assessment Flashcards
(100 cards)
1
Q
Situation: Health Promotion is one of the significant Programs emphasized by the Department of Health and any tertiary hospital to prevent illness.
1. Health promotion is best represented by which activity? A. administering immunizations B. giving a bath C. preventing accidents in the home D. performing diagnostic procedures
A
A. administering immunizations
2
Q
- Which of the following is an example of the emotional component of wellness?
A. The client chooses healthy foods
B. A new father decides to take parenting classes
C. A client expresses frustration with her partner’s substance abuse
D. A widow with no family decides to join a bowling league
A
A. The client chooses healthy foods
Rationale:
3
Q
- Which individual appears to have “taken on” the sick role?
A. An obese client states, “I deserve to have a heart attack.”
B. A mother is ill and says, “I won’t be able to make your lunch today.”
C. A man with low back pains misses several physical therapy appointments
D. An older adult states, “My horoscope says I will be well again.”
A
A. An obese client states, “I deserve to have a heart attack.”
Rationale:
4
Q
- Because a client recently diagnosed with diabetes mellitus is confident that blood sugar control can be improved
with diet and exercise alone and recently checked out a video on the management of diabetes at the Health
Maintenance Office education center, the client’s actions are most representative of which model?
A. Health belief model
B. Clinical model
C. Role performance model
D. Agent-host-environment model
A
D. Agent-host-environment model
Rationale:
5
Q
Situation: The Nursing Service of a hospital is observing and adopting the Model of Benner’s Clinical Proficiency level.
5.A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is
at which of Benner’s stages of nursing expertise?
A. advanced beginner
B. competent
C. proficient
D. expert
A
B. competent
Rationale:
6
Q
- Which provides the best explanation of describing nursing as a practice discipline?
A. nursing focuses on performing the professional role
B. it takes time and experience to become a competent nurse
C. research and theory development is a central focus
D. nurses function as a members of a team who form a practice group
A
A. nursing focuses on performing the professional role
Rationale:
7
Q
- Person, environment, health, and nursing constitute the metaparadigm for nursing because they do which of the
following?
A. provide a framework for implementing the nursing process
B. can be utilized in any setting when caring for a client
C. can be utilized to determine applicability of a research study
D. focus on the needs of a group of clients
A
B. can be utilized in any setting when caring for a client
Rationale:
8
Q
- Which is an accurate statement about the role of nursing theory?
A. practice theories assist nurse to reflect on the effectiveness of what they do
B. midlevel theories, describing the interrelationships among a broad range of concepts within nursing, have
been well tested through nursing research
C. all school of nursing in the United States are organized around one of the conceptual models described in
this chapter
D. nursing theory guides the direction of research but not that of education or practice
A
B. midlevel theories, describing the interrelationships among a broad range of concepts within nursing, have
been well tested through nursing research
Rationale:
9
Q
- The client has difficulty in swallowing problem. Although the client refused the procedure, the nurse insisted and
inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because
the nurse is most likely to be found guilty of which of the following?
A. an unintentional tort
B. assault
C. invasion of privacy
D. battery
A
C. invasion of privacy
Rationale:
10
Q
Situation: A male surgical nurse is preparing the post-operative orders.
10. The staff nurse discovers that a Physician has prescribed an unusually large dosage of medication. Which is the most appropriate action? A. administer the medication B. notify the prescriber C. call the pharmacist D. refuse to administer the medication
A
B. notify the prescriber
Rationale:
11
Q
- A Physician prescribes one tablet, but the nurse accidentally administers two. After notifying the physician, the
nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in
suing the nurse for malpractice?
A. no, the client was not harmed
B. no, the nurse notified the primary care provider
C. yes, a breach of duty exists
D. yes, foreseeability is present
A
D. yes, foreseeability is present
Rationale:
12
Q
- The Physician consultant in a tertiary hospital wrote a do-not-resuscitate (DNR) order. The nurse recognizes that
which applies in the planning care for this client?
A. The client may no longer make decisions regarding his or her own health care
B. The client and family know that the client will most likely die within the next 48 hours
C. The nurses will continue to implement all treatments focused on comfort and symptom management
D. A DNR order from a previous admission is valid for the current admission
A
B. The client and family know that the client will most likely die within the next 48 hours
Rationale:
13
Q
- When an ethical issue arises, one of the most important nursing responsibilities in managing client care
situations is which of the following?
A. be able to defend the morality of one’s own actions
B. remain neutral and detached when making ethical decisions
C. ensure that a team is responsible for deciding ethical questions
D. follow the client and family’s wishes exactly
A
A. be able to defend the morality of one’s own actions
Rationale:
14
Q
- Which of the following situations is most clearly a violation of the underlying principles associated with
professional nursing ethics?
A. the hospital policy permits use of internal fetal monitoring during labor. However, there is literature to
both support and refute the value of this practice
B. when asked about the purpose of a medication, a nurse colleague responds, “Oh, I never look them up. I
just give what is prescribed.”
