NURSING 122 EXAM 1 QUESTIONS WITH COMPLETE
SOLUTIONS
A 62-year-old woman is being discharged home with her
husband after surgery for a hip fracture from a fall at home.
When providing discharge teaching about home safety to this
patient and her husband, the nurse knows that:
A) A safe environment promotes patient activity.
B) Assessment focuses on environmental factors only.
C) Teaching home safety is difficult to do in the hospital setting.
D) Most accidents in the older adult are caused by lifestyle
factors. Correct Answer A. Older adults are frequently fearful
of falling and thus often limit activity. A safe environment,
which decreases the risk of a fall, promotes patient activity.
A child in the hospital starts to have a grand mal seizure while
playing in the playroom. What is your most important nursing
intervention during this situation?
A) Begin cardiopulmonary respiration.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from
injury. Correct Answer D. Once a seizure begins, you need to
monitor the patient and provide a safe environment. A seizure is
not an indication for cardiopulmonary resuscitation. A person
having a seizure should not be restrained, but the environment
should be made safe. Objects should not be forced into the
mouth. See the Skills in the chapter for more information.
,A couple is with their adolescent daughter for a school physical
and state they are worried about all the safety risks affecting this
age. What is the greatest risk for injury for an adolescent?
A) Home accidents
B) Physiological changes of aging
C) Poisoning and child abduction
D) Automobile accidents, suicide, and substance abuse Correct
Answer D. Risks to the safety of adolescents involve many
factors outside the home because much of their time is spent
away from home and with their peer group. According to the
Centers for Disease Control and Prevention, the risk of motor
vehicle accidents is higher among 16- to 19-year-old drivers
than any other age-group. In an attempt to relieve the tensions
associated with physical and psychosocial changes and peer
pressures, some adolescents engage in risk-taking behaviors
such as smoking, drinking alcohol, and using drugs.
A diabetic patient recovering from back surgery has long
toenails that need cutting both for the patient's comfort and for
hygienic purposes. What action should the nurse take to resolve
the patient's problem?
A. Trim the toenails after soaking them for 10 minutes.
B. Ask the physician for a referral to a podiatrist.
C. Let the patient trim his own toenails.
D. Ask the patient's wife if she will trim his toenails. Correct
Answer B. Patients with diabetes are prone to decreased
circulation and increased infection in the lower extremities. It is
best to have a professional trim the toenails. The patient would
not be able to do it because of his recent back surgery. Page 455
,A family member is providing care to a loved one who has an
infected leg wound. What would you instruct the family member
to do after providing care and handling contaminated equipment
or organic material?
A) Wear gloves before eating or handling food.
B) Place any soiled materials into a bag and double bag it.
C) Have the family member check with the doctor about need
for immunization.
D) Perform hand hygiene after care and/or handling
contaminated equipment or material. Correct Answer D.
Clean hands interrupt the transmission of microorganisms from
family members.
A fragile, 87-year-old nursing home resident is admitted to the
hospital with dehydration and increased confusion. The patient
has upper limb restraints to prevent her from pulling out her
nasogastric tube. What instructions does the nurse give to
nursing assistive personnel (NAP)? Correct Answer The use
of restraints is associated with serious complications resulting
from immobilization such as pressure ulcers, pneumonia,
constipation, and incontinence. In some cases death has resulted
because of restricted breathing and circulation. The restraint
itself could injure the underlying skin. Routine checks are
required to prevent or decrease these complications. The NAP
needs to notify the nurse if there is a change in skin integrity,
circulation, or patient's breathing and provide range of motion,
nutrition and hydration, skin care, toileting, and opportunities
for socialization at least every 2 hours.
A home care nurse is preparing the home for a patient who is
discharged to home following a left-sided stroke. The patient is
, cooperative and can ambulate with a quad-cane. Which of the
following must be corrected or removed for the patient's safety?
(Select all that apply.)
A) The rubber mat in the walk-in shower
B) The three-legged stool on wheels in the kitchen
C) The braided throw rugs in the entry hallway and between the
bedroom and bathroom
D) The night-lights in the hallways, bedroom, and bathroom
E) The cordless phone next to the patient's bed Correct Answer
B,C. Stools on wheels and braided throw rugs are hazards that
put the patient at risk for falls. By planning ahead and
collaborating, the home care nurse can provide a safe home
environment for the patient after discharge.
A male nurse is caring for a 32-year-old female Muslim patient
who has an indwelling Foley catheter. After introducing himself
to the patient, the nurse learns that the patient does not want him
to help her with personal hygiene care. Which of the following
is(are) appropriate actions? (Select all that apply.)
A) Finding a female nurse to help the patient
B) Convincing the patient that he will work quickly and provide
as much privacy as possible
C) Skipping hygiene care for the day except for the parts that the
patient can complete independently
D) Asking the patient if she prefers a family member assist with
the care Correct Answer A,D. Cultural variations affecting
hygiene care include gender-congruent concerns. Pressuring
patients to accept cultural values that they do not believe in and
value is inappropriate. Patients with Foley catheters require
routine perineal care; skipping care is not a safe practice.
