Which of the following behaviors alerts the nurse to consider the need for restraint?

The patient continues to remove the nasogastric tube.

Upon suspecting abuse, the school nurses best next action is which of the following?

Contacting Social Services and reporting suspected abuse

RN is preparing to assess the external genitalia of a 25y/o woman of Chinese descent. First

Assess the pts feelings and explain the purpose of the exam

An elderly pt has been on high doses of antibiotics & is experiencing a sudden loss of hearing

Stop antibiotic use until the physician responds.

Older adults may have changes in sexual functioning. What can increase sexual stamina. SATA

Eat well balanced meals and eliminate excess fats and sugars, Plan sexual activity around when the couple feels rested, Avoid alcohol and tobacco.

Which are appropriate for the dx of Spiritual distress? Select all that apply

Teach relaxation, guided imagery, and meditation., Offer to pray with the patient., Develop activities to heal body, mind, and spirit

Based on the following data, which person is likely to have the highest self-esteem?

Latino adolescent female who has strong ethnic pride

A cancer pt asks the RN what the criteria are for hospice care. What should the nurse answer?

Expected to live less than 6 to 12 more months

Focusing on breathing and one part of the body at a time

Progressive relaxation training

When assessing the pts thorax, the nurse should

Compare symmetrical areas from side to side

Which behavior by a student nurse will require intervention

The student nurse shares patient information with a friend.

Which information should the nurse include in teaching staff about health care reimbursement

Home health, long-term care RNs docum. affects reimbursement

Pt is weak but refuses to use a bedpan & wants to get up to use the commode. RN should

Assistance from family & assist pt to get up

Which statement requires a professor to intervene

Older adults dont need to worry about STIs

Which of the following statements made by the new graduate nurse requires the RN to intervene?

Assessment only provide info about the effectiveness of care

A teen with celiac disease continues to eat food she knows will make her ill. RN should

Assist teen in meeting diet restrictions

The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is

Inspiratory phase is 3times longer than the expiratory phase

a new RN has a strategy to prevent burnout. The best strategy would be for the new RN to

Identify limits and scope of work responsibilities.

Which patient is most in need of a nurses referral to adoption services?

infertile couple opposed to artificial insemination

Which is an indication that the pt understands the directions regarding the antibiotic meds

The patient states, I will finish the antibiotic in ten days

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Nursing 2 Quiz Flashcards | StudBud

