: 1
The advantage of a concept map is its central focus on the client rather than the clients disease or
health alteration.
DIF: C dm 255 OBJ: Analysis
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Research has shown that which of the following nursing skills is best strengthened through the
use of concept mapping? (Select all that apply.)
1
Client teaching related to health and wellness topics
2
Evaluation of client outcomes in regards to nursing care
3
Identification of patterns in the clients health assessment data
4
Recognition of relationships among the clients various health
issues
5
Planning specialized nursing interventions to meet a clients
health needs
Facilitating assessment data collection through observation
and communication
6
ANS: 2, 3, 4, 5
Concept mapping significantly improved students abilities to see patterns and relationships as
well as to organize, plan, and evaluate nursing care. Client teaching and assessment collecting
are not markedly affected by concept mapping.
Chapter 18. Planning Nursing Care
MULTIPLE CHOICE
1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon.
The client tells the nurse that she wants to have her hair shampooed. Which of the following is
the most appropriate label with regard to prioritizing her request?
1
Low priority
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2
An unmet need
3
Intermediate priority
A safety and security need
4
ANS: 1
The clients request would be of low priority because it is not directly related to a specific illness
or prognosis. An unmet need is not the most appropriate label for the clients request. The clients
request is not an intermediate priority. An intermediate priority is one that involves the nonemergent, nonlife-threatening needs of the client. The clients request is not a safety and security
need; the outcome does not threaten her well-being.
DIF: A dm 262 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by
trade and has been admitted for eye surgery should include:
1
Returning to sewing
2
Preventing ocular infection
3
Administering eye drops on time in the hospital
4
Performing independent hygienic care in the hospital
ANS: 1
Long-term goals focus on prevention, rehabilitation, discharge, and health education. An
appropriate long-term goal for this client would be for rehabilitation and the clients return to
occupation, in this case sewing. Preventing ocular infection is a short-term goal. A short-term
goal is expected to be achieved within a short time, usually in less than 1 week. In 1 weeks time,
the clients risk for infection should be greatly reduced. Administering eye drops on time in the
hospital is a short-term goal. Long-term goals are usually designed for problem resolution after
discharge, especially from an acute care setting. Performing independent hygienic care in the
hospital is a short-term goal. Long-term goals are usually made for problem resolution after
discharge, especially from an acute care setting.
DIF: A dm 265 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
3. The nurse writes the following goal for a client who is hypertensive: Client will maintain a
blood pressure within acceptable limits. Which of the following would be the most appropriate
outcome criterion?
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1
Client will request pain medication as needed.
2
Client will experience no headache or dizziness.
Client will identify at least two things that cause stress.
3
4
Client will have a 7 AM blood pressure reading less than
140/90.
ANS: 4
Client will have a 7 AM blood pressure reading less than 140/90 would be the most appropriate
outcome criterion. It is client-centered, singular, observable, measurable, time-limited, and
realistic. Client will request pain medication as needed does not allow the nurse to be able to
determine if change has taken place. It would be more measurable to state the client will rate
pain below 4 on a scale of 0 to 10 by 24 hours. Client will experience no headache or dizziness is
not time-limited. Client will identify at least two things that cause stress is not time-limited or
singular.
DIF: A dm 266 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
4. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which
of the following nursing interventions is considered as physician- or prescriber-initiated?
1
Teaching a client to administer his or her insulin injection
2
Assisting a new mother with learning the art of breast-feeding
3
Notifying the nutritionist of a clients specific dietary
preferences
4
Administering a cleansing enema in preparation for
radiological testing
ANS: 4
Preparing a client for a diagnostic test is an example of a physician-initiated intervention.
Teaching a client to administer his or her insulin injection is an example of a nurse-initiated
intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated
intervention. Notifying a nutritionist of a clients dietary preferences is a collaborative
intervention.
DIF: A dm 268 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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5. Nursing interventions should be documented according to specific criteria in order that they
may be clearly understood by other members of the nursing team. The intervention statement
Nurse will apply warm, wet soaks to the patients leg while awake lacks which of the following
components?
1
2
3
4
Method
Quantity
Frequency
Performing staff
ANS: 3
The intervention statement does not include how frequently the warm soaks should be applied.
The method is applying warm, wet soaks to the patients leg while awake. The quantity is warm,
wet soaks. The qualification of the person who will perform the action is the designation of the
nurse.
DIF: A dm 273 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
6. In order that they are clear and easily understood by other members of the health care team,
the nurse recognizes that client goals or outcomes should be documented according to specific
criterion. Of the following, the outcome statement that best meets the established criteria is:
1
Client will describe activity restrictions.
2
Client will verbalize understanding of treatments.
3
Client will be ambulated in hallway 3 times each day.
Clients respiratory rate will remain within 20 to 24 breaths per
minute by 9/24.
4
ANS: 4
Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24 is a correctly
written outcome statement. It is client-centered, singular, observable, measurable, time-limited,
and realistic. Client will describe activity restrictions is not time-limited. Client will verbalize
understanding of treatments is not observable or time-limited. The client will state the purpose of
the breathing treatments by 4/10 would be more appropriate. Client will be ambulated in hallway
3 times each day is not client-centered. A correct outcome statement would be Client will
ambulate in the hall 3 times a day.
DIF: A dm 267 OBJ: Comprehension
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
7. The client is receiving postural drainage from physical therapy and intermittent breathing
treatments from respiratory therapy. Which type of care plan would be the ideal method to
document interventions for this client?
1
Nursing Kardex
2
3
Computerized care plan
Critical pathway
4
Standardized care plan
ANS: 3
Critical pathways allow staff from all disciplines to develop integrated care plans for a projected
length of stay or number of visits for clients with a specific case type. The nursing Kardex is a
card-filing system that allows quick reference to the particular needs of the client for certain
aspects of nursing care. A computerized care plan is a standardized care plan on the computer. A
standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical
problem. The nurse individualizes the care plan for the clients needs.
DIF: A dm 274 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
8. The nurse is involved in requesting a management consultation for personnel-related issues.
Which of the following is true regarding the consultation process in which the nurse is involved?
1
The problem area should be totally delegated to the consultant.
2
Consultation is often used when the exact problem remains
unclear.
3
The problem area is identified by any member of the health
care team.
4
Feelings about the problem should be described to the
consultant by the nurse.
ANS: 2
Consultation is appropriate when the nurse has identified a problem that cannot be solved using
personal knowledge, skills, and resources, or when the exact problem remains unclear. A
consultant objectively entering a situation can more clearly assess and identify the exact nature
of the problem. The whole problem is not turned over to the consultant. The consultant is not
there to take over the problem but is there to assist the nurse in resolving it. The person
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requesting the consult usually identifies the problem area. The nurse should not bias the
consultant with subjective and emotional conclusions about the client and problem.
DIF: A dm 276 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
9. In completing an assessment on an assigned client, the nurse obtains important information for
planning nursing care. Which of the following client needs should take priority?
1
2
3
4
Difficulty breathing
Financial problems
A nutritional deficit
An impending divorce
ANS: 1
Difficulty breathing would be the highest priority client need. In general, priorities that protect
clients basic needs of safety, adequate oxygenation, and comfort are considered high priority.
Financial problems are a low-priority client need. Financial problems are not directly related to a
specific illness or prognosis but may affect the clients future well-being. A nutritional deficit is
an intermediate priority client need. It involves a nonlife-threatening need of the client. An
impending divorce is a low-priority client need. It is a need that is not directly related to a
specific illness or prognosis but may affect the clients future well-being.
DIF: C dm 262 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
10. The nurse recognizes that client goals or outcomes should be documented according to
specific criterion in order that they are clear and easily understood by other members of the
health care team. Of the following, the outcome statement that best meets the established criteria
is the following:
1
Vital signs will return to within normal levels for a middle
aged adult.
2
Nursing assistant will ambulate the client in the hallway 3
times each day.
3
Lungs will be clear to auscultation and respiratory rate will be
20/minute.
Output will be at least 100 mL/hour of clear yellow urine
within 24 hours.
4
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ANS: 4
Output will be at least 100 mL/hour of clear yellow urine within 24 hours. is client-centered,
singular, observable, measurable, time-limited, and realistic. Vital signs will return to within
normal levels for a middle aged adult. is not measurable (i.e., guidelines for normal are not
stated), and it is not time-limited (e.g., by when?). Nursing assistant will ambulate the client in
the hallway 3 times each day. is not client-centered. Lungs will be clear to auscultation and
respiratory rate will be 20/minute. is not singular and it is not time-limited.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
11. In goal setting, the nurse is aware that the factor that is associated with available client
resources and motivation is:
1
Realistic
2
Observable
3
Measurable
4
Client-centered
ANS: 1
The nurse sets realistic goals that can be achieved. This increases the clients motivation. The
nurse also takes available resources into consideration in order to set realistic goals. Being
observable means the nurse must be able to determine through observation if change has taken
place. Being measurable means the goal is written so the nurse has a standard against which to
measure the clients response to nursing care. Being client-centered means the goal should reflect
the clients behavior and responses expected as a result of nursing interventions.
DIF: A dm 267 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
12. Nursing interventions may be categorized based upon the degree of nursing autonomy. An
example of a nurse-initiated intervention is:
1
Providing client teaching
2
Administering medication
3
Ordering a liver CAT scan
4
Referring a client to physical therapy
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ANS: 1
Health teaching is an example of a nurse-initiated intervention. Administering medication is a
physician-initiated intervention. Ordering a CAT scan is a physician-initiated intervention.
Referring a client to physical therapy is a collaborative intervention.
DIF: A dm 267-268 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
13. Nursing interventions may be categorized based upon the degree of nursing autonomy.
Which of the following nursing interventions is considered as physician- or prescriber-initiated?
1
Taking vital signs
2
Providing support to a family
3
Changing a dressing 2 times each day
4
Measuring intake and output each shift
ANS: 3
Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs is a
nurse-initiated intervention. Providing support to a family is a nurse-initiated intervention.
Measuring intake and output is a nurse-initiated intervention.
DIF: A dm 268 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
14. Which one of the following interventions selected by the nurse is classified as Level 2,
Domain 2 (Physiological: complex)?
1
Maintaining regular bowel elimination
2
Promoting the health of the entire family
3
Managing severely restricted body movement
Restoring tissue integrity to areas damaged by friction
4
ANS: 4
Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2
(Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2,
Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2,
Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1
(Physiological: Basic).
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DIF: A dm 270 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
15. In documentation of nursing care plans, critical pathways differ from traditional nursing care
plans in their:
1
2
Client outcomes
Client assessment
3
Nursing interventions
4
Multidisciplinary approach
ANS: 4
Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine,
nursing, pharmacy, and social work, to develop integrated care plans for a projected length of
stay or number of visits for clients with a specific case type. Client outcomes are included in both
critical pathways and traditional nursing care plans. Client assessment is necessary for
developing and evaluating critical pathways and traditional nursing care plans. Nursing
interventions are included in critical pathways and in the traditional nursing care plan.
DIF: A dm 274 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
16. Nursing interventions should be documented according to specific criteria in order that they
may be clearly understood by other members of the nursing team. The most appropriate of the
following intervention statements is:
1
Offer fluids to the client q2h
2
Observe the clients respirations
3
Change the clients dressing daily
4
Irrigate the nasogastric tube q2h with 30 ml normal saline
ANS: 4
Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention
statement. It includes the action, frequency, quantity, and method. Offer fluids to the client q2h
lacks the component of quantity. Observe the clients respirations fails to indicate the frequency
or method. Also, what is the reason for observation of the clients respirations? Change the clients
dressing daily omits the method.
DIF: C dm 267 OBJ: Analysis
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
17. Nursing interventions should be documented according to specific criteria in order that they
may be clearly understood by other members of the nursing team. The most appropriate of the
following intervention statements is the following:
1
Take vital signs.
2
3
Refer client to a therapist.
Turn client as needed while in bed.
4
Apply two 4 4 dry gauze dressing pads tid.
ANS: 4
Apply two 4 4 dry gauze dressing pads tid. is the most appropriate. It identifies the action,
frequency, quantity, and method. Take vital signs. fails to indicate the frequency and fails to
completely indicate nursing actions (e.g., what parameters are used to notify the physician).
Refer client to a therapist. fails to completely indicate nursing interventions (e.g., what type of
therapist). Turn client as needed while in bed. fails to state an accurate frequency or precisely
indicate the nursing actions.
DIF: A dm 267 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
18. Care plans created by nursing students usually differ from those that are completed by nurses
working on client units. An aspect of the plan that is usually included in the students care plan
but not in the clients record is:
1
Client outcomes
2
Nursing diagnoses
3
Scientific rationales
Nursing interventions
4
ANS: 3
An aspect of a nursing care plan that is usually included in the students care plan, but not in the
clients record, is scientific rationales. Client outcomes are included in both student care plans and
the clients record. Nursing diagnoses are included in both student care plans and the clients
record. Nursing interventions are a component of both student care plans and a nursing care plan
in the clients record.
DIF: A dm 271 OBJ: Knowledge
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
19. The purpose and distinction of a concept map, which a nurse may use when implementing a
plan of care, are for:
1
2
Multidisciplinary communication
Quality assurance in the health care facility
3
Provision of a standardized format for client problems
4
Identification of the relationship of client problems and
interventions
ANS: 4
A concept map is a diagram of client problems and interventions that shows their relationship to
one another. Multidisciplinary communication is enhanced with the use of critical pathways, not
concept maps. The use of a concept map promotes critical thinking and helps nurses to organize
complex client data, process complex relationships, and achieve a holistic view of the clients
situation. The purpose is not quality assurance in the health care facility. Standardized or
computerized care plans provide a standardized format for client problems, not the concept map.
A concept map is highly individualized.
DIF: A dm 274 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis
of knowledge deficient related to new diagnosis and treatment needs. The most appropriate
outcome statement based upon the established criteria is the following:
1
Client will perform glucose measurements often.
2
Client will appear less anxious regarding diagnosis.
3
Urinary output will reach normal young adult levels.
Client will independently perform subcutaneous insulin
injection by 8/31.
4
ANS: 4
Client will independently perform subcutaneous insulin injection by 8/31. is the most appropriate
outcome statement. It addresses the nursing diagnosis by identifying a singular outcome the
client can realistically achieve, is observable, and provides a time frame. Client will perform
glucose measurements often. does not specify a time frame. Client will appear less anxious
regarding diagnosis. is not an appropriate outcome statement. There is no specific behavior
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observable for will appear. Urinary output will reach normal young adult levels. is not an
appropriate outcome statement. It does not provide a standard against which to measure the
clients response to nursing care, and therefore is not measurable. It is also not time-limited.
DIF: A REF: 267 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
21. Which of the following is the best example of an intermediate prioritized client need for a
client diagnosed with risk of injury related to poor skin integrity?
1
Applying adequate clothing to ensure the clients warmth
2
Providing sufficient quantities of an aloe-based skin lotion
3
Helping the client select her favorite foods from the menu
form
4
Dressing the clients feet in non-skid soled slippers when
ambulating
ANS: 2
An intermediate priority is one that involves the non-emergent, nonlife-threatening needs of the
client. Having sufficient aloe-based lotion is required for maintaining good skin integrity but is
not required for meeting a life-threatening need. Although the other options are an intermediate
need, they are not the best option because they are not directly related to the clients stated
nursing diagnosis.
DIF: C dm 262 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
22. Which of the following would be the best example of a short-term safety goal for a client
who recently experienced abdominal surgery?
1
The client will show no systemic or local signs of infection by
time of discharge from hospital.
2
The client will demonstrate an understanding of the proper use
of patient-controlled analgesia (PCA).
The client will demonstrate effective coughing and deepbreathing techniques within 2 hours of surgery.
3
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4
The client will consistently use the call bell to notify the staff
of a need for assistance to the bathroom upon return to the
nursing unit.
ANS: 4
Although all the options represent short-term goals, this option (consistently use the call bell to
notify the staff) is directly related to client safety because it deals with fall prevention. Although
this is short-term goal (by time of discharge), it is not as directly related to safety as some other
options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as
directly related to safety as some other options. Although this is short-term goal (2 hours), it is
not as directly related to safety as some other options.
DIF: C dm 265 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
23. Which of the following would be the most appropriate outcome criterion for the goal, Clients
pain will be managed to within an acceptable level within 30 minutes of receiving pain
medication.
1
Client will deny presence of any pain or discomfort.
2
Client will rate pain at a level of 3 or less out of a possible 10.
3
Client will demonstrate ability to request pain medication as
needed.
Client will identify two external factors that decrease presence
of pain.
4
ANS: 2
Client will rate pain at a level of 3 or less out of a possible 10 would be the most appropriate
outcome criterion because it is directly related to the management of pain levels as reflected by
the pain scale. Client will deny presence of any pain or discomfort does not necessarily reflect a
reasonable goal. Although client will demonstrate ability to request pain medication as needed is
directed towards pain management, it does not have the primary focus that evaluating the pain
management intervention has. Client will identify two external factors that decrease presence of
pain is not the best option because it does not directly relate to pain management but the
identification of contributing factors.
DIF: C dm 266 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
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24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the
morning. Which of the following client needs should take priority?
1
2
3
4
Inventory of clothes and other personal belongings
Orientation to the nursing unit and individual room
Interview regarding medications currently being taken
Assessment of body systems for presurgery checklist
ANS: 2
The clients admission has no acute physical needs and so the emotional need of familiarization
with the environment has priority. Inventory of clothes and other personal belongings does not
reflect a priority because it does not relate directly to a physical need, and there are other
emotional needs of higher priority. Interview regarding medications currently being taken does
not reflect a priority because it does not relate directly to a physical need, and there are emotional
needs of higher priority. Although assessment of body systems for presurgery checklist reflects a
needed nursing action, it is not a priority because it does not relate directly to physical need, and
there are other emotional needs of higher priority.
DIF: C dm 262 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
25. Which of the following outcomes, made by a nurse planning care for a client recently fitted
with a hearing aid, best reflects an understanding of short-term client education goals?
1
Client will properly clean the hearing aid ear piece daily with
soap and water.
2
Client will state 3 positive effects of wearing his hearing aid at
follow-up appointment.
3
Client will wear hearing aid while awake to help improve his
ability to understand instructions.
Client will demonstrate ability to change the batteries in his
hearing aid before leaving clinic today.
4
ANS: 4
Although all the options represent short-term goals, client will demonstrate ability to change the
batteries in his hearing aid before leaving clinic today is directly related to patient education
because it relates to the proper care of the hearing aid. Client will properly clean the hearing aid
ear piece daily with soap and water does not directly relate to client education but more to an
expected client action. The goal does not include a time limit for compliance. Although client
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will state 3 positive effects of wearing his hearing aid at follow-up appointment may be a shortterm goal (depends on time of next appointment), it is not as directly related to client education
as it is compliance-oriented. Although client will wear hearing aid while awake to help improve
his ability to understand instructions may be a short-term goal, although there is no time limit, it
is not as related to client education as some other options.
DIF: C dm 262-263 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
26. Which of the following statements made by a new nursing graduate best reflects an
understanding of expected outcomes?
1
It gives the client something positive to strive towards.
2
They are statements of how the clients behavior should
change.
3
They are measurable criteria by which I can evaluation
whether a goal has been achieved.
4
They provide the client with suggestions on how to achieve
their long and short term goals.
ANS: 3
They are measurable criteria by which I can evaluation whether a goal has been achieved. It is
necessary to use expected outcomes or measurable criteria to evaluate goal achievement.
Although outcomes are directed at times toward the alteration of client behavior, They are
statements of how the clients behavior should change. is not the best option provided to reflect
an understanding of the term. It gives the client something positive to strive towards and They
provide the client with suggestions on how to achieve their long and short term goals are
incorrect as outcomes are nursing-oriented, not client-oriented.
DIF: C dm 266 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following
statements best reflects an understanding of client-centered goals?
1
The clients A1C levels will be 7 or below at the first testing
date.
2
The client will experience no blood sugar readings below 60
mg/dL before first follow up visit.
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3
The client will be visited weekly by home health nursing staff
beginning 1 week after discharge.
4
The client will demonstrate the ability to appropriately
measure blood sugar levels using a glucometer by discharge
from nursing unit.
ANS: 4
A client-centered goal is a specific and measurable behavior or response that reflects a clients
highest possible level of wellness and independence in function, therefore The client will
demonstrate the ability to appropriately measure blood sugar levels using a glucometer by
discharge from nursing unit is correct. Although The clients A1C levels will be 7 or below at the
first testing date and The client will experience no blood sugar readings below 60 mg/dL before
first follow up visit are appropriate, they are not the best options because they do not reflect
independence in function. The client will be visited weekly by home health nursing staff
beginning 1 week after discharge is not client-centered because it does not reflect a clients
highest possible level of wellness and independence in function.
DIF: C dm 267 OBJ: Evaluation
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
28. The expected outcome that best evaluates the presurgical goal of, Client will understand
purpose of coughing and deep breathing within 4 hours of returning to room is:
1
Client will demonstrate proper technique for coughing and
deep breathing
2
Client will cough and deep breathe every 1 hour while awake
without staff prompting
3
Client is capable of restating the purpose of coughing and deep
breathing in own words
4
Clients lungs will be free of abnormal breath sounds within 1
hour of being returned to room
ANS: 2
An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This
option best represents evaluation of the clients understanding of the purpose of deep breathing
and coughing because it shows appropriate compliance. Although demonstration evaluates the
proper technique, it is not the best option to evaluate understanding of purpose. Although
restatement evaluates understanding, it is not the best option to evaluate understanding of
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purpose because it does not include client compliance. The clients lungs being free of abnormal
breath sounds within 1 hour is more reflective of a goal than of an expected outcome.
DIF: C dm 266 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
29. Which of the following statements made by the nurse best reflects an understanding of the
clients role in goal setting?
1
2
He knows what he needs better than anyone else.
When he sets the goals he is more likely to follow the plan.
3
He identifies the goals and then together we create the plan of
action.
4
He is best suited to determine the level of effort he is capable
of providing.
ANS: 4
Unless you set goals mutually and make a clear plan for action, clients will not follow the care
plan. Clients alone are not always appropriately prepared to set and plan goals without
professional help. Although the other answers may be true for many clients, it is not a guarantee
that the client possesses all the skills and knowledge necessary to set and plan realistic goals.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
30. A nurse is caring for a client who experienced short-term memory loss as a result of a head
injury. Which of the following statements made by the nurse regarding goal setting requires
follow-up by the nurse manager?
1
The client will certainly need frequent reorientation to the care
plan goals.
2
I will restate the goals Ive created for him regularly so as to
win his compliance.
3
Im not sure that his family will be able to support him with
these goals but I will discuss it with them.
He seems very willing to work towards achieving his goals but
his condition will certainly create barriers.
4
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ANS: 2
If a client or significant other is not able to participate in goal development, you assume
responsibility until the client is able to participate. It is vital that to the degree that the client is
capable, the client be included in the decision-making process. Frequent reorientation to the care
plan goals may be true and so does not require follow-up. The nurse seems pessimistic about the
familys ability to play a role in the clients care plan but declares that an attempt will be made to
include them; so follow-up is not an immediate priority. The client seems very willing to work
towards achieving his goals may be true and so does not require follow-up because there is no
indication of the nurses intention to minimize his participation.
DIF: C dm 265 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
31. Which of the following goals best shows that the nurse understands the concept of a clientcentered goal?
1
2
Client will consume at least 75% of each meal served.
ADLs will be completed before breakfast is served.
3
Pain will be managed so as to be rated at 3 or less out of 10.
4
Client will be transported to physical therapy by 9 AM daily.
ANS: 1
Client will consume at least 75% of each meal served is correct. Outcomes and goals reflect the
clients behavior and responses expected as a result of nursing interventions. Write a goal to
reflect client behavior, not to reflect your goals or interventions. The other options are nursingcentered.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
32. Which of the following client-centered goals best rest reflects singular focus?
1
Client will cough and deep breathe every hour while awake.
2
Client will be free of shoulder and elbow pain by discharge.
3
Client will adhere to a low-fat diet and lose 3 pounds in 30
days.
4
Client will ambulate to the bathroom for the purpose of
showering daily.
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ANS: 4
Each goal and outcome addresses only one behavior or response. In this case the client will walk
to the shower daily. Although coughing and deep breathing are usually done as a unit, they are
really two separate actions. The client being free of shoulder and elbow pain by discharge relates
to two different anatomical locations. Adhering to a diet and losing 3 pounds are two different
actions.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
33. The nurse realizes that goals should be singular in focus primarily because:
1
The nurse will find it difficult to modify the plan of care if the
goals are not met.
2
The client may not have the strength to accomplish multiply
behavioral changes.
The client may have difficulty focusing on more than one
behavioral modification at a time.
3
4
The nurse will find it difficult to identify appropriate
interventions to address multiple behaviors.
ANS: 1
The nurse finding it difficult to modify the plan of care if the goals are not met is correct.
Singularity allows you to decide if there is a need to modify the plan of care because only one
response is considered. Although the other answers may be true, they are not the primary reason
for having only one focus per goal.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
34. Which of the following goals concerning client anxiety is the best example of measurability?
1
Client will be less anxious by discharge.
2
Client will appear less anxious by discharge.
3
Client will report anxiety at less than 3 out of 5 by discharge.
Client pulse rate and blood pressure will be within normal
limits by discharge.
4
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ANS: 3
You need to be able to observe if change takes place in a clients status. Observable changes occur
in physiological findings and the clients knowledge, perceptions, and behavior. You observe
outcomes by directly asking clients about their condition or by using assessment skills. The
client rating his anxiety is one method of observing improvement. The phrase will be less
anxious is not observable. The phrase will appear less anxious is not observable. Although pulse
rate and blood pressure may be affected by anxiety, there is no assurance that normal readings
reflect an improvement.
DIF: C dm 267 OBJ: Anxiety
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
35. Which of the following goals best reflects measurability?
1
2
Clients emotional state will be stable by time of discharge.
Client will experience normal sensations in feet by discharge.
3
Client will report being free of shoulder pain by discharge.
4
Client will have acceptable range of motion in elbow by
discharge.
ANS: 3
Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes
precisely. Pain free relates to quantity as well as quality. Do not use vague qualifiers such as
normal, acceptable, or stable in an expected outcome statement. Vague terms result in guesswork
in determining a clients response to care.
DIF: C dm 267 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
36. When developing appropriate nurse-initiated interventions for a client admitted to an acute
care facility for abdominal pain, the nurse must first consider:
1
The institutions policies and procedures
2
The states defined scope of nursing practice
3
The clients physiological and psychological needs
4
The scientific rationale for the proposed nursing action
ANS: 2
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Each state within the United States has developed a Nurse Practice Act that defines the legal
scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a majority of
states, independent nursing interventions pertain to activities of daily living, health education and
promotion, and counseling. Although the other answers must be considered, they are not the first
consideration.
DIF: C dm 268 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated
intervention is to:
1
2
Facilitate the intervention in a timely manner
Evaluate the clients response to the intervention
3
Possess the technical skills required to implement the
intervention
4
Provide client education regarding the implementation of the
intervention
ANS: 3
Each physician-initiated intervention requires specific nursing responsibilities and technical
nursing knowledge. Although the other options are expectations, they are not the primary
consideration.
DIF: C dm 268 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
38. The primary function of a care plan is to provide:
1
The client with continuity of care
2
The staff with written client-centered nursing interventions
3
An established criteria for the evaluation of nursing outcomes
An organized means of exchanging information between
caregivers
4
ANS: 1
The nursing care plan enhances the continuity of nursing care by listing specific nursing
interventions needed to achieve the goals of care. Although the rest are functions, they are not the
primary function.
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DIF: C dm 269 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which of the following characteristics are considered guidelines for the writing of appropriate
goals and outcomes? (Select all that apply.)
1
2
Singular
Realistic
3
Practical
4
Observable
5
Measurable
6
Meaningful
ANS: 1, 2, 4, 5
There are seven guidelines for writing goals and expected outcomes. The guidelines are clientcentered, singular, observable, measurable, time-limited, mutual, and realistic. Practical and
meaningful are not recognized characteristics
Chapter 19. Implementing Nursing Care
MULTIPLE CHOICE
1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is
manipulation of the clients environment. This involves the nurse:
1
Repositioning the client q2h
2
Removing clutter from the clients room
3
Delegating ambulation of clients to the nursing assistant
4
Providing pain medication to the client before a dressing
change
ANS: 2
Making rooms free of clutter is an example of manipulating the environment to create safe
surroundings. The remaining options are examples of the organization of care and personnel.
DIF: A dm 282 OBJ: Comprehension
TOP: Nursing Process: Implementation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and
itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The
nurse is using which one of the following intervention methods?
1
Preventive measures
2
Assisting with ADLs
3
Preparing for special procedures
4
Compensation for adverse reactions
ANS: 4
Nursing actions that control for adverse reactions reduce or counteract the reaction, such as
administering an antihistamine after an allergic reaction to a medication. Preventive measures
promote health and prevent illness while assisting with ADLs and preparing for special
procedures are direct care measures.
DIF: A dm 283-284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning
laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides
to withhold the Coumadin. Which step of the implementation process is she using?
1
Reassessing the client
2
Stating an expected outcome
3
Revising the nursing diagnosis
4
Modifying the nursing care plan
ANS: 4
The nurse is modifying the nursing care plan. Data have been updated to reflect the clients
current status of an elevated PTT; nursing diagnoses and specific interventions are revised. In
this case, the revised intervention is withholding the Coumadin. By gathering further assessment
data and revising nursing interventions, the nurse is modifying the nursing care plan.
DIF: A dm 282 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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4. The nurse notes that a narcotic is to be administered per epidural cath. The nurse; however,
does not know how to perform this procedure. Which aspect of the implementation process
should be followed?
1
Seek assistance
2
3
Reassess the client
Use interpersonal skills
4
Critical decision making
ANS: 1
If a nurse does not know how to perform a procedure, he or she should seek assistance.
Information about the procedure is obtained from the literature and the agencys procedure book.
All equipment necessary for the procedure is collected. Finally, another nurse who has completed
the procedure correctly and safely provides assistance and guidance. Reassessing the client is a
partial assessment that may focus on one dimension of the client or on one system. Interpersonal
skills are used to develop a trusting relationship, express a level of caring, and communicate
clearly with the client, family, and health care team. Critical decision making is used when the
nurse implements the care plan using the knowledge bases necessary for care planning and then
completing the planned interventions most effectively.
DIF: A dm 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an
example of which type of nursing skill?
1
Cognitive
2
Interactive
3
Psychomotor
4
Communication
ANS: 1
Cognitive skills involve the application of nursing knowledge. Being able to identify a clients
discharge needs is a cognitive skill. Interactive skills are interpersonal skills such as developing a
trusting relationship and communicating effectively. Psychomotor skills involve the integration
of cognitive and motor skills such as with administering an injection. Effective communication is
an interpersonal skill. The nurse communicates with the client and family when providing client
teaching and emotional support. The nurse communicates with the health care team to achieve
client outcomes.
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DIF: A dm 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. An example of a cognitive nursing skill is:
1
2
Providing a soothing bed bath
Communicating with the client and family
3
Giving an injection to the client per the physicians orders
4
Recognizing the potential complications of a blood transfusion
ANS: 4
Cognitive skills involve the application of nursing knowledge. Understanding normal and
abnormal physiological and psychological responses is a cognitive skill, as in recognizing the
potential complications of a blood transfusion. Providing a soothing bed bath involves both
interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is
expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed
bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with
the client and family is an example of an interpersonal skill. Giving an injection to the client is a
psychomotor skill.
DIF: A dm 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. An enterostomal nurse shows a clients significant other how to assist with the supplies for the
ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the
clients significant other, the nurse is using what type of nursing skill?
1
Affective
2
Cognitive
3
Interactive
Psychomotor
4
ANS: 4
Psychomotor skills involve the integration of cognitive and motor activities, such as in providing
ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the
rationale for therapeutic interventions, understanding normal and abnormal physiological and
psychological responses, and being able to identify client learning and discharge needs all
require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their
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families, and other health care team members. Effective communication is an example of an
interpersonal skill. Affective means pertaining to an emotion or mental state.
DIF: A dm 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm
casts, the nurse should select which of the following methods of nursing intervention?
1
2
3
4
Teaching
Counseling
Compensating for adverse reactions
Assisting with activities of daily living (ADLs)
ANS: 4
A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a
direct care method that helps the client use a problem-solving process to develop new attitudes
and feelings. It does not meet the physical need for assistance with ADLs. Teaching is an
implementation method used to present correct principles, procedures, and techniques of health
care to clients and to inform clients about their health status. Compensating for adverse reactions
means the nurse takes action to reduce or counteract the reaction, such as by administering an
antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would
be compensating for the clients impaired mobility.
DIF: A dm 285 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. The plan of care offers a number of different types of nursing interventions that may be
incorporated in. An example of a nurse implemented specific life-saving measure is:
1
Administering analgesics
2
Restraining a violent client
3
Initiating stress-reduction therapy
Teaching the client how to take his/her pulse rate
4
ANS: 2
Restraining a violent client is an example of a life-saving measure to protect the client. The
purpose of a life-saving measure is to restore physiological or psychological equilibrium.
Administering analgesics is an example of physical care techniques. It is not a life-saving
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measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching
the client how to take his or her pulse rate is an example of the nursing intervention of teaching.
The focus is for the client to obtain new knowledge or psychomotor skills.
DIF: A dm 285 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. To provide optimum care, a nursing intervention should be based on:
1
2
3
4
An appropriate nursing diagnosis
Subjective and objective client data
Sound clinical judgment and knowledge
Identified physical and psychosocial needs of the client
ANS: 3
The assessment data direct the nurse in the formulation of a client-specific care plan grounded
within clear, relevant nursing diagnoses and directed towards appropriate, attainable client
outcomes. A nursing intervention is any treatment, based upon clinical judgment and knowledge
that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are
evidence-based, providing the most current, up-to-date, and effective approaches for client
problems. Interventions include both direct and indirect care measures, aimed at individuals,
families, and/or the community.
DIF: C dm 279 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following interventions is the best example of an indirect intervention directed
towards client safety?
1
Checking on a restrained client every 15 minutes
2
Performing hand hygiene between client contacts
3
Including the diagnosis at risk for injury related to falls to a
clients care plan
Turning on a night light to illuminate the path to the bathroom
4
ANS: 4
Indirect care interventions are treatments performed away from the client but on behalf of the
client or group of clients. For example, indirect care measures include actions for managing the
clients environment (e.g., safety and infection control), documentation, and interdisciplinary
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collaboration. Directly impacting the light level in a clients room to minimize the risk for falls is
the best example of a safety-oriented indirect care intervention. Including a nursing diagnosis
regarding falls would also be an example of an indirect care intervention but it is not as actively
affecting the clients safety. Checking a restrained client is a direct care intervention because it
involves actual client contact, while performing hand hygiene is directed more towards infection
control than safety.
DIF: C dm 287 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. Which of the following interventions best reflects the nurses understanding of direct care
interventions regarding a cognitively impaired clients need for social interaction?
1
Arranging for the client to attend a sing along in the dayroom
2
Helping the client place a long distance telephone call to his
daughter
3
Turning the clients television on when his or her favorite
program is playing
4
Talking about the clients favorite sports team while redressing
his or her wound
ANS: 4
Direct care interventions are treatments performed through interactions with clients. Actively
engaging in a conversation with the client is the best direct care intervention and so demonstrates
the best understanding of the concept. Facilitating interaction does not have as much impact as
being actively involved. Turning on the TV is an example of an indirect care intervention.
DIF: C dm 285 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. The primary reason for the establishment of standing orders is to:
1
Provide appropriate nursing autonomy in settings where client
needs can change rapidly
2
Facilitate adequate care when direct contact with a primary
health care provider is not immediately possible
3
Allow nurses to provide certain routine therapies without first
notifying the primary health care provider
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4
Afford the client interventions that reflect the appropriate
standard of care in the absence of a primary health care
provider
ANS: 1
Licensed prescribing physicians or health care providers in charge of care at the time of
implementation approve and sign standing orders. These orders are common in critical care
settings and other specialized practice settings where clients needs change rapidly and require
immediate attention, thus providing for nursing autonomy to assess and implement appropriate
care.
DIF: C dm 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. Which of the following statements best reflects the nurses understanding of the function of
client reassessment?
1
The clients blood pressure is lower this morning than it was
yesterday morning.
2
30 minutes after receiving his pain medication, the client
evaluated his pain at 3 out of 10.
3
Turning the client every 2 hours has helped in the healing of
the pressure ulcer on his coccyx.
4
Since the client has been ambulating to the bedroom without
difficulty, Ill walk with him to the dayroom after dinner.
ANS: 4
When reassessment results in the collection of new data that identify a new client need, the care
plan is modified. Modification of a plan also occurs when a clients health care need shows
improvement or is resolved. The other options reflect recognition of a change in the clients
condition but do not reflect an alteration of the care plan.
DIF: C dm 281-282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. Which of the following statements made by a nurse practitioner best reflects an
understanding of the availability of clinical practice guidelines?
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1
Clinical guidelines are so very helpful in providing the most
up-to-date nursing care.
2
Im sure we could get a team together and develop a pressure
ulcer prevention protocol or search sites for established
protocols.
I am particularly impressed by the type 2 diabetic guidelines
posted on the National Guidelines Clearinghouse (NGC) site.
3
4
Im told that for gerontological issues, the Gerontological
Nursing Interventions Research Center (GNIRC) is the
primary resource site.
ANS: 3
There are clinical practice guidelines already developed by national health groups. These
guidelines are readily available to any clinician or health care institution that wishes to adopt
evidence-based guidelines in the care of clients with specific health problems. The best option
reflects the nurses personal experience with a published protocol.
DIF: C dm 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. The fundamental goal for the development of a protocol for care of a client who has had a
myocardial infarction client is to:
1
Implement care that has its basis in evidence-based practice
2
Produce care plans that are specific to the individual client
needs
Improve the standard of care provided to the clients cared for
on that unit
3
4
Provide the staff on that unit with guidelines to ensure the
delivery of quality care
ANS: 3
Clinicians within a health care agency sometimes choose to review the scientific literature and
their own standard of practice to develop guidelines and protocols in an effort to improve their
standard of care. All the other options are potential outcomes of the implementation of a
protocol.
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DIF: C dm 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which of the following nursing actions is most likely a result of the nurses clinical
experience?
1
Placing an immobile client on a turning schedule
2
Always assessing a clients IV site before hanging a new bag of
fluid
3
Requesting that the nursing assistant have vital signs recorded
by 0815
4
Administering a pain medication 30 minutes before changing a
burn dressing
ANS: 2
As a nurse gains clinical experience, he or she will be able to consider which interventions have
worked previously, which have not, and why. The decision to check each IV site has become a
practice standard for this nurse as a result of previous experiences with IV sites. The remaining
options are either standards of care or facility/unit standards.
DIF: C dm 280 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. Which of the following statements made by a new nursing graduate requires immediate
follow-up by the nurses mentor?
1
Older clients with arthritis require additional time to complete
to complete their own AM care.
2
My clients wife says he loves chocolate milk so I will order
his dietary supplement in chocolate.
3
My client just received some bad news regarding her tests. Ill
see if the chaplain can visit this evening.
Teenage diabetics seem to have a more difficult time making
good food choices in order to control their blood sugars.
4
ANS: 3
The nurse delivers each intervention within the context of a clients unique situation. It is an
assumption that a client who has received bad news would want a visit from a clergy member.
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The other options represent statements relating to normal characteristics of a specific
development stage, condition, or preference.
DIF: C dm 279 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. A client reports to the nurse that the room is too hot. Which of the following nursing actions
best reflects the nurses understanding of the therapeutic manipulation of the clients environment?
1
Bringing a portable fan into the room
2
Assisting the client in the removal of excess clothing
3
Offering to ambulate the client into the visiting lounge
4
Closing the blinds to minimize the sunshine through the
windows
ANS: 1
Although closing the blinds may manipulate the environment, it will always minimize the
ambient light in the room. Cooling the room by introducing the fan will not impact any other
aspect of the environment. It may not be appropriate for the client to remove clothing and
leaving the room is only a temporary solution to the problem.
DIF: C dm 282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following statements made by a new graduate nurse regarding the modification
of a clients care plan requires immediate follow-up by the nurses preceptor?
1
I will review the care plan before I do my charting.
2
The client prefers to bathe at night, so thats what Ill do.
3
I gave her a bed bath this morning, but she could really
manage showering herself.
4
The order reads clear liquids, but I hear good bowel sounds
and shes really hungry.
ANS: 4
With the assessment data supporting advancement in diet, the new graduate should initiate a
modification of the clients nursing care plan because this directly impacts the clients nutritional
status. Although facilitating client independence is appropriate, this option does not have priority
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over the option impacting nutrition. The other options do not involve modification of the care
plan.
DIF: C dm 282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following statements regarding utilization of personnel made by a new graduate
nurse requires immediate follow-up by the nurses mentor?
1
My LPN is really good with dressings, so I usually delegate
them to her.
2
I always take the time to ambulate a post op client the first
time out of bed.
3
I always try to help my nursing assistant with the clients who
require a total bed bath.
4
I have my nursing assistant take and document all vital signs
and intake and outputs.
ANS: 4
The nurse is responsible for determining whether to perform an intervention or to delegate it to
another member of the nursing team. Assessment of a client directs the decision about delegation
and not the intervention alone. Vital signs are important indicators of a clients health status and
the task should be delegated to ancillary personnel only when the client is in a stable condition;
otherwise, the nurse should be responsible. The other options reflect responsible assignment of
personnel.
Chapter 20. Evaluation
MULTIPLE CHOICE
1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they
agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3
weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of:
1
A realistic goal
2
A compliant client
3
A negative evaluation
A nonmeasurable goal
4
ANS: 3
This is an example of a negative evaluation. During evaluation, the nurse is able to determine
that the client has not met the expected outcome of decreasing smoking by one cigarette each
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week but rather has increased his smoking. This is not an example of a realistic goal. It is an
example of the evaluation step of the nursing process. The client is noncompliant. The goal is
measurable. During evaluation, the nurse determines if expected outcomes are met in order to
judge if goals have been met.
