,NUR155/NUR 155 Foundations of Nursing Exam 3 |
Galen College | 2026/2027 Edition (PDF)
1. Which of the following best describes the concept of "sensoristasis"?
A) A state of optimal arousal and alertness
B) The ability to perceive an object by touch alone
C) A state of extreme drowsiness
D) The permanent shortening of muscle tissue
Correct Answer: A state of optimal arousal and alertness
Rationale: Sensoristasis refers to a person's state of optimal arousal, where the individual is alert and
able to respond appropriately to stimuli. This is distinct from somnolence (extreme drowsiness),
stereognosis (the ability to perceive objects by touch), and contractures (permanent muscle shortening).
2. A nurse is caring for a patient who is somnolent. Which of the following best describes the patient's
level of consciousness?
A) The patient is alert and oriented
B) The patient is extremely drowsy but responds to stimuli
C) The patient is unresponsive to all stimuli
D) The patient is confused and disoriented
Correct Answer: The patient is extremely drowsy but responds to stimuli
Rationale: Somnolence is a state of extreme drowsiness in which the patient can be aroused and will
respond to stimuli. This is a decreased level of consciousness but not as severe as unresponsiveness.
Acute confusion (delirium) and chronic confusion (dementia) are different conditions.
3. A patient who is unable to recognize objects by touch alone, despite having intact sensory pathways,
is experiencing:
A) Agnosia
,B) Stereognosis
C) Proprioception
D) Kinesthesia
Correct Answer: Agnosia
Rationale: Agnosia is the loss of the ability to recognize objects through a particular sense, such as
touch, even though the sensory pathways are intact. Stereognosis is the normal ability to perceive
objects by touch, proprioception is awareness of body position, and kinesthesia is awareness of body
movement.
4. What is the primary purpose of using a gait belt when transferring a patient?
A) To restrain the patient during the transfer
B) To provide a secure grip for the nurse and control the patient's center of gravity
C) To lift the patient completely off the bed
D) To assess the patient's muscle strength
Correct Answer: To provide a secure grip for the nurse and control the patient's center of gravity
Rationale: A gait belt provides the nurse with a secure grip and control during a transfer, reducing the
risk of a fall by helping to manage the patient's center of gravity. It is not a restraint, is not used to lift
the patient entirely, and is not primarily an assessment tool for muscle strength.
5. According to standard fall prevention protocols, which of the following interventions should be
implemented for a patient at high risk for falls?
A) Keep all four side rails raised at all times
B) Place the bed in the lowest position with the brakes locked
C) Restrict the patient to bed rest without bathroom privileges
D) Position the call light out of the patient's immediate reach
Correct Answer: Place the bed in the lowest position with the brakes locked
, Rationale: Keeping the bed in the lowest position with the brakes locked is a key fall prevention
intervention. All four side rails up is considered a restraint and can increase fall risk, and the call light
should always be within the patient's reach.
6. A nurse is applying physical restraints to a patient. Which of the following actions is essential to
include in the patient's plan of care?
A) Apply the restraint tightly to prevent the patient from removing it
B) Secure the restraint to the side rail of the bed
C) Perform neurovascular and skin assessments at least every 2 hours
D) Document the type of restraint used but not the reason for its use
Correct Answer: Perform neurovascular and skin assessments at least every 2 hours
Rationale: When a patient is in restraints, the nurse must perform neurovascular and skin checks at least
every 2 hours to prevent injury. Restraints should be applied loosely enough to allow circulation and
movement, secured to the bed frame (not the side rail), and the reason for use must be documented.
7. Which of the following is a correct statement about the use of physical restraints in a healthcare
setting?
A) Restraints should be used as a first-line intervention for patient safety
B) A physician's order is required before applying restraints in an emergency
C) Restraints can be applied by any healthcare worker without specific training
D) The least restrictive device should be selected and used for the shortest duration possible
Correct Answer: The least restrictive device should be selected and used for the shortest duration
possible
Rationale: The principle of using the least restrictive restraint is a fundamental ethical and legal
guideline. Restraints should never be a first-line intervention, require a physician's order (except in
emergencies where a time-limited order is obtained), and should be applied only by trained personnel.