C. the nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by fellow nurses at another facility
D. a client reports that he didn’t quite tell the doctor the truth when asked is he was following this
therapeutic diet at home
A
B. when asked about the purpose of a medication, a nurse colleague responds, “Oh, I never look them up. I
just give what is prescribed.”
Rationale:
15
Q
Situation: Maria is a Nurse Manager in St. Peters Hospital. One of the clients came to her seems confused and asking if she can help her in her personal problems.
- Which of the following statements would be most helpful when a nurse is assisting clients in clarifying their values?
A. “That was not good decision. Why did you think it would work?”
B. “The most important is to follow the plan of care. Did you follow all your doctor’s orders?”
C. “Some people might have made a different decision. What led you to make your decision?”
D. “If you had asked me, I would have given you my opinion about what to do. Now, how do you feel about
your choice?”
A
D. “If you had asked me, I would have given you my opinion about what to do. Now, how do you feel about
your choice?”
Rationale:
16
Q
- Which of the following is an example of a primary prevention activity?
A. antibiotic treatment of a suspected urinary tract infection
B. occupational therapy to assist a client in adapting his or her home environment following a stroke
C. nutrition counseling for young adults with a strong family history of high cholesterol
D. removal of tonsils for a client with recurrent tonsillitis
A
C. nutrition counseling for young adults with a strong family history of high cholesterol
Rationale:
17
Q
- A client is seeking to control health care costs for both preventive and illness care. Although no system
guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be
seen with
A. Medicare
B. an individual fee-for-service insurance
C. a preferred provider organization (PPO)
D. a health maintenance organization (HMO)
A
D. a health maintenance organization (HMO)
Rationale:
18
Q
- When performing collaborative health care, Nurse Manager Maria must implement which of the following?
A. assume a leadership role in directing the health care team
B. rely on the expertise of other health care team members
C. be physically present for the implementation of all aspects of the care plan
D. delegate decision-making authority to each health care provider
A
D. delegate decision-making authority to each health care provider
Rationale:
19
Q
Situation: Sophie a Medical nurse is finally checking the discharge orders of a client Mr. George.
- The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client
states which of the following?
A. “As soon as I get home, the nurse will come out, look at where I live, and see what kind of care I will need.”
B. “All I need are my medications and a ride home. Then I’m all ready for discharge.”
C. “When I visit my doctor in 10 days, they will show me how to change my bandages.”
D. “I have the phone numbers of the home care nurse and the therapist who will visit me at home tomorrow.”
A
C. “When I visit my doctor in 10 days, they will show me how to change my bandages.”
Rationale:
20
Q
- St. Peters Hospital a tertiary hospital is adopting the new modern system in their hospital. What is the
challenge most associated with the utilization of an electronic client record system?
A. cost
B. accuracy
C. privacy
D. durability
A
C. privacy
Rationale:
21
Q
- What is one disadvantage associated with electronic (e.g., Internet-based) courses?
A. they take longer
B. interpersonal communication is not possible
C. everyone has to “log on” at the same time
D. it is harder to establish a sense of community
A
C. everyone has to “log on” at the same time
Rationale:
22
Q
- What is the primary advantage of using computers while conducting nursing research?
A. locating potential participants
B. designing the steps of the research plan
C. analyzing the quantitative data
D. disseminating the research findings
A
C. analyzing the quantitative data
Rationale:
23
Q
Situation: One nurse expresses that the manager prepared the holiday work schedule unfairly. The manager states that it is the same type of schedule used in the past and other nurses have no problems with it.
- Which response indicates the nurse is displaying an attitude of critical thinking?
A. accepting the preferences of the other nurses since there are several of them
B. recognizing that the nurse must be researched a false conclusion
C. considering going to a higher authority than the manager for an explanation
D. continuing to query the manager until the nurse understands the explanation
A
C. considering going to a higher authority than the manager for an explanation
Rationale:
24
Q
- In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and performs
which of the following before implementing the plan?
A. reexamines the purpose for making the decision
B. consults the client and family members to determine their view of the criteria
C. identifies and considers various means for reaching the outcomes
D. determines the logical course of action should intervening problems arise
A
B. consults the client and family members to determine their view of the criteria
Rationale:
25
25. Which reasoning process describes the nurse’s actions when the nurse evaluates possible solutions for care of
an infected wound for optimal client outcomes?
A. intuition
B. research process
C. trial and error
D. problem solving
Situation: Every nurse must utilize a nursing tool which is the Nursing Process to determine the problems of the
clients and deliver safe patient care.
B. research process
Rationale:
26
```
26. Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the
nursing process to provide nursing care?
