Nursing 110 final

The nurse is participating at a health fair at the local mall giving influenza vaccines to
senior citizens. What level of prevention is the nurse practicing?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Quaternary prevention
Primary prevention is aimed at health promotion and includes health-education
programs, immunizations, and physical and nutritional fitness activities. It can be
provided to an individual and includes activities that focus on maintaining or improving
the general health of individuals, families, and communities. It also includes specific
protection such as immunization for influenza.
A patient experienced a myocardial infarction 4 weeks ago and is currently participating
in the daily cardiac rehabilitation sessions at the local fitness center. In what level of
prevention is the patient participating?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Quaternary prevention
Tertiary prevention involves minimizing the effects of long-term disease or disability by
interventions directed at preventing complications and deterioration following the
myocardial infarction. Tertiary-prevention activities are directed at rehabilitation rather
than diagnosis and treatment. Care at this level aims to help patients achieve as high a
level of functioning as possible, despite the limitations caused by illness or impairment.
This level of care is called preventive care because it involves preventing further
disability or reduced functioning.
Based on the transtheoretical model of change, what is the most appropriate response
to a patient who states: "Me, exercise? I haven't done that since junior high gym class,
and I hated it then!"
A) "That's fine. Exercise is bad for you anyway."
B) "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month."
C) "I understand. Can you think of one reason why being more active would be helpful
for you?"
D) "I'd like you to ride your bike 3 times this week and eat at least four fruits and
vegetables every day."
The patient's response indicates that the patient is in the precontemplation stage and
does not intend to change his behavior in the next 6 months. In this stage the patient is
not interested in information about the behavior and may be defensive when confronted
with it. Asking an open-ended question may stimulate the patient to identify a reason to
begin a behavior change. Nurses are challenged to motivate and facilitate change in
health behavior when working with individuals.
A patient comes to the local health clinic and states: "I've noticed how many people are
out walking in my neighborhood. Is walking good for you?" What is the best response to
help the patient through the stages of change for exercise?
A) "Walking is OK. I really think running is better."
B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next
week?"
C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat
more fruits and vegetables."
D) "They probably aren't walking fast enough or far enough. You need to spend at least
45 minutes if you are going to do any good."
The patient's response indicates that the patient is in the contemplative state, possibly
intending to make a behavior change within the next 6 months. The nurse's statement
reinforces the behavior and provides a specific goal for the patient to begin a walking
plan.
A male patient has been laid off from his construction job and has many unpaid bills. He
is going through a divorce from his marriage of 15 years and has been seeing his pastor
to help him through this difficult time. He does not have a primary health care provider
because he has never really been sick and his parents never took him to the physician
when he was a child. Which external variables influence the patient's health practices?
(Select all that apply.)
A) Difficulty paying his bills
B) Seeing his pastor as a means of support
C) Family practice of not routinely seeing a health care provider
D) Stress from the divorce and the loss of a job
External factors impacting health practices include family beliefs and economic impact.
How patients' families use health care services generally affects their health practices.
Their perceptions of the serious nature of diseases and their history of preventive care
behaviors (or lack of them) influence how patients will think about health. Economic
variables may affect a patient's level of health by increasing the risk for disease and
influencing how or at what point the patient enters the health care system.
The nurse is conducting a home visit with an older adult couple. She assesses that the
lighting in the home is poor and there are throw rugs throughout the home and a low
footstool in the living room. She discusses removing the rugs and footstool and
improving the lighting with the couple. The nurse is addressing which level of need
according to Maslow?
A) Physiological
B) Safety and security
C) Love and belonging
D) Self-actualization
The teaching addresses the need for safety and security. The throw rugs, low lighting,
and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority
safety issue for older adults.
When taking care of patients, the nurse routinely asks them if they take any vitamins or
herbal medications, encourages family members to bring in music that the patient likes
to help the patient relax, and frequently prays with her patients if that is important to
them. The nurse is practicing which model?
A) Holistic
B) Health belief
C) Transtheoretical
D) Health promotion
The nurse is using a holistic model of care that considers emotional and spiritual well-
being and other dimensions of an individual to be important aspects of physical
wellness. The holistic health model of nursing attempts to create conditions that
promote optimal health. 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.
When illness occurs, different attitudes about it cause people to react in different ways.
What do medical sociologists call this reaction to illness?
A) Health belief
B) Illness behavior
C) Health promotion
D) Illness prevention
Illness behavior involves how people monitor their bodies, define and interpret their
symptoms, take remedial actions, and use the resources in the health care system.
Personal history, social situations, social norms, and past experiences can affect illness
behavior.
A patient at the community clinic asks the nurse about health promotion activities that
she can do because she is concerned about getting diabetes mellitus since her
grandfather and father both have the disease. This statement reflects that the patient is
in what stage of the health belief model?
A) Perceived threat of the disease
B) Likelihood of taking preventive health action
C) Analysis of perceived benefits of preventive action
D) Perceived susceptibility to the disease.
The health belief model addresses the relationship between a person's beliefs and
behaviors. It provides a way of understanding and predicting how patients will behave in
relation to their health and how they will comply with health care therapies. In the
perceived susceptibility to the disease phase, the patient recognizes the familial link to
the disease.
A nurse works in a special care unit for children with severe immunology problems and
is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother
and sister are back in Greece. The nurse is having difficulty communicating with the
father. What action does the nurse take?
A) Care for the boy as she would any other patient
B) Ask the manager to talk with the father and keep him out of the unit
C) Have another nurse care for the boy because maybe that nurse will do better with
the father
D) Search for help with interpretation and understanding of the cultural differences by
contacting someone from the local Greek community
The nurse needs to understand how the Greek culture impacts the father's health
beliefs and communication with health care providers. Cultural variables must be
incorporated into the child's plan of care. Cultural background influences beliefs, values,
and customs. It influences the approach to the health care system, personal health
practices, and the nurse-patient relationship. Cultural background may also influence an
individual's beliefs about causes of illness and remedies or practices to restore health. If
nurses are not aware of their own and other cultural patterns of behavior and language,
they may not be able to recognize and understand a patient's behavior and beliefs and
may have difficulty interacting with the patient.
A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which
statement made by the patient indicates that he is experiencing a problem with body
image?
A) "I just don't have any energy to get out of bed in the morning."
B) "I've been attending church regularly with my wife since I got out of the hospital."
C) "My wife has taken over paying the bills since I've been in the hospital."
D) "I don't go out very much because everyone stares at me."
The amputation resulted in a change in physical appearance that caused a change in
body image. Reactions of patients and families to changes in body image depend on
the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at
which changes take place, and the support services available. When a change in body
image such as results from a leg amputation occurs, the patient generally adjusts in the
following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation.
The patient's statement indicates he is in the stage of withdrawal.
The patient states she joined a fitness club and attends the aerobics class three nights
a week. The patient is in what stage of behavioral change?
A) Precontemplation
B) Contemplation
C) Preparation
D) Action
The patient is in the action stage of behavioral change. In this stage the patient is
actively engaged in strategies to change behavior. This stage may last up to 6 months.
The nurse is developing a health promotion program on healthy eating and exercise for
high school students using the health belief model as a framework. Which statement
made by a nursing student is related to the individual's perception of susceptibility to an
illness?
A) "I don't have time to exercise because I have to work after school every night."
B) "I'm worried about becoming overweight and getting diabetes because my father has
diabetes."
C) "The statistics of how many teenagers are overweight is scary."
D) "I've decided to start a walking club at school for interested students."
The statement indicates that the patient is concerned about developing diabetes and
believes that there is a risk or susceptibility based on recognition of a familial link for the
disease. Once this link is recognized, the patient may perceive the personal risk for
diabetes.
The nurse assesses the following risk factors for coronary artery disease (CAD) in a
male patient. Which factors are classified as genetic and physiological? (Select all that
apply.)
A) Sedentary lifestyle
B) Father died from CAD at age 50
C) History of hypertension
D) Eats diet high in sodium
E) Elevated cholesterol level
F) Age is 44 years
Genetic and physiological risk factors include those related to heredity, genetic
predisposition to an illness, or those that involve the physical functioning of the body.
Certain physical conditions such as being pregnant or overweight place increased
stress on physiological systems (e.g., the circulatory system), increasing susceptibility
to illness in these areas. A person with a family history of coronary artery disease is at
risk for developing the disease later in life because of a hereditary and genetic
predisposition to the disease.
Which activity represents secondary prevention?
A) A home health care nurse visits a patient's home to change a wound dressing.
B) A 50-year-old woman with no history of disease attends the local health fair and has
her blood pressure checked.
C) The school health nurse provides a program to the first-year students on healthy
eating.
D) The patient attends cardiac rehabilitation sessions weekly.
Secondary prevention focuses on individuals who are experiencing health problems or
illnesses and who are at risk for developing complications or worsening conditions. The
home health nurse changing the wound dressing is an activity that is focused on
preventing complications. Much of the nursing care related to secondary prevention is
delivered in homes, hospitals, or skilled nursing facilities.
A nurse hears a colleague tell a nursing student that she never touches a patient unless
she is performing a procedure or doing an assessment. The nurse tells the student that
from a caring perspective:
A) She does not touch the patients either.
B) Touch is a type of verbal communication.
C) There is never a problem with using touch.
D) Touch forms a connection between nurse and patient.