Galen College | 2026/2027 Edition (PDF)
1. Which of the following best describes the concept of "sensoristasis"?
A) A state of optimal arousal and alertness
B) The ability to perceive an object by touch alone
C) A state of extreme drowsiness
D) The permanent shortening of muscle tissue
Correct Answer: A state of optimal arousal and alertness
Rationale: Sensoristasis refers to a person's state of optimal arousal, where the individual is alert and
able to respond appropriately to stimuli. This is distinct from somnolence (extreme drowsiness),
stereognosis (the ability to perceive objects by touch), and contractures (permanent muscle shortening).
2. A nurse is caring for a patient who is somnolent. Which of the following best describes the patient's
level of consciousness?
A) The patient is alert and oriented
B) The patient is extremely drowsy but responds to stimuli
C) The patient is unresponsive to all stimuli
D) The patient is confused and disoriented
Correct Answer: The patient is extremely drowsy but responds to stimuli
Rationale: Somnolence is a state of extreme drowsiness in which the patient can be aroused and will
respond to stimuli. This is a decreased level of consciousness but not as severe as unresponsiveness.
Acute confusion (delirium) and chronic confusion (dementia) are different conditions.
3. A patient who is unable to recognize objects by touch alone, despite having intact sensory pathways,
is experiencing:
A) Agnosia
,B) Stereognosis
C) Proprioception
D) Kinesthesia
Correct Answer: Agnosia
Rationale: Agnosia is the loss of the ability to recognize objects through a particular sense, such as
touch, even though the sensory pathways are intact. Stereognosis is the normal ability to perceive
objects by touch, proprioception is awareness of body position, and kinesthesia is awareness of body
movement.
4. What is the primary purpose of using a gait belt when transferring a patient?
A) To restrain the patient during the transfer
B) To provide a secure grip for the nurse and control the patient's center of gravity
C) To lift the patient completely off the bed
D) To assess the patient's muscle strength
Correct Answer: To provide a secure grip for the nurse and control the patient's center of gravity
Rationale: A gait belt provides the nurse with a secure grip and control during a transfer, reducing the
risk of a fall by helping to manage the patient's center of gravity. It is not a restraint, is not used to lift
the patient entirely, and is not primarily an assessment tool for muscle strength.
5. According to standard fall prevention protocols, which of the following interventions should be
implemented for a patient at high risk for falls?
A) Keep all four side rails raised at all times
B) Place the bed in the lowest position with the brakes locked
C) Restrict the patient to bed rest without bathroom privileges
D) Position the call light out of the patient's immediate reach
Correct Answer: Place the bed in the lowest position with the brakes locked
, Rationale: Keeping the bed in the lowest position with the brakes locked is a key fall prevention
intervention. All four side rails up is considered a restraint and can increase fall risk, and the call light
should always be within the patient's reach.
6. A nurse is applying physical restraints to a patient. Which of the following actions is essential to
include in the patient's plan of care?
A) Apply the restraint tightly to prevent the patient from removing it
B) Secure the restraint to the side rail of the bed
C) Perform neurovascular and skin assessments at least every 2 hours
D) Document the type of restraint used but not the reason for its use
Correct Answer: Perform neurovascular and skin assessments at least every 2 hours
Rationale: When a patient is in restraints, the nurse must perform neurovascular and skin checks at least
every 2 hours to prevent injury. Restraints should be applied loosely enough to allow circulation and
movement, secured to the bed frame (not the side rail), and the reason for use must be documented.
7. Which of the following is a correct statement about the use of physical restraints in a healthcare
setting?
A) Restraints should be used as a first-line intervention for patient safety
B) A physician's order is required before applying restraints in an emergency
C) Restraints can be applied by any healthcare worker without specific training
D) The least restrictive device should be selected and used for the shortest duration possible
Correct Answer: The least restrictive device should be selected and used for the shortest duration
possible
Rationale: The principle of using the least restrictive restraint is a fundamental ethical and legal
guideline. Restraints should never be a first-line intervention, require a physician's order (except in
emergencies where a time-limited order is obtained), and should be applied only by trained personnel.
