Unit 1

Question 1

After completing an initial assessment on a patient the nurse has charted that his respirations are eupneic and his pulse is 58. this type of data would be: 
Objective
Reflective
Subjective
Introspective

Answer 1

Objective

Question 2

A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot". This type of data would be:
Objective
Reflective
Subjective
Introspective

Answer 2

Subjective

Question 3

Novice nurses, without background of skills and experience to draw from, are more likely to make their decisions using:
intuition
a set of rules
articles in journal
advice from supervisors

Answer 3

Set of Rules

Question 4

Which of the following statements best describes the tasks of late adulthood?
Older adults must quickly try to resolve the conflicts of earlier times.
Older adults must accept that they cannot change the past and make peace with their lives.
Older adults generally feel great sadness and worry about death: this allows them to accept their mortality.
Older adults must never feel satisfied with their lives because it gives them goals to achieve.

Answer 4

Older adults must accept that they cannot change the past and make peace with their lives.

Question 5

An infant weighs 3.2 kg (7lbs) at birth. During the well-child visit 6 months later, the nurse would expect the infant to weigh at least:

5. 5 kg (12 lbs)
6. 4 kg (14 lbs)
7. 7 kg (17 lbs)
8. 5 kg ( 21 lbs)

Answer 5

6.4 kg (14 lbs)

Question 6

During which period is physical growth most rapid?
Birth to 1 year
3 to 5 years
6 to 10 years
16 to 18 years

Answer 6

Birth to 1 yr

Question 7

The nurse is testing a 10 year old child’s ability to understand conservation of matter. Which of the following test would be appropriate?
Ask her to sort blocks by colour and shape.
Ask her to order blocks from smallest to biggest.
Ask her to determine which glass of water has more water in it, the tall skinny glass or the short fat glass.
Ask her to make a code using the alphabet and then write the message in the code she made up.

Answer 7

Ask her to determine which glass of water has more water in it, the tall skinny glass or the short fat glass.

Question 8

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly.Which of the following statements does the nurse know is most accurate?

Is excited about her pregnancy but nervous about labour.

Is exhibiting verbal and nonverbal behavior that do not match.

Is excited abut the pregnancy but her husband is not and this is upsetting to her.

Is not excited about her pregnancy but believes the nurse will respond negatively to her if she states this.

Answer 8

Is exhibiting verbal and nonverbal behavior that do not match.

Question 9

Because the physical environment in which an interview takes place is an important consideration for the success of the interview, the interviewer should:

Reduce noise by turning off the television and radios.
Keep a distance of about o.6 m (12ft) or closer between himself or herself and the patient.
Ensure dim lighting that make the room cozier and will help the patient relax.
Arrange seating across a desk or table to allow the patient some personal space.

Answer 9

Reduce noise by turning off the television and radios.

Question 10

At which phase of the interview could the following statement be made? “Mr. S. I would like to ask you some questions about your health and your daily activities so that we can better plan your stay here”.

During the summary.
While closing the interview.
During the body of the interview.
When opening / introducing the interview.

Answer 10

When opening / introducing the interview.

Question 11

During an interview the nurse states “ You motioned shortness of breath. Tell me more about that”. Identify the verbal skill used with this statement.

Reflection.
Facilitation.
Direct question.
Open ended question.

Answer 11

Open ended question.

Question 12

When taking history from a newly admitted patient, the nurse notices that he is pausing often and looking at the nurse expectantly. What would ne the nurse’s best response to this behavior?

Be silent and allow him to continue.
Smile at him and say “ Don’t worry about all this. I’m sure we can find out why you’re having these pains”.
Lean back in the chair and say “Mr. J. you are looking at me kind of funny, there isn’t anything wrong is there?”.
Stand up and say “ I can see this interview is uncomfortable for you. We can continue it another time”.

Answer 12

Stand up and say “ I can see this interview is uncomfortable for you. We can continue it another time”.

Question 13

A 17 year old single mother is describing how difficult it is to raise a 2 year old by herself. During the course of the interview she states “I can’t believe my boyfriend left me to do this all by myself. What a terrible thing to do to me!”. Which of the following is the best responses by the nurse uses empathy?

“you feel alone?”
“you can’t believe he left you alone”.
“ It must be very hard to face this all by yourself”.
“ I would be angry too, raising a child by yourself is no picnic”.

Answer 13

” It must be very hard to face this all by yourself”.

