Nur 101 Complete Detailed Exam 2025

Nur 101 Complete Detailed Exam 2025 The nurse should assess every client to determine if stress reduction interventions should be part of the plan of care. The rationale for this action is that: a. There are more persons experiencing mental illness now than in the past. b. Life is so much more stressful than it has ever been. c. The occurrence of stress in clients is unpredictable. d. Clients often develop maladaptive coping strategies. - Correct Answer-The occurrence of stress in clients is unpredictable. A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? a. Impaired communication b. Readiness for Enhanced Communication c. Impaired Verbal Communication d. Sensory alteration - Correct Answer-Impaired communication Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking: a. Requires reasoned thought b. Asks the questions "why" or "how' c. Is a hierarchical process d. Demands specialized thinking skills - Correct Answer-Requires reasoned thought As the nurse you have writing the nursing diagnosis list below. Which portion of the statement represents the etiology Activity intolerance r/t prolonged bed rest AEB(AMB) increased heart rate, decreased blood pressure with activity, patient statements of weakness, & dyspnea with exertion. a. Activity Intolerance b. Prolonged Bed Rest c. Increased Heart Rate d. Dyspnea with Exertion - Correct Answer-Prolonged Best Rest The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an a. Focused Assessment b. Initial assessment c. Ongoing assessment NUR 101 NUR 101 d. Special needs assessment - Correct Answer-Ongoing assessment A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a: a. Critical pathway. b. Nursing care plan. c. Case manager. d. Traditional care model. - Correct Answer-Critical pathway The nurse is caring for a patient who refuses pain medication despite the nurse's explaining its importance in the healing process. After the nurse considers the patient cultural descent which intervention(s) by the nurse is/are appropriate for this patient? a. Assess the patient's pain levels at less frequent intervals. b. Document in the patient's record that the patient does not want to take opioids. c. Utilize nonpharmacological measures to help control the patient's pain. d. Notify the primary care provider of the patient's noncompliance. - Correct Answer Document in the patient's record that the patient does not want to take opiods. Utilize nonpharmalogical measures to help control the patient's pain. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing? a. Family launching young adults b. Postparental family c. Family with frail elderly d. Family with teenagers and young adults - Correct Answer-Postparental family Which aspects of healthcare are affected by a client's culture? Choose all that apply. a. How the clients views healthcare b. How the client views illness c. How the client will pay for healthcare services d. The types of treatments the client will accept e. When the client will seek healthcare services - Correct Answer--How the client views illness. - The types of treatments the client will accept. -When the client will seek healthcare services. The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. The nurse made indicates the nursing assistive personnel change the patient's position NUR 101 NUR 101 every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? a. Determine whether she has gathered enough assessment data. b. Judge whether the interventions achieved the stated outcomes. c. Follow-up to make verify care for the nursing diagnosis was given. d. Decide whether the nursing diagnosis was accurate for the patient's condition. - Correct Answer-Judge whether the interventions achieved the stated outcomes. When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should a. Explain to the client how weight gain occurs b. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. Instruct the UAP to re-weigh the client in 2 hours - Correct Answer-Check the calibration and re-weigh the client The client's activity level has decreased post-hip replacement surgery. She has been receiving opioid analgesia and has decreased fluid intake. The nurse chooses a. A risk nursing diagnosis b. A syndrome nursing diagnosis c. An actual nursing diagnosis d. A possible nursing diagnosis - Correct Answer-A risk nursing diagnosis College courses such as Microbiology and Human Growth and Development present content that is considered part of theoretical nursing knowledge. True False - Correct Answer-True A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. In order to develop a nursing diagnosis, the nurse must now: a. Analyze the assessment data. b. Consult standards of care. c. Decide which interventions are appropriate. d. Ask the client's perceptions of her health problem. - Correct Answer-Analyze the assessment data The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step should the nurse do first? NUR 101 NUR 101 a. Assessment b. Diagnosis c. Plan outcomes d. Plan interventions - Correct Answer-Assessment An older Native American male has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? a. Acute care facility b. Ambulatory care facility c. Extended care facility d. Assisted living facility - Correct Answer-Assisted living facility The physician prescribes metoprolol tartrate (a beta blocker) for an African American patient with hypertension. Based on the patient's ethnicity, the nurse should monitor the effectiveness of therapy closely, because: a. Higher doses of the drug may be needed to be effective. b. More gastrointestinal side effects occur with this group. c. Flushing and palpitations are common among African d. Rebound hypotension commonly occurs in this group. - Correct Answer-Higher does of the drug may be needed to be effective. The client is dying of cancer and can no longer swallow. The son states to the nurse, "You MUST give dad some water, he always drank a lot of water." The nurse's best response would be a. "You sound very upset. Tell me more about your