Timby’s Fundamental Nursing Skills and Concepts, 12th edition Answers and Rationales for End-of-Chapter NCLEX-Style Review Questions Attachments area

1 Timby’s Fundamental Nursing Skills and Concepts, 12th edition Answers and Rationales for End-of-Chapter NCLEX-Style Review Questions Chapter 1 Test-Taking Strategy: Note the key word “first.” Apply principles concerning delegation to select an answer. 1. Answer: 3. Rationale: Whenever delegating a task, it is essential to determine the competency of the person who is being assigned to the delegated task. Although all of the other actions are important to perform, ensuring that the delegated task can be performed accurately is most important. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word “first.” Apply principles concerning delegation to select an answer. 2. Answer: 2. Rationale: The LPN’s priority is Client B, who is potentially the most unstable. After determining that Client B is recovering safely postoperatively, the LPN can attend to the needs of the other assigned clients. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment 2 Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most important.” Select the option that reflects the most pertinent data about the client’s current condition. 3. Answer: 4. Rationale: When obtaining a report on a postoperative client, an LPN should expect to be told the client’s most recent blood pressure, an indication of the client’s recovery status. The client’s age and occupation are facts the LPN may wish to know, but they are not essential to the forthcoming plan for care. Whether or not the client consumed food is helpful, but it is not the most important information the LPN needs to know at this time. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Reduction of Risk Potential Test-Taking Strategy: Note the key word and modifier “most important.” Recall that the person who delegates a task is still ultimately responsible for it. 4. Answer: 1. Rationale: Whenever a task is delegated, the delegator is responsible for ensuring that the task is performed and determining the outcome. The LPN may choose to recheck the client’s blood pressure to validate its accuracy, if the reported blood pressure is unusual. Teaching the client about controlling blood pressure and assessing the client’s family history for heart disease are important aspects of client care, but neither is the most important action at this time. 3 Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most reasonable.” Use the process of elimination to select the client whose outcome is least predictable. 5. Answer: 1. Rationale: LPNs should be assigned to clients who have predictable outcomes. A client with unrelieved chest pain seems to the most potentially unstable within this mix of assignments. Based on the information in the questions, Clients B, C, and D appear to require care that is within the LPN’s scope of practice. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 2 Test-Taking Strategy: Note the key words and modifier “most appropriate” and “first.” Use the steps in the nursing process to guide the selection of the answer. 1. Answer: 3. Rationale: The first step in the nursing process is assessment. Data collection precedes determining needs, setting goals, and developing a plan for care. 4 Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Apply the responsibilities of the practical nurse to help select the answer. 2. Answer: 2. Rationale: A licensed practical nurse works under the direction of a registered nurse. A registered nurse can delegate the task of acquiring basic information from the client to a licensed practical nurse, but the registered nurse is responsible for ensuring that the admission database is complete. The registered nurse is responsible for identifying nursing diagnoses and developing the initial plan of care for preventing, reducing, or resolving the nursing diagnoses. The registered nurse delegates implementation of the plan of care to the licensed practical nurse and encourages the licensed practical nurse to make future contributions to the initial care plan. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key words and modifier which in this case is “highest priority.” Apply Maslow’s Hierarchy of Needs to select the answer. 3. Answer: 1. Rationale: Ineffective airway clearance reflects a problem affecting breathing, a basic physiologic need. The remaining diagnoses affect other levels of Maslow’s hierarchy. Ineffective coping affects the needs of 5 safety and security. Deficient diversional activity affects self-actualization. Interrupted family processes affect the need for love and belonging. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most appropriate.” Select an answer for revising the plan of care when progress has not been made. 4. Answer: 4. Rationale: When a client has not made progress or only some progress in reaching a goal, it is most appropriate to add new nursing orders, discontinue ineffective measures, and/or readjust the target date. Urging the client to try harder, places blame on the client for not achieving the goal. A client should receive as much assistance with bathing as required if the client cannot do so independently. Suggesting that staff give less assistance is a form of neglect. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most appropriate.” Consider the next best source for data other than the client. 5. Answer: 2. Rationale: The client is the primary source for data collection, but if the client is unable to provide that information, the family may be 6 consulted. Visitors, clergy, or the employer are inappropriate sources for health care data, and discussing the client with them may violate the client’s right to privacy. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 3 Test-Taking Strategy: Note the key words “first action.” Select the option that represents the most immediate line of authority, communication, and responsibility within the organization. 1. Answer: 4. Rationale: The first step when a nurse suspects another of stealing narcotics is to report the information to the immediate nursing supervisor. Providing specific observations and facts is important. Once the information is validated, the nursing supervisor is responsible for proceeding with other possible legal and ethical actions. It is unethical to damage the character of a colleague by discussing the situation prematurely. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most important.” Use the process of elimination to select the data that have the highest priority for nursing care. 7 2. Answer: 3. Rationale: An advance directive is a written statement identifying a competent person’s wishes concerning end-of-life health care. The advance directive is valuable to the nurse and physicians because it will guide them in managing the client’s care. Proof of insurance is important to the billing department of the health care agency. The client’s date of birth and social security number may be useful to a social worker for determining whether the client qualifies for Medicare or other services from social agencies. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most appropriate.” Use the process of elimination to select the action that provides a written account regarding an injury or potential injury. 3. Answer: 2. Rationale: An incident report is a tool for risk management; it helps to determine measures for preventing potentially litigious events. It also is a tool that could be used in court in a nurse or health agency’s defense. Fall precautions are implemented when the nurse determines that a client is at risk for falling; they are overdue after a fall, but none the less necessary. The nurse gives the nursing supervisor the written incident report; it is not a part of the client’s medical record. The physician is informed of the incident, may examine the client, and determines whether the client’s family is notified. 8 Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most appropriate” and additional information in the stem that states, “no advance directive.” Use the process of elimination to select the option that corresponds with a nurse’s responsibility in the absence of any written order to withhold emergency care. 4. Answer: 4. Rationale: Legally, the nurse must begin resuscitative efforts following the “code” policies in the institution because there must be a written medical order for a “no code.” Noting the time of death, notifying the physician, and performing postmortem care are responsibilities if resuscitative efforts fail. Cognitive Level: Apply Category of Client Needs: Physiological Integrity Client Needs Subcategory: Physiological Adaptation Test-Taking Strategy: Note the key word “best.” Use the process of elimination to select the option that allows the client to document information regarding his or her end of life wishes. 5. Answer: 4. Rationale: Although advance directives are not required, all clients should be asked if one exists. Most health agencies have advance directive forms that a client can complete upon admission. Services of a lawyer are unnecessary when creating an advance directive. Obtaining verbal information about terminal care, although helpful, is not legally useful. The 9 client may want to share the information identified in an advance directive with the family, but the client's family does not have any responsibility for completing an advance directive. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 4 Test-Taking Strategy: Note the key word and modifier “highest priority.” Apply Maslow’s hierarchy of needs to select an answer.. 1. Answer: 2. Rationale: The highest priority for client care is relief of labored breathing. Breathing is a basic physiologic need. Feeling powerless affects the need for security. Family support is an issue that affects the need for love and belonging. Issues of self-esteem follow the others in the list. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Identify the key word in the stem of the question, “initial.” Consider the action that is basic before all others. 2. Answer: 4. Rationale: Initial examination by a family practice physician is the first step in primary care. The family practice physician may then refer the client for secondary or tertiary care. Cognitive Level: Analyze 10 Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Identify the key word in the stem of the question, “best.” Use the process of elimination to exclude strategies for controlling health care costs rather than caring for a client. 3. Answer: 2. Rationale: A referral to a home health nursing organization before discharge helps to transition a terminal client's care from an acute care agency to home care without appreciable interruption. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Analyze the stem to determine what the question asks. In this case, it asks for a sequential listing of Maslow's hierarchy of needs from the lowest to highest levels. 4. Answer: 2, 5, 1, 4, 3 is the correct progressive sequence in Maslow’s hierarchy of human needs. Cognitive Level: Remember Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care 11 Test-Taking Strategy: Use Maslow’s hierarchy to eliminate options affecting lower level needs. 5. Answer: 1. Rationale: Anxiety is a vague uneasy feeling that results from anticipating an actual or potential threat to a person’s well-being. Although the source of the threat is unidentifiable, it produces a variety of physical and emotional changes as energy is expended in worrying. Cognitive Level: Apply Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Chapter 5 Test-Taking Strategy: Use the process of elimination to select manifestations of a stress response. Recall that during a stress response, the body is initially flooded with stimulating hormones, epinephrine and norepinephrine, and later with cortisol. 1. Answer: 1, 2, 4, 5. Rationale: Choices 1, 2, 4, and 5 are the examples of physiologic and cognitive responses to stress. Clients may drink liquids to relieve a dry mouth, but excessive thirst is more indicative of some other health-related problem. Cognitive Level: Apply Client Needs Category: Psychosocial Integrity Client Needs Subcategory: None 12 Test-Taking Strategy: Identify the key word in the stem of the question which is "initial." Recall that prevention has a higher priority than treatment. 2. Answer: 3. Rationale: Stress management techniques help to reduce the release of norepinephrine and epinephrine and promote normal blood pressure. Primary prevention involves eliminating the potential for an illness. Blood pressure assessment is a secondary preventive measure that provides a means for early diagnosis. It is premature to give a client information about medications before a diagnosis is made. Teaching about the hazards of hypertension can motivate a client to implement measures to reduce health risks, but offering the client a tool, like methods for stress management, is most appropriate initially. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to select the situational event that has the most severe impact on a client's equilibrium. 3. Answer: 1. Rationale: According to Holmes’ and Rahe’s Social Readjustment Rating Scale, death of a spouse is the most stressful event a person experiences. The other examples are significant stressors but less intense than the death of a spouse. 13 Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Analyze the information this question asks, which requires selecting a coping mechanism from among four options that correlates with one in which the client's belief contradicts factual evidence. 4. Answer: 4. Rationale: Denial is a coping mechanism in which a person rejects objective information and believes something else is true. Denial protects the ego from dealing with threatening information. Somatization is a coping mechanism in which a person manifests an emotional stressor via a physical disorder or symptom. Regression is manifested by behaving in a manner characteristic of a younger age. Displacement involves expressing one’s anger toward something or someone unlikely to retaliate. Cognitive Level: Apply Category of Client Needs: Psychosocial Integrity Test-Taking Strategy: Identify the key word in the stem of the question which in this case is "most benefit." Select the answer from among the four options that can prevent, rather than manage, the consequences of smoking. 