NUR 126 - Exam 1 questions with verified answers
"Nursing diagnosis is a clinical judgment about an individual, family, or
community response to actual or potential health problems or life
processes. Nursing diagnosis provides Ans✓✓✓ the basis for selection
of nursing interventions to achieve outcomes for which the nurse has
accountability." (NANDA, 2008)
"Nursing process" Ans✓✓✓ assessment, nursing diagnosis, planning,
intervention, and evaluation
A confused older-adult patient is wearing thick glasses and a hearing
aid. Which intervention is the priority to facilitate communication?
Ans✓✓✓ Allow time for the patient to respond.
A factory requires its employees to wear hearing protection and hard
hats while on the job. Protection against occupational hazards is an
example of which level of preventive care? Ans✓✓✓ primary
A health care provider may suspect that a patient is experiencing
urinary retention when the patient has Ans✓✓✓ small amounts of
urine voided two or three times per hour
A newly admitted patient states that he has recently had a change in
medications and reports that stools are now dry and hard to pass. This
type of bowel pattern is consistent with Ans✓✓✓ constipation
,A normal pulse strength is graded at what number? Ans✓✓✓ 2+
A nurse infused by a spirit of inquiry will Ans✓✓✓ raise questions,
challenge traditional, existing practices, and seek creative approaches
to problem-solving
A nurse is about to use the Wong-Baker FACES pain level. Which of the
following should the nurse know in order to use this pain scale?
Ans✓✓✓ This scale is useful for adult patients who have cognitive
impairments
A nurse is implementing nursing care measures for patients with
challenging communication issues. Which types of patients will need
these nursing care measures? Ans✓✓✓ A child who is developmentally
delayed. An older adult patient who is demanding. A female patient
who is outgoing and flirty. A teenager frightened by the prospect of
impending surgery
A nurse is planning to administer a dose of intravenous morphine
sulfate for a postoperative patient. Which of the following is a pain
management protocol that should be used by the nurse in this
situation? Ans✓✓✓ Have an opioid antagonist available during the
administration
,A nurse wants to present information about flu immunizations to the
elderly in the community. Which type of communication should the
nurse use? Ans✓✓✓ Public
A nursing diagnosis allows Ans✓✓✓ the nurse to diagnose and treat
the identified problem; to communicate what is done with other
professionals, and refocuses the nurse on the nursing scope of practice.
A nursing diagnosis is of a standardized language that defines the
patient's Ans✓✓✓ response to a problem
A patient had surgery for a total knee replacement a week ago and is
currently participating in daily physical rehabilitation sessions at the
surgeon's office. In what level of prevention is the patient participating
Ans✓✓✓ Tertiary
A patient has a healthcare-associated infection (HAI). This terminology
means that the patient Ans✓✓✓ Acquired the infection while
hospitalized
A patient has bibasilar pneumonia. You would expect vibrations
through tactile fremitus to get Ans✓✓✓ stronger
A patient has trouble speaking words, and the patient's speech is
garbled. Which nursing diagnosis is most appropriate for this patient?
Ans✓✓✓ impaired verbal communication
, A patient is aphasic and the nurse notices that the patient's hands
shake intermittently. Which nursing action is most appropriate to
facilitate communication? Ans✓✓✓ Use a picture board
A patient just received a diagnosis of cancer. Which statement by the
nurse demonstrates empathy? Ans✓✓✓ This must be hard news to
hear.
A patient says you are the worst nurse I have ever had. Which response
by the nurse is most assertive? Ans✓✓✓ I feel uncomfortable after
hearing that statement
A patient suffers from sleep pattern disturbance. To promote adequate
sleep, the most important nursing intervention is Ans✓✓✓
synchronizing the medication, treatment, and vital sign schedule
A patient with a spinal cord injury must learn to use a wheelchair and
perform ADLs independently, the nurse knows that this level of care is
Ans✓✓✓ tertiary
A provider order is required for restraints. The order must be Ans✓✓✓
Current, State the type and location or restraints: 2-point (wrist), 4-
point (wrist and ankle). Specify the duration and circumstances under
which it will be used. Never ordered as needed: Orders are renewed in
a specific time frame
"Nursing diagnosis is a clinical judgment about an individual, family, or
community response to actual or potential health problems or life
processes. Nursing diagnosis provides Ans✓✓✓ the basis for selection
of nursing interventions to achieve outcomes for which the nurse has
accountability." (NANDA, 2008)
"Nursing process" Ans✓✓✓ assessment, nursing diagnosis, planning,
intervention, and evaluation
A confused older-adult patient is wearing thick glasses and a hearing
aid. Which intervention is the priority to facilitate communication?
