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Excellence with Expert Solutions and Correct
Responses from Global Authorities
When conducting an admission assessment, the nurse should ask the client about the use
of complimentary healing practices. Which statement is accurate regarding the use of
these practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary
healing practices. Conventional approaches to health care can be depersonalizing and
often fail to take into consideration all aspects of an individual, including body, mind, and
spirit. Often complimentary healing practices can be used in conjunction with
conventional medical practices (C), rather than interfering (A) with conventional practices,
causing adverse effects (B), or replacing conventional medical care (D).
Correct Answer: C
A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first?
A. Sexual activity patterns.
B. Nutritional history.
C. Leisure activities.
D. Financial stressors. Caffeine, sugars, and alcohol can lead to increased levels of
anxiety, so a nutritional history (C) should be obtained first so that health teaching can be
,initiated if indicated. (A and C) can be used for stress management. Though (D) can be a
source of anxiety, a nutritional history should be obtained first.
Correct Answer: B
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is
the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the swelling is diminished (B).
This will help reduce the client's anxiety and promote acceptance of the colostomy. (A)
does not provide helpful teaching or support. (C) is a useful action, and may be taken after
the nurse provides pertinent teaching. The client is not yet demonstrating readiness to
learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
, C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her experiences
with you." (C) displays sensitivity and understanding without judging the client. (A) is
judgmental in that it is telling the client how she feels and is also insensitive. (B) would give
the client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support is not offered, this response could be
interpreted as dismissing the client and avoiding the problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. The nurse signs the consent form to
witness that the client voluntarily signs the consent (A), that the client's signature is
authentic, and that the client is otherwise competent to give consent. It is the healthcare
provider's responsibility to ensure the client fully understands the procedure (B). The
nurse's signature does not indicate (C or D).
Correct Answer: A
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
Excellence with Expert Solutions and Correct
Responses from Global Authorities
When conducting an admission assessment, the nurse should ask the client about the use
of complimentary healing practices. Which statement is accurate regarding the use of
these practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary
healing practices. Conventional approaches to health care can be depersonalizing and
often fail to take into consideration all aspects of an individual, including body, mind, and
spirit. Often complimentary healing practices can be used in conjunction with
conventional medical practices (C), rather than interfering (A) with conventional practices,
causing adverse effects (B), or replacing conventional medical care (D).
Correct Answer: C
A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first?
A. Sexual activity patterns.
B. Nutritional history.
C. Leisure activities.
D. Financial stressors. Caffeine, sugars, and alcohol can lead to increased levels of
anxiety, so a nutritional history (C) should be obtained first so that health teaching can be
,initiated if indicated. (A and C) can be used for stress management. Though (D) can be a
source of anxiety, a nutritional history should be obtained first.
Correct Answer: B
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is
the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the swelling is diminished (B).
This will help reduce the client's anxiety and promote acceptance of the colostomy. (A)
does not provide helpful teaching or support. (C) is a useful action, and may be taken after
the nurse provides pertinent teaching. The client is not yet demonstrating readiness to
learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
, C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her experiences
with you." (C) displays sensitivity and understanding without judging the client. (A) is
judgmental in that it is telling the client how she feels and is also insensitive. (B) would give
the client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support is not offered, this response could be
interpreted as dismissing the client and avoiding the problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. The nurse signs the consent form to
witness that the client voluntarily signs the consent (A), that the client's signature is
authentic, and that the client is otherwise competent to give consent. It is the healthcare
provider's responsibility to ensure the client fully understands the procedure (B). The
nurse's signature does not indicate (C or D).
Correct Answer: A
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