5. Answer: 1. Rationale: Encouraging teenagers to never begin smoking cigarettes is most beneficial because it involves eliminating the potential for illness before it occurs. Advocating that smokers with a chronic cough seek 14 medical evaluation is an example of secondary prevention as it involves screening for early diagnosis. Offering suggestions for smoking cessation and explaining how to apply nicotine patches are examples of tertiary prevention because they have the potential for minimizing the consequences of smokingrelated diseases. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Chapter 6 Test-Taking Strategy: Note the key terms "first step," indicating the answer requires identifying a priority. 1. Answer: 4. Rationale: Determining a client’s food preferences forms the basis for menu planning and dietary selections within the prescribed restrictions of the client’s therapeutic diet. Incorporating cultural preferences, if they exist, promotes the potential for compliance with a diet. Although the trends in the client’s blood glucose level and knowledge of drug therapy are important, they are secondary to preparation for diet teaching. Once he or she has identified the client’s food preferences, the nurse personalizes the exchange list by emphasizing the allowed amounts of those foods that the client is accustomed to eating. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None 15 Test-Taking Strategy: Use the process of elimination and knowledge of Asian American communication patterns to select an option that is better than any of the others. 2. Answer: 2. Rationale: Clients who have retained their Asian culture will feel most comfortable if the nurse maintains a distance just beyond arm’s reach. People from non-Anglo cultures often find physical closeness with strangers to be discomforting. Touch also may provoke anxiety; it is important to explain when and how a client will be touched if that is necessary. A position within the doorway to the room is too distant during an interview, regardless of the client’s culture. Cognitive Level: Apply Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination and knowledge of biologic variations among African American infants to select an option that is better than any of the others. 3. Answer: 1. Rationale: Dark blue–pigmented areas, known as Mongolian spots, are common on the lower back and buttocks of dark-skinned infants and children. The pigmentation tends to fade by the time a child is 5 years of age. The nurse who is unfamiliar with this normal physiologic variation may misinterpret it as a sign of physical abuse. This case does not warrant informing Child Protective Services or the physician. There is no justification for examining other children in the home for abuse. 16 Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key words "most appropriate," which indicates one choice is better than any of the others. Determine if the practice of smudging is harmful or harmless to a native American's physical health. 4. Answer: 2. Rationale: When a cultural practice is not unsafe or potentially injurious to the client, it is best to incorporate the client’s belief system along with the scientific regimen for treatment. Implying that the client’s cultural practices are not beneficial is an example of ethnocentrism. The tribal elder has not claimed to be a physician; rather, he or she is performing a ritual with a long cultural tradition. Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to exclude options that are not compatible with the dietary practices of orthodox Jews. 5. Answer: 3, 4. Rationale: Based on the Old Testament of the Bible, those who practice Orthodox Judaism may eat any animal that has cloven hooves and chews its cud and anything that has fins and scales. Only tuna and chicken meet the permitted criteria, any pork products and shellfish, such as crab, lobster, oysters, clams, and shrimp, do not. 17 Cognitive Level: Apply Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic Care and Comfort Chapter 7 Test-Taking Strategy: Note the key words and modifier "best initial response." Select the statement that should occur first and eliminate options that should be avoided or postponed until later. 1. Answer: 1. Rationale: Paraphrasing is a therapeutic communication technique by which the nurse lets the client know empathetically that he or she has understood both the content and the feelings of the client’s statement. The nurse avoids any emotional support or involvement by offering to arrange contact with the surgeon. Giving advice and disagreeing with the client are nontherapeutic forms of communication. Cognitive Level: Apply Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Note the key word and modifier "most helpful." Select the option that promotes nurse–client communication by eliminating options that hamper or avoid dealing with the client's emotionally charged situation. 2. Answer: 3. Rationale: The best therapeutic nursing action is to facilitate the client’s discussion of his or her feelings. Reading literature on an emotional topic and thinking privately may help some people, but they are not as effective as verbalizing thoughts for most people. If the client requests a 18 second opinion, the nurse should pursue it; however, it is inappropriate for the nurse to initiate the suggestion. Doing so is considered false reassurance because it implies that the nurse believes the present medical regimen is less than optimal and that other alternatives can change the outcome. Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Note the key word "best." Select the option that provides the client with the most immediate relief from anxiety and fear by eliminating options that can be delayed or are less beneficial in the current circumstance. 3. Answer: 2. Rationale: The nurse performs the role of educator by providing explanations to a client who is unfamiliar with hospital equipment. Explanations are best in simple, understandable terms. Once informed, the client has a basis for interpreting and coping with what are unique experiences. The client is unlikely to understand what the name of a heart rhythm implies. Administering a tranquilizer or distracting the client with a magazine does not help prevent a similar fearful response if the situation recurs. Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None 19 Test-Taking Strategy: Select an option that is compatible with a task that an unlicensed caregiver can perform. Eliminate tasks that correlate with those that a licensed nurse can perform. 4. Answer: 2. Rationale: The nurse delegates tasks within the nursing assistant’s legal scope of job performance. Administering medications, collaborating with laboratory personnel about diagnostic test results, and performing physical assessments are nursing responsibilities. The nurse could delegate those to another licensed nurse or a nursing student who has demonstrated competencies in these skills. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word "best." Select an option that restores reality for the client. Eliminate options that may be emotionally upsetting, cognitively unrealistic, or sustain the client's false expectation. 