DIF: A REF: 291 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy.
One outcome criterion is that the client can state five symptoms that indicate a possible problem
that should be reported. The client is able to tell the nurse three symptoms. The evaluation
statement would be:
1
2
3
4
Goal met; client able to state three symptoms
Goal not met; client able to list three symptoms
Goal not met; client unable to list five symptoms
Goal partially met; client able to state three symptoms
ANS: 4
The client is showing changes but does not yet meet criteria set; therefore, the goal is partially
met. The clients response, being able to state three symptoms, does not meet or exceed the
outcome criteria of being able to state five symptoms. The clients response, being able to list
three symptoms, demonstrates some change. If the client were showing no progress, then the
goal would not be met. If the client were showing no progress, then the goal would not be met.
However, this clients response does indicate some change.
DIF: A dm 296 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The nurse begins to auscultate the clients lungs. While listening, the nurse notices fresh bloody
drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct
pressure to the wound site. This is an example of:
1
Performing a nursing assessment
2
Reorganizing the nursing diagnoses
3
Implementing nursing interventions
4
Critically analyzing client assessment data
ANS: 4
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The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is
analyzing data presented. This is demonstrated by the nurse setting priorities and effectively
implementing the safest nursing action. The nurse is doing more than performing a nursing
assessment. The nurse is taking action based on new assessment data. The nurse is not
reorganizing nursing diagnoses. The nurse is implementing the priority nursing action. This is
not an example of setting realistic goals and implementing nursing interventions. Applying direct
pressure to a wound site to stop bleeding demonstrates critical analysis of the data and
implementation of the safest nursing action.
DIF: A dm 298 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. The client is able to ambulate without signs or symptoms of shortness of breath. Which
statement by the nurse is the best example of an objective evaluation of the clients goal
attainment?
1
Client has no pain after ambulating.
2
Client has no manifestations of nausea while up in hall.
Client walked well and did not have any problem when up.
3
4
Client has no evidence of respiratory distress when
ambulating.
ANS: 4
Client has no evidence of respiratory distress when ambulating is the best example of an
objective evaluation of the clients goal attainment. It uses the same evaluative measures gathered
during assessment and clearly describes objective data. Client has no pain after ambulating does
not use the same evaluative measure gathered during assessment. The assessment measure
concerned respiratory changes during ambulation, not pain. If the clients pain level were going to
be used as an evaluative measure, it would be optimal to have the client report the pain using a
pain scale to make it more measurable for comparison. Client has no manifestations of nausea
while up in hall is not the best example of an objective evaluation of the clients goal attainment.
It does not use the same evaluative measure gathered during assessment. The assessment
measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more
subjective. Client walked well and did not have any problem when up is not the best example of
an objective evaluation. It includes the nurses interpretation rather than documentation of
objective data.
DIF: A dm 294 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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5. When modifying a care plan to meet a client whose status has changed significantly over the
past few days, the nurse should:
1
2
Redevelop the entire client care plan
Focus on changing the nursing diagnoses and goals
3
Perform a complete reassessment of all client factors
4
Add more nursing interventions from a standardized plan of
care
ANS: 3
A complete reassessment of all client factors relating to the nursing diagnosis and etiology is
necessary when modifying a plan. After reassessment the nurse will determine what components
of the care plan are accurate for the situation. It may not require redoing the entire care plan. The
nurse should not only focus on the nursing diagnoses and goals that have changed. Interventions
may also need revising to meet new goals. Adding more nursing interventions may or may not be
necessary. The nurse adjusts interventions on the basis of the clients response and previous
experience with similar clients. Standards of care are used to determine whether the right
interventions have been chosen or whether additional ones are required.
DIF: A dm 297 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. Based on the following outcome criterion determined by the nurse: Client will independently
complete necessary assessments prior to administration of digoxin (cardiotonic) the nurse will
evaluate the clients ability to:
1
Assess the respiratory rate
2
Palpate the radial pulse
3
Review dietary habits
Inspect color of the skin
4
ANS: 2
The nurse should compare the established outcome criteria with the clients behavior or response.
In this case the client is expected to independently complete the necessary assessments before
administration of digoxin. The client should be able to palpate the radial pulse as an assessment
before administration of digoxin. The outcome criterion does not state anything about exercise.
During evaluation, the nurse is to judge the degree of agreement between the outcome criteria
and the clients behavior. The outcome criterion does not state anything about diet. Evaluating
whether the client reviews dietary habits would not be comparable to necessary assessment
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before medication administration. The outcome criterion does not state anything about the skin.
The nurse, who knows that digoxin is a cardiotonic, understands that the client should be
assessing the heart rate.
DIF: A dm 291 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. The nurse has determined the following outcome for a client with a skin impairment:
Erythema will be reduced in 3 days. Evaluation will specifically focus on:
1
Selection of appropriate wound care
2
3
Notation of the odor and color of drainage
Inspection of the color and condition of the area
4
Measurement of the diameter of the ulceration daily
ANS: 3
Erythema is reddening of the skin; therefore, the evaluation should specifically focus on
inspection of the color of the skin, as stated in the outcome criterion. Selection of appropriate
wound care is an intervention, not an evaluation of a clients behavior or response. The outcome
criterion does not state anything about drainage. Noting the color and amount of drainage may be
a part of reassessment of the client, but is not what the nurse is evaluating according to this
outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the
ulceration. During the evaluation step of the nursing process, the clients behavior or response
should be compared to the outcome criterion and judged for degree of agreement between the
two.
DIF: A dm 294 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive
secretions. An outcome for the client is that the airways will be free of secretions. A positive
evaluation will focus upon the clients:
1
Respiratory rate
2
Complaint of chest pain
3
Lungs clear bilaterally on auscultation
Ability to perform incentive spirometry
4
ANS: 3
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Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation
is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator
of respiratory status, but it is not the best way to determine if airways are free of secretions. A
complaint of chest pain would be a negative outcome, and it is not the focus for determining
whether airways are free of secretions as written in the outcome statement. Having the ability to
perform incentive spirometry does not determine whether the airways are clear or not. It is an
intervention that may help achieve clear airways.
DIF: A dm 294 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. A client shares with the nurse that they have, almost reached the goal of smoking only one-half
pack of cigarettes a day. The best example of a nursing intervention to correct this unmet
outcome is:
1
Discuss with the client the desire to comply with the ordered
therapy
2
Suggest that the client use another smoking cessation tool to
achieve the goal
3
Reevaluate the time frame originally decided upon for
achievement of the goal
4
Suggest that the strength of the prescribed nicotine patches be
increased to 21 mg
ANS: 4
An unmet outcome reveals the client has not responded to interventions as planned. As a result,
the nurse changes the plan of care by trying different therapies or changing the frequency or
approach of existing therapies. The best option is one that adds to the existing therapy. The
remaining options should have been explored as a part of the goal-setting process or exercised if
the current therapy proves ineffective.
DIF: C dm 296 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. The primary purpose of the nursing evaluation process is to:
1
Determine the effectiveness of the nursing care provided
2
Identify interventions that are ineffective in achieving client
goals
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3
Establish the progress the client is making towards health and
wellness
4
Critique the nurses ability to implement appropriate nursing
interventions
ANS: 1
The evaluation process determines the effectiveness of nursing care. The remaining options are
all examples of evaluation but do not reflect the primary purpose of nursing evaluation.
DIF: C dm 291 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following statements best reflects a goal based on a clinical standard of
practice?
1
2
Client will lose 10 pounds in 90 days.
Client will walk 30 feet with minimal assistance.
3
Clients peripheral intravenous site will be free of redness.
4
Clients chronic pain will be managed with oral medication by
discharge.
ANS: 3
Goals often are also based on standards of care or guidelines established for minimal safe
practice. Prevention of acquired infection is a standard of practice; the remaining options reflect
client-specific goals.
DIF: C dm 293 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. Which of the following outcomes best reflects a nurse-sensitive client outcome?
1
Client will consume 75% of all meals.
2
Client will perform personal hygiene daily.
3
Client will experience no falls during hospitalization.
4
Client will report lessened anxiety regarding surgical
procedure.
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ANS: 3
A nurse-sensitive client outcome is a measurable client or family state, behavior, or perception
largely influenced by and sensitive to nursing interventions. The nurse is instrumental in the
prevention of falls while the remaining options are dependent on the client.
DIF: C dm 293 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to
monitor blood glucose levels daily. Which of the following statements best reflects the clients
understanding of the need for therapy?
1
Client agrees to test blood glucose levels 4 times a day.
2
Client records blood glucose levels for a 3-week period.
3
Client is observed testing his blood glucose level before
breakfast.
4
Client is able to demonstrate the proper technique for
performing a finger stick.
ANS: 2
During the planning phase of the nursing process it is important for you to select an observable
client state, behavior, or self-reported perception that will reflect goal achievement. The actual
written result of regular blood glucose monitoring is the best indicator of the clients
understanding of the importance of regular testing. The remaining options may show initial
willingness or ability to perform the test but do not show consistent compliance.
DIF: C dm 293 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. Which of the following nursing notes demonstrates the best evaluation of nursing
interventions regarding the care provided?
1
Pressure ulcer located on left heel has shown improvement.
2
Pressure ulcer located on left heel has responded to treatment.
3
Pressure ulcer on left heel is no longer producing purulent
drainage.
4
Pressure ulcer on left heel has not enlarged in size within the
last 24 hours.
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ANS: 3
In many clinical situations it is important to collect evaluative measures over a period of time to
determine if a pattern of improvement or change exists. The absence of purulent drainage
indicates successful nursing interventions while the other options either fail to provide
measurable data regarding the wound or indicate no improvement.
DIF: C REF: 294 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. Which of the following statements made by a clients family is the most reliable for use in the
evaluation of a clients outcome?
1
2
3
4
Mom has been eating 90% of all of her meals since shes been
home.
My daughter is in much less pain now that she is going to
physical therapy.
My husband has been less depressed since hes been on that
antidepressant pill.
Mom has been so much better since shes been able to get up
and walk by herself.
ANS: 1
Input from the family and other caregivers can be used to evaluate client outcomes but it is best
to use their observations of measurable actions, such as the amount eaten, than to rely on their
subjective opinions of a clients reaction, such as pain, anxiety, or mood.
DIF: C dm 294 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which
of the following nursing actions represents the evaluation phase of the nursing process?
1
IV is discontinued.
2
Warm compress applied to IV site.
3
Site reinspected for presence of swelling.
IV site observed as having significant swelling.
4
ANS: 3
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Evaluation, the final step of the nursing process, is crucial to determine whether, after application
of the nursing process, the clients condition or well-being improves. The remaining options
represent the assessment and implementation phases.
DIF: A dm 291 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which of the following questions, asked by a nurse, best reflects an understanding of
effective evaluation?
1
Do you feel confident in the use of your glucometer?
2
Have you been following your low carbohydrate diet?
Any questions regarding the tests you are scheduled for today?
3
4
May we review what we discussed earlier about your
medications?
ANS: 4
In effective evaluation, the nurse compares client behavior and responses that were assessed
before delivering nursing interventions with behavior and responses that occur after
administering nursing care. The answer shows direct client knowledge related to the material
previously discussed, while the other options reflect close-ended questions that require only a yes
or no answer.
DIF: C dm 291 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that
requires repositioning the client every 2 hours. Which of the following represents the best
evaluation method for this intervention?
1
No additional pressure ulcers are noted over a 1-week period.
2
Client expresses a decrease in pressure ulcer related pain
within 1 week.
3
The clients pressure ulcer shows a decrease in size over a 1week period.
The turning schedule is initiated to reflect appropriate
positioning for a 1-week period.
4
ANS: 3
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You conduct evaluation measures to determine if you met expected outcomes, not if nursing
interventions were completed. The decrease in size of the pressure ulcer best evaluates the
effectiveness of this intervention while the remaining options reflect client opinion, further skin
breakdown, or implementation of the intervention.
DIF: C dm 291 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following statements best defines quality improvement (performance
improvement)?
1
The assessment of the delivery system responsible for the
implementation of client-oriented interventions
2
Integration of evidence-based practice research into the
delivery process used to implement client-oriented
interventions
3
High-priority evaluation process directed towards
differentiating between good and poor intervention delivery by
providers
4
An ongoing evaluation of interventions that is used to improve
the delivery of health care for the purpose of managing the
clients needs
ANS: 4
Quality improvement (QI) and performance improvement (PI) are interchangeable terms that
describe an approach to the continuous study and improvement of the processes of providing
health care services to meet the needs of clients and others. The remaining options reflect
individual facets of QI.
DIF: C dm 298 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. The primary reason for documenting discontinued portions of the care plan when a client
goal has been met is to ensure:
1
Effective use of both nursing time and resources
2
Delivery of both timely and relevant nursing care
3
Concrete evidence of successful outcome achievement
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4
Minimal ineffective communication among the nursing staff
ANS: 2
Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue
interventions for that portion of the plan of care. Continuity of care assumes that care provided to
clients is relevant and timely. The remaining options refer to the potential nursing outcomes
related to poor documentation of care plan editing.
DIF: C dm 297 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following nursing actions should be initiated first when dealing with the
following unmet client goal: Client will lose 10 pounds in 3 months?
1
Interview the client to identify reasons why the goal was not
met.
2
Assess the client for possible physical reasons for failure to
lose the weight.
3
Discuss with the client whether they were truly motivated to
lose the weight.
4
Re-evaluate whether it was realistic for the client to lose 10
pounds in 3 months.
ANS: 1
When goals are not met, the nurse should identify the factors that interfere with goal
achievement. The remaining options reflect actions to be taken after the interview to further
determine how the care plan will be modified.
DIF: C dm 297 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. When a client goal is unmet, which of the following nursing actions is most appropriate?
1
Reevaluation of the original client goal
2
Selection of new but appropriate interventions
3
Evaluation of the clients ability and motivation to be
compliant
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4
Repetition of the entire nursing process regarding the nursing
diagnosis
ANS: 4
When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing
process sequence for that nursing diagnosis to discover changes the plan needs. The remaining
options reflect individual elements within the nursing process.
DIF: C dm 297 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following is a recognized focus area for quality improvement (performance
improvement) evaluations? (Select all that apply.)
1
Effective care
2
Delivery of care
3
4
Client satisfaction
Exceeding the standard of care
5
Identification of missed client needs
6
Multidisciplinary approach to client care
ANS: 1, 2, 3, 4
Quality improvement is concerned with exceeding the standard of care, examining ways to be
more efficient, improving client satisfaction, and focusing on service. Although the remaining
options are pertinent, they are not major considerations of QI evaluation.
Chapter 21. Managing Patient Care
MULTIPLE CHOICE
1. It is necessary for the nurse manager to delegate tasks to the staff. Which of the following is a
requirement of the delegation process?
1
Working alongside the staff to evaluate their care
2
Functioning from a laissez-faire style of leadership
3
Obtaining the employees voluntary acceptance of the task
4
Communicating the work assignment in understandable terms
ANS: 4
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When delegating, the nurse should always provide unambiguous and clear directions by
describing a task, the desired outcome, and the time period within which the task should be
completed. The nurse manager does not necessarily have to work alongside staff to evaluate their
care. The nurse manager can often evaluate staff performance in client outcomes. A laissez-faire
style of leadership is not a requirement for delegation. Tasks should be delegated to those who
are capable, not necessarily to those who are willing.
DIF: A dm 309 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. As the nurse starts to perform a procedure, a peer says, Ive done that before. Would you like
me to help? The peers leadership style is described as:
1
Directing
2
Coaching
3
Democratic
4
Laissez-faire
ANS: 2
This situational leadership style is described as coaching. The peer is willing to explain the
procedure and provide the opportunity for clarification. Directing is a highly directive style of
leadership where leaders provide specific instructions and close supervision. A laissez-faire style
of leadership is where the leader intervenes as little as possible in the direction of others. The
laissez-faire style of leadership is described as nondirective, permissive, ultraliberal. A
democratic leadership style encourages group discussion and decision making. The democratic
leadership style is described as participative and consultative.
DIF: A OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. A unit manager on a busy multi-service medical nursing unit decides to take responsibility for
the direct client care of one of the many new admissions. Later the manager decides she is too
busy to give adequate client care. Which of the following situational leadership styles does the
nurse manager need to apply?
1
Coaching
2
Supporting
3
Delegating
4
Directing
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ANS: 3
Delegation is transferring responsibility for the performance of an activity or task while retaining
accountability for the outcome. To be more efficient in providing adequate client care, the
manager needs to use delegation. Coaching would not be the situational leadership style to apply.
The manager does not have time to explain decisions and provide the opportunity for
clarification. Supporting would not be the situational leadership style of choice. The manager
does not need to share ideas and facilitate decision making of other employees at this time.
Directing is a highly directive style of leadership. The manager needs to delegate, not provide
specific instructions and close supervision.
DIF: A dm 309 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. Which of the following statements best reflects the autocratic style of leadership?
1
Lets discuss this case study thoroughly and decide on a plan of
action as a group.
2
Ill try to pair you in comparable work teams, and lets evaluate
the success of this approach in 2 weeks.
Everyone knows their work assignment, so lets not meet
together unless we have an unexpected crisis.
3
4
Ill consider each of your requests, and then Ill give you the
guidelines for establishing new acuity ratings for our clients.
ANS: 4
Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity
ratings for our clients reflects the autocratic style of leadership. The leader is making the
decision. Lets discuss this case study thoroughly and decide on a plan of action as a group
reflects the democratic style of leadership. The leader encourages group discussion and decision
making. Ill try to pair you in comparable work teams, and lets evaluate the success of this
approach in 2 weeks reflects the delegating style of leadership. Responsibility and
implementation are being turned over to the group, but the leader remains accountable. Everyone
knows their work assignment, so lets not meet together unless we have an unexpected crisis
reflects the laissez-faire style of leadership. There is much freedom, and the leader assumes a
hands off approach.
DIF: A OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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5. To meet the needs of assigned clients and the responsibilities associated with the position,
nurses need to be aware of time management techniques. The time management skills for the
nurse include:
1
Meeting all of the clients needs in the early morning hours
2
Anticipating possible interruptions by therapists and visitors
3
Leaving each day unplanned to allow for adaptations in
treatments
4
Completing client assessments and treatments individually at
separate times
ANS: 2
To manage time, the nurse must anticipate when care will be interrupted for medication
administration and any diagnostic testing, and the nurse should also determine the best time for
planned therapies such as dressing changes, client education, and client ambulation. Meeting all
the needs in the early morning hours would be unrealistic. Some activities have specific time
limits in terms of addressing client needs and some activities follow scheduled routines
according to hospital policy. The nurse may also have to work around other schedules, such as if
the client had a test ordered for the morning. Therefore, the nurse cannot expect to meet all of the
clients needs at a specified time of day. Because the nurse has a limited amount of time with
clients, it is essential to remain goal-oriented and make a plan for using time wisely. Time
management involves using client goals as a way to identify priorities. The nurse in reviewing
the care requirements organizes his or her time so the activities of care and client goals can be
achieved. A nurse should complete the activities started with one client before moving on to
another.
DIF: A dm 308 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. In anticipation of a nursing shortage, the nursing management in a facility is investigating a
nursing care delivery model that involves the division of tasks, with one nurse assuming the
responsibility for particular tasks. This model is called:
1
Total patient care
2
Functional nursing
3
Team nursing
Primary nursing
4
ANS: 2
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Functional nursing is task-focused, not client-focused. In this model, tasks are divided, with one
nurse assuming responsibility for specific tasks. Total patient care is a model of care where an
RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of
care, but retains accountability for care of all assigned clients. In team nursing a registered nurse
leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians.
The team members provide direct client care to groups of clients, under the direction of the RN
team leader. Nurse assistants are given client assignments rather than being assigned particular
tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a
caseload of clients over time. Typically the RN selects the clients for his or her caseload and
cares for the same clients during their hospitalization or stay in the health care setting.
DIF: A dm 303 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. One advantage of a decentralized management structure for nursing units over a centralized
structure is that:
1
Communication pathways are simplified
2
Staff are not responsible for defining their roles
3
Managers handle all of the difficult decision making
4
Each staff member is accountable for evaluating the plan of
care
ANS: 4
In decentralized management, decision making is moved down to the level of staff. It requires
workers to be empowered to accept greater responsibility for the quality of client care provided.
This means that each staff member is accountable for evaluating the plan of care.
Communication pathways are not simplified. If decentralized decision making is in place,
professional staff have a voice in identifying the RN role. Each RN on the work team is
responsible for knowing his or her role and how it is to be implemented on the nursing unit. In
decentralized management, there is autonomy. In other words, there is freedom to decide and act.
The nurse manager does not necessarily handle the difficult decisions. Those staff members who
are best informed about a problem or issue make decisions on the basis of knowledge.
DIF: A dm 304 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. Indicators in a quality improvement program that evaluates the manner in which care is
delivered are:
1
Structure indicators
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2
Team indicators
3
Process indicators
Client indicators
4
ANS: 3
A quality indicator for evaluating the manner in which care is delivered is a process indicator.
Structure indicators evaluate the structure or systems for delivering care; an example is
adherence to checking if emergency carts are adequately stocked. There is no team indicator.
Client indicators would actually be outcome indicators. Outcome indicators evaluate the end
result of care delivered.
DIF: A dm Chapter 20, 298 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. A threshold of 90% is identified for an outcome indicator in the quality improvement program.
Which of the following situations indicates a need for further review of the quality improvement
plan?
1
The waiting time for clinic appointments has decreased 96%.
2
Clients with renal dialysis expressed a 95% satisfaction with
their care.
3
In 93% of clients, subjective expressions of postoperative pain
have decreased.
4
Wound infections are evident in 92% of clients after care of
their IV access ports.
ANS: 4
Wound infections are exceeding the designated threshold, indicating a need for further review of
the quality improvement plan. Waiting time for clinic appointments has decreased, meeting the
threshold. Satisfaction with care meets the threshold. Expressions of pain have decreased,
meeting the threshold.
DIF: A dm Chapter 20, 298 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. In anticipation of a nursing shortage, the nursing management in a facility are investigating a
nursing care delivery model that involves staff members working under the direction of a
registered nurse leader. This model is called:
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1
Team nursing
2
3
Primary nursing
Functional nursing
4
Total patient care nursing
ANS: 1
In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs,
and nurse assistants or technicians. The team members provide direct client care to groups of
clients, under the direction of the RN team leader. Nurse assistants are given client assignments
rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby
an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the
clients for his or her caseload and cares for the same clients during their hospitalization or stay in
the health care setting. Functional nursing is task-focused, not client focused. In this model, tasks
are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a
model of care where an RN is responsible for all aspects of care for one or more clients. The RN
may delegate aspects of care but retains accountability for care of all assigned clients.
DIF: A dm 303 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Accountability is a critical aspect of nursing care. An example of a specific decision-making
process of accountability is demonstrated by:
1
Selecting the medication schedule for the client
2
Implementing discharge teaching plans that meet individual
needs
3
Evaluating the clients outcomes following implementation of
care
Promoting participation of all staff members in regular unit
meetings
4
ANS: 3
Accountability refers to individuals being responsible for their actions. It involves follow-up and
a reflective analysis of ones decisions to evaluate their effectiveness. Selecting the medication
schedule for the client is an example of taking responsibility. Implementing discharge teaching
plans that meet individual needs is an example of autonomy. Promoting participation of all staff
members in unit meetings is an example of decentralized management and of promoting
authority.
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DIF: A dm 305 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. The student nurse is seeking to learn skills associated with priority setting. In discussing
different priorities of care, an example of a second-order priority is:
1
2
3
4
The need to urinate
An obstructed airway
The side effects of a medication
Activities of daily living in the home environment
ANS: 1
Second-order priority needs are actual problems for which the client or family has requested
immediate help, such as a full bladder. An obstructed airway is a first-order priority need because
it is an immediate threat to a clients survival or safety. Side effects of a medication is an example
of a third-order priority need. It is a relatively urgent actual or potential problem that the client or
family does not recognize. Activities of daily living in the home environment is a fourth-order
priority need. It is an actual or potential problem with which the client or family may need help
in the future.
DIF: A dm 307 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. The nurse on the unit is determining which activities may be delegated to assistive personnel.
Assuming that the nurse assistant is competent, which one of the following activities may be
safely delegated by the registered nurse?
1
Vital signs on a stable client
2
An admission history on a new client
3
Initial transfer of a postoperative client
Administration of medications prepared by the nurse
4
ANS: 1
An institutions policies and procedures and job description for assistive personnel provide
specific guidelines in regard to which tasks or activities can be delegated. The nurse should
match tasks to the delegates skills, such as delegating vital signs to a nurse assistant. It would not
be appropriate to delegate an admission history on a new client to a nurse assistant. The RN
should perform this task. Initial transfer of a postoperative client should not be delegated to a
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nurse assistant, as the client would be considered unstable. The RN should perform this task. The
nurse should not delegate medication administration to a nurse assistant, even if the nurse
prepared it. The nurse assistant is not licensed to administer medication.
DIF: A dm 309 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. The most important responsibility of a nurse manager is to:
1
Foster an environment that enables staff to provide quality
nursing care
2
Provide leadership and role modeling for nursing and ancillary
staff
3
Evaluate the delivery of nursing care in regard to its effect on
client outcomes
4
Create a unit attitude of cooperative engagement directed
toward positive client outcomes
ANS: 1
Perhaps the most important responsibility of the nurse executive is to establish a vision for
nursing that enables managers and staff to provide quality nursing care. The remaining options
are means by which the manager can affect the proper environment.
DIF: C dm 302 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. The primary benefit of achieving Magnet status is the nursing staff is empowered to make
innovative changes that:
1
Promote nursing autonomy
2
Positively affect client care outcomes
3
Enhance the perception of the nursing profession
Strengthen the collaborative RN/MD relationship
4
ANS: 2
A Magnet hospital empowers the nursing team to make changes and be innovative. This culture
and empowerment combine to produce a strong collaborative relationship among team members
and so ultimately improves client quality outcomes. The remaining options are outcomes of the
Magnet status but not the primary benefit.
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DIF: C dm 302 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. Which of the following statements best reflects the nurses understanding of team nursing?
1
The team provides the client care and I provide the leadership
and decision making.
2
I will manage the complex care and delegate the remaining
care to my LPN and ancillary assistants.
3
Everyone on the team has responsibilities and is accountable
to me regarding the effective execution of that care.
4
I delegate the care of the clients to the appropriate team
members and I am responsible for coordinating and directing
that care.
ANS: 4
In team nursing a registered nurse (RN) leads a team that is made up of other RNs, licensed
practical nurses (LPNs) or licensed vocational nurses (LVNs), and nurse assistants or
technicians. The team members provide direct client care to groups of clients under the direction
of the RN team leader. In this model, nurse assistants have client assignments rather than being
assigned particular nursing tasks. The remaining options fail to provide an inclusive definition of
team nursing.
DIF: C dm 303 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which statement best reflects the major limitation of the team nursing model?
1
The team really needed an extra pair of hands today.
2
It complicates things when you have a different team each day.
3
Getting our two new admissions stabilized took up all of my
time today.
4
My nursing assistants need to be in-serviced on how to do a
bladder scan.
ANS: 3
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One of the limitations to the model is that the team leader does not spend a large amount of time
with clients. Depending on the mix of staff members, this sometimes means that clients see an
RN infrequently. Risks exist if an RN is unable to make necessary client assessments and be
involved in important clinical decision making. The remaining options refer to less frequent
problems inherent to the team nursing model.
DIF: C dm 303 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. Which of the following clients would most benefit from the case manager model of nursing
care?
1
2
A client diagnosed with end-stage renal failure
A client who has a chronic wound on the left foot
3
A client newly diagnosed with type 2 diabetes mellitus
4
A postoperative client who had a cholecystectomy (gallbladder
removal)
ANS: 1
A case manager follows up with the client after discharge home. Case managers do not always
provide direct care, but instead they work with and supervise the care delivered by other staff
members. Case managers actively coordinate client discharge planning by identifying health care
needs, determining the availability of services and resources, and assisting the client in choosing
cost-efficient health care options. The client dealing with end-stage renal failure would most
benefit from this model of care because the clients case is the most complex and will require
extension discharge support.
DIF: C dm 304 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following actions is the best example of a nurse exercising nursing authority?
1
Assigning team responsibilities to individual team members
2
Evaluating a team members ability to perform a bladder scan
3
Readjusting a clients turning schedule to provide hourly
repositioning
Determining that a client will not be ambulated based on
assessment findings
4
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ANS: 4
Authority refers to legitimate power to give commands and make final decisions specific to a
given position. Canceling a clients ambulation is the best example because it shows critical
thinking in determining the appropriateness of an intervention. The remaining options are better
examples of nursing responsibility.
DIF: C dm 305 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following actions best reflects accountability for the clients care outcomes?
1
Reassessing a clients BP when the reported value is higher
than usual
2
Assisting a team member in providing a client with a complete
bed bath
3
Reevaluating a clients pain 30 minutes after administering
pain medication
4
Asking a clients daughter to bring her fathers non-skid slippers
to the hospital
ANS: 1
Accountability refers to individuals being responsible for their actions. It means that a nurse
accepts the commitment to provide excellent client care and the responsibility for the outcomes
of the actions in providing that care. Reassessing an abnormally high BP is the best example of
nursing accountability because it shows the nurse being responsible for the accuracy of the
assessment. The remaining options better reflect nursing responsibility.
DIF: C dm 305 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. When the oncology units interdisciplinary team meets every Monday morning at 0830 to
discuss the units individual clients, the group is best displaying:
1
Staff education
2
Collaborative practice
3
Team communication
4
Nursing shared governance
ANS: 2
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Collaboration of health care team members is required to help meet the complex needs of clients
in health care settings. Such collaborative interaction may strengthen individual members
knowledge and communication skills. Nursing shared governance is a process directed towards
the standard of nursing care among a particular groups of professional nurses.
DIF: C dm 306 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. Clinical nursing decisions are best made using:
1
Clinical pathways
2
3
Accurate assessment data
Previous nursing knowledge
4
Interdisciplinary collaboration
ANS: 2
When beginning an assignment with a client, the first nursing activity involves a focused but
complete assessment of the clients condition. This information enables the nurse to make an
accurate clinical decision as to the clients health problems and required nursing therapies. The
remaining options support the clinical decision-making process.
DIF: C dm 307 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. A client has reported all of the following; which should be given priority by the nurse?
1
Pain
2
Hunger
3
Anxiety
4
Constipation
ANS: 1
When a client has diverse priority needs, it helps to focus on the clients basic needs; pain will
exacerbate the clients anxiety and interfere with eating and thus should be attended to first.
While a concern, constipation is the lowest priority problem.
DIF: C dm 307 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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24. A nurse who performs a skin assessment while bathing an immobile client would be
displaying:
1
2
3
4
Efficiency
Leadership
Organization
Effectiveness
ANS: 1
Effective use of time means doing the right things, whereas efficient use of time means doing
things right. The nurse is showing efficiency by combining various nursing activitiesin other
words, doing more than one thing at a time. Organization is a general term that may include
efficiency, while leadership is the ability to manage people and resources.
DIF: A dm 307-308 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. When the nurse gathers all the equipment needed for a particular procedure and arranges the
clients room for proficient implementation of the procedure, the nurse is displaying:
1
Multitasking
2
Organization
3
Effectiveness
4
Professionalism
ANS: 2
The well-organized nurse approaches any planned procedures by having all of the necessary
equipment available and making sure the client is prepared. It always is wise to have the work
area organized and preliminary steps completed before asking co-workers for assistance.
Multitasking is dealing with more than one task at a time while being effective means doing the
right things correctly. Being professional means showing the characteristics of performing the
expected tasks of the profession.
DIF: A dm 308 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. The primary reason the nurse asks for help when changing a clients complicated dressing is
to:
1
Foster efficient client-oriented interventions
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2
Facilitate a comfortable, safe dressing change
3
Minimize the amount of time spent on a specific task
4
Engage in collaborative learning with other health care
professionals
ANS: 2
A nurse should never hesitate to have staff assist, especially when there is an opportunity to make
a procedure or activity more comfortable and safer for the client. While it is possible that having
help with a task can be a learning experience as well as making the task more efficient and less
time-consuming, it is not always the case and not the primary reason for asking for assistance.
DIF: C dm 308 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. The nurse is prioritizing care for two postoperative abdominal surgery clients; the first is 15
hours postoperative and the second is ready for discharge. Which of the interventions should be
accomplished first?
1
Discharge pain control
2
First day dangling and ambulation
3
First day post op coughing and deep breathing
4
Discharge teaching regarding the dressing change
ANS: 3
The first clients goals center on restoring physiological function impaired as a result of the stress
of surgery. The second clients goals center on adequate preparation to assume self-care at home.
Physiological interventions, particularly those affecting breathing, should receive priority.
Dangling and ambulation may be addressed after the second client is readied for discharge.
DIF: C dm 307 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. Which of the following statements made by a nurse related to the organization of client care
requires follow-up by the mentor?
1
I had my LPN bring the Foley catheterization supplies into the
room so theyd be there when I got there.
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2
I delegated all the stable vital signs to my nursing assistant and
the treatments to the LPN.
3
I was taking vitals on one client, dangling a second client
while I had the third expelling an enema.
Organization was never a strength of mine, but I believe Im
getting better at completing all my clients care.
4
ANS: 3
Good time management involves completing one task before starting another. If possible,
complete the activities started with one client before moving on to the next. Care will then
become less fragmented, and the nurse will be better able to focus on what is being done for each
client. As a result, it is less likely that errors will be made. The remaining options are not
reflective of poor management and so do not need follow-up.
DIF: C dm 308 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following are recognized competencies for an entry-level nurse? (Select all that
apply.)
1
Views clients holistically
2
Utilizes the nursing process
3
Participates in life-long learning
4
5
Exhibits nursing professionalism
Delegates client care appropriately
6
Exhibits expert nursing knowledge
ANS: 1, 2, 3, 4, 5
All provided options are recognized competencies for entry-level nurses except the ability to
practice with expert nursing knowledge. This will be acquired with time and experience.
DIF: C dm 302 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. To achieve Magnet status, the nursing staff of a hospital must exhibit: (Select all that apply.)
1
A client first mentality
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2
Autonomy of personal practice
3
Strong involvement in life-long learning
Ability to use state of the art technology
4
5
6
Strong nurse-health care provider collaboration
Clinical competence through earned certifications
ANS: 1, 2, 3, 5, 6
All provided options are characteristics required of the nursing staff for recognition as a Magnet
hospital except for expertise with state of the art technology.
DIF: C dm 302-303 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The advantages of team nursing include: (Select all that apply)
1
Fosters team cooperation
2
Allows for ancillary staff autonomy
3
Strengthens the RN-client relationship
4
Facilitates decision making at the clinical level
5
Encourages collaboration between team members
Provides management experience for team leaders
6
ANS: 1, 4, 5, 6
An advantage of team nursing is the collaborative style that encourages each member of the team
to help the other members. This model has a high level of autonomy for the team leader and is an
example of decision making occurring at a clinical level. Team nursing can limit the actual time
the RN spends with the clients; ancillary staff are not afforded autonomy regardless of the
nursing care model because their work must be supervised by the RN.
Chapter 22. Ethics and Values
MULTIPLE CHOICE
1. The client states that she needs to exercise regularly, watch her weight, and reduce her fat
intake. This demonstrates that the client:
1
Values health promotion activities
2
Believes she will not become sick
3
Believes she will have a heart attack
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4
Has unrealistic expectations for herself
ANS: 1
A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets
standards that influence behavior. The client is expressing her value of health promotion
activities. A belief is a conviction of the truth or reality of a thing. The client does not state she
believes these health promotion activities will keep her from becoming sick. A belief is a
conviction of the truth of a thing. The clients statement does not indicate she believes she will
have a heart attack. These are not unrealistic expectations.
DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. A client has actively picketed for gun control. During a robbery of his business, he was shot in
the leg. As the nurse assists him with morning care, which statement would the nurse expect him
to make that coincides with his values?
1
Firearms may have a place in our society.
2
Individuals should arm themselves for protection.
3
Prosecution should be the maximum for that felon.
Protection is a necessary evil for the good guy of the world.
4
ANS: 3
Individual experience influences what we come to value. The client who experienced a gunshot
during a robbery of his business may value gun control and verbalize a desire to have his attacker
prosecuted for the violent crime. The client who has picketed for gun control and who was
gunshot is unlikely to value firearms in our society. The individual who has actively picketed for
gun control is unlikely to desire the use of guns. The individual would be more likely to believe
that if there were gun control, there would be no need for guns. The individual who has actively
picketed for gun control is unlikely to desire the use of guns. The individual would be more
likely to believe that if there were gun control, there would be no need for guns.
DIF: A dm 316 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. A secondary school teacher with advanced multiple sclerosis insists on teaching from a
wheelchair and being treated the same as other colleagues. The teacher is demonstrating which of
the following?
1
Prizing her choice
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2
Choosing from alternatives
3
Considering all consequences
Acting with a pattern of consistency
4
ANS: 1
The teacher is demonstrating prizing her choice. She cherishes her choice of being treated like
everyone else despite her medical condition and publicly affirms the choice by teaching from a
wheelchair and insisting she be treated the same as her colleagues. At this point, the teacher is
not choosing from alternatives. She could have chosen to quit teaching, but she did not. She has
already made her choice. The teacher is not demonstrating considering all consequences. She has
already made her choice. At this point, the teacher is not demonstrating acting with a pattern of
consistency. She is not repeating a behavior.
DIF: A dm 316 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. The nurse recognizes that values clarification interventions are beneficial for the client when:
1
The client and nurse have different beliefs
2
The client is experiencing a values conflict
3
The nurse is unsure of a clients personal values
4
The client has chosen to reject the normal values
ANS: 2
Values clarification can help clients gain an awareness of personal priorities, identify ambiguities
in values, and resolve major conflicts between values and behavior. Values clarification for
nurses can help nurses strengthen their ability to advocate for a client because nurses are better
able to identify personal values and accurately identify the values of the client. Values
clarification is not necessarily beneficial for the client when the client and nurse have different
beliefs. Values clarification for the client will not necessarily help the nurse who is unsure of the
clients values. Values clarification interventions for the client will help the client, not the nurse,
gain awareness. The values that an individual holds reflect cultural and social influences,
relationships, and personal needs. Values vary among people and develop and change over time.
Therefore it may be inappropriate to state a client has rejected normal values when value systems
vary among people. What is considered normal to one person may not be to another.
DIF: A dm 316 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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5. The nurse is working with the client and trying to clarify the clients values regarding his care.
Which of the following statements reflects an example of the type of response a nurse should use
in a values clarification situation?
1
Your questions were pretty blunt.
2
3
Tell me what youre thinking right now.
Ive felt that way before. Id be upset, too.
4
You seem concerned about your tests. Let me explain them.
ANS: 2
Tell me what youre thinking right now is correct. Values clarification is a process of selfdiscovery in which the nurse should assist the client. The goal of values clarification with a client
is effective nurse-client communication. As the client becomes more willing to express problems
and feelings, the nurse can better establish an individualized plan of care. The character of a
nurses response to a client can motivate the client to examine personal thoughts and actions.
When the nurse makes a clarifying response, it should be brief and nonjudgmental. Your
questions were pretty blunt is incorrect. Values clarification is a process of self-discovery in
which the nurse should assist the client. The character of a nurses response to a client can
motivate the client to examine personal thoughts and actions. When the nurse makes a clarifying
response, it should be brief and nonjudgmental. The client is being judgmental in this response.
Ive felt that way before. Id be upset, too is incorrect as well. The nurse should not influence the
client with his or her own values, even if they are similar. You seem concerned about your tests.
Let me explain them is also incorrect. This statement is therapeutic in that it is reflective of a
clients feeling, and offers information. However, it does not encourage the client to examine their
values.
DIF: A dm 316 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. A nurses use of ethical responsibility can best be seen in which of the following nursing
actions?
1
Delivery of competent care
2
Formation of interpersonal relationships
3
Correct application of the nursing process
Evaluation of new computerized technologies
4
ANS: 1
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The term responsibility refers to the characteristics of reliability and dependability. In
professional nursing, responsibility includes a duty to perform actions well and thoughtfully.
When the nurse provides competent care, the nurse is demonstrating ethical responsibility.
Formation of interpersonal relationships is not an ethical responsibility. Application of the
nursing process is not an ethical responsibility. Evaluation of new computerized technologies is
not an ethical responsibility.
DIF: A dm 314-315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. A nursing student that immediately informs her clinical instructor after she realizes that she
has administered the wrong dose of medication to a patient is best described professionally as:
1
Confident
2
Trustworthy
3
Compliant
4
Accountable
ANS: 4
Accountability refers to the ability to answer for ones own actions. The goal is the prevention of
injury to the client. The student nurse who informs her instructor of an error is being accountable
for her actions and has a goal to prevent injury to the client. The student nurse would not be
described professionally as confident (i.e., sure of oneself). The student is not best described as
trustworthy. To be trustworthy, one is worthy of trust or confidence and reliable. In this case, the
student was not reliable to administer medication correctly. This student nurse is not best
described professionally as compliant. The student is not acting in accordance with wishes,
commands, or requirements.
DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. A client who is recently diagnosed with cancer is encouraged to consider sharing the
information with her family so they can support her through the decisions she will need to make
regarding her care. The nurse is using the principle of:
1
Confidentiality
2
Fidelity
3
Veracity
4
Justice
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ANS: 3
Veracity in general means accuracy or conformity to truth. The nurse is encouraging the client to
be truthful with the clients family. Confidentiality means to not impart private matters. Fidelity
refers to the agreement to keep promises. Justice refers to fairness.
