NUR 215 FINAL SET UPDATED EXAM 2025

Therapeutic Communication - Exploring the client's feelings and concerns in a non judgmental manner. Low Self-Esteem Indicator - Negative self-talk and feelings of worthlessness are key indicators of low self-esteem. Chain of Infection - Hand hygiene is the most effective method to prevent the transmission of infectious agents and break the chain of infection. Glove Removal Timing - Gloves should be removed immediately after a procedure or when contaminated to prevent the spread of pathogens. PPE for Measles - An N95 respirator and gloves are required when caring for a patient with measles. Oral Care for Unconscious Patient - Providing oral care with chlorhexidine helps reduce microbial buildup, prevent infections, and address oral hygiene concerns. Position for Oral Care - The lateral position prevents aspiration by allowing fluids to drain out of the mouth. OTC Medications Understanding - Patients should understand that OTC medications can interact with prescribed drugs, leading to potentially harmful effects. Need for Further Teaching on OTC - Herbal supplements and vitamins can interact with prescription medications, and the healthcare provider must be informed of all substances the patient is taking. Positive TB Skin Test Criteria (Healthy Individual) - A positive result is an induration of 15 mm or more. Positive TB Skin Test Criteria (Immunocompromised) - An induration of 5 mm or more is considered positive. Positive TB Skin Test Criteria (Close Contact) - An induration of 5 mm or more is positive for close contacts of TB cases. Cultural Sensitivity in Healthcare - Encouraging open communication about cultural and spiritual needs helps create a supportive environment and reduces stress. NUR215 NUR215 Stage of Sleep for Dreaming - Dreaming occurs during REM (Rapid Eye Movement) sleep, which is characterized by brain activity similar to wakefulness. Stage of Sleep for Mental Restoration - Mental and emotional restoration occurs during REM sleep due to its role in memory consolidation and emotional processing. Signs of Sleep Deprivation - Sleep deprivation often results in cognitive impairment, irritability, fatigue, and difficulty concentrating. Impaired memory and irritability - Sleep deprivation often results in cognitive impairment, irritability, fatigue, and difficulty concentrating. Log Rolling Technique - What is the proper technique to log roll a patient in bed? A. Keep the patient's body straight and roll them as a single unit B. Bend the patient's knees and rotate the hips first C. Move the head and neck last to avoid injury D. Turn the patient without assistance to minimize discomfort. Correct Answer: A. Keep the patient's body straight and roll them as a single unit. Rationale: Log rolling keeps the spine aligned, preventing twisting or further injury, particularly in patients with spinal precautions. Cane Use with Right-Sided Weakness - What is the correct technique for using a cane when a patient has right-sided weakness? A. Hold the cane on the right side and move it with the left leg B. Hold the cane on the left side and move it with the right leg C. Hold the cane on the right side and move it independently D. Use the cane only when climbing stairs. Correct Answer: B. Hold the cane on the left side and move it with the right leg. Rationale: The cane is held on the stronger side (left) and advanced simultaneously with the weak leg (right) for proper support. UTI Management - A patient reports symptoms of a UTI. What is the nurse's first action? A. Administer antibiotics B. Obtain a urine sample for testing C. Educate the patient about fluid intake D. Document the symptoms and notify the provider. Correct Answer: B. Obtain a urine sample for testing. Rationale: A urine sample should be collected to confirm the diagnosis and guide treatment. Risk for Foot and Nail Infection - Which client is at greatest risk for foot and nail infections? A. A healthy 30-year-old who exercises regularly B. A 45-year-old with diabetes mellitus C. A 60-year-old with a sedentary lifestyle D. A 20-year-old athlete with a foot blister. Correct Answer: B. A 45-year-old with diabetes mellitus. Rationale: Diabetes increases the risk of foot and nail infections due to poor circulation and delayed wound healing. Oxygen Delivery Systems - Which oxygen delivery system provides the highest concentration of oxygen? A. Nasal cannula B. Simple face mask NUR215 NUR215 C. Non-rebreather mask D. Venturi mask. Correct Answer: C. Non-rebreather mask. Rationale: A non-rebreather mask delivers up to 100% oxygen, the highest concentration among common oxygen delivery systems. Therapeutic Communication with Families of Deceased Patients - Which therapeutic communication approach is most appropriate for families at the bedside of a deceased patient? A. 