5. Answer: 2. Rationale: Asking the client to talk about her mother is a form of reminiscing. It can serve as a distraction from the belief that her mother will visit. Telling the client that her mother is deceased may upset the client and lead to an argument with the nurse. By telling the client that he or she will call reinforces the client's belief that her mother’s visit will still be forthcoming. A client with Alzheimer disease is not likely to remember the last time her mother was seen. 20 Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Chapter 8 Test-Taking Strategy: Eliminate options that describe physical skills or skills that involve feelings or emotions. 1. Answer: 2, 3, 5. Rationale: Listing, identifying, and summarizing are activities that are characterized as being activities in the cognitive domain. Assembling falls within the psychomotor domain. Defending is an example of a learning activity within the affective domain. Cognitive Level: Apply Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Apply the steps in the nursing process to arrange the options. 2. Answer: 3, 2, 1, 5, 4. Rationale: Determining what the client wants to know involves the nursing process step of assessment. Dividing information into manageable amounts relates to planning. Encouraging feedback occurs during implementation of the teaching plan. Determining the client’s recall of information is a form of evaluation. Documenting the outcome of client teaching is the last nursing activity. Cognitive Level: Apply 21 Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Note the key word and modifier “most essential.” Use the nursing process to select an option that is necessary before other nursing actions. 3. Answer: 1. Rationale: Before the nurse can proceed with teaching, he or she should assess the child’s height and weight to determine whether the child is within norms for his or her age group. Another pertinent assessment is determining if the child has any food allergies or health problems affected by food. A MyPlate diagram, a tool developed by the U.S. Department of Agriculture for promoting a healthy intake of food, is a useful guideline for normal, healthy nutrition, but serving sizes require modification for a child, especially when he or she is underweight or overweight. It is inappropriate for the nurse to plan 1 week’s menus without knowing what the mother usually prepares for the family and the budget for purchasing groceries. Recipes are the mother’s personal choice, and various cookbooks are available from resources other than the nurse’s own collection. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None 22 Test-Taking Strategy: Select the option that provides the best evidence of learning. 4. Answer: 2. Rationale: Directly observing the client’s performance is the best method for evaluating if he or she learned the information. The client may correctly describe the importance of performing breathing exercises, yet not actually perform the skill. The client may say he or she is performing the exercises even if this is untrue. Monitoring the respiratory rate is not the best technique for determining whether, when, and how often the client is performing the exercises because the rate changes in response to many variables, such as current level of activity and oxygenation status. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to select the most appropriate age-related method for learning. 5. Answer: 1. Rationale: Using dolls or puppets as a teaching aid is the most appropriate strategy for a preschooler’s cognitive ability. Pamphlets and diagrams are too abstract for a child of this age. The preschooler might confuse use of a videotape as a form of entertainment rather than personal instruction. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance 23 Client Needs Subcategory: None Chapter 9 Test-Taking Strategy: Use the process of elimination to exclude situations that do not apply to the HIPAA legislation. Recall that this law protects the confidentiality of clients from others who are not involved in the client’s care. 1. Answer: 2. Rationale: Publicly identifying the names of clients violates their right to confidentiality. The number of clients assigned to each nursing team member depends on the person’s knowledge and experience and the clients’ acuity level. Posting the names of staff demonstrates respect for the right of clients to know who is managing their care. The Kardex is a resource that the nurse and members of the nursing team use frequently for current information about clients. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most important.” Review the choices and select the option that contradicts the principles of legally defensible charting. 2. Answer 1. Rationale: Documenting in a partially filled space violates legal principles. Any empty space should be followed by a line to prevent someone from adding information that appears to be included in someone else's charting. Although it is best to document promptly after providing care for the 24 client, most agency's recommend that documentation should be updated within a minimum of 2 hours. Abbreviations are acceptable as long as they are compatible with those approved by the agency. A first initial followed by the person's last name and title are best, but the practice of using the full name is not likely to be considered illegal, especially if more than one employee has the same first initial and last name. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Note the key word and modifier “most appropriate.” Select options that describe actions for documenting data electronically, saving the documentation, and restoring the status of the computer allowing its use by others. 3. Answer: 1, 2. Rationale: Logging on automatically allows the user to select parts of the medical record for documenting information. The entered data will be attributed to the logged on user. Logging off terminates the current documentation. When leaving the bedside computer, the main menu screen prevents others from accessing the electronic medical record without logging on for authorization. Turning off the computer will require time for rebooting the client's electronic medical record the next time access is required. Entering data on other clients should not take place on a different client's bedside computer; it can be done at a terminal at the nursing station. The bedside 25 computer screen can be turned away from the view of others; it is not necessary to ask family or visitors to leave. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Use the process of elimination to select an option that allows information about a client to be shared without the client’s consent. 4. Answer: 4. Rationale: The duty to protect public health outweighs the duty to maintain confidentiality. Health information can be disclosed without the client’s permission in cases in which there is a diagnosed reportable communicable disease, but it is always advisable to seek legal advice before doing so. The usual recipient of the information in this case is the Department of Public Health. Instances of attempted suicide, substance abuse, and a desire to terminate treatment should not be revealed to anyone outside the persons providing the client’s health care without permission of the client. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Read all the options carefully. Apply principles of legally defensible charting that apply to correcting written documentation. 26 5. Answer: 2, 4, 6. Rationale: Corrections must be made in such a way that all words are readable without any attempt to conceal information. The single crossed through line should be accompanied by the writer's initials, date, and an explanation of the nature of the error. The corrected information should then be documented. Obliterating or trying to erase the incorrect information can be contested in a lawsuit as an effort to cover responsibility for malpractice. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 10 Test-Taking Strategy: Select the option that is similar to the time it takes to sing the song "Happy Birthday" twice. 1. Answer: 3. Rationale: The Centers for Disease Control and Prevention recommend rubbing the hands with the alcohol-based product for a minimum of 15 seconds or longer if the hands are not completely dry. Most containers of an alcohol-based product dispense a volume that will facilitate a liquid state for at least 15 seconds. If the hands are dry before 15 seconds, perhaps an insufficient volume was used and the hands have not been effectively cleaned. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control 27 Test-Taking Strategy: Consider if each option is true or false. Eliminate any false or incorrect options. 2. Answer: 1, 2, 4, 6. Rationale: When a mask is worn, it must cover both the nose and the mouth, which could be ports of entry for airborne microorganisms. Masks that have loose ties are secured at the back of the head and neck; other types of masks may be secured behind the ears. A mask should be changed every 20 to 30 minutes or sooner if it becomes moist. Once a mask is removed, it is held by the ties and deposited within a lined waste container. A mask should not be touched while caring for a client. A mask that comes in contact with the chest area of the nurse's uniform causes a transfer of microorganisms. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control Test-Taking Strategy: When some or all options seem appropriate, select one option that represents a priority. Consider an action that interrupts the chain of infection. 3. Answer: 3. Rationale: Using individual bath linen prevents the potential entry of microorganisms present in the infected person's eye secretions into or onto uninfected individuals. Eating a nutritious diet and using sunglasses to filter ultraviolet light are healthful behaviors, but they are not specific to the client’s disorder or spread of infection. The use of aspirin if not contraindicated may relieve some of the client’s discomfort, but it will not prevent the 28 transmission of the client's infectious microorganism. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control Test-Taking Strategy: Consider whether each option describes correct or incorrect actions when performing hand washing. In this question, select options that violate medically aseptic practices; in other words, the actions that are incorrect. 4. Answer: 1, 5. Rationale: Rings that contain faceted jewels or crevices tend to retain microorganisms and should not be worn when caring for clients. The faucet should be turned off with the paper towel that was used to dry the hands. All the remaining options are appropriate when hand washing is performed. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Eliminate options that have the potential for contamination. 5. Answer: 2. Rationale: The outer 1-in margin of a sterile field is considered contaminated; all sterile supplies must avoid this perimeter. The outer triangle of the wrapped contents is first unfolded away from the nurse. When adding a sterile basin, it is unwrapped, the edges of the wrapper are secured in one 29 hand, and the unwrapped basin is placed on the sterile field. If a solution is required, the nurse holds the container 4 to 6 in above the basin to avoid splashing the surface of the sterile field. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control Chapter 11 Test-Taking Strategy: Although all the options may protect the client's privacy, select the best option from among those provided. 1. Answer: 2. Rationale: Under the privacy and security components added to the Health Insurance Portability and Accountability Act (HIPAA), a health care institution must protect clients’ health information. Permission must be obtained before sharing health information with any third party. When interacting directly with a client, it is respectful to use the client’s surname unless permission has been given otherwise. A client’s surname is not used in public locations, such as an elevator or cafeteria. When communicating with staff, referring to a client by a room number disregards the client’s unique identity. All medical records, which are kept confidential, contain both the client’s name and medical record number. Cognitive Level: Apply Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care 30 Test-Taking Strategy: Eliminate options that identify information that is unnecessary or may be obtained by personnel in the business office. Select the option that correlates with information that is important to the nursing care of the client. 2. Answer: 3. Rationale: The federal Patient Self-Determination Act ensures clients’ right to have advance directives, declaring their wishes regarding lifesustaining treatment. If a client has not prepared a document of this nature, the nurse provides information and an accompanying form with which to do so. Social Security numbers are not medically necessary. A client’s Medicare status and information about health insurance are important for collecting third-party payment for health care, but the information is obtained by personnel in the admitting or business office of the health care agency. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Select the option that is most representative of manifestations associated with stimulation of the sympathetic nervous system. 3. Answer: 2. Rationale: Anxiety is usually manifested via sympathetic nervous system stimulation. Of the four choices, restlessness and disturbed 31 sleep correlate most with anxiety. Being quiet and withdrawn, eating less than expected, and missing family members suggest depression or loneliness. Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to select the agency whose mandate is to ensure the safety of vulnerable adults. 