A. proposes hypotheses
B. generates desired outcomes
C. reviews results of laboratory tests
D. documents care
```
B. generates desired outcomes
Rationale:
27
27. Which of the following elements is best categorized as secondary subjective data?
A. the nurse measures a weight loss of 10 pounds since the last clinic visit
B. spouse states the client has lost all appetite
C. the nurse palpates edema in lower extremities
D. client states severe pain when walking up stairs
D. client states severe pain when walking up stairs
Rationale:
28
28. The use of conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
A. correlation of the data with other members of the health care team
B. demonstration of cost-effective care
C. utilization of creativity and intuition in creating a plan of care
D. collection of all necessary information for a thorough appraisal
A. correlation of the data with other members of the health care team
Rationale:
29
29. The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a
seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?
A. Assess the client’s needs.
B. Delineate the client’s problems and strengths.
C. Determine which interventions are most likely to succeed.
D. Estimate the cost of several different approaches.
B. Delineate the client’s problems and strengths.
Rationale:
30
30. In the diagnostic statement, “Excess fluid volume related to decreased venous return as manifested by lower
extremity edema (swelling),” the etiology of the problem is which of the following?
A. Excess fluid volume
B. Decreased venous return
C. Edema
D. Unknown
A. Excess fluid volume
Rationale:
31
Situation: After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the post anesthesia recovery unit. The client has been on the orthopedic floor for several hours.
```
31. Which type of planning will be least useful during the first shift on the orthopedic unit?
A. Initial
B. Ongoing
C. Discharge
D. Strategic
```
D. Strategic
Rationale:
32
32. The nurse recognizes which of the following as a benefit of using a standardized care plan?
A. No individualization is needed
B. The nurse chooses from a list of interventions
C. They are much shorter than nurse-authored care plans
D. They have been approved by accrediting agencies
B. The nurse chooses from a list of interventions
Rationale:
33
33. Which of the following is likely to occur if the goal statement is poorly written?
A. There is no standard against which to compare outcomes
B. The nursing diagnoses cannot be prioritized
C. Only dependent nursing interventions can be used
D. It is difficult to determine which nursing interventions can be delegated.
D. It is difficult to determine which nursing interventions can be delegated.
Rationale:
34
34. Which of the following principles does the nurse use in selecting interventions for the care plan?
A. Actions should address the etiology of the nursing diagnosis
B. Always select independent interventions when possible
C. There is one best intervention for each goal/outcome
D. Interventions should be “doing”, not just “monitoring”
C. There is one best intervention for each goal/outcome
Rationale:
35
```
35. When initiating the implementation phase of the nursing process, the nurse performs which of the following
phases first?
A. Carrying out nursing interventions
B. Determining the need for assistance
C. Reassessing the client
D. Documenting interventions
```
A. Carrying out nursing interventions
Rationale:
36
36. Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity
before it is carried out?
A. When the activity is routine (e.g., raising the bed rails)
B. When the activity occurs at regular intervals (e.g., turning the client in bed)
C. When the activity is to be carried out immediately (e.g., a stat medication)
D. It is never acceptable
Situation: Nurses are always reminded to observe proper charting in documentation.
C. When the activity is to be carried out immediately (e.g., a stat medication)
Rationale:
37
37. Which action by a nurse ensures confidentiality of a client’s record?
A. The nurse logs on to the client’s file and leave the computer to answer the client’s call light
B. The nurse shares her computer password
C. The nurse closes a client’s computer file and logs off
D. The nurse leaves client computer worksheets at the computer work station
C. The nurse closes a client’s computer file and logs off
Rationale:
38
38. The case management model using critical pathways would be appropriate for a client with which diagnosis?
A. Myocardial infarction (heart attack)
B. Diabetes, hypertension
C. Myocardial infarction, diabetes, hypertension
D. Diabetes, hypertension, an infected foot ulcer, senile dementia
C. Myocardial infarction, diabetes, hypertension
Rationale:
39
39. After making a documentation error, which action should the nurse take?
A. Use correcting liquid to cover the mistake and make a new entry
B. Draw a line through it and write error above the entry
C. Draw a line through it and write mistaken entry above it
D. Draw a line through the mistake and write mistaken entry with initials above it.
Situation: The Pediatric Nurse is attending to the needs of the newly admitted children at different age group.
Significant principles are important to be considered to deliver safe patient care. The following refer to these
questions.
B. Draw a line through it and write error above the entry
Rationale:
40
40. The parents of a 5-month-old infant and a 3-year old child ask the nurse abut the sequence and timing of
developmental milestones for the infant. Which is the most appropriate response?