Question 14

The nurse enters a patients room and finds her crying because the patient has just found that the lump in her breast is cancerous. The patient says “ I am afraid of Um you know”. The nurse’s most therapeutic response would be to say in a gentle manner:

“You’re afraid you might lose your breast?”
“No I am not sure what you are talking about”.
“I’ll wait here until you get yourself under control and then we can talk”.
“I can see you are very upset. Perhaps we should discuss this later”.

Answer 14

“You’re afraid you might lose your breast?”

Question 15

During an interview, a parent is sitting with an open posture. As the interviewer begins to discuss his son’s treatment, the father suddenly crosses his arms against his chest and crosses his legs. This would suggest that he is:

Just changing positions.
More comfortable in this position.
Tired and needs a break in the interview.
Uncomfortable talking about his son’s treatment.

Answer 15

More comfortable in this position.

Question 16

During an examination of a 3 year old child the nurse needs to take her blood pressure. What could the nurse do to gain the child’s full co-operation?

Tell the child that the blood pressure cuff is going to give her arm a big hug.
Tell the child that the blood pressure cuff is asleep and cannot wake up.
Give the blood pressure cuff a name and refer to it by the name during the assessment.
Tell the child that by using the blood pressure cuff we can see how strong her muscles are.

Answer 16

Tell the child that by using the blood pressure cuff we can see how strong her muscles are.

Question 17

An Aboriginal woman has come to the clinic for diabetes follow up teaching. During the interview, the nurse notices that the patient never makes eye contact and speaks mostly looking down to the floor. Which of the following statement about this situation is true?”

She is nervous and embarrassed.
She has something to hide and is ashamed,
She is showing inconsistent verbal and non verbal behaviors
She is showing that she is listening carefully to what the nurse is saying.

Answer 17

She is showing that she is listening carefully to what the nurse is saying.

Question 18

The nurse is conducting a health interview with a patient named Salil. There is a language barrier, and no interpreter available. Which is the best example of an appropriate question for the nurse to ask in this situation?

“Does Salil take medication?”
“Do you sterilize the bottles?”
“Do you have nausea and vomiting?”
“He has been taking his medication hasn’t he?”

Answer 18

“Does Salil take medication?”

Question 19

A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate?

Trained interpreter
Male family member
Female member
Volunteer university student from the foreign language studies department.

Answer 19

Trained interpreter

Question 20

During an interview at what distance would the nurse expect that most of the interview will take place?

Intimate zone
Personal distance
Social distance
Public distance

Answer 20

Social distance

Question 21

A female nurse is interviewing a male patient who is close in age to the nurse. During the interview the patient makes an overly sexual comment. The nurse’s best response would be:

“stop that immediately!”
“oh you are too funny. Let’s keep going with the interview”.
“Do you think I would be interested?”
“It make me uncomfortable when you talk that way. Please don’t.”

Answer 21

“It make me uncomfortable when you talk that way. Please don’t.”

Question 22

Which of the following statements best describes the purpose of a “Health History”

To provide an opportunity for interaction between patient and nurse.
To provide a form for obtaining the patient’s biological information.
To document the normal and abnormal findings of a physical assessment.
To provide a database of subjective information about the patient’s past and current health.

Answer 22

To provide a database of subjective information about the patient’s past and current health.

Question 23

A patient tells the nurse that she has been experiencing abdominal pain for the past week. Which of the following would be the best response by the nurse?

“Can you point where it hurts?”
“ We’ll talk more about that later in the interview”.
“What have you had to eat in the past 24 hours?”
“Have you ever had surgeries on you abdomen?”

Answer 23

“Can you point where it hurts?”

Question 24

A patient tells the nurse that he is allergic to penicillin. Which of the following would be the nurse’s best response to this information?

“Are you allergic to any other drug?”
“How often have you received penicillin?”
“I’ll record your allergy on your chart so you won”t receive any”
“Please describe what happens to you when you take penicillin.”

Answer 24

“Please describe what happens to you when you take penicillin.”

Question 25

Which of the following statements represents subjective data about the patient’s skin?

Skin appears dry
No obvious lesions
Denies color change
Lesions noted lateral aspect right arm.

Answer 25

Denies color change

Question 26

The nurse is obtaining the health history the health history of an 87 year old woman. Which of the following areas of questioning would be most useful at this time?
Obstetric history.
Childhood illnesses
General health for the past 20 years
Current health promotion activities.

Answer 26

Current health promotion activities

Question 27

A 90 year old patient tell the nurse he is unable to remember the names of the drugs he is taking or what they are for. An appropriate response would be:

“Can you yell me what they look like?”
“Don’t worry about it you are only taking two”.
“How long have you been taking each of these pills?”
“Would you ask a family member to bring in your medication?”