4. Answer: 4. Rationale: Adult Protective Services is an agency that investigates and pursues accountability of individuals who are physically, socially, emotionally, or financially victimizing vulnerable adults. The Commission on Aging assists older adults to enjoy quality of life by providing prepared meals, transportation to medical appointments, and recreational activities. The Visiting Nurses Association provides nursing care to homebound clients. Older Americans’ Ombudsman investigates and resolves complaints made by nursing home residents. Cognitive Level: Analyze Category of Client Needs: Psychosocial Integrity Client Needs Subcategory: None Test-Taking Strategy: Eliminate options that fail to correlate with the client's level of care. 32 5. Answer: 2. Rationale: An intermediate care facility provides care and assistance for clients who require health-related services such as help with mobility retraining, but do not require 24-hour nursing care. Skilled care facilities provide 24-hour nursing care for clients who require procedures that only a licensed nurse can perform, such as administering injectable medications. Basic care facilities provide residential care for clients who need meal and laundry services, but who can independently perform their own activities of daily living. Assisted living facilities provide apartments or suites with options for group meals and activities. They are designed for individuals who continue to function independently, but who can no longer maintain their personal residence. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 12 Test-Taking Strategy: Use the process of elimination to select assessment options that are considered accurate as well as anatomically and developmentally appropriate for a young pediatric client. 1. Answer: 2, 4, 5. Rationale: The rectal site provides the best measurement for children less than 3 years of age, but care must be taken to avoid injuring a young child who is not cooperative. Because infants can be injured internally with rectal thermometers and because they lose heat through their skin at a greater rate than other age groups, the axilla and the groin, areas where there 33 is skin-to-skin contact, have traditionally been appropriate for temperature assessment in this age group. An assessment over the temporal artery in the forehead is sufficient for infants. Because it is difficult to locate and keep an oral thermometer in place, an oral temperature assessment is not appropriate at this age. Use of a tympanic membrane thermometer is not advised in children younger than 2 years of age because the diameter of the ear canal is smaller than the probe, resulting in an erroneously low reading. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Reduction of Risk Potential Test-Taking Strategy: Analyze each option and select only those actions that support accuracy and conscientious care of the client. 2. Answer: 4, 6. Rationale: To obtain an accurate oral temperature, an oral temperature assessment is delayed 30 minutes after the client has consumed hot or cold beverages or food. The nursing assistant shows respect for the client by offering an explanation as to why the routine for temperature assessment is being modified. Although a rectal temperature assessment is an alternative for collecting accurate data, most adults would prefer having an oral temperature assessment; delaying the assessment for 30 minutes is not unrealistic. The temperature and all other vital signs are important data and should not be omitted or postponed longer than necessary. Keeping the thermometer in the client's mouth for 5 minutes will not improve the accuracy of the assessment if done immediately after consuming food or beverages. 34 Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Although some or all the options may have merit, based on the key term "best," select the option that represents a priority. 3. Answer: 2. Rationale: Shivering takes place at the onset of a fever as a physiologic mechanism to assist the hypothalamus to reach a higher set point. Covering the client provides comfort and shortens the period of chilling. Once the temperature reaches a plateau and the client ceases to chill, the extra covers can be removed. Fluid replacement and facilitating evaporation with adequate circulation of environmental air are appropriate when diaphoresis occurs in the later phase of a fever. Rest conserves energy to compensate for an elevated metabolic rate caused by the fever, but it is not the most important nursing action in response to shivering. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic Care and Comfort 4. Answer: 2, 3. Rationale: An alternative for obtaining an accurate heart rate when a radial pulse assessment may be unreliable is to assess the apical heart rate or use a Doppler stethoscope, which detects movement of blood 35 through a peripheral artery and converts the movement to sounds. The heart rate could also be palpated over an alternative peripheral arterial site, provided the pulse can be felt easily. Although the ulnar artery is a branch of the brachial artery, it is not considered a location for assessing a peripheral pulse. If the nurse cannot assess the radial pulse accurately, it is inappropriate to obtain an apical–radial heart rate. Data that may be inaccurate should never be documented. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to identify the sequence of Korotkoff sounds. Select the option that corresponds accurately with the diastolic blood pressure measurement. 5. Answer: 3. Rationale: Phase IV of Korotkoff sounds is the pressure at which a muffled sound is first heard after distinct tapping sounds. The point of change is considered the diastolic blood pressure measurement in an adult. Option 1 correlates with Phase III of Korotkoff sounds. Option 2 correlates with Phase II of Korotkoff sounds. Option 4 describes Phase I of Korotkoff sounds, which correlates with the peak arterial pressure during heart contraction and is recorded as the systolic blood pressure measurement. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None 36 Test-Taking Strategy: Use the process of elimination to select the option that is most appropriate when caring for the described client. 6. Answer: 2. Rationale: Orthostatic or postural hypotension is a drop in blood pressure that results in lightheadedness, dizziness, and even syncope (fainting) when a client with circulatory problems, dehydration, or using a diuretic, antihypertensive, or other drug assumes an upright position. Rising gradually provides time for baroreceptors to stimulate increased blood flow to the brain to prevent or reduce symptoms. Increasing fluid intake, if not contraindicated, is more appropriate than limiting fluid intake. Remaining on bed rest is unnecessary and may cause problems associated with inactivity. Ambulating is not contraindicated but should be temporarily postponed until the client is no longer experiencing symptoms. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control Chapter 13 Test-Taking Strategy: Read the list of options and place them in the order they are performed from the first to last. 1. Answer: 3, 1, 4, 2. Rationale: The abdomen is always inspected and then auscultated—in that sequence—before using palpation or percussion techniques. Percussion is the least used nursing assessment technique which is the reason for listing it last in the sequence. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings. 37 Cognitive Level: Remember Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Note the key word “essential,” indicating one answer is better than any other. Select the option that is most important to assess. 