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1. A mother rescues two of her four children from a house fire. In the
emergency department, she cries, "I should have gone back in to get them. I
should have died, not them." What is the nurse's best response?
a. "The smoke was too thick. You couldn't have gone back in."
b. "You're feeling guilty because you weren't able to save your children."
c. "Focus on the fact that you could have lost all four of your children."
d. "It's best if you try not to think about what happened. Try to move
on." - Correct Answer: B (The best response by the nurse is,
"You're experiencing feelings of guilt because you weren't able to
save your children." This response utilizes the therapeutic
communication technique of reflection which identifies a client's
emotional response and reflects these feelings back to the client so
that they may be recognized and accepted.)
2. Which of the following are examples of objective data? (Select all that
apply.)
a. When asked to report their pain on a scale from 0 to 10, the patient
reports a 6.
b. The patient's liver is non palpable.
c. The patient's scalp is round, symmetrical, and no bumps or lumps are
present.
d. The patient has had frequent headaches for the past few weeks.
, e. The patient's tympanic membrane is a pearly/gray white. -
Correct Answer: B C E
3. The nurse is helping a patient with hemiparesis take a few steps. A gait belt
has been applied. The patient is using a cane. Where should the nurse stand
in relation to the patient?
A. On the patient's strong side
B. On the patient's weak side
C. Behind the patient
D. In front of the patient - Correct Answer: B
4. The nurse is preparing to delegate the ambulation of a patient with the use
of a gait belt to nursing assistive personnel (NAP). Which statement made
by NAP requires the nurse to follow up?
A. "I will be sure to put nonskid slippers on the patient before
getting him up to ambulate."
B. "I will use the under-axillae technique to help him up to a
standing position."
C. "Rocking the heavier patient into a standing position seems
to work really well for me."
D. "I will grasp the gait belt in the middle of the patient's back."
- Correct Answer: B
5. The nurse is preparing to initiate ambulation with a patient who is
recovering from a stroke. What information will help the nurse determine
how far to walk?
A. Ask the patient how far she would like to go.
B. Review the health care provider's order.
, C. Review the medical record to see how far the patient has
walked during the past several therapeutic ambulations.
D. Review the records of other patients who are at a similar
point in their stroke rehabilitation. - Correct Answer: A
(Setting mutual goals increases the likelihood of success in
achieving the goal of ambulation. The health care provider's
order will only state "ambulate"; it will not specify how far to
ambulate the patient. The patient's circumstances or
condition may not be similar to those he or she undertook
during the past several ambulations. Patient care should be
individualized. The status of other patients in stroke
rehabilitation is not relevant to this patient.)
6. The nurse is ambulating a patient with a gait belt when he says he feels sick
to his stomach. What would the nurse do?
A. Return the patient to the bed or chair (whichever is closer).
B. Encourage the patient to complete the distance of
ambulation.
C. Help him to the restroom.
D. Ease him to the floor. - Correct Answer: A
7. The nurse has applied a gait belt to a postoperative patient to facilitate
ambulation. Within a few feet of the bed, the patient begins to complain of
dizziness and leans heavily on the nurse. What would be the nurse's initial
response?
A. Slowly lower the patient to the floor.
B. Attempt to sit the patient down on a chair just a few steps
away.
C. Try to hold the patient up until the dizziness passes.
, D. Call for assistance in a loud but calm voice. - Correct
Answer: A
8. The nurse is preparing to provide perineal care for a female patient who is
on bed rest. Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent - Correct Answer: D
9. How can the nurse promote infection control while providing perineal care
for a female patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing
it.
C. By cleansing the patient's labia from the pubic area toward
the rectum.
D. By using warm water to cleanse the patient's entire perineal
area. - Correct Answer: C (Cleansing the labia from the
pubic area toward the rectum minimizes the risk of
introducing microorganisms from the rectum to the urethra
and vagina. Although avoiding tension on the catheter is
encouraged in order to prevent its accidental dislodgment,
this precaution does not pertain to infection control. Patting
the skin dry, rather than rubbing it, helps minimize skin
damage, but this action does not pertain to infection control.
Cleansing with soap and water reduces the number of
microorganisms in the perineal area. Using warm water
alone, however, has little effect.)