A. “This infant should reach the milestones at the same time as your older child.”
B. “The infant may reach the milestones in a different order than your older child.”
C. “The sequence of reaching each milestone should follow the same pattern but may be at a different rate.”
D. “There are no predictable patterns. Try to enjoy the uniqueness of each child.”
D. “There are no predictable patterns. Try to enjoy the uniqueness of each child.”
Rationale:
41
41. The nurse knows that the study of growth and development is an exploration of which of the following?
A. Physical changes of the growing child
B. Increasing complexity of function and skill progression of the growing child
C. Environmental factors such as family, religion and culture of the growing child
D. Physical developments and the increasing level and progression of function and skill of the growing child
D. Physical developments and the increasing level and progression of function and skill of the growing child
Rationale:
42
42. The nurse examines a 2-year old child recently hospitalized with pneumonia. Which pattern of behavior is most
likely to be exhibited by the child?
A. Lies quietly while the nurse listens to the lungs
B. Asks many questions about what the nurse is doing and hearing
C. Fusses, cries and pushes the nurse away during assessment of the breath sounds
D. Enjoys playing “nurse” with the stethoscope, and listens t self and others’ breath sounds
C. Fusses, cries and pushes the nurse away during assessment of the breath sounds
Rationale:
43
43. A 14-year old is scheduled to have surgical repair of a spinal curvature (scoliosis). The adolescent will be
hospitalized for about two weeks. Which nursing intervention will be most helpful during the hospital stay?
A. Have peers visit frequently during the day
B. Instruct parents to room-in with her
C. Encourage her to go to the recreation room
D. Encourage her to arrange for her teachers to provide her with homework
B. Instruct parents to room-in with her
Rationale:
44
Situation: The parent of an 8-month old girl who has been admitted to the hospital with pneumonia is worried about the infant having sudden infant death syndrome (SIDS).The parent stated that “My sister’s baby died at the age of 2 months and all he had was a little cold.
44. Which is the nurse’s best response?
A. “You don’t need to worry. Your daughter is too old for SIDS.”
B. “Girls are less likely to have SIDS than boys are.”
C. “We don’t know what causes SIDS, so I would try not to worry about it.”
D. “You must be very anxious; let’s talk about SIDS and what you are thinking.”
D. “You must be very anxious; let’s talk about SIDS and what you are thinking.”
Rationale:
45
45. Four-year-old Angie, whose grandmother recently died, tells the nurse, “My grandma has wings just like
angels. She flew to heaven yesterday and tomorrow she’ll be back.” Which is the nurse’s best response?
A. “She’s not coming back, honey.”
B. “It is normal for a little one to make believe.”
C. ”You must miss your grandma a lot.”
D. “When people get old, they die.”
C. ”You must miss your grandma a lot.”
Rationale:
46
46. Which statement most accurately describes physical development during the school-age years?
A. Child’s weight almost triples
B. Child acquires stereognosis
C. Few physical changes occur during middle childhood
D. Fat gradually increases, which contributes to the child’s heavier appearance
C. Few physical changes occur during middle childhood
Rationale:
47
```
47. The routine physical examination of a female client between the ages of 25 and 64 is most likely to reveal that
the client has which type of cancer?
A. Cervical cancer
B. Lymphoma
C. Lung cancer
D. Colon cancer
```
A. Cervical cancer
Rationale:
48
48. Which statement about moral development in adults is the most correct?
A. Moral development is completed during adolescence
B. Moral development continues throughout adulthood
C. Moral development is highly individualized
D. Moral development correlates to spiritual development
Situation: A nurse in tertiary hospital with a long-term care facility (Elderly Unit) is caring for several older adults with
noticeable hearing losses.
B. Moral development continues throughout adulthood
Rationale:
49
49. Which is the best way for the nurse to communicate with these clients?
A. Speak slowly using the proper volume and as few words as possible
B. Write the information using large lettering
C. Speak in a low and distinct voice tone
D. Have the client increase the volume in the hearing aid
A. Speak slowly using the proper volume and as few words as possible
Rationale:
50
50. While being admitted to rehabilitation unit an 82-year old woman mentions to the nurse that she “has trouble
holding her water,” adding “if I could have that tube back in me like I had in the hospital, I wouldn’t have so
many accidents.” What is the nurse’s best response?
A. “Don’t worry, the staff will bring plenty of pads to keep you dry.”
B. “I’ll put the tube back in you so you will stay dry.”
C. “Tell me more about your problem.”
D. “Just call the staff and we will help you to the bathroom in time.”
D. “Just call the staff and we will help you to the bathroom in time.”
Rationale:
51
Situation: Assessment is one of the significant components of the nursing process. Gina a Novice nurse is assigned in a Medical ward. She is preparing to continue the nursing assessment to several admitted patients.
51. When performing an initial assessment, what phrase validates the importance of collecting past health
history?
A.To determine both current and future health risks
B. To determine both allergies to food or drugs
C. To ensure the client receives anyspecific dietary needs
D. To ensure the client receives all prescribed medications
A.To determine both current and future health risks
Rationale:
52
52. Gina is performing a psychosocial history on a 56-year-old woman with a history of diabetes and hypertension being brought to the emergency room with multiple bruises after an argument with her husband. In performing the psychosocial assessment, what action must Gina take?