Nursing 2 Quiz

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Answers

1
Which of the following behaviors alerts the nurse to consider the need for restraint?
The patient continues to remove the nasogastric tube.
The patient refuses to call for help to go to the bathroom.
The patient does not sleep and continues to ask for items.
The patient gets confused regarding the time at night.
2
After providing care, a nurse charts in the patients record. Which entry should the RN document
Drank adequate amounts of water
Skin pale and cool
Apparently is asleep with eyes closed
Appears restless when sitting in the chair
3
Pt says they believe in life after death, now im not sure The RN says here is. RN is trying to
Support the patients agnostic beliefs.
Provide hope.
Support the horizontal dimension of spiritual well-being.
Strengthen the patients religion.
4
Upon suspecting abuse, the school nurses best next action is which of the following?
Realizing that abuse victim usually report abusive situation
Contacting Social Services and reporting suspected abuse
Ignoring the findings, child abuse is a declining problem
Interviewing the patient in the presence of his/her teacher
5
RN determines that it is especially important to perform which focused exam for a premature pt
Respiratory
Cardiac
Hearing acuity
Ophthalmic
6
If an RN gets stuck with a needle in her hand, she is at risk for
Clostridium difficile.
MRSA
Diphtheria.
Hepatitis B.
7
Sounds are created by air moving through smaller airways
Vesicular
Bronchial
Rhonchi
Bronchialvesicular
8
RN is preparing to assess the external genitalia of a 25y/o woman of Chinese descent. First
Drape the patient to enhance patient comfort.
Ask the pt if she would like her mom to be present
Place the patient in the lithotomy position.
Assess the pts feelings and explain the purpose of the exam
9
Pediatric stressors related to self-esteem reflect which maturational school age category
Adolescence
Early adulthood
Elementary school age
Preadolescence
10
Blowing sound over the carotid artery
Bruit
Phlebitis
Clubbing
Right-sided heart failure
11
Objective, ongoing reviews to determine the degree to which quality improvement standards R met
Communication
Research
Legal Documentation
Auditing
12
Which of the following is not an element in the development or chain of infection
Means of transmission
Formation of immunoglobulin
Reservoir for pathogen growth
Infectious agent or pathogen
13
An elderly pt has been on high doses of antibiotics & is experiencing a sudden loss of hearing
Tell the pt that older pts often lose low-frequency hearing
Tell the pt that rapid hearing loss is normal in the elderly
Hearing loss usually occurs with thinning of the eardrum
Stop antibiotic use until the physician responds.
14
Older adults may have changes in sexual functioning. What can increase sexual stamina. SATA
Eat well balanced meals and eliminate excess fats and sugars
Encourage intimate touching, such as hugging and kissing.
Plan sexual activity around when the couple feels rested
Avoid alcohol and tobacco.
15
Loud low-pitched rumbling coarse sounds during insp or exp that sometimes clear by coughing
Bronchial
Stridor
Crackles
Rhonchi
16
Which are appropriate for the dx of Spiritual distress? Select all that apply
Teach relaxation, guided imagery, and meditation.
Offer to pray with the patient.
Develop activities to heal body, mind, and spirit
Assess for potential suicide.
17
Provides the most current info that has been entered into the EHR
Admission history
EMR
Patient care summary
Admission flow sheet
18
Which of the following sensory changes are normal with aging?
Impaired night vision
Increase in taste discrimination
Difficulty hearing low pitch
Heightened sense of smell
19
Based on the following data, which person is likely to have the highest self-esteem?
African American adolescent male who has severe acne
Latino adolescent female who has strong ethnic pride
Caucasian boy who lives below federal poverty level
Adolescent who was suspended twice from high school
20
Dependent upon a persons culture, development life experiences beliefs & ideas about life
Spirituality.
Religion.
Faith.
Self-transcendence.
21
A cancer pt asks the RN what the criteria are for hospice care. What should the nurse answer?
Having a terminal illness, such as cancer
Needing assistance with pain management
Completion of an advance directive
Expected to live less than 6 to 12 more months
22
Focusing on breathing and one part of the body at a time
Group biofeedback
Meditation
Group psychotherapy
Progressive relaxation training
23
The nurse contacts the patients medical provider over which potential drug-drug interaction?
Lisinopril and echinacea
Lisinopril and hydrochlorothiazide
Warfarin and ginkgo biloba
Echinacea and warfarin
24
When assessing the pts thorax, the nurse should
Change the position of the stethoscope between insp. and exp
Compare symmetrical areas from side to side
Begin with the posterior lobes on the right side
Complete the left side and then the right side
25
Individuals/familys/communitys relationship to stress and the reaction to stress.
Ego defense model
Situational model
Neuman systems model
Evidence-based practice model
26
Which RN dx for psychological concerns for a pt with both hearing and visual sensory impairment
Impaired physical mobility
Self-care deficit
Social isolation
Risk for falls
27
Which position is this?
Supine
Dorsal
Laying
Prone
28
Manifests signs and symptoms to types of infection
illness stage
Convalescence
incubation stage
Prodromal stage
29
Which behavior by a student nurse will require intervention
The student nurse reviews the patients medical record.
The student nurse documents meds administered to the pt
The student nurse reads the patients plan of care.
The student nurse shares patient information with a friend.
30
A nurse is charting on a patients record. Which action is most accurate legally?
Charts legibly
Uses correction fluid to correct error
States the patient is belligerent
Writes entry for another nurse
31
The step after inspection when assessing the abdomen is
Percussion
Auscultation
Deep palpation
Palpation
32
Pt informs RN that she often becomes nauseated when riding in cars. This is a
Balance deficit
Neurological deficit
Visual deficit
Hearing deficit
33
One of several formats or structured notes within a POMR (Problem-oriented Med Record)
Progress Notes
Case management
Focused Charting
EMR
34
Which information should the nurse include in teaching staff about health care reimbursement
Home health, long-term care RNs docum. affects reimbursement
Sentinel events determine reimbursement issues
HIPAA is the basis for establishing reimbursement
Clinical info system must be installed by 2014
35
What type of breath sound is this?
Wheezing
Rhonci
Bronchial/Vesicular breathing
Normal
36
Pt on antidepressants states I feel happier but my sex drive is gone. Which RN dx is priority
Deficient knowledge about contraception
Risk for self-directed violence
Ineffective coping
Sexual dysfunction
37
Pt is weak but refuses to use a bedpan & wants to get up to use the commode. RN should
Tell the pt that he is too weak & needs to use the bedpan
Assistance from family & assist pt to get up
Insert rectal tube so pt doesnt need to actively defecate
Put the pt on a bedpan and stay with him until finished
38
Which statement requires a professor to intervene
Using pillows & pain meds PRN before sex often helps w/pain