Ans✓✓✓ Allow time for the patient to respond.
A factory requires its employees to wear hearing protection and hard
hats while on the job. Protection against occupational hazards is an
example of which level of preventive care? Ans✓✓✓ primary
A health care provider may suspect that a patient is experiencing
urinary retention when the patient has Ans✓✓✓ small amounts of
urine voided two or three times per hour
A newly admitted patient states that he has recently had a change in
medications and reports that stools are now dry and hard to pass. This
type of bowel pattern is consistent with Ans✓✓✓ constipation
,A normal pulse strength is graded at what number? Ans✓✓✓ 2+
A nurse infused by a spirit of inquiry will Ans✓✓✓ raise questions,
challenge traditional, existing practices, and seek creative approaches
to problem-solving
A nurse is about to use the Wong-Baker FACES pain level. Which of the
following should the nurse know in order to use this pain scale?
Ans✓✓✓ This scale is useful for adult patients who have cognitive
impairments
A nurse is implementing nursing care measures for patients with
challenging communication issues. Which types of patients will need
these nursing care measures? Ans✓✓✓ A child who is developmentally
delayed. An older adult patient who is demanding. A female patient
who is outgoing and flirty. A teenager frightened by the prospect of
impending surgery
A nurse is planning to administer a dose of intravenous morphine
sulfate for a postoperative patient. Which of the following is a pain
management protocol that should be used by the nurse in this
situation? Ans✓✓✓ Have an opioid antagonist available during the
administration
,A nurse wants to present information about flu immunizations to the
elderly in the community. Which type of communication should the
nurse use? Ans✓✓✓ Public
A nursing diagnosis allows Ans✓✓✓ the nurse to diagnose and treat
the identified problem; to communicate what is done with other
professionals, and refocuses the nurse on the nursing scope of practice.
A nursing diagnosis is of a standardized language that defines the
patient's Ans✓✓✓ response to a problem
A patient had surgery for a total knee replacement a week ago and is
currently participating in daily physical rehabilitation sessions at the
surgeon's office. In what level of prevention is the patient participating
Ans✓✓✓ Tertiary
A patient has a healthcare-associated infection (HAI). This terminology
means that the patient Ans✓✓✓ Acquired the infection while
hospitalized
A patient has bibasilar pneumonia. You would expect vibrations
through tactile fremitus to get Ans✓✓✓ stronger
A patient has trouble speaking words, and the patient's speech is
garbled. Which nursing diagnosis is most appropriate for this patient?
Ans✓✓✓ impaired verbal communication
, A patient is aphasic and the nurse notices that the patient's hands
shake intermittently. Which nursing action is most appropriate to
facilitate communication? Ans✓✓✓ Use a picture board
A patient just received a diagnosis of cancer. Which statement by the
nurse demonstrates empathy? Ans✓✓✓ This must be hard news to
hear.
A patient says you are the worst nurse I have ever had. Which response
by the nurse is most assertive? Ans✓✓✓ I feel uncomfortable after
hearing that statement
A patient suffers from sleep pattern disturbance. To promote adequate
sleep, the most important nursing intervention is Ans✓✓✓
synchronizing the medication, treatment, and vital sign schedule
A patient with a spinal cord injury must learn to use a wheelchair and
perform ADLs independently, the nurse knows that this level of care is
Ans✓✓✓ tertiary
A provider order is required for restraints. The order must be Ans✓✓✓
Current, State the type and location or restraints: 2-point (wrist), 4-
point (wrist and ankle). Specify the duration and circumstances under
which it will be used. Never ordered as needed: Orders are renewed in
a specific time frame