D.Touch is relational and leads to a connection between nurse and patient. It involves
contact and noncontact touch. Contact touch involves obvious skin-to-skin contact,
whereas noncontact touch refers to eye contact.
Of the five caring processes described by Swanson, which describes "knowing the
patient"?
A) Anticipating the patient's cultural preferences
B) Determining the patient's physician preference
C) Establishing an understanding of a specific patient
D) Gathering task-oriented information during assessment
C.Knowing the context of a patient's illness helps you choose and individualize
interventions that will actually help him or her. Strive to understand an event as it has
meaning in the life of the other. Knowing the patient is essential when providing patient-
centered care. Two elements that facilitate knowing are continuity of care and clinical
expertise.
A Muslim woman enters the clinic to have a woman's health examination for the first
time. Which nursing behavior applies Swanson's caring process of "knowing the
patient?"
A) Sharing feelings about the importance of having regular woman's health
examinations
B) Gaining an understanding of what a woman's health examination means to the
patient
C) Recognizing that the patient is modest; obtaining gendercongruent caregiver
D) Explaining the risk factors for cervical cancer
B. You should strive to understand an event as it has meaning in the life of the other.
Knowing the patient is essential when providing patient-centered care.
Helping a new mother through the birthing experience demonstrates which of
Swanson's five caring processes?
A) Knowing
B) Enabling
C) Doing for
D) Being with
B. The caring behavior of enabling facilitates the other's passage through life transitions
(e.g., birth, death) and unfamiliar events. When a nurse practices enabling, the patient
and nurse work together to identify alternatives and resources.
A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses
his love for the Bible with his nurse, who recommends a favorite Bible verse. Another
nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The
patient's nurse replies:
A) "Spiritual care should be left to a professional."
B) "You are correct, religion is a personal decision."
C) "Nurses should not force their religious beliefs on patients."
D) "Spiritual, mind, and body connections can affect health."
D. Spirituality offers a sense of connectedness, intrapersonally (connected with
oneself), interpersonally (connected with others and the environment), and
transpersonally (connected with the unseen, God, or a higher power). In a caring
relationship the patient and nurse come to know one another so both move toward a
healing relationship.
Which of the following is a strategy for creating work environments that enable nurses to
demonstrate more caring behaviors?
A) Increasing the working hours of the staff
B) Increasing salary benefits of the staff
C) Creating a setting that allows flexibility and autonomy for staff
D) Encouraging increased input concerning nursing functions from physicians
C.These factors all affect nursing satisfaction. When nurses' job satisfaction is high,
they have a greater connectedness with their patients and believe that caring practices
are part of the nursing culture.
When a nurse helps a patient find the meaning of cancer by supporting beliefs about
life, this is an example of:
A) Instilling hope and faith.
B) Forming a human-altruistic value system.
C) Cultural caring.
D) Being with.
A. Instilling hope and faith helps to increase an individual's capacity to get through an
event or transition and face the future with meaning.
An example of a nurse caring behavior that families of acutely ill patients perceive as
important to patients' well-being is:
A) Making health care decisions for patients.
B) Having family members provide a patient's total personal hygiene.
C) Injecting the nurse's perceptions about the level of care provided.
D) Asking permission before performing a procedure on a patient.
D. Caring for the family takes into consideration the context of the patient's illness and
the stress it imposes on all members.
A nurse demonstrates caring by helping family members:
A) Become active participants in care.
B) Provide activities of daily living (ADLs).
C) Remove themselves from personal care.
D) Make health care decisions for the patient.
A. Caring for the family takes into consideration the context of the patient's illness and
the stress it imposes on all members.
Listening is not only "taking in" what a patient says; it also includes:
A) Incorporating the views of the physician.
B) Correcting any errors in the patient's understanding.
C) Injecting the nurse's personal views and statements.
D) Interpreting and understanding what the patient means.
D. Listening is powerful. It conveys the nurse's full attention and interest. A true caring
presence involves listening. Listen to what is important to another person and the
meaning of a situation to that person.
A nurse is caring for an older adult who needs to enter an assisted-living facility
following discharge from the hospital. Which of the following is an example of listening
that displays caring?
A) The nurse encourages the patient to talk about his concerns while reviewing the
computer screen in the room.
B) The nurse sits at the patient's bedside, listens as he relays his fear of never seeing
his home again, and then asks if he wants anything to eat.
C) The nurse listens to the patient's story while sitting on the side of the bed and then
summarizes the story.
D) The nurse listens to the patient talk about his fears of not returning home and then
tells him to think positively.
C. Attentive listening lets the nurse hear the patient's story and then correctly
summarize it. It does not occur when the nurse is distracted by equipment or other
personnel. The importance of listening is not to distract the patient or solve the problem,
but rather to hear what the patient has to say and understand what the situation means
to him.
Presence involves a person-to-person encounter that:
A) Enables patients to care for self.
B) Provides personal care to a patient.
C) Conveys a closeness and a sense of caring.
D) Describes being in close contact with a patient.
C. Providing presence is a person-to-person encounter conveying closeness and a
sense of caring. It involves "being there" and "being with." "Being there" is not only a
physical presence but also includes communication and understanding. Presence is an
interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability,
and adaptation to unique circumstances.
A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion,
and explains the procedure to the patient. She tells the patient what to expect; just
before inserting the catheter, she tells the patient to relax and that, once the catheter is
in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully
insert the Foley catheter. This is an example of what type of touch?
A) Caring touch
B) Protective touch
C) Task-oriented touch
D) Interpersonal touch
C. Nurses use task-orientated touch when performing a task or procedure. An expert
nurse learns that any procedure is more effective when administered carefully and in
consideration of any patient concern.
A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He
and his parents made the decision that he would move home and they would help him
in the final stages of his disease. The family participates in his care, but lately the nurse
has increased the amount of time she spends with the family. Whenever she enters the
room or approaches the patient to give care, she touches his shoulder and tells him that
she is present. This is an example of what type of touch?
A) Caring touch
B) Protective touch
C) Task-oriented touch
D) Interpersonal touch
A. Caring touch is a form of nonverbal communication. You express this in the way you
hold a patient's hand, give a back massage, gently position a patient, or participate in a
conversation. When using a caring touch, you connect with the patient physically and
emotionally.
Match the following caring behaviors with their definitions.
A. Sustaining faith in one's capacity to get through a situation
B. Striving to understand an event's meaning for another person
C. Being emotionally there for another person
D. Providing for another as he or she would do for themselves.

Knowing
Being with
Doing for
Maintaining belief
Striving to understand an event's meaning for another person:Knowing, Being
emotionally there for another person:Being with, Providing for another as he or she
would do for themselves.:Doing for, Sustaining faith in one's capacity to get through a
situation:Maintaining belief
The nurse's first action after discovering an electrical fire in a patient's room is to:
A) Activate the fire alarm.
B) Confine the fire by closing all doors and windows.
C) Remove all patients in immediate danger.
D) Extinguish the fire by using the nearest fire extinguisher.
C. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in
immediate danger
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-
old son drank. Which of the following is the most important instruction the nurse gives to
this parent?
A) Give the child milk.
B) Give the child syrup of ipecac.
C) Call the poison control center.
D) Take the child to the emergency department.
C. A poison control center is the best resource for patients and parents needing
information about the treatment of an accidental poisoning
The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased
balance, and instability. On the basis of the patient's data, which one of the following
nursing diagnoses indicates an understanding of the assessment findings?
A) Activity intolerance
B) Impaired bed mobility
C) Acute pain
D) Risk for falls
D. For adults age 65 and older, impaired balance and difficulty with gait are risks for the
nursing diagnosis of risk for falls
A couple is with their adolescent daughter for a school physical and state they are
worried about all the safety risks affecting this age. What is the greatest risk for injury for
an adolescent?
A) Home accidents
B) Physiological changes of aging
C) Poisoning and child abduction
D) Automobile accidents, suicide, and substance abuse
D. Risks to the safety of adolescents involve many factors outside the home because
much of their time is spent away from home and with their peer group. According to the
Centers for Disease Control and Prevention, the risk of motor vehicle accidents is
higher among 16- to 19-year-old drivers than any other age-group. In an attempt to
relieve the tensions associated with physical and psychosocial changes and peer
pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking
alcohol, and using drugs.
The nurse found a 68-year-old female patient wandering in the hall. The patient says
she is looking for the bathroom. Which interventions are appropriate to ensure the
safety of the patient? (Select all that apply.)
A) Insert a urinary catheter.
B) Leave a night light on in the bathroom.
C) Ask the physician to order a restraint.
D) Keep the bed in low position with upper and lower side rails up.
E) Assign a staff member to stay with the patient.
F) Provide scheduled toileting during the night shift.
G) Keep the pathway from the bed to the bathroom clear.
B,F,G. Older adults in an unfamiliar environment may become confused. A night light
may be beneficial for safety and orientation. Toileting is a common reason for a patient
attempting to get out of bed. Placing the patient on a routine toileting schedule should
help decrease this risk factor. Hospital environments can quickly become cluttered with
equipment, personal items, and other things that create a hazard for falling. Keep
pathways clear. All alternatives should be tried and considered before using a restraint.
Restraint should not be an initial response. The bed should be kept in a low position.
Upper side rails may be used; however, the addition of lower side rails can increase the
risk of injury. The use of side rails alone for a disoriented patient may cause more
confusion and further injury. A confused patient who is determined to get out of bed
attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt
usually results in a fall or injury.