DIF: A OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. The correct sequence for attaining the resolution of an ethical problem is:
1
2
3
4
Examine values, evaluate, and identify the problem
Evaluate the outcomes, gather data, and consider actions
Gather facts, verbalize the problem, and consider actions
Recognize the dilemma, evaluate, and gather information
ANS: 3
The correct sequence for resolving ethical problems is recognizing the dilemma, gathering facts,
examining ones own values, verbalizing the problem, considering actions, negotiating the
outcome, and evaluating the action.
DIF: A dm 319 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. A nurse is ambivalent as to the need to vigorously suction the secretions of a terminal client
in a comatose state. Which of the following is an appropriate statement by the nurse in regard to
processing an ethical dilemma?
1
I just feel like I should not suction this client.
2
I need to know the legalities of the living will of this client.
3
I cannot figure out whats right in this situation. I need to
collect more data.
4
My spiritual beliefs mandate that I continue to provide all the
interventions in my scope of practice.
ANS: 3
The first step in processing an ethical dilemma is determining whether the problem is an ethical
one. The nurse who cannot figure out what is right, is stating a characteristic of an ethical
dilemma, which is that the problem is perplexing. The next step is to gather as much information
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as possible that is relevant to the case. I just feel like I should not suction this client is the nurse
is stating the problem according to her feelings. I need to know the legalities of the living will of
this client is the nurse who wants to know the legalities of the living will of a client is collecting
some, but not all, data pertaining to the problem. My spiritual beliefs mandate that I continue to
provide all the interventions in my scope of practice is the nurse stating her own beliefs.
DIF: A dm 316-317 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following statements best illustrates the deontological ethical theory?
1
I believe this disease was allowed by a supreme being.
2
He has become a stronger individual through experiencing the
loss of his father.
3
Under no circumstances would it ever be right for a person to
stop CPR efforts.
4
The chemotherapy did not cure this person, but it provided a
better life for him.
ANS: 3
Under no circumstances would it ever be right for a person to stop CPR efforts is correct.
Deontology defines actions as right or wrong based on their right-making characteristics, such as
fidelity to promises, truthfulness, and justice. Deontology does not look at consequences of
actions to determine rightness or wrongness. Fidelity to promises and beneficence may be
principles upon which this statement is based on determining wrongness. I believe this disease
was allowed by a supreme being does not reflect the deontological ethical theory. Because it
reflects a relationship between disease and a supreme being, it follows the feminist ethical
theory. He has become a stronger individual through experiencing the loss of his father does not
best illustrate the deontological ethical theory because it is citing a consequence. It follows the
utilitarian ethical theory. The chemotherapy did not cure this person, but it provided a better life
for him does not best illustrate the deontological ethical theory because it is citing a
consequence. It follows the utilitarian ethical theory.
DIF: A dm 316-317 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. On admission to the hospital, a terminal cancer patient says he has a living will. This
document functions to state the clients desire to:
1
Receive all technical assistance to prolong his life
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2
Have his wife make the decisions regarding his care
3
Be allowed to die without life-prolonging techniques
Have a lethal injection administered to relieve his suffering
4
ANS: 3
A living will is an advance directive, prepared when the individual is competent and able to
make decisions, regarding that persons specific instructions about end-of-life care. Living wills
allow people to specify whether they would want to be intubated, treated with pressor drugs,
shocked with electricity, and fed or hydrated intravenously. A living will specifies what
interventions the client does not want, so that his or her life will not be prolonged. If his wife has
power of attorney she would be able to make decisions regarding the clients care. Assisted
suicide, such as a lethal injection, is not a function of a living will. A living will defines a clients
wishes for withholding treatment that would prolong his or her life.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. At an accident scene a nurse stopped and began to provide emergency care for the victims.
Her actions are best labeled ethically as:
2
Triage
Beneficence
3
Nonmaleficence
4
Respect for persons
1
ANS: 2
Beneficence refers to taking positive actions to help others, as in providing emergency care at an
accident scene. Triage is the screening and classification of casualties to make optimal use of
treatment resources and to maximize the survival and welfare of clients. Nonmaleficence is the
avoidance of harm or hurt. Respect for persons has to do with treating people equally despite
their social standing, for example.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. The nurse is aware that an ethics committee in a health care facility serves to:
1
Interview all persons involved in a case
2
Illustrate circumstances that demonstrate malpractice
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3
Serve as a resource for specific situations that may occur
4
Examine similar previous instances for comparison of
outcome decisions
ANS: 3
Ethics committees serve as a resource to support the processing of ethical dilemmas. Ethics
committees serve several purposes: education, policy recommendation, and case consultation or
review. Although an ethics committee may gather further information, ethics committees do not
interview all persons involved in a case. Rather, they offer consultation or case review.
Illustrating circumstances that demonstrate malpractice is not a purpose of an ethics committee.
Examining similar previous instances for comparison of outcome decisions may be part of data
gathering to help process an ethical dilemma or for policy recommendation, but it is not the
purpose of an ethics committee.
DIF: A dm 321 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. In the emergency department a client feels that she has been waiting longer than the other
individuals due to the fact that she has no insurance. The ethical principle that is involved in this
exact situation is:
1
2
Justice
Autonomy
3
Beneficence
4
Nonmaleficence
ANS: 1
Justice refers to treating people fairly. Allocation of resources and access to health care involves
the ethical principle of justice. The client without medical insurance should not have to wait
longer to receive health care than those with insurance. Autonomy refers to a persons
independence. Autonomy represents an agreement to respect anothers right to determine a course
of action. Beneficence refers to taking positive actions to help others. Nonmaleficence refers to
the avoidance of harm or hurt.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. Regarding the nurses use of the specific ethical principle of autonomy in a client situation, an
example would be:
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1
Learning to do a procedure safely and effectively
2
3
Returning to speak to a client at an agreed upon time
Preparing the clients room for comfort and privacy
4
Supporting a clients right to refuse a specific type of therapy
ANS: 4
Following the ethical principle of autonomy, the nurse allows a client to make his or her own
decisions regarding care and then supports that decision. Learning how to perform a procedure
safely and effectively is a nurses use of ethical responsibility. Returning to speak to a client at an
agreed upon time demonstrates the ethical principle of fidelity. Preparing the clients room for
comfort and privacy is a nurses use of ethical responsibility.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which of the following statements reflects application of the specific ethical principle of
confidentiality?
1
Im concerned that funding may affect the outpatient program.
2
Im going to make sure that the client understands the
instructions.
I cannot share that information with you about the clients
condition.
3
4
I need to get more information about the clients personal
health history.
ANS: 3
I cannot share that information with you about the clients condition reflects the application of the
ethical principle of confidentiality. Information is not to be shared with others without specific
client consent. Im concerned that funding may affect the outpatient program reflects a concern
regarding allocation of resources. It is not a confidentiality issue. The nurse who makes sure a
client has gained understanding is being ethically responsible. I need to get more information
about the clients personal health history reflects data gathering. Information gathered is to be
used for the purpose of providing competent health care. It should not be shared with others
without specific consent of the client.
DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. The client has been diagnosed with malignant bone cancer and the treatment involves
chemotherapy on an outpatient basis. While treating the cancer the client unfortunately becomes
very ill, experiences significant side effects from the therapy, and has a severe reduction in the
quality of life. The specific ethical principle that is in question in this situation is:
1
2
Veracity
Fidelity
3
Justice
4
Nonmaleficence
ANS: 4
Nonmaleficence is the avoidance of harm or hurt. Whether the discomforts of treatment are
benefiting the client or are worse than the disease itself have to be considered. The health care
professional tries to balance the risks and benefits of a plan of care while striving to do the least
harm possible. Veracity refers to truthfulness. This situation is not questioning truthfulness.
Fidelity refers to the agreement to keep promises. This situation does not question fidelity.
Justice refers to fairness. This situation is not a matter of justice.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following statements best reflects the nurses ethical concern for nonmaleficence
regarding the clients treatment plan?
1
The radiation therapy has not substantially decreased the
clients tumor related pain.
2
The client expressed the idea that this treatment was
definitively going to cure her cancer:
The clients family requested that she not be informed of the
seriousness of her cardiac condition.
3
4
The procedure is quite invasive, and there is little chance that
it will improve the clients quality of life.
ANS: 4
Nonmaleficence is the avoidance of harm or hurt. Whether the discomforts of treatment are
benefiting the client or are worse than the disease itself have to be considered. The health care
professional tries to balance the risks and benefits of a plan of care while striving to do the least
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harm possible. The remaining options are related to veracity (truthfulness), fidelity (keeping a
promise), and possibly fairness.
DIF: A dm 314 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following statements related to confidentiality made by a nurse requires
immediate follow-up by the nurse manager?
1
I believe the client is eligible for both Medicare and Medicaid.
2
The client with pneumonia has tested positive for TB
(tuberculosis).
3
Did you know that the client in Room 45 has a daughter who
has type 1 diabetes mellitus?
4
I arranged for the clients information to be faxed to the
assistive living facility she will be transferred to.
ANS: 3
This information is private and the nurse is violating the clients right to confidentiality because
the information has no bearing on the care needs of the client. The remaining options are not
reflective of an ethical breech because the exchange of that information has a direct bearing on
the clients care.
DIF: C dm 315 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following nursing actions best reflects a nurses commitment to the ethical
principle of fostering autonomy regarding an older client living in an extended care facility?
1
Providing options regarding the furniture arrangement of the
clients room
2
Supporting a clients decision to adopt a DNR (do not
resuscitate) status
Allowing sufficient time for the client to independently
accomplish morning hygiene
3
4
Consulting the client regarding personal preferences regarding
treatment options
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ANS: 2
Following the ethical principle of autonomy, the nurse facilitates a clients decision-making
process in order to make their own decisions regarding all aspects of life, including their care,
and then supports those decisions. The most important and possibly controversial decision is that
of DNR status and thus shows the greatest commitment on the nurses part.
DIF: C dm 314 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. Which of the following statements made by a terminally ill client reflects the best
understanding of the purpose of a living will?
1
It will make sure my wishes are respected.
2
My family wont be burdened with making those hard
decisions.
I dont want strangers making those kinds of decisions for me.
3
4
I can make my wishes known while I still have the ability to
express them.
ANS: 4
A living will is an advance directive, prepared when the individual is competent and able to
make and communicate personal decisions, regarding specific instructions about end-of-life care.
The remaining options represent motivation for implementing a living will.
DIF: C dm Chapter 23, 328 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The nurse is showing respect for a clients right to autonomy regarding an invasive procedure
by:
1
Obtaining consent for the procedure
2
Performing the procedure appropriately
3
Providing client education regarding the procedure
4
Being frank when discussing the pros and cons of the
procedure
ANS: 1
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The signed consent ensures that the nurse obtained the clients permission before proceeding with
the procedure. The remaining options are examples of nonmaleficence, client right to be
informed, and veracity.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. The nurse holds a clients hand during a painful procedure. This action shows a positive act
towards the client that is referred to as:
1
Veracity
2
3
Fidelity
Beneficence
4
Nonmaleficence
ANS: 3
Beneficence refers to taking positive actions to help others. The practice of beneficence
encourages the urge to do good for others. The agreement to act with beneficence also requires
that the best interests of the client remain more important than self-interest. The remaining
options reflect truthfulness, keeping true to a promise, and doing no harm.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. When a nurse considers the possible positive effect a treatment will have against the pain it
may cause the client, the nurse is displaying:
1
Justice
2
Fidelity
3
Beneficence
4
Nonmaleficence
ANS: 4
Nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not
only the will to do good but also the equal commitment to do no harm. The remaining options
refer to fairness, truthfulness, and kindness.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. When a client who is in need of a lung transplant is placed on the organ donor registry
according to his current health needs, this is an example of ethical:
1
2
Justice
Fidelity
3
Beneficence
4
Nonmaleficence
ANS: 1
Health care providers agree to strive for fairness in health care. Criteria set by a national
multidisciplinary committee make every effort to ensure justice by ranking client organ
recipients according to need. The remaining options refer to keeping a promise, kindness, and
doing no harm.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. Abandoning a client would be an example of a nurses failure to professionally display:
1
Justice
2
Fidelity
3
Beneficence
4
Nonmaleficence
ANS: 2
Fidelity refers to the agreement to keep promises. A commitment to fidelity supports the
reluctance to abandon clients. The remaining options refer to fairness, kindness, and doing no
harm.
DIF: A dm 314 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. The nursing professional code of ethics is best defined as:
1
The criteria for judging nursing professionalism
2
A benchmark for professional nursing deeds and actions
3
The nursing professions expectations of its members behavior
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4
A document that holds nurses responsible for professional
behavior
ANS: 3
It is a collective statement about the groups expectations and standards of behavior. The
remaining options are not accurate or complete descriptions of the nursing professional code of
ethics.
DIF: C dm 314 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
29. The nurse has successfully completed a distance learning class on ECG (electrocardiogram)
interpretation. This is an example of the nurse exhibiting the professional principle of:
1
Advocacy
2
3
Responsibility
Accountability
4
Confidentiality
ANS: 2
The word responsibility refers to a willingness to respect obligations and to follow through on
promises. The nurse has a responsibility to remain competent to practice so that he or she is able
to reliably follow through on responsibilities. The remaining options are reflective of other
professional principles.i
DIF: A dm 314-315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. The nurse is explaining the rationale for seeking the familys permission to apply a physical
restraint to a combative client. This is an example of the nurse exhibiting the professional
principle of:
1
Advocacy
2
Responsibility
3
Accountability
4
Confidentiality
ANS: 3
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Accountability refers to the ability to answer for ones own actions. Nurses should ensure that
their professional actions are explainable to their clients and to their employer. The remaining
options are reflective of other professional principles.
DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
31. The nurse realizes that sharing ones computer password is a violation of which of the
professional nursing principles?
1
Advocacy
2
3
Responsibility
Accountability
4
Confidentiality
ANS: 4
When medical records are computerized, computer security measures include special access
codes for all authorized users; sharing private passwords is a breech of client confidentiality
because it allows unauthorized individuals to access client information. The remaining options
are reflective of other professional principles.
DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
32. The belief that all life is sacred and must be preserved regardless of the quality of that life is
an example of:
1
Cultural bias
2
Personal value
3
Universal truth
4
Individual preference
ANS: 2
A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets
standards that influence behavior. A cultural bias refers to interpreting and judging phenomena in
terms particular to ones own culture while a universal truth is so overwhelmingly true that all
mankind respects and acknowledges the validity of the statement. An individual preference is a
personal choice.
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DIF: A dm 315 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
33. The nurse realizes that an individual clients value system is most affected by:
1
2
3
4
Life experiences
Economic status
Spiritual beliefs
Formal education
ANS: 1
Development of values begins in childhood, shaped by experiences within the family unit,
especially dramatic events during the formative years. The other options may influence the value
system, but not to the same extent.
DIF: C dm 316 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
34. An older client is experiencing the greatest problem with the concept of autonomy when he
has difficulty:
1
Expressing his need for pain medication
2
Disagreeing with his health care provider
3
Participating in discussions regarding his treatment
4
Discussing his need for assistive living arrangements
ANS: 2
Older people are usually not as familiar with the concept of autonomy as people from younger
generations. As a result, older adults are sometimes uncomfortable disagreeing with doctors or
nurses. They view assertiveness as a violation of trust. The remaining options reflect autonomy
problems but management of personal health issues is the most important issue.
DIF: C dm 314 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following elements are essential among a group working towards the successful
resolution of a conflict of opinion? (Select all that apply.)
1
Similar value systems
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2
Presumption of good will
3
Similar cultural background
Client-centered decision making
4
5
6
Strict adherence to confidentiality
Participation of all involved parties
ANS: 2, 4, 5, 6
The resolution of conflicting opinions works best when the following elements are part of the
process: the presumption of good will on the part of all participants, strict adherence to
confidentiality, client-centered decision making, and the welcome participation of families and
primary caregivers. The remaining options represent group characteristics that usually minimize
conflict in decision making.
DIF: C dm 319 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. Although the American Nurses Associations (ANAs) code of ethics is reviewed and revised
regularly to reflect changes in nursing practice, the basic principles that remain constant are:
(Select all that apply)
1
Advocacy
2
Reliability
3
Responsibility
4
Accountability
5
Confidentiality
Professionalism
6
ANS: 1, 3, 4, 5
The American Nurses Association (ANA) established the first code of nursing ethics decades
ago. The ANA reviews and revises the Code regularly to reflect changes in practice. Basic
principles remain constant; however, responsibility, accountability, advocacy, and confidentiality.
Although admirable, the remaining options are not considered core principles of the code.
DIF: C dm 315 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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3. The nurse knows that when making choices concerning the adoption of evidence-based
practice, the literature must be reviewed regarding its: (Select all that apply)
1
2
3
Content
Relevance
4
Reliability
Ethical soundness
5
Economic feasibility
6
Transcultural versatility
ANS: 1, 2, 3, 4
Nurses make choices regarding evidence-based practice proposals based on content, relevance,
reliability, and the ethical implications to their practice. The remaining options are not typically
considered when evaluating the global usefulness of research findings.
Chapter 23. Legal Implications in Nursing Practice
MULTIPLE CHOICE
1. Which source of law best addresses a situation where nurse accidentally administers an
incorrect dosage of morphine sulfate to the client?
1
Civil law
2
Criminal law
3
Common law
4
Administrative law
ANS: 1
Civil laws protect the rights of individual persons within our society and encourage fair and
equitable treatment among people. Generally, violations of civil laws cause harm to an individual
or property and damages involve payment of money. Administering an incorrect dosage of
morphine sulfate would fall under civil law because it could cause harm to an individual.
Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment).
Common law is created by judicial decisions made in courts when individual legal cases are
decided (i.e., informed consent). Administrative law is created by administrative bodies, such as
state boards of nursing when they pass rules and regulations (i.e., the duty to report unethical
nursing conduct)
DIF: A dm 326 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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2. What standard of care applies to the student nurses conduct when providing care normally
performed by a registered nurse (RN)?
1
2
The same standard of care as an RN
A standard of care of an unlicensed person
3
No special standard of care because her faculty member is
responsible for her conduct
4
A standard similar to but not the same as the staff nurse with
whom she is assigned to work
ANS: 1
Student nurses are expected to perform as professional nurses (i.e., as an RN would in providing
safe client care). Students are not working in the same capacity as an unlicensed person, and
therefore are not compared to the standard of an unlicensed person. No special standard of care
because her faculty member is responsible for her conduct is not a true statement. Staff nurses
may serve as preceptors, but that does not excuse the student from performing at the level of an
RN. If a client is harmed as a direct result of a nursing students actions or lack of action, the
liability for the incorrect action is generally shared by the student, instructor, hospital or health
care facility, and university or educational institution.
DIF: A dm 333 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. Which of the following is the most important factor in a nurse deciding whether or not to carry
malpractice insurance?
1
The nurses knowledge level of Good Samaritan laws
2
The amount of malpractice insurance provided by the nurses
employer
3
The time frames and individual liability of the employers
malpractice coverage
The evaluation of whether the nurse works in a critical area of
nursing where clients have higher morbidity and mortality
rates
4
ANS: 3
It would be important to know the time frames of the employers malpractice coverage. In other
words, is the nurse only covered during the times he or she is working within the institution? It
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would be important to know the individual liability. For example, if sued, what financial
responsibility would the nurse have? The nurse should be aware of Good Samaritan laws, but
this would not be sufficient coverage for most nursing practice. Therefore it is not the most
importance factor in determining whether to purchase private malpractice insurance. The amount
of malpractice insurance provided by the employer is not the most important factor in deciding
whether to carry private insurance. Generally, the employers malpractice insurance coverage is
much greater than private insurance coverage. The area of nursing in which the nurse is
employed is not the most important factor in deciding whether or not to carry malpractice
insurance. Lawsuits can occur anywhere.
DIF: A dm 334-335 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. An unconscious client with a head injury needs surgery to live. His wife only speaks French,
and the health care providers are having a difficult time explaining his condition. Which of the
following is the most correct answer regarding this situation?
1
An institutional review board needs to be contacted to give
their emergency advice on the situation.
2
The health care team should continue with the surgery after
providing information in the best manner possible.
3
A friend of the family could act as an interpreter, but the
explanation could not provide details of the clients accident,
because of confidentiality laws.
4
Two licensed health care personnel should witness and sign
the preoperative consent indicating they heard an explanation
of the procedure given in English.
ANS: 2
In emergency situations, if it is impossible to obtain consent from the client or an authorized
person, the procedure required to benefit the client or save a life may be undertaken without
liability for failure to obtain consent. In such cases, the law assumes that the client would wish to
be treated. In an emergency, it is not necessary to contact the institutional review board. In doing
so, it would take up valuable time. A family member or acquaintance that is able to speak a
clients language should not be used to interpret health information. An official interpreter must
be available to explain the terms of consent (except in an emergency situation). Telephone
consents usually require two witnesses. This is not the case in this situation.
DIF: A dm 333 OBJ: Comprehension
TOP: Nursing Process: Implementation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. A physician asks a family nurse practitioner to prescribe a medication that the nurse
practitioner knows is incompatible with the current medication regimen. If the nurse practitioner
follows the physicians desire, which of the following is the most correct answer?
1
Good Samaritan laws will protect the nurse.
2
The nurse practitioner will be liable for the action.
3
This type of situation is why nurse practitioners should have
malpractice insurance.
4
If the nurse practitioner has developed a good relationship
with the client, there will probably not be a problem.
ANS: 2
A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any
harm suffered by the client. Good Samaritan laws will not protect the nurse in this situation.
Good Samaritan laws are for providing care at the scene of an accident. The nurse should refuse
to administer the medication when he or she knows it is wrong. Having malpractice insurance is
not the answer, as it does not protect the client from harm. The nurse practitioner should refuse
administering the medication. Developing a good relationship with the client is important, but
will not protect the nurse from legal liability for providing incompetent care.
DIF: A dm 327 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. A registered nurse interprets a scribbled medication order by the attending physician as 25 mg.
The nurse administers 25 mg of the medication to a client, and then discovers that the dose was
incorrectly interpreted and should have been 15 mg. Who would ultimately be responsible for the
error?
1
Attending physician
2
Assisting resident
3
Pharmacist
4
Nurse
ANS: 4
A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any
harm suffered by the client. The nurse should clarify the order with the physician if unable to
read the order. The attending physician could be included in a lawsuit, but it would be the nurse
who is ultimately responsible for the error. The assisting resident would not be ultimately
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responsible for the error. The assisting resident did not carry out an inaccurate order. The
pharmacist could be included in a lawsuit, but it would be the nurse who is ultimately
responsible for the error because the nurse was the individual who carried out an inaccurate
order.
DIF: A dm 327 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. A nurse is being asked to move from the eye unit to a general surgery floor where she in
inexperienced in this specialty due to an influenza epidemic among the nursing staff. She is
aware of her inexperience. The nurses initial recourse is to:
1
2
Fill out a report noting her dissatisfaction
Ask to work with another general surgery nurse
3
Notify the State Board of Nursing of the problem
4
Politely refuse to move, take a leave-of-absence day, and go
home
ANS: 2
Nurses who float should inform the supervisor of any lack of experience in caring for the type of
clients on the nursing unit. They should also request and be given orientation to the unit. Asking
to work with another general surgery nurse would be an appropriate action. A nurse can make a
written protest to nursing administrators, but it should not be the nurses initial recourse.
Notifying the state board of nursing should not be the nurses initial recourse. The nurse should
first notify the supervisor and request appropriate orientation and training. If problems continue,
the nurse should attempt the usual chain of command within the institution before contacting the
state board of nursing. A nurse who refuses to accept an assignment may be considered
insubordinate, and clients will not benefit from having less staff available.
DIF: A dm 335-336 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. There are issues concerning death and dying may influence nursing practice which the nurse
recognizes. Concerning the legalities of death and dying issues, which of the following is true?
1
Passive euthanasia is illegal in all states.
2
Assisted suicide is a constitutional right.
3
Organ donation must be attempted if it will save the recipients
life.
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4
Feedings may be refused by competent individuals who are
unable to self-feed.
ANS: 4
Competent clients have the right to refuse treatment. This includes life-saving hydration and
nutrition. This is not a true statement. Furthermore, physician-assisted suicide is legal in the state
of Oregon. In 1997 the Supreme Court ruled that there is no fundamental constitutional right to
assisted suicide. Organ donation does not have to be attempted to save a recipients life.
DIF: A dm 330 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. The Joint Commission (TJC) sets standards of care, in which an institution is required to have:
1
Limits of professional liability
2
3
Educational standards for nurses
A delineated scope of practice for health professionals
4
Written nursing policies and procedures for client care
ANS: 4
The TJC requires that accredited hospitals have written nursing policies and procedures.
Standards of care help define the limits of professional liability. The TJC does not require an
institution to have limits of professional liability. Nurse practice acts establish educational
requirements for nurses. Nurse practice acts define the scope of nursing practice. The rules and
regulations enacted by the state board of nursing define the practice of nursing more specifically.
The American Nurses Association has developed standards for nursing practice that delineate the
scope, function, and role of the nurse and establish clinical practice standards.
DIF: A dm 326 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. In the event that a nursing license is revoked, which of the following is correct?
1
The hearings are usually held in court.
2
Due process rights are waived by the nurse.
3
Appeals may be made regarding the decisions.
4
The federal government becomes involved in the procedures.
ANS: 3
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Because a license is viewed as a property right, due process must be followed before a license
can be suspended or revoked. Due process means that nurses must be notified of the charges
brought against them, and that the nurses have an opportunity to defend against the charges in a
hearing. Hearings for suspension or revocation of a license do not occur in court but are usually
conducted by a hearing panel of professionals. Due process must be followed. They do not have
to be waived by the nurse. Some states, not the federal government, provide administrative and
judicial review of such cases after nurses have exhausted all other forms of appeal.
DIF: A dm 330 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which one of the following actions is an example of an unintentional tort?
1
2
3
4
Restraining a client who refuses care
Taking photos of a clients surgical wounds
Leaving the side rails down and the client falls and is injured
Talking about a clients history of sexually transmitted diseases
ANS: 3
An unintentional tort is an unintended wrongful act against another person that produces injury
or harm. An example of an unintentional tort would be leaving the side rails down and the client
falls and is injured. Restraining a client who refuses care would be an example of assault and
battery. Taking photos of a clients surgical wounds without the clients permission is an example
of invasion of privacy. Talking about a clients history of sexually transmitted diseases would fall
under the category of invasion of privacy. Personal information should be kept confidential.
DIF: A dm 332 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. Which one of the following individuals may legally give informed consent?
1
A 16-year-old for her newborn child
2
A sedated 42-year-old preoperative client
3
The friend of an 84-year-old married client
4
A 56-year-old who does not understand the proposed treatment
plan
ANS: 1
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An emancipated minor, one who is below the age of 18 but who is a parent, can legally give
informed consent for the care of her newborn. An emancipated minor can also be someone below
the age of 18 who is legally married. A person who has been sedated cannot legally give
informed consent. Consent should be obtained before a sedative is administered. If the 84-yearold client were unable to give consent, then the clients wife would be the person legally
authorized to do so on the clients behalf. In order for a friend to be legally able to give consent,
he or she would have to possess power of attorney or legal guardianship of the client. If a client
does not understand the proposed treatment plan, the nurse must notify the physician or nursing
supervisor and must make certain that clients are informed before signing the consent.
DIF: A dm 332-333 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. When a nurse signs as a witness on an informed consent form, she is indicating that the
client:
1
Fully understands the procedure
2
3
Agrees with the procedure to be done
Has voluntarily signed the consent form
4
Has authorized the physician to continue with the treatment
ANS: 3
The nurses signature witnessing the consent means that the client voluntarily gave consent, that
the clients signature is authentic, and that the client appears to be competent to give consent. It is
the physicians responsibility to make sure the client fully understands the procedure. If the nurse
suspects the client does not understand, the nurse should notify the physician. The nurses
signature does not indicate that the client agrees with the procedure, but that the client has
voluntarily given consent and is competent to do so. Clients also have the right to refuse
treatment, which is also signed and witnessed. The nurses signature does not verify that the client
has authorized the physician to continue with treatment. It only verifies that the consent was
given voluntarily, the client is competent to give consent, and the signature is authentic.
DIF: A dm 332 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. A nurse who is working with clients who have DNR (do not resuscitate) orders knows that
these orders:
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1
Are legally required for terminally ill clients
2
May be written by the physician without client consent if
resuscitation is futile
Are maintained throughout the clients stay in either an acute
care or a long-term care facility
3
4
Follow nationally consistent standards for implementation of
client interventions
ANS: 2
If the client is unable, and there is no surrogate available to give consent, the DNR order can be
written but only if the physician is reasonably medically certain that the resuscitation would be
futile. A DNR order is not legally required for terminally ill patients.. DNR orders are not
necessarily maintained throughout the clients stay because a clients condition may warrant a
change in DNR status. The attending physician must review the DNR orders every 3 days for
hospitalized clients or every 60 days for clients in residential health facilities. There is no
nationally consistent standard for DNR implementation. States have their own statutes regarding
DNR orders.
DIF: A dm 328-329 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. The nurse understands the implications of the Patient Self-Determination Act. This
legislation requires that:
1
Clients designate a power of attorney
2
DNR orders for clients meet standard criteria
3
Organ donation is required upon death, if possible
4
Information be provided to the client regarding rights for
refusal of care
ANS: 4
The Patient Self-Determination Act requires health care institutions to provide written
information to clients concerning the clients rights under state law to make decisions, including
the right to refuse treatment and formulate advance directives. The Patient Self-Determination
Act does not require clients to designate a power of attorney. The Patient Self-Determination Act
does not require that DNR orders meet standard criteria. The Patient Self-Determination Act does
not require organ donation upon death. It is the clients decision whether he or she wants to
participate in organ donation.
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DIF: A dm 328 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. The newly enacted Health Insurance Portability and Accountability Act (HIPAA) of 2003
requires:
1
2
Insurance coverage for all clients
Policies on how to report communicable diseases
3
Limits on information and damages awarded in court cases
4
Safeguards to protect written and verbal information about
clients
ANS: 4
The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and
health agencies to have specific policies and procedures in place to ensure that there are
reasonable safeguards to protect written and verbal communications about clients. HIPAA does
not require insurance coverage for all clients. It limits the extent to which health plans may
impose preexisting condition limitations and prohibits discrimination in health plans against
individual participants and beneficiaries based on health status. HIPAA does not require policies
on how to report communicable diseases. It does require safeguards to protect written and verbal
information about clients. HIPAA does not require limits on information and damages awarded
in court cases.
DIF: A dm 329 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. A client is told by his nurse that he has to take the medications, including an injection. The
client refuses the medications, but continues to have them administered by the nurse. This action
is an example of the intentional tort of:
1
Assault
2
Battery
3
Malpractice
Invasion of privacy
4
ANS: 2
Battery is any intentional touching without consent. An example of battery is a nurse who gives a
medication after the client has refused. Assault is any intentional threat to bring about harmful or
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offensive contact. No actual contact is necessary. Malpractice is negligence committed by a
professional such as a nurse or physician. This case is not an example of malpractice. Invasion of
privacy is where the client has unwanted intrusion into his or her private affairs. This case is not
an example of invasion of privacy.
DIF: A dm 331 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. A nurse who is working with a client who has been diagnosed with AIDS reveals the clients
name and diagnosis with a co-worker on the way downstairs in an elevator. Unknowingly, a
friend of the client that happens to be sharing the elevator and hears the entire story. The nurse
who shared the information may be held liable for:
1
2
3
4
Slander
Assault
Malpractice
Invasion of privacy
ANS: 1
A nurse can be held liable for slander if he or she shares private client information that can be
overheard by others. Assault is any intentional threat to bring about harmful or offensive contact.
No actual contact is necessary. The nurse in this situation has not committed assault. Malpractice
is negligence committed by a professional such as a nurse or physician. Nursing malpractice
results when care falls below the standard of care. This case is not an example of malpractice.
Invasion of privacy occurs when the client has unwanted intrusion into his or her private affairs.
This case is not an example of invasion of privacy. This instance falls under the category of
defamation of character.
DIF: A dm 331 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. A nurse stealing narcotics from an acute care nursing unit is guilty of a:
1
Civil offense
2
Criminal offense
3
Common law offense
Administrative law offense
4
ANS: 2
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Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment).
A felony is a crime of a serious nature that has a penalty of imprisonment for greater than 1 year
or even death. A misdemeanor is a less serious crime that has a penalty of a fine or imprisonment
for less than 1 year. An example of criminal conduct for nurses is misuse of a controlled
substance. Civil laws protect the rights of individual persons within our society and encourage
fair and equitable treatment among people. Common law is created by judicial decisions made in
courts when individual legal cases are decided (i.e., informed consent). Administrative law is
created by administrative bodies, such as state boards of nursing, when they pass rules and
regulations.
DIF: A dm 326 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. The case of a nurse accused of unethical nursing conduct will be heard by the state board of
nursing. This is an example of:
1
Civil law
2
3
Criminal law
Common law
4
Administrative law
ANS: 4
Administrative law is created by administrative bodies, such as state boards of nursing when they
pass rules and regulations such as unethical nursing conduct. Civil laws protect the rights of
individual persons within our society and encourage fair and equitable treatment among people.
Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment).
Common law is created by judicial decisions made in courts when individual legal cases are
decided.
DIF: A dm 330 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following statements made by a nursing student regarding responsibility for
provided care requires immediate follow-up by the nursing instructor?
1
Im not held to the same standards as a licensed RN.
2
I am required to provide the safest, appropriate care I am
capable of.
3
My clinical instructor is ultimately responsible for the care I
provide.
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4
No one expects nursing students to provide care on the level as
an experienced RN.
ANS: 3
Student nurses are expected to perform as professional nurses, that is, as an RN would in
providing safe, appropriate client care. The clinical instructor is responsible for proper
instruction, supervision, and guidance but the student is responsible for their own acts. The
remaining options do reflect misconceptions, but the issue of responsibility has priority.
DIF: C dm 333 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. The nurse is having difficulty reading the prescribed dosage on a handwritten order for a pain
medication. The most appropriate action to ensure the clients safety and to minimize legal issues
is for the nurse to:
1
Ask another RN to confirm the order
2
Request the pharmacist to interpret the order
Call the health care provider to clarify the order
3
4
Consult a current drug book to determine the normal dosage
range
ANS: 3
A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any
harm suffered by the client. The nurse should clarify the order with the prescriber if unable to
read the order. Although asking others to interpret the order may appear prudent, it is ultimately
the nurses responsibility if a medication error is made. Although the drug book may provide a
normal range it does not aid in determining definitively what the order intended.
DIF: A dm 336 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The legal basis for a nurse to provide emergency treatment without consent to a client
incapable of informed consent is:
1
Such care is clearly a nursing responsibility
2
To fail to provide such care is nursing negligence
3
It is presumed that the client would want the emergency
treatment
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4
Health care providers have an obligation to provide emergency
treatment
ANS: 3
In emergency situations, if it is impossible to obtain consent from the client or an authorized
person, the law assumes that the client would wish to be treated. Providing appropriate nursing
care is a nursing responsibility, and failure to do so is negligence.
DIF: C dm 332 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. An experienced pediatric nurse is reassigned to an adult oncology floor because of staffing
issues and immediately recognizes a lack of experience in this specialty. Which of the following
nursing actions shows a lack of professionalism?
1
Politely declining the assignment
2
Filling out a report noting her dissatisfaction
3
Asking to work with another oncology nurse
Notifying the state board of nursing of the problem
4
ANS: 1
A nurse who refuses to accept an assignment may be considered insubordinate, and clients will
not benefit from having less staff available. This is an unprofessional attempt to resolve the
problem. Asking to work with another oncology nurse, sending a written protest, and notifying
the state nursing board would be appropriates action, and so are not examples of unprofessional
behavior.
DIF: C dm 335 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. Although a nurse may not agree, the nurse recognizes that a terminally ill client has the legal
right to:
1
Seek passive euthanasia in some states
2
Sign an organ donor pledge statement
3
Refuse DNR (do not resuscitate) status
4
Refuse treatment in the form of food and water
ANS: 4
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Competent clients have the right to refuse treatment. This includes life-saving hydration and
nutrition. Physician-assisted suicide is legal in the state of Oregon, and it is legally a clients
decision to declare a DNR status or to sign an organ donor card.
DIF: A dm 328 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. Which of the following statements best reflects a nurses understanding of the proper critical
thinking process regarding the need for personal malpractice insurance?
1
The states Good Samaritan laws protect me outside of the
hospital.
2
I work in a very low risk area of nursing, so I dont really have
a need.
The hospital carries its own malpractice insurance, so I dont
need extra.
3
4
Lawsuits can occur years after the event, so I carry my own
liability insurance.
ANS: 4
The employing institutions insurance only covers nurses while they are working within the scope
of their employment. Because nurses are professionals and it is often difficult to separate their
private lives from their professional skills, nurses need to consider purchasing individual
professional liability insurance, even if the employing institution has coverage. It would be
important to know the time frames of the employers malpractice coverage. The nurse may be
only covered during the times he or she is working within the institution. Good Samaritan laws
have a narrow scope and would not cover many nursing activities. Although it is true that some
areas of nursing have a higher potential for liability claims, all areas have risk. The hospitals
insurance may not cover all potential expenses and may not be applicable in all liability
situations.
DIF: C dm 334-335 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. Which of the following statements made by a nurse puts the nurse at risk for assault of the
client?
1
You will be sorry if you dont agree to take this medication.
2
You cant refuse this medication if you really want to feel
better.
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3
Ill be so disappointed in you if you dont take your medication.
4
Ill tell your son you arent cooperating if you dont take your
medication.
ANS: 1
Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is
necessary. Threatening to tell a family member may be a breech of confidentiality; the remaining
options are examples of unnecessary pressuring of the client.
This case is not an example of invasion of privacy.
DIF: C dm 331 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. Which of the following statements made by a nurse shows the best understanding regarding
the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 2003?
1
Im always careful to close the door when taping or listening to
the units shift report.
2
The nursing assistants know to hand me the vital signs sheet
and not just put it on the medication cart.
I called the radiology department to tell them I would be
faxing the client information they requested.
3
4
The clients niece called to see how she slept last night, but I
told her I couldnt share that with her over the phone.
ANS: 3
The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and
health care agencies to have specific policies and procedures in place to ensure that there are
reasonable safeguards to protect written and verbal communications about clients. By notifying
the receiver of an impending client-oriented fax, the nurse has taken a reasonable measures to
ensure it is seen by only the appropriate individuals. Although the remaining options deal with
safeguards, the potential for a breech in client confidentiality is not as great in those scenarios.
DIF: C dm 331 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
29. Which of the following statements made by a nurse reflects the best understanding of the
legal safeguards of a DNR (do not resuscitate) order?
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1
All family members need to agree before a DNR order can be
written.
2
All terminally ill clients are ultimately required to be declared
a DNR status.
The DNR order on the terminally ill client in Room 45 needs
reviewed today.
3
4
If the clients family cant be located, the physician will write
the DNR order.
ANS: 3
DNR orders are not necessarily maintained throughout the clients stay because a clients
condition may warrant a change in DNR status. To ensure client safety, the attending physician
must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in
residential health facilities. If there is no living will or durable power of attorney appointed,
members of the family will be consulted regarding a DNR order. Although not all family
members need to agree, an order will usually not be written if some family members express
strong opposition to the status change. If no family can be located, the attending physician has
the legal right to write the order. There is no legal requirement for a terminally ill client to be
required to assume DNR status.
DIF: C dm 328-329 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. Which of the following statements made by a nurse reflects a lack of understanding regarding
a DNR (do not resuscitate) order?
1
All family members need to agree before a DNR order can be
written.
2
All terminally ill clients are ultimately required to be declared
a DNR status.
The DNR order on the terminally ill client in Room 45 needs
reviewed today.
3
4
If the clients family cant be located the physician will write the
DNR order.
ANS: 1
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If there is no living will or durable power of attorney appointed, members of the family will be
consulted regarding a DNR order. Although not all family members need to agree, an order will
usually not be written if some family members express strong opposition to the status change.
DNR orders are not necessarily maintained throughout the clients stay because a clients
condition may warrant a change in DNR status. To ensure client safety, the attending physician
must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in
residential health facilities. If no family can be located, the attending physician has the legal right
to write the order. There is no legal requirement for a terminally ill client to be required to
assume DNR status.
DIF: C dm 328-329 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
31. Which of the following statements made by a nurse shows a lack of understanding regarding
the Uniform Anatomical Gift Act?
1
A client must be 21 to give consent to be an organ donor.
2
All clients admitted to the hospital are asked about becoming
an organ donor.
We have a form here on the unit that must be signed to show a
clients informed consent to be an organ donor.
3
4
In our state, you can check the back of a clients drivers license
to verify whether they are an organ donor.
ANS: 1
An individual who is at least 18 years of age has the right to make an organ donation (defined as
a donation of all or part of a human body to take effect upon or after death). Donors need to
make the gift in writing with their signature. In many states, adults sign the back of their drivers
license, indicating consent to organ donation. In most states, required request laws mandate that
at the time of admission to a hospital, a qualified health care provider has to ask each client older
than 18 whether he or she is an organ or tissue donor.
DIF: C dm 329 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
32. The nurse is heard stating to another staff member that, the client in Room 54 is such a
whiner; you would think she was dying. This nurse is liable of:
1
Libel
2
Slander
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3
Malpractice
4
Invasion of privacy
ANS: 2
Defamation of character is the publication of false statements either verbally or in writing that
result in damage to a persons reputation. Slander occurs when one verbalizes the false statement.
Libel is the written defamation of character, whereas invasion of privacy occurs when the client
has unwanted intrusion into his or her private affairs. Malpractice is negligence committed by a
professional such as a nurse or physician. Nursing malpractice results when care falls below the
standard of care.
DIF: A dm 332 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
33. Which of the following nursing statements reflects the best understanding of the importance
of appropriate nursing documentation regarding risk management?
1
If the client isnt compliant, Im sure to put that in my notes.