dad." b. "Your father is dying from cancer and water will not stop this process." c. "Research shows that withholding oral fluids decreases edema." d. "I will call the physician and get orders to insert a nasogastric tube for the water." - Correct Answer-"You sound very upset. Tell me more about your dad." The client has reddened skin and an open abrasion on his elbow from prolonged bedrest. In examining the components of the nursing diagnosis "Impaired Skin Integrity", the reddened skin and open abrasion would be a. The related factors b. The risk factors c. The defining characteristics d. The diagnostic label - Correct Answer-The defining characteristics NUR 101 NUR 101 A patient who had surgery 8 hours ago has not voided. The nurse notifies the physician for an order to insert an indwelling urinary catheter. Which of the following statements should the nurse use to describe the procedure to the patient? "I need to: a. "put a Foley in you because you haven't voided since your surgical procedure." b. "insert a tube into your bladder to drain the urine because you haven't urinated since surgery." c. "catheterize you because you haven't urinated since having your surgery." - Correct Answer-"insert a tube into your bladder to drain the urine because you haven't urinated since surgery" The nurse teaches the client how to change his ostomy appliance. This is an example of a. An indirect-care intervention b. An independent intervention c. A dependent intervention d. A collaborative intervention - Correct Answer-An independent intervention It is a very busy day on the nursing unit. The RN asks the UAP to complete the following tasks. He delegates inappropriately when asking the UAP to a. Make sure the client takes his pills after his meal b. Ambulate the post-surgical client to the bathroom c. Bathe the client who is listed as a fall risk d. Feed the client with severe visual impairment - Correct Answer-Make sure the client takes his pills after his meal A nurse develops the nursing diagnosis of Impaired Memory related to fluid and electrolyte imbalances AEB inability to recall events. Which goal/outcome must be included on the care plan? a. Check current medication for mind-altering side effects b. Demonstrates use of techniques to help with memory loss c. Drinks at least 1500cc of fluid per day d. Takes electrlyte supplements with meals - Correct Answer-Demonstrate use of techniques to help with memory loss An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states "I don't want a man taking care of me." Which cultural barrier is this patient exhibiting? a. Ethnocentrism b. Racism c. Sexism NUR 101 NUR 101 d. Chauvinism - Correct Answer-Sexism A 65-year-old patient is admitted to the hospital with heart failure. The patient's best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Considering the family nursing approach, how should the nurse plan discharge education? a. Involve the friend and children in the patient's care, discharge planning, and home care. b. Encourage the friend to wait until discharge to provide care for the patient at home. c. Explain to the friend that for confidentiality reasons she cannot be involved even if the patient consents. d. Encourage liberal visiting hours by the friend and the patient's children. - Correct Answer-Involve the friend and children in the patient's care, discharge planning, and home care. Which of the following is the most important reason for nurses to be critical thinkers? a. Nurses need to follow policies and procedures. b. Nurses work with other healthcare team members. c. Nurses care for clients who have multiple health problems d. Nurses have to be flexible and work variable schedules. - Correct Answer-Nurse care for clients who have multiple health problems. The nurse administering pain medication every 4 hours is an example of which aspect of patient care? a. Assessment data b. Nursing diagnosis c. Patient outcome d. Nursing intervention. - Correct Answer-Nursing intervention A family assessment should include the following areas. a. Coping patterns b. Health beliefs c. Medical history d. Physical exam - Correct Answer-Coping patterns Health beliefs Which of the following suggest that a family health problem may exist? Family members: a. Respect each other's need for privacy. NUR 101 NUR 101 b. Enact decisions made by the most powerful member. c. Do not consider a conflict resolved until everyone agrees. d. Set boundaries between family members. - Correct Answer-Enact decisions made by the most powerful member. Do not consider a conflict resolved until everyone agrees. Identify the long-term goal a. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow b. Client will administer his own insulin using correct technique by discharge c. Client's pressure ulcer will show presence of granulation tissue in 30 days d. Client's urine output will be 400 mL per 8 hour shift within 72 hours - Correct Answer Client's pressure ulcer will show presence of granulation tissue in 30 days It would be most important for the nurse to instruct the NAP to assist clients of which faith to wash their hands before meals? a. Christian b. Jewish c. Mormon d. Muslim - Correct Answer-Muslim After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing? a. Alarm Stage b. Resistance Stage c. Exhaustion d. Recovery - Correct Answer-Exhaustion The nurse is caring for a 42-year-old, patient who underwent emergency coronary artery bypass graft surgery. He is selfemployed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patient's discharge? a. Ethnic background b. Family support c. Unemployment d. Health care coverage - Correct Answer-Family support NUR 101 NUR 101 A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." You recognize this reaction as Anxiety rather than Fear because (choose all that apply): a. it concerns future or anticipated events. b. it concerns anticipation of danger rather than a present danger. c. there is no shakiness or tearfulness present. d. there is a psychological rather than a physical threat. - Correct