'I know how you feel. I lost someone too.' B. 'Your loved one is in a better place now.' C. 'It's okay to feel sad; I'm here if you'd like to talk.' D. 'Let's focus on the positive memories you shared.' Correct Answer: C. 'It's okay to feel sad; I'm here if you'd like to talk.' Rationale: Acknowledging emotions and offering support demonstrates empathy and therapeutic communication. Preventing Constipation - Which action is most effective in preventing constipation? A. Encouraging a high-fiber diet and adequate fluid intake B. Avoiding physical activity to conserve energy C. Using laxatives daily to promote bowel movements D. Limiting fluid intake to reduce bloating. Correct Answer: A. Encouraging a high-fiber diet and adequate fluid intake. Rationale: Fiber and fluids promote healthy bowel movements by softening stool and improving peristalsis. Signs of Hypoxia - Which are early signs of hypoxia? A. Cyanosis and decreased blood pressure B. Restlessness and confusion C. Bradycardia and lethargy D. Increased appetite and fatigue. Correct Answer: B. Restlessness and confusion. Rationale: Early signs of hypoxia include restlessness, confusion, and tachycardia due to decreased oxygenation. Signs of Systemic Infection - Which findings indicate a systemic infection? A. Localized redness and warmth B. Fever, fatigue, and elevated WBC count C. Tenderness at the site of infection D. Increased appetite and energy. Correct Answer: B. Fever, fatigue, and elevated WBC count. Rationale: Systemic infections cause generalized symptoms such as fever, fatigue, and elevated white blood cell counts. General Adaptation Syndrome: Exhaustion Phase - What are the expected vital sign changes in the exhaustion phase of the general adaptation syndrome? A. Decreased blood pressure, bradycardia, and tachypnea B. Increased blood pressure, tachycardia, and tachypnea C. Decreased blood pressure, tachycardia, and tachypnea D. Increased blood pressure, bradycardia, and bradypnea. Correct Answer: C. Decreased blood pressure, tachycardia, and tachypnea. Rationale: During the exhaustion phase, the body depletes its resources, leading to decreased BP, tachycardia, and tachypnea. Assessing Pallor in Dark-Skinned Patients - What is the best site to assess for pallor in a dark-skinned patient? A. Nail beds and palms B. Lips and fingertips C. Conjunctivae and mucous membranes D. Sclera and earlobes. Correct Answer: C. Conjunctivae and mucous membranes. Rationale: Pallor in dark-skinned patients is most reliably NUR215 NUR215 assessed in areas with less pigmentation, such as the conjunctivae and mucous membranes. Preventing Spread of Infection with Contact Isolation - Which action helps prevent the spread of infection in a patient on contact isolation? A. Wear a surgical mask when entering the room B. Perform hand hygiene before and after patient contact C. Use an N95 respirator for all interactions D. Place the patient in a room with negative airflow. Correct Answer: B. Perform hand hygiene before and after patient contact. Rationale: Hand hygiene is the most effective way to prevent the spread of infection. Contact precautions also include using gloves and gowns. Patients at Greatest Risk of Falls - Which patient is at the greatest risk of falls? A. A 30 year-old with a history of hypertension B. A 70-year-old recently started on antihypertensive medication C. A 40-year-old with chronic back pain D. A 25-year-old with diabetes mellitus. Correct Answer: B. A 70-year-old recently started on antihypertensive medication. Rationale: Older adults are at a higher risk for falls, and antihypertensive medications can cause dizziness or orthostatic hypotension, increasing the risk. Ensuring Patient Safety When Using a Walker - What is the correct technique for using a walker? A. Push the walker forward and step with the stronger leg first B. Push the walker forward and step with the weaker leg first C. Lift the walker forward and step with both legs simultaneously D. Step with the stronger leg first, then push the walker forward. Correct Answer: B. Push the walker forward and step with the weaker leg first. Rationale: When using a walker, the weaker leg moves forward first to provide stability and support. Maladaptive Ways to Cope with Stress - Which behavior indicates maladaptive coping with stress? A. Journaling daily experiences B. Drinking alcohol excessively C. Exercising regularly D. Talking with a support group. Correct Answer: B. Drinking alcohol excessively. Rationale: Excessive alcohol use is a maladaptive coping mechanism and can worsen stress-related issues. Kubler-Ross Five Stages of Grief - Which statement reflects the denial stage of Kubler Ross's grief model? A. 