2
Im always careful to document any changes in the clients
condition.
3
My notes are the proof that I provided the client with effective,
appropriate care.
4
When there is a lawsuit, the nursing notes are the first thing
the attorney looks at.
ANS: 3
The nurses documentation is often the evidence of care received by a client and serves as proof
that the nurse acted reasonably and safely. The remaining options are not incorrect but do not
identify the primary importance to the nurse.
DIF: C dm 336 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
34. Which of the following statements reflects a nurses need for further instructions regarding an
incident report?
1
I hope this incident report will help determine a way to help
prevent falls.
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2
Risk management will want to review the incident report on
the clients fall.
3
I put the incident report on the clients fall in his chart as soon
as I was finished.
I need to review the guidelines before I fill out this incident
report regarding the clients fall.
4
ANS: 3
The report is confidential and separate from the medical record. The remaining options reflect an
understanding about incident reports.
DIF: C 336 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
35. Regarding hours worked and frequency of errors, recent research has shown that nurses
working more than 12.5 hours per shift and more than a 40-hour week are:
1
Reporting more physical illnesses than those working only 40
hours per week
2
Three times more likely to commit an error in nursing
judgment related to client care
3
Experiencing more physical injuries than those working only
40 hours per week
4
Experiencing signs of emotional burn out more frequently than
those working only 40 hours per week
ANS: 2
Results showed that nurses who worked shifts lasting 12.5 hours or more had a three times
greater likelihood of making an error. Overtime increased the odds of making at least one error
regardless of length of original shift scheduled. The remaining options are not supported by
research data.
DIF: C REF: 335 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
36. While working as a nursing assistant, a nursing student is asked to reinsert a Foley catheter
by the RN. Which of the following reflects the most appropriate initial student response to the
request?
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1
Notify the nursing supervisor of the inappropriate request.
2
3
Tell the RN that she can only perform as a nursing assistant.
Agree to perform the task but with the supervision of the RN.
4
Jointly read the nursing assistant job description with the RN.
ANS: 2
When students work as nursing assistants or nurses aides, they should not perform tasks that do
not appear in a job description for a nurses aide or assistant. The remaining options do not
appropriately address the immediate situation.
DIF: C REF: 333-334 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following statements is true regarding the implications of the nurses signature as
a witness for a clients consent? (Select all that apply.)
1
Client signed voluntarily.
2
The signature is authentic.
3
Client appears to be competent.
Client appears knowledgeable about the procedure.
4
5
6
The nurse has discussed the possible risks of the procedure.
The nurse has discussed possible post procedure nursing care.
ANS: 1, 2, 3, 4
The nurses signature witnessing the consent means that the client voluntarily gave consent, that
the clients signature is authentic, and that the client appears to be competent to give consent.
When nurses provide consent forms for clients to sign, nurses must ask the clients if they
understand the procedure for which they are giving consent. If clients deny understanding or you
suspect they do not understand, notify the physician or nursing supervisor. Nursing care post
procedure should be discussed but is not inferred by a nurses signature as a witness. Discussing
possible risk factors is the physicians responsibility.
DIF: C REF: 332-333 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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2. When documenting notification of the primary health care provider concerning a client whose
condition is deteriorating, the nurse must be sure to include which of the following? (Select all
that apply.)
1
Clients wife at bedside.
2
3
Client rating pain at 3 out of 10 at 0920.
Client asking to have wife called to come to hospital.
4
Dr. Smith notified of clients pain rating of 8 out of 10 at 0900.
5
Client administered 2 mg morphine sulfate IV every 5 minutes
for two doses.
Client ordered morphine sulfate 2 mg IV every 5 minutes until
pain relief is achieved.
6
ANS: 2, 4, 5, 6
The nurse must be certain to document that the physician was notified and his or her response,
nursing action in follow-up of orders, and the clients response. The remaining options are not
relevant to the proper documentation of the situation.
Chapter 24. Communication
MULTIPLE CHOICE
1. The client tells the nurse that he understands most of the information but still has questions
concerning the medication after the nurse has provided the client with information regarding the
treatment plan for the diagnosis the. This response is an example of:
1
Referent
2
Receiver
3
Channel
4
Feedback
ANS: 4
This response is an example of feedback. Feedback is the message returned by the receiver. The
referent motivates one person to communicate with another, such as a time schedule. This is not
an example of a referent. The receiver is the person who receives and decodes the message. This
question is not asking about the receiver, but rather the response. Channels are means of
conveying and receiving messages through visual, auditory, and tactile senses. This response is
not an example of a channel.
DIF: A REF: 343 OBJ: Comprehension
TOP: Nursing Process: Implementation/Evaluation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse is in the process of conducting an admission interview with the client. At one point
in the discussion, the client has provided information that the nurse would like to clarify. The
nurse employs the technique of clarification as indicated by the response:
1
Im not sure that I understand what you mean by that statement.
2
The ECG records information about your hearts electrical
activity.
3
Lets look at the problem you have had with your medication
when you were home.
4
Whats your biggest concern related to your hospitalization at
the moment?
ANS: 1
Im not sure that I understand what you mean by that statement is correct. Clarifying is when the
nurse checks whether understanding is accurate by restating an unclear message to clarify the
senders meaning, or by asking the other person to restate the message, explain further, or give an
example of what the person means. This response indicates the nurse wants to clarify what the
client is saying so he or she can have an accurate understanding of what the client means. The
ECG records information about your hearts electrical activity is an example of providing
information, not clarification. Lets look at the problem you have had with your medication when
you were home is an example of focusing, not clarification. Whats your biggest concern related
to your hospitalization at the moment is an example of sharing empathy.
DIF: A REF: 354 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The faculty member is reviewing a process recording with the student nurse. The student has
been working with a client who has had an amputation of the lower left leg and is emotionally
fragile. The student receives positive feedback from the faculty member for the following
response made to the client:
1
Why are you so upset today?
2
Im sure that everything will be all right.
3
You shouldnt cry. The wound will heal soon.
It must be very difficult to have this happen to you.
4
ANS: 4
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It must be very difficult to have this happen to you is an example of using the therapeutic
communication technique of sharing empathy. Why are you so upset today? is an example of a
nontherapeutic communication technique of asking for explanations. Im sure that everything will
be all right is an example of a nontherapeutic communication technique of giving false
reassurance. You shouldnt cry. The wound will heal soon is an example of a nontherapeutic
communication technique of giving disapproval.
DIF: A REF: 353 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. When reaching over the side rails to take a clients blood pressure, he draws back. To promote
effective communication, the nurse should first:
1
Tell the client that the blood pressure can be taken at a later
time
2
Rotate the nurses who are assigned to take the clients blood
pressure
3
Continue to perform the blood pressure assessment quickly
and quietly
4
Apologize for startling the client and explain the need for
touching the client
ANS: 4
Nurses often have to enter a clients personal space to provide care. The nurse should convey
confidence, gentleness, and respect for privacy. This response demonstrates respect and provides
information so the client can understand the need for personal contact. Telling the client that the
blood pressure can be taken at a later time does not promote effective communication. Rotating
the nurses who are assigned to take the clients blood pressure impedes the nurses ability to form
a therapeutic, helping relationship. Continuing to perform the procedure quickly and quietly may
send a negative nonverbal message. It also does not promote effective communication.
DIF: A REF: 343 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. Communication involves both active listening and body language working together. The nurse
actively listens to the client and:
1
Sits facing the client
2
Keeps the arms and legs crossed
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3
Leans back in the chair away from the client
4
Avoids eye contact as much as is physically possible
ANS: 1
Active listening means to be attentive to what the client is saying both verbally and nonverbally.
A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the
message that the nurse is there to listen and is interested in what the client is saying. For active
listening, the arms and legs should be uncrossed. This posture suggests that the nurse is open to
what the client says. For active listening, the nurse should lean toward the client. This posture
conveys that the nurse is involved and interested in the interaction. For active listening, the nurse
should establish and maintain intermittent eye contact. This conveys the nurses involvement in
and willingness to listen to what the client is saying.
DIF: A REF: 344 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. During the assessment phase of the nursing process, the nurse may uncover data that help to
identify communication problems. An example of this information is:
1
2
Extreme dyspnea or shortness of breath
Urinary frequency and pain
3
Chronic stomach pain
4
Lack of appetite
ANS: 1
An extremely breathless person must use oxygen to breathe rather than speak. Urinary frequency
may interrupt conversation but is not a communication problem. Chronic stomach pain would
not be a communication problem. The patient with chronic pain is, to some degree, used to the
pain. A lack of appetite is not a communication problem.
DIF: A REF: 349 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. When a nurse tells an advanced nurse practitioner that her client is slipping a little in reference
to hemodynamic pressures, The nurse is using:
1
Brevity
2
Relevance
Pacing and control.
3
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4
Connotative meaning
ANS: 4
The connotative meaning is the shade or interpretation of a words meaning influenced by the
thoughts, feelings, or ideas people have about the word. Slipping a little in reference to
hemodynamic pressures is an example of using connotative meaning. Brevity means that
communication is simple, brief, and direct. This is not an example of using brevity. Relevance
means the message is relevant or important to the situation at hand. This is not an example of
using relevance. Pacing and control mean speaking slowly enough to enunciate clearly and not
changing subjects rapidly. This is not an example of using pacing and control.
DIF: A REF: 344 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this
diagnostic test, the client moves away from the nurse. This is an example of what influencing
factor in communication?
1
Gender
2
Environment
3
Space and territoriality
Sociocultural background
4
ANS: 3
Territoriality is the need to gain, maintain, and defend ones right to space. The client who moves
away from the nurse during a conversation is demonstrating the influence of space and
territoriality on communication. This not an example of gender influencing communication. This
is not an example of environment influencing communication. Noise, temperature extremes,
distractions, and lack of privacy are examples of environmental factors that may influence
communication. Although people do maintain varying distances between each other depending
on their culture, this is not an example of sociocultural background influencing communication,
as cultural orientation is not mentioned in this situation.
DIF: A REF: 345 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. The nurse will often display empathy in communication with clients. Of the following
responses by the nurse, which one best conveys empathy?
1
Good morning. How did you sleep last night?
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2
I can understand your concern about learning to inject
yourself.
3
Do you mean you would like to talk to the new family nurse
practitioner?
Can you describe to me what the pain in your abdomen feels
like right now?
4
ANS: 2
I can understand your concern about learning to inject yourself is correct. Empathy is the ability
to understand and accept another persons reality, to accurately perceive feelings, and to
communicate this understanding to others. Good morning. How did you sleep last night? is
asking a question. It does not convey empathy. Do you mean you would like to talk to the new
family nurse practitioner? is asking a question to clarify the clients meaning. It does not convey
empathy. Can you describe to me what the pain in your abdomen feels like right now? is asking a
relevant question that may focus on a particular topic. It is not an example of empathy.
DIF: A REF: 353 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. In working with a client who is newly diagnosed with diabetes mellitus, the nurse provides
feedback to the client on her progress in learning the treatment regimen. Of the following, the
nurse demonstrates the use of therapeutic communication by stating:
1
2
3
4
I believe that you have come a long way in learning how to
manage your care.
It didnt look like you were ever going to be able to get the
injection technique.
Check your blood sugar unless you really want to come back
to the hospital again.
You dont appear to have any real interest in managing your
daily dietary intake.
ANS: 1
In stating, I believe that you have come a long way in learning how to manage your care the
nurse is demonstrating the use of therapeutic communication by sharing hope. The nurse is
pointing out that personal growth can come from illness experiences. It didnt look like you were
ever going to be able to get the injection technique is a negative statement. The nurse should not
state observations that might embarrass or anger the client. Check your blood sugar unless you
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really want to come back to the hospital again does not demonstrate the use of therapeutic
communication. It implies disapproval and is an aggressive, threatening type of response. You
dont appear to have any real interest in managing your daily dietary intake is not a therapeutic
statement. It is negative and aggressive in nature. If it is a true observation, it is one the nurse
should not state as it could anger the client.
DIF: A REF: 353 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Ive never told anyone this information about my son, is an example of a parent:
1
Identifying problems
2
Building trust
3
Clarifying roles
4
Revealing
ANS: 2
This response is an example of trust. Trusting another person involves risk and vulnerability, but
it also fosters open, therapeutic communication and enhances the expression of feelings,
thoughts, and needs. This statement is not an example of revealing. Although the parent may
have provided information that was never before revealed, in this statement the parent is
indicating there is trust between himself or herself and the nurse practitioner. This statement is
not clarifying roles of the nurse and client. This statement is not an example of identifying
problems and goals.
DIF: A REF: 348 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. Discussing the clients follow-up dietary needs immediately after the surgery when the client
is experiencing discomfort is an error in:
1
Pacing
2
Intonation
3
Timing and relevance
4
Denotative meaning
ANS: 3
Discussing follow-up dietary needs immediately after surgery when the client is experiencing
discomfort is an error in timing and relevance. The client is less likely to be able to pay attention
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and comprehend instruction when in pain, and immediately after surgery, discussing follow-up
dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not
an example of an error in pacing. Intonation is the tone of voice used. This is not an example of
an error in intonation. Denotative meaning is when a single word can have several meanings.
This is not an example of an error in denotative meaning.
DIF: A REF: 3744 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. The nurse is aware of the clients zones of personal space when planning interactions. The
zone of personal space and touch that extends the greatest amount from an individual is the:
1
2
Social zone
Personal zone
3
Consent zone
4
Vulnerable zone
ANS: 1
The social zone extends the greatest amount from an individual in personal space and touch. It is
a distance of 4 to 12 feet. Permission is not needed for touch in the social zone. The personal
zone is 18 inches to 4 feet. The consent zone of touch requires permission. The vulnerable zone
is in the consent zone of touch. Because the vulnerable zone implies special care is needed,
permission is required.
DIF: A REF: 348 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. Throughout the nursing process communication is used. During the evaluation phase,
communication is specifically used by the nurse to:
1
Delegate activities to other staff members
2
Validate the clients health and wellness needs
3
Acquire both verbal and nonverbal client feedback
Document expected outcomes and planned interventions
4
ANS: 3
The nurse and client determine whether the plan of care has been successful by evaluating the
client communication outcomes established during planning. This process involves acquiring
verbal and nonverbal feedback. Delegation is not the purpose of communication in the evaluation
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phase of the nursing process. Delegation is more likely to be used in the implementation phase of
the nursing process. Validation of the clients needs is not why the nurse specifically uses
communication in the evaluation phase of the nursing process. Validation of the clients needs is
often determined when data are gathered during the assessment phase of the nursing process.
Documenting expected outcomes and planned interventions is part of the planning phase of the
nursing process, not the evaluation phase.
DIF: A REF: 344 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. There are a number of variables that may influence the clients communication with the health
care team. Which of the following is an example of an interpersonal variable?
1
Postoperative discomfort
2
An extremely warm room
3
A talkative roommate
4
A loud television
ANS: 1
Interpersonal variables are factors within both the sender and receiver that influence
communication. An example of an interpersonal variable is postoperative discomfort. An
extremely warm room is an example of an environmental variable that may affect
communication. A talkative roommate is an example of an environmental variable that may
affect communication because of the lack of privacy and distraction. Noise, such as a loud
television, is an example of an environmental variable that may affect communication.
DIF: A REF: 343-344 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. A helping relationship is being established between nurse and client. In addressing the client,
the nurse should:
1
Use the clients first name
2
Touch the client right away to establish contact
3
Sit far enough away from the clients personal space
4
Always knock and pause before entering the clients room
ANS: 4
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Common courtesy is part of professional communication. To practice courtesy, the nurse says
hello and goodbye, knocks on doors before entering, and uses self-introduction. Knocking on
doors is important in addressing the client. Because using last names is respectful in most
cultures, nurses usually use the clients last name in the initial interaction, and then use the first
name if the client requests it. Touching the client right away would not be an appropriate action
in establishing a helping relationship. It would more likely be interpreted as invading the clients
personal space. Sitting far enough away from the client is important in that the nurse should not
enter the clients personal space when establishing a helping relationship. However, leaning
toward the client conveys that the nurse is involved and interested in the client. Knocking on the
door before entering the clients room would be the first step in addressing the client properly.
DIF: A REF: 348 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. In using communication skills with clients, the nurse evaluates which response as being the
most therapeutic?
1
Why dont you stick to the special diet?
2
I noticed that you didnt eat lunch. Is something wrong?
3
I think you need to find another physician thats better than this
one.
4
We cant continue talking about your problems; its time for
your bath.
ANS: 2
The nurse who is sharing an observation, I noticed that you didnt eat lunch. Is something wrong?
is using the most therapeutic response. Sharing observations often helps the client communicate
without the need for extensive questioning, focusing, or clarification. Why dont you stick to the
special diet? is an example of a nontherapeutic response. It is asking for an explanation. Why
questions can cause resentment, insecurity, and mistrust. I think you need to find another
physician thats better than this one. is not a therapeutic response. It is giving a personal opinion.
Changing the subject, We cant continue talking about your problems; its time for your bath, is
not therapeutic.
DIF: A REF: 352 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. When dealing with toddlers or preschoolers what communication technique may be used
most effectively?
1
Using analogies to explain health-related ideas
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2
Allowing manipulation of equipment to be used
3
Moving quickly and minimizing contact to avoid distress
4
Focusing on what other children on the unit may have been
doing
ANS: 2
Allowing toddlers and preschoolers to touch and examine objects that will come in contact with
them is an effective communication technique. Toddlers and preschoolers are unable to
understand analogies. Sudden movements can be frightening. Children often prefer to make the
first move in interpersonal contacts. Focusing on what other children have done is not an
effective communication technique for toddlers or preschoolers. Communication should be
focused on the child.
DIF: A REF: 350 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. When working with a client with aphasia, the nurse may attempt to enhance communication
by:
1
Using visual cues
2
Speaking loudly
3
Using open-ended questions
4
Communicating through a speech therapist
ANS: 1
The nurse may enhance communication for a client with aphasia by using visual cues (e.g.,
words, pictures, and objects) when possible. The nurse should not shout or speak too loudly to
enhance communication with a person who has aphasia. The nurse should ask simple questions
that require yes or no answers to enhance communication with the client who has aphasia. Using
a speech therapist is not the primary way to enhance communication with a client who has
aphasia. The nurse can use communication techniques to facilitate communication and to
develop a helping relationship with the client. The speech therapist may help the client to learn
new ways or to relearn how to communicate.
DIF: A REF: 357 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following statements best reflects the clients positive feedback to the nurses
question, Do you understand how to check your blood sugar?
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1
Nodding affirmatively
2
3
I test it 4 times a day.
Yes, I understand how to do it.
4
Demonstrating a fingerstick to the nurse
ANS: 4
Feedback is the message the receiver returns. It indicates whether the receiver understood the
meaning of the senders message. Demonstrating the technique is the best way to show the nurse
an understanding of the process. The other options either nonverbally or verbally indicate
understanding; they are not as conclusive as showing understanding.
DIF: C REF: 343 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following nursing statements is the best example of the communication tool of
clarification?
1
Please say that again.
2
I dont think I understand.
3
What did you mean by that?
4
Can you give me an example?
ANS: 4
To check whether understanding is accurate, ask the other person to rephrase it, explain further,
or give an example of what the person means. By asking for an example, the nurse is best able to
determine the meaning of the clients statement. The other options either simply ask the client to
repeat the statement or state that the nurse needs further information.
DIF: C REF: 354 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. Which of the following is the single most negative factor affecting a nurses credibility?
1
Deficient technical skills
2
Unethical or illegal behavior
3
Lack of caring and empathy
Poor nurse-client communication
4
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ANS: 4
Breakdown in communication is a top contributor to errors in the workplace and threatens
professional credibility. The remaining options affect credibility but not to the extent that poor
communication does.
DIF: C REF: 340 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The best communicator is the nurse who:
1
Thinks critically
2
Is a good listener
3
Is comfortable talking
4
Empathizes with the client
ANS: 1
Nurses who develop good critical thinking skills make the best communicators. The remaining
options identify components of good communication.
DIF: C REF: 340-341 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. Which of the following statements shows the best attempt by a nurse to overcome personal
biases?
1
So how does that make you feel?
2
Most people really like Dr. Jones.
3
I know how that must frighten you.
How much did the medication help your pain?
4
ANS: 1
People often assume that others think, feel, act, react, and behave as they would in similar
circumstances. They tend to distort or ignore information that goes against their expectations,
preconceptions, or stereotypes. This statement clearly shows the nurse attempting to assist the
client in expressing his or her personal feelings. The remaining options all make a presumption
about the clients feelings or attitudes.
DIF: C REF: 341 OBJ: Analysis
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. A close, effective nurse-client relationship impacts interpersonal communication most by
facilitating:
1
2
3
4
Client education regarding health-related issues
The accurate interpretation of shared information
A free exchange of information between client and nurse
The clients expression of physical and emotional needs
ANS: 2
The more the sender and receiver have in common and the closer the relationship, the more
likely they will accurately perceive one anothers meaning and respond accordingly. The
remaining options are outcomes of an effective nurse-client relationship but they do not impact
communication as directly.
DIF: C REF: 340 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. Mentally reviewing the steps of a complicated nursing procedure before entering the clients
room is an example of:
1
Nonverbal communication
2
Interpersonal communication
3
Intrapersonal communication
Transpersonal communication
4
ANS: 2
A type of intrapersonal communication, self-instructions, provides a mental rehearsal for difficult
tasks or situations so individuals are able to deal with them more effectively. Interpersonal
communication is one-to-one interaction between the nurse and another person that often occurs
face to face while transpersonal communication is interaction that occurs within a persons
spiritual domain. Nonverbal communication includes all five senses and everything that does not
involve the spoken or written word.
DIF: A REF: 342 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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27. The nurse can best detect that a client needs clarification of the information provided on a
special diet by:
1
2
Asking the client frequently if they have any questions
Assessing the clients nonverbal cues that suggest confusion
3
Providing the client with written supportive materials on the
diet
4
Requesting that the client rephrase the information in his or
her own words
ANS: 2
You determine the need for clarification by watching the listener for nonverbal cues that suggest
confusion or misunderstanding. The remaining options are means of reinforcing or evaluating the
listeners understanding of the information.
DIF: C REF: 354 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. The nurse observes a client with head bowed and hands folded seemingly in prayer. The
nurse recognizes this as an example of:
1
Nonverbal communication
2
Interpersonal communication
3
Intrapersonal communication
4
Transpersonal communication
ANS: 4
Transpersonal communication is interaction that occurs within a persons spiritual domain. Many
persons use prayer, meditation, guided reflection, religious rituals, or other means to
communicate with their higher power. Intrapersonal communication, self-talk or self-instruction
provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with
them more effectively. Interpersonal communication is one-to-one interaction between the nurse
and another person that often occurs face to face while nonverbal communication includes all
five senses and everything that does not involve the spoken or written word.
DIF: A REF: 342 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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29. The nurse is discussing discharge instructions with a client who was recently diagnosed with
type 1 diabetes mellitus and is now taking insulin. The nurse recognizes this as an example of:
1
2
3
4
Nonverbal communication
Interpersonal communication
Intrapersonal communication
Transpersonal communication
ANS: 2
Interpersonal communication is one-to-one interaction between the nurse and another person that
often occurs face to face. Transpersonal communication is interaction that occurs within a
persons spiritual domain whileintrapersonal communication, self-talk or self-instruction provides
a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more
effectively. Nonverbal communication includes all five senses and everything that does not
involve the spoken or written word.
DIF: A REF: 342 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. A nurse provides a brief but concise orientation to the use of the rooms telephone and
television to a newly admitted older client experiencing abdominal pain. The clients daughter
later reports that her father attempted to call her but was never shown how to use the telephone.
The most likely cause for the clients apparent lack of knowledge retention is:
1
Admission to the hospital has caused mild confusion that is
not atypical in older clients
2
The pain was distracting him from focusing on the information
when it was provided
3
He is experiencing forgetfulness regarding newly introduced
nonessential information
The nurse did not take adequate time to explain the use of
either the telephone or the television
4
ANS: 2
Timing is critical in communication. Even though a message is clear, poor timing prevents it
from being effective. Do not begin routine teaching when a client is in severe pain or emotional
distress. Although the other options may affect client retention of information, the scenario did
not provide reason to believe that any of the options rather than poor timing was the primary
factor.
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DIF: C REF: 344 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
31. An older client who appears confused after discussing his new diagnosis of Parkinsons
disease shares with the nurse that, I didnt understand much of what you said. The nurse
determines that the most likely cause of the clients failure to understand is that:
1
The conversation included unfamiliar medical terminology
2
The client is in denial concerning the diagnosis of Parkinsons
disease
The nurses choice of timing for the client education was poor
3
4
The etiology of the condition is too complicated for this client
to understand
ANS: 1
Medical jargon (technical terminology used by health care providers) sounds like a foreign
language to clients unfamiliar with the health care setting. Limiting use of medical jargon to
conversations with other health team members will improve communication. The remaining
options may have contributed to the problem, but the more common problem deals with
inappropriate use of jargon.
DIF: C REF: 344 OBJ: Analysis
TOP: Nursing Process: Planning/Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
32. The nurse shares with a client diagnosed with bipolar disorder who is in the manic phase that,
The CNA will be in 20 minutes to complete your ADLs. This nurse-initiated communication will
likely result in client confusion or noncompliance because:
1
The timing of the conversation was poorly chosen
2
The client was not actively involved in the decision-making
process
The conversation relied on terms familiar only to health care
providers
3
4
The nurse assumed that the client would accept the nursing
assistants help
ANS: 3
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Medical jargon (technical terminology used by health care providers) sounds like a foreign
language to clients unfamiliar with the health care setting. Limiting use of medical jargon to
conversations with other health team members will improve communication. The remaining
options may contribute to client confusion and/or noncompliance, but the heavy reliance on
unfamiliar terms is the most likely primary cause in this situation.
DIF: C REF: 344 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
33. The nurse sits on a chair alongside a clients bed to discuss the postoperative nursing care the
client will receive. The therapeutic outcome of sitting beside the client is that:
1
The nurse-client relationship will be strengthened
2
The client will feel less threatened by the nurses presence
The nurse can appear more relaxed during the conversation
3
4
The nurse and client will be equal participants in the
conversation
ANS: 1
Looking down on a person establishes authority, whereas interacting at the same eye level
indicates equality in the relationship. While the remaining options may be correct in some
situations, the primary benefit of the nurse sitting is to convey to the client that both are equal
contributors to the conversation.
DIF: C REF: 345 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
34. The nurse enters a clients room and finds her crying softly. The most therapeutic statement
the nurse can make at this time is to ask:
1
Are you alright?
2
Why are you crying?
3
What can I do to help you?
Is being hospitalized upsetting you?
4
ANS: 2
Sounds have several interpretations: crying may communicate happiness, sadness, or anger. The
nurse needs to validate such nonverbal messages with the client to interpret them accurately.
Although the other options may elicit information regarding the clients tears, they make
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assumptions or attempt to provide generalized comfort without first establishing the cause of the
tears.
DIF: C REF: 345 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
35. Supporting a client by holding onto her elbow while accompanying her as she ambulates
around the nursing unit is considered social touching and so would typically:
1
Be considered nonthreatening by the client
2
Not require the clients permission
3
Be viewed as therapeutic by the nurse
4
Not be needed unless the client was ataxic
ANS: 2
A persons hands, arms, shoulders, and back are considered social zones and typically do not
cause a client emotional discomfort if touched, and so permission to do so is not generally
required. Nurses frequently move into clients personal space because of the nature of caregiving.
You need to convey confidence, gentleness, and respect for privacy, especially when your actions
require intimate contact or involve a clients vulnerable zone. The remaining options do not
necessarily deal with a clients social touching zone.
DIF: C REF: 353-354 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
36. When meeting for the first time, the home health nurse smiles warmly and shakes the clients
hand. The nurse-client relationship is in the:
1
Working phase
2
Orientation phase
3
Termination phase
Preinteraction phase
4
ANS: 2
When the nurse and client meet and get to know one another, they are engaged in the orientation
phase of the nurse-client relationship. The remaining options are phases that occur either before
or after the orientation phase.
DIF: C REF: 346 OBJ: Analysis
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TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
37. The nurse recognizes that a clients sense of personal control is most therapeutically impacted
when:
1
2
The client attends a self-help/support group
The nurse encourages the client to make menu selections
3
The client views a video on the use of a personal glucose
monitor
4
The nurse provides instructions on a patient-controlled
analgesic (PCA) pump
ANS: 4
Personal control over the situation contributes to emotional comfort. Pain control is a very basic
need, and by providing the client with the power to control that pain, the need has been
therapeutic. The remaining options contribute to personal control but not on the same elemental
level as pain control.
DIF: C REF: 348 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
38. Which of the following statements made by a nurse best reflects an understanding of the
therapeutic value of perceived client control?
1
The client was very interested in the information about support
groups.
2
The client fell right to sleep when I told her the procedure was
canceled.
3
Research has shown that clients are less stressed when told
what to expect.
I always include the client in on any decisions regarding their
nursing care.
4
ANS: 3
Research has shown that personal control over a situation contributes to emotional comfort. By
informing the client of expectations, the clients personal sense of control is increased and
emotional stress should then be decreased. The remaining options show an understanding of
emotional comfort but do not express an understanding of the origin of that comfort.
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DIF: C REF: 348 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
39. Which of the following statements made by a nurse most reflects a poor understanding of
trustworthiness regarding nurse-client communication in response to a clients report that, I dont
like the night shift nurse?
1
2
How can I meet your needs and expectations on dayshift?
Tell me more about why you dislike the night shift nurse.
3
Can you give me an example of why you are dissatisfied?
4
The nurse on night shift has your well being in mind always.
ANS: 2
To foster trust, the nurse communicates warmth and demonstrates consistency, reliability,
honesty, competence, and respect. Sharing personal information or gossiping about others sends
the message you cannot be trusted and damages interpersonal relationships. The nurse appears to
be gossiping by the way the client is encouraged to discuss what the night shift nurse is doing.
The remaining options show varying degrees of addressing the clients statement.
DIF: C REF: 348 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
40. Which of the following statements made by a nurse most reflects the best understanding of
the effect assertiveness has on interpersonal communication?
1
Can anyone help; Im feeling overwhelmed today?
2
I think we need to tell the doctors to write more legibly.
3
I will need some help with that complicated dressing change.
4
You will need to do the admission assessments today because
Im so busy.
ANS: 3
Assertiveness conveys a sense of self-assurance while also communicating respect for the other
person. Assertive responses often contain I messages, such as I want, I need, I think, or I feel, but
in a fashion that is not demeaning or demanding. The remaining options are not the best
examples because some lack an explanation of the nurses actual needs while others are not
respectfully stated.
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DIF: C REF: 348 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
41. The nurse identifies the nursing diagnosis risk for injury for a client who is unable to verbally
communicate effectively. The primary risk for injury occurs because the client:
1
2
Lacks the ability to tell the staff what he or she needs
Cannot notify the staff when he or she has fallen
3
Is not able to effectively use the call bell to communicate
4
Displays impatience when needs are not met effectively
ANS: 1
The client who cannot communicate effectively will often have difficulty expressing needs and
responding appropriately to the environment. A client who is unable to speak is at risk for injury
unless the nurse identifies an alternate communication method. The remaining options relate to
potential outcomes of ineffective verbal communication but not to the risk for injury.
DIF: C REF: 351 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
42. Which of the following statements made by a nurse reflects a need for further instruction
regarding communicating with the older adult client?
1
Children and the elderly have the same communication
barriers.
2
If I tell him why he needs to know something, hell usually
listen.
3
Hearing deficits can certainly make communication a
challenge.
I always try to have family around when I talk with an elderly
client.
4
ANS: 1
Even though some older adults have communication barriers, you need to communicate with
them on an adult level and avoid patronizing or speaking in a condescending manner. Older
adults do not necessarily have the same barriers as children. The remaining options reflect
interventions and/or statements that are not inappropriate and so do not require further
instructions.
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DIF: C REF: 356-357 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Which of the following critical thinking attitudes contributes to an effective nurse-client
relationship? (Select all that apply.)
1
2
3
Fairness
Guarded
4
Curiosity
Creativity
5
Perseverance
6
Self-confidence
ANS: 1, 3, 4, 5, 6
Curiosity motivates the nurse to communicate and know more about a person. Perseverance and
creativity are also attitudes conducive to communication because they motivate the nurse to
communicate and identify innovative solutions. A self-confident attitude is important because the
nurse who conveys confidence and comfort while communicating more readily establishes an
interpersonal, helping-trust relationship. Risk-taking rather than a guarded attitude is important
because colleagues sometimes question the suggested nursing interventions. At the same time, an
attitude of fairness goes a long way in the ability to listen to both sides of any discussion.
DIF: C REF: 340-341 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse realizes that the cancer support group for breast cancer clients will be most effective
if the group: (Select all that apply.)
1
2
3
Is not too large
Is similar in age
4
Members feel valued
Communicates freely
5
Shares a common culture
6
Meets in a comfortable place
ANS: 1, 3, 4, 6
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Small groups are more effective when they are a workable size and have an appropriate meeting
place, suitable seating arrangements, and cohesiveness and commitment among group members.
Group participants need to feel accepted, feel able to communicate openly and honestly, and
actively listen to others in the group. Similarity in age and similarity in culture are not necessary
criteria for a successful group interaction.
DIF: C REF: 342 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The nurse is preparing a community outreach program on stress management. The nurse
realizes that speaking in public requires some specific adaptations regarding: (Select all that
apply.)
1
Makeup
2
Clothing attire
3
Vocal inflection
4
5
Voice projection
Physical gesturing
6
Making eye contact
ANS: 3, 4, 5, 6
Public communication requires special adaptations in eye contact, gestures, voice inflection, and
use of media materials to communicate messages effectively. Makeup and clothing need to be
appropriate but do not require specific adaptations.
DIF: C REF: 342 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. Which of the following are reasons for communication during the assessment phase of the
nursing process? (Select all that apply.)
1
2
3
Providing information to the client
Obtaining information from the client
4
Establishment of the nurse-client relationship
Identification of the clients physical health needs
5
Mutual goal setting regarding client health needs
6
Identification of clients emotional health
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ANS: 1, 2, 4, 5, 6
The reasons for communication include information exchange, goal achievement, problem
resolution, and expression of feelings. The initiation of the nurse-client relationship is not
considered a facet of assessment communication.
Chapter 25. Patient Education
MULTIPLE CHOICE
1. The client has been informed that he can be discharged once he can irrigate his colostomy
independently. The client requests the nurse to observe his irrigation technique. Which of the
following learning motives is the client displaying?
1
2
3
4
Physical need
Social activity
Task mastery
Evaluation stance
ANS: 3
Task mastery motives are based on needs such as achievement and competence. The client who
must demonstrate irrigating his colostomy independently in order to be discharged is displaying
the learning motive of task mastery. A physical motive may be seen in the client who desires to
return to a level of physical normalcy. A social motive is the need for connection, social
approval, or self-esteem. An evaluation stance would be determining whether the outcomes of
the teaching-leaning process met the clients goal. Evaluation is not a learning motive.
DIF: A REF: 366-367 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. An industrial nurse is planning to give an informative talk on hypertension to employees in
honor of heart month. He plans to teach individuals how to take their blood pressure
measurements. Which information is important for him to ask the planning committee before this
presentation?
1
Ages of all employees involved
2
Names of employees who are married
3
Number of employees with high blood pressure
4
Type of room available and number of participants
ANS: 4
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The number of persons being taught, the need for privacy, the room temperature, the room
lighting, noise, the room ventilation, and the room furniture are important factors when choosing
the setting. The ideal setting helps the client focus on the learning task. Knowing the specific
ages of all the people involved is not as important as providing an environment conducive to
learning. It is not necessary to know the names of employees who are married to teach
individuals how to take their blood pressure. Whether an employee has high blood pressure
should not be as important to the teacher as providing an environment conducive to learning.
Having high blood pressure may be a motivating factor for employees to learn how to take their
blood pressure, because of its personal relevance.
DIF: A REF: 369 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. The nurse established the following objective for the client who was unable to void: The
clients intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is
indicated by the client:
1
2
3
4
Voiding at least 1000 mL during the shift
Verbalizing abdominal comfort without pressure
Having adequate fluid intake and urinary output
Drinking 240 mL of fluid five or six times during the shift
ANS: 4
The nurse evaluates success by observing the clients performance of each expected behavior.
Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six
times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at
least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective.
The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort
without pressure is not an evaluation of the objective regarding specific fluid intake. Having
adequate intake and output is not accurate feedback indicating success. The term adequate is not
quantified.
DIF: A REF: 381 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients.
For a toddler, the nurse should use:
1
Role-playing
2
Problem-solving
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3
Independent learning
4
Simple explanations and pictures
ANS: 4
Effective teaching methodologies for the toddler include simple explanations and picture books
that describe a story of children in a hospital or clinic. Role-playing is an appropriate teaching
methodology for the preschooler. Problem-solving is an appropriate teaching methodology for
the adolescent. Independent learning is best used as a teaching methodology for the young or
middle adult.
DIF: A REF: 368 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
5. The nurse has important information to share with a parent who has brought his child to the
emergency department. The nurse discovers that the parent, who appears very anxious, has just
learned his son will require surgery. The most effective teaching approach in this situation is:
1
2
Telling
Trusting
3
Participating
4
Group teaching
ANS: 1
The telling approach is useful when limited information must be taught. If a client is highly
anxious but it is vital for information to be given, telling can be effective. The entrusting
approach provides the client the opportunity to manage self-care. The nurse observes the clients
progress and remains available to assist without introducing more new information. This would
not be the most effective teaching approach in this situation. Participating involves the nurse and
client setting objectives and becoming involved in the learning process together. This would not
be the most effective teaching approach in this emergency situation. Group teaching would not
be the most effective teaching approach in this situation. A person who is anxious would benefit
more from individual instruction.
DIF: A REF: 376 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. A client, after being taught of the clinical manifestations of inflammation to enable early
detection of a complication of a surgical wound states, I will look at the wound four times a day
and tell my surgeon if it looks red or swollen. Her statement is an example of:
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1
Attitudes
2
3
Application
Analysis
4
Evaluation
ANS: 2
Application involves using abstract, newly learned ideas in a concrete situation. The client who
is taught the clinical manifestations of inflammation and who will assess for signs such as
redness or edema is using newly learned information in a concrete manner. Attitude has to do
with affective learning. The client is not expressing an attitude, but is applying new knowledge in
a concrete way. Analysis involves breaking down information into organized parts. The client is
not demonstrating analysis. Evaluation is a judgment of the worth of a body of information for a
given purpose. The client is not expressing judgment.
DIF: A REF: 365 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. The client continues to ask questions about a surgical wound. The client states, I think I would
like help the first time I look at my wound. This is an example of:
1
Adaptation
2
Perception
3
Organizing
4
Guided response
ANS: 4
A guided response is the performance of an act under the guidance of an instructor. The client
who is seeking help is demonstrating a guided response. Adaptation occurs when a person is able
to change a motor response when unexpected problems arise. The client is not exhibiting
adaptation. Perception is being aware of objects or qualities through the use of sense organs. This
situation is not an example of perception. Organizing is developing a value system by identifying
and organizing values and resolving conflicts. This situation is not an example of organizing.
DIF: C REF: 449 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. There are many factors are assessed before teaching the client to learn insulin injection sites,
but the most important factor for the nurse to assess first is the:
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1
Previous knowledge level of the client
2
3
Willingness of the client to want to learn the injection sites
Financial resources available to the client for the equipment
4
Intelligence and developmental level of the individual client
ANS: 2
If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first
factor the nurse should assess before teaching. To determine learning needs, the nurse should
assess the clients previous knowledge level. However, this would not be the most important
factor for the nurse to assess first. Assessing the financial resources available to the client for
obtaining equipment is important; however, it is not the most important factor for the nurse to
assess first. Assessing the clients physical and cognitive ability to learn is important. However, it
is not the most important factor for the nurse to assess first.
DIF: A REF: 364 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle
of the lesson the client asks, Why have my feet been swelling? The nurse stops and responds to
the client. Which of the following is the teaching principle that the nurse should follow?
1
Timing
2
Setting priorities
3
Building on existing knowledge
4
Organizing the teaching materials
ANS: 1
The nurse who stops a demonstration of applying anti-embolitic stockings to answer a clients
question is following the teaching principle of timing. If the client has a question, it is important
to answer the question immediately, so the client may return his or her focus to the task being
taught. Setting priorities is important to conserve the time and energy of the client and nurse. The
nurse who stops to answer a question is not setting priorities. A client learns best on the basis of
preexisting cognitive abilities and knowledge. This situation is not an example of building on
existing knowledge. Organizing teaching materials means the nurse considers the order of
information to present. This is not an example of organizing teaching materials.
DIF: A REF: 375 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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10. Clients give various responses to teaching sessions. For the nurse, an example of an
evaluation of a psychomotor skill is:
1
2
3
4
Client states side effects of a medication
Client responds appropriately to eye contact
Client independently plans an exercise program
Client demonstrates the proper use of a walking cane
ANS: 4
Determining whether the client is able to demonstrate a newly learned skill is an example of an
evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require
the integration of mental and muscular activity, such as walking with a cane. Having the client
state side effects of a medication is an example of an evaluation of cognitive learning.
Determining whether a client responds appropriately to eye contact is an example of evaluation
of affective learning. The client who planned an exercise program is demonstrating cognitive
learning.
DIF: A REF: 366 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Different topics are presented in the information sessions that are held in the outpatient clinic.
In planning for a session on health maintenance/illness prevention, the nurse should select a topic
on:
1
Use of assistive devices, such as canes
2
Self-help devices for post-CVA clients
3
Stress management techniques for working parents
Environmental alterations for clients in wheelchairs
4
ANS: 3
Stress management techniques for working parents is an appropriate topic for health
maintenance/illness prevention. Use of assistive devices, such as canes, is not a health
maintenance/illness prevention topic. It is a coping with impaired function topic. Self-help
devices for post-CVA clients is not a health maintenance/illness prevention topic. It is a coping
with impaired function topic. Environmental alterations for clients in wheelchairs is not a health
maintenance/illness prevention topic. It is a coping with impaired function topic.
