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Which assessment finding of the integumentary system is the most important to report to the
health care provider ( HCP ) or dermatologist?
1. Tan or brown macule spots
2. Thick , brittle , yellowed nails
3. Thin skin with purple patches
4. Irregular , raised , crusted lesion Answer: 4. Irregular , raised , crusted lesion
The nurse determines that a resident is fatigued today , so a partial bath would be acceptable in
place of a full bath . Regarding the partial bath , which instructions will the nurse give to the un
licensed assistive personnel ( UAP ) ? 1. " Assist the patient to wash the perineal area and then
the hands . "
2 . " Help the resident wash his face , hands , armpits , and perineal area . "
3 . " Before breakfast , help the resident wash his hands and face . "
4 . " Perform a partial bath on the patient , just for today . " Answer: 2 . " Help the resident wash
his face , hands , armpits , and perineal area . "
The nurse sees that patient is taking a diuretic medication . Which laboratory result is the nurse
most likely to monitor ?
1. Serum potassium
2. Urinalysis results
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,3. Blood glucose
4. Serum calcium Answer: 1. Serum potassium
The nurse is most likely to question the prescription for an enteral feeding tube for which patient
?
1. 68 - year - old patient who was in an auto accident
2. 73 - year - old patient who has advanced dementia
3. 65 - year - old patient who sustained severe burns
4 . 70 - year - old patient who had surgery for lip cancer Answer: 2. 73 - year - old patient who
has advanced dementia
The UAP tells the nurse that for the past 3 days , a thin brown liquid has been oozing from the
resident's rectal area , but there is no formed stool . What would the nurse do first ?
1 . Tell the UAP to assist the resident to the bathroom every 2 hours .
2. Instruct the UAP to continue to change the incontinence pants as needed . 3 . Check the
resident for a fecal impaction and assess the surrounding skin . 4. Obtain an order for a stool
hemoccult and culture and sensitivity . Answer: 3 . Check the resident for a fecal impaction and
assess the surrounding skin .
The patient retired years ago . He was very involved with community , family , and friends, but
now appears content to spend more time alone and others support his privacy. Which theory of
aging most directly explains his behavior?
1. Disengagement theory
2. Exchange theory
3. Continuity theory
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, 4 . Activity theory Answer: 1. Disengagement theory
Which nurse is most likely to need an extensive knowledge and understanding of the Patient
Self-Determination Act?
1. Nurse A helps patients and families understand Medicare benefits
2. Nurse B cares for patients and families during end of life
3. Nurse C works at an outpatient surgical and diagnostic center
4. Nurse D counsels older people at a community senior citizen center Answer: 2. Nurse B cares
for patients and families during end of life
The patient has a history of peripheral vascular disease. Which symptom is the cause for greatest
concern?
1 . Gradual and progressive edema going up both legs
2 . Excessive warmth of the leg on the dominant side
3. Sudden onset of a cold foot on the non-dominant side
4 . Cramping of the calf muscles after exertion Answer: 4 . Cramping of the calf muscles after
exertion
The patient is recovering from a stroke , but some residual symptoms continue . Which statement
by a nursing student demonstrates an understanding that precautions need to be taken during
meals ?
1 . " The aphasia improves as the condition improves . "
2. " Dysphagia creates a risk for developing pneumonia . "
3. " Presbyopia will improve with corrective devices . "
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