Older adults dont need to worry about STIs
Avoiding alcohol use will enhance your sexual functioning.
You need to tell your partner how you feel about sex
39
Which of the following statements made by the new graduate nurse requires the RN to intervene?
Assessment helps understand their pts emotional needs.
Assessment only provide info about the effectiveness of care
Uses assessment data to see if medication is working
use data from pt assessment to determine educational needs.
40
The CAM therapy that is known to alter immune function is which of the following
Imagery
Biofeedback
Acupuncture
Breath work
41
A teen with celiac disease continues to eat food she knows will make her ill. RN should
Assist teen in meeting diet restrictions
Teach the patient about the food pyramid.
Administer antidiarrheal medications with meals.
Admonish the teen regarding her poor diet choices
42
Best exam position for a complete geriatric physical exam on a weak pt with bilateral pneumonia
Sims position
Prone position
Lateral recumbent
Supine position
43
A class about stress reduction after cardiac bypass surgery is which type of intervention
Tertiary
Secondary
Primary
44
RN is teaching guided imagery to a prenatal class. ID an example of guided imagery
Singing
Back massage
Sensory peaceful words
Listening to music
45
The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is
The expiration phase is longer than the inspiration phase.
Inspiratory phase is 3times longer than the expiratory phase
The expiration phase is 2times longer than the inspiration
The inspiratory and expiratory phase are exactly the same
46
RN knows to not use which of the following treatment products for Pediculosis humananus capitis
Lindane-based shampoo
Vinegar hair rinse
Fine-toothed comb
Pediculicide
47
hx of asthma, eczema, & allergic rhinitis, the RN expects which physical finding on nasal exam?
Yellow discharge
Pale nasal mucosa
Polyp
Puffiness of nasal mucosa
48
a new RN has a strategy to prevent burnout. The best strategy would be for the new RN to
Write for 10 minutes in a journal every day.
Delegate complex nursing tasks to licensed professional RNs
Identify limits and scope of work responsibilities.
Use progressive muscle relaxation.
49
Which patient is most in need of a nurses referral to adoption services?
A patient considering abortion for an unwanted pregnancy
A woman who suffered miscarriage during her first pregnancy
A couple who has been attempting conception for 3 months
infertile couple opposed to artificial insemination
50
The nurse recognizes a lump on the testis as a potential sign of which of the following?
Testicular cancer
Inguinal hernia
Sexually transmitted infection
Diuretic use
51
Which is an indication that the pt understands the directions regarding the antibiotic meds
The patient reads the medication prescription out loud.
The patient asks where to get the prescription filled.
The patient nods throughout the educational session.
The patient states, I will finish the antibiotic in ten days
52
Which of the following is the most important point to be included in education about smoking
It affects the cilia lining the upper airways in the lungs
Smoke from tobacco products clings to your clothing and hair
Smoking tobacco products can be very expensive.
Smoking can affect the color of the patients fingernails.
53
Which of the following statement about religion and spirituality is true?
Spirituality is unique to the individual.
Religion is a unifying theme in peoples lives.
Religion and spirituality are synonymous.
Spirituality encompasses religion.
54
Whats required after exposure to blood by a cut from a scalpel in the perioperative area
Testing the patient and offering treatment to the nurse
Placing the scalpel in a needle safe container
Providing a medical evaluation of the nurse to the manager
Removing sterile gloves and disposing of in kick bucket
55
Physiological symptoms of a stress response include all of the following except
Constricted pupils.
Tachycardia.
Elevated blood pressure.
Tachypnea.
56
A pt admits that he knew for months that he had an STI but didnt report it. RN knows that pts
Are hesitant to admit they contracted an STI.
Are uncomfortable discussing sexual health issues
Have lifestyles that subject them to repeated exposure.
Do not acknowledge the importance of STI testing & treatment
57
RN recognizes the new RN ability to determine pt safety risks when which behavior is observe
Checking patient identification once every shift
Disposing of used needles in a red needle container
Raising all four side rails per family request
Multitasking by gathering two patients medications
58
The primary purpose of a pts med record is to
Provide validation for hospital charges
Provide the nurse with a defense against malpractice
Communicate accurate, timely info about the pt
Satisfy requirements of accreditation agencies
59
Focuses on deviations from the est. norm or abnormal findings; highlights trends/changes
Progress notes
Critical pathways
Charting by exception
Focus charting
60
Based on the following data, which person is likely to have the highest self-esteem?
Caucasian boy who lives below federal poverty level
Latino adolescent female who has strong ethnic pride
Adolescent who was suspended twice from high school
African American adolescent male who has severe acne
61
Which position is this?
Lithiotomy
Dorsal Recumbent
Supine
Prone
62
HPV vaccines are recommended to prevent
Genital lesions.
Swollen perianal tissues.
Vaginal discharge.
Cervical cancer.
63
The pt states that he is a spiritual person but doesnt practice any specific religion. This is
Indicate a lack of faith.
Indicate a strong religious affiliation.
Reasonable.
contradictory
64
RN assists pt to ID several activities that the pt is looking forward to in life. This is
Faith
Charity
Time management
Hope
65
The HPV vaccine
Is recommended only after a female becomes sexually active.
Is safe for children over the age of 5 and lasts 10 years.
Requires a three-injection series to be fully effective.
Will prevent a female from ever getting cervical cancer.
66
A therapeutic touch practitioner scans the patients body to identify what?
Accumulated tension
Blocked chakra
The flow of Qi
Structural and functional imbalance
67
In caring for the patients spiritual needs, the nurse understands that
A caring presence involves listening to the pts wishes only.
Establishing presence is part of the art of nursing.
RN must use her expertise to make decisions for the pt
Presence involves doing for the patient.
68
The nurse knows that the ability to recognize and interpret stimuli is known as
Sensation
Reception
Perception
Reaction
69
Physical injury, neglect, malnutrition, bruising, fear of care giver are all signs of
Abuse
Mental illness
Risk for falls
Pneumonia
70
Which of the following would most immediately threaten an individuals safety
A sprained ankle
70% Humidity
unrefrigerated fresh vegetables
Lack of water
71
RN prepared an audiotaped exchange with another RN of info about a pt. This is
Consultation.
Record.
Referral.
Report.
72
While caring for a pt who vomits without warning, the nurse has contaminated hands Next the RN
Instruct the patient to wash his face and hands.
Use an alcohol-based waterless hand gel.
Wash hands with an antimicrobial soap and water.
Clean hands with wipes from the bedside table.
73
During the eval stage of the critical thinking model applied to a pt coping with stress RN will
ID stress management interventions for achieving outcomes