DIF: A REF: 362 OBJ: Comprehension
TOP: Nursing Process: Planning
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. The nurse is evaluating the responses of clients to teaching sessions. An example of an
evaluation of a clients attainment of a cognitive skill is:
1
Client explains that the medication should be taken with meals
2
Client looks at the surgical incision without requiring
prompting
3
Client uses crutches appropriately to move both up and down
stairs
4
Client independently capable of dressing self after eating
breakfast
ANS: 1
The client who is able to explain that the medication should be taken with meals is demonstrating
attainment of a cognitive skill. The client who is able to look at the surgical incision without
prompting is demonstrating attainment of affective learning. The client who uses crutches
appropriately is demonstrating attainment of a psychomotor skill. The client who dresses self
after breakfast is most likely demonstrating attainment of psychomotor learning.
DIF: A REF: 365 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. The nurse evaluates which of the following statements as an indication that the client is not
ready to learn at this time?
1
I need to understand more about the reason for the colostomy.
2
I will find out more about that when the support group meets.
3
Theres no sense in showing me that now. Im too sick right
now.
Please be sure to tell me if I am completing all the steps
correctly.
4
ANS: 3
Readiness to learn is related to the stage of grieving. This response by the client is demonstrating
anger. The client is unwilling to learn at this time. The client has not yet reached the acceptance
state of grieving in which learning can occur. This statement indicates the client is ready to learn
and desires to find out more to gain understanding. This statement indicates the client is willing
to learn. The client who requests feedback is expressing readiness to learn.
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DIF: A REF: 362 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. In planning to teach an older adult client, the nurse should incorporate which teaching
method or principle into the plan?
1
2
3
4
Keep teaching sessions short.
Teach in the early morning or late evening.
Put as much as possible into each teaching session.
Focus on teaching a family member or caregiver instead.
ANS: 1
Keeping teaching sessions short is an appropriate method when teaching an older adult client.
The older adult should be taught when the client is alert and rested, not early morning or late
evening. The teaching session should not be filled with numerous topics. The older adult client is
capable of learning and should be the focus. A family member or caregiver may be included in
teaching, but the older adult client should not be excluded.
DIF: A REF: 376 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. The nurse has completed an assessment on the client and identified the following nursing
diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching
that was planned?
1
Activity intolerance related to pain
2
Ineffective management of treatment regimen
3
Noncompliance with prescribed exercise plan
Knowledge deficit regarding impending surgery
4
ANS: 1
Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The
nursing diagnosis of activity intolerance related to pain indicates a need to postpone teaching.
Teaching may be delayed until the nursing diagnosis is resolved or the health problem is
controlled. Ineffective management of treatment regimen does not indicate a need to postpone
teaching. Ineffective management of treatment regimen reinforces the need for teaching.
Noncompliance with prescribed exercise plan does not indicate a need to postpone teaching. The
client who is noncompliant may require further teaching. Knowledge deficit regarding
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impending surgery does not indicate a need to postpone teaching. A knowledge deficit reinforces
the need for teaching.
DIF: A REF: 366 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. There are a variety of teaching methodologies that may be utilized to meet the clients needs.
Which teaching method is best applied to a cognitive learning need?
1
2
3
4
Modeling of behavior
Discussion of feelings
Computer-assisted instruction
Demonstration of a procedure
ANS: 3
An independent project such as computer-assisted instruction is an appropriate teaching method
for cognitive learning. Modeling of behavior is an appropriate teaching method for psychomotor
learning. Discussion of feelings is an appropriate teaching method for affective learning.
Demonstration is an appropriate teaching method for psychomotor learning.
DIF: A REF: 365 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. For a functionally illiterate client, the nurse particularly focuses on:
1
Using intricate analogies and examples
2
Avoiding lengthy return demonstrations
3
Incorporating familiar nonmedical terminology
Providing longer learning sessions with the client
4
ANS: 3
When teaching a functionally illiterate client, the nurse should use simple terminology, avoiding
medical jargon. The nurse should incorporate familiar terminology to enhance the clients
understanding. The nurse should use simple analogies and real life examples. The nurse should
ask for return demonstrations as this provides the opportunity to clarify instructions and time to
review procedures. Although teaching sessions may be kept short, they should be scheduled at
more frequent intervals.
DIF: A REF: 378-379 OBJ: Comprehension
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates
evidence-based information. The nurse recognizes that evidence obtained about adult learners
has identified that this group prefers:
1
Computer-assisted instruction
2
3
Traditional classroom settings
Long sessions with plenty of technical information
4
Interesting personal communication techniques
ANS: 4
Adults have a wide variety of personal and life experiences to employ. Therefore adult learning
is enhanced when they are encouraged to use these experiences to solve problems. Evidencebased information indicates that adult clients prefer interactive, personal communication with
nurses or physicians. Evidence-based information indicates computer-assisted learning is not a
preferred method of instruction by many adult learners. As clients become more comfortable
with computers, this preference may change. Evidence-based information indicates that not all
clients are comfortable in class settings or in support groups. Other educational opportunities
should be available. Adult learners prefer short teaching sessions without a great deal of
technical information.
DIF: A REF: 369 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. While teaching the client about management of his heart disease, a nurse might use a strategy
that is implemented to promote learning in the affective domain such as:
1
Asking the client what he believes he needs to know about the
diagnosis
2
Providing brochures both on current exercises and on nutrition
guidelines
Encouraging the client to personally discuss his feelings about
his health status
3
4
Having the client return-demonstrate self-measurement of his
own blood pressure
ANS: 3
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An intervention to promote learning in the affective domain would be encouraging the client to
discuss his feelings about his health status. Asking the client what he believes he needs to know
about the diagnosis would be an intervention to promote learning in the cognitive domain.
Providing brochures on current exercises and nutrition guidelines would be an intervention to
promote learning in the cognitive domain. Having the client return-demonstrate selfmeasurement of his blood pressure would be an intervention to promote learning in the
psychomotor domain.
DIF: A REF: 365 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. The nurse is preparing to present a teaching session on skin protection for a group of older
adults at a senior center. A principle that has been found to be most effective in teaching older
adults is:
1
2
3
4
Moving the group along at a predetermined pace
Providing information in longer teaching sessions
Speaking very slowly and in a louder tone of voice
Beginning and ending each session with important information
ANS: 4
The nurse should begin and end each teaching session with important information because
clients are more likely to remember information that is taught early in the teaching session, and
key points can be summarized at the end. Repetition also reinforces learning. The group should
not be moved along at a predetermined pace. Clients may have questions that would go
unanswered if there were a predetermined pace. Or, sometimes teaching sessions have to be
stopped after the nurse observes a clients loss of concentration such as nonverbal cues of poor
eye contact or slumped posture. Shorter (approximately 20 minutes), frequent sessions are more
easily tolerated and retain the clients interest in the material. The nurse should face the client and
speak in a low tone of voice for the older adult with a hearing problem.
DIF: A REF: 380-381 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client
diagnosed to be in the early stage of Alzheimers disease. The nurse best deals with the clients
cognitive deficits by:
1
Providing written material to supplement the discussion
2
Arranging for family to be present during the discussion
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3
Presenting the material in two short but focused sessions
4
Requiring the client to restate the information in her own
words
ANS: 2
The clients family needs to understand and accept many changes in the patients physical and/or
cognitive capabilities. The familys ability to provide support results in part from education,
which begins as soon as the nurse identifies the clients needs and the family displays a
willingness to help. The remaining options may support retention of material but not as
effectively as including family in the educational sharing.
DIF: C REF: 381 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. The nurse recognizes that the clients teaching plan is most directly driven by:
1
The clients identified learning needs
2
3
The complexity of the clients health needs
The clients readiness and motivation to learn
4
The presence of cultural or physical barriers
ANS: 1
Teaching is most effective when it responds to the learners needs. While assessing and
diagnosing a clients health care problems, the nurse identifies the need for education that in turn
generates the teaching plan. The remaining options reflect factors that will affect both the
teaching plan and the clients learning.
DIF: C REF: 363 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The nurse recognizes that the primary goal of a clients teaching plan is to:
1
Facilitate a knowledge-based client decision-making process
2
Provide information that brings about informed client consent
3
Enhance the clients sense of personal control regarding his or
her health care
Therapeutically affect the clients health, wellness, and
independence
4
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ANS: 4
Creating a well-designed, comprehensive teaching plan that fits a clients unique learning needs
ultimately helps clients make informed decisions about their care and results in clients becoming
healthier and more independent. The remaining options affect the primary goal by enhancing
decision making, providing for informed consent, and bringing about a sense of personal control.
DIF: C REF: 363 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. Which of the following teaching topics is an example of health maintenance and promotion
and illness prevention?
1
2
3
4
Glucose monitoring at home
Living with rheumatoid arthritis
Stress managements impact on depression
What to expect after hip replacement surgery
ANS: 1
Promoting healthy behavior through education allows clients to assume more responsibility for
their health. Greater knowledge results in better health maintenance habits. When clients become
more health conscious, they are more likely to seek early diagnosis of health problems. The
remaining options address restoration of health and coping with impaired functioning, whereas
stress management is a topic that relates to the promotion of health and the prevention of illness.
DIF: A REF: 362-363 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. Which of the following teaching topics is an example of restoration of health?
1
Glucose monitoring at home
2
Living with rheumatoid arthritis
3
Stress managements impact on depression
What to expect after hip replacement surgery
4
ANS: 4
Injured or ill clients need information and skills to help them regain or maintain their levels of
health. The remaining options address health maintenance and promotion and illness prevention
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and coping with impaired functioning while what to expect after hip replacement surgery is a
topic that relates to the restoration of health and function.
DIF: A REF: 363 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. Which of the following actions is the primary nursing responsibility regarding client
education?
1
2
Providing accurate, current, relevant information
Answering the clients questions regarding health-related issues
3
Assessing the individual clients readiness and motivation to
learn
4
Identifying areas where clients are in need of educational
information
ANS: 1
Nurses have an ethical responsibility to teach their clients (Redman, 2005, 2007). The
information needs to be accurate, complete, and relevant to the clients needs. The remaining
options are factors that affect learning and so require the nurses attention but are not as primary
as providing information that is accurate, current, and relevant to the clients needs.
DIF: C REF: 363 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for
checking her blood glucose level four times a day, this is an example of:
1
Cognitive learning
2
Affective learning
3
Impaired learning
Psychomotor learning
4
ANS: 4
Psychomotor learning involves acquiring skills that require the integration of mental and
muscular activity. The remaining options are involved with expression of feelings and acceptance
of attitudes, opinions, or values or the acquisition of knowledge. Impaired learning involves
alteration to the normal learning process that requires alterations in methods and techniques.
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DIF: A REF: 366 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that
correlates with the number of carbohydrates he is allowed for that meal, this is an example of:
1
2
Cognitive learning
Affective learning
3
Impaired learning
4
Psychomotor learning
ANS: 1
Cognitive learning includes all intellectual behaviors and requires thinking. The remaining
options are involved with expression of feelings and acceptance of attitudes, opinions, or values
or acquiring skills that require the integration of mental and muscular activity. Impairing learning
involves alteration to the normal learning process that requires alterations in methods and
techniques.
DIF: A REF: 365 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
29. Which of the following statement best reflects the nurses appropriate attention to a clients
need for self-efficacy?
1
What can I do to help you lose the weight?
2
Are you really ready to start a regular exercise regimen?
3
After you watch me demonstrate this inhaler, you will have no
problems using it at all.
4
Come on; with all the self-help products out there, you will be
able to stop smoking.
ANS: 3
Self-efficacy refers to a persons perceived ability to successfully complete a task. When people
believe that they are able to execute a particular behavior, they are more likely to actually
perform the behavior consistently and correctly. Although the other options are related to
behavioral change to achieve a goal, they do not support the client by both encouragement and
providing the skills necessary to be successful.
DIF: C REF: 367 OBJ: Analysis
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
30. A client has been recently told that the primary cancer has metastasized, and the cancer is
considered terminal. When the nurse offers to discuss palliative care options, the client replies,
Im going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has
been made. The nurse recognizes this response as:
1
2
3
4
Anger
Disbelief
Bargaining
Acceptance
ANS: 2
In this example, the client avoids discussion of the illness, choosing to believe a mistake has
been made. The remaining options are other stages of the grieving process.
DIF: A REF: 368 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
31. A client has been recently told that the primary cancer has metastasized and the cancer is
considered terminal. When the nurse offers to discuss palliative care options the client replies, I
cant understand why you all want to upset me by bringing the topic up. Now please just leave me
alone. The nurse recognizes this response as:
1
Anger
2
Disbelief
3
Bargaining
Acceptance
4
ANS: 1
In this example, the client blames others and complains. The client often directs anger toward the
nurse or others. The remaining options are other stages of the grieving process.
Chapter 26. Informatics and Documentation
MULTIPLE CHOICE
1. The nurse is preparing the information that will be provided to the staff on the next shift.
Which of the following should the nurse include in the inter-shift report to nursing colleagues?
1
Audit of client care procedures
2
The clients diagnostic-related group
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3
All routine care procedures required by the client
4
Instructions given to the client in a teaching plan
ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the clients
response. This should not include detailed content unless staff members ask for clarification. The
nurse should relay to staff significant changes in the way therapies are given, but should not
describe basic steps of a procedure. The clients diagnosis-related group is not essential
background information to be shared in an inter-shift report. The nurse should not review all
routine care procedures or tasks.
DIF: A REF: 399 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. An incident report is to be completed because the client climbed over the side rails and fell to
the floor. The correct reporting of an incident involves which of the following?
1
2
The witnessing nurse completes the report.
Details of the incident are subjectively described.
3
An explanation of the possible cause for the incident is
entered.
4
A notation is included in the medical record that an incident
report was prepared.
ANS: 1
The nurse who witnessed the incident is the one who completes the report. Details of the incident
should be objectively described. An explanation of the possible cause is not included. The
sequence of events is described objectively. A notation is not included in the medical record that
an incident report was written.
DIF: A REF: 403 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. Which is the most appropriate notation for a use to use according to the guidelines that should
be followed when documenting client care?
1
1230Clients vital signs taken.
2
0700Client drank adequate amount of fluids.
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3
0900Demerol given for lower abdominal pain.
4
0830Increased IV fluid rate to 100 mL/hr according to
protocol.
ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and essential
information. This notation (0830) provides the time and action taken by the nurse including the
reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry
(0700) does not provide the specific amount the client drank. Stating adequate is subjective, not
objective. This notation (0900) does not have the client describe his or her pain or rate it
according to a pain scale for comparison later. It also does not indicate whether the clients pain
was in the lower left or lower right quadrant, or both.
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
4. The nurse makes a late entry in a clients record. Which of the following is the best example of
how to document this type of situation?
1
2:45 PMASA gr X given for temperature of 38.1 C.
2
8:30 AMClient received Percodan (1 tablet) PO an hour before
going to radiology.
12:15 PMI gave the client morphine 10 mg IM at 11:10 AM but
did not document it then.
3
4
8:30 PMAbdominal dressing change at 7:30 PM. No s/s of
infection, and wound edges approximating well.
ANS: 1
This is the best example of a late entry. The time (2:45 PM) is indicated along with the action
and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why
the Percodan was given. What was the clients level of pain? Where was the pain located? The
nurse does not need to document about herself; only the client. In this option (12:15 PM), the
nurse does not indicate why the morphine was given (clients level of pain? location of pain?).
This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing
used, or the clients tolerance of the procedure.
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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5. The following statement: Upon exertion, the client is wheezing and experiencing some
dyspnea, is an example of:
1
2
3
4
The P of PIE
FOCUS documentation
The R in DAR documentation
The S in SOAP documentation
ANS: 1
These data are examples of the P of PIE because they describe the problem. FOCUS charting
does not concentrate on only problems. It is structured according to a clients concerns. The R in
DAR documentation is the response of the client. This situation describes the clients problem,
not the clients response. The S in SOAP documentation represents subjective data (verbalizations
of the client).
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
6. To locate the recording of a nurses description of the teaching provided to the client on
performance of self-medication administration, one would look in a(n):
1
Kardex
2
Incident report
3
Nursing history form
Discharge summary form
4
ANS: 4
A nurses description of the teaching provided to the client on performance of self-medication
administration is recorded in the discharge summary form. A Kardex is a written form that
contains basic client information. A Kardex contains an activity and treatment section and a
nursing care plan section that organizes information for quick reference as nurses give changeof-shift report. It does not include a description of teaching that was provided to the client. An
incident report is any event that is not consistent with the routine operation of a health care unit
or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a
complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data
about the client.
DIF: A REF: 397-398 OBJ: Comprehension
TOP: Nursing Process: Evaluation
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MSC: NCLEX test plan designation: Safe, Effective Care Environment
7. The nurse has made an error and is documenting such on the clients record and notes. The
action that the nurse should take is to:
1
2
Draw a straight line through the error and initial it.
Erase the error and write over the material in the same spot.
3
Use a dark color marker to cover the error and continue
immediately after that point.
4
Footnote the error at the bottom of the page.
ANS: 1
If a nurse has made an error in documentation, the nurse should draw a single line through the
error, write the word error above it, and sign his or her name or initials. Then record the note
correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while
recording because charting becomes illegible. Also, entries should only be made in ink so they
cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if
the nurse was attempting to hide something or deface the record. Footnotes are not used in
nursing documentation.
DIF: A REF: 388-389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
8. The new staff nurse is having her documentation evaluated by the charge nurse. On review of
her charting, the charge nurse notes that there is evidence of appropriate documentation when the
new staff nurse:
1
Uses a pencil to make the entries
2
Uses correction fluid to correct written errors
3
Identifies an error made by the attending physician
Dates and signs all of the entries made in the record
4
ANS: 4
Each entry should begin with the time and end with the signature and title of the person
recording the entry. All entries should be recorded legibly and in black ink because pencil can be
erased. The nurse should never erase entries, never use correction fluid, or never use a pencil.
The use of correction fluid could make the charting become illegible and it may appear as if the
nurse were attempting to hide something or to deface the record. If the physician made an error,
the nurse should not document it in the clients chart. It should be documented in an incident
report.
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DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
9. What is the correct response for the licensed practical nurse that answers the phone to respond
within the following scenario? The physician calls to leave orders late at night for one of his
clients.
1
Let me get the Registered Nurse on the phone.
2
I am unable to take the order at this time. Please call in the
morning.
3
Please repeat the order for me so I can make sure it is written
correctly.
4
Let me have your phone number and I will have the supervisor
call you back.
ANS: 1
A telephone order involves a physician stating a prescribed therapy over the phone to a registered
nurse. Saying that an order is unable to be taken and to call back in the morning is not an
appropriate response and not in the clients best interest. It is best to repeat any prescribed orders
back to the physician, who can then verify if it is correct or clarify the order. This is not the
appropriate response. A registered nurse needs to take the verbal order, but it does not have to be
the nursing supervisor.
DIF: A REF: 402 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
10. The client developed a slight hematoma on his left forearm. The nurse labels the problem as
an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm
feels better. What is documented as the R in FOCUS charting?
1
Infiltrated IV line
2
My arm feels better
3
Elevation of left forearm
Slight hematoma on left forearm
4
ANS: 2
The R in FOCUS charting is the clients response. In this case, the nurse would document, My
arm feels better. Infiltrated IV line would be documented as D referring to data in FOCUS
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charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing
intervention. Slight hematoma on left forearm is the D referring to data in FOCUS charting.
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following is evaluated as a legally appropriate notation?
1
2
Dr. Green made an error in the amount of medication to
administer.
Verbalized sharp, stabbing pain along the left side of chest.
3
Nurse Williams spoke with the client about the surgery.
4
Client upset about the physical therapy.
ANS: 2
Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left
side of chest is an example of an objective description of a clients behavior. The nurse should not
document physician made error. Instead, the nurse could chart that Dr. Green was called to
clarify order for medication administration. The nurse should chart only for himself or herself. In
this case, nurse Williams should write the charting entry. Only objective descriptions of the
clients behavior should be recorded. For example: Client states, I dont want physical therapy! I
want to go home!
DIF: A REF: 388-389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. To avoid legal risks and possible lack of confidentiality associated with computerized
documentation, many programs currently have:
1
Periodic changes in staff passwords
2
Thumbprint identification restrictions
3
All nursing staff uses the same access code
4
Only centralized medical records use the client data
ANS: 1
A good system of computerized documentation requires periodic changes in personal passwords
to prevent unauthorized persons form tampering with records. Many programs do not have
thumbprint identification restrictions. All nurses do not use the same access code. Each nurse
should have his or her own password. Only centralized medical records using the client data is
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not a true statement. Authorized health care providers from any department can access and use
the data.
DIF: A REF: 406 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
13. Which of the following nursing statements reflects the best understanding of the role of
documentation and the Medicare reimbursement policy?
1
2
Medicare reviews client charts to determine care given.
Good charting results in good Medicare reimbursement.
3
Our nursing salaries are paid for by the Medicare
reimbursement funds.
4
The hospital is reimbursed for the nursing care documented in
the client chart.
ANS: 4
Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for
each diagnosis-related group (DRG). Everything that is done for a client must be documented in
the medical record for the health care institution to recover its costs.
DIF: C REF: 387 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
14. The professional nurse realizes there is both a legal and an ethical obligation to keep client
information obtained through examination, observation, conversation, or treatment:
1
Secured
2
Accessible
3
Confidential
4
Documented
ANS: 3
Nurses are legally and ethically obligated to keep information about clients confidential. Nurses
may not discuss a clients examination, observation, conversation, or treatment with other clients
or staff not involved in the clients care. The other options are primarily directed towards written
records and are not ethically oriented.
DIF: A REF: 385 OBJ: Comprehension
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
15. Which of the following nursing statements regarding the release of a clients medical record
to another institution requires immediate follow-up by the nurses manager?
1
Im pretty sure this will require the clients permission.
2
Are you sure of the exact policy? Do you know what I should
do?
3
The client agreed to the consultation, so Ill have the chart sent
over.
4
I think the client will need to give a verbal consent before it
can be sent.
ANS: 3
Each institution has policies to control the manner for sharing records. In most situations, clients
are required to give written permission for release of medical information. The other options
have the nurse asking for help or expressing doubt about the proper protocol for the release of
the records; these would be appropriate statements and the manager should provide the correct
information.
DIF: C REF: 385 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
16. Regarding access to client records, the nursing faculty informs the nursing students to be
prepared to:
1
Show the unit staff proper student identification
2
Sign a confidentiality agreement when on the unit to preplan
3
Review the medical record only in the presence of unit staff
4
Obtain permission from the client to access his or her medical
record
ANS: 1
When nurses and other health care professionals have a legitimate reason to use records for data
gathering, research, or continuing education, they obtain appropriate authorization according to
agency policy. Nursing students and faculty may be required to present identification indicating
access to the record is authorized. The remaining options are not required if the student is
properly identified and shows need to access the material.
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DIF: C REF: 385 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
17. Which of the following nursing actions is most directly aimed at affording a client
confidential treatment of his or her medical information while minimizing delay in accessing
needed medical and nursing care?
1
Notifying the client of the institutions privacy policy
2
Denying nonessential personal access to the clients medical
records
3
Acquiring the clients verbal consent to share his or her
medical record with essential personnel
4
Requiring that the client sign the Health Insurance Portability
and Accountability Act (HIPAA) form
ANS: 1
Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to
eliminate barriers that could delay access to care, required only that health care providers notify
clients of their privacy policy and make a reasonable effort to get written acknowledgment of this
notification.
DIF: A REF: 385 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
18. When another health care professional is asked to assess a client for the purpose of
suggesting treatment to the primary health care provider, this is called a:
1
Referral
2
Consultation
3
Transfer report
4
Multidisciplinary meeting
ANS: 1
Referrals are the request for services by another care provider usually for the purpose of
determining appropriate client care. Consultations are a form of discussion whereby one
professional caregiver actually gives formal advice about the care of a client to another caregiver.
The remaining options are methods of exchanging general information regarding a client.
DIF: A REF: 386 OBJ: Comprehension
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following nursing notations shows the best understanding regarding the need to
document only objective client assessment data?
1
2
Client was angry because breakfast was not to her liking.
Client is depressed; was observed crying while alone in room.
3
Client expressed pain as an 8 out of 10, was diaphoretic,
guarding her abdomen and clenching her fists.
4
Client was verbally abusive to staff when approached
concerning clients continued attempts to smoke in the
bathroom.
ANS: 3
Do not write personal opinions. Document observable, measurable client-oriented data only. The
remaining options either make assumptions regarding observed client behavior or fail to
objectively describe the noted client behavior.
DIF: C REF: 388-389 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
20. Which of the following nursing notations shows the greatest need for instruction regarding
the need to document only objective client assessment data?
1
Client was angry because breakfast was not to her liking.
2
Client is depressed; was observed crying while alone in room.
3
Client expressed pain as an 8 out of 10, was diaphoretic,
guarding her abdomen and clenching her fists.
4
Client was verbally abusive to staff when approached
concerning clients continued attempts to smoke in the
bathroom.
ANS: 2
Do not write personal opinions. Document observable, measurable client-oriented data only.
Recording that the client is depressed based on the observation of tears is not objective and so is
not acceptable. While one option does report only observable, measurable behavior, the
remaining options, while noting observed client behavior, do fail to objectively describe the
noted client behavior.
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DIF: C REF: 388-389 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
21. Which of the following statements made by a nurse most reflects a need for additional
instruction on areas of client care requiring nursing documentation?
1
The fact that the client refused the prescribed antidepressant
medication was noted in his chart.
2
I provided a detailed description of the dressing change in the
clients chart in order to show it was done as prescribed.
3
The clients wife told me he often develops a rash when he
comes into contact with scented soaps, so I noted that in his
chart.
4
I had a long conversation with the client concerning his fears
about his upcoming surgery and I mentioned his concerns in
my nursing note.
ANS: 2
Common charting mistakes that can result in malpractice include the following: (1) failing to
record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to
record that medications have been given; (4) failing to record drug reactions or changes in clients
condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued
medication. Detailed descriptions of procedures are not included in the nursing notes.
DIF: C REF: 388 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
22. The nursing faculty recognizes the correct way to instruct the nursing students to
acknowledge their charting in a clients medical record is:
1
James Thicket, NS, WVU
2
J. Jones, NS, Montclair Shores College
3
N.H, SN, Bellfield City Community College
4
Linda Mozden, SN, Fairmont State University
ANS: 4
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A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational
institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College).
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
23. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:
1
2
Shows a lack of competency
Displays little attention to detail
3
Contributes to serious treatment errors
4
Negatively affects the accuracy of the documentation
ANS: 3
Spelling errors can result in serious treatment errors; for example, the names of certain
medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling
such terms can result in medication errors that may cause serious harm to a client. The other
options are correct but do not have the seriousness of client care errors.
DIF: C REF: 389 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
24. Related to Problem Oriented Medical Record (POMR) documentation, which of the
following statements made by a nurse reflects the greatest need for additional instruction on the
proper management of a resolved client problem?
1
His surgery corrected the mobility problem, so I drew a line
through it and dated it.
2
The clients problem list has several resolved problems on it;
should I take them off?
3
The client no longer has anxiety issues so I highlighted that
problem on his problem list.
He doesnt experience any dizziness now that we have his
medication regulated, so Ive erased that from his problem list.
4
ANS: 4
New problems are added as they are identified. When a problem has been resolved, record the
date and highlight it or draw a line through the problem and its number. Erasure is not an
acceptable method of showing that a problem has been resolved.
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DIF: A REF: 390-391 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
25. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?
1
2
Risk for injury related to falling due to dizziness
Client fell while walking to bathroom unassisted
3
Client continues to report periods of dizziness upon sitting up
4
Educated to the purpose of dangling on the bedside before
standing
ANS: 1
The problem is reflected by a nursing diagnosis while the interventions are related to nursing
actions directed toward minimizing or eliminating the problem. The evaluation is the clients
objective or subjective response to the nursing intervention.
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
26. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method?
1
Risk for injury related to falling due to dizziness
2
Client fell while walking to bathroom unassisted
3
Client continues to report periods of dizziness upon sitting up
Educated to the purpose of dangling on the bedside before
standing
4
ANS: 4
The problem is reflected by a nursing diagnosis while the interventions are related to nursing
actions directed toward minimizing or eliminating the problem. The evaluation is the clients
objective or subjective response to the nursing intervention.
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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27. Related to Problem Oriented Medical Record (POMR) documentation, which of the
following statements made by a nurse reflects the greatest need for additional instruction on the
proper management of a resolved client problem?
1
His surgery corrected the mobility problem, so I draw a line
through it and dated it.
2
The clients problem list has several resolved problems on it;
should I take them off?
The client no longer has anxiety issues so I highlighted that
problem on his problem list.
3
4
He doesnt experience any dizziness now that we have his
medication regulated, so Ive erased that from his problem list.
ANS: 4
New problems are added as they are identified. When a problem has been resolved, record the
date and highlight it or draw a line through the problem and its number. Erasure is not an
acceptable method of showing that a problem has been resolved.
DIF: A REF: 387 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
28. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?
1
Risk for injury related to falling due to dizziness
2
Client fell while walking to bathroom unassisted
3
Client continues to report periods of dizziness upon sitting up
4
Educated to the purpose of dangling on the bedside before
standing
ANS: 1
The problem is reflected by a nursing diagnosis while the interventions are related to nursing
actions directed toward minimizing or eliminating the problem. The evaluation is the clients
objective or subjective response to the nursing intervention.
DIF: A REF: 385 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
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29. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method?
1
2
Risk for injury related to falling due to dizziness
Client fell while walking to bathroom unassisted
3
Client continues to report periods of dizziness on sitting up
4
Educated to the purpose of dangling on the bedside before
standing
ANS: 4
The problem is reflected by a nursing diagnosis while the interventions are related to nursing
actions directed toward minimizing or eliminating the problem. The evaluation is the clients
objective or subjective response to the nursing intervention.
DIF: A REF: 390 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)
1
Accurate
2
Inclusive
3
Well organized
4
Show continuity of care
5
Record nursing opinion
6
Identify client outcomes
ANS: 1, 2, 3, 4, 6
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical
data, maintain continuity of care, track client outcomes, and reflect current standards of nursing
practice. Nursing documentation should include nursing observations, not nursing opinions.
DIF: C REF: 390-391 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)
1
Safe nursing practice
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2
Continuity of client care
3
Positive client outcomes
Efficient time management
4
5
6
Cost-conscious nursing care
Effective nurse-client relationships
ANS: 1, 2, 4
Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors.
While important, the remaining options are not criteria for effective nursing documentation.
DIF: C REF: 391 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
3. Problem Oriented Medical Record (POMR) method of documentation includes which of the
following sections? (Select all that apply.)
1
Database
2
Care plan
Evaluations
3
4
5
Problem list
Interventions
6
Progress notes
ANS: 1, 2, 4, 6
The POMR has the following major sections: database, problem list, care plan, and progress
notes. Interventions and evaluations are documentation sections related to PIE (Problem,
Interventions, and Evaluation) charting.
Chapter 27. Patient Safety and Quality
MULTIPLE CHOICE
1. The nurse has investigated safety hazards and recognizes that which one of the following
statements is accurate regarding safety needs?
1
Bacterial contamination of foods is uncontrollable.
2
Fire is the greatest cause of unintentional death.
3
Carbon dioxide levels should be monitored in home settings.
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4
Temperature extremes seldom affect the safety of clients in
acute care facilities.
ANS: 3
Annual inspections of heating systems, chimneys, and appliances should be done in private
homes. Carbon monoxide detectors are available but should not be used as a replacement for
proper use and maintenance of fuel-burning appliances. Bacterial contamination of foods is
controllable. The FDA is a federal agency responsible for the enforcement of federal regulations
regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect
consumers against the sale of impure or dangerous substances. Motor vehicle accidents are the
leading cause of unintentional death, not fire. Temperature extremes can affect the safety of
clients in acute care facilities, especially the elderly.
PTS: 1 DIF: A REF: 812 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimers
disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1
Confusion
2
3
Impaired judgment
Sensory deficits
4
History of falls
ANS: 4
According to the falls assessment tool, the greatest indicator of risk is a history of falls.
According to the falls assessment tool, the second leading risk factor for falls is confusion.
According to the falls assessment tool, impaired judgment is the fourth leading risk factor for
falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for
falls.
PTS: 1 DIF: A REF: 817 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
3. An inservice program is being offered in the hospital on bioterrorism and the response of the
health care agency. During the program, the mitigation phase is described. The nurse is informed
that this phase includes:
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1
Determination of hazard vulnerability and the impact of the
emergency situation
2
3
Steps taken to manage the effects of the event and an
inventory of available resources
Steps taken by staff to triage victims
4
Restoration of essential services
ANS: 1
The mitigation phase consists of the assessment process to determine hazard vulnerability for the
hospitals service area. This includes an identification of the kinds of emergency situations that
are most likely to occur and their probable impact. During the preparedness phase, steps are
taken to manage the effects of the event, and an inventory of available resources is taken. During
the response phase, steps are taken by staff to triage victims. During the recovery phase, steps are
taken to restore essential services.
PTS: 1 DIF: A REF: 821 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
4. An inservice program is being offered in the hospital on bioterrorism and the response of the
health care agency. An important aspect of the program is the recognition of the signs and
symptoms of bacterial and viral infections. A practice drill is held and the nurse recognizes that
the clients admitted with possible anthrax will demonstrate:
1
Abdominal cramping, diarrhea, drooping eyelids, jaw clench,
and difficulty swallowing
2
Flulike symptoms, gastrointestinal distress, and papular
lesions
3
Fever, cough, chest pain, and hemoptysis
Vesicular skin lesions on the face and extremities
4
ANS: 2
Clinical features of anthrax include flulike symptoms, gastrointestinal distress, and papular
lesions. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing
are clinical features of botulism. Fever, cough, chest pain, and hemoptysis are characteristic of
plague. Vesicular skin lesions on the face and extremities are seen with smallpox.
PTS: 1 DIF: A REF: 821 OBJ: Comprehension
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
5. A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to
use for this client to prevent removal of the IV line would be a(n):
1
2
Wrist restraint
Jacket restraint
3
Elbow restraint
4
Mummy restraint
ANS: 4
A mummy restraint is used short-term for a small child or infant for examination or treatment
involving the head and neck. This would be the most appropriate type of restraint to use for a 1year-old child who is going to receive an IV line. The wrist restraint maintains immobility of an
extremity to prevent the client from removing a therapeutic device, such as an IV tube. It would
not be the best choice for starting an IV on a 1-year-old child. The jacket restraint is often used to
prevent a client from getting up and falling. It is not the best choice for starting an IV line. An
elbow restraint is commonly used with infants and children to prevent elbow flexion, such as
after an IV line is in place.
PTS: 1 DIF: A REF: 832 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
6. A 79-year-old resident in a long-term care facility is known to wander at night and has fallen
in the past. Which of the following is the most appropriate nursing intervention?
1
An abdominal restraint should be placed on the client during
sleeping hours.
2
The client should be checked frequently during the night.
3
A radio should be left playing at the bedside to assist in reality
orientation.
4
The client should be placed in a room that is away from the
activity of the nurses station.
ANS: 2
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Alternatives to restraints should be attempted first. (A physicians order is required for restraints
to be applied.) The most appropriate intervention is to check on the client frequently. Alternatives
to restraints should be attempted first before an abdominal restraint while sleeping.
A radio may help orientate a client to reality. However, the most appropriate intervention for the
client who wanders is to check on the client frequently. Clients who wander should be assigned
to rooms near the nurses station and checked on frequently.
PTS: 1 DIF: C REF: 832 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
7. The workmen cause an electrical fire when installing a new piece of equipment in the
intensive care unit. A client is on a ventilator in the next room. The first action the nurse should
take is to:
1
2
3
4
Pull the fire alarm
Attempt to extinguish the fire
Call the physician to obtain orders to take the client off the
ventilator
Use an Ambu-bag and remove the client from the area
ANS: 4
If there is a fire, and the client is on life support, the nurse should maintain the clients respiratory
status manually with an Ambu-bag and move the client away from the fire. The first action of the
nurse is not to pull the fire alarm. The workmen could do that. The workman can attempt to
extinguish the fire. The nurse should attend to the client who is closest to the fire in the next
room. The nurse should not call the doctor to obtain orders to take the client off the ventilator
because this will take valuable time. The client needs to be moved away from the fire, and the
source of oxygen needs to be discontinued, as it is combustible. The client will need to be
manually resuscitated with an Ambu-bag.
PTS: 1 DIF: C REF: 839 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire.
The most appropriate type of fire extinguisher for the nurse to use is the:
1
Type A
2
Type B
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3
Type C
4
Type D
ANS: 1
Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and
plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are
used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire
extinguishers are used for electrical equipment. There is no type D fire extinguisher.
PTS: 1 DIF: A REF: 840 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
9. A visiting nurse completes an assessment of the ambulatory client in the home and determines
the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the
client will benefit the most from:
1
Installing fluorescent lighting throughout the house
2
3
Becoming oriented to the position of the furniture and
stairways
Maintaining complete bed rest in a hospital bed with side rails
4
Applying physical restraints
ANS: 2
Orienting the client to the position of furniture in the room and stairways is the best intervention
to help prevent falls for the client with decreased vision. Attempts should be made to reduce
glare. Light bulbs that are 60 watts or less may be increased to 75 watts to help improve
visibility. The best intervention to prevent falls is to first orient the client to the surroundings.
Maintaining complete bed rest is not the best option. Complete bed rest can cause other health
problems resulting from a lack of mobility. The client should not be restrained for poor vision.
Attempts should be made to help compensate for the decreased vision in order to prevent falls.
PTS: 1 DIF: C REF: 819 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
10. Which one of the following statements by the parent of a child indicates that further teaching
by the nurse is required?
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1
Now that my child is 2 years old, I can let her sit in the front
seat of the car with me.
2
3
I make sure that my child wears a helmet when he rides his
bicycle.
I have spoken to my child about safe sex practices.
4
My child is taking swimming classes at the community center.
ANS: 1
This statement indicates that further teaching is required. Children weighing less than 80 pounds
or who are under 8 years of age should always be in an age/weight-appropriate car seat that has
been installed according to manufacturers directions. In cars with a passenger air bag, children
under 12 should be in the back seat. Answer 2 is an appropriate safety measure to reduce injuries
from falling off a bike or being hit by a car. Answer 3 is an important safety measure because
many adolescents begin sexual relationships. Answer 4 is an appropriate safety measure that may
someday save a childs life.
PTS: 1 DIF: C REF: 827 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
11. The nurse assesses that the client may need a restraint and recognizes that:
1
An order for a restraint may be implemented indefinitely until
it is no longer required by the client
2
Restraints may be ordered on an as-needed basis
3
No order or consent is necessary for restraints in long-term
care facilities
4
Restraints are to be periodically removed to have the client
reevaluated
ANS: 4
Restraints must be periodically removed, and the nurse must assess the client to determine if the
restraints continue to be needed. Answer 1 is not a true statement. A physicians order for
restraints must have a limited time frame. If the orders are renewed, it should be done so within a
specified time frame according to the agencys policy. Restraints are not to be ordered prn (as
needed). The use of restraints must be part of the clients medical treatment. An order or consent
is necessary for restraints in long-term care facilities.
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PTS: 1 DIF: A REF: 831 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
12. On entering the clients room, the nurse sees a fire burning in the trash can next to the bed.
The nurse removes the client and calls in the fire. The next action of the nurse is to:
1
2
3
4
Extinguish the fire
Remove all of the other clients from the unit
Close all the doors of client rooms
Move the trash can into the bathroom
ANS: 3
The next action the nurse should take is to confine the fire by closing doors and windows and
turning off oxygen and electrical equipment. The nurse should extinguish the fire using an
extinguisher after closing the doors of the client rooms. After activating the alarm, the nurse
should close all the doors, not remove all of the other clients from the unit. Answer 4 would not
be an appropriate action because the nurse could get burned in attempting to move the trash can.
PTS: 1 DIF: A REF: 839 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
13. A mother of a young child enters the kitchen and finds the child on the floor. There is a bottle
of cleanser next to the child and particles of the substance around the childs mouth. The parents
first action should be to:
1
Call the Poison Control unit
2
Provide ipecac syrup
3
Check the childs airway and breathing
4
Remove the particles of cleanser from the mouth
ANS: 3
The first action is to assess for airway patency, breathing, and circulation. After checking the
childs airway, breathing, and circulation, the parent should remove any particles of cleanser from
the mouth. The parent should identify the type and amount of substance ingested and then call
the Poison Control unit. The parent should only administer ipecac syrup if instructed to induce
vomiting by the Poison Control unit. Administering ipecac is not the parents first action.
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Removing the particles of cleanser is not the parents first action. The parent may do so after
assessing the childs airway, breathing, and circulation.
PTS: 1 DIF: C REF: 840 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
14. Which of the following nursing assessment data are most reflective of hypothermia?
1
Cyanotic lips, fingers, and toes
2
Rectal temperature of 35 C (95 F)
3
Bradycardia of 56 beats per minute
Exposure to outdoor temperatures of <32 F
4
ANS: 2
Hypothermia occurs when the core body temperature is 35 C (95 F) or below. While the
remaining options are not incorrect, they may be due to other factors.
PTS: 1 DIF: A REF: 812 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk
for heatstroke or heat exhaustion?
1
A 65-year-old diagnosed with COPD
2
A 35-year-old novice marathon runner
3
A 15-year-old playing in an outdoor tennis tournament
4
A 9-month-old whose bedroom is cooled with a mechanical
fan
ANS: 1
Exposure to extreme heat raises the core body temperature, resulting in heatstroke or heat
exhaustion. Chronically ill clients, older adults, and infants are at greatest risk for injury from
extreme heat. These clients need to avoid extremely hot, humid environments. While the
remaining options reflect a risk, it is not as high as the answer.