A. Determine whether the client has allergies.
B. Determine what medications the client is taking.
C. Establish an atmosphere of trust.
D. Promote an environment of fun and harmony.
C. Establish an atmosphere of trust.
Rationale:
53
53. Which clinicalscenario validates an appropriate question for a male patient to determine his mentalstatus?
A. Asking an elderly man about "pop" singers
B. Asking a 23-year-old man about his education level
C. Asking a teenage girl about her cultural background
D. Asking an 80-year-old woman about sexual practices
B. Asking a 23-year-old man about his education level
Rationale:
54
54. Gina is preparing a plan of care for an individual just admitted to the unit. She is assessing the client. What
data when analyzed would be the most significant?
A. The client’s ability to utilize large words
B. The client’s ability to speak logically
C. The client’s ability to communicate in English
D. The client’s ability to randomly speak his mind
B. The client’s ability to speak logically
Rationale:
55
```
55. If Gina is assessing a client's psychosocial development, what indicators would be relevant to understanding
the client's developmentalstage?
A. The client’s age
B. The client’srace
C. The client’s personal history
D. The client’s current health status
```
C. The client’s personal history
Rationale:
56
Situation: Carlo an Out Patient nurse clinic nurse is conducting an interview to a 28-year-old healthy Asian woman just moved to the city and is seeing the physician for the first time.
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56. What information would be beneficial as the nurse develops a relationship with the client?
A. Family health history
B. Past health history
C. Habits, customs, beliefs
D. Psychosocial history
```
C. Habits, customs, beliefs
Rationale:
57
57. Carlo the nurse also admitted an 18-year-old woman brought to the clinic after falling down steps at the high
school and fracturing her right wrist. He uses inspection, percussion, and auscultation to determine the client's respiratory status. With percussion, Nurse Carlo noted resonance. What action should he take?
A. Alert the physician to the abnormal finding.
B. Teach the client to cough and deep breathe.
C. Document the results as a normal finding.
D. Instruct the client to breathe through her nose.
D. Instruct the client to breathe through her nose.
Rationale:
58
58. Carlo requested to a student nurse to listen to the heart of a 42-year-old man and notes an extra sound. The
student confirmsthe presence of the extra sound with Nurse Carlo and together it is noted that the client has a murmur. Which characteristic isthe best description of a heart murmur?
A. Pitch
B. Intensity
C. Duration
D. Quality
A. Pitch
Rationale:
59
59. A client is being admitted to the hospital from the physician's office. The orders will be faxed to the hospital
unit shortly. After Nurse Carlo completes the initial assessment and client history, develops a plan of care
based on the assessment, how often should Carlo complete a physical assessment on the client?
A. Per physician orders
B. At the beginning of every shift
C. Before 0900 every day
D. Based on the client’s condition
B. At the beginning of every shift
Rationale:
60
60. Carlo admitted a 68-kg 65-year-old woman to the hospital this morning with a medical diagnosis of
dehydration. When taking the client's history, which information is mostsignificant?
A. The client has noticed an increase in being thirsty over the last 2 weeks.
B. The client has lost 8 lb over 2 weeks using the same scale at home.
C. The client's urine has been dark, yellow, and clear.
D. The client has had trouble swallowing,stating she does not have enough saliva.
C. The client's urine has been dark, yellow, and clear.
Rationale:
61
Situation: An Out Patient Clinic is conducting a Health Promotive lecture. The classic definition of "wellness" is an integrated method of functioning that is oriented to maximizing the prospective of which the individual is capable of achieving within his environment. The following questions refer to health promotion and rehabilitation.
```
61. A nurse would focus on which concept when promoting a client's well-being?
A. Being free of disease
B. Ongoing goal toward greater wellness
C. Prevention of illness
D. Being free of injury
```
C. Prevention of illness
Rationale:
62
62. A male client who has been paraplegic since an accident 6 years ago is in for a follow-up visit for a laceration
on his lower left leg from a wheelchair basketball game he participated in last week. The client is bright,
cheery, and eager to get back to playing basketball. In revising the client's plan of care, what modelshould the
nurse use asthe foundation?
A. Role-performance model
B. Reiterative model
C. Clinical model
D. Eudemonistic model
C. Clinical model
Rationale:
63
63. A nurse is working with a male client who has been noncompliant with treatment in the past. The client has a
long history of alcohol abuse and diabetes. Through discussion the nurse learns a great deal about the client,
his past, his beliefs and where he sees himself in the future. How will thisinformation assist the nurse?
A. Understanding why a client isseeking medical attention
B. Using the modelsto educate a client on illness prevention
C. Understanding the client’s perceptionsto aid in communication
D. Providing clients withmotivatorsto improve their health
A. Understanding why a client isseeking medical attention
Rationale:
64
Situation: Fe is a Clinic Nurse in the Out-Patient Clinic. The following patients seek consultation. One is a 32-year-old female client who is overweight with a 2-year history of diabetes has had some issues with controlling her blood sugar and another medication is being added to her regimen. Structuring a diet for the client would not be as beneficial as having the client use self-management support strategies.