2. Answer: 3. Rationale: It is important to document the color, odor, amount, and viscosity of sputum. The client’s family history may or may not correlate with the client’s current condition. The client’s heart rate may be elevated if his or her temperature is elevated or oxygenation status is compromised, but a focused assessment of the heart rate is less critical than the characteristics of sputum. Measures the client is using to manage his or her cough are helpful, but the characteristics of the sputum are more significant for the diagnostic process. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Recall the characteristics of the lesions in the options. Select the option that correlates with the description in the question. 3. Answer: 2. Rationale: A vesicle is a skin lesion that contains clear serum, such as a blister. A papule is a lesion that is solid. A pustule is a skin lesion that is filled with pus, a white or yellow appearance, rather than being clear. A 38 nodule is a solid mass of tissue. Cognitive Level: Remember Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None 4. Answer: Place an "X" to the right of the sternum at the second intercostal space. Rationale: The S2 heart sound, or the "dub" of "lub-dub," is heard louder to the right of the sternum at the second intercostal space. The S1 heart sound, the "lub" of "lub-dub," is louder on the right side of the chest at the fifth intercostal space in midline with the clavicle. Cognitive Level: Remember Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Note the key words “distant visual acuity.” Read the choices carefully. Select options that correlate with assessing the ability to see distant objects clearly. 5. Answer: 2, 5. Rationale: To test distant visual acuity, the nurse needs a Snellen chart on which there are lines of progressively smaller letters or symbols that the client reads from a distance of 20 ft from the chart. A penlight is used to assess a client's pupillary response. A tuning fork is used to test bone and air conduction of sound. An ophthalmoscope is used to visualize structures within the posterior of the eye. A Jaeger chart is used to test a client's near vision when the client holds it at a comfortable reading distance. A 39 newspaper with varying sizes of newsprint could be substituted for a Jaeger chart. Cognitive Level: Remember Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Chapter 14 Test-Taking Strategy: Analyze the information the question asks. In this question, select the client's statement that is incorrect. 1. Answer: 1. Rationale: Unlike a colonoscopy, an anesthetic is not administered to clients undergoing a sigmoidoscopy. Clients can eat lightly before a sigmoidoscopy. A flexible sigmoidoscope is used more commonly than one that is rigid. The sigmoidoscope is inserted through the anus and traverses the rectum to the sigmoid area of the lower bowel. Clients can take medications that do not interfere with the test findings prior to a sigmoidoscopy. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Use the key word "essential" to identify an option that represents a priority. 40 2. Answer: 2. Rationale: Anything containing metal is removed before a chest X-ray. The metal object may be misinterpreted as diseased tissue. Fasting is not required before a chest X-ray. No contrast dye is given before or during a chest X-ray. Analgesia (pain medication) is not usually necessary because there is no discomfort from the chest X-ray itself. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Use the key word and modifier "most appropriate" to select the one option that is better than any of the others. 3. Answer: 1. Rationale: Douching in the days before obtaining a specimen for a Pap test interferes with accurate test results because it removes cervical cells. None of the other instructions is a necessity before a pelvic examination, and Pap test are performed. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Analyze the options and select those that are accurate. 4. Answer: 2, 3, 4. Rationale: Confirming that the test strip code and the code programmed into the glucometer ensures accuracy in the test results. 41 Washing the hands with soap and water and drying the hands is sufficient for cleaning the hands. If an alcohol swab is used, the alcohol must have evaporated prior to the puncture. The test spot must be completely saturated with blood. If the test strip is partially covered, the results will be inaccurate or the machine may indicate an error has occurred. Capillary blood glucose is generally measured 30 minutes before a meal and prior to bedtime. The sides of the thumb or fingers are appropriate sites for a puncture, not the central pad. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Test-Taking Strategy: Arrange the nursing actions in the sequence the nurse would follow when assisting with a pelvic examination and collection of cervical and endocervical cells. 5. Answer: 3, 5, 1, 2, 4. Rationale: The nurse helps the client to a lithotomy position and places the client’s legs and feet in stirrups. The examiner uses a vaginal speculum to visualize the cervix of the uterus. Various applicators (soft tipped, spatula, and brush) are used to obtain samples of cells. Once the samples are obtained, the examiner applies them to slides which the nurse must spray with a fixative or the nurse inserts the applicators within a liquid chemical solution that will be sent to the laboratory. After the cell samples have been obtained, the examiner inserts a lubricated gloved finger within the vagina and rectum to assess the structure of the ovaries. 42 Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Coordinated Care Chapter 15 Test-Taking Strategy: Note the key word “best.” Review the options and select the food item that would create the most discomfort. 1. Answer: 1. Rationale: When the mucous membranes of the oral cavity are inflamed, it is best to eliminate foods that are acidic, salty, spicy, dry, or very hot. Other than tomato soup, none of the other foods has these characteristics. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic Care and Comfort Test-Taking Strategy: Note the key words “best” and “initial.” Select the option that should be implemented first before any other measures. 2. Answer: 2. Rationale: Chewing food thoroughly helps the bolus to descend through the esophagus. Restricting dietary intake to baby food is unnecessary and could contribute to constipation. Drinking liquids helps to keep the mouth moist, but may be difficult to swallow for a client with weakness or paralysis of the tongue or pharynx manifested by coughing and choking. In the latter case, 43 oral liquids should be thickened. Eliminating dairy products will not promote the ability to swallow. Cognitive Level: Analyze Category of Client Needs: Safe and Effective Care Environment Client Needs Subcategory: Safety and Infection Control Test-Taking Strategy: Note the key word and modifier “best evidence.” Select the option that demonstrates the result of improved nutrition better than any other options. 