The family of a patient who is confused and ambulatory insists that all four side rails be
up when the patient is alone. What is the best action to take in this situation? (Select all
that apply.)
A) Contact the nursing supervisor.
B) Restrict the family's visiting privileges.
C) Ask the family to stay with the patient.
D) Inform the family of the risks associated with side-rail use.
E) Thank the family for being conscientious and put the four rails up.
F) Discuss alternatives with the family that are appropriate for this patient.
C,D,F. The family is concerned about ensuring a safe environment for their loved one.
The nurse should discuss their concerns, the risk of using restraints related to using four
side rails, and safer alternatives such as the presences of a family member. If the family
still insists on use of four side rails, you could contact the nursing supervisor to further
discuss the situation with them. This is not a reason to restrict visitation; but, although
you should appreciate their concern, the use of four side rails should be avoided.
A physician writes an order to apply a wrist restraint to a patient who has been pulling
out a surgical wound drain. Place the following steps for applying the restraint in the
correct order.
___ 1. Explain what you plan to do.
___ 2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure.
___ 3. Determine that restraint alternatives fail to ensure patient's safety.
___ 4. Identify the patient using proper identifier.
___ 5. Pad the patient's wrist.
3,4,1,5,2.
A child in the hospital starts to have a grand mal seizure while playing in the playroom.
What is your most important nursing intervention during this situation?
A) Begin cardiopulmonary respiration.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from injury.
D. Once a seizure begins, you need to monitor the patient and provide a safe
environment. A seizure is not an indication for cardiopulmonary resuscitation. A person
having a seizure should not be restrained, but the environment should be made safe.
Objects should not be forced into the mouth. See the Skills in the chapter for more
information.
A 62-year-old woman is being discharged home with her husband after surgery for a hip
fracture from a fall at home. When providing discharge teaching about home safety to
this patient and her husband, the nurse knows that:
A) A safe environment promotes patient activity.
B) Assessment focuses on environmental factors only.
C) Teaching home safety is difficult to do in the hospital setting.
D) Most accidents in the older adult are caused by lifestyle factors.
A. Older adults are frequently fearful of falling and thus often limit activity. A safe
environment, which decreases the risk of a fall, promotes patient activity.
A fragile, 87-year-old nursing home resident is admitted to the hospital with dehydration
and increased confusion. The patient has upper limb restraints to prevent her from
pulling out her nasogastric tube. What instructions does the nurse give to nursing
assistive personnel (NAP)?
The use of restraints is associated with serious complications resulting from
immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In
some cases death has resulted because of restricted breathing and circulation. The
restraint itself could injure the underlying skin. Routine checks are required to prevent or
decrease these complications. The NAP needs to notify the nurse if there is a change in
skin integrity, circulation, or patient's breathing and provide range of motion, nutrition
and hydration, skin care, toileting, and opportunities for socialization at least every 2
hours.
The nursing assessment of an 80-year-old patient who demonstrates some confusion
but no anxiety reveals that the patient is a fall risk because she continues to get out of
bed without help despite frequent reminders. The initial nursing intervention to prevent
falls for this patient is to:
A) Place a bed alarm device on the bed.
B) Place the patient in a belt restraint.
C) Provide one-on-one observation of the patient.
D) Apply wrist restraints.
A. Consider and implement alternatives as appropriate before the use of a restraint. A
bed alarm is an alternative that the nurse implements independently.
To ensure the safe use of oxygen in the home by a patient, which of the following
teaching points does the nurse include? (Select all that apply.)
A) Smoking is prohibited around oxygen.
B) Demonstrate how to adjust the oxygen flow rate based on patient symptoms.
C) Do not use electrical equipment around oxygen.
D) Special precautions may be required when traveling with oxygen
A,C,D. When oxygen is in use, precautions need to be taken to prevent fire and protect
the patient. Patients need to be taught precautions, which include posting "Oxygen in
Use" signage, not using oxygen around electrical equipment or flammable products,
properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not
adjusting liter flow without a physician's order, and taking precautions when traveling
with oxygen
How does the nurse support a culture of safety? (Select all that apply.)
A) Completing incident reports when appropriate
B) Completing incident reports for a near miss
C) Communicating product concerns to an immediate supervisor
D) Identifying the person responsible for an incident
A,B,C. Completing incident reports for actual and near-miss events helps the facility
track information and identify trends and patterns that need to be addressed.
Communicating product concerns to a responsible supervisor allows the facility to
further investigate and determine if additional action is required.
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke
and a recent fall. The wife stated that he has a history of high blood pressure, which is
controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect
and problems with spatial and perceptual abilities and is impulsive. He has moderate
left-sided weakness that requires the assistance of two and the use of a gait belt to
transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in
place. What factors increase his fall risk at this time? (Select all that apply.)
A) Smokes a pack a day
B) Used a cane to walk at home
C) Takes antihypertensive and diuretics
D) History of recent fall
E) Neglect, spatial and perceptual abilities, impulsive
F) Requires assistance with activity, unsteady gait
G) IV line, urinary catheter
C,D,E,F,G. Smoking is not a risk factor for falls. Because the patient used the cane at
home, it is not a current risk factor for falls. Risk is determined by his current status.
At 3 am the emergency department nurse hears that a tornado hit the east side of town.
What action does the nurse take first?
A) Prepare for an influx of patients
B) Contact the American Red Cross
C) Determine how to restore essential services
D) Evacuate patients per the disaster plan
A. The emergency department nurse needs to prepare for the potential influx of patients
first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but
not initially. The American Red Cross is not contacted initially. Determination of how to
restore essential services is part of the disaster plan and is determined before an actual
event.
The Collins family includes a mother, Jean; stepfather, Adam; two teenage biological
daughters of the mother, Lisa and Laura; and a biological daughter of the father, 25-
year-old Stacey. Stacey just moved home following the loss of her job in another city.
The family is converting a study into Stacey's bedroom and is in the process of
distributing household chores. When you talk to members of the family, they all think
that their family can adjust to lifestyle changes. This is an example of family:
A) Diversity.
B) Durability.
C) Resiliency.
D) Configuration.
C. Resiliency is the ability of the family to cope with the unexpected. In this scenario the
family used resources to provide some short-term solutions for the adult child's return
home.
The most common reason grandparents are called on to raise their grandchildren is
because of:
A) Single parenthood.
B) Legal interventions.
C) Dual-income families.
D) Increased divorce rate.
B. This new parenting responsibility is caused by a number of societal factors: the
increase in the divorce rate, dual-income families, and single parenthood. But most
often it is a consequence of legal intervention when parents are unfit or renounce their
parental obligations.
A family's access to adequate health care, opportunity for education, sound nutrition,
and decreased stress is affected by:
A) Development.
B) Family function.
C) Family structure.
D) Economic stability.
D. The ability of families to meet health care, education, and basic needs is often
affected by the economic resources of the family
David Singer is a single parent of a 3-year-old boy, Kevin. Kevin has well-managed
asthma and misses day care infrequently. David is in school studying to be an
information technology professional. His income and time are limited, and he admits to
going to fast-food restaurants frequently for dinner. However, he and his son spend a lot
of time together. David receives state-supported health care for his son, but he does not
have health insurance or a personal physician. He has his son enrolled in a
government-assisted day care program. Which of the following are risks to this family's
level of health? (Select all that apply.)
A) Economic status
B) Chronic illness
C) Underinsured
D) Government-assisted day care
A,C. David's economic status is stretched. He has multiple resources for his son, but he
is not insured. Thus, as a result, there is a potential that David does not follow through
with personal health promotion activities. Although asthma is a chronic illness, this is
well managed, and there is adequate health care for his son.
The Cleric family, which includes a mother, stepfather, two teenage biological daughters
of the mother, and a biological daughter of the father is an example of a(n):
A) Nuclear family.
B) Blended family.
C) Extended family.
D) Alternative family
B. Blended families result when two people who have children from a previous
marriage/relationship marry.
Which of the following are possible outcomes with clear family communication? (Select
all that apply.)
A) Family goals
B) Decision making
C) Methods of discipline
D) Impaired coping
A,B,C. Clear and direct family communication assists the family in creating goals,
decision making, progressing through the family development cycle, and coping with
stressors.
Communication among family members is an example of family:
A) Attributes.
B) Function.
C) Structure.
D) Development
B. Communication is a component of family functioning, whether that be setting goals,
coping, or establishing discipline. Family functioning is what the family does, and
communication is an important component of function
Which of the following contribute to family hardiness? (Select all that apply.)
A) Family meetings
B) Established family roles
C) Willingness to change in time of stress
D) Passive orientation to life
A,B,C. Family hardiness is the internal strengths and durability of the family unit. It
includes a sense of control over the outcome of life, a view of change as beneficial and
growth producing, and an active orientation (such as family meetings) rather than
passive orientation in adapting to stressful events. Family meetings, understanding of
roles, and adaptation to stressors along with a willingness to change affect family
hardiness.
Which of the following demonstrate family resiliency? (Select all that apply.)
A) Resuming full-time work when spouse loses job
B) Arguing ways to deal with problems among siblings
C) Developing hobbies when children leave home
D) Placing blame on family members
A,C. Family resiliency is the ability to cope with expected and unexpected stressors.
Resiliency helps to evaluate healthy responses when individuals and families are
experiencing stressful events.