```
64. Which strategy would benefit the client and assist in meeting the goal of controlling the blood sugar?
A. Behavior management
B. Role management
C. Emotional management
D. Physical management
```
A. Behavior management
Rationale:
65
65. Fe is also attending to the admission of a male client who is an account executive is in need of reducing his
blood pressure. He made some changesin his diet and state that he needsto exercise but neverseems to find
time. Which of the following skill sets will be the most beneficial to the client at this point in his treatment
plan?
A. Problem solving
B. Decision making
C. Resource utilization
D. Client empowerment
D. Client empowerment
Rationale:
66
```
66. Nurse Fe is working with Lito a 32 year old, with low health literacy in the clinic this morning. The nurse is providing education on his condition and how to improve his health. Which question should the nurse expect Lito will ask to verify his understanding of the information provided?
A. How often should I exercise?
B. What is my main problem?
C. When is my payment due?
D. What do I need to do?
```
A. How often should I exercise?
Rationale:
67
67. Nurse Fe is admitting with a client who is obese (>100 lb over ideal body weight). In order to promote healthy
living, which goalshould the client work on?
A. Losing weight
B. Losing 100 pounds
C. Losing 50 pounds a year
D. Walking for 15 minutes three times this week
D. Walking for 15 minutes three times this week
Rationale:
68
68. A 51-year-old female is more than 50 lb overweight with a history of degenerative joint disease. Nurse Fe is completing a nutritional assessment. What additional assessment data should Nurse Fe collect?
A. Have the client keep a 3-day dietary log.
B. Have the client list her favorite foods.
C. Have the client bring in a copy of her grocery list.
D. Have the client write down the timesshe ate.
A. Have the client keep a 3-day dietary log.
Rationale:
69
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69. Nurse Fe is attending with a female client who is 5'2" and 170 lb with high cholesterol. Nurse Fe just informed that she is a prime candidate for coronary artery disease (CAD). The client is aware that diet, exercise, and a good mental attitude are necessary in order to promote health. Which health care professional would benefit
the client at thistime?
A. Physical therapist
B. Cardiologist
C. Psychologist
D. Dietitian
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D. Dietitian
Rationale:
70
70. Nurse Fe, conducts health assessment, to a male client tells her thatsince he was promoted but not happy and
just lounges on the couch after dinner. The nurse has noted the client's weight and blood pressure are
increasing. What prescription should the nurse expect the physician to write?
A. Nutritional consultation
B. Routine daily exercise
C. Blood pressure medication
D. Antidepressant medication
A. Nutritional consultation
Rationale:
71
Situation: Kate is preparing the patients’ consultation list. During a routine office visit, a male client mentions all his physical and mental problems are due to the increased stress in his life. The client requests help in coping with stress.
71. What should the Nurse Kate include in her assessment?
A. A history of the client’s daily physical activity routines
B. An evaluation of the client’s diet through the use of daily logs
C. An evaluation of the client’stobacco and alcohol use
D. A history detailing how the client feels and acts when stressed
D. A history detailing how the client feels and acts when stressed
Rationale:
72
72. A female client complaining of increasing stress in her life visits the clinic. After the assessment and the
discussion, Nurse Kate and client develop a plan. Which intervention should the nurse include in her
instructionsto the client?
A. Ensure 8 hours ofsleep a night
B. Reduce exercise from five times a week to two times a week
C. Drink one glass of wine nightly before bed
D. Reduce intake of complex carbohydrates
A. Ensure 8 hours ofsleep a night
Rationale:
73
73. A 45-year-old woman is visiting the clinic for her annual checkup. During the assessment the client admits to
drinking at least two alcoholic drinks a day. What additional health issue should Nurse Kate assessfor?
A. Drug abuse
B. Cirrhosis
C. Alcohol abuse
D. Stress
C. Alcohol abuse
Rationale:
74
74. A 17-year-old male unemployed high school dropout is visiting the clinic for relief from a sinusinfection. Nurse
Kate provides education on symptom management. What other topic of education should the nurse address
for this client?
A. Fast driving
B. Poor eating habits
C. Drug abuse
D. Unprotected sex
C. Drug abuse
Rationale:
75
Situation: A client presents to the emergency department with shortness of breath. During the assessment, the nurse discovers the client smokes. Nurse Barbie provides educational materials to the client regarding smoking cessation.