Answer 27

“Would you ask a family member to bring in your medication?”

Question 28

Which of the following best describes the purpose of a functional assessment?

It assesses how the individual is coping with life at home.
It determines how children are meeting developmental milestones.
It can identify any memory problems an individual may be experiencing.
In the case of the older adult it helps they are managing day to day activities.

Answer 28

In the case of the older adult it helps they are managing day to day activities.

Question 29

Which of the following is an example of symptom.

Chest pain
Clammy skin
Serum potassium level 4.2 mEq/L
A temperature of 37*c

Answer 29

Chest pain

Question 30

The nurse is performing a health assessment on a 16 yer old girl, who has been brought to the clinic by her parents. Which of the following instructions would be most appropriate before the interview begins?

“Please stay with your daughter during the interview, you can answer questions she is not able”.
“It would help to interview the three of you together.”
“While I interview your daughter, will you please stay in the room and complete family health history questionnaires.”
“While I interview your daughter, will you step out to the waiting room and complete family health history questionnaires.”

Answer 30

“While I interview your daughter, will you step out to the waiting room and complete family health history questionnaires.”

Question 31

During a staff meeting, nurses discuss the problems with accessing research studies in order to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help this problem?
A) Form a committee to conduct research studies.
B) Post published research studies on the unit’s bulletin boards.
C) Encourage the nurses to visit the library to review studies.
D) Teach the nurses how to conduct electronic searches for research studies.

Answer 31

Teach the nurses how to conduct electronic searches for research studies.

Question 32

When discussing the use of the term “subculture,” the nurse recognizes that it is best described as:
A) fitting as many people into the majority culture as possible.
B) defining small groups of people who do not want to be identified with the larger culture.
C) singling out groups of people who suffer differential and unequal treatment as a result of cultural variations.
D) identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

Answer 32

Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

Question 33

When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fasting growing population is:
A) Hispanic.
B) Black.
C) Asian.
D) American Indian.

Answer 33

Hispanic

Question 34

During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating "the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society" reflects which term?
A) Mores
B) Norms
C) Culture
D) Social learning

Answer 34

Culture

Question 35

A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, “I quit smoking after my wife died 7 years ago.” However, the nurse notices an open package of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
A) “Mr. K., I know that you are lying.”
B) “Mr. K., come on, tell me how much you smoke.”
C) “Mr. K., I didn’t realize your wife had died. It must be difficult for you at this time. Please tell me more about that.”
D) “Mr. K., you have said that you don’t smoke, but I see that you have an open package of cigarettes in your pocket.”

Answer 35

“Mr. K., you have said that you don’t smoke, but I see that you have an open package of cigarettes in your pocket.”

Question 36

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects evidence-based practice?
EBP relies on tradition for support of best practices.
EBP is simply the use of best practice techniques for treatment of patients.
EBP emphasizes the use of best evidence with the clinician’s experience.
The patient’s own preferences are not important with EBP.

Answer 36

EBP emphasizes the use of best evidence with the clinician’s experience.

Question 37

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, sleep
Breathing, sleep, pain
Sleep, breathing, pain
Sleep, pain, breathing

Answer 37

Breathing, pain, sleep

Question 38

What is the step of the nursing process that includes data collection by health history, Planning
Diagnosis
Evaluation
Assessment

Answer 38

Assessment

Question 39

When reviewing concepts of health, the nurse recalls that components of holistic health include which of these?
Disease originates from the external environment.
The individual human is a closed system.
Nurses are responsible for a patient’s health state.
Holistic health views the mind, body, and spirit as interdependent.

Answer 39

Holistic health views the mind, body, and spirit as interdependent.

Question 40

A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
A follow-up data base to evaluate changes at appropriate intervals
An episodic data base because of the continuing, complex medical problems of this patient
A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health
An emergency data base because of the need to rapidly collect information and make accurate diagnoses

Answer 40

A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health

Question 41

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
Establish priorities.
Identify expected outcomes.
Evaluate the individual’s condition and compare actual outcomes with expected outcomes.
Interpret data and then identify clusters of cues and make inferences.

Answer 41

Evaluate the individual’s condition and compare actual outcomes with expected outcomes.

Question 42

The nurse is reviewing the development of culture. Which statement is correct regarding the development of one’s culture? Culture is:
Genetically determined on the basis of racial background.
Learned through language acquisition and socialization.
A nonspecific phenomenon and is adaptive but unnecessary.
Biologically determined on the basis of physical characteristics.

Answer 42

Learned through language acquisition and socialization.