Reassess stress related symptoms compare w/expected outcomes
Establish short- and longterm goals w/pt experiencing stress
nursing interventions to promote the pt adaptation to stress
74
small, circumscribed skin lesions filled with serous fluid
Papule
Wheal
Pustule
Vesicle
75
While assessing the skin of an 82y/o male patient, nonpainful ruby red papules on the pts trunk
Document cherry angiomas as a normal geriatric skin finding.
Document the presence of edema.
Tell the pt that he has a benign squamous cell carcinoma
Tell them he has basal cell carcinoma
76
During change of shift...
2 or more RNs always visit pts to review plan of care
Pt info is communicated from one RN to another
RN should exchange judgements about pt attitudes
RN should ID nursing dx and clarify pt priorities
77
RN creates a referral to pastoral care when he/she realizes that the patient is in need of
Transfer to the psychiatric unit.
Psychiatric care.
Spiritual care.
Return to religious affiliation.
78
Which action would indicate a break in sterile technique?
Touching protective eyewear
Accepting sterile supplies from the surgeon
Staying with the sterile table once it is open
Standing with hands folded on chest
79
Medical hx of asthma, eczema, and allergic rhinitis. Physical finding on nasal exam is
Polyp
Pale nasal mucosa
Puffiness of nasal mucosa
Yellow discharge
80
The reason for writing in indelible ink on the surgical site the word correct is to
Label the correct patient.
Distinguish the correct surgical site.
Comply with the surgeons preference.
Adhere to the correct regulatory standard.
81
Which of the following comments by the patient would indicate a need for further education?
when its cold out, i can warm up my car in the garage
If dizzy while using the heater, have it inspected
Change the CO detector batteries at daylight savings time
I will schedule an appt with a chimney inspector next week
82
What is the involuntary motion of retracting the body from painful stimuli?
Perception
Sensation
Reception
Reaction
83
Which of the following findings requires the nurse to contact the pt Dr for further exam?
A black fundus of the eye
A thin white ring along the margin of the iris
Dilated pupils
A black pupil
84
A basic foundational principle of chiropractic care is that
Subluxation will cause permanently restricted joint movement
Chiropractic care is risk free.
Structure and function coexist.
Human beings need external hands-on care to be healthiest.
85
Level is based on the type and number of nursing interventions required over a 24 hr period
Discharge summary forms
Acuity Records
Patient care summary
Flow Sheets
86
The pt has dysuria and hematuria. How does the RN proceed to assess for kidney inflammation
Uses deep palpation posteriorly
Lightly palpates each abdominal quadrant
Inspects abdomen for abnormal movement
Percuss posteriorly costovertebral angle @ the scapular line
87
Which information is critical for the RN to report during hand-off
The patient had a good day with no complaints.
The family is poor and had to go on welfare.
The family is demanding and argumentative.
The patient has a new pain medication, Lortab.
88
RN would be most concerned about risk of malnutrition for a pt with which sensory deficit
Disequilibrium
Peripheral neuropathy
Xerostomia
Cataracts
89
When pt is first admit, they weigh 250lbs. The next day they weigh 256lbs. The RN should eval
Decreased nutritional reserves.
Anorexia.
Fluid retention.
Fluid loss.
90
Infection comes from microorganisms outside the individual that do not exist in normal flora
Exogenous
Endogenous
91
Pt who is taking meds for ED is most at risk for
Ineffective coping related to chronic illness.
Sexual dysfunction related to low self-esteem.
Anxiety related to erectile dysfunction.
Impaired circulation due to medication.
92
For a rectal examination of a nonambulatory male pt, he needs to be placed in which position?
Sims position
Knee-chest
Forward bending with flexed hips
Dorsal recumbent
93
A spike in postop infection; this type of health care-associated infection is
Endogenous
Exogenous
Nosocomial
Iatrogenic
94
The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to
Trying to pull up on furniture
Growing ability to explore and oral activity.
Being dropped by a caregiver.
Learning to walk.
95
Any manual method, physical or mechanical device, material that immobilizes a pt is a
Chemical restraint
Mechanical restraint
Physical restraint
96
The best term for breath sounds created by air moving through large lung airways is
Bronchovesicular.
Rhonchi.
Bronchial.
Vesicular.
97
Which assessment of the pt would indicate an adaptation to a hearing deficit r/t presbcusis
The patient isolates himself from social situations.
The pt frequently cleans out his ears with a cotton swab
The pt asks the nurse to speak loudly during conversations.
The pt turns one ear toward the nurse during conversation
98
Which position is this?
Dorsal Recumbent
Sims
Right Lateral Recumbent
Prone
99
An incident report is
Report of an RN's behavior submitted to the hospital admin.
A legal claim against a nurse for negligent care
A summary report of all falls occurring on a nursing unit
A report of an event inconsistent with routine pt care
100
Different reactions to the same situation would be explained best by which of the following
Strong financial resources
Restorative care
Immaturity and intelligence factors
Maturational and sociocultural factors
101
The comprehensive abdominal examination would include, in proper order, which of the following?
Inspection, palpation, percussion
Percussion, inspection, auscultation
Inspection, auscultation, palpation
Inspection, palpation, auscultation
102
All of this info needs to documented for a telephone report except
When the call was made
Who made it
Who was called
Where the call was made
103
Which intervention will be most effective in helping pt resume sexual activity after ostomy
Reassure the pt that people resume sex the same week
Inform pt about a support group for people with ostomies
Discuss ways to adapt to new body image
Teach about intimate activities that incorporate the ostomy
104
Which of the following preventive screenings does the RN recommend for a 50y/o male pt
Ca125 blood test once a year
Digital rectal examination of the prostate (DRE) annually
Complete eye examination every year
Colonoscopy every 3 years
105
Number of sound wave cycles generated per second by a vibrating object
Duration
Amplitude
Quality
Frequency
106
Pt has a urinary cath. After the RN empties the collection bag and disposes of the urine, next
Remove eye protection and dispose of in garbage.
Wash hands with soap and water.
Use alcohol-based gel on hands.
Remove gloves and dispose of in garbage.
107
RN encourages which of the following to reduce childrens stress regarding homework assignments
Time management skills
Prevention of iron deficiency anemia
Routine preventative health visits
Speech articulation skills
108
Pt is 54y/o, 148lbs, 5ft 8in tall. The nurse realizes that this pt is
Obese.
Underweight.
Overweight.
At his desired weight.
109
Multidisciplinary care plans that include pt problems, key interventions, & expected outcomes
Progress notes
Critical pathways
Charting by exception
Focus charting
110
RN realizes that entropion places the elderly pt at risk for which of the following
Exophthalmos
Strabismus
Infection
Ectropion
111
The developmental stage that carries the highest risk of injury from a fall