PTS: 1 DIF: C REF: 812 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
16. The nurse should recognize which of the following clients as being at greatest risk for an
unintentional death?
1
2
3
4
A 58-year-old who skis regularly
A 44-year-old alcoholic who lives alone
A 72-year-old identified as at high risk for falls
A 34-year-old diagnosed with chronic depression
ANS: 3
Among older adults 65 years and older, falls are the leading cause of unintentional death. While
the remaining options reflect clients at risk, the probability is not as great.
PTS: 1 DIF: C REF: 813 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
17. Which of the following nursing interventions has the greatest likelihood of minimizing the
risk of injury for a client who frequently gets out of bed at night to go into the bathroom?
1
Limiting fluid intake after 6 PM
2
Illuminating the pathway to the bathroom
3
Toileting the client whenever awake at night
Checking on the client at least hourly during the night
4
ANS: 2
While checking on the client frequently is not incorrect, night-lights in dark halls, bathrooms,
and the rooms of children and older adults help maintain safety by reducing the risk of falls. The
remaining options are more directed at controlling urinary output than preventing injury.
PTS: 1 DIF: C REF: 813 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the
greatest emphasis on the:
1
Prevention role smoke detectors play
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2
Dangers of careless smoking habits
3
Supervision of children around open flames
Importance of readily accessible fire extinguishers
4
ANS: 2
The leading cause of fire-related death is careless smoking. While the other options reflect risk,
they are not as highly prioritized as the answer.
PTS: 1 DIF: C REF: 813 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
19. The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:
1
Physical abuse
2
Accidental injury
3
Contagious diseases
4
Stranger abduction
ANS: 2
Injuries are the leading cause of death in children older than 1 year of age and cause more deaths
and disabilities than do all diseases combined.
PTS: 1 DIF: A REF: 814 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
20. The nurse is preparing a safety-related program for a group of parents of 5- to 14-year-olds.
Which of the following topics is most likely to positively impact the leading cause of injury for
this age-group?
1
Keeping them safe while they play sports
2
3
Bicycle riding with safety in mind
Safety first when around water
4
Dont let fire hurt your child
ANS: 2
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Children 5 to 14 years of age account for nearly one third of bicyclists killed in traffic accidents.
While the remaining options deal with risk factors, the priority relates to bicycle-oriented
accidents.
PTS: 1 DIF: C REF: 815 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
21. The nurse recognizes which of the following clients is at greatest risk for an accidental death?
1
2
A 60-year-old who is a weekend alcoholic
A 40-year-old who is a professional mountain climber
3
A 35-year-old who commutes 35 miles to work each morning
4
A 50-year-old who recently lost his job because of a workrelated injury
ANS: 4
The adult experiencing a high level of stress is more likely to have an accident or illness such as
headaches, gastrointestinal (GI) disorders, and infections. While the remaining options identify
risks, they are not a high as that of the stressed adult.
PTS: 1 DIF: C REF: 815 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury
caused by:
1
The physical collapse that occurs at the onset of the seizure
2
Muscle strains that result from the severe muscle jerking
during the seizure
3
The tongue laceration that occurs from jaw clenching during
the seizure
Aspiration resulting from the temporary loss of consciousness
after the seizure
4
ANS: 1
During a fall, or as a result of muscle jerking, musculoskeletal injuries can occur. The fall is the
most problematic since is occurs in the vast majority of the seizure events.
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PTS: 1 DIF: C REF: 817 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
23. Which of the following clients is at greatest risk for injury related to medical diagnoses and
conditions?
1
2
A history of asthma and alcohol abuse
A history of heart failure and urinary urgency
3
A history of hypertension and wearing corrective lenses
4
A history of chronic bronchitis and impaired hearing
ANS: 2
This client is likely using diuretics that increase the frequency of voiding and result in the client
having to use toilet facilities more often. Falls often occur with clients who have to get out of bed
quickly because of urinary urgency.
PTS: 1 DIF: C REF: 817 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
24. The nurse is conducting an admission interview and assessment on a cognitively impaired,
uncooperative client for the risk for injury. Which of the following options will most likely
provide the information to confirm the diagnosis?
1
Base the degree of risk on observable data at the time of the
clients current hospital admission.
2
Closely monitor the clients behavior and habits until risk for
injury can be reasonably determined.
Make certain critically sound assumptions are based on the
clients developmental stage and current cognitive stasis.
3
4
Interview the clients family, friends, and/or caregivers
regarding prehospitalization risk factors.
ANS: 4
In many cases family members are important resources in assessing a clients fall risk. Families
often are able to report on the clients level of confusion and ability to ambulate.
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PTS: 1 DIF: C REF: 818 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
25. A nurse working in an acute care facilitys emergency department should recognize which of
the following client reports as being most suspicious of a terrorist attack?
1
Four deaths resulting from a privately owned airplane crashing
into a four-story building
2
Numerous reports of respiratory distress among older adults
who attended an outdoor musical event
3
15 cases of nausea and vomiting reported over a 2-day period
when 4 cases would be within normal for the facility
4
10 children, all who attended a child-oriented arts and crafts
fair, presenting with rashes on their hands and faces
ANS: 3
An unusual increase in the number of people seeking care, especially with fever, respiratory, or
gastrointestinal complaints, is a classic indicator of such an event. While the other options
present possible indicators, there are other possible reasons for the incidents.
PTS: 1 DIF: C REF: 820 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
26. The nurse is discussing safety issues with the mother of three children. Which of the
following statements has the greatest possibility for decreasing the potential for injury among the
children?
1
Where do you see a need for safety improvements in your
home?
2
Keep all toxic liquids capped and stored out of reach of the
children.
3
Installing safety gates at the top and bottom of each set of
stairs will help minimize falls.
Take great care to keep the children away from kitchen
appliances and tools that can hurt them.
4
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ANS: 1
Clients generally expect to be safe in their homes and health care settings. However, there are
times when a clients view of what is safe does not agree with that of the nurse. For this reason,
any assessment needs to include the clients understanding of his or her perception of risk factors.
The remaining options are directed toward specific safety issues.
PTS: 1 DIF: C REF: 824 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
27. The nurse recognizes that the greatest benefit of engaging the mother of two small children
into a discussion about child-proofing her home is that:
1
2
The home will be safe for the immediate time being
If an accident occurs, it will likely be minor in nature
3
She is likely to monitor the house for safety issues in the
future
4
She will serve as a role model regarding safety issues for her
children
ANS: 3
The client who is an active participant in reducing threats to safety becomes more alert to
potential hazards.
PTS: 1 DIF: C REF: 824 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
28. The nurse and a mother of two small children are discussing child safety issues. Which of the
following nursing interventions has the greatest potential for using collaboration to help ensure
the childrens safety?
1
Arranging to teach the children how to react in the case of a
fire in the home
2
Teaching the children to telephone 911 if there is ever an
emergency in the home
Helping the mother identify an emergency person for the
children to telephone in the case of an emergency
3
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4
Helping the mother create a list of emergency telephone
numbers to be posted next to the homes telephone
ANS: 4
Clients need to learn how to identify and select resources within their community that enhance
safety (e.g., neighborhood block homes, local police departments, and neighbors willing to check
on a clients well-being).The remaining options deal with individual aspects of a complete plan.
PTS: 1 DIF: C REF: 824 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes
that which of the following active strategy topics has the greatest potential for decreasing injuries
in this population by affecting lifestyle changes?
1
Avoiding the nicotine habit
2
Keeping immunizations up to date
3
Eating a well-balanced, low-fat diet
Wearing a seat belt when riding in an automobile
4
ANS: 4
To promote an individuals health, it is necessary for the individual to be in a safe environment
and to practice a lifestyle that minimizes risk of injury. Active strategies are those in which the
individual is actively involved through changes in lifestyle (e.g., wearing seat belts or installing
outdoor lighting) and participation in wellness programs. Accidents involving automobiles
account for the most substantial number of injuries and deaths among this population from
among the options provided.
PTS: 1 DIF: C REF: 824 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
30. The nurse is discussing measures to minimize the risk of injury from an automobile accident
with an 83-year-old adult client who lives alone and claims to drive only to church, the doctors
office, and for groceries. Which of the following suggestions has the greatest potential for
affecting this clients safety?
1
Take public transportation whenever it is available.
2
Plan errands around church or doctors appointments.
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3
Plan driving for short trips and only during the daylight hours.
4
Arrange for family or friends to drive you whenever it is
possible.
ANS: 3
The nurse educates clients regarding safe driving tips (e.g., driving shorter distances or only in
daylight, using side and rearview mirrors carefully, and looking behind them toward their blind
spot before changing lanes). The other options, while not incorrect, may not be realistic or
appealing to an independent client.
PTS: 1 DIF: C REF: 824 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
31. Which of the following assessment findings is most critical in a client who is currently being
restrained with mechanical wrist restraints?
1
Angry, loud crying
2
3
Urinary incontinence
Reddened areas on wrists
4
Hands are cool to the touch
ANS: 4
While the use of any restraint may be associated with serious complications, including pressure
ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most
serious are contractures, nerve damage, and circulatory impairment. The coolness of the clients
hands indicates poor circulation and can result in permanent damage.
PTS: 1 DIF: C REF: 837 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
32. The nurse is discussing a newly ordered diuretic with an older adult client who is homebound. Which of the following suggestions has the greatest potential for minimizing the clients
risk for injury related to urinary urgency or incontinence?
1
Consider decreasing fluid intake after 6 PM.
2
Illuminate the path to the bathroom at night.
3
Encourage the client to urinate immediately before bed.
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4
Encourage the client to take the medication early in the
morning.
ANS: 4
Nocturia and incontinence are more frequent in older adults. Give diuretics in the morning.
While the other options may have value, they do not have an impact on the situation as directly
as the administration of the medication.
PTS: 1 DIF: C REF: 813 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the
client is at high risk for developing a nosocomial infection. One of the most important things that
the nurse can do to prevent this client from obtaining a nosocomial infection is to:
1
Practice appropriate hand hygiene
2
Request prophylactic antibiotics for the client
3
Place the client in isolation
4
Encourage the client to turn, cough and deep breath every 2
hours
ANS: 2
Antibiotics should be used appropriately to prevent resistant organisms. The best way to prevent
nosocomial infections is to perform hand hygiene before and after each client encounter and after
contact with contaminated objects. Isolation will not in itself prevent a nosocomial infection.
Answer 4 will help prevent atelectasis, but not necessarily a nosocomial infection.
PTS: 1 DIF: B REF: 829 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a
scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot
when adding hot water from the tap to her bath while she was in the tub. The nurse should do
which of the following?
1
Report the incident as suspected elder abuse.
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2
Suggest that the temperature of the hot water heater be
lowered.
3
Instruct the client that she should not be taking tub baths to
prevent this from happening again.
Discuss the incident with social services so that arrangements
can be made for the client to go to a nursing home on
discharge from the hospital.
4
ANS: 2
Hot water from the tap should not have the potential to scald, because it is a safety hazard. The
client had a plausible explanation for the incident without other signs to indicate abuse. There is
no reason that the client should not be able to continue to take tub baths if the water temperature
is within a safe range. The client has no other indications that she is in any danger of caring for
herself; thus Answer 4 is not appropriate.
PTS: 1 DIF: A REF: 824 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
35. A nurse in the emergency department (ED) of a community hospital notes that an unusually
high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea,
vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse
is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of:
1
Botulism
2
Anthrax
3
Plague
4
Smallpox
ANS: 2
The symptoms of the clients all point to an endemic outbreak of anthrax.
PTS: 1 DIF: A REF: 816 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
36. When discussing the new mothers pending discharge from the hospital, the nurse determines
that additional client teaching needs to take place because of which of the following comments?
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1
My husband has installed the new car seat in the middle of the
backseat of our car.
2
I cant wait to put my baby in her new crib with the ensemble
that my mom made sheets, blankets, and bumper to match.
I need to place my baby on her back to sleep, right?
3
4
I have checked all my babys toys to make sure that they dont
contain lead paint.
ANS: 2
Newborns should not be placed in cribs with loose comforters, bumper pads, etc. The middle of
the back seat is the safest place to put the infant car seat. Babies should not be placed on their
stomachs with their mouth and nose in close proximity to the mattress, which is associated with
sudden death syndrome. Lead paint on infant toys can lead to brain damage.
PTS: 1 DIF: A REF: 829 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
37. A confused client on a ventilator was restrained to prevent him from pulling out his
endotracheal tube. Which of the following could be a possible alternative measure that the nurse
could use to avoid the use of the restraints?
1
Orient the client to the environment and explain the need for
the endotracheal tube.
2
Provide a trained sitter to continuously supervise the client.
3
Camouflage the endotracheal tube with stockinette dressing.
4
Promote relaxation techniques.
ANS: 2
A trained sitter can prevent the client from pulling out the endotracheal tube. The client is
confused and does not understand. The endotracheal tube cannot be camouflaged effectivelythe
client feels it more than sees it. Because the client is confused, it may be very difficult to
communicate relaxation techniques so that the client has an understanding.
PTS: 1 DIF: C REF: 821 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
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38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter.
Which of the following can the nurse delegate to the nursing assistive personnel?
1
2
3
4
Applying restraints
Obtaining a physicians order to restrain the client
Document the events that led to restraining the client
Evaluating the effectiveness of the restraints
ANS: 1
Although the nursing assistive personnel can apply the restraints under the nurses direction, they
cannot document, evaluate, or take physicians orders.
PTS: 1 DIF: A REF: 826 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
39. A nurse finds that an electrical cord has shorted out in a clients room, causing a fire. The
nurse should do which of the following actions first?
1
Activate the alarm.
2
Confine the fire by closing the clients door.
3
Remove the client from the room.
Extinguish the fire.
4
ANS: 3
The mnemonic RACE should be used to help remember to rescue or remove all clients in
immediate danger, activate the alarm, confine the fire, and extinguish the fire
PTS: 1 DIF: A REF: 832 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
40. Which of the following statements indicates that the client is at risk for an electrical shock at
home?
1
I had to cut off the third prong on the electrical plug so that it
would fit in the extension cord.
2
My bread got stuck in my toaster this morning, and I
unplugged it before trying to remove it.
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3
I always read the owners manual when I purchase a new
electrical appliance.
4
I always make sure that I am standing in a dry area before
operating electrical equipment.
ANS: 2
The third prong is used to ground the piece of equipment. Improperly grounded equipment can
cause electrical injury.
PTS: 1 DIF: B REF: 834 OBJ: Application
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive
personnel notifies the nurse that the client is having a seizure. The first thing that the nurse
should do when arriving in the room is to:
1
Raise the bed side rails
2
Put the bed in the lowest position
3
Position the client safely
4
Provide privacy
ANS: 3
Although Answers 1, 2 and 3 are all important safety interventions, the priority is to safely
position the client. It is important to provide privacy, but safety interventions are a priority.
PTS: 1 DIF: B REF: 840 OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
42. A client with a history of epilepsy arrives in the emergency department experiencing status
epilepticus. The nurse should never do which of the following?
1
Document sequence of events, including any adverse
outcomes.
2
Prepare to initiate IV access.
3
Access oxygen and suctioning equipment.
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4
Open clients mouth by placing fingers on jaw and inserting
thumb on bottom teeth to place oral airway between seizures.
ANS: 4
Nurses should never put their fingers in or close to a clients mouth who is or has been
experiencing seizure activity, to prevent being bitten in the event that the client should
experience more seizure activity. The nurse is responsible for all of these measures in Answers 1,
2, and 3 to provide for the safety of the client, as well as document the sequence of events
including any unexpected outcomes.
PTS: 1 DIF: B REF: 842 OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection
Control
MULTIPLE RESPONSE
1. The nurse caring for clients in an acute care facility recognizes that attending to the safety of
each client is most likely to result in: (Select all that apply.)
1
Freedom from illness
2
A shorter hospital stay
3
4
Attention to the basic human needs
A well-founded sense of well-being
5
Preservation of the optimal functioning level
6
Minimal exposure to bacterial cross-contamination
ANS: 2, 3, 4, 5, 6
Safety in health care settings reduces the incidence of illness and injury, prevents extended
length of treatment and/or hospitalization, improves or maintains a clients functional status, and
increases the clients sense of well-being. A safe environment gives protection to the staff as well,
allowing them to function at an optimal level. A safe environment includes meeting basic needs,
reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and
controlling pollution. While a reduction of illness is an expectation, there is no assurance of the
freedom from illness.
PTS: 1 DIF: A REF: 843 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection
Control
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2. The nurse recognizes that children living in older housing that may contain lead-based paints
may exhibit which of the following signs and symptoms? (Select all that apply.)
1
2
3
Vomiting
Anorexia
4
Headaches
Bloody urine
5
Thoracic rash
6
Swollen joints
ANS: 1, 2, 3
Signs and symptoms of lead poisoning typically include impaired hearing, vomiting, headaches,
appetite loss, and learning and behavioral problems. The remaining options are not typically seen
with this condition.
Chapter 28. Infection Prevention and Control
MULTIPLE CHOICE
1. The client has a 6-inch laceration on his right forearm. The arm develops an infection. Which
of the following is a sign of an acute inflammatory process?
1
A blanching of the skin
2
A decrease in temperature at the site
3
A decrease in the number of white blood cells
4
A release of histamine trhat adds to the pain response
ANS: 4
A sign of an acute inflammatory process is pain. The swelling of inflamed tissues increases
pressure on nerve endings, causing pain. Chemical substances such as histamine also stimulate
nerve endings, adding to the pain response. The skin is not blanched; but rather, with the increase
in local blood flow; it is reddened. The symptom of localized warmth results from a greater
volume of blood at the inflammatory site. The cellular response of acute inflammation involves
WBCs arriving at the site. There is an increase in WBCs, rather than a decrease.
DIF: A REF: 646 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
2. A female client has been undergoing diagnostic testing since admission to the medical unit in
the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the
nurse will report which of the following findings to the physician, which is abnormal?
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1
Erythrocyte sedimentation rate (ESR) 35 mm/hr
2
3
White blood cell (WBC) count 8000/mm3
Neutrophils 65%
4
Iron 75 g/100 mL
ANS: 1
The normal erythrocyte sedimentation rate for women is 20 mm/hr. The clients ESR is 35 mm/hr,
indicating the presence of the inflammatory process. The normal WBC count is 5000-10,000/
mm3. The client is within normal limits at 8000/mm3. The normal neutrophil count is 55-70%.
The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is
within normal limits at 75 g/100 mL.
DIF: A REF: 646 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
3. The nurse is observing the new staff member work with the client. Of the following activities,
which one has the greatest possibility of contributing to a nosocomial infection and requires
correction?
1
Washing hands before applying a dressing
2
Taping a plastic bag to the bed rail for tissue disposal
3
Placing a Foley catheter bag on the bed when transferring a
client
Using alcohol to cleanse the skin before starting an
intravenous line
4
ANS: 3
The staff member who places the Foley catheter bag on the bed when transferring the client is
placing the client at risk for a nosocomial infection because urine in the catheter or drainage tube
may reenter the bladder (reflux). Washing hands before applying a dressing is a correct action to
help prevent a nosocomial infection. Taping a plastic bag to the bed rail for tissue disposal is a
correct action to aid the client in proper disposal of secretions. Using alcohol to cleanse the skin
before starting an intravenous line is a correct action to prevent a nosocomial infection of the
bloodstream.
DIF: A REF: 648 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
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4. Droplet precautions will be instituted for the client admitted to the infectious disease unit with:
1
Streptococcal pharyngitis
2
3
Herpes simplex
Pertussis
4
Measles
ANS: 1
Droplet precautions are instituted when droplets are larger than 5 micrometers, such as in the
case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex.
Airborne precautions are instituted with pulmonary TB. Airborne precautions are instituted with
measles.
DIF: A REF: 662 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
5. In a small rural hospital they work with a wide variety of clients. Of this afternoon clients
admitted, the nurse acknowledges the client with the highest susceptibility to infection is the
individual with:
1
Burns
2
Diabetes
3
Pulmonary emphysema
4
Peripheral vascular disease
ANS: 1
Burn clients have a very high susceptibility to infection because of the damage to skin surfaces.
This would be the individual with the highest risk for infection. Victims of chronic diseases such
as diabetes mellitus and multiple sclerosis are susceptible to infection because of general
debilitation and nutritional impairment. Diseases that impair body system defenses, such as
emphysema and bronchitis (which impair ciliary action and thicken mucus), increase
susceptibility to infection. Diseases that impair body system defenses, such as peripheral
vascular disease (which reduces blood flow to injured tissues), increase susceptibility to
infection.
DIF: C REF: 668-669 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
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6. A nurse must display understanding of the mental implications of a client on isolation
precautions when planning care to control the risk of:
1
2
3
4
Denial
Aggression
Regression
Isolation
ANS: 4
A sense of loneliness may develop because normal social relationships become disrupted. The
nurse should plan care to control the risk of the client feeling isolated. Denial is not a risk related
to isolation. Aggression is not a risk for the client on isolation precautions. Regression is not a
risk related to isolation.
DIF: A REF: 661 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
7. Surgical aseptic techniques are employed by a nurse when:
1
Inserting an intravenous catheter
2
Placing soiled linen in moisture-resistant bags
3
Disposing of syringes in puncture-proof containers
4
Washing hands before changing a dressing
ANS: 1
Surgical asepsis should be used during procedures that require intentional perforation of the
clients skin, such as with the insertion of IV catheters. The nurse is employing medical aseptic
technique when placing soiled linen in moisture-resistant bags. The nurse is employing medical
aseptic technique when disposing of syringes in puncture-proof containers. The nurse is
employing medical aseptic technique when washing hands before changing a dressing.
DIF: A REF: 669 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
8. A nurse is changing the dressing and accidentally drops the packing onto the clients abdomen.
The client has a large, deep abdominal incision that is packed with sterile half-inch packing and
covered with a dry 4 4 gauze. The nurse should:
1
Add alcohol to the packing and insert it into the incision
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2
Throw the packing away, and prepare a new one
3
Pick up the packing with sterile forceps, and gently place it
into the incision
Rinse the packing with sterile water, and put the packing into
the incision with sterile gloves
4
ANS: 2
A sterile object (the packing) remains sterile only when touched by another sterile object. The
clients abdomen is not sterile; therefore, the nurse should throw the packing away and prepare a
new one. The nurse should not add alcohol to the packing and insert it into the incision.
The packing is considered contaminated as it touched a nonsterile surface and should be
discarded. The nurse should not rinse the packing with sterile water and put the packing into the
incision as it is considered contaminated. It touched a nonsterile surface. The nurse should throw
the packing away and prepare a new one.
DIF: A REF: 669 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
9. A client has a viral infection. Which of the following is typical of the illness stage of the
course of her infection?
1
There are no longer any acute symptoms.
2
An oral temperature reveals a febrile state.
3
The client was first exposed to the infection 2 days ago but has
no symptoms.
4
The client feels sick but is able to continue her normal
activities.
ANS: 2
During the illness stage the client manifests signs and symptoms specific to the type of infection.
The client with a viral infection would likely exhibit a fever. There are no longer any acute
symptoms during the convalescent period. An example of a client in the incubation period is
when the client was first exposed to the infection 2 days ago, but has no symptoms.
The client who feels sick but is able to continue normal activities is in the prodromal stage of a
course of infection.
DIF: A REF: 646 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Safety and Infection Control
10. The nurse recognizes that special care must be taken in the handling of which of the
following to prevent the transmission of hepatitis A?
1
2
Blood
Feces
3
Saliva
4
Vaginal secretions
ANS: 2
To prevent the transmission of hepatitis A, the nurse needs to take special care when handling
feces. Hepatitis B and C may be found in blood. Hepatitis A is not found in saliva. Hepatitis A is
not found in vaginal secretions.
DIF: A REF: 643 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
11. The parent of a preschool child asks the nurse how chickenpox (varicella zoster) is
transmitted. The nurse identifies that the virus is:
1
Carried by a vector organism
2
Carried though the air in droplets after sneezing or coughing
3
Transmitted through person-to-person contact
4
Acquired through contact with contaminated objects
ANS: 2
Varicella zoster virus (chickenpox) is transmitted by droplets carried through the air after
sneezing or coughing. Varicella zoster virus (chickenpox) is not transmitted by a vector.
Person-to-person contact is not responsible for varicella zoster virus (chickenpox) transmission.
The transmission of varicella zoster virus (chickenpox) does not occur by contact with
contaminated objects.
DIF: A REF: 643 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
12. While working with clients in the postoperative period, the nurse is very alert to the results of
laboratory tests. Which one of the following results is indicative of an infectious process?
1
Iron 80 g/100 mL
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2
Neutrophils 65%
3
White blood cells (WBC) 18,000/mm3
Erythrocyte sedimentation rate (ESR) 15 mm/hr
4
ANS: 3
An elevated WBC count is indicative of an acute infection. The normal WBC count is 5000 to
10,000/mm3. The normal neutrophil count is 55%-70%. The client is within normal limits at
65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 80 g/100
mL. The normal erythrocyte sedimentation rate (ESR) is up to 15 mm/hr for men and up to 20
mm/hr for women. The client is within normal limits at 15 mm/hr.
DIF: A REF: 651 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
13. Which of the following is an example of a nursing intervention that is implemented to reduce
a reservoir of infection for a client?
1
Covering the mouth and nose when sneezing
2
Wearing disposable gloves
3
Isolating clients articles
4
Changing soiled dressings
ANS: 4
To control or eliminate reservoir sites for infection, the nurse eliminates or controls sources of
body fluids, drainage, or solutions that might harbor microorganisms. The nurse also carefully
discards articles that become contaminated with infectious material such as in changing soiled
dressings. Covering the mouth and nose when sneezing is an intervention to control a portal of
exit. Wearing disposable gloves helps protect the susceptible host. Isolating clients articles is an
intervention to control transmission.
DIF: A REF: 643 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
14. In preventing and controlling the transmission of infections, the single most important
technique is:
1
Hand hygiene
2
The use of disposable gloves
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3
The use of isolation precautions
4
Sterilization of equipment
ANS: 1
The most important and most basic technique in preventing and controlling transmission of
infections is hand hygiene. Use of disposable gloves may help reduce the transmission of
infections, but is not the single most important technique to prevent and control the transmission
of infections. The use of isolation precautions is not the single most important technique to
prevent and control the transmission of infections. Sterilization of equipment is not the single
most important technique to prevent and control the transmission of infections.
DIF: A REF: 655 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
15. A client with active tuberculosis is admitted to the medical center. The nurse recognizes that
admission of this client to the unit will require the implementation by the staff of:
1
2
Airborne precautions
Droplet precautions
3
Contact precautions
4
Reverse isolation
ANS: 1
A client with active tuberculosis requires airborne precautions. A client with active tuberculosis
does not require droplet precautions, as the droplet nuclei of tuberculosis are smaller than 5
micrometers. Contact precautions are not necessary for the client with active tuberculosis.
Reverse isolation is not required for the client with active tuberculosis
DIF: A REF: 645 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
16. The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which
action is consistent with sterile asepsis?
1
Clean forceps may be used to move items on the sterile field.
2
Sterile fields may be prepared well in advance of the
procedures.
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3
The first small amount of sterile solution should be poured and
discarded .
4
Wrapped sterile packages should be opened starting with the
flap closest to the nurse.
ANS: 3
Before pouring the solution into the container, the nurse pours a small amount (1 to 2 mL) into a
disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the
bottle. This action is consistent with sterile asepsis. Sterile forceps should be used to move items
on a sterile field when using sterile asepsis. Sterile fields should not be prepared well in advance
of a sterile procedure. A sterile object or field becomes contaminated by prolonged exposure to
air. Wrapped sterile packages should be opened starting with the flap farthest away from the
nurse (i.e., the top flap).
DIF: A REF: 674 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
17. Older adult clients may react differently to infectious processes and a nurse suspects that her
older adult client may be experiencing hypostatic pneumonia. The nurse must be alert to atypical
signs and symptoms, such as:
1
Hypotension
2
3
Confusion
Erythema
4
Chills
ANS: 2
An infection in older adults may not present with typical signs and symptoms. Atypical
symptoms such as confusion, incontinence, or agitation may be the only symptoms of an
infectious illness. An unexplained increased heart rate, confusion, or generalized fatigue may be
the only symptoms of pneumonia in the older adult. Hypotension is not one of the atypical
symptoms of an older adult experiencing infection. It may be a symptom of a systemic infection
related to an elevation in body temperature (regardless of age).
Erythema is a typical symptom of a localized infection.
Chills are a typical symptom of a systemic infection.
DIF: A REF: 649-650 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
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18. What is the correct order for a nursing assistant for putting on the protective equipment when
caring for a client in isolation?
1
Wash her hands, apply the mask and eyewear, put on the
gown, and then apply gloves
2
Apply the mask and eyewear, put on the gown, wash her
hands, and then apply gloves
3
Wash her hands, put on the gown, apply the mask and
eyewear, and then apply the gloves
4
Put on the gown, apply the mask and eyewear, wash her hands,
and then apply gloves
ANS: 1
The correct sequence for putting on protective equipment is to perform hand hygiene, apply the
mask and eyewear, apply gown, and then apply gloves. Apply the mask and eyewear, put on the
gown, wash her hands, and then apply gloves; wash her hands, put on the gown, apply the mask
and eyewear, and then apply the gloves; put on the gown, apply the mask and eyewear, wash her
hands, and then apply gloves are not the correct sequences for putting on protective equipment.
DIF: A REF: 664 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
19. A client has requires a mid-abdominal surgical incision which necessitates a sterile dressing.
An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to:
1
Put sterile gloves on before opening sterile packages
2
Discard packages that may have been in contact with the area
below waist level
3
Place the cap of the sterile solution well within the sterile field
Place sterile items on the very edge of the sterile drape
4
ANS: 2
A sterile object held below a persons waist is considered contaminated. To maintain sterile
asepsis, packages that may have been in contact with the area below waist level should be
discarded. Sterile gloves are not put on before opening sterile packages as the outside of the
packages is not sterile. The nurse uses hand hygiene and opens sterile packages, being careful to
keep the inner contents sterile. After a cap or lid is removed, it is held in the hand or placed
sterile side (inside) up on a clean surface. A bottle cap or lid should never rest on a sterile
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surface, even though the inside of the cap is sterile. The edges of a sterile field are considered to
be contaminated. Sterile items should be placed in the middle of the sterile field to maintain
sterile asepsis.
DIF: A REF: 669 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
20. The nurse is preparing to assist with a sterile procedure in the surgical suite. An appropriate
technique that the nurse includes in the surgical scrub is to:
1
Keep the hands below the elbows throughout the scrub
2
3
Use a brush on the palms and dorsal surface of the hands
Maintain the scrub for at least 2 to 5 minutes
4
Wash well around all jewelry
ANS: 3
A surgical scrub should be maintained for at least 2 to 5 minutes. To avoid contamination during
a surgical hand scrub, the nurse holds the hands above the elbows. Several studies suggest that
neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially
when an alcohol-based product is used. For maximum elimination of bacteria, all jewelry should
be removed.
DIF: A REF: 675 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
21. An appropriate isolation procedure for the nurse to implement when working with a client
who is found to have methicillin-resistant Staphylococcus aureus (MRSA) is to:
1
Leave all linen in the clients room
2
Place specimen containers in plastic bags for transport
3
Wipe the stethoscope off before removing it from the room
4
Remove the mask and goggles first when leaving the clients
room
ANS: 2
Specimen containers should be placed in plastic bags for transport with a label on the outside of
the bag. Linen should be placed in an impervious linen bag and may be removed from the clients
room. Bags should be tied securely at the top with a knot. For the person infected with MRSA,
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equipment remains in the room. After discharge or with the discontinuation of isolation, client
care equipment is properly cleaned and reprocessed, and single-use items are discarded.
Gloves should be removed first when leaving the clients room.
DIF: A REF: 667 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
22. A client is found to have a bacterial infection of Escherichia coli. The nurse, recognizing the
effects of this bacterium, anticipates that the client will demonstrate:
1
Diarrhea
2
3
Coughing
Cold sores around the mouth
4
Discharge from the eyes
ANS: 1
Escherichia coli causes gastroenteritis and urinary tract infections. The client with E. coli
infection is likely to demonstrate diarrhea. E. coli is found in the colon, not the respiratory tract.
Cold sores are seen with herpes simplex virus (type 1), not with E. coli. Discharge from the eyes
is not seen with E. coli infection. It may be seen with Neisseria gonorrhoeae.
DIF: A REF: 643 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
23. Which of the following clients is at greatest risk for acquiring an infection?
1
A 56-year-old with a urinary catheter 2 days after
prostatectomy
2
A 27-year-old diagnosed with human immunodeficiency virus
(HIV)
3
A 43-year-old who is 3 days post appendectomy and is
currently afebrile
A 16-year-old with a compound fractured femur as a result of
a bike accident
4
ANS: 4
Clients are at risk for acquiring infections because of lower resistance to infectious
microorganisms, increased exposure to numbers and types of disease-causing microorganisms,
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and invasive procedures. The exposure to earth-bound microorganisms makes the compound
fracture client at the greatest risk since that risk is uncontrollable.
DIF: C REF: 644 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
24. A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus
(MRSA). Which of the following statements reflects the best understanding of the clients
condition?
1
This client has the bacteria present but it hasnt become
infected.
2
This makes the clients MRSA very infectious and so a danger
to others.
Just be sure to follow standard precautions and there wont be a
problem.
3
4
The client needs to be watched closely for a conversion to
active MRSA.
ANS: 1
If a microorganism is present or invades a host, grows, and/or multiplies but does not cause
infection, this is referred to as colonization.
DIF: C REF: 643 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
25. The greatest drawback to the routine use of antibacterial hand soaps and gels is that they:
1
Are expensive
2
Irritate the skin
3
Kill resident flora
4
Encourage resistant bacteria
ANS: 2
Antibacterial products kill resident flora and that can lead to the development of infection. The
remaining options may be true but they are not the primary negative outcome of the regular use
of antibacterial hand cleansing products.
DIF: C REF: 646 OBJ: Analysis
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
26. The nurse knows that Staphylococcus aureus found normally on the skin of a client who has
had surgery poses a particular risk for that client developing:
1
2
3
4
A cold sore
Gastroenteritis
A wound infection
A urinary tract infection
ANS: 3
Staphylococcus aureus found normally on/in skin, hair, anterior nares, and the mouth can result
in wound infections, pneumonia, food poisoning, and cellulitis. Streptococcus (-hemolytic group
B) organisms may result in urinary tract infections or gastroenteritis while herpes simplex is viral
in nature.
DIF: A REF: 669 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
27. What is the most appropriate answer to the clients question, Whats the difference between
antibacterial and antimicrobial hand soaps?
1
There is no real difference; use the less expensive.
2
Antibacterial soaps are more effective at preventing infections.
3
Antimicrobial soap is better since it wont kill the good bacteria
on the skin.
4
Any soap will do; its the technique for proper hand washing
that is the key.
ANS: 3
The use of antimicrobial hand hygiene products is recommended because they remove transient
organisms but leave resident flora intact. There is a difference in the products and it is true that
the effectiveness of hand hygiene is dependent on proper technique, but the clients question is
best answered by the information provided in option 3.
DIF: C REF: 646 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
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28. A presurgical client asks the nurse why it seems so easy to get an infection in the wound after
surgery. The nurses most appropriate response to this question is:
1
The contaminated dressing acts as a breeding ground for
microorganisms that then infect the wound.
2
The bodys immune system is weakened by the surgery and
cant fight off the infection as effectively.
3
While infections occur, there are many very effective
antibiotics available to help minimize the risk of that
happening.
4
The surgical wound provides the microorganisms on the
surrounding skin a path to enter deep into the bodys tissues.
ANS: 4
Resident skin microorganisms are not virulent. However, they can cause serious infection when
surgery or other invasive procedures allow them to enter deep tissues. While the other options
are not incorrect, they do not answer the clients question as effectively.
DIF: C REF: 643 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
29. The nurse obtains a new, dry nebulizer when preparing to give an elderly asthmatic client a
nebulizer treatment because the risk of infection is increased because:
1
The clients age increases the risk factor for potential infection
2
The clients immune system is compromised as a result of
asthma
There is a potential presence of Pseudomonas organisms in the
reservoir
3
4
There is a chance for microorganisms to enter the body via the
respiratory system
ANS: 3
Pseudomonas organisms survive and multiply in nebulizer reservoirs used in the care of clients
with respiratory problems. While the remaining options are correct, they are not the primary
reason for getting a new, dry nebulizer.
DIF: C REF: 643 OBJ: Analysis
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TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
30. A client is told that he is a carrier of the hepatitis B virus. When asked to explain this
situation in more detail, the nurses best response is:
1
2
You need to be careful not to pass the virus to other people.
You arent sick, but you do have the virus within your body.
3
Be tested often so as to monitor whether the virus becomes
active.
4
While you show no signs of the illness, you can pass the virus
to others.
ANS: 4
Carriers are persons who show no symptoms of illness but who have pathogens on or in their
bodies that are transferred to others. While the other options are not incorrect, they do not
address the clients questions as directly as does the answer.
DIF: C REF: 643 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
31. The nurse can best minimize the risk for infection when initiating an intravenous site by:
1
Proper vein site selection
2
Effective topical skin preparation
3
Appropriate site dressing
4
Gloving for the procedure
ANS: 2
When a needle pierces a clients skin regardless of the location, organisms enter the body if
proper skin prepping was not performed. The remaining options have an effect on infection
control but not to the degree that skin prepping does.
DIF: C REF: 644-645 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
32. A client enters a neighborhood walk-in clinic reporting the symptoms of a head cold. When
the health care provider does not prescribe an antibiotic, the client asks the nurse to explain why
not. The nurses most appropriate response is:
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1
Antibiotics arent usually necessary for colds, and they are
really very expensive if you dont have insurance.
2
You know what they say; a cold will go away with medication
in 2 weeks; without medication in 14 days.
Your health care provider believes in treating the symptoms
since there are so many different strains of the common cold.
3
4
Common colds dont usually require an antibiotic, and taking
one results in making it harder to treat infections when they do
occur.
ANS: 4
Organisms with resistance to key antibiotics are becoming more common in acute care settings.
This is associated with the frequent and sometimes inappropriate use of antibiotics. While the
remaining options are not incorrect, they may seem insensitive or incomplete in answering the
clients question.
DIF: C REF: 646 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
33. The nurse is caring for a postoperative client with a localized sinus infection. The most
appropriate means by which the nurse can minimize the risk of this client developing a systemic
infection is to:
1
Adhere strictly to standard precaution techniques
2
Dispense prescribed anti-infective medication as ordered
3
Monitor the client regularly for exacerbation of the sinus
infection
Review lab work daily to determine the presence of increased
white cell count
4
ANS: 1
If an infection is localized (e.g., a wound infection), use of standard precautions and personal
protective equipment (PPE) will block the spread of infection to other sites, thus preventing an
infection that affects the entire body instead of just a single organ or part (systemic). While the
other options are not incorrect, they are not as directed at minimizing the risk of infection as is
the answer.
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DIF: C REF: 645 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
34. The nurse and a client are discussing the clients tendency to develop numerous colds during
the winter months. The clients health history reveals that he is a 1 pack a day smoker. Which of
the following nursing statements is most appropriate regarding the possible relationship between
the clients cigarette smoking and the frequency of winter colds?
1
2
3
4
Smoking decreases your bodys immune system, and so you
cant fight off the colds as effectively.
If you stopped smoking you would have fewer colds and just
generally feel better all year around.
The nicotine in the cigarettes has an effect on your blood
vessels, decreasing the circulation of antibodies that would
attack the cold viruses.
Smoking damages the little hairs in your nose and airways so
they cant trap the airborne cold viruses and keep them from
entering your body.
ANS: 4
Cilia lining the upper airway trap inhaled microbes and sweep them outward in mucus to be
expectorated or swallowed. Smoking appears to paralyze these tiny hairs, and so they are not
able to function effectively. Consequently, microbes including the cold viruses are able to enter
into the respiratory tract. The other options present unproven theories, generalized statements, or
less thorough explanations of the relationship between smoking and respiratory illnesses.
DIF: C REF: 647 OBJ: Analysis
TOP: Nursing Process: Implantation
MSC: NCLEX test plan designation: Safety and Infection Control
35. Which of the following clients is at greatest risk for acquiring a health careassociated
(nosocomial) infection?
1
A 32-year-old hospitalized for 2 days for migraine headaches
2
A client with type 1 diabetes who has been experiencing
hypoglycemia
3
A trauma victim taken directly from the ED to surgery and
then to the postsurgical unit
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4
A pregnant 24-year-old diagnosed with both sinusitis and otitis
media and prescribed an oral antibiotic
ANS: 3
The number of health care employees having direct contact with a client, the type and number of
invasive procedures, the therapy received, and the length of hospitalization influence the risk of
infection. The other options do not have the potential for infection as does the client who has
been treated in various locations within the health care facility.
DIF: C REF: 648 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
36. A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse
recognizes that the clients nutritional history is of primary importance since:
1
Nutrition is vital to the clients overall health status
2
The clients food intake will likely be decreased as a result of
the illness
3
Wound healing and infection prevention are negatively
impacted by poor nutrition
The clients habits regarding food intake are directly related to
this hospitalization
4
ANS: 3
A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility
increases a clients susceptibility to infection and delays wound healing. While the other options
are not incorrect, they are not as directly related to the cause of the clients poorly healing,
infected wounds.
DIF: C REF: 650 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
37. A client admitted for an abdominal hysterectomy reports that she has been under a lot of
stress since the death of her mother and wonders how that will affect her surgery and recovery.
Which of the following nursing statements reflects the most therapeutic response to the clients
question?
1
Being under stress isnt going to help your recovery; you need
to relax and focus on yourself and getting well.
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2
Your mothers death must be very stressful for you but she
would want you to concentrate on getting healthy.