'This can't be happening to me.' B. 'Why did this happen to me?' C. 'If I do everything right, I can fix this.' D. 'I feel so empty and hopeless.' Correct Answer: A. 'This can't be happening to me.' Rationale: Denial is the first stage of grief, characterized by refusal to accept the reality of the situation. Bargaining Stage of Grief - Which statement by a patient reflects the bargaining stage of grief? A. 'If I can just live long enough to see my granddaughter graduate, I'll be okay.' B. 'Why is this happening to me? I don't deserve this.' C. 'I don't want to talk about this right now.' D. 'I've accepted my condition and am ready to move forward.' Correct Answer: A. Bargaining - Making deals to extend life or delay grief. NUR215 Anger Stage - Emotional response characterized by frustration and blame. Depression Stage - Deep sadness and feelings of emptiness or hopelessness. Denial Stage - Rejecting reality, hoping the situation isn't true. Acceptance Stage - Finding peace and coming to terms with loss. Alarm Stage - Initial response to stress activating the sympathetic system. Exhaustion Stage - Depletion of body's resources leading to fatigue. Sympathetic Nervous System - Prepares body for 'fight or flight' response. Physiological Response - Physical changes like increased heart rate during stress. Pupil Dilation - Enlargement of pupils to enhance vision under stress. Palliative Care - Symptom management at any illness stage. Hospice Care - Comfort care for patients expected to live 6 months or less. Rigor Mortis - Stiffening of muscles occurring 2-4 hours after death. Postmortem Care - Care procedures performed after a patient's death. Suicidal Ideation - Thoughts of self-harm or ending one's life. Loss of Interest - Inability to enjoy previously pleasurable activities. Imminent Death Signs - Cool, mottled skin and decreasing blood pressure. Grieving Process - Emotional journey through stages of loss. Supportive Presence - Being available to provide emotional comfort. Fatigue from Stress - Chronic stress leads to exhaustion and sleep issues. Hope in Grief - Holding onto positive outcomes despite loss. Emotional Exploration - Discussing feelings to understand and cope with grief. Coping Mechanisms - Strategies to manage stress and emotional pain. Sympathetic Activation - Increased heart rate and respiratory rate during stress. NUR215 NUR215 NUR215 Comfort Care - Focus on quality of life in terminal illness. Medical Device Removal - Devices removed during postmortem unless required. Grief Resources - Materials provided to assist in coping with loss. Palliative care - Can be provided alongside curative treatments from the time of diagnosis to improve the quality of life for patients with serious illnesses. Hospice care - For terminally ill patients who focus on comfort rather than curative treatments and have a prognosis of six months or less. Enteral Feeding Through NG Tube - Flushing the tube with 15-30 mL of water before and after feeding prevents blockages and maintains patency. Postmortem care - Personal belongings are removed and documented before family viewing. Normal grief reaction - Feelings of sadness and moments of crying. Nurse's response to family loss - Expressing empathy and offering support shows compassion and therapeutic communication. Priority in hospice care - Addressing physical, emotional, and spiritual comfort. Trigeminal neuralgia and constipation risk - Soft diets are low in fiber. Common symptoms of grief - Fatigue, sadness, and difficulty concentrating. Supporting families during end-of-life care - Keeping the family informed and involved helps them cope and feel supported. PQRST in pain assessment - Provocation, Quality, Radiation, Severity, Timing. Palliative care interventions at home - Pain management, emotional support, and assistance with activities of daily living. Assessing pallor in dark-skinned patients - The conjunctivae and mucous membranes are the best sites. Preventing infection with contact isolation - Washing hands before and