Older adulthood
Adulthood
School age
Preschool
112
Drawbacks of complementary and alternative therapies would be all of the following except
Minimal supportive research studies.
Strong support by allopathic medical providers.
Lack of evidence-based guidelines.
Lack of long tradition of therapies taught in education
113
The most appropriate CAM therapy that the nurse can recommend for excessive worry & work stress
Chiropractic therapy
Acupuncture
Ayurvedic herbs
Meditation
114
The nurse and the patient have the same religious affiliation. Because of this, the nurse
Must use an assessment tool to assess the patients beliefs.
Can assume that they have the same spiritual beliefs.
Should not impose her personal values on the patient.
Can skip the spiritual belief assessment.
115
Integrating all pt info into one record regardless of the # of times a pt is treated
Electronic medical record
Electronic charting record
Electronic problem record
Electronic health record
116
A long-term outcome for an individual who is learning relaxation therapy is
Having no tension in his life.
Increasing the focus on himself.
Identifying tension in body & consciously releasing tension
Increasing delta brain activity.
117
The nurse knows that a patient does not fully understand the changes of aging when the pt says
Orgasms are no longer achievable after menopause.
I will no longer ovulate after menopause.
As men age, their ability to sexually perform may decrease.
Hormones of sexual regulation decrease with age
118
First step in a nurses initial assessment is
Inspection, light palpation.
Light palpation, deep palpation, inspection.
Auscultation, deep palpation, light palpation.
Deep palpation, light palpation, inspection.
119
Depressing the area 4 cm to assess the conditions of organs
Deep palpation
Light palpation
120
Learning the nature of an illness and the individual patient's response
Auditing
Education
Research
Legal documentation
121
Which of these should be reviewed when observing a patient? (Select all that apply)
Body color, odor, hygiene and grooming
Body type/movements/Gait
Gender/Race
Age
122
Aware of the potential for health care associated infection R/T a PICC, the nurse is careful to
Use nonallergenic tape and dressings on the patient.
Utilize local anesthetic on the site as ordered.
Select catheter of appropriate size for the appropriate vein
Prepare the skin with 2% chlorhexidine gluconate.
123
Aware of the need for Standard Precautions, the nurse is careful to
Don gloves when wearing artificial nails.ANS: B
Avoid contact with intact skin without wearing gloves.
Teach the patient about good nutrition.
Wear eyewear when emptying a urinary drainage bag.
124
The RN assesses for equipment-related accidents when using
A measuring device that measures urine.
Sequential compression devices.
Computer-based documentation.
A manual medication-dispensing device.
125
SOAP with intervention and evaluation added
PIE
Focus Charting
Progress note
SOAPIE
126
Describes length of time that vibrations last
Duration
Amplitude
Quality
Frequency
127
Involves repressing an anxiety-producing conflict & transforming it into a nonorganic symptoms
Denial
Conversion
Compensation
Dissociation
128
Which position is this?
Knee-Chest
Sims
Dorsal Recumbent
Lithiotomy
129
Pt wants to have an elective abortion. RNs religious values are strongly opposed. RN should
Refer pt to a family planning center
Continue to care for the pt limit conversation
Attempt to educate pt about the consequences
Because of moral issues, another RN will care for Pt
130
Person states he was not shoplifting despite being caught on camera. This is which ego defense
Dissociation
Denial
Compensation
Conversion
131
A blowing sound is auscultated over the carotid artery. This finding is called
Phlebitis
Bruit.
Clubbing.
Right-sided heart failure.
132
The component that should receive the highest priority before a physical exam is
Preparation of the equipment
Psychological preparation of the patient
Preparation of the enviornment
Physical preparation of the patient
133
The severity of a patient's illness depends on all of the following except
Extent of infection
Susceptibility of the host
Incubation period
Pathogenicity of the microorganism
134
Pt responds correctly to questions and instructions but cannot form words coherently. This is
Combination Aphasia
Receptive Aphasia
Sensory Aphasia
Expressive Aphasia
135
pt states I just dont feel like going to work I have no energy and I cant eat or sleep
Encourage the purchased of OTC sleep aids to help with sleep
Dont be concerned with self harm, pt has no indication of it
Assess the potential for suicide and make referrals
Ignore individual pt goals until the current crisis is over
136
Describes sounds of similar frequency and loudness
Frequency
Duration
Amplitude
Quality
137
While washing hands, the nurse touches the sink. What is the next action the nurse should take?
Extend the handwashing procedure to 5 minutes.
Inform the physician and recruit another nurse to assist.
Repeat handwashing using antiseptic soap,
Rinse and dry hands, and begin assisting the physician
138
Purpose of unconscious ego defense mechanisms is which of the following for the individual
Evaluate an event for its personal meaning.
Trigger the stress control functions of medulla oblongata
Protect against feelings of worthlessness and anxiety.
Facilitate the use of problem-focused coping.
139
A trauma survivor is requesting sleep meds because of bad dreams. Concerned about PTSD RN asks
Are you having chest pain?
Can you describe your phobias?
Are you reliving your trauma?
Can you tell me when you wake up?
140
The 1994 Dietary Supplement Health and Education Act impacted herbal therapies in what way?
Classified herbs as natural foods
Allowed herbs to be sold as dietary supplements
Allowed for labeling of herbal medicines as safe
Classified herbs as beneficial, harmful, or neutral
141
Use of DAR (data, action, and response)
Critical Pathways
Focus Charting
Case management
Charting by exception
142
In a pt with pneumonia, the nurse hears high-pitched continuous sounds over the bronchi on exp
Crackles
Rhonchi
Friction rubs
Wheezes
143
The second heart sound (S2) occurs when
The mitral and tricuspid valves close
Systole begins
The aortic and pulmonic valves close
There is rapid ventricular filling
144
Pt is a member of the 7th Day Adventist religion is to get a test done on a saturday RN should
Inform the physician that the tests cannot be performed.
Order the tests without questioning.
Discuss the patients beliefs about the Sabbath.
Reorder the tests for Sunday.
145
The therapy that is more effective in tx physical ailments than preventing disease
Complementary
Alternative
Mind-body
Allopathic
146
Stroke pt is having difficulty eating. The RN includes which intervention in the plan of care
Obtain an order for antidepressant meds
Order the pt food that does not require utensils
Teach pt about special devices to assist with eating meals
Place a consult for a home health nurse
147
RN is using the source record and wants to find the daily weights. Where should the RN look
Medical history and examination
Database
Graphic sheet and flow sheet
Progress notes
148
Which interventions would indicate the ability to recognize the inflammatory response
Rest, ice, compression, and elevation
Orient to date, time, and place
Passive range-of-motion exercises
Turn, cough, and deep breathe
149