3. Answer: 2. Rationale: Maintaining or gaining weight is the best evidence that a client’s nutritional needs are being met. The client could remain alert yet be malnourished. Because eating food is both an emotional and physical phenomenon, well-nourished, satiated people may feel hungry when they see, smell, or think about food. The client’s tolerance of pain may increase with improved nutrition, but it is not the best criterion for determining the outcome of a nutritional regimen. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic Care and comfort 44 Test-Taking Strategy: Recall and select items on a clear liquid diet that are transparent. 4. Answer: 3, 4, 5. Rationale: A clear liquid diet contains items that are generally transparent and do not contain any pulp or bits of food like broth, flavored gelatin, and clear fruit juices such as apple and grape juice. Items that contain milk such as puddings, custard, milkshakes, yogurt, and creamed soups are included on a full liquid. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic care and comfort Test-Taking Strategy: Recall normal ranges of common laboratory values and apply them to the options. 5. Answer: 1. Rationale: A desirable total cholesterol test value is less than 200 mg/dL. Optimally, high-density lipoprotein (HDL) should be more than 60 mg/dL. A low-density lipoprotein (LDL) level of 135 mg/dL is borderline high. A normal triglyceride level is less than 150 mg/dL. Cognitive Level: Create Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Chapter 16 45 Test-Taking Strategy: Note the key term and modifier "most important." Use the process of elimination to determine which option is better than any of the others. 1. Answer: 1. Rationale: To evaluate trends in weight that may reflect deficient or excess fluid volumes, the nurse weighs the client at the same time daily using the same scale each time. The amount of clothing is similar at each weighing. If the time of weighing is consistent, the amount of food or liquids that the client has been consuming is not likely to vary considerably. It is important to collaborate with the client, but obtaining the weight is not omitted or postponed for frivolous reasons. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Use the process of elimination to select the items that are high in sodium that would be restricted on a low-sodium diet. 2. Answer: 1. 3, 6. Rationale: Soy sauce, dairy products especially hard cheese, and cured meat or fish like smoked salmon are high in sodium and, therefore, is restricted on a low-sodium diet. Lemon juice and onion powder (not salt) can be used liberally. Maple syrup is not restricted for its sodium content but may be limited if the client needs to lose weight. Cognitive Level: Apply 46 Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Note the key word and modifier "most correct." Analyze the options to determine which answer is accurate among others that contain incorrect information. 3. Answer: 1. Rationale: A unit of packed blood cells contains similar numbers of blood cells in less fluid volume. A unit of packed red blood cells is prepared by removing approximately two-thirds of the plasma from 1 unit of whole blood. Administration of packed red blood cells is preferred for clients who need a blood transfusion but for whom additional water within the circulatory system is hazardous. Typically, the candidate for packed blood cells is someone prone to excess fluid volume. Packed red blood cells pose the same risk for an allergic transfusion reaction as whole blood. Neither a transfusion of packed red blood cells nor whole blood stimulates the bone marrow to produce more red blood cells. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Note that the question asks for the unit of blood that would be hazardous or fatal if administered to this client. Eliminate the units of blood that would be safe to administer. 47 4. Answer: 4. Rationale: A person with A, Rh-positive blood type would have an incompatibility reaction if transfused with AB, Rh-positive blood. Type O is referred to as the universal donor. In an emergency, anyone can receive type O blood. People who are Rh-positive can receive compatible blood types that are either Rh-positive or Rh-negative. The reverse is not true; in other words, a person who is Rh-negative should never be given Rh-positive blood. Cognitive Level: Apply Category of Client Needs: Physiological Integrity Client Needs Subcategory: Pharmacological Therapies Test-Taking Strategy: Note the key word and modifier “most indicative.” Use the process of elimination to select the manifestation that correlates with a transfusion reaction better than any other answer. 5. Answer: 2. Rationale: Hypotension is one sign of a serious blood transfusion reaction. In a serious transfusion reaction, urine production is decreased. Swelling and pale skin at the infusion site are indications of a problem with the administration of the blood rather than a reaction to the blood. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Pharmacological Therapies 48 Chapter 17 Test-Taking Strategy: Use the process of elimination to select the option that is unlikely to facilitate removing a lice infestation. 1. Answer: 3. Rationale: Hair conditioner is not recommended for those infected with head lice because it coats the hair and protects the nits (eggs) attached to the shafts of hair. Pediculocide shampoos are effective, but some contain strong neurotoxic or carcinogenic chemicals that may be harmful for clients who are pregnant, nursing, younger than 2 years, or who have open wounds, epilepsy, or asthma. Manual removal with a fine-toothed combing tool is best for removal of nits and live lice. The water temperature is of no consequence as long as it is not so hot as to burn the scalp. Cognitive Level: Analyze Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Analyze the descriptions in each option and select the one that correlates with the manifestations associated with psoriasis. 2. Answer: 2. Rationale: Psoriasis is characterized by areas of redness covered with silvery scales. Areas affected usually include the elbows, knees, and scalp, although other areas are also affected. No other choice is a characteristic description of psoriasis. Cognitive Level: Analyze 49 Category of Client Needs: Health Promotion and Maintenance Client Needs Subcategory: None Test-Taking Strategy: Eliminate options that are likely to aggravate itching. 3. Answer: 1. Rationale: Soaking or immersing areas of itching skin in water with substances like oatmeal or cornstarch relieves itching. Rough fibers, such as wool, irritate the skin and contribute to itching. Bathing or showering frequently with soap removes skin oils and adds to or causes itching. Rubbing the skin creates skin irritation and contributes to itching and skin discomfort. Cognitive Level: Analyze Category of Client Needs: Physiological Integrity Client Needs Subcategory: Basic Care and Comfort Test-Taking Strategy: Analyze the options and select those that can cause a person who wears a hearing aid to experience shrill noise. 4. Answer: 2, 4, 5. Rationale: Malposition within the ear, a kinked receiver tubing, and excessive volume are common causes of feedback from a hearing aid that are easily corrected to eliminate the problem of feedback. An incorrect battery position and accumulation of cerumen are likely to c