STUDY GUIDE
COMPREHENSIVE NURS 6050 AGENDA
COMPARISON GRID & FACT QUESTIONS
AND ANSWERS GRADED A+
◉ During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is then
very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's
report?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is
experiencing
D. Description of the family's home environment
Rationale:
School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that
promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful
data. The nurse cannot determine option C.
1
,◉ The nurse assesses a 2-year-old who is admitted for dehydration
and finds that the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What should the nurse do
next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Rationale:
The nurse should first check the tubing and height of the bag on the
IV pole, which are common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the bag, tubing clamp
closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the paediatric client), and infiltration. Veno
spasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse
may need to adjust the stabilizing tape on a positional needle or
flush the venous access with normal saline, but less invasive
actions should be implemented first.
◉ Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh Day Adventist who needs a blood transfusion
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, STUDY GUIDE
D. Muslim man who needs a total knee replacement
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited, so
facing this decision may place the client at risk for spiritual distress.
There is no prohibition of hospice care for members of the Jewish
faith. Jehovah's Witnesses, not Seventh Day Adventists, prohibit
blood transfusions. There is no conflict in the Muslim faith with
regard to joint replacement.
◉ Which intervention is most important to include in the plan of
care for a client at high risk for the development of postoperative
thrombus formation?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Rationale:
Thrombus (clot) formation can occur in the lower extremities of
immobile clients, so the nurse should plan to encourage activities to
increase mobility, such as frequent ambulation in the hallway.
Option A helps promote alveolar expansion, reducing the risk for
atelectasis. Option B reduces the risk for aspiration. Option C
reduces the risk for postoperative
infection.
3
, ◉ Which nonverbal action should the nurse implement to
demonstrate active listening?
A. Sit facing the client.
B. Cross arms and legs.
C. Avoid eye contact.
D. Lean back in the chair.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic
communication and attentiveness, the nurse should sit facing the
client, which lets the client know that the nurse is there to listen.
Active listening skills include postures that are open to the client,
such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate
involvement and willingness to listen to the client, eye contact
should be established and maintained.
◉ A seriously ill female client tells the nurse, "I am so tired and in so
much pain! Please help me to die." Which is the best response for the
nurse to provide?
A. Administer the prescribed maximum dose of pain medication.
B. Talk with the client about her feelings related to her own death.
C. Collaborate with the health care provider about initiating
antidepressant therapy.
4
COMPREHENSIVE NURS 6050 AGENDA
COMPARISON GRID & FACT QUESTIONS
AND ANSWERS GRADED A+
◉ During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is then
very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's
report?
A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is
experiencing
D. Description of the family's home environment
Rationale:
School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that
promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful
data. The nurse cannot determine option C.
1
,◉ The nurse assesses a 2-year-old who is admitted for dehydration
and finds that the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What should the nurse do
next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Rationale:
The nurse should first check the tubing and height of the bag on the
IV pole, which are common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the bag, tubing clamp
closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the paediatric client), and infiltration. Veno
spasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse
may need to adjust the stabilizing tape on a positional needle or
flush the venous access with normal saline, but less invasive
actions should be implemented first.
◉ Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh Day Adventist who needs a blood transfusion
2
, STUDY GUIDE
D. Muslim man who needs a total knee replacement
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited, so
facing this decision may place the client at risk for spiritual distress.
There is no prohibition of hospice care for members of the Jewish
faith. Jehovah's Witnesses, not Seventh Day Adventists, prohibit
blood transfusions. There is no conflict in the Muslim faith with
regard to joint replacement.
◉ Which intervention is most important to include in the plan of
care for a client at high risk for the development of postoperative
thrombus formation?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Rationale:
Thrombus (clot) formation can occur in the lower extremities of
immobile clients, so the nurse should plan to encourage activities to
increase mobility, such as frequent ambulation in the hallway.
Option A helps promote alveolar expansion, reducing the risk for
atelectasis. Option B reduces the risk for aspiration. Option C
reduces the risk for postoperative
infection.
3
, ◉ Which nonverbal action should the nurse implement to
demonstrate active listening?
A. Sit facing the client.
B. Cross arms and legs.
C. Avoid eye contact.
D. Lean back in the chair.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal
communication techniques. To facilitate therapeutic
communication and attentiveness, the nurse should sit facing the
client, which lets the client know that the nurse is there to listen.
Active listening skills include postures that are open to the client,
such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate
involvement and willingness to listen to the client, eye contact
should be established and maintained.
◉ A seriously ill female client tells the nurse, "I am so tired and in so
much pain! Please help me to die." Which is the best response for the
nurse to provide?
A. Administer the prescribed maximum dose of pain medication.
B. Talk with the client about her feelings related to her own death.
C. Collaborate with the health care provider about initiating
antidepressant therapy.
4