A nurse has provided care to a patient. Which entry should the nurse document in the pt record?
Incision 1in in length w/out redness drainage or edema
Patient is hard to care for and refuses all tx and meds
Status unchanged, doing well
Patient seems to be in pain and states, I feel uncomfortable
150
Interval between entrance of the pathogen into the body and appearance of the symptoms
Prodromal stage
Convalescence
illness stage
Incubation period
151
Abnormal thyroid shape during the physical exam. RN offers the pt and observes her drinking to
Test the patients gag reflex.
Visualize an enlarged thyroid gland.
Visualize the uvula and soft palate.
Evaluate for exostosis.
152
RN is teaching a pt and family about hand hygiene in the home. Teach about handwashing before
And after shaking hands.
Opening the refrigerator.
And after using a computer.
And after treatments.
153
The cognitive skill of learning to tolerate uncertain and unfamiliar experiences
Passivity.
Focusing.
Receptivity.
Mindfulness.
154
Onset of nonspecific signs and symptoms to more specific symptoms
Incubation stage
Convalescence
Illness stage
Prodromal Stage
155
When is the best time the nurse should start discharge planning for a patient?
Upon admission
When the primary care provider writes the order
Right before discharge
After the congestion is treated
156
The nurse explains to the patient that interventions for fall precautions include
Checking on the patient once a shift.
Placing all four side rails in the up position.
Encouraging visitors in the early evening.
Placing a high risk for falls armband on the patient.
157
Female Pt of muslim faith is on hospice. The plan of care would include
Female health care workers care for the body after death
Male health care workers care for the body after death
Body preparation for cremation.
Body preparation for autopsy.
158
Identify a sociocultural factor that can lead to developmental problems.
Prolonged poverty
Childhood obesity
Loss of stamina
Family relocation
159
Infection that occurs when part of the pts flora becomes altered and overgrowth results
Endogenous
Exogenous
160
Which advantage is there of standardized documentation forms in nursing info systems
Reduced errors of omission
More time to read charts
Varied clinical databases
Increased hospital costs
161
Sounds are created by air moving through the trachea close to the chest wall
Rhonci
Bronchialvesicular
Bronchial
Bruit
162
Which response by the nurse is most effective in establishing an open rapport with a patient?
Inform the patient that all encounters are confidential.
Share an anecdote.
Tell pt she must be honest about sexual experience shes had
Ask the pt what concerns/fears she has related to the visit
163
pt needs and process, individual therapies, pt education, & discharge planning are conveyed
Diagnostic-Related Groups
Communication
Education
Report
164
Pt tells RN that he wants to have sex with his spouse but is afraid to in a hospital. RN should
Stress importance of using contraceptives
Ask pt if it would be ok to have a monitor on in the room
Arrange a schedule for intimacy when pt is well rested
Educate pt about dangers of strenuous activity
165
Biofeedback will
Allow me to manipulate my stressed out joints.
Direct my energies in an intentional way when stressed
Help w/thoughts feelings & physiological response to stress.
Let me assess and redirect my energy fields.
166
When caring for a terminally ill patient, the nurse should focus on the fact that
Members of church or synagogue play no part in the pts care
Spiritual care is the least important nursing intervention.
Spiritual needs need to be sacrificed for physical priority
RNs relationship w/pt allows understanding of pt priorities
167
The school nurse is assessing the tympanic membranes of a 3-year-old child by
Using an otoscope grip while pulling the auricle upward
Using an otoscope grip while pulling the auricle downward
Pulling the auricle upward and backward
168
Which position is this?
Dorsal Recumbent
Supine
Sims
Prone
169
A preceptor is working with a new RN on documentation. Which requires intervention
The new nurse uses a black ink pen to chart
The new nurse ends each entry with signature and title
The new nurse keeps the password secure.
The new nurse charts consecutively on every other line
170
Female pt has brittle hair. Based on these findings, which lab test would be ordered?
Lead level
Liver function test
Thyroid-stimulating hormone test
Complete blood count
171
Provides baseline data to compare with changes in the pts condition
Pt care summary
EMR
Admission nursing history forms
Flow sheets
172
In assessing the spiritual health of her patients, the nurse understands that
Spiritual beliefs change as patients grow and develop.
Basis of beliefs of older people focuses on 1 or 2 factors
Older adults express spirituality by focusing on themselves
Spiritual health in older adults leads to peace
173
Story-like format that can be repetitious info and time consuming
Focus Charting
Critical Pathways
Progress Notes
Narrative
174
The RN sets up a nonbarrier sterile field on the pts table. Which would be contamination
Sterile saline solution is spilled on the field
RN keeps the top of the table above her waist
Sterile objects are kept within the 1 inch border
RN, who has a cold, wears a double mask
175
nursing action that would increase a pt risk for developing a health care associated infection
Urinary cath bag placed below the level of the bladder
Clean technique for inserting a urinary catheter
Use a sterile bottled solution more than once in 24 hrs
Use of surgical aseptic technique to suction an airway
176
Describes the loudness, soft to loud
Quality
Amplitude
Frequency
Duration
177
Classification system on pts medical diagnoses that support reimbursement
Patient Groups
Diagnostic-Related Groups
Minorities
Legal Documentation
178
Family cry and scream after learning of pts death. This is Bowlby Attachment Theory stage of
Disorganization and despair
Yearning and searching
Numbing
Bargaining
179
Individual risk factors that can threaten safety are (Select all that apply)
Impaired mobility
Lifestyle
Sensory or communication impairment
Lack of sensory awareness
180
Subjective, objective, assessment, and plan
POAS Note
Progress Note
SOAP Note
PIE
181
Which info is critical for the nurse to include during hand-off about a pt with chest pain
Pupils equal and reactive to light
Sharp pain of 8 on a scale of 1 to 10
Had poor results from the pain medication
The family is a pain
182
An assessment finding example for caregiver strain would be which of the following?
Caregiver routinely creates a weekly menu plan.
Caregiver can identify respite care provider.
Caregiver attends religious service.
Caregiver has not received medical care when ill.
183
Pressing inward 1 cm
Light Palpation
Deep palpation
184
Which type of breath sound is this?
Plural rub
Stridor
Rhonci
Wheezing
185
The nursing student can help geriatric patients self-concept by using which technique?
Discussing current weather
Encouraging patients to sing
Allowing patients extra computer time
Reviewing old photos with patients
186
Database, problem list, care plan, and progress notes
CAT
POMR
EHR
EMR
187
In discussing spiritual well-being, the nurse identifies that the vertical dimension involves
The positive relationships/connections people have w/others
Confidence in something for which there is no proof.
Providing an attitude of something to live for
The transcendent relationship between a person and God.