75. Whatstatement validatesthe client's understanding of the risksinvolved with smoking?
A. “I have tried manytimesto quitsmoking.”
B. “I getso anxious, all I do is yell at the kids.”
C. “If I quit, I will put on unnecessary weight.”
D. “If I don’t quit I amat risk for many diseases.”
D. “If I don’t quit I amat risk for many diseases.”
Rationale:
76
76. Another client a 67-year-old female client who lives alone was admitted to the hospital complaining of pain
and bruising on her left leg. The client is being discharged this morning. What action should the Nurse Barbie
take in preparation for the client's discharge?
A. Review the client’s home environment with the client.
B. Instruct the client on how to take the pain medication.
C. Recommend the client buy new shoesthat are light.
D. Recommend the client keep her left leg elevated.
B. Instruct the client on how to take the pain medication.
Rationale:
77
77. Nurse Barbie is presenting to a community group on the topic of health and wellness, especially early
detection. The nurse emphasizes the need for individuals to be aware of chronic diseases like hypertension,
coronary artery disease, cancer, and diabetes. Which intervention should the nurse stress?
A. Adopt a healthy diet.
B. Exercise regularly.
C. Schedule screening tests.
D. Quit smoking.
Situation: Mae is a new graduate nurse for one year. She just finished her 6 months voluntary training program in a
secondary hospital.
A. Adopt a healthy diet.
Rationale:
78
78. Which of these actionsismost typical of a novice nurse?
A. Assesses the most important client problemsfirst
B. Prioritizes assessments based on the client’s diagnosis
C. Independently implements nursing actions based on the client assessment
D. Follows the assessment checklist carefully when doing client assessments
D. Follows the assessment checklist carefully when doing client assessments
Rationale:
79
79. Which of these nursing actions indicate that Nurse Mae is using evidence-based nursing practice?
A. The nurse follows the hospital policy when doing a wound dressing change.
B. The nurse studies current nursing journals for data to use in client teaching.
C. The nurse checks medications carefully before giving them to a client.
D. The nurse uses a computerized documentation system for charting care.
B. The nurse studies current nursing journalsfor data to use in client teaching.
Rationale:
80
80. A client tells the Nurse Mae about taking large amounts of vitamins to help maintain health. Which information
should the Nurse Mae include in client teaching?
A. Vitamins from established pharmaceutical companies are safe to take.
B. Vitamin supplements are ineffective in treating health problems.
C. It is important to discuss the use of vitamins with the physician.
D. An adequate amount of vitamins can be obtained from food.
D. An adequate amount of vitamins can be obtained from food.
Rationale:
81
81. A new client asks the Nurse Mae, "What do you think about using herbal treatments instead of prescribed medications for treating health problems?" Which response by the nurse is most appropriate?
A. "Which types of herbal remedies are you using?"
B. "Are you currently taking any herbal medications?"
C. "Do you believe that herbal therapies can be helpful?"
D. "Are you aware that herbal drugs can have many side effects?"
B. "Are you currently taking any herbal medications?"
Rationale:
82
Situation: Another Novice Nurse just finished her training period and is assigned in an Out Patient department. As a routine preparation for consultation she is conducting interview with patients.
82. Which action should the Nurse working in a outpatient care clinic take first in order to be most effective in
assisting a patient to achieve blood pressure control?
A. Educate the patient about the consequences of hypertension.
B. Provide patient teaching about diet and high blood pressure.
C. Determine the patient’s beliefs about health and wellness.
D. Schedule the patient for frequent clinic appointments
B. Provide patient teaching about diet and high blood pressure.
Rationale:
83
83. Which of the following actions is most appropriate for the Head Nurse working in a Physician's office to
delegate to a nursing Staff Nurse?
A. Teach a patient about a newly ordered medication.
B. Assess a patient’s understanding of a disease process.
C. Call a patient to follow up about a medication change.
D. Set up equipment for aminorsurgical procedure.
A. Teach a patient about a newly ordered medication.
Rationale:
84
84. When orienting a nurse with extensive hospital experience working in an Out Patient Clinic setting, the nurse
manager plans to assist the nurse in learning techniques for:
A. focused assessment.
B. holistic assessment.
C. head-to-toe assessment.
D. multidimensional assessment.
A. focused assessment.
Rationale:
85
85. To ensure that a 72-year-old client in the clinic takes ordered antibiotics appropriately, the most important
nursing intervention is to:
A. call the antibiotic order to the client’s pharmacy.
B. give the client samples of the antibiotic.
C. provide medication teaching to the client and family.
D. be sure the client has the prescription.
C. provide medication teaching to the client and family.
Rationale:
86
86. An example of primary preventive care provided by the nurse in the outpatient clinic is:
A. encouraging a 22-year-old to exercise several times weekly.
B. screening a 50-year-old for prostate cancer.
C. teaching a newly diagnosed diabetic to self-administer insulin.
D. checking blood pressure for an obese client.
C. teaching a newly diagnosed diabetic to self-administer insulin.
Rationale:
87
87. Which of these nursing actions for a client with high blood pressure is most appropriate for the nurse working
in the out- patient clinic setting to delegate midwives?