Question 43

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? “The caregiver:
Is able to speak the patient’s native language.”
Possesses some basic knowledge of the patient’s cultural background.”
Applies the proper background knowledge of a patient’s cultural background to provide the best possible health care.”
Understands and attends to the total context of the patient’s situation.”

Answer 43

Applies the proper background knowledge of a patient’s cultural background to provide the best possible health care.”

Question 44

A physician in the clinic is frequently bothered when patients arrive late for appointments. The physician is so irritated by this behavior that he often finds it hard to provide appropriate care to these individuals. What should he do first in trying to overcome this difficulty?
Identify the meaning of health to the patient.
Understand that these cultural practices are helpful to the patient.
Allow the patients to arrive late and build this into his schedule.
Examine his own culturally based values, beliefs, attitudes, and practices.

Answer 44

Examine his own culturally based values, beliefs, attitudes, and practices.

Question 45

The nurse recognizes that the first step in understanding the health care needs of another person is
Identifying the meaning of health to the other person.
Understanding one’s own heritage-based cultural values, beliefs, attitudes, and practices relevant to health and illness.
Understanding how the health care delivery system works.
Being knowledgeable about the person’s social background.

Answer 45

Understanding one’s own heritage-based cultural values, beliefs, attitudes, and practices relevant to health and illness.

Question 46

The nurse is asking questions about a patient’s health beliefs. Which questions are appropriate? Select all that apply.
“What is your definition of health?”
“Does your family have a history of cancer?”
“How do you describe illness?”
“What did your mother do to keep you from getting sick?”
“Have you ever had any surgery?”
“How do you keep yourself healthy?”

Answer 46

“What is your definition of health?”
“How do you describe illness?”
“What did your mother do to keep you from getting sick?”
“How do you keep yourself healthy?”

Question 47

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
“Mr. Y., at your age, surely you have been hospitalized before!”
“Mr. Y., I just need permission to get your medical records from County Medical.”
“Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?”
“Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?”

Answer 47

“Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?”

Question 48

The nurse has used interpretation regarding a patient’s statement or actions. After using this technique, it would be best for the nurse to:
Apologize because this can be demeaning for the patient.
Allow the patient time to confirm or correct the inference.
Continue with the interview as though nothing has happened.
Immediately restate the nurse’s conclusion on the basis of the patient’s nonverbal response.

Answer 48

Allow the patient time to confirm or correct the inference.

Question 49

A man arrives at the clinic for an annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview?
“How is your family?”
“How is your job?”
“Tell me about your hypertension.”
“How has your health been since your last visit?”

Answer 49

“How has your health been since your last visit?”

Question 50

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care?
J. M. is a 59-year-old male here for “ulcerative colitis.”
J. M. came into the clinic complaining of black stools for the past 24 hours.
J. M., a 59-year-old male, states he has ulcerative colitis and wants it checked.
J. M. is a 59-year-old male here for having “black stools” for the past 24 hours.

Answer 50

J. M. is a 59-year-old male here for having “black stools” for the past 24 hours.

Question 51

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
“Do you wear glasses?”
“Are you able to dress yourself?”
“Do you have any thyroid problems?”
“How many times a day do you have a bowel movement?”

Answer 51

“Are you able to dress yourself?”

Question 52

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
“Please stay during the interview; you can answer for her if she does not know the answer.”
“It would help to interview the three of you together.”
“While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?”
“While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”

Answer 52

“While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”

Question 53

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
Mental status assessment diagnoses specific psychiatric disorders.
Mental disorders occur in response to everyday life stressors.
Mental status functioning is inferred through assessment of an individual’s behaviors.
Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

Answer 53

Mental status functioning is INFERRED through assessment of an individual’s behaviors.

Question 54

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes:
She probably doesn’t have any problems at all.
She is just trying to shock people and her dress should be ignored.
She has manic syndrome because of her abnormal dress and grooming.
That more information should be gathered to decide whether her dress is appropriate.

Answer 54

That more information should be gathered to decide whether her dress is appropriate.

Question 55

During a mental status examination, the nurse wants to assess a patient’s affect. The nurse “How do you feel today?”
“Would you please repeat the following words?”
“Have these medications had any effect on your pain?”
“Has this pain affected your ability to get dressed by yourself?”

Answer 55

“How do you feel today?”

Question 56

The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
Inspection usually yields little information.
Inspection takes time and reveals a surprising amount of information.
Inspection may be somewhat uncomfortable for the expert practitioner.
Inspection requires a quick glance at the patient’s body systems before proceeding on with palpation.

Answer 56

Inspection takes time and reveals a surprising amount of information.