188
Pt asks the RN for her phone number. How should the RN handle this situation
Give the pt her number but ask that he call after work hours
Ask a coworker to take over care for this patient.
Give the patient false information to appease him.
Redefine the boundaries of professionalism.
189
The nurse assesses the skin turgor of the pt by
Grasping skin on the back of the forearm & releasing
Inspecting the buccal mucosa with a penlight
Palpating the skin with the dorsum of the hand
Pressing the skin for 5 secs, releasing, and noting depth
190
Which interventions would take priority in a plan of care for a pt who presents with pneumonia
Assume that the patient is in pain and treat accordingly.
Observe the patient for decreased activity tolerance.
Maintain the temperature at 65 F.
Provide the patient ice chips as requested.
191
A circumscribed elevation of skin filled w/serous fluid on upper lip, 4cm in diameter. This is
Pustule
Nodule
Macule
Vesicle
192
A pt who has had several sexual partners in the past month. Which contraceptive should they use
Condom
Oral contraceptive
Spermicide
Diaphragm
193
Which type of breath sound is this?
Rhonci
Wheeze
Amphoric
Pulmonary Friction Rub
194
Which statement indicates that the staff needs more education about informatics
Need to know how to apply scientific evidences from database
The RN should be able to discover, retrieve, and use info
Computer competency means the RN is competent in informatics
195
15yo pt is unsure about getting the HPV vaccine. The RN should respond by saying
Remind her that her mother knows best
Promote importance of the vaccine, she should get it asap
Ask the pt how many sexual partners shes had in the past
Ask the pt what concerns she may have about the vaccination
196
Which of the following is correctly charted according to the 6 guidelines for quality recording
Had a good day. Up and about in room
Was depressed today
Respirations rapid; lung sounds clear
Crying, states she doesnt want visitors to see her like this
197
All herbal supplements should be evaluated with current pharmacological medications
False
True
198
Pt has a small amount of a white, thick substance on the patients uncircumcised glans penis
Notify his provider about a suspected STI.
Avoid embarrassing questions about sexual activity.
Recognize this as a normal finding.
Tell the patient to avoid doing self-examinations
199
To perform an examination of female genitalia the nurse would put the pt in which position
Knee-chest
Sitting
Dorsal recumbent
Lithotomy
200
The pt is having a difficulty dealing with AIDS dx. States Im isolated from my family RN should
Assure the pt that his father will accept his situation soon
Use therapeutic communication to establish trust and caring.
Tell pt if your father cant get over it, forget it, move on
Tell the pt has no control & has to face consequences
201
What is the usual temperature comfort range for most patients?
60 F to 75 F
25 C to 28 C
65 F to 75 F
15 C to 17 C
202
The patient is admitted with chronic back pain. The nurse who is caring for this patient should
Realize that the pts only goal is relief of the back pain
Focus on finding quick remedies for the back pain.
Help pt realize that theres no hope of relief from pain
Look at how pain influences the patients ability to function
203
A pt asks RN what signs and symptoms are associated with chlamydia. How should the RN respond?
1st sign is frequency and burning with urination
Dementia results if chlamydia goes untreated too long.
Small red blisters appear first and then multiply.
Symptoms usually only affect women
204
How should you clean the stethoscope
Cleaning stethoscope with alcohol
Using alcohol-based hand disinfectant
Running warm water over stethoscope for patient comfort
Cleaning stethoscope with Betadine
205
Which medication could cause an abnormal drug interaction in a pt taking an antidepressant med
Aspirin
Ginger
Chamomile
Digoxin
206
Pts choose to use unconventional therapy because
They are willing to pay more to feel better
It is now widely accepted by the FDA
They want religious approval for the remedies they use
They are dissatisfied with conventional medicine
207
Provides current info that is accessible to all members of the health care team
Admission sheet
Discharge planning sheet
Admission nursing history forms
Flow sheet
208
Acute symptoms of infection disappear
Prodromal Stage
Incubation period
Illness stage
Convalescence
209
Which situation shows the RN has a good understanding about auditing & monitoring pt HR
Compares tx to find the best outcome
Care not documented is still care provided
Determines that standards of care are met by reviewing pt HR
reimbursement is based on the DRG documented in pts records
210
Important skin cancer prevention for a pt who is taking oral contraceptives
Extra precautions in the sun secondary to the prescription
Applying broad-spectrum sunscreen of SPF 5
Applying water-based sunscreen only before swimming
Using tanning bed daily for 7 days before college break trip
211
Which of the following nursing interventions will assist in decreasing the risk of infection?
Teaching the patient about fall prevention
Teaching the patient about the effects of alcohol
Teaching the patient to select nutritious foods
Teaching the patient to take a temperature
212
which priority concern would require collaboration with social services to address the pt needs
The electricity was turned off 2 days ago.
The home is not furnished with a microwave oven.
The water comes from the county water supply.
A son and family recently moved into the home.
213
Which position is this?
Prone
Lithiotomy
Sims
Dorsal Recumbent
214
Lumps on the testis is a sign of
Testicular cancer
Sexually transmitted infection
Inguinal hernia
Diuretic use
215
A 68yo female asks RN if a contraceptive is still necessary.
Yes as long as a barrier doesnt decrease sexual performance
Lets discuss this what your current level of sexual activity
A barrier such as a condom is recommended
No you have gone through menopause & cant become pregnant
216
Today, spirituality is
Pt centered and has no bearing on the RNs belief patterns
Less important than coping with the patients illness.
Awareness of inner self & sense of connection w/higher being
Equated to formal religious practice
217
What should the nurse ask to understand how visual alterations affect pts self-care ability
Have you stopped reading books?
How do you protect yourself from injury at work?
How does your vision impairment make you feel?
Are you able to prepare a meal or write a check?
218
RN is caring for a pt who claims that he doesnt believe in God. The nurse realizes that this pt
Is an atheist/agnostic.
Believes that what he does is meaningless.
Finds no meaning through relationships with others.
Is devoid of spirituality.
219
Which pt statement indicates understanding regarding the mode of transmission of this disease
When I go camping, I will be sure to wear sunscreen.
When I go camping I will be sure to use hand gel on my hands
When I go camping, I will be sure to wear insect repellent.
When I go camping, I will drink bottled water.
220
The developmental self concept task known as initiative versus guilt would occur in
3-week-old neonate
5-year-old kindergarten student
11-year-old student
15-year-old high school student
221
What nursing action is appropriate for a pt with C. Diff
Use soap and water instead of hand sanitizer
Place the patient on Droplet Precautions.