A. Education about symptoms of hypertension
B. Weekly monitoring of blood pressure (BP)
C. Referral to a dietitian for dietary teaching
D. Assessment for possible complications
A. Education about symptoms of hypertension
Rationale:
88
88. Which action by a new nurse orienting to work in the outpatient clinic indicates a need for more education
about the professional role in an Out Patient Clinic care?
A. The nurse asks the nursing assistant to schedule a client for the next appointment.
B. The nurse instructs a client to call the clinic if medication side effects occur.
C. The nurse calls a client on the telephone to ask about daily sodium intake.
D. The nurse leaves a message about a laboratory test on the client’s phone recorder.
D. The nurse leaves a message about a laboratory test on the client’s phone recorder.
Rationale:
89
Situation: In the Nursing Unit Charge Nurses must be aware of the different procedures to be delegated to Novice nurses and other members of the health team.
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89. Which nursing activity is appropriate for the Charge Nurse to delegate to a Novice Nurse working in an
ambulatory care setting?
A. Performing telephone triage
B. Assisting with procedures
C. Developing treatment protocols
D. Coordinating client care
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B. Assisting with procedures
Rationale:
90
90. Charge Nurses are working in a clinic with a Novice nurses. Which of these activities is most appropriate for the
staff nurses to do?
A. Take vital signs as clients arrive for appointments.
B. Schedule follow-up appointments as clients leave.
C. Administer immunizations and vaccinations.
D. Teach clients about new medications or treatments.
A. Take vital signs as clients arrive for appointments.
Rationale:
91
91. A client who is newly enrolled in a health maintenance organization (HMO) tells the nurse, "I don't understand
exactly what an HMO is." The nurse explains that HMOs:
A. offer only health promotion services.
B. are designed to help contain health care costs.
C. allow clients more flexibility in choosing their physicians.
D. provide ambulatory care services rather than inpatient services.
B. are designed to help contain health care costs.
Rationale:
92
92. Which of these nursing activities is an example of the case management role of the nurse who is working in a
university student health clinic?
A. Referrals to appropriate services such as mental health and nutrition
B. Administration of meningococcal immunizations
C. Telephone triage of clients to determine the need for clinic services
D. Use of standardized protocols to order medications
Situation: A Charge Nurse needs to delegate some patient care activities to a Novice Nurse.
A. Referrals to appropriate services such as mental health and nutrition
Rationale:
93
93. Which care is most appropriate to delegate?
A. Pre-meal blood glucose monitoring for a client with diabetes
B. Ambulation of a client who has been complaining of dyspnea
C. Assistance with feeding for a client who has difficulty swallowing
D. Vital sign checks for a client who has just been admitted with chest pain
D. Vital sign checks for a client who has just been admitted with chest pain
Rationale:
94
94. Which of the following tasks is most appropriate for the Charge nurse to delegate to a Novice nurse working on
the general medical unit?
A. Assessment of a newly admitted client
B. Insertion of a nasogastric tube for a nauseated client
C. Administration of insulin to a diabetic client
D. Education of a client about risk factors for heart disease
A. Assessment of a newly admitted client
Rationale:
95
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95. For physiologically unstable clients, such as those in the intensive care unit, the optimal model for organizing
nursing care is:
A. primary nursing.
B. functional nursing.
C. case management.
D. team nursing.
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C. case management.
Rationale:
96
96. When the nurse manager is making hospital staffing assignments based on acuity, which factor is most
important to consider?
A. The number of clients on each nursing unit
B. The medical diagnoses of the clients on each unit
C. The recent results from client satisfaction surveys for each unit
D. The amount of time that each client is likely to require for nursing care
A. The number of clients on each nursing unit
Rationale:
97
97. When a medication error occurs, the nurse should complete an incident report in order to:
A. identify the staff member who is responsible for the error.
B. assist with changes to improve future medication safety.
C. assure that the error is documented in the client record.
D. meet the requirements of most regulatory agencies.
C. assure that the error is documented in the client record.
Rationale:
98
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98. Which of these categories of risk is most likely to increase hospital liability and patient injury?
A. Early hospital discharges
B. Lack of availability of medications
C. Unsigned treatment consent forms
D. Early hospital discharges
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C. Unsigned treatment consent forms
Rationale:
99
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99. Based on the five rights of delegation, which task is appropriate for the nurse to delegate to nurse trainee?
A. Dressing change
B. Intravenous line discontinuation
C. Reviewing discharge instructions
D. Ambulating a client
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D. Ambulating a client
Rationale:
100
100. In planning for the future of acute health care, nurse managers should anticipate:
A. more emphasis on use of nursing research to improve client care
B. decreased use of emergency departments as access to care improves
C. the lower incidences of chronic illness will change demand for nursing services
D. improved funding for hospital care as the “boomer” population ages
A. more emphasis on use of nursing research to improve client care
Rationale:
