NUR200 EXAM 2 UPDATED ACTUAL Questions and CORRECT Answers
a. circumscribed, flat, non palpable and less than 1 cm
(THIS IS MACULE)
Which patient is most likely to have a nodule type of lesion, b. circumscribed, elevated, palpable, 1 to 2 cm (THIS IS
based on the assessment findings in the chart? NODULE)
a. circumscribed, flat, non palpable and less than 1 cm c. irregularly shaped, elevated, solid, pale, red in color
b. circumscribed, elevated, palpable, 1 to 2 cm (THIS IS WHEAL)
c. irregularly shaped, elevated, solid, pale, red in color d. flat, elevated, rough to touch, and larger than 1 cm (THIS
d. flat, elevated, rough to touch, and larger than 1 cm IS PLAQUE)
answer: B
The home care nurse assesses a stage I pressure injury
on an older adult patient who has limited mobility from a A. Deliver high protein shakes twice a day
stroke. What should the nurse include when educating the b. exercise extremities every 4 hours
patient's daughter about her care? Select all that apply. c. be sure position is changed at least every 2 hours
A. Deliver high protein shakes twice a day d. keep skin moist and layer sacral area with extra sheet
b. exercise extremities every 4 hours e. use pillows to pad all bony prominences
c. be sure position is changed at least every 2 hours
d. keep skin moist and layer sacral area with extra sheet answer: a, b, c, e
e. use pillows to pad all bony prominences
which is true regarding autolytic wound debridement on a. this method can be used for larger debridement
a wound? select all that apply b. this method can increase the risk of maceration to the
a. this method can be used for larger debridement adjacent skin
b. this method can increase the risk of maceration to the c. this method can be performed in any type of setting
adjacent skin d. this method can be performed on patients who require
c. this method can be performed in any type of setting fast debridement
d. this method can be performed on patients who require e. this method does not cause pain if the dressing is in
fast debridement place
e. this method does not cause pain if the dressing is in
place answer: B, C, E
1. wash hands and apply clean gloves
2. remove soiled
,Arrange the steps to be followed by a nurse when cleaning
wound dressing and discard
and preparing a wound.
3. remove the gloves and wash hands
wash hands and apply clean gloves
4. apply clean gloves and irrigate the wound thoroughly
remove soiled wound dressing and discard
with saline
wipe the surface of the wound with a sterile gauze
5. wipe the surface of the wound with a sterile gauze
remove the excess saline from the wound
6. remove the excess saline from the wound
assess and measure the wound
7. assess and measure the wound
apply clean gloves and irrigate the wound thoroughly with
saline
correct order
remove the gloves and wash hands
The nurse is inspecting the skin and nails of a newly
a. back for acne
admitted patient. Which assessment is priority during ad-
b. scalp for lesions
mission and routinely?
c. pressure points for redness
a. back for acne
d. nails for cleanliness
b. scalp for lesions
c. pressure points for redness
answer: c
d. nails for cleanliness
The nurse is discharging a patient with a wound. What
A. Iron
dietary changes should the nurse suggest be increased
b. B vitamins
to improve wound healing? Select all that apply
c. protein
A. Iron
d. zinc
b. B vitamins
e. vitamin c
c. protein
d. zinc
answer: A, B, C, D, E
e. vitamin c
the nurse is teaching an 80-year-old patient about skin
a. " i should bathe for at least 20 minutes"
care. Which statement made by the patient indicates the
b. "i should use pH balanced soap for cleansing"
need for further learning? Select all that apply.
c. "i should apply moisturizer every other day"
a. " i should bathe for at least 20 minutes"
d. "i should clean the skin immediately after incontinence"
b. "i should use pH balanced soap for cleansing"
e. "i should use skin barrier creams to prevent exposure
c. "i should apply moisturizer every other day"
,d."i should clean the skin immediately after inconti-
to moisture"
nence"
e. "i should use skin barrier creams to prevent exposure
answer: a, c
to moisture"
The nurse is preparing a discharge plan for a 78 year
A. The patient will drive herself home.
old woman. Which likely scenario should the nurse antic-
B. The patient lives in a homeless shelter.
ipate?
C. The patient is a widow and lives alone.
A. The patient will drive herself home.
D. The patient receives a government pension.
B. The patient lives in a homeless shelter.
C. The patient is a widow and lives alone.
answer: c
D. The patient receives a government pension.
The nurse is performing a cardiovascular assessment on
A. Irregular pulse and diminished lung sounds
an older adult patient. Which physical signs of normal
B. Heart rate of 88 bpm and a heart murmur
aging can be expected?
C. Systolic blood pressure of 150 mm Hg and a fourth
A. Irregular pulse and diminished lung sounds
heart sound
B. Heart rate of 88 bpm and a heart murmur
D. Productive cough and hoarseness
C. Systolic blood pressure of 150 mm Hg and a fourth
heart sound
ANSWER: C
D. Productive cough and hoarseness
When assessing the patient with cognitive impairment,
A. Vascular dementia
the nurse should be aware that this is the most common
B. Parkinson's disease
cause of dementia:
A. Vascular dementia C