3
Stress does have a negative effect on the bodys ability to heal;
is there anything I can do to help you minimize the stress you
feel?
Your health care provider can prescribe you some medication
to help you cope with the stress; would you like me to mention
it?
4
ANS: 3
Increased stress elevates cortisone levels, causing decreased resistance to infection and the
ability to heal. While the other options may not be incorrect, they do not have the degree of
therapeutic value as does the answer since it explains the effects of stress and also offers support.
DIF: C REF: 650 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
38. A client admitted for an abdominal hysterectomy reports that she has been under a lot of
stress since the death of her mother and wonders how that will affect her surgery and recovery.
Which of the following nursing interventions reflects the most therapeutic understanding of the
relationship stress has on the body and its ability to recover from surgery?
1
Suggest a demonstration of relaxation techniques
2
Arrange for the hospital chaplain to visit the client
3
Offer to call and get an order for an antianxiety medication
4
Share a personal antidote concerning a similarly stressful
situation
ANS: 1
Increased stress elevates cortisone levels, causing decreased resistance to infection and the
ability to heal. Reinforcement of relaxation techniques would be the most therapeutic response
because it would provide the client with a long-term, self-initiated coping mechanism. It would
not be appropriate to arrange for a clergy visit without first discussing it with the client. Sharing
a similar personal situation would have little therapeutic value, and such a personal nurseoriented conversation should be avoided. While facilitating antianxiety medication may not be
incorrect, it is premature at this time.
DIF: C REF: 650 OBJ: Analysis
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TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Safety and Infection Control
39. The nurse is providing care for a client who postoperatively has developed an infected
incisional wound and is depressed and anorexic. Which of the following nursing interventions
has priority?
1
Sterile wound care
2
3
Frequent small meals
Administration of antidepressant medication
4
Educating the client regarding wound care at home
ANS: 1
The priority of administering therapies to promote wound healing overrides the goal of educating
the client to assume self-care therapies at home. While the other options reflect appropriate
interventions for this client, none has priority over wound care.
DIF: C REF: 652 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
40. The nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot
wounds, on how to minimize the risk for infection related to poor wound healing by not being a
susceptible host. The most appropriate suggestion would be to:
1
Inspect feet and legs daily for skin breakdown
2
See a podiatrist regularly for appropriate foot care
3
Keep blood sugar levels within normal range to maximize the
ability to heal
4
Eat well-balanced meals in order to provide the nutrients
necessary for healing
ANS: 4
Good infection control begins with prevention. Review with clients and their families preventive
measures to strengthen their defenses. In the case of a diabetic client, keeping blood sugar levels
within normal limits maximizes the clients ability to both heal and fight infection. While the
other options are not incorrect, they are more directed towards healing than prevention.
DIF: C REF: 652 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Safety and Infection Control
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MULTIPLE RESPONSE
1. For infectious organisms to grow and multiply enough to cause illness, they need an
environment that has appropriate amounts of: (Select all that apply.)
1
2
Food
Space
3
Water
4
Oxygen
5
Warmth
6
Darkness
ANS: 1, 3, 4, 5, 6
To thrive, organisms require a proper environment, including appropriate food, oxygen, water,
temperature, pH, and light. Space does not generally affect microorganism growth.
DIF: C REF: 643-644 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Safety and Infection Control
2. Which of the following are considered portals of exit in the chain of infection? (Select all that
apply.)
1
A bleeding cut
2
A hardy sneeze
3
A kiss on the lips
4
5
A urinary catheter
A scraped knuckle
6
A friendly handshake
ANS: 1, 2, 3, 4, 5
After microorganisms find a site to grow and multiply, they must find a portal of exit if they are
to enter another host and cause disease. Portals of exit include sites such as blood, skin/mucous
membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental
(mother to fetus). Unless the skin of the hands was broken (not intact), this contact would not be
considered a portal of exit.
DIF: C REF: 644 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Safety and Infection Control
3. Which of the following assessment data indicate the presence of a local inflammatory process?
(Select all that apply.)
1
2
Client reports being cold
Left elbow warm to the touch
3
Elevated white blood cell (WBC) count
4
Pitting edema of +2 around the right ankle
5
Client reports knee pain of 5 on a scale of 1 to10
6
Client observed grimacing while raising shoulder to brush hair
ANS: 2, 4, 5, 6
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of
function in the affected body part. When inflammation becomes systemic, other signs and
symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph
node enlargement, or organ failure.
Chapter 29. Vital Signs
MULTIPLE CHOICE
1. A client has developed pneumonia, and his temperature has increased to 37.7 C. The client is
shivering and feels uncomfortable. The nurse should:
1
Apply hot packs to the axilla and groin
2
Wrap the clients four extremities
3
Restrict oral fluid consumption
4
Apply a hypothermia mattress
ANS: 3
Wrapping the clients extremities has been recommended to reduce the incidence and intensity of
shivering. Hot packs should not be applied to the clients axilla and groin. Fluids should not be
restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may
be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used,
as further stimulation of shivering should be avoided.
DIF: A REF: 506 OBJ: Comprehension
TOP: Nursing Process: Application
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
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2. The client comes to the emergency department after having been in the sun for an extended
period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is
suspected and the nurse observes for:
1
Diaphoresis
2
3
Confusion
Temperature of 36 C
4
Decreased heart rate
ANS: 2
Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual
disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin, not
diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and
hypothalamic malfunction. A normal temperature is 36 to 38 C. With heatstroke the clients body
temperature may reach as high as 45C. The heart rate is increased with heatstroke, not decreased.
DIF: A REF: 507 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
3. A construction worker is seen in the emergency department with low blood pressure, normal
pulse rate, diaphoresis, and weakness. These are clinical signs of:
1
Heatstroke
2
Heat cramp
3
Hypothermia
4
Heat exhaustion
ANS: 4
The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the
client were experiencing heatstroke, the client would have an increased pulse rate and would not
be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent
with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of
memory, or cyanosis.
DIF: A REF: 508 OBJ: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An
appropriate action would be to:
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1
Take the rectal temperature
2
3
Take the oral temperature as planned
Have the child rinse out the mouth with warm water
4
Wait 20 minutes before assessing the oral temperature
ANS: 4
The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should
wait, rather than measuring the childs temperature rectally, as this is not an emergency situation.
Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth
with warm water may also provide an inaccurate reading of the childs actual body temperature.
The nurse should wait 20 minutes and measure the childs oral temperature.
DIF: A REF: 510 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
5. The client is seen in the emergency center for heat exhaustion as a result of exposure. The
nurse anticipates that treatment will include:
1
Replacement of fluid and electrolytes
2
Initiation of oral antibiotic therapy
3
Application of hypothermia wraps
4
Alcohol sponge baths
ANS: 1
The treatment of heat exhaustion includes transporting the client to a cooler environment and
restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps
are not used to treat heat exhaustion. Alcohol baths are not recommended.
DIF: A REF: 508 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
6. The appropriate site for taking the pulse of a 2-year-old is:
1
Radial
2
Apical
3
Femoral
4
Pedal
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ANS: 2
The brachial or apical pulse is the best site for assessing an infants or young childs pulse because
other peripheral pulses are deep and difficult to palpate accurately. The radial pulse is not the
best site for assessing a 2-year-olds pulse. The femoral pulse is not the best site for assessing a 2year-olds pulse. The pedal pulse is not the best site for assessing a 2-year-olds pulse.
DIF: A REF: 521 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
7. The client appears to be breathing faster than before. The nurse should:
1
Ask the client if he has felt stressful
2
3
Have the client lay down on the bed
Count the clients rate of respirations
4
Palpate the clients own radial pulse
ANS: 3
The first action the nurse should take is to assess the clients respiratory rate. The nurse can then
determine if it is within normal limits and will be able to compare it to the previous measurement
to determine if the client is breathing faster than before. Stress may increase an individuals
respiratory rate. The nurse should first make the objective measurement of the clients rate.
Having the client lay down may decrease a clients respiratory rate, but the nurse should first
assess the client before implementing any nursing measures. The nurse should count the
respiratory rate. Based on these findings the nurse may or may not need to take the clients pulse.
Assessing the pulse will not verify if the client is breathing faster.
DIF: A REF: 529 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
8. A nurse administers pain medication for a client complaining of pain. The nurse first assesses
vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per
minute; respirations, 26 breaths per minute. The nurses most appropriate action is to:
1
Give the medication
2
Ask if the client is anxious
3
Check the clients dressing for bleeding
4
Recheck the clients vital signs in 30 minutes
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ANS: 1
The clients vital signs are consistent with the client being in pain. It would be safe and
appropriate for the nurse to give the pain medication. Asking if the client is anxious is not the
most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood
pressure, increased pulse). The most appropriate action is for the nurse to administer pain
medication. Rechecking would not be the most appropriate action. The nurse should medicate the
client for pain.
DIF: C REF: 529 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood
pressure in the leg. The nurse expects the diastolic pressure to be:
1
10 to 40 mm Hg higher than in the brachial artery
2
3
20 to 30 mm Hg lower than in the brachial artery
40 to 50 mm Hg higher than in the brachial artery
4
Essentially the same as that in the brachial artery
ANS: 4
When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40
mm Hg than that in the brachial artery, but the diastolic pressure is the same. The systolic
pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the brachial artery.
Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements.
DIF: A REF: 546 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
10. An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following
blood pressure, pulse, and respiration measurements, respectively, is considered to be within the
expected limits for a client of this age?
1
BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min
2
BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min
3
BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min
4
BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min
ANS: 1
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These measurements are within the expected limits for an older client. An adults average blood
pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure
should not exceed 140/90 mm Hg. The range for an adults pulse is 60-100 beats/min. The
expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30
breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm
Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this
age.
DIF: A REF: 527 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values for
a client of this age are:
1
P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg
2
3
P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg
P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg
4
P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg
ANS: 3
These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is
75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure
range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or
taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm
Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R =
40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm
Hg are not expected values of a 10-year-old client.
DIF: A REF: 537 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
12. The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse
will report the following finding that is out of the expected range for a client of this age:
1
T = 37.4 C
2
P = 110 beats/min
3
R = 20 breaths/min
4
BP = 120/76 mm Hg
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ANS: 2
The expected pulse range for an adult is 60-100 beats/min. This clients pulse is elevated at 110
beats/min. This clients temperature is within the normal range of 36 to 38 C for an adult. This
clients respiratory rate is within the normal range of 12-20 breaths/min for an adult. This clients
blood pressure reading is within the normal range of 120/80 mm Hg for an adult.
DIF: A REF: 527 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
13. When using a glass thermometer at home to accurately assess axillary temperature, the nurse
should tell the parent of a 1 1/2-year-old child to:
1
2
Hold the thermometer at the bulb end
Cleanse the thermometer in hot water
3
Assess the thermometer for 5 minutes
4
Allow the child to hold the thermometer
ANS: 3
When assessing a clients axillary temperature with a glass thermometer, the thermometer should
be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the
bulb. The thermometer should be covered with a plastic sheath when in use and after used the
plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot
water, as it could cause the thermometer to break. The parent should hold the thermometer, not
the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill.
DIF: A REF: 630 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
14. The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54
beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary
output. The nurse should:
1
Retake the vital signs in 30 minutes
2
Continue with care as planned
3
Administer a stimulant
4
Notify the physician
ANS: 4
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The nurse should notify the physician, as these are abnormal findings. The clients respirations
are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The clients pulse
rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be
=120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not
normal, and should be reported to the physician. The nurse should not wait another 30 minutes to
retake vital signs. The present readings warrant notifying the physician. These are abnormal
findings. The nurse should not continue with care as planned. The nurse should first notify the
physician. Administering a stimulant would require a physicians order and may not be what the
client requires. For example, the client may need a narcotic antagonist rather than a stimulant.
DIF: B REF: 504 OBJ: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the
client says, I feel dizzy. The nurse should:
1
Go for help
2
3
Take the clients blood pressure
Assist the client into a sitting position
4
Tell the client to take several deep breaths
ANS: 3
The nurses primary concern should be the patients safety and preventing an accidental fall. If the
client just got up from bed and is complaining of dizziness, the client may be experiencing
orthostatic hypotension. The nurse should first assist the client to sit down before performing any
other assessment. The nurse should not leave the client and go for help. The nurse should assist
the client to a sitting position. If help is required, the nurse can then put on the clients call light.
The nurse may take the clients blood pressure after assisting the client to a sitting position to
prevent the client from falling. The nurse should first assist the client to sit down to prevent the
client from falling accidentally. The nurse may then assess the client. If the nurse finds during the
assessment that the clients pulse oximetry is low, the nurse may instruct the client to take deep
breaths.
DIF: B REF: 538 OBJ: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse
assistant, if the assistant:
1
Wraps the cuff too loosely around the arm
2
Deflates the blood pressure cuff too quickly
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3
Repeats the blood pressure assessment too soon
4
Presses the stethoscope too firmly in the antecubital fossa
ANS: 1
If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure
measurement may be a false high reading. A false low systolic and false high diastolic blood
pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may
be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading
may be obtained if the stethoscope is applied too firmly against the antecubital fossa.
DIF: A REF: 541 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
17. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that
treatment will include:
1
2
An alcohol and water bath
Ice packs to the axillae and groin
3
Tepid, plain water sponge down
4
Application of a cooling blanket
ANS: 4
Blankets cooled by circulating water delivered by motorized units increase conductive heat loss.
Cooling blankets are used to reduce a fever. Bathing with an alcohol/water solution is not
recommended because it may lead to shivering. Shivering is counterproductive and can increase
energy expenditure up to 400%. Application of ice packs to the axillae and groin is no longer
recommended because they may induce shivering (which is counterproductive and increases the
clients energy expenditure), and because they have no advantage over antipyretic medications.
Tepid sponge baths are no longer recommended because it may lead to shivering and is no more
advantageous than administering antipyretics.
DIF: A REF: 520 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
18. The nurse is alert to which of the following factors that lowers the blood pressure?
1
Stress-producing anxiety
2
Heavy alcohol consumption
3
Cigarette, cigar, or pipe smoking
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4
Prescribed diuretic administration
ANS: 4
Diuretics lower blood pressure by reducing reabsorption of sodium and water by the kidneys,
thus lowering circulating fluid volume.
The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure.
Heavy alcohol consumption has been linked to hypertension.
Cigarette smoking has been linked to hypertension.
DIF: A REF: 537 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
19. While the nurse is taking the clients blood pressure, the client asks if the reading is high. In
accordance with the newest guidelines, the nurse informs the client that a blood pressure
measurement that is consistent with hypertension is:
1
120/70 mm Hg
2
3
130/84 mm Hg
120/78 mm Hg
4
118/80 mm Hg
ANS: 2
The diagnosis of prehypertension in adults is made when an average of two or more diastolic
readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of
multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm
Hg. Hypertension is noted with diastolic readings greater than 90 mm Hg and systolic readings
greater than 140 mm Hg. According to the newest guidelines, this clients blood pressure reading
(130/84 mm Hg) would fall into the pre-hypertension category.
Normal is 120/80 mm Hg; this is a normal blood pressure reading.
Normal is 120/80 mm Hg; this is a normal blood pressure reading.
Normal is 120/80 mm Hg; this is a normal blood pressure reading.
DIF: A REF: 537 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
20. After measuring the clients vital signs, the nurse obtains the following results: blood pressure
= 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5 C. The
nurse should:
1
Retake the blood pressure
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2
Retake the clients temperature
3
Report all of the findings immediately
Record the findings as within normal limits
4
ANS: 1
The normal blood pressure reading is 120/80 mm Hg. This clients blood pressure is significantly
higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood
pressure measurement does not qualify as a diagnosis of hypertension; it would have to be
elevated on at least two separate occasions). The nurse should retake the blood pressure. The
clients temperature is within normal limits for a rectal temperature. The average rectal
temperature is 37.5 C. The nurse should repeat the blood pressure measurement to confirm the
reading before reporting the findings. The blood pressure reading is not within normal limits.
The pulse rate, respiratory rate, and temperature are within normal limits.
DIF: B REF: 537 OBJ: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
21. The client is identified by the nurse as having a remittent fever. The student asks what that
means and the nurse explains that a remittent fever is:
1
2
3
4
A constant body temperature above 100.4 F with little
fluctuation
Spikes that are interspersed with normal temperatures within
24 hours
Spikes and falls in temperature, but temperature does not
return to the normal limits
Periods of febrile episodes interspersed with normal body
temperatures
ANS: 3
A remittent fever spikes and falls without a return to normal temperature levels.
A sustained fever is a constant body temperature continuously above 38 C (100.4 F) that
demonstrates little fluctuation. An intermittent fever has fever spikes interspersed with usual
temperature levels. Temperature returns to acceptable levels at least once in 24 hours.
A relapsing fever has periods of febrile episodes interspersed with acceptable temperature values.
DIF: A REF: 508 OBJ: Comprehension
TOP: Nursing Process: Planning
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
22. The nurse is working in the newborn nursery. In planning for temperature measurement, the
nurse will obtain the reading on the infants by using the:
1
2
Oral site
Rectal site
3
Axillary site
4
Tympanic site
ANS: 3
The axillary site can be used with newborns and uncooperative clients. The oral site should not
be used with infants. The rectal site should not be used for routine vital signs in newborns. The
tympanic site is questioned as being accurate in newborns.
DIF: A REF: 515 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
23. A client is being monitored with pulse oximetry. On review of the following factors, the
nurse suspects that the values will be influenced by:
1
The placement of the sensor on the extremity
2
A diagnosis of peripheral vascular disease
3
A reduced amount of artificial light in the room
4
The increased ambient temperature of the clients room
ANS: 2
Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry
reading. The sensor should be placed on an extremity site (such as an earlobe or digit) with
adequate local circulation and the site should be free of moisture. Reduced light in the room will
not affect the oximetry reading. Outside light sources can interfere with the oximeters ability to
process reflected light. An increased temperature of the room will not affect the oximetry
reading. If the room was very cold, the clients peripheral blood flow may decrease, affecting the
oximetry reading.
DIF: A REF: 533 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
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24. An individual contacts the emergency department of the local hospital to ask what to do for a
skiing partner who appears to be suffering from hypothermia. The victim is alert and able to
respond to questions. The nurse instructs the individual who has called to have the victim:
1
Take sips of brandy
2
3
Drink a bowl of warm soup
Drink a cup of very hot coffee
4
Run the affected extremities under hot water
ANS: 2
A conscious client benefits from drinking hot liquids such as soup. Alcohol should be avoided.
Caffeinated fluids should be avoided. Extremities should be warmed gradually. Tissue damage
could occur if placed under hot water. The entire body should be warmed, such as by putting
heating pads next to the head and neck that lose heat the quickest.
DIF: B REF: 508 OBJ: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
25. A spouse assists the nurse evaluating the measurement of the clients blood pressure. The
nurse feels additional teaching is required if the spouse is observed:
1
Deflating the cuff at 2 mm Hg/second
2
Having the client sit down for the measurement
3
Using the same time each day for the measurement
Taking the blood pressure after the client comes back from a
walk
4
ANS: 4
The clients blood pressure should not be measured after the client has exercised, smoked, or
ingested caffeine. The client should wait 30 minutes before assessment of the blood pressure.
The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be
sitting in a chair. The blood pressure should be assessed at the same time each day.
DIF: A REF: 537 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
26. The nurse measures the blood pressure in the leg due to the fact that the client has bilateral
casts on the upper extremities. The nurse palpates the pulse before the measurement at the:
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1
Popliteal fossa behind the knee
2
Inner side of the ankle below the medial malleolus
Top of the foot between the extension tendons of the great toe
3
4
Inguinal ligament midway between the symphysis pubis and
the anterior superior iliac spine
ANS: 1
The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation
when taking the blood pressure in the leg. The inner side of the ankle, top of the foot, and
inguinal ligament are not the correct sites for assessment.
DIF: A REF: 546 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
27. The clients apical pulse will be taken by a student. According to the nurse the stethoscope
should be placed along the left clavicular line at the:
1
Second to third intercostal space
2
Third to fourth intercostal space
3
Fourth to fifth intercostal space
Fifth to sixth intercostal space
4
ANS: 3
An apical pulse should be assessed at the clients PMI. The PMI is located at the fourth to fifth
intercostal space at the left midclavicular line. Second to third intercostals space is not the correct
placement for auscultating a clients apical pulse. The PMI is higher and more medial in children
under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child.
Fifth to sixth is not the correct placement for auscultating a clients apical pulse.
DIF: A REF: 525 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
28. The nurse enters the room to measure the clients pulse rate. The nurse recognizes that the
clients rate may be increased as a result of:
1
A febrile condition
2
Administration of digoxin
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3
The clients athletic conditioning
4
Unrelieved severe postoperative pain
ANS: 1
Fever and heat may increase a clients pulse rate. Digoxin is a negative chronotropic drug; it will
decrease the clients pulse rate. A conditioned athlete who participates in long-term exercise will
have a lower heart rate at rest. Unrelieved severe pain increases parasympathetic stimulation;
decreasing the heart rate.
DIF: A REF: 526 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
29. Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with
periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse
reports this respiratory assessment as:
1
Biots respirations
2
3
Kussmauls respirations
Hyperpneic respirations
4
Cheyne-Stokes respirations
ANS: 4
Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating
periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths
that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows
and becomes shallow, and the pattern climaxes in apnea before respiration resumes. Biots
respirations are abnormally shallow for two to three breaths followed by an irregular period of
apnea. Kussmauls respirations are abnormally deep, regular, and increased in rate. Hyperpneic
respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they
normally occur during exercise.
DIF: A REF: 532 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
30. The nurse has assigned the vital signs of the elderly clients residing in the facilitys assisted
living unit to the nursing assistant. Which of the following statements made by the ancillary
personnel requires immediate correction by the RN?
1
As you age your blood pressure may go up, but it doesnt have
to if your vessels are healthy.
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2
If anyones oral temperature is over 100 F, Ill let you know
right away since that means they have a fever.
3
I always wait a good 30 minutes after returning the older client
back to bed before I count their pulse.
I watch the elderly clients stomach and count the number of
times it rises when I am counting respirations.
4
ANS: 2
RAT: The temperature of older adults is at the lower end of the normal temperature range, 36 to
36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore temperatures
considered within normal range sometimes reflect a fever in an older adult. The normal range for
blood pressure is the same for older adults and younger people, while older adults depend more
on accessory abdominal muscles during respiration than on weaker thoracic muscles, so
observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse
rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would
not be inappropriate.
DIF: C REF: 506 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
31. The nurse appropriately instructs trained ancillary personnel to avoid using an electronic
blood pressure cuff to take the blood pressure of which of the following clients?
1
2
3
4
A 25-year-old who was admitted for depression and anxiety
A 69-year-old diagnosed with Parkinsons disease 5 years ago
A 57-year-old prescribed antihypertensive medication 6 weeks
ago
An 80-year-old client whose systolic BP is routinely assessed
in the low 90s
ANS: 2
Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction
(e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to
cooperate are reasons to avoid using an electronic BP monitor. The clients Parkinsons disease
causes tremors, so a manual cuff should be used when assessing this clients BP.
DIF: C REF: 546 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
32. The nurse appropriately instructs trained ancillary personnel to use an electronic blood
pressure cuff to take the blood pressure of which of the following clients?
1
2
A 25-year-old who was admitted for alcohol detoxification
A 69-year-old diagnosed with Parkinsons disease 5 years ago
3
A 57-year-old placed on antihypertensive medication therapy 2
months ago
4
An 80-year-old client whose systolic BP is routinely assessed
in the high 80s
ANS: 1
Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction
(e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and inability to cooperate
are reasons to avoid using an electronic BP monitor. The answer reflects the client whose BP is
most stable and best assessable via electronic BP monitor.
DIF: A REF: 546 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units
clients. Which of the following statements made by the assistive personnel shows the best
understanding regarding appropriate communication of the BP readings?
1
Ill ask the clients what their blood pressure usually runs.
2
Ill give you a list of all the readings I get before I chart them.
3
Ill chart the results and let you know whose pressure is high.
4
Ill recheck any pressure that seems higher than their normal.
ANS: 2
The nurse is responsible for assessing the impact of changes in blood pressure and so must be
aware of each clients reading, not merely the values that the assistive personnel believes to be
high. Asking the client to share what their BP is routinely and/or retaking a questionable reading
is appropriate but not directly related to effective communication of the findings.
DIF: C REF: 539 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
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34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units
clients. Which of the following statements made by the assistive personnel shows the greatest
need for additional instruction regarding appropriate communication of the BP readings?
1
Ill give you a list of all the readings after I chart them.
2
May I ask the clients what their blood pressure usually runs?
3
Ill chart the results and let you know whose pressure is
running high.
4
Do you want me to take the readings before they get their
medications?
ANS: 3
The nurse is responsible for assessing the impact of changes in blood pressure and so must be
promptly made aware of each clients reading, not merely the values that the assistive personnel
believes to be high. The questions asked may reflect a need for further instruction, but the issues
are not as critical as the need to report all readings for the nurse to evaluate.
DIF: C REF: 539 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
35. The nurse has assessed a clients blood pressure (BP) using the left thigh because of bilateral
upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The nurse expects the
present BP reading to be:
1
10-40 mm Hg higher systolic pressure than before the casting
2
5-10 mm Hg higher reading in both systolic and diastolic
pressures
Representative of the original baseline established before the
casting
3
4
A slight decrease in the diastolic pressure when compared to
precasting pressure
ANS: 1
Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but
the diastolic pressure is the same.
DIF: A REF: 546 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
36. The nurse is using a manual cuff to assess the blood pressure of a client experiencing
hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should
use which of the following as a guide for inflating the cuff appropriately?
1
Review the clients chart for his last blood pressure reading.
2
Ask the client what his typical blood pressure reading is when
taken manually.
3
Inflate 30 mm Hg higher than where the radial pulse can no
longer be palpated.
4
Take the clients blood pressure both sitting and standing and
use the higher reading.
ANS: 3
The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure
before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate
the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse
was palpated. Taking the blood pressure in various positions will not help eliminate the possible
loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or
reviewing the chart may provide information concerning the clients pressure, these options are
not the recommended method for minimizing the effect of the auditory gap on the assessment
process.
DIF: C REF: 541 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
37. The nurse is assessing an elderly clients blood pressure during a routine visit. When asked,
the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The
nurse determines that the clients pressure today is 134/70 mm Hg. The nurse recognizes that the
most likely cause of the elevation is:
1
The difference between the monitoring equipment being used
2
The client may be experiencing mild anxiety regarding the
check-up
3
The effects of aging on the clients ability to hear the first
Korotkoff sound
The client is not inflating the cuff sufficiently to detect the
systolic pressure
4
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ANS: 2
Blood pressure measurements taken at the clients place of employment or in a health care
providers office are higher than those taken at the clients home. The remaining options may be a
factor but they are not the most likely.
DIF: C REF: 537 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
38. The nurse is assessing a clients blood pressure to establish a baseline. The pressure in the
right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that
these data:
1
2
3
4
Reflect a normal variation
Should be reported to the clients health care provider
Dictate that pressure should be monitored in the left arm
Indicate that the client may be experiencing vascular problems
ANS: 2
During the initial assessment, obtain and record the blood pressure in both arms. Normally there
is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent
assessments, measure the blood pressure in the arm with the higher pressure. Pressure differences
greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or
nurse in charge. Reporting the assessment findings is the most appropriate outcome.
DIF: C REF: 536 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
39. The nurse recognizes that which of the following clients present at the annual July 4th
marathon is at greatest risk for hyperthermia and the resulting heatstroke?
1
A 34-year-old running for the first time in the July 4th
marathon who is sweating profusely
2
A 16-year-old volunteer, with type 1, insulin-dependent
diabetes, who is checking runners in for the marathon at the
starting gate
3
A 75-year-old who is prescribed medication for Crohns disease
and who is sitting outdoors watching her granddaughter run
the marathon
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4
A 55-year-old diagnosed with bipolar disease and prescribed a
phenothiazine (Serentil), who will be walking the marathon
course
ANS: 2
Clients at risk include those who are very young or very old and those who have cardiovascular
disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications
that decrease the bodys ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics,
amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work
strenuously (e.g., athletes, construction workers, and farmers). While all the options represent
risk factors, the degree of exercise, medical history, and age are greatest for the 16-year-old
client with diabetes.
DIF: C REF: 506 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
40. The nurse recognizes that which of the following clients present at the annual July 4th
marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke?
1
The 75-year-old who has forgot where the car is parked
2
The 16-year-old volunteer whose skin appears sunburned but
dry
3
The 34-year-old who finished the race and is reporting leg
cramps
The 55-year-old observer who complains of nausea and being
thirsty
4
ANS: 2
Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea,
muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature
sometimes as high as 45 C (113 F) with an increase in heart rate and lowering of blood pressure.
The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat
because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the
client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent
neurological damage occurs unless cooling measures are rapidly started.
DIF: C REF: 508 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
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41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the units
clients. Which of the following statements made by the assistive personnel shows the greatest
need for additional instruction regarding appropriate temperature monitoring orally?
1
Are all the clients cooperative enough to take the temperatures
orally?
2
Do you want me to take the temperature tympanically on
everyone?
Ill wait until breakfast is over so I wont distract them from
eating.
3
4
Ill chart the results and let you know whose temperature is
running high.
ANS: 3
When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has
smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so
that the assessment will occur before breakfast or to allow enough time to pass after breakfast so
as not to affect the readings. The options containing a question reflect a need for knowledge but
do not have priority over an obvious indication of possible poor assessment technique. The nurse
needs to evaluate the readings and so should be sure to give the assistive personnel guidance as
to what readings are running high.
DIF: C REF: 510 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
42. Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?
1
A polished ring finger of a client with pneumonia whose nail
capillary refill time is 2.5 seconds
2
A pierced earlobe of a client with a closed head injury whose
nail capillary refill time is 3.5 seconds
The ring finger of a client with Parkinsons disease that has a
capillary refill time of less than 3 seconds
3
4
An earlobe of a client who is experiencing moderate
diaphoresis with a nail capillary refill time of 3.5 seconds
ANS: 2
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Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement
by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site.
Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial
nails).
DIF: C REF: 534 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
43. The nurse has asked the assistive personnel to take the blood pressure of a client who
experienced a left mastectomy 3 days ago. Which of the following statements by the assistive
personnel shows the best understanding regarding the appropriate assessment technique for this
particular client?
1
2
3
4
Is there anything affecting her right arm?
Has she been experiencing any edema in that left arm?
How long has it been since she had her breast removed?
Ill wait until shes been medicated for pain before I take it.
ANS: 1
Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous
shunt or fistula is present; breast or axillary surgery has been performed on that side; or the
extremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer
reflects an understanding that the right arm is the extremity of choice for monitoring this clients
blood pressure.
DIF: C REF: 539 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
MULTIPLE RESPONSE
1. The nurse is assisting the wife of a client who has been diagnosed with hypertension to
monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all
that apply.)
1
At the same time each day
2
On the same arm each time
3
In the same position each time
4
After the client has had a brief rest
5
After his blood pressure medication
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6
Right before getting up in the morning
ANS: 1, 2, 3, 4
Instruct the client or primary caregiver to take BP at same time each day and after the client has
had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure
is taken. The other options are not necessary because they do not affect blood pressure readings.
DIF: C REF: 537 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
2. Which of the following factors make using a pulse oximeter on an elderly client challenging?
(Select all that apply.)
1
Possibility of decreased cardiac output
2
3
Potential for peripheral vascular disease
Existence of decreased red blood cell count
4
Uncooperative behavior related to senility
5
Inability to comprehend rationale for monitoring
6
Vasoconstriction related to impaired heat regulation
ANS: 1, 2, 3, 6
Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the
likelihood of peripheral vascular disease, decreased cardiac output, cold-induced
vasoconstriction, and anemia. It would be inappropriate to assume that the process is made more
difficult because of the remaining options because they are not seen in the majority of the elderly
population.
DIF: C REF: 533 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
3. The nurse is providing a health promotion session regarding the factors that contribute to
heatstroke for members of a college cross-country running team. Which of the following
statements should the nurse include in the discussion? (Select all that apply.)
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1
Take frequent breaks to rest out of the sun.
2
The greater the humidity, the greater the hazard.
Wear clothing that will absorb the perspiration.
3
4
5
The higher the temperature, the higher the risk.
The more fluids you drink, the fewer chances you take.
6
Pay attention to pacing yourself when its hot and muggy.
ANS: 2, 4, 5, 6
Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tight-fitting
clothing in hot environments; exercising in poorly ventilated areas; sudden exposures to hot
climates; poor fluid intake before, during, and after exercise. When paying close attention to
avoiding risk factors for heatstroke, the remaining options are not required.
DIF: C REF: 507-508 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
4. The nurse is discussing risk factors for hypertension with family members attending a selfhelp group meeting for clients in cardiac rehabilitation. Which of the following statements made
by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.)
1
2
3
4
Low fat foods are your blood pressures best friend.
Have your triglycerides checked on a regular basis.
Ideal weight is ideal for keeping blood pressure under control.
Nicotine is a no-no when attempting to control blood pressure.
5
If they are prescribed, take your blood pressure medicine as
suggested.
6
Keep alcohol consumption down and your blood pressure will
be down.
ANS: 1, 2, 3, 4, 6
Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking,
heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued
exposure to stress are risk factors linked to hypertension. Medication compliance, while
important, is related to the management of hypertension, not prevention.
DIF: C REF: 537-538 OBJ: Analysis
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TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
5. The nurse is discussing the correct technique for taking a blood pressure with clients and their
caregivers. Which of the following nursing statements would appropriately identify the most
likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that
apply.)
1
2
3
The cuff cannot be too small or too big.
Dont release the air out of the cuff to quickly.
4
Keep the arm you are using at the level of the heart.
If you are having difficulty, try taking it in the other arm.
5
The stethoscope needs to be placed directly over a pulse point.
6
Remember to pump up the cuff until you can no longer feel the
pulse.
ANS: 1, 2, 5, 6
Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is
probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse;
the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic
readings. The remaining options do not directly affect the actual hearing of the blood pressure.
DIF: C REF: 539 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
6. The nurse is discussing the proper technique for obtaining an accurate blood pressure reading
with assistive nursing personnel. Which of the following statements reflect techniques that will
minimize the risk of a false high systolic reading? (Select all that apply.)
1
Slowly deflate the pressure from the cuff.
2
Wrap the cuff snuggly around the clients arm.
3
Always support the clients arm at the level of the heart.
4
5
Be sure that the cuff is wide enough for the clients arm.
Allow the arm to rest before repeating the blood pressure.
6
Make sure your stethoscope is fitted in your ears appropriately.
ANS: 2, 3, 4, 5
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Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or unevenly,
resting the arm below heart level, and repeating assessments too quickly all contribute to a
falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will
likely result in a falsely low systolic reading.
Chapter 30. Health Assessment and Physical Examination
MULTIPLE CHOICE
1. The position that maximizes the nurses ability to assess the clients body for symmetry is:
1
2
Sitting
Supine
3
Prone
4
Dorsal recumbent
ANS: 1
Sitting upright provides full expansion of the lungs and provides better visualization of
symmetry of upper body parts. The supine position maximizes the nurses ability to assess pulse
sites. The prone position is used only to assess extension of the hip joint.
The dorsal recumbent position is used for abdominal assessment because it promotes relaxation
of abdominal muscles.
PTS: 1 DIF: A REF: 559 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
2. When assessing the pallor of a client with dark skin, the nurse will specifically look at the:
1
Buccal mucosa of the mouth
2
Dorsal surface of the hands
3
Ear lobe
4
Sclera
ANS: 1
Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds.
The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The
ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client.
The best site to inspect for jaundice, not pallor, is the sclera.
PTS: 1 DIF: A REF: 567 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns.
In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated
cause. The client also states that she is having trouble sleeping, and she appears anxious. Based
on these findings, the nurse suspects that the client may be experiencing:
1
2
3
4
Substance abuse
Domestic violence
Vascular disease
Mental illness
ANS: 2
Injuries and trauma that are inconsistent with the reported cause; multiple injuries including
bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are
all indicators of possible domestic violence. The findings are not consistent with substance
abuse. Indicators of substance abuse may include frequent missed appointments or emergency
department visits, having a history of changing doctors, history of activities that place the client
at risk for HIV infections, complaints of insomnia or chest pain, and a family history of
addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle
marks, homemade tattoos, or increased vascularity of the face. These findings are not indicative
of vascular disease. Symptoms of vascular disease may include edema, color changes of the
lower extremities, and weakened pedal pulses. These findings are not indicative of mental
illness. The client is coherent.
PTS: 1 DIF: C REF: 563 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
4. A client in the clinic has been having severe headaches and some visual disturbances. The
nurse performs an eye examination. Which of the following is true concerning the procedure for
this assessment?
1
The red reflex should be assessed with the ophthalmoscope.
2
To evaluate the lower eyelids, the nurse uses a syringe with
sterile water.
3
Accommodation is tested by asking the client to comply with
the nurses requests.
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4
The lacrimal apparatus is assessed with a dull object to
stimulate normal reflex conditions.
ANS: 1
To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex.
To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe
and sterile water are not necessary for this assessment. Accommodation is tested by asking the
client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm
from the clients nose. The pupils normally converge and accommodate by constricting when
looking at close objects. The lacrimal apparatus is best assessed by inspecting for edema and
redness; and palpating it gently to detect tenderness, which cannot be felt normally.
PTS: 1 DIF: A OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
5. In preparing to conduct a physical examination on a client, the nurse plans to:
1
Perform painful procedures at the end of the exam
2
Take long, detailed notes of all the findings during the exam
3
Keep the TV or radio on to distract the client throughout the
exam
Assess the dominant side of the clients body only in the
examination
4
ANS: 1
In organizing a physical examination, the nurse should perform painful procedures near the end
of the examination. The nurse should record quick notes during the examination to avoid keeping
the client waiting. Observations can be completed at the end of the examination. The TV or radio
should be turned off so as to not distract the client throughout the examination, and to provide an
environment conducive to auscultation.
Both sides of the body should be assessed for comparison to determine symmetry. A degree of
asymmetry is normal in the dominant versus nondominant arm.
PTS: 1 DIF: A REF: 562 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
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6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit.
Which of the following is accurate regarding the procedure for a thyroid assessment for this
client?
1
Deep palpation should be used anterior and posterior.
2
Swallowing sips of water causes the isthmus of the thyroid
gland to rise.
The posterior approach is used when the fingers are placed
over the trachea.
3
4
The diaphragm of the stethoscope is best used for the
auscultation of bruits.
ANS: 2
During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow
once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The
nurse should feel if it is enlarged. Normally the thyroid gland is small, smooth, and free of
nodules. Light, gentle palpation is needed to feel any abnormalities.
For the posterior approach, both of the nurses hands are placed around the neck, with two fingers
of each hand on the sides of the trachea just beneath the cricoid cartilage.
The bell of the stethoscope is best for auscultation of bruits.
PTS: 1 DIF: A REF: 591 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
7. When auscultating the clients lungs, a nurse notes normal vesicular sounds as:
1
Medium-pitched blowing sounds with inspirations that equal
expirations
2
Loud, high-pitched, hollow sounds with expiration longer than
inspiration
3
Soft, breezy, low-pitched sounds with longer inspiration
4
Sounds created by air moving through small airways
ANS: 3
Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times
longer than the expiratory phase. Medium-pitched blowing sounds with inspiration equaling
expiration are bronchovesicular breath sounds. Loud, high-pitched, hollow sounds with longer
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expiration are bronchial breath sounds. Vesicular sounds are created by air moving through
smaller airways. Abnormal breath sounds result from air passing through narrowed airways.
PTS: 1 DIF: A REF: 596 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old child at
the:
1
Fourth intercostal space, left of the midclavicular line
2
3
Fifth intercostal space, left of the midclavicular line
Second intercostal space, right of the midclavicular line
4
Third intercostal space, right of the midclavicular line
ANS: 2
By the age of 7, a childs PMI is in the same location as in adults; that is, the fifth intercostal
space, left of the midclavicular line. The PMI of an 8-year-old child is more likely to be located
at the fifth intercostal space, left of the midclavicular line.
The PMI is not located to the right of the midclavicular line. The PMI of an infant is at the third
or fourth intercostal space, left of the midclavicular line.
PTS: 1 DIF: A REF: 598 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
9. The nurse suspects that the client may have vascular disease. During the examination, the
nurse is alert to the clients complaints of:
1
Headache, dizziness, and tingling of body parts
2
Diplopia, floaters, and headaches
3
Leg cramps, numbness of extremities, and edema
4
Pain and cramping in the lower extremities relieved by
walking
ANS: 3
Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or
swelling or cyanosis of feet, ankles, or hands are indicative of vascular disease.
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Headache, dizziness, and tingling of body parts are more likely associated with a neurological
problem, not vascular disease. Diplopia, floaters, and headaches are indicative of an eye
problem, not vascular disease. Pain and cramping in the lower extremities are usually worsened
with activity in vascular disease.
PTS: 1 DIF: A REF: 602 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
10. A 21-year-old woman asks when she should perform a breast self-examination during the
month. The nurse should inform the client:
1
2
Any time you think of it.
At the same time each month.
3
On the first day of your menstrual period.
4
Two to three days after your menstrual period.
ANS: 4
The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no
longer swollen or tender from hormone elevations. The woman should check her breasts the
same time each month 2-3 days after the menstrual period ends. At the same time each month is
partially true. The client also should be informed to perform the BSE 2 to 3 days after the
menstrual period ends. On the first day of the menstrual period is not the best time for a woman
to perform a BSE. The breasts will be enlarged and tender from hormone elevations.