When nurses view the family as context, their primary focus is on the:
A) Family members within a system.
B) Family process and relationships.
C) Family relational and transactional concepts.
D) Health needs of an individual member.
D. When you view the family as context, the primary focus is on the health and
development of an individual member existing within a specific environment (i.e., the
patient's family). Although the focus is on the individual's health status, assess how
much the family provides the individual's basic needs.
Diane is a hospice nurse who is caring for the Robinson family. This family is providing
end-of-life care for their grandmother, who has terminal breast cancer. When Diane
visits the home 3 times a week, she focuses on symptom management for the
grandmother and assists the family with coping skills. Diane's approach is an example
of which of the following?
A) Family as context
B) Family as patient
C) Family as system
D) Family as structure
B. When the family as patient is the approach, family processes and relationships (e.g.,
parenting or family caregiving) are the primary focuses of nursing care.
Which of the following are included in a family function assessment? (Select all that
apply.)
A) Cultural practices
B) Decision making
C) Rituals and celebrations
D) Neighborhood crime data
A,B,C. Cultural practices help identify culturally related health practices, diets, and
religious practices. Decision making provides information as to how the family copes
and meets challenges related to changes in family life or dynamics. Rituals and
celebrations address how a family celebrates accomplishments and how they deal with
challenges. Neighborhood crime data are relevant for community assessment, but they
do not give sufficient information about family function.
Karen Johnson is a single mother of a school-age daughter. Linda Brown is also a
single mother of two teenage daughters. Karen and Linda are active professionals, have
busy social lives, and date occasionally. Three years ago they decided to share a house
and housing costs, living expenses, and child care responsibilities. The children
consider one another as their family. This family form is considered a(n):
A) Diverse family relationship.
B) Blended family relationship.
C) Extended family relationship.
D) Alternative family relationship.
D. This relationship includes multiadult households, "skip-generation" families,
communal groups with children, "nonfamilies," cohabitating partners, and homosexual
couples.
During a visit to a family clinic the nurse teaches the mother about immunizations, car
seat use, and home safety for an infant and toddler. Which type of nursing interventions
are these?
A) Health promotion activities
B) Acute care activities
C) Restorative care activities
D) Growth and development-care activities
A. Health promotion activities focus on interventions designed to maintain the physical,
social, emotional, and spiritual health of the family unit. They can include information
about specific health behaviors, family coping techniques, and growth and development.
Which best defines family caregiving? (Select all that apply.)
A) Designing a nurturing family to raise children
B) Providing physical and emotional care for a family member
C) Establishing a safe physical environment for a family
D) Monitoring for side effects of illness and treatments
B,C,D. Family caregiving involves the routine provision of services and personal care
activities for a family member by spouses, siblings, or parents. Caregiving activities
include finding resources, personal care (bathing, feeding, or grooming), monitoring for
complications or side effects of illness and treatments, providing instrumental activities
of daily living (shopping or housekeeping), and the ongoing emotional support and
decision making that is necessary.
The nurse is aware that preschoolers often display a developmental characteristic that
makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is
an example of:
A) Logical reasoning.
B) Egocentrism.
C) Concrete thinking.
D) Animism.
D. This is the belief that inanimate objects have lifelike qualities; it is a component of
magical thinking evident in preoperational thought
An 18-month-old child is noted by the parents to be "angry" about any change in
routine. This child's temperament is most likely to be described as:
A) Slow to warm up.
B) Difficult.
C) Hyperactive.
D) Easy.
B. Children described as "difficult" adapt slowly to new routines and express their
emotions forcefully; they like consistent structure.
Nine-year-old Brian has a difficult time making friends at school and being chosen to
play on the team. He also has trouble completing his homework and, as a result,
receives little positive feedback from his parents or teacher. According to Erikson's
theory, failure at this stage of development results in:
A) A sense of guilt.
B) A poor sense of self.
C) Feelings of inferiority.
D) Mistrust.
C. School-age children need to feel real accomplishment and be accepted by peers to
develop a sense of industry.
The nurse teaches parents how to have their children learn impulse control and
cooperative behaviors. This would be during which of Erikson's stages of development?
A) Trust versus mistrust
B) Initiative versus guilt
C) Industry versus inferiority
D) Autonomy versus sense of shame and doubt
B. Toddlers are learning that parents and society have expectations about behaviors
and that they must learn to control their behavior.
When Ryan was 3 months old, he had a toy train; when his view of the train was
blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting
the presence of:
A) Object permanence.
B) Sensorimotor play.
C) Schemata.
D) Magical thinking.
A. He is now in Piaget's later stage of sensorimotor thought and has learned that
objects exist even though he cannot see or touch them.
When preparing a 4-year-old child for a procedure, which method is developmentally
most appropriate for the nurse to use?
A) Allowing the child to watch another child undergoing the same procedure
B) Showing the child pictures of what he or she will experience
C) Talking to the child in simple terms about what will happen
D) Preparing the child through play with a doll and toy medical equipment
D. Preschoolers are in the preoperational stage of cognitive development and learn
more easily when play is used to teach
A 35-year-old woman is speaking with you about her recent diagnosis of a chronic
illness. She is concerned about her treatment options in relation to her ability to
continue to care for her family. As she considers the options and alternatives, she
incorporates information, her values, and emotions to decide which plan will be the best
fit for her. She is using which form of cognitive development?
A) Conventional reasoning
B) Formal operations
C) Integrity versus despair
D) Postformal thought
D. Adults recognize that there are various solutions to problems and that different
situations demand different solutions.
You are caring for a recently retired man who appears withdrawn and says he is "bored
with life." Applying the work of Havinghurst, you would help this individual find meaning
in life by:
A) Encouraging him to explore new roles.
B) Encouraging relocation to a new city.
C) Explaining the need to simplify life.
D) Encouraging him to adopt a new pet.
A. The activity theory states that continuing an active, involved lifestyle results in greater
satisfaction and well-being.
Place the following stages of Freud's psychosexual development in the proper order by
age progression.
1. Oedipal
2. Latency
3. Oral
4. Genital
5. Anal
3, 5, 2, 1, 4
According to Piaget's cognitive theory, a 12-year-old child is most likely to engage in
which of the following activities?
A) Using building blocks to determine how houses are constructed
B) Writing a story about a clown who wants to leave the circus
C) Drawing pictures of a family using stick figures
D) Writing an essay about patriotism
B. As adolescents mature, their thinking moves to abstract and theoretical subjects.
They have the capacity to reason with respect to possibilities.
Allison, age 15 years, calls her best friend Laura and is crying. She has a date with
John, someone she has been hoping to date for months, but now she has a pimple on
her forehead. Laura firmly believes that John and everyone else will notice the blemish
right away. This is an example of the:
A) Imaginary audience.
B) False-belief syndrome.
C) Personal fable.
D) Personal absorption syndrome.
A. Adolescents are quite egocentric and have the belief that everyone is focused on
them and sees all of their flaws.
Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends,
"Did you hear about Kathy? You know, she fools around so much; I heard she was
pregnant. That would never happen to me!" This is an example of adolescent:
A) Imaginary audience.
B) False-belief syndrome.
C) Personal fable.
D) Sense of invulnerability
D. Adolescents can be risk takers and believe that they are immune to the negative
consequences of behaviors; they are just beginning to be future oriented in their thought
process and see everything as black or white
Teaching an older adult how to use e-mail to communicate with a grandchild who lives
in another state is an example of ____________, which aids cognitive performance by
using new approaches.
A) Cognitive development
B) Activity theory
C) Selective optimization with compensation
D) Formal operations
C. As adults age, they put more of their energies into activities associated with
meaningful relationships
Dave reports being happy and satisfied with his life. What do we know about Dave?
A) He is in one of the later developmental periods, concerned with reviewing his life.
B) He is atypical, since most people in any of the developmental stages report
significant dissatisfaction with their lives.
C) He is in one of the earlier developmental periods, concerned with establishing a
career and satisfying long-term relationships.
D) It is difficult to determine Dave's developmental stage since most people report
overall satisfaction with their lives in all stages
D. Each of the life stages can be achieved successfully and result in satisfaction,
including old age
You are working in a clinic that provides services for homeless people. The current local
regulations prohibit providing a service that you believe is needed by your patients. You
adhere to the regulations but at the same time are involved in influencing authorities to
change the regulation. This action represents which stage of moral development?
A) Instrumental relativist orientation
B) Social contract orientation
C) Society-maintaining orientation
D) Universal ethical principle orientation
B. At this stage the individual recognizes that at times the law must be changed to meet
the needs of society and that all people have basic rights, regardless of their social
group.
In an interview with a pregnant patient, the nurse discussed the three risk factors that
have been cited as having a possible effect on prenatal development. They are:
A) Nutrition, stress, and mother's age.
B) Prematurity, stress, and mother's age.
C) Nutrition, mother's age, and fetal infections.
D) Fetal infections, prematurity, and placenta previa.
A. The woman's diet before and during pregnancy has a significant effect on fetal
development; the mother's age may contribute to a risk for chromosomal defects (older
mothers) or the lack of prenatal care (adolescent mothers); pregnancy is often
accompanied by stress because of all of the developmental changes, and it is important
to know whether or not the mother has an effective support system.
A parent has brought her 6-month-old infant in for a well-child check. Which of her
statements indicates a need for further teaching?
A) "I can start giving her whole milk at about 12 months."