SOLUTIONS
A 62-year-old woman is being discharged home with her
husband after surgery for a hip fracture from a fall at home.
When providing discharge teaching about home safety to this
patient and her husband, the nurse knows that:
A) A safe environment promotes patient activity.
B) Assessment focuses on environmental factors only.
C) Teaching home safety is difficult to do in the hospital setting.
D) Most accidents in the older adult are caused by lifestyle
factors. Correct Answer A. Older adults are frequently fearful
of falling and thus often limit activity. A safe environment,
which decreases the risk of a fall, promotes patient activity.
A child in the hospital starts to have a grand mal seizure while
playing in the playroom. What is your most important nursing
intervention during this situation?
A) Begin cardiopulmonary respiration.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from
injury. Correct Answer D. Once a seizure begins, you need to
monitor the patient and provide a safe environment. A seizure is
not an indication for cardiopulmonary resuscitation. A person
having a seizure should not be restrained, but the environment
should be made safe. Objects should not be forced into the
mouth. See the Skills in the chapter for more information.
,A couple is with their adolescent daughter for a school physical
and state they are worried about all the safety risks affecting this
age. What is the greatest risk for injury for an adolescent?
A) Home accidents
B) Physiological changes of aging
C) Poisoning and child abduction
D) Automobile accidents, suicide, and substance abuse Correct
Answer D. Risks to the safety of adolescents involve many
factors outside the home because much of their time is spent
away from home and with their peer group. According to the
Centers for Disease Control and Prevention, the risk of motor
vehicle accidents is higher among 16- to 19-year-old drivers
than any other age-group. In an attempt to relieve the tensions
associated with physical and psychosocial changes and peer
pressures, some adolescents engage in risk-taking behaviors
such as smoking, drinking alcohol, and using drugs.
A diabetic patient recovering from back surgery has long
toenails that need cutting both for the patient's comfort and for
hygienic purposes. What action should the nurse take to resolve
the patient's problem?
A. Trim the toenails after soaking them for 10 minutes.
B. Ask the physician for a referral to a podiatrist.
C. Let the patient trim his own toenails.
D. Ask the patient's wife if she will trim his toenails. Correct
Answer B. Patients with diabetes are prone to decreased
circulation and increased infection in the lower extremities. It is
best to have a professional trim the toenails. The patient would
not be able to do it because of his recent back surgery. Page 455
,A family member is providing care to a loved one who has an
infected leg wound. What would you instruct the family member
to do after providing care and handling contaminated equipment
or organic material?
A) Wear gloves before eating or handling food.
B) Place any soiled materials into a bag and double bag it.
C) Have the family member check with the doctor about need
for immunization.
D) Perform hand hygiene after care and/or handling
contaminated equipment or material. Correct Answer D.
Clean hands interrupt the transmission of microorganisms from
family members.
A fragile, 87-year-old nursing home resident is admitted to the
hospital with dehydration and increased confusion. The patient
has upper limb restraints to prevent her from pulling out her
nasogastric tube. What instructions does the nurse give to
nursing assistive personnel (NAP)? Correct Answer The use
of restraints is associated with serious complications resulting
from immobilization such as pressure ulcers, pneumonia,
constipation, and incontinence. In some cases death has resulted
because of restricted breathing and circulation. The restraint
itself could injure the underlying skin. Routine checks are
required to prevent or decrease these complications. The NAP
needs to notify the nurse if there is a change in skin integrity,
circulation, or patient's breathing and provide range of motion,
nutrition and hydration, skin care, toileting, and opportunities
for socialization at least every 2 hours.
A home care nurse is preparing the home for a patient who is
discharged to home following a left-sided stroke. The patient is
, cooperative and can ambulate with a quad-cane. Which of the
following must be corrected or removed for the patient's safety?
(Select all that apply.)
A) The rubber mat in the walk-in shower
B) The three-legged stool on wheels in the kitchen
C) The braided throw rugs in the entry hallway and between the
bedroom and bathroom
D) The night-lights in the hallways, bedroom, and bathroom
E) The cordless phone next to the patient's bed Correct Answer
B,C. Stools on wheels and braided throw rugs are hazards that
put the patient at risk for falls. By planning ahead and
collaborating, the home care nurse can provide a safe home
environment for the patient after discharge.
A male nurse is caring for a 32-year-old female Muslim patient
who has an indwelling Foley catheter. After introducing himself
to the patient, the nurse learns that the patient does not want him
to help her with personal hygiene care. Which of the following
is(are) appropriate actions? (Select all that apply.)
A) Finding a female nurse to help the patient
B) Convincing the patient that he will work quickly and provide
as much privacy as possible
C) Skipping hygiene care for the day except for the parts that the
patient can complete independently
D) Asking the patient if she prefers a family member assist with
the care Correct Answer A,D. Cultural variations affecting
hygiene care include gender-congruent concerns. Pressuring
patients to accept cultural values that they do not believe in and
value is inappropriate. Patients with Foley catheters require
routine perineal care; skipping care is not a safe practice.