Wear an N95 respirator when entering the patient room.
Teach the patient cough etiquette.
222
RN caring for Pt who has had unprotected sex with HIV+ partner. RN informs pt
You may have flulike symptoms in 6 months
I will set you up with a support group to help cope w/dying
Have your blood drawn today to see if you were infected
Antiretroviral therapy has been effective in slowing disease
223
Which position is this?
Left Lateral Recumbent
Supine
Dorsal Recumbent
Right Lateral Recumbent
224
A 12yo female pt complains that her periods are making her fat. RN should say
Stop snacking on sweets and replace them with vegetables
Does the weight fluctuate throughout the month?
i promise no one notices this but you
Changes are normal with menstration; try not to get upset
225
A terminally ill patient is experiencing constipation secondary to pain medication. The RN will
Administer enemas twice daily for 7 days.
Use a stimulant laxative and increase fluid intake.
Contact the provider to discontinue pain medication.
Massage the patients abdomen.
226
Which position is this?
Standing
Prone
Sitting
Knee-Chest
227
Which actions would be appropriate to prevent the spread of disease using contact precautions
Use dedicated BP cuff that stays in pts room for that pt
Wear gown, gloves, face mask, and goggles
Place pt in a room with negative airflow
Transport pt quickly when going to radiology
228
A holistic nurse would be a nurse who
Recognizes the mind-body-spirit connection.
Provides spiritual literature to patients.
Recommends a vegan diet for all patients.
Knows about resources for fresh herbs.
229
Sites for HAI: Urinary tract, surgical or traumatic wounds, respiratory tract, bloodstream
False
True
230
Which of the following statements would indicate an understanding of the nature of pneumonia
pneumonia may not pose a risk to others
Clinical signs and symptoms are not present in pneumonia.
We need to isolate the patient in a negative pressure room.
The patient will not be able to return home.
231
Which of the following best describes iatrogenic infection
Occurs when pt are infected with their own organisms
Involves an incubation period of 3-4 weeks before detection
Results from extended infection of the urinary tract
Results from diagnostic or therapeutic procedure
232
Includes meds, diet, community resources, and follow-up care
Patient care summary
Standardized care plan
Discharge summary forms
Flow sheets
233
How does the nurse proceed to assess for kidney inflammation?
Lightly palpates each abdominal quadrant
Percusses posteriorly costovertebral angle at scapular line
Uses deep palpation posteriorly
Inspects abdomen for abnormal movement
234
When considering the ego defense mechanism of conversion, the nurses next best action is
Recommend acupuncture.
Obtain history of any recent life stressors.
Recommend a regular exercise program.
Confront the patient on malingering.
235
When eval a pt risk for spiritual crises which are part of the evaluation process? SATA
Review the patients view of his/her purpose in life.
Review the pts self-perception regarding spiritual health
Discuss with family and associates the pts connectedness.
Ask whether the patients expectations are being met.
236
Which behavior should the nurse implement to reduce data entry errors in the computer system
Share password with only one other staff member.
Chart on the computer immediately after care is provided.
Use the same password all the time
Print out and review computer nursing notes at home.
237
A patient is being discharged home. Which information should the nurse include?
Acuity level
Kardex
Standardized care plan
Community resources
238
If an error is made while recording, the nurse should
Obtain a new RN's note and rewrite the entries
Draw a single line through the error and initial it
Erase it or scratch it out
Leave a blank space in the note
239
Which action would most likely increase the risk of a pt contracting a UTI
Providing perineal hygiene at least once a shift
Allow drainage bag port to touch the graduated receptacle
Reusing the pt graduated receptacle to empty the bag
Emptying the urinary drainage bag once a shift
240
To perform a proper gynecological assessment, the RN would place the pt in which position
Dorsal Recumbent
Knee-chest
Sitting
Litotomy
241
The nursing student can help geriatric patients self-concept by using which technique?
Reviewing old photos with patients
Encouraging patients to sing
Allowing patients extra computer time
Discussing current weather
242
The organization that facilitates the evaluation of alternative medical treatments is the
American Holistic Nurses Association.
U.S. Department of Health and Human Services.
National Center for Complementary and Alternative Medicine.
Food and Drug Administration.
243
When Pt on respiratory isolation must be transported, the RN
Places a mask on the pt before leaving the room
Instruct pt to cover his mouth with tissue when sneezing
Advises other health care team members to wear masks& gowns
Get an order to prohibit pt from transport
244
Clinic that is staffed by allopathic and complementary practitioners
Naturopathic medical clinic
Integrative medical clinic
Ayurvedic clinic
Healing intention clinic
245
Which position is this?
Left Lateral Recumbent
Supine
Right Lateral Recumbent
Dorsal Recumbent
246
The pt most at risk for developing an infection is the pt who
Has been admitted for stabilization of atrial fibrillation.
Is recovering from a right total hip arthroplasty.
Has been admitted with dehydration.
Is in observation for chest pain.
247
Meds that are used to manage a pts behavior that are not standard tx for the pts condition
Chemical Restraint
Phyiscal Restraint
Mechanical Restraint
Pharmacologic Restraint
248
The best equipment to test central vision for preschoolers is which of the following?
Penlight
Reading test
E chart
Snellen test
249
RN is admitting a pt w/an infectious disease process. What would the RN ask the pt
What is your marital status; single, married, or divorced?
Do you have a chronic disease, and how long have you had it?
Do you have any religious beliefs that influence care
Do you have any children living in the home?
250
One benefit of meditation over other forms of behavioral therapy is that meditation
Cures hypertension.
Does not require memorization.
Improves communication skills.
Balances insulin and other body hormones.
251
When observing a fire, a nurse should immediately
Report the fire
Close all windows and doors to contain the fire
Attempt to extinguish the fire
Assist the pt to a safe place
252
In a cardiac dysrhythmia clinic, a pt asks about using acupuncture to help alleviate stress
It is very clearly contraindicated.
Do not allow needles near the heart.
It is acceptable, but do not use electro-acupuncture.
You do not look like you have an infection, so it will be OK
253
Teen pt informs RN that hes unsure about his sexuality. RN est. a trusting relationship by
At your age, it is normal to be curious about both genders.
Those are abnormal impulses. You should seek therapy.
Having questions about sexuality is normal.
Dont worry. Its just a phase you will grow out of.
254
The nurse should include which of the following teaching points in the safety of adolescents
Adolescents need info about the effects of beer on the liver
Need unsupervised time with friends two-three times a week
Parents and friends should teach adolescents how to drive.
Need to be reminded to use seatbelts on long trips