B) "I can continue to breastfeed for another 6 months."
C) "I've started giving her plenty of fruit juice as a way to increase her vitamin intake."
D) "I can start giving her solid food now."
C. Breast milk or formula is recommended at this time; fruit juice is not considered a
nutritive addition.
The type of injury a child is most vulnerable to at a specific age is most closely related
to which of the following?
A) Provision of adult supervision.
B) Educational level of the parent
C) Physical health of the child
D) Developmental level of the child
D. The child's cognitive and physical development need to be considered initially when
assessing the potential risk for injury.
Which approach would be best for the nurse to use with a hospitalized toddler?
A) Always give several choices.
B) Set few limits to allow for open expression.
C) Use noninvasive methods when possible.
D) Gain cooperation before attempting treatment.
D. Toddlers are learning to become independent and frequently display negative
behavior if an effort to gain their trust is not provided initially. Providing too many
choices does not support their efforts to gain control.
The nurse is providing information on prevention of sudden infant death syndrome
(SIDS) to the mother of a young infant. Which of the following statements indicates that
the mother has a good understanding?
A) "I won't use a pacifier to help my baby sleep."
B) "I'll be sure my baby does not spend any time on her abdomen."
C) "I'll place my baby on her back for sleep."
D) "I'll be sure to keep my baby's room cold."
C,D. The American Academy of Pediatrics has clearly recommended that infants be
placed on their backs for sleep to help prevent SIDS. Keeping the room cool is also
important.
In evaluating the gross-motor development of a 5-month-old infant, which of the
following would the nurse expect the infant to do?
A) Roll from abdomen to back
B) Move from prone to sitting unassisted
C) Sit upright without support
D) Turn completely over
A. The 5-month-old infant should be able to turn from abdomen to back.
Parents are concerned about their toddler's negativism and ask the nurse for guidance.
Which is the most appropriate recommendation?
A) Provide more attention.
B) Reduce opportunities for a "no" answer.
C) Be consistent with punishment.
D) Provide opportunities for the toddler to make decisions.
B. Giving toddlers realistic choices reduces the opportunity for a negative response and
helps support their need for control.
When nurses are communicating with adolescents, they should:
A) Be alert to clues to their emotional state.
B) Ask closed-ended questions to get straight answers.
C) Avoid looking for meaning behind adolescents' words or actions.
D) Avoid discussing sensitive issues such sex and drugs.
A. Adolescents are searching for their identity and trying to become emotionally
independent from parents while maintaining family ties. Depression, substance abuse,
and violence are all real concerns during this period; thus the nurse must be aware of
the adolescent's emotional state.
Which of the following statements is most descriptive of the psychosocial development
of school-age children?
A) Boys and girls play equally with each other.
B) Peer influence is not yet an important factor to the child.
C) They like to play games with rigid rules.
D) Children frequently have "best friends."
D. Peer relationships become very important to school-age children, and they usually
develop close friendships.
You are caring for a 4-year-old child who is hospitalized for an infection. He tells you
that he is sick because he was "bad." Which is the most correct interpretation of his
comment?
A) Indicative of extreme stress
B) Representative of his cognitive development
C) Suggestive of excessive discipline at home
D) Indicative of his developing sense of inferiority
B. Preschoolers exhibit "egocentric" thought, meaning that they truly believe that their
thinking is shared by others and that they can control their environment by their
thoughts.
At a well-child examination, the mother comments that her toddler eats little at
mealtime, will only sit briefly at the table, and wants snacks all the time. Which of the
following should the nurse recommend?
A) Provide nutritious snacks.
B) Offer rewards for eating at mealtimes.
C) Avoid snacks so she is hungry at mealtime.
D) Explain to her firmly why eating at mealtime is important.
A. Toddlers are not growing as quickly as they did during infancy and thus eat smaller
meals; nutritious snacks can help to ensure that they gain the nutrients they need.
An 8-year-old child is being admitted to the hospital from the emergency department
with an injury from falling off her bicycle. Which of the following will most help her adjust
to the hospital?
A) Explain hospital routines such as meal times to her.
B) Use terms such as "honey" and "dear" to show a caring attitude.
C) Explain when her parents can visit and why siblings cannot come to see her.
D) Since she is young, orient her parents to her room and hospital facility.
A. School-age children are able to think logically and can classify objects or routines;
having an understanding of what to expect can help them cope with a new experience.
The school nurse is counseling an obese 10-year-old child. What factor would be
important to consider when planning an intervention to support the child's health?
A) Concentrate on the child only rather than the family since it is the child's
responsibility.
B) Consider the use of medications to suppress the appetite.
C) First plan for weight loss through dieting and then add activity as tolerated.
D) Plan food intake to allow for growth
D. Although growth slows down during the school-age years, it is still important that
appropriate nutrients be provided to promote growth. Children need adequate caloric
intake along with activity for gross-motor development. Dieting might not provide the
intake necessary.
You are working in an adolescent health center when a 15-yearold patient shares with
you that she thinks she is pregnant and is worried that she may now have a sexually
transmitted infection (STI). Her pregnancy test is negative. What is your next priority of
care?
A) Contact her parents to alert them of her need for birth control.
B) Refer her to a primary health care provider to obtain a prescription for birth control.
C) Counsel her on safe sex practices.
D) Ask her to have her partner come to the clinic for STI testing.
C. Adolescent pregnancy and STIs are concerns that should be addressed by the nurse
to support health care.
While working in the high-school clinic, one of the students tells you that she is worried
about her friend who has started to refuse to participate in group activities, no longer
cares about how she looks at school, and is not going to all of her classes. Your
assessment of these symptoms may indicate that:
A) She has just broken up with her boyfriend and time will heal all.
B) You will need to observe her over time to see if symptoms persist.
C) School may be too difficult for her right now.
D) She may be at increased risk for suicide.
D. Depression is a major health concern for adolescents and can be triggered by many
factors; the symptoms that are listed indicate increased risk.
With the exception of pregnant or lactating women, the young adult has usually
completed physical growth by the age of:
A) 18.
B) 20.
C) 25.
D) 30.
B. Physical growth in the young adult is usually completed by the age of 20.
The nurse is completing an assessment on a male patient, age 24. Following the
assessment, the nurse notes that his physical and laboratory findings are within normal
limits. Because of these findings, nursing interventions are directed toward activities
related to:
A) Instructing him to return in 2 years.
B) Instructing him in secondary prevention.
C) Instructing him in health promotion activities.
D) Implementing primary prevention with vaccines
C. Although young adults generally have a minimum of major health problems, lifestyles
such as tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical
activity put them at risk for health problems. Instructing them in health-promotion
activities can decrease lifestyle-related health issues.
When determining the amount of information that a patient needs to make decisions
about the prescribed course of therapy, many factors affect the patient's compliance
with the regimen, including educational level and socioeconomic factors. Which
additional factor affects compliance?
A) Gender
B) Lifestyle
C) Motivation
D) Family history
C. Motivation plays a key role in compliance with a prescribed course of therapy.
However, motivation can be influenced by a variety of factors, including age,
experience, family history, social support, and pressure from health care providers.
A patient is laboring with her first baby, which is coming 2 weeks early. Her husband is
in the military and might not get back in time, and both families are unable to be with her
during labor. The doctor decides to call in which of the following people employed by the
birthing area to be a support person to be present during labor?
A) Nurse
B) Midwife
C) Assistant
D) Lay doula
D. Although a nurse and midwife would be supportive during labor, the scope of practice
for nurses and midwives far exceeds that of a support person present during labor. An
assistant is incorrect. This woman has no family available to support her during the
laboring process and delivery. A lay doula is a support person who is present during
labor to assist women who have no other source of support.
A single young adult female interacts with a group of close friends from college and
work. They celebrate birthdays and holidays together. In addition, they help one another
through many stressors. She views these individuals as:
A) Family.
B) Siblings.
C) Substitute parents.
D) Alternative family structure.
A. Families can be defined biologically, legally, or as a social network with personally
constructed ties and ideologies
Sharing eating utensils with a person who has a contagious illness increases the risk of
illness. This type of health risk arises from:
A) Lifestyle.
B) Community.
C) Family history.
D) Personal hygiene habits.
D. In all age-groups personal hygiene habits can be risk factors for the spread of
contagious diseases. Sharing eating utensils with a person who has a contagious illness
increases the risk of illness.
A 50-year-old woman has elevated cholesterol profile values that increase her
cardiovascular risk factor. One method to control this risk factor is to identify current diet
trends and describe dietary changes to reduce the risk. This nursing activity is a form of:
A) Referral.
B) Counseling.
C) Health education
D) Stress management techniques.
C. The nurse is engaged in health teaching as she offers dietary information to the
woman to enable her to make decisions about her dietary health practices in an attempt
to lower her cholesterol.
A 34-year-old female executive has a job with frequent deadlines. She notes that, when
the deadlines appear, she has a tendency to eat high-fat, high-carbohydrate foods. She
also explains that she gets frequent headaches and stomach pain during these
deadlines. The nurse provides a number of options for the executive, and she chooses
yoga. In this scenario yoga is used as a(n):
A) Outpatient referral.
B) Counseling technique.
C) Health promotion activity.
D) Stress-management technique.
D. Relaxation techniques such as imagery, biofeedback, and yoga help recondition the
patient's response to stress. Yoga is an ancient practice of controlling body and mind
through physical and mental harmony. It is frequently used as an effective intervention
for stress and stress-related physical symptoms.