Question 57

The nurse is assessing a patient’s skin during an office visit. What is the best technique to use to best assess the patient’s skin temperature? Use the:
Fingertips because they’re more sensitive to small changes in temperature.
Dorsal surface of the hand because the skin is thinner than on the palms.
Ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
Palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

Answer 57

Dorsal surface of the hand because the skin is thinner than on the palms.

Question 58

The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
Avoid palpation of reported “tender” areas because this may cause the patient pain.
Quickly palpate a tender area to avoid any discomfort that the patient may experience.
Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Answer 58

Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Question 59

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
Warm the end piece of the stethoscope by placing it in warm water.
Leave the gown on so that the patient does not get chilled during the examination.
Make sure that the bell side of the stethoscope is turned to the “on” position.
Check the temperature of the room and offer blankets to the patient if he or she feels cold.

Answer 59

Check the temperature of the room and offer blankets to the patient if he or she feels cold.

Question 60

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an “unexplained” weight loss of 10 pounds over the last 6 weeks. The nurse knows that:
His weight loss is probably from unhealthy eating habits.
Chronic diseases such as hypertension cause weight loss.
Unexplained weight loss often accompanies short-term illnesses.
His weight loss is probably the result of a mental health dysfunction.

Answer 60

Unexplained weight loss often accompanies short-term illnesses.

Question 61

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
Wait 30 minutes if the patient has ingested hot or iced liquids.
Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
Place the thermometer in front of the tongue and have the patient close his or her lips.
Shake the mercury-in-glass thermometer down to 98° F before taking the temperature.

Answer 61

Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.

Question 62

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse’s next action would be to:
Notify the physician immediately.
Consider this a normal finding in children and young adults.
Check the child’s blood pressure and note any variation with respiration.
Document that this child has bradycardia and continue with the assessment.

Answer 62

Consider this a normal finding in children and young adults.

Question 63

A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1 to 10 scale. What does the nurse suspect?
She is addicted to her pain medications and cannot obtain pain relief.
She does not want to trouble the nursing staff with her complaints.
She is not in pain but rates it high to receive pain medication.
She has experienced chronic pain for years and has adapted to it.

Answer 63

She has experienced chronic pain for years and has adapted to it.

Question 64

When assessing a patient’s pain, the nurse knows that an example of visceral pain would be:
Hip fracture.
Cholecystitis.
Second-degree burns.
Pain after a leg amputation.

Answer 64

Cholecystitis

Question 65

During assessment of a patient’s pain, the nurse keeps in mind that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply.
Sleeping
Moaning
Diaphoresis
Bracing
Restlessness
Rubbing

Answer 65

Sleeping
Bracing
Rubbing

Question 66

The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find?
Obesity
Hypotension
Osteomalacia
Coronary artery disease

Answer 66

Osteomalacia

Question 67

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
The absorption of nutrients may be impaired.
The constipation may represent a food allergy.
She may need emergency surgery for the problem.
The gastrointestinal problem will increase her caloric demand.

Answer 67

The absorption of nutrients may be impaired.

Question 68

A patient tells the nurse that his food just doesn’t have any taste anymore. The nurse’s best response would be:
“That must be really frustrating.”
“When did you first notice this change?”
“My food doesn’t always have a lot of taste either.”
“Sometimes that happens but your taste will come back.”

Answer 68

“When did you first notice this change?”

Question 69

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find?
An increase in hair growth
Inadequate nutrient food intake
Weight 10% to 20% over ideal
Sore, inflamed buccal cavity

Answer 69

Inadequate nutrient food intake

Question 70

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
Subcutaneous fat deposits are high in the newborn.
Sebaceous glands are overproductive in the newborn.
The newborn’s skin is more permeable than that of the adult.
The amount of vernix caseosa rises dramatically in the newborn.

Answer 70

The newborn’s skin is more permeable than that of the adult.

Question 71

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
An increased possibility of bruising
Skin sensitivity as a result of exposure to salt water
Lack of availability of glucose monitoring supplies
The importance of sunscreen and avoiding direct sunlight

Answer 71

The importance of sunscreen and avoiding direct sunlight

Question 72

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
The woman could be at increased risk for infection and lesions because of her chronic diseases.
With her diabetes, she has increased circulation to her foot and it could cause severe bleeding.
She is 75 years old and is unable to see, so she puts herself at greater risk for self-injury with the scissors.
With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

Answer 72

The woman could be at increased risk for infection and lesions because of her chronic diseases.

Question 73

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
Anasarca
Scleroderma
Pedal erythema
Clubbing of the nails

Answer 73

Clubbing of the nails