Answer-It concerns future or anticipated events. It concerns anticipation of danger rather than a present danger. There is a psychological rather than a physical threat. A nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. The critical thinking attitude she is exhibiting is termed a. Independent thinking b. Intellectual humility c. Intellectual courage d. Fair-mindedness - Correct Answer-Independent thinking The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. The nurse should assess closely for which complication? a. Skin breakdown b. Urinary tract infection c. Bowel incontinence d. Renal calculi - Correct Answer-Skin breakdown Which question helps the nurse to assess family structure? a. Where does your family live? b. How are family decisions made in your family? c. With which religious affiliation is your family associated? d. What is your ethnic background? - Correct Answer-How are family decision made in your family? Identify the client outcome/goal that is written correctly. a. The client's urine output will be adequate by the end of the shift b. The client's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge c. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow - Correct Answer-The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow NUR 101 NUR 101 Which statement about the nursing process is correct? a. It was developed from the ANA Standards of Care. b. It is a problem-solving method to guide nursing activities. c. It is a linear process with separate, distinct steps. d. It involves care that only the nurse will give. - Correct Answer-It is a problem-solving method to guide nursing activities. A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing: a. Assimilation. b. Socialization. c. Acculturation. d. Immigration. - Correct Answer-Acculturation Which statement(s) about culture is/are true? Choose all that apply. a. Culture exists on both material and non-material levels. b. Culture mainly influences food choices and special holidays. c. Cultural customs change over time at different rates. d. Culture is learned through life experiences shared by other cultural members. - Correct Answer-Culture exists on both material and non material levels. Cultural customes change over time at different rates. What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome? a. Promotes fluid retention by increasing the reabsorption of water by kidney tubules b. Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle c. Increases the use of fats and proteins for energy and conserves glucose for use by the brain d. Promotes fluid retention by causing the kidneys to reabsorb more sodium - Correct Answer-Promotes fluid retention by increasing the reabsorption of water by kidney tubules The nurse notes on the admission form that the client has indicated "no religious preference." He understands that a. The client does not follow the practices of a specific faith NUR 101 NUR 101 b. The client is in denial about his religious beliefs c. The client does not believe in God or a "higher power" d. The client will not want to pray or visit with the chaplain - Correct Answer-The client does not follow the practices of a specific faith The physician prescribes HUMALOG® (insulin lispro) injections for an Native American patient with Diabetes Mellitus type II. Based on the patient's ethnicity, the nurse should monitor the effectiveness of therapy closely, because: a. Higher doses of the drug may be needed to be effective. b. More gastrointestinal side effects occur with this group. c. Rapid heart rates and palpitations are common among Native Americans. d. Rebound hyperglycemia commonly occurs in this group. - Correct Answer-Higher doses of the drug may be needed to be effective. The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? a. Importance of quitting smoking b. Availability of community resources c. Adherence to a low-fat diet d. Importance of physical exercise - Correct Answer-Availability of community resources Identify the priority nursing diagnosis a. Impaired verbal communication related to altered central nervous system b. Fluid volume excess related to compromised regulatory mechanism c. Impaired physical mobility related to discomfort d. Activity intolerance related to generalized weakness - Correct Answer-Fluid volume excess related to compromised regulatory mechanism Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client? a. Noting that the client's body language indicates that he or she is fatigued b. Maintaining eye contact with the client if it is not culturally inappropriate to do so c. Carefully guiding the conversation so that important topics are discussed d. Asking the client directly, "Why are you not taking your insulin?" - Correct Answer Asking the client directly, "Why are you not taking your insulin?" A client who is taking the drug atenolol (Tenormin) may not exhibit the expected increase in ________________ and _____________during the alarm stage of the general adaptation syndrome. NUR 101 NUR 101 a. blood pressure and pulse b. anxiety and stress c. fear and distress d. alertness and awareness - Correct Answer-blood pressure and pulse Which of the following is considered a "practice" (as opposed to a belief or value)? a. Always drinking water after exercise b. Thinking often about cleanliness c. Emphasis on success d. Maintaining youth - Correct Answer-Always drinking water after exercise The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present-oriented? a. "I know I need to lose weight; I'll have to begin an exercise program right away." b. "If I change my diet and begin exercising, maybe I can control my blood pressure without medications." c. "I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult." d. "I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke." - Correct Answer-"I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult." In caring for a patient with comorbidities, the nurse draws upon her knowledge of Native Americans, diabetes and the resulting issue of skin integrity. In a spirit of inquiry