A 50-year-old male patient is seen in the clinic. He tells the nurse that he has recently
lost his job and his wife of 26 years has asked for a divorce. He has a flat affect. Family
history reveals that his father committed suicide at the age of 53. The nurse should
assess for the following:
A) Cardiovascular disease
B) Depression
C) Sexually transmitted infection
D) Iron deficiency anemia
B. Depression is common among middle-age adults and has a variety of causes. Risk
factors for depression include disappointments or losses at work, at school, or in family
relationships and family history.
Middle-age adults frequently find themselves trying to balance responsibilities related to
employment, family life, care of children, and care of aging parents. People finding
themselves in this situation are frequently referred to as being a part of:
A) The sandwich generation.
B) The millennial generation.
C) Generation X.
D) Generation Y.
A. The sandwich generation is a generation of people who care for their aging parents
while supporting their own children. According to the Pew Research Center, just over
one in every eight Americans ages 40 to 60 is both raising a child and caring for a
parent.
Intimate partner violence (IPV) is linked to which of the following factors? (Select all that
apply.)
A) Alcohol abuse
B) Pregnancy
C) Unemployment
D) Drug use
A,B,C,D. IPV has been linked to alcohol abuse, especially heavy drinking; stress from
unemployment of the perpetrator; drug use; and pregnancy. The greatest risk of IPV
occurs during the reproductive years, with a pregnant woman having a 35.6% greater
risk of being a victim of IPV than a nonpregnant woman.
Sexually transmitted infections (STIs) continue to be a major health problem in young
adults. Men ages 20 to 24 years have the highest rate of which STI?
A) Chlamydia
B) Syphilis
C) Gonorrhea
D) Herpes zoster
A. In 2008 20- to 24-year-old men had the highest rate of chlamydia among all men
(1056.1 per 100,000 population), with chlamydia rates in men of this age-group
increasing by 12.6% from the previous year.
Formation of positive health habits may prevent the development of chronic illness later
in life. Which of the following are examples of positive health habits? (Select all that
apply.)
A) Routine screening and diagnostic tests
B) Unprotected sexual activity
C) Regular exercise
D) Excess alcohol consumption
A,C. Routine screening and diagnostic tests (e.g., laboratory screening for serum
cholesterol or serum glucose levels, mammography, or colonoscopy) provide early
detection of health issues. Regular exercise helps to maintain weight and improve
musculoskeletal functioning.
Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a
person's roles and responsibilities during middle adulthood. When assessing the
knowledge base of both the middle-age patient with a chronic illness and his family, the
assessment should include which of the following? (Select all that apply.)
A) The medical course of the illness
B) The prognosis for the patient
C) Coping mechanisms of the patient and family
D) The need for community and social services
A,B,C,D. When assessing the patient with a chronic illness, it is important that the nurse
know how much the patient and his family know about how the illness has progressed
and the long-term prognosis for the patient. This includes understanding the patient's
and families' ability and readiness to accept the illness and the outlook for the patient.
Understanding the coping mechanisms used by the patient and family helps the nurse
to determine how to teach and counsel them about his or her treatment regimen and
whether or not community or social services are needed and will be accepted to help
the patient and family.
A 45-year-old obese woman tells the nurse that she wants to lose weight. After
conducting a thorough assessment, the nurse concludes that which of the following may
be contributing factors to the woman's obesity? (Select all that apply.)
A) The woman works in an executive position that is very demanding.
B) The woman works out at the corporate gym at 5 am two mornings per week
C) The woman says that she has little time to prepare meals at home and eats out at
least four nights a week.
D) The woman says that she tries to eat "low cholesterol" foods to help lose weight.
A,C. Demanding and stressful work environments can lead to frequent stress eating of
nonnutritious foods. Frequently eating away from home and eating fast food have been
identified as contributing factors to obesity.
A student nurse is caring for a 78-year-old patient with multiple sclerosis. The patient
has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's
temperature was 37.1 C (98.8 F). The student reports her recent assessment to the
registered nurse (RN): the patient's temperature is 37.2 C (99 F); the Foley catheter is
still in place, draining dark urine; and the patient is uncertain what time of day it is. From
what the RN knows about presentation of symptoms in older adults, what should he
recommend?
A) Tell the student that temporary confusion is normal and simply requires reorientation
B) Tell the student to increase the patient's fluid intake since the urine is concentrated
C) Tell the student that her assessment findings are normal for an older adult
D) Tell the student that he will notify the physician of the findings
D. The patient may have subtle symptoms of a urinary tract infection, as evidenced by a
slight increase in body temperature, development of confusion, and the dark-colored
urine. Temporary confusion is not a normal condition in older adults. Increasing the fluid
intake is acceptable but not a recommendation for the set of symptoms the patient
presents. The presenting set of symptoms is not normal.
A patient's family member is considering having her mother placed in a nursing center.
You have talked with the family before and know that this is a difficult decision. Which of
the following criteria would you recommend in choosing a nursing center? (Select all
that apply.)
A) The center should be clean, and rooms should look like a hospital room.
B) There should be adequate staffing on all shifts.
C) Social activities should be available for all residents.
D) Three meals should be served daily with a set menu and serving schedule.
E) Family involvement in care planning and assisting with physical care is necessary.
B,C,E. Adequate staffing, provision of social activities, and active family involvement are
essential. Meals should be high quality with options for what to eat and when it is
served. A nursing center should be clean, but it should look like a person's home.
A nurse has conducted an assessment of a new patient who has come to the medical
clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes
mellitus for 20 years. He is alert but becomes easily distracted during the nursing
history. He recently moved to a new apartment, and his pet beagle died just 2 months
ago. He is most likely experiencing:
A) Dementia.
B) Depression.
C) Delirium.
D) Disengagement.
B. Factors that often lead to depression include presence of a chronic disease or a
recent change or life event (such as loss). Patients are alert but easily distracted in
conversation.
A major life event such as the death of a loved one, a move to a nursing home, or a
cancer diagnosis could precipitate:
A) Dementia.
B) Delirium.
C) Depression.
D) Stroke.
C. The onset of depression could be abrupt or gradual, but the usual cause is a major
life-altering event in the life of the person experiencing the depression.
Sexuality is maintained throughout our lives. Which answer below best explains
sexuality in an older adult?
A) When the sexual partner passes away, the survivor no longer feels sexual.
B) A decrease in an older adult's libido occurs.
C) Any outward expression of sexuality suggests that the older adult is having a
developmental problem.
D) All older adults, whether healthy or frail, need to express sexual feelings.
D. Sexuality is normal throughout the life span, and older adults need to be able to
express their sexual feelings
Older adults experience a change in sexual activity. Which best explains this change?
A) The need to touch and be touched is decreased.
B) The sexual preferences of older adults are not as diverse.
C) Physical changes usually do not affect sexual functioning.
D) Frequency and opportunities for sexual activity may decline.
D. As a result of loss of a loved one or a chronic illness in themselves or their partner,
opportunities for sexual activity may decline
You see a 76-year-old woman in the outpatient clinic. Her chief complaint is vision. She
states she has really noticed glare in the lights at home. Her vision is blurred; and she is
unable to play cards with her friends, read, or do her needlework. You suspect that she
may have:
A) Presbyopia.
B) Disengagement.
C) Cataract(s).
D) Depression.
C. Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of
vision. Presbyopia is a common eye condition resulting in a person having difficulty
adjusting to near and far vision. The symptoms are not reflective of depression since
her vision affects her ability to interact. She has not chosen to avoid her friends.
Disengagement is a term referring to aging theory.
A nurse is caring for a patient preparing for discharge from the hospital the next day.
The patient does not read and has a hearing loss. His family caregiver will be visiting
before discharge. What can you do to facilitate the patient's understanding of his
discharge instructions? (Select all that apply.)
A) Speak loudly so the patient can hear you.
B) Sit facing the patient so he is able to watch your lip movements and facial
expressions.
C) Present one idea or concept at a time.
D) Send a written copy of the instructions home with him and tell him to have the family
review them.
E) Include the family caregiver in the teaching session
B,C,E. Teaching and communication are more effective with older adults when you sit
and face the patient and present one idea or concept at a time. This requires planning.
Speaking loudly can distort sound. Speak in a normal tone. Sending instructions is
helpful but will not directly facilitate the patient's own understanding. Sharing information
with a caregiver provides someone to clarify instructions.
Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result, the
older adult is less able to discern:
A) Spicy and bland foods.
B) Salty, sour, and bitter tastes.
C) Hot and cold food temperatures.
D) Moist and dry food preparations.
B. Often an older adult uses "heavy" spices because of his or her inability to taste the
food.
Kyphosis, a change in the musculoskeletal system, leads to:
A) Decreased bone density in the vertebrae and hips.
B) Increased risk for pathological stress fractures in the hips.
C) Changes in the configuration of the spine that affect the lungs and thorax.
D) Calcification of the bony tissues of the long bones such as in the legs and arm
C. This can also affect the ability of the patient to deep breath and cough effectively.
A 63-year-old patient is retiring from his job at an accounting firm where he was in a
management role for the past 20 years. He has been with the same company for 42
years and was a dedicated employee. His wife is a homemaker. She raised their five
children, babysits for her grandchildren as needed, and belongs to numerous church
committees. What are your major concerns for this patient? (Select all that apply.)
