RNSG 1413 - Exam 4 (34, 36, 37, 38, 41, 42, 43, 44)
- ANS -
\"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her
routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this
unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? - ANS
-Facilitating mourning
\A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory
depression. For which acid-base imbalance will the nurse most closely monitor this child? - ANS -Respiratory acidosis
\A 9 year old is proudly telling the nurse about mastering the yellow belt in a martial arts class. Which developmental
stage is the child exhibiting? - ANS -Industry versus inferiority
\A cancer patient asks the nurse what the criteria are for hospice care. Which information should the nurse share with the
patient? - ANS -It is for those expected to live less than 6 months
\A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? -
ANS -"How many times a day do you urinate?"
\A co-worker asks the nurse to explain spirituality. What is the nurse's best response? - ANS -It is awareness of one's
inner self
\A community health nurse is providing an educational session at the senior center on how to promote sleep. Which
practices should the nurse recommend? - ANS --Sleep where you sleep best
-Use sedatives as a last resort
-Decreased fluids 2 to 4 hours before sleep
-Get up if unable to fall asleep in 15 to 30 minutes
\A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her
spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is
the female nurse experiencing? - ANS -Complicated grief
\A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While
planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to
,the care plan? - ANS -Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her
friends.
\A male patient in stable condition is in the intensive care unit (ICU) and is asking to see his spouse and two daughters.
What should the nurse do? - ANS -Allow the wife and daughters to visit at the patient's request
\A male patient states, "I'm such a loser, I only had that job for a month." Which outcome criteria will the nurse add to the
patient's care plan? - ANS -The patient will verbalize two life areas in which he functions well
\A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? - ANS -Aortic and
pulmonic
\A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At
what time should the infusion be completed - ANS -2345 Monday
\A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the
upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death.
Which nursing principle does the nurse's action best demonstrate? - ANS -Facilitation of normal mourning
\A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's
function will the nurse share with the patient? - ANS -Carries out gas exchange
\A nurse grimaces while changing a patient's colostomy bag. Which effect will the nurse's behavior most likely have on the
patient? - ANS -Promote development of a negative body image
\A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let
the blood infuse? - ANS -4 hours
\A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? - ANS
-Temperature 101.3° F
\A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by
the patient will best indicate successful teaching - ANS -Potatoes and fresh fruit
\A nurse is assessing a group of adolescents. Which person is most likely to have the highest self-esteem? - ANS -Latino
adolescent female who has strong ethnic pride
\A nurse is assessing a group of patients. Match the assessment finding to the area the nurse is assessing. - ANS -I am
ugly with all these burn scars - disturbed body image
I am one with the universe - identity confusion
I am good for nothing - low self-esteem
, I am a good mother - role performance
\A nurse is assessing a patient for possible altered self-concept. Which assessment findings is consistent with altered
self-concept? - ANS -Hesitant to express opinions
\A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed.
The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention.
On which transfusion complication will the nurse focus interventions? - ANS -Fluid volume overload
\A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe
the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle
around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? -
ANS -Visceral pain
\A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? - ANS
--Cancer
-Diabetes
-Infections
\A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid
volume deficit? - ANS -Postural hypotension
\A nurse is assessing a patient's self-concept. Which area should the nurse assess first? - ANS -Role performance
\A nurse is assessing a patient's self-concept. Which areas will the nurse include? - ANS -Identity
Body image
Coping behaviors
Significant other's support
\A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the
recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? - ANS -Uses
chlorhexidine skin antisepsis prior to insertion
\A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate.
Which factor does the nurse remember when planning care for this type of hyperventilation? - ANS -Increased metabolic
demands
- ANS -
\"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her
routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this
unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? - ANS
-Facilitating mourning
\A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory
depression. For which acid-base imbalance will the nurse most closely monitor this child? - ANS -Respiratory acidosis
\A 9 year old is proudly telling the nurse about mastering the yellow belt in a martial arts class. Which developmental
stage is the child exhibiting? - ANS -Industry versus inferiority
\A cancer patient asks the nurse what the criteria are for hospice care. Which information should the nurse share with the
patient? - ANS -It is for those expected to live less than 6 months
\A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? -
ANS -"How many times a day do you urinate?"
\A co-worker asks the nurse to explain spirituality. What is the nurse's best response? - ANS -It is awareness of one's
inner self
\A community health nurse is providing an educational session at the senior center on how to promote sleep. Which
practices should the nurse recommend? - ANS --Sleep where you sleep best
-Use sedatives as a last resort
-Decreased fluids 2 to 4 hours before sleep
-Get up if unable to fall asleep in 15 to 30 minutes
\A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her
spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is
the female nurse experiencing? - ANS -Complicated grief
\A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While
planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to
,the care plan? - ANS -Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her
friends.
\A male patient in stable condition is in the intensive care unit (ICU) and is asking to see his spouse and two daughters.
What should the nurse do? - ANS -Allow the wife and daughters to visit at the patient's request
\A male patient states, "I'm such a loser, I only had that job for a month." Which outcome criteria will the nurse add to the
patient's care plan? - ANS -The patient will verbalize two life areas in which he functions well
\A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? - ANS -Aortic and
pulmonic
\A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At
what time should the infusion be completed - ANS -2345 Monday
\A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the
upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death.
Which nursing principle does the nurse's action best demonstrate? - ANS -Facilitation of normal mourning
\A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's
function will the nurse share with the patient? - ANS -Carries out gas exchange
\A nurse grimaces while changing a patient's colostomy bag. Which effect will the nurse's behavior most likely have on the
patient? - ANS -Promote development of a negative body image
\A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let
the blood infuse? - ANS -4 hours
\A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? - ANS
-Temperature 101.3° F
\A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by
the patient will best indicate successful teaching - ANS -Potatoes and fresh fruit
\A nurse is assessing a group of adolescents. Which person is most likely to have the highest self-esteem? - ANS -Latino
adolescent female who has strong ethnic pride
\A nurse is assessing a group of patients. Match the assessment finding to the area the nurse is assessing. - ANS -I am
ugly with all these burn scars - disturbed body image
I am one with the universe - identity confusion
I am good for nothing - low self-esteem
, I am a good mother - role performance
\A nurse is assessing a patient for possible altered self-concept. Which assessment findings is consistent with altered
self-concept? - ANS -Hesitant to express opinions
\A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed.
The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention.
On which transfusion complication will the nurse focus interventions? - ANS -Fluid volume overload
\A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe
the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle
around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? -
ANS -Visceral pain
\A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? - ANS
--Cancer
-Diabetes
-Infections
\A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid
volume deficit? - ANS -Postural hypotension
\A nurse is assessing a patient's self-concept. Which area should the nurse assess first? - ANS -Role performance
\A nurse is assessing a patient's self-concept. Which areas will the nurse include? - ANS -Identity
Body image
Coping behaviors
Significant other's support
\A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the
recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? - ANS -Uses
chlorhexidine skin antisepsis prior to insertion
\A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate.
Which factor does the nurse remember when planning care for this type of hyperventilation? - ANS -Increased metabolic
demands