PTS: 1 DIF: A REF: 610 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
11. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in
skin color that is smaller than 1 cm. This finding is documented by the nurse as a:
1
Macule
2
Papule
3
Vesicle
Nodule
4
ANS: 1
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This finding is consistent with the definition of a macule. A papule is a palpable, circumscribed,
solid elevation in skin, smaller than 0.5 cm. A vesicle is a circumscribed elevation of skin filled
with serous fluid, smaller than 0.5 cm. A nodule is an elevated solid mass, deeper and firmer than
a papule, 0.5-2.0 cm.
PTS: 1 DIF: A REF: 570 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
12. The nurse asks a client to explain the meaning of the phrase, Every cloud has a silver lining.
This part of the examination is designed to measure:
1
2
Knowledge
Judgment
3
Association
4
Abstract thinking
ANS: 4
Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects
the capacity for abstract thinking. The client with altered mentation will likely interpret the
phrase literally or merely rephrase the words. An example of assessing knowledge would be
asking the client their reason for seeking health care. This example is not designed to measure
knowledge. The nurse is not attempting to measure judgment. An example of assessing judgment
would be to ask the client what they would do if they suddenly became ill when alone at home.
The nurse is not attempting to measure association. An example of assessing association would
be to ask the client to complete a phrase, such as a dog is to a beagle as a cat is to a
.
PTS: 1 DIF: A REF: 633 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
13. Measurement of the clients ability to differentiate between sharp and dull sensations over the
forehead tests which cranial nerve?
1
Optic
2
Facial
3
Trigeminal
4
Oculomotor
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ANS: 3
The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing
the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face.
The optic nerve is tested by using the Snellen chart or asking the client to read printed material.
The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower
eyebrows while looking for asymmetry. Also, having the client identify salty or sweet taste on
the front of the tongue tests the facial nerve. The oculomotor nerve is tested by assessing
directions of gaze and testing papillary reaction to light and accommodation.
PTS: 1 DIF: A REF: 634 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
14. Assessment of the clients skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The
nurse identifies this as a:
1
2
Nodule
Macule
3
Vesicle
4
Wheal
ANS: 3
This finding is consistent with the definition of a vesicle. A nodule is an elevated solid mass,
deeper and firmer than a papule, 0.5-2.0 cm. A macule is a flat, nonpalpable change in skin color,
smaller than 1 cm. A wheal is an irregularly-shaped, elevated area or superficial localized edema
that varies in size.
PTS: 1 DIF: A REF: 570 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
15. The expected appearance of the oral mucosa in a light-skinned adult is:
1
Pinkish-red, smooth, and moist
2
Light pink, rough, and dry
3
Cyanotic, with rough nodules
4
Deep red, with rough edges
ANS: 1
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Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth. Oral
mucosa may appear more dry in an older adult because of reduced salivation but is not rough.
Cyanotic mucosa with rough nodules would be an abnormal finding. Oral mucosa should not
appear deep red with rough edges in a light-skinned adult.
PTS: 1 DIF: A REF: 587 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
16. The nurse notes an exaggeration of the posterior curvature of the thoracic spine, during the
assessment of a 90-year-old client, as:
1
2
Lordosis
Osteoporosis
3
Scoliosis
4
Kyphosis
ANS: 4
Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback).
Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease
that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine.
PTS: 1 DIF: A REF: 627 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
17. The best position for the nurse to position the client in order to auscultate the apical site, if a
low-pitched murmur is suspected during prior assessment, is:
1
Sitting up
2
Standing
3
Lying on the left side
4
Dorsal recumbent
ANS: 3
Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side
(lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing
lung expansion and symmetry of the upper extremities. Standing is not the best position for
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auscultating a heart murmur. The dorsal recumbent position is best used for abdominal
assessment.
PTS: 1 DIF: A REF: 559 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
18. As part of the examination, the nurse will be assessing the clients balance. The test that
should be administered is the:
1
Weber test
2
3
Allen test
Romberg test
4
Rinne test
ANS: 3
The Romberg test assesses the clients balance. The Weber test assesses for unilateral deafness.
The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture).
The Rinne test compares bone conduction hearing with air conduction.
PTS: 1 DIF: A REF: 636-637 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
19. Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial
nerve VIII, the nurse should:
1
Ask the client to read printed material
2
Assess the directions of gaze
3
Assess the clients ability to hear the spoken word
4
Ask the client to say ah
ANS: 3
To test cranial nerve VIII (auditory), the nurse should assess the clients ability to hear the spoken
word. To test cranial nerve II (optic), the nurse should assess the clients ability to read printed
material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse
should assess the clients directions of gaze. To assess cranial nerve X (vagus), the nurse should
ask the client to say ah.
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PTS: 1 DIF: A REF: 634 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
20. A student nurse is working with a client who has asthma. The primary nurse tells the student
that wheezes can be heard on auscultation. The student expects to hear:
1
2
3
4
Coarse crackles and bubbling
High-pitched musical sounds
Dry, grating noises
Loud, low-pitched rumbling
ANS: 2
Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during
inspiration or expiration; usually louder on expiration. Coarse crackles and bubbling are not
descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, lowpitched rumbling is characteristic of rhonchi.
PTS: 1 DIF: A REF: 596 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
21. The nurse instructs the male client that the protocol for testicular self-examination is to:
1
Perform the examination annually after age 35
2
Use both hands to roll the testicles and feel the consistency
3
Perform the examination before bathing or showering
4
Contact the physician if a cordlike structure is felt on the top
and back of the testicle
ANS: 2
The nurse instructs the male client that the protocol for testicular self-examination is to use both
hands to gently roll the testicle, feeling for lumps, thickening, or a change in consistency
(hardening). All men 15 years and older should perform the testicular self-exam monthly. The
examination should be performed after a warm bath or shower when the scrotal sac is relaxed. A
cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis.
PTS: 1 DIF: A REF: 623 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
22. The nurse uses olfaction in the clients assessment. If a sweet, fruity smell is noticed in the
oral cavity, the nurse suspects:
1
2
3
4
Diabetic acidosis
Gum disease
Stomatitis
Malabsorption syndrome
ANS: 1
A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis. Halitosis of the
oral cavity is indicative of gum disease. Stomatitis is characterized by oral pain, bad breath,
inflammation, and oral ulcers in the mouth. Foul-smelling stools in the infant is indicative of
malabsorption syndrome.
PTS: 1 DIF: A REF: 557 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
23. A client with cardiopulmonary disease receives a physical examination performed by a nurse.
Knowing the client history, the nurse is attentive when checking the nails for the presence of:
1
Clubbing
2
Paronychia
3
Beaus lines
4
Splinter hemorrhages
ANS: 1
Clubbing of the nails is caused by a chronic lack of oxygen, such as occurs in heart or pulmonary
disease. Paronychia is caused by local infection or trauma. Beaus lines are caused by systemic
illness such as severe infection or by injury to the nail. Splinter hemorrhages are caused by minor
trauma, subacute bacterial endocarditis, or trichinosis (infection by the roundworm).
PTS: 1 DIF: A REF: 575 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
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24. During the physical examination, the client tells the nurse that he has been told he has
myopia. The nurse expects to find that the client:
1
2
3
4
Is nearsighted
Has decreased peripheral vision
Has diminished night vision
Experiences more glare, flashes, and floaters
ANS: 1
Myopia is nearsightedness. Peripheral vision is not reduced with myopia. The client with myopia
is able to see close objects, but not distant objects. Peripheral vision may be decreased in openangle glaucoma. Diminished night vision may occur with cataracts, not myopia. Problems with
glare, flashes, and floaters may indicate eye disease and the client should be referred to a
physician.
PTS: 1 DIF: A REF: 577 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
25. The school-aged child is taken to the school nurse after experiencing a nosebleed during a
softball game. The appropriate intervention is for the nurse to:
1
Have the child lean backward
2
Apply pressure to the anterior nose
3
Apply a warm cloth to the area
Have the child close his mouth and blow his nose
4
ANS: 2
The nurse should have the child who is experiencing a nosebleed sit up and lean forward to avoid
aspiration of blood, apply pressure to the anterior nose with the thumb and forefinger as the child
breathes through the mouth, and apply ice or a cold cloth to the bridge of the nose if pressure
fails to stop bleeding. The child should not lean backward as this may cause the child to aspirate
blood. A cold cloth will slow bleeding and help blood to coagulate, not a warm cloth. The child
should breathe through the mouth. Blowing his nose may only continue bleeding as it may
disturb any clot formation
PTS: 1 DIF: A REF: 586 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
26. An older adult client is visiting the physicians office for a check-up. The client asks the nurse
how often the influenza and pneumonia vaccines should be obtained. The nurse responds to the
client that these vaccinations should be done:
1
2
Every 6 months
Annually
3
Every 5 years
4
Every 7 years
ANS: 2
Older adults should be counseled to receive annual influenza and pneumonia vaccinations. It is
not necessary to receive these vaccinations every 6 months. The influenza and pneumonia
vaccines should be obtained annually in the older adult because of their greater susceptibility to
respiratory tract infection. It is recommended that older adults receive the influenza and
pneumonia vaccines annually because they have a greater susceptibility to respiratory tract
infection.
PTS: 1 DIF: A REF: Chapter 34, 649
OBJ: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
27. A pregnant client is seen by the nurse in the antenatal clinic. On inspection, the nurse expects
that this clients breasts will have:
1
Softer tissue
2
Flatter nipples
3
Darkened areola
4
Diminished superficial veins
ANS: 3
Normal changes of the breasts during pregnancy include the areola becoming darker and the
diameter increasing. Breast tissue becomes softer during menopause, not pregnancy.
Nipples become flatter in older adulthood. Superficial veins become more prominent during
pregnancy.
PTS: 1 DIF: A REF: 612 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
28. At a medical clinic, a client with vascular insufficiency is seen frequently. The nurse will give
the client additional instruction about her condition if the client:
1
2
3
4
Walks regularly
Wears knee-length stockings
Elevates the feet when sitting
Alternates periods of sitting and standing
ANS: 2
The client with risk or evidence of vascular insufficiency should not wear tight clothing over the
lower body or legs, such as knee-length stockings. Walking regularly is recommended for the
client with vascular insufficiency. The client with vascular insufficiency should elevate his or her
feet when sitting. The client with vascular insufficiency should avoid sitting or standing for long
periods.
PTS: 1 DIF: A REF: 605 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
29. During the physical examination, the nurse should assess the clients glands by using the:
1
Dorsum of the hand
2
Pads of the fingers
3
Palmar surface of the hand
Fingertip grasp of the tissue
4
ANS: 2
To assess the clients glands, the nurse should use the pads of the fingers and palpate gently. The
dorsum of the hand may be used to detect skin temperature, not to assess the clients glands. The
palmar surface of the hand is not used to assess the clients glands.
The nurse should not use a fingertip grasp of the tissue when assessing a clients glands.
PTS: 1 DIF: A REF: 589 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
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30. The nurse is evaluating the client for conduction deafness in the right ear. In using Webers
test, the nurse appropriately places the tuning fork and confirms this type of deafness when:
1
2
3
4
Sound is not heard in either ear
Sound is heard best by the client in the left ear
Sound is heard best by the client in the right ear
Sound is reduced and heard longer through air conduction
ANS: 3
In conduction deafness, sound is heard best in the impaired ear. Sound that is not heard in either
ear is not indicative of conduction deafness. Sound would not be heard best by the client in the
left ear if there was conduction deafness in the right ear. This option is describing the Rinnes test,
not the Webers test. In conduction deafness, bone-conducted sound can be heard longer. In
sensorineural loss, sound is reduced and heard longer through air.
PTS: 1 DIF: A REF: 584 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
31. The presence of arterial insufficiency is suspected during an inspection of the lower
extremities when the nurse observes:
1
Increased hair growth
2
Cooler skin temperatures
3
Marked edema
4
Brown pigmentation
ANS: 2
In the presence of arterial insufficiency, the client has signs resulting from an absence of blood
flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower
extremities become dusky red when the extremity is lowered. They feel cool to touch because
blood flow is blocked to the extremity. Decreased hair growth or the absence of hair growth over
the legs may indicate arterial insufficiency. Marked edema is seen in venous insufficiency, not
arterial insufficiency. Brown pigmentation around the ankles is seen in venous insufficiency.
Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and
thickened nails.
PTS: 1 DIF: A REF: 608 OBJ: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
32. The sounds heard over the trachea during the auscultation of the thorax, are expected to be:
1
2
Soft, low-pitched, and breezy
Loud, high-pitched, and hollow
3
Moist, crackling, and bubbling
4
High-pitched and musical
ANS: 2
Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow. Soft,
low-pitched, and breezy sounds are heard over the lungs periphery.
Moist, crackling, and bubbling sounds are adventitious sounds known as crackles and are caused
by sudden reinflation of groups of alveoli and disruptive passage of air. They are most commonly
heard in dependent lobes: right and left lung bases. High-pitched and musical sounds are
wheezes. Wheezes can be heard over all lung fields.
PTS: 1 DIF: A REF: 596 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
33. The nurse tests the function of the clients cranial nerves during the neurological component
of the physical examination. In testing cranial nerve III, the nurse verifies the clients ability to:
1
Smile and frown
2
Read printed material
3
Identify sweet and sour tastes
4
React to light with changes in pupil size
ANS: 4
In testing cranial nerve III (oculomotor), the nurse determines the clients ability to react to light
with changes in pupil size. Testing accommodation will also assess cranial nerve III. In testing
cranial nerve VII (facial), the nurse determines the clients ability to smile and frown. In testing
cranial nerve II (optic), the nurse determines the clients ability to read printed material. In testing
cranial nerve IX (glossopharyngeal), the nurse determines the clients ability to identify sweet and
sour tastes.
PTS: 1 DIF: A REF: 634 OBJ: Knowledge
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
34. Which of the following statements made by a nurse reflects the best understanding of the
health value of conducting a blood pressure (BP) screening at a senior citizens centers health
fair?
1
This is a high risk group, so assessing BP allows us to identify
clients at risk and send them for treatment.
2
Older adults enjoy health fairs, so its a good place to screen
substantial numbers of clients for hypertension.
3
Hypertension doesnt present symptoms early on, so screening
elder adults is a wonderful preventive measure.
4
Blood pressure problems are common among this group, so its
a good way to monitor the effectiveness of their medications.
ANS: 1
Health screenings focus on a specific physical problem. For example, blood pressure screenings
detect the risk for high blood pressure. If this screening determines that a client has a risk for
disease, the nurse refers the client for a more complete physical examination. While the other
options are not incorrect, they do not show the most thorough understanding of the value of
health screenings.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
35. Which of the following statements made by the RN preparing to conduct a clients initial
health history shows the best understanding of the therapeutic objective of the interview?
1
Its all about finding out what the problems are and discovering
the best way to fix them.
2
Clients are more comfortable when you take the time to get to
know them and their problems.
3
I use it as an opportunity to show the client that his care is
very important to the hospitals staff.
It is the most appropriate way to initiate the therapeutic nature
of the nurse-client relationship.
4
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ANS: 1
The main objective of interacting with clients is to find out what their concerns are and to help
them find solutions. While the other options are not incorrect, they do not express the primary
objective of information gathering directed towards client care.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
36. A client reports pain in his left ankle since twisting it yesterday. Which of the following
assessment findings best supports the clients claims of ankle pain?
1
The client grimaces when walking to the examination room.
2
The clients left ankle is swollen with noted bruising.
The client reports a pain rating of 7 on a scale of 1 to 10.
3
4
The clients heart rate increases after walking to the
examination room.
ANS: 2
A subsequent physical assessment can reveal information that refutes, confirms, or supplements
the history. Think critically about the information the client provides, apply knowledge from
previous clinical care, and methodically conduct the examination to create a clear picture of the
clients status. The objective signs of swelling and bruising best support the possible spraining of
the ankle and the resulting claim of pain. The increase in heart rate is subjective but can be a
result of various factors, pain being only one. The remaining options reflect objective data.
PTS: 1 DIF: C REF: 553 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
37. While bathing an elderly client who has limited abilities for self-care, the nurse notices
several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries
all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up
by the nurse to ensure appropriate nursing care for this clients skin is to:
1
Revise the clients care plan to show the need for the
application of moisturizing lotion
2
Assume personal responsibility to apply the moisturizing
lotion daily to the clients skin
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3
Encourage the client to tell whomever bathes her to apply the
moisturizing lotion to her areas of dry skin
4
Inform the staff that the clients skin is showing signs of
breakdown and moisturizing lotion needs to be applied daily
ANS: 1
The nurse revises the written care plan so that other nurses and nursing assistive personnel know
the type of skin care to provide. The other options are less likely to convey the information
effectively.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
38. Which of the following statements best reflects an understanding of the most effective means
of showing nursing accountability for client care?
1
I always try to tailor client education to my clients care needs.
2
A clients care plan is never stagnate; it always needs updating.
3
Selecting the most appropriate interventions is the key to
quality care.
4
By re-assessing the client regularly, I can tell if the
interventions are working.
ANS: 4
Nurses demonstrate accountability for their nursing care through evaluating the results of nursing
interventions. Nurses make accurate, detailed, objective measurements through physical
assessment. These measurements determine whether the expected outcomes of care are met. The
remaining options are correct but not as directly related to nursing accountability for effective
client care.
PTS: 1 DIF: C REF: 554 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
39. The nurse encourages the client to relax and take a deep, slow breath in order to prepare for a
palpating assessment of the abdomen. The primary reason for this is to:
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1
Encourage the client to be emotionally comfortable and
relaxed
2
Distract the client from the actual possible discomfort the
pressure may cause
Facilitate the effectiveness of the palpating technique to detect
abdominal masses
3
4
Allow the client an opportunity to cope with any bad feelings
regarding the examination
ANS: 3
Before palpation, help the client relax and be comfortable because muscle tension during
palpation impairs effective assessment. To promote relaxation, have the client take slow, deep
breaths and place the arms along the side of the body. While the other options may be reasonable,
they are not the primary reason for encouraging the client to relax.
PTS: 1 DIF: C REF: 554 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
40. The nurse is about to palpate the clients abdomen to determine the margins of the liver. The
primary reason for using the bimanual palpation method is to:
1
Minimize client discomfort
2
Minimize lower hand desensitivity
3
Assist in manipulation of the organ
4
Facilitate quick assessment of the abdomen
ANS: 2
When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the
clients skin. Use the other hand (active hand) to apply pressure to the sensing hand. The lower
hand does not exert pressure directly and thus remains sensitive to detect organ characteristics.
This technique does assist in the effective, efficient assessment of the abdomen, but its primary
purpose is directed towards hand sensitivity.
PTS: 1 DIF: C REF: 555 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
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41. Which of the following statements made by a nursing student regarding assessment technique
requires immediate follow-up by the clinical instructor?
1
I always rub my hands together before touching the client.
2
I found that both of the clients carotid arteries beat
simultaneously.
3
It will take a lot of practice for me to be master the art of
percussion.
4
I always warm the stethoscopes diaphragm before listening for
bowel sounds.
ANS: 2
Do not palpate a vital artery with pressure that obstructs blood flow nor assess both such arteries
at the same time since this could result in a dangerous lack of blood flow to the brain. The
remaining options are not inaccurate and so do not require immediate follow-up.
PTS: 1 DIF: C REF: 602 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
42. The primary reason for encouraging a client to urinate before beginning a physical
examination is:
1
It avoids stimulation of the bladder during palpation or
percussion of the abdomen
2
It minimizes the possibility of urinary incontinence caused by
embarrassment or awkward positioning
A full bladder can hinder the examination of the clients
abdominal, genitalia, and rectal areas
3
4
Voiding before the examination will encourage the client to
relax, thus facilitating the assessment
ANS: 3
An empty bladder and bowel facilitate examination of the abdomen, genitalia, and rectum. The
remaining options may be plausible reasons, but they are not the primary one.
PTS: 1 DIF: C REF: 558 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
43. The nurse recognizes that which of the following clients should be thoroughly assessed for
their ability to be safely placed in the supine position?
1
An 18-year-old who suffered a fractured elbow playing
football
2
A 20-year-old hospitalized with abdominal pain to rule out an
appendicitis
3
A 74-year-old client who requires 3 L of continuous oxygen
via nasal cannula
4
A 37-year-old reporting complaints of vaginal bleeding
between menstrual periods
ANS: 3
Clients who are experiencing any degree of respiratory distress will not find this position
comfortable and should not be placed in this position because it will make breathing even more
difficult. If the client becomes short of breath easily, raise the head of the bed. The other clients
may not prefer this position, but there is no medical reason for avoiding it.
PTS: 1 DIF: C REF: 558-589 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
44. A male nursing student is assigned to change the abdominal dressing of a 74-year-old female.
The clinical nursing instructor asks that a female nurse assist him with the procedure. The
primary reason for this decision is:
1
It diverts the clients attention during the assessment and
procedure
2
It provides a third party to ensure proper conduct of all
involved
3
It facilitates a comfortable, efficient environment for the client
It assists with the wound assessment and changing of the
abdominal dressing
4
ANS: 2
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When the client and nurse are of opposite gender, it helps to have a third person of the clients
gender in the room. The presence of a third person ensures the client that the examiner will
behave ethically. This person is also a witness to the examiners conduct as well as the clients.
While a second health care provider may be useful during the assessment and procedure, that is
not the primary reason for their presence.
PTS: 1 DIF: C REF: 560 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
45. The shift report states that a client has crackles in both lungs. Which statement by the nurse,
preparing to assess the client, best reflects a thorough understanding of the recorded assessment
finding?
1
I wonder if they are fine, medium, or coarse.
2
3
Ill listen again and reassess after I ask him to cough.
That musical sound is hard to miss as they breathe out.
4
I wish it was recorded where in the lungs they were heard.
ANS: 2
Crackles are most common in dependent lobes: right and left lung bases. Fine crackles are highpitched, fine, short, interrupted crackling sounds heard during the end of inspiration and usually
not cleared with coughing; medium crackles are lower, more moist sounds heard during the
middle of inspiration and not cleared with coughing; and coarse crackles are loud, bubbly sounds
heard during inspiration and not cleared with coughing. Reassessing and asking the client to
cough provide the clearest understanding of this type of breath sound. Musical sounds are
representative of wheezes, not crackles.
PTS: 1 DIF: C REF: 596 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
46. The most appropriate method to use to assess a carotid artery for the presence of a bruit is to:
1
Palpate each artery lightly; first the right side and then the left
2
Have the client turn the head towards the side being
auscultated
Place the bell of the stethoscope over the artery near the outer
edge of the clavicle
3
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4
Have the client hold the breath while auscultating with the
stethoscope bell
ANS: 3
Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the
posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away
from the side being examined. Ask the client to hold the breath for a moment so that breath
sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation.
Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.
PTS: 1 DIF: C REF: 603 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
47. The shift report states that a client has crackles in both lungs. Which statement by the nurse
preparing to assess the client best reflects a thorough understanding of the recorded assessment
finding?
1
I wonder if they are fine, medium or coarse.
2
3
Ill listen again and reassess after I ask him to cough.
That musical sound is hard to miss as they breathe out.
4
I wish it was recorded where in the lungs they were heard.
ANS: 2
Crackles are most common in dependent lobes: right and left lung bases, Fine crackles are highpitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not
cleared with coughing. Medium crackles are lower, more moist sounds heard during middle of
inspiration; not cleared with coughing and coarse crackles are loud, bubbly sounds heard during
inspiration; not cleared with coughing. Reassessing and asking the client to cough provides the
clearest understanding of this type of breath sounds. Musical sounds are representative of
wheezes not crackles.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
48. The most appropriate method to use to assess for a carotid artery for the presence of a bruit is
to:
1
Palpate each artery lightly; first the right side and then the left
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2
Have the client turn the head toward the side being auscultated
3
Place the bell of the stethoscope over artery near outer edge of
the clavicle
Have the client hold the breath while auscultating with the
stethoscope bell
4
ANS: 3
Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the
posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away
from the side being examined. Ask the client to hold the breath for a moment so that breath
sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation.
Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
MULTIPLE RESPONSE
1. The primary outcome for information collected during a nursing physical examination should
be to: (Select all that apply.)
1
Establish the clients baseline of function
2
Evaluate both nursing and client outcomes
3
Identify any changes in the clients health status
4
Provide rationale for client admission or discharge
Identify appropriate nursing diagnoses to determine nursing
care
5
6
Determine accuracy of information obtained from the client
interview
ANS: 1, 2, 3, 5, 6
Providing rationale for client admission or discharge is not an outcome of a nursing physical
assessment.
PTS: 1 DIF: C REF: 553 OBJ: Analysis
TOP: Nursing Process: Assessment
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MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
2. During the health history, the client reports back and knee pain. Which of the following
interview questions should the nurse ask in order to further define the clients complaints? (Select
all that apply.)
1
2
When did the pain start?
What, if anything, lessens the pain?
3
Have you sought help for this pain before?
4
Can you describe the pain you feel to me?
5
Is there anything that makes the pain worse?
6
Has the pain affected your ability to earn a living?
ANS: 1, 2, 4, 5
The health history involves a lengthy client interview to gather subjective data about the clients
condition. Gather information about the clients health from the health history. The answers are
questions designed to obtain subjective information related to the clients complaints. The
remaining options are not of significant value related to the cause and treatment of the clients
pain.
PTS: 1 DIF: C OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
3. The nurse recognizes the importance of an accurate, thorough physical assessment and health
history. Which of the following facets of care are directly dependent on the database of
information collected? (Select all that apply.)
1
Identification of client likes and dislikes
2
Support of the nurse-client relationship
3
Selection of client-centered interventions
4
5
Revision of client care plan as appropriate
Evaluation of nursing and client outcomes
6
Identification of appropriate nursing diagnosis
ANS: 3, 4, 5, 6
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The accuracy of the database allows for the development of an individualized nursing diagnosis.
Physical assessment findings determine the etiology of the diagnosis so that the selection of
interventions is appropriate for the care plan. Physical assessment is ongoing, and thus the care
plan changes with the clients condition. Monitor the clients progress and responses to therapies
to review existing diagnoses and identify new problems.
PTS: 1 DIF: C REF: 554 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
4. Which of the following health history and physical assessment findings place an elderly client
admitted for abdominal pain at risk for infection? (Select all that apply.)
1
Redness at the IV site
2
Productive yellow cough
3
Foley catheter placement
4
5
History of bipolar disorder
Oral temperature of 98.8 F
6
Recent radiation for prostate cancer
ANS: 1, 2, 3, 6
Learn to group significant findings into clusters of data that reveal actual or risk for nursing
diagnoses. A history of bipolar disorder and an oral temperature of 98.8 F do not indicate the
client is at risk for an infection.
PTS: 1 DIF: C REF: 563 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress
Management
5. Which of the following nursing actions best shows an understanding of the guiding principles
regarding the inspection method of physical assessment? (Select all that apply.)
1
Positioning the client so as to expose body parts adequately
but with attention to modesty
2
Providing a general survey of the clients body, area by area
and extremity by extremity
3
Comparing each area inspected with the same area on the
opposite side of the clients body
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4
Evaluating each body area for size, shape, color, symmetry,
position, and abnormalities
5
Providing sufficient lighting to ensure adequate visualization
of the clients body during the assessment
Conducting the assessment in a time conscious manner to
minimize the clients physical and emotional discomfort
6
ANS: 1, 3, 4, 5
The inspection portion of the assessment is detail-oriented and must be done thoroughly, which
may be time-consuming.
PTS: 1 DIF: C REF: 596 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical
Assessment
6. A 76-year-old adult female is brought to a neighborhood client after being found wandering
around the local park. The client appears disheveled and reports being hungry. Which of the
following assessment and interview findings would cause the nurse to suspect elder abuse?
(Select all that apply.)
1
Keeps asking when she can go
2
Repeatedly states, Dont hurt me.
3
Chafing around wrists and ankles
4
5
Bruises in various stages of healing
Falls asleep in the examination room
6
Cant name the President of the United States
ANS: 2, 3, 4
These findings and behaviors are consistent with those exhibited by older adults who have
experienced physical and/or emotional abuse. The remaining options are not as directly
connected with abuse and may be a result of other physical or cognitive disorders.
Chapter 31. Medication Administration
MULTIPLE CHOICE
1. A client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic
(anti-nausea) medication. The nurse recognizes that which of the following is accurate?
1
An enteric-coated medication should be given.
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2
3
4
Medication will not be absorbed as easily because of the
nausea.
A parenteral route is the route of choice.
A rectal suppository must be administered.
ANS: 3
The parenteral route provides a means of administration when oral medications are
contraindicated. Onset of action is quicker. There is less cause for embarrassment than with a
rectal suppository. An enteric-coated medication is given orally. Because the client is vomiting,
the oral route should not be used. Nausea does not affect the rate of absorption. It is inaccurate to
state that a rectal suppository must be administered. A rectal suppository is one option. The
disadvantage of a rectal suppository is that insertion often causes embarrassment for the client. It
is contraindicated if there is rectal bleeding or if the client had rectal surgery. Stool in the rectum
can impair absorption.
DIF: A REF: 694 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
2. The client receiving an intravenous infusion of morphine sulfate begins to experience
respiratory depression and decreased urine output. This effect is described as:
1
Therapeutic
2
Toxic
3
Idiosyncratic
4
Allergic
ANS: 2
Toxic levels of morphine may cause severe respiratory depression. Toxic effects may develop
after prolonged intake of a medication or when a medication accumulates in the blood because of
impaired metabolism or excretion. The client with a decreased urine output is not excreting the
morphine. The therapeutic effect is the expected or predictable physiological response a
medication causes. Respiratory depression and decreased urine output are not the desired (i.e.,
therapeutic) effects of morphine.
An idiosyncratic effect is when a medication causes an unpredictable outcome, such as when a
client overreacts or underreacts to a medication. This is not an example of an idiosyncratic effect.
When a client experiences an allergic response to a medication, the medication acts as an
antigen, triggering the release of the bodys antibodies. The client may experience itching,
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urticaria, or a rash, or, in more severe cases, may have difficulty breathing. The clients response
to morphine is not an example of an allergic effect.
DIF: A REF: 691 OBJ: Comprehensive
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
3. The client is to receive a medication via the buccal route. The nurse plans to implement which
of the following actions?
1
Place the medication inside the cheek.
2
3
Crush the medication before administration.
Offer the client a glass of orange juice after administration.
4
Use sterile technique to administer the medication.
ANS: 1
Administration of a medication by the buccal route involves placing the solid medication in the
mouth and against the mucous membranes of the cheek until the medication dissolves. Crushing
the medication is not necessary because it is designed to dissolve in the clients cheek. Clients are
not to take any liquids with, or immediately after, medications given by buccal administration.
The mouth is not sterile. Sterile technique is not necessary for buccal administration.
DIF: A REF: 693 OBJ: Comprehensive
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
4. The physician orders a grain and a half of Seconal to help a client sleep. The label on the
medication bottle reads Seconal 100 mg. How many capsules should the nurse give the client?
1
2
1
3
4
2
ANS: 2
To calculate this problem, the nurse should first convert the measurements to one system.
Because 1 grain = 60 mg, the nurse may multiply 1 by 60 to equal 90 mg. The nurse may then
use the following formula for calculating a drug dosage:
90 mg
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100 mg x 1 capsule = 0.9 capsules
Because 0.9 of a capsule cannot be administered, it is rounded to 1 capsule. The nurse will
administer 1 capsule.
Options 1 and 3 are not correct dosage calculations. Furthermore, capsules cannot be halved.
Option 4 is not a correct dosage calculation.
DIF: B REF: 696 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
5. The physician has ordered 6 mg of morphine sulfate every 3 to 4 hours prn for a clients
postoperative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much
solution should the nurse give?
1
2
1/5 mL
1/3 mL
3
2/5 mL
4
1/4 mL
ANS: 3
The nurse should use the following formula to calculate a drug dosage:
6 mg
15 mg x 1 mL = 2/5 mL
Options 1, 2, and 4 are not correct dosage calculations.
DIF: B REF: 697 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
6. To determine proper drug dosages for children, calculations are most precisely made on the
basis of the childs:
1
Weight
2
Height
3
Age
Body surface area
4
ANS: 4
The most accurate method of calculating pediatric doses is based on a childs body surface area.
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Drug calculations are not most precise when made on the basis of a childs weight. Height and
weight do not always correlate with the maturity of the childs organs, such as the liver for
metabolizing a drug. Drug calculations are not most precise when made on the basis of a childs
height. Drug calculations are not most precise when made on the basis of a childs age. Children
vary widely in size and maturity for chronological age.
DIF: A REF: 698 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
7. The nurse is documenting administration of a medication that is given at 10:00 AM, 2:00 PM,
and 6:00 PM. The medication that the nurse is documenting is:
1
Morphine sulfate 10 mg q4h prn
2
Inderal 10 mg PO bid
3
Diazepam 5 mg PO tid
4
Keflex 500 mg PO q8h
ANS: 3
The medication is being given 3 times a day, 4 hours apart. The medication the nurse is
documenting is diazepam 5 mg PO tid. Although the medication is being given 4 hours apart, it
is not being given every 4 hours. If it were given every 4 hours, it could be given 6 times in 24
hours, not 3, as with tid administration. Bid means twice a day. The client is receiving the
medication 3 times a day. The medication is not administered every 8 hours.
DIF: A REF: 699 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
8. The nurse is working on the pediatric unit. In preparing to give medications to a preschool-age
child, an appropriate interaction by the nurse is:
1
Do you want to take your medication now?
2
Would you like the medication with water or juice?
3
Let me explain about the injection that you will be getting.
If you dont take the medication now, you will not get better.
4
ANS: 2
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Allowing the child the choice of taking a medication with water or juice may have greater
success because the child is involved. The child should not be given the option of not taking a
medication. The nurse should explain the procedure to a child, using short words and simple
language appropriate to the childs level of comprehension. Long explanations may increase a
childs anxiety. Option 4 is not a motivation for a child to take a prescribed medication. Giving
the child a star or token afterward would be more motivating for a child.
DIF: A REF: 715 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
9. In preparing two different medications from two vials, the nurse must:
1
Inject fluid from one vial into the other
2
Uncap the syringe and wipe the needle with an alcohol
preparation before inserting into either vial
3
Discard the medication from vial number 2 if medication from
vial number 1 is pushed into it
Insert air into the first vial, but not the second vial
4
ANS: 3
If a vial becomes contaminated with another medication, it should be discarded. Fluid from one
vial should not be injected into another, as it would contaminate the second vial. The needle
should not be wiped with alcohol. It is considered sterile and does not require to be wiped with
alcohol. Wiping the needle would place the nurse at risk for a needle stick. Air should be inserted
into both vials, making sure the needle does not touch the solution in the first vial.
DIF: B REF: 715 OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
10. The nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH
insulin for injection. The nurse instructs the client to:
1
Inject air into the regular insulin and then into the NPH insulin
2
Withdraw the regular insulin first
3
Inject air into and withdraw the NPH insulin immediately
4
Inject air into both vials and withdraw the regular insulin first
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ANS: 4
The client should be taught to inject air into both vials and withdraw the regular insulin first. Air
should be injected into the vial of NPH insulin and then the vial of regular insulin. The regular
insulin should be withdrawn after air has been injected into both vials. Air should be injected into
the vial of NPH insulin and then the vial of regular insulin. The regular insulin should be
withdrawn immediately after injecting the air into the vial of regular insulin. The NPH insulin is
then withdrawn.
DIF: A REF: 742 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
11. A client has a prescription for a medication that is administered via an inhaler. To determine
if the client requires a spacer for the inhaler, the nurse will determine the:
1
Dosage of medication required
2
Coordination of the client
3
Schedule of administration
4
Use of a dry powder inhaler
ANS: 2
Spacers are especially helpful when the client has difficulty coordinating the steps involved in
self-administering inhaled medications. The use of a spacer is not dependent on the dosage of
medication. The use of a spacer is not dependent on the schedule of administration. Spacers are
not required with the use of a dry powder inhaler.
DIF: A REF: 729 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
12. The student nurse reads the order to give a 1-year-old client an intramuscular injection. The
appropriate and preferred muscle to select for a child is the:
1
Deltoid
2
Dorsogluteal
3
Ventrogluteal
Vastus lateralis
4
ANS: 3
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Research that has investigated complications associated with IM injection sites indicates that the
ventrogluteal site is the preferred site for most injections given to adults and children over 7
months. The deltoid muscle is not developed enough for an IM injection in the 1-year-old client.
The dorsogluteal site is not recommended because of the risk of the needle hitting the sciatic
nerve. The vastus lateralis is a preferred site for infants less than 12 months old.
DIF: A REF: 751 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
13. The nurse administers the intramuscular medication of iron by the Z-track method. The
medication was administered by this method to:
1
Provide faster absorption of the medication
2
Reduce discomfort from the needle
3
Provide more even absorption of the drug
4
Prevent the drug from irritating sensitive tissue
ANS: 4
The Z-track method is used to minimize local skin irritation by sealing the medication in muscle
tissue. The Z-track method does not provide faster absorption of the medication. The Z-track
method does not reduce discomfort from the needle. The Z-track method does not provide a
more even absorption of the drug.
DIF: A REF: 753 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
14. The client is ordered to have eye drops administered daily to both eyes. Eye drops should be
instilled on the:
1
Cornea
2
Outer canthus
3
Lower conjunctival sac
4
Opening of the lacrimal duct
ANS: 3
Eye drops should be instilled into the lower conjunctival sac. The conjunctival sac normally
holds 1 or 2 drops and provides even distribution of medication across the eye. The cornea is
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very sensitive. If drops were instilled onto the cornea it would stimulate the blink reflex. The
outer canthus would not hold the eye drop, medication would be wasted, and it would not be
distributed evenly across the eye. The opening of the lacrimal duct is not the correct site for eye
drops to be instilled. It would not provide even distribution of drops across the eye, and
medication would most likely be wasted because this area could not contain the drops.
DIF: A REF: 723 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
15. Following the administration of ear drops to the left ear, the client should be positioned:
1
2
Prone
Upright
3
Right lateral
4
Dorsal recumbent with hyperextension of the neck.
ANS: 3
The client should remain in the side-lying position, in this case the right lateral position, for 2 to
3 minutes after ear drops are administered. The prone position is not recommended following
administration of ear drops. The upright position is not recommended following ear drop
administration. The ear drops would run out of the ear canal. The dorsal recumbent position with
the neck hyperextended is not recommended following the administration of ear drops.
DIF: A REF: 728 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
16. The order is for eye medication, ii gtt OD. The nurse administers:
1
2 mL to the right eye
2
2 drops to the left eye
3
2 drops to the right eye
2 drops to both eyes
4
ANS: 3
ii = 2; gtt = drops. OD = right eye. gtt is the abbreviation for drops, not mL. OS = left eye. OU =
both eyes.
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DIF: A REF: 723 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
17. The most effective way in the acute care environment to determine the clients identity before
administering medications is to:
1
2
3
4
Ask the clients name
Check the name on the chart
Ask the other caregivers
Check the clients name band
ANS: 4
To identify a client correctly, the nurse checks the medication administration form against the
clients identification bracelet and asks the client to state his or her name to ensure that the clients
identification bracelet has the correct information. The nurse may ask the client his or her name
if the identification bracelet is missing or illegible and obtain a new identification bracelet for the
client. The nurse should ask the client to state his or her full name. The nurse should not merely
say the clients name and assume that the clients response indicates that he or she is the right
person. Checking the name on the chart does not identify the right client. Asking other caregivers
is not the most effective way to determine a clients identity before administering medications.
The nurse should develop the habit of checking the clients name band.
DIF: A REF: 708 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
18. An order is written for Demerol 500 mg IM q3-4h prn for pain. The nurse recognizes that this
is significantly more than the usual therapeutic dose. The nurse should:
1
Give 50 mg IM as it was probably intended to be written
2
Refuse to give the medication and notify the nurse manager
3
Administer the medication and watch the client carefully
4
Call the prescriber to clarify the order
ANS: 4
The nurse should question the order if the written order is illegible, the dose seems unusually low
or high, or the medication seems inappropriate for the clients condition. The nurse should call the
prescriber to clarify the order. The nurse cannot independently change physicians orders. The
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nurse would have to call the prescriber and receive the order for the change. The nurse should
first call the prescriber and clarify the order. If the prescriber does not change the order, the nurse
may then refuse to give the medication and notify the nurse manager. The nurse could be held
accountable for administering an ordered medication that is knowingly inappropriate for the
client.
DIF: B REF: 705 OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
19. An order is written for 80 mg of a medication in elixir form. The medication is available in
80 mg/tsp strength. The nurse prepares to administer:
1
2 mL
2
5 mL
3
10 mL
4
15 mL
ANS: 2
The nurse should first change the household measurement to a metric equivalent (5 mL = 1 tsp).
Then the nurse should use the formula for calculating a medication dosage:
80 mg
80 mg 5 mL = 5 mL
Option 1 is an incorrect dosage.
Option 3 is an incorrect dosage. 10 mL would equal 2 teaspoons, in this case, 160 mg.
Option 4 is an incorrect dosage. 15 mL would equal 3 teaspoons, in this case, 240 mg.
DIF: B REF: 696-698 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
20. The client is to receive a Mantoux test for tuberculosis. This test is administered via an
intradermal injection. The nurse recognizes that the angle of injection that is used for an
intradermal injection is:
1
15 degrees
2
30 degrees
3
45 degrees
90 degrees
4
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ANS: 1
The angle of injection for an intradermal injection is 5 to 15 degrees. 30 degrees is not the
correct angle of injection. Subcutaneous injections may be administered at a 45-degree angle.
Subcutaneous or intramuscular injections may be administered at a 90-degree angle.
DIF: A REF: 753 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral
Therapies
21. The nurse prepares to administer an intradermal injection for the administration of
medication for:
1
Pain
2
Allergy sensitivity
3
Anticoagulant therapy
4
Low-dose insulin requirements
ANS: 2
Pain medications are not administered intradermally.
Intradermal injections are typically given for allergy testing or tuberculin screening.
Anticoagulants are not administered intradermally. They are typically given subcutaneously.
Intradermal injections are not used for low-dose insulin requirements.
DIF: A REF: 753 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designati