A) The loss of his work role
B) The risk of social isolation
C) A determination if the wife will need to start working
D) How the wife expects household tasks to be divided in the home in retirement
E) The age the patient chose to retire
A,D. The psychosocial stresses of retirement are usually related to role changes with a
spouse or within the family and to loss of the work role. Often there are new
expectations of the retired person. This patient is not likely to become socially isolated
because of the size of the family. Whether the wife will have to work is not a major
concern at this time, nor is the age of the patient.
During a home health visit a nurse talks with a patient and his family caregiver about the
patient's medications. The patient has hypertension and renal disease. Which of the
following findings places him at risk for an adverse drug event? (Select all that apply.)
A) Taking two medications for hypertension
B) Taking a total of eight different medications during the day.
C) Having one physician who reviews all medications
D) Patient's health history
E) Involvement of the caregiver in assisting with medication administration
B,D. The patient is at risk for an adverse drug event (ADE) because of polypharmacy
and his history of renal disease, which affects drug excretion. Taking two medications
for hypertension is common. Having one physician review all medications and involving
a family caregiver are desirable and are safety factors for preventing ADEs.
You are caring for an 80-year-old man who recently lost his wife. He shares with you
that he has been drinking more than he ever did in the past and feels hopeless without
his wife. He reports that he rarely sees his children and feels isolated and alone. This
patient is at risk for:
A) Dementia.
B) Liver failure.
C) Dehydration.
D) Suicide.
D. The patient is sharing that he is depressed. Key concepts include recent loss of his
wife, excessive drinking, hopelessness, and isolation, making him at risk for suicide.
You are working with an older adult after an acute hospitalization. Your goal is to help
this person be more in touch with time, place, and person. What might you try?
A) Reminiscence
B) Validation therapy
C) Reality orientation
D) Body image interventions
C. Reality orientation is a communication technique that can help restore a sense of
reality, improve level of awareness, promote socialization, elevate independent
functioning, and minimize confusion.
A 71-year-old patient enters the emergency department after falling down stairs in the
home. The nurse is conducting a fall history with the patient and his wife. They live in a
one-level ranch home. He has had diabetes for over 15 years and experiences some
numbness in his feet. He wears bifocal glasses. His blood pressure is stable around
130/70. The patient does not exercise regularly and complains of weakness in his legs
when climbing stairs. He is alert, oriented, and able to answer questions clearly. What
are the fall risk factors for this patient? (Select all that apply.)
A) Presence of a chronic disease
B) Impaired vision
C) Residence design
D) Blood pressure
E) Leg weakness
F) Exercise history
B,E,F. Risk factors for falling include sensory changes such as visual loss,
musculoskeletal conditions affecting mobility (in this case weakness), and
deconditioning (from lack of exercise). The mere presence of a chronic disease is not a
risk factor unless it is a condition such as a neurological disorder that alters mobility or
cognitive function. The patient's blood pressure is stable, and there is no report of
orthostatic hypotension. A one-floor residence should not pose risks.
A patient on bed rest for several days attempts to walk with assistance. He becomes
dizzy and nauseated. His pulse rate jumps from 85 to 110 beats/min. These are most
likely symptoms of which of the following?
A) Rebound hypertension
B) Orthostatic hypotension
C) Dysfunctional proprioception.
D) Central nervous system rebound hypotension
B. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness,
nausea, tachycardia, pallor, and even fainting.
Which action(s) are appropriate for the nurse to implement when a patient experiences
orthostatic hypotension? (Select all that apply.)
A) Call for assistance.
B) Allow patient to sit down.
C) Take patient's blood pressure and pulse.
D) Continue to ambulate patient to build endurance.
E) If patient begins to faint, allow him to slide against the nurse's leg to the floor.
A,B,C,E. If the patient has a fainting (syncope) episode or begins to fall, assume a wide
base of support with one foot in front of the other, thus supporting the patient's body
weight (see Fig. 38-5, A to C). Extend one leg and let the patient slide against it; gently
lower the patient to the floor, protecting his or her head. Take the patient's blood
pressure and pulse as soon as possible after incident.
Which of the following best motivates a patient to participate in an exercise program?
A) Giving a patient information on exercise
B) Providing information to the patient when the patient is ready to change behavior
C) Explaining the importance of exercise when a patient is diagnosed with a chronic
disease such as diabetes
D) Following up with instructions after the health care provider tells a patient to begin an
exercise program
B. Patients are more open to developing an exercise program when they are at a stage
of readiness to change their behavior. Once the patient is at the stage of readiness,
collaborate with him or her to develop an exercise program that fits his or her needs and
provide continued follow-up support and assistance until the exercise program becomes
a daily routine.
Which of the following is a principle of proper body mechanics when lifting or carrying
objects?
A) Keep the knees in a locked position.
B) Bend at the waist to maintain a center of gravity.
C) Maintain a wide base of support.
D) Hold objects away from the body for improved leverage.
C. Maintaining a wide base of support allows for proper body mechanics. Locking the
knees or bending at the waist causes strain on the lower back. Holding objects close to
the body helps use the center of gravity for leverage.
Which group of patients is at most risk for severe injuries related to falls?
A) Adolescents
B) Older adults
C) Toddlers
D) Young children
B. Some older adults walk more slowly and are less coordinated. They also take smaller
steps, keeping their feet closer together, which decreases the base of support. Thus
body balance is unstable, and they are at greater risk for falls and injuries
A nurse plans to provide education to the parents of school-aged children and includes
which of the following result of children being less physically active outside of school?
A) An increase in obesity
B) An increase in heart disease
C) Higher computer literacy
D) Improved school attendance and grades
A. It is increasingly clear that children are less active, resulting in an increase in
childhood obesity. Strategies for physical activity incorporated early into a child's daily
routine may provide a foundation for lifetime commitment to exercise and physical
fitness.
A nursing assistive personnel asks for help to transfer a patient who is 125 pounds
(56.8 kg) from the bed to a wheelchair. The patient is unable to assist. What is the
nurse's best response?
A) "As long as we use proper body mechanics, no one will get hurt."
B) "The patient only weighs 125 lb. You don't need my assistance."
C) "Call the lift-team for additional assistance."
D) "The two of us can easily lift the patient."
C. Body mechanics alone are not sufficient to prevent musculoskeletal injuries when
positioning or transferring patients (see Table 38-1). Teaching the use of patient-
handling equipment or the use of a lift-team in combination with proper body mechanics
is more effective.
You are transferring a patient who weighs 320 lb (145.5 kg) from his bed to a chair. The
patient has an order for partial weight bearing as a result of bilateral reconstructive knee
surgery. Which of the following is the best technique for transfer?
A) Use a transfer board.
B) Obtain a stand assist device.
C) Implement a three-person carry.
D) Use the ceiling-mounted lift.
D. The use of patient-handling equipment helps prevent injury to health care workers
and patients.
Which is the correct gait when a patient is ascending stairs on crutches?
A) A modified two-point gait. The affected leg is advanced between the crutches to the
stairs.
B) A modified three-point gait. The unaffected leg is advanced between the crutches to
the stairs.
C) A swing-through gait.
D) A modified four-point gait. Both legs advance between the crutches to the stairs.
B. When ascending stairs on crutches, the patient usually uses a modified three-point
gait (see Fig. 38-13).
A patient recovering from bilateral knee replacements is prescribed bilateral partial
weight bearing. You reinforce crutch walking knowing that which of the following crutch
gaits is most appropriate for this patient?
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
A. The two-point gait requires at least partial weight bearing on each foot (see Fig. 38-
12). The patient moves a crutch at the same time as the opposing leg, so that the crutch
movements are similar to arm motion during normal walking.
A patient with a right knee replacement is prescribed no weight bearing on the right leg.
You reinforce crutch walking knowing that which of the following crutch gaits is most
appropriate for this patient?
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
B. Three-point alternating, or three-point, gait requires the patient to bear all of the
weight on one foot. In a three-point gait, the patient bears weight on both crutches and
then on the uninvolved leg, repeating the sequence (see Fig. 38-12, B).
A patient on week-long bed rest is now performing isometric exercises. Which nursing
diagnosis best addresses the safety of this patient?
A) Disturbed thought processes
B) Impaired skin integrity
C) Disturbed body image
D) Risk for activity intolerance
D. The nursing diagnosis, risk for activity intolerance, best relates to patient safety
because of the potential for orthostatic hypotension associated with prolonged bed rest.
Which of the following activities does the nurse delegate to nursing assistive personnel
in regard to crutch walking? (Select all that apply.)
A) Notify nurse if patient reports pain before, during, or after exercise.
B) Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness
when obtaining vital signs before and/or after exercise.
C) Notify nurse of vital sign values.
D) Evaluate the patient's ability to use crutches properly.
E) Prepare the patient for exercise by assisting in dressing and putting on shoes.
A,B,C,E. These are all correct as they are within the nursing assistive personnel
activities (e.g., notifying the nurse or completing assigned activities). Evaluation is within
the scope of professional nursing practice and is not delegated.
Select statements that apply to the proper use of a cane. (Select all that apply.)
A) For maximum support when walking, the patient places the cane forward 15 to 25 cm
(6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to
the cane so body weight is divided between the cane and the stronger leg.
B) A person's cane length is equal to the distance between the elbow and the floor.
C) Canes provide less support than a walker and are less stable.
D) The patient needs to learn that two points of support such as both feet or one foot
and the cane need to be present at all times.
A,C,D. A person's cane length is equal to the distance between the greater trochanter
and the floor. For maximum support when walking, the patient places the cane forward
15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The patient needs to
learn that two points of support (i.e., both feet or one foot and the cane) are present at
all times.
A patient is discharged after an exacerbation of chronic obstructive pulmonary disease
(COPD). She states, "I'm afraid to go to pulmonary rehabilitation." What is your best
response?
A) Pulmonary rehabilitation provides a safe environment for monitoring your progress.
B) You have to participate or you will be back in the hospital.
C) Tell me more about your concerns with going to pulmonary rehabilitation.
D) The staff at our pulmonary rehabilitation facility are professionals and will not cause
you any harm.
A. Pulmonary rehabilitation is beneficial in helping patients reach an optimal level of
functioning. Some patients are fearful of participating in exercise because of the
potential of worsening dyspnea (difficulty breathing). Pulmonary rehabilitation provides a
safe environment for monitoring the progress of patients.
An older adult has limited mobility as a result of a surgical repair of a fracture hip.
During assessment you note that the patient cannot tolerate lying flat. Which of the
following assessment data support a possible pulmonary problem related to impaired
mobility? (Select all that apply.)
A) B/P = 128/84
B) Respirations 26 per minute on room air
C) HR 114
D) Crackles heard on auscultation
E) Pain reported as 3 on scale of 0 to 10 after medication
B,C,D. Patients with reduced mobility are at risk for retained pulmonary secretions, and
this risk increases in postoperative patients. As a result of retained secretions, the
respiratory rate increases. The heart rate also increases because the heart is trying to
improve oxygen levels. These symptoms are of concern for older adults because, if left
untreated, further complications such as heart failure can occur.
A patient has her call bell on and looks frightened when you enter the room. She has
been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to
breathe, and I can't catch my breath." Your first action is to:
A) Call the health care provider to report this change in condition.
B) Give the patient a paper bag to breathe into to decrease her anxiety.
C) Assess her vital signs, perform a respiratory assessment, and be prepared to start
oxygen.
D) Explain that this is normal after such trauma and administer the ordered pain
medication.
C. These are signs of possible pulmonary emboli, which can be life threatening. You
must assess your patient, be prepared to start oxygen, and have someone call the
surgeon while you stay with the patient to continue to monitor her status.
The nurse puts elastic stockings on a patient following major abdominal surgery. The
nurse teaches the patient that the stockings are used after a surgical procedure to:
A) Prevent varicose veins.
B) Prevent muscular atrophy.
C) Ensure joint mobility and prevent contractures.
D) Promote venous return to the heart.
D. Elastic stockings maintain external pressure on the lower extremities and assist in
promoting venous return to the heart. This increase in venous return helps reduce the
stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in
the lower extremities.
A nurse is teaching a community group about ways to minimize the risk of developing
osteoporosis. Which of the following statements made by a woman in the audience
reflects a need for further education?
A) "I usually go swimming with my family at the YMCA 3 times a week."
B) "I need to ask my doctor if I should have a bone mineral density check this year."
C) "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I
need in my diet."
D) "I'll check the label of my multivitamin. If it has calcium, I can save money by not
taking another pill. "
D. Just because a multivitamin has calcium in it does not mean that the woman is
receiving enough to meet her needs. She must know her requirement and make the
decision based on that rather than on the value for calcium on the label.
The patient at greatest risk for developing multiple adverse effects of immobility is a:
A) 1-year-old child with a hernia repair.
B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident
(CVA).
C) 51-year-old woman following a thyroidectomy.
D) 38-year-old woman undergoing a hysterectomy.
B. The older the patient and the greater the period of immobility, which can be
significant following a hemorrhagic stroke, the greater is the number of systems that can
be affected by the immobility.
An older adult who was in a car accident and fractured his femur has been immobilized
for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists
this patient out of bed for the first time?
A) Chronic pain
B) Impaired skin integrity
C) Risk for ineffective cerebral tissue perfusion
D) Risk for activity intolerance
D. Patients on bed rest are at risk for activity intolerance, which increases patients' risk
for falling.
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000
units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient
is receiving enteral feedings through a small-bore nasogastric (NG) tube because of
dysphagia. Which of the following symptoms requires the nurse to call the health care
provider immediately?
A) Pale yellow urine
B) Unilateral neglect
C) Slight movement noted on the R side
D) Coffee ground-like aspirate from the feeding tube
D. When patients are receiving medications such as heparin or enoxaparin (Lovenox),
you must assess for signs of bleeding. These include overt signs such as bleeding from
their gums or covert signs, which can be detected by testing their stool or observing
their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding
in the gastrointestinal tract.
A home care nurse is preparing the home for a patient who is discharged to home
following a left-sided stroke. The patient is cooperative and can ambulate with a quad-
cane. Which of the following must be corrected or removed for the patient's safety?
(Select all that apply.)
A) The rubber mat in the walk-in shower
B) The three-legged stool on wheels in the kitchen
C) The braided throw rugs in the entry hallway and between the bedroom and bathroom
D) The night-lights in the hallways, bedroom, and bathroom
E) The cordless phone next to the patient's bed
B,C. Stools on wheels and braided throw rugs are hazards that put the patient at risk for
falls. By planning ahead and collaborating, the home care nurse can provide a safe
home environment for the patient after discharge.
The nurse is caring for a patient whose calcium intake must increase because of high
risk factors for osteoporosis. The nurse would recommend which of the following
menus?
A) Cream of broccoli soup with whole wheat crackers and tapioca for dessert
B) Hamburger on soft roll with a side salad and an apple for dessert
C) Low-fat turkey chili with sour cream and fresh pears for dessert
D) Chicken salad on toast with tomato and lettuce and honey bun for dessert
A. The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all
great sources of calcium.
Before transferring a patient from the bed to a stretcher, which assessment data does
the nurse need to gather? (Select all that apply.)
A) Patient's weight
B) Patient's level of cooperation
C) Patient's ability to assist
D) Presence of medical equipment
E) 24-hour calorie intake
A,B,C,D. By assessing the patient thoroughly you make the correct decision concerning
your ability to manage him or her safely, the need for additional personnel, the patient's
ability or inability to assist you with the transfer, and the proper equipment to use for the
transfer. The calorie intake for the past 24 hours does not affect safe transfer.
A patient of any age can develop a contracture of a joint when:
A) The adductors muscles are weakened as a result of immobility.
B) The muscle fibers become shortened because of disuse.
C) The calcium-to-phosphorus ratio becomes disrupted.
D) There is a deficiency in vitamin D.
B. The adductor muscles are stronger than the abductor muscles; when patients are
immobile and the joint is not exercised through their ROM, the adductor muscle fibers
shorten, resulting in the contracture of that joint, which is usually permanent.
Immobilized patients are at risk for impaired skin integrity. Which of the following
interventions would reduce this risk? (Select all that apply.)
A) Repositioning patient every 1 to 2 hours while awake
B) Using an objective, valid scale to assess patient's risk for pressure ulcer
development
C) Using a device to relieve pressure when patient is seated in chair
D) Teaching patient how to shift weight at regular intervals while sitting in a chair
E) A good rule is: the higher the risk for skin breakdown, the shorter the interval
between position changes
B,C,D,E. Patients must be repositioned around the clock, not just when they are awake.
An objective assessment scale allows the nurse to assess for pressure ulcer risk over
time. Once the risk is identified, the assessment tool guides the nurse in selecting
appropriate pressure-relief devices. Showing the patient how to reduce his or her risk by
shifting pressure is also important. Frequent and meaningful position changes that are
in concert with the patient's condition and risk factors are necessary to reduce pressure
ulcer developments.
Which of the following indicates that additional assistance is needed to transfer the
patient from the bed to the stretcher?
A) The patient is 5 feet 6 inches and weighs 120 lbs.
B) The patient speaks and understands English.
C) The patient received an injection of morphine 30 minutes ago for pain.
D) You feel comfortable handling a patient of his size and with his level of cooperation
C. The morphine injection would change the patient's ability to safely follow directions
and participate in the transfer; therefore additional help would be needed to safely
transfer the patient from the bed to the stretcher.
A patient with left-sided weakness asks his nurse, "Why are you walking on my left
side? I can hold on to you better with my right hand." What would be your best
therapeutic response?
A) "Walking on your left side lets me use my right hand to hold on to your arm. In case
you start to fall, I can still hold you."
B) "Would you like me to walk on your right side so you feel more secure?"
C) "Either side is appropriate, but I prefer the left side. If you like, I can have another
nurse walk with you who will hold you on the right side."
D) "By walking on your left side I can support you and help keep you from injury if you
should start to fall. By holding your waist I would protect your shoulder if you should
start to fall or faint.
D. Walking on the affected (weak side) side and holding the patient around the waist or
using a gait belt gives you better control if the patient starts to fall. If you were holding
the patient's arm as he was falling, you might dislocate his shoulder.
Which is an outcome for a patient diagnosed with osteoporosis?
A) Maintain serum level of calcium.
B) Maintain independence with activities of daily living (ADLs).
C) Reduce supplemental sources of vitamin D.
D) Reverse bone loss through dietary manipulation.
B. The main goal is to maintain independence in ADLs once osteoporosis is diagnosed.
It is best to identify individuals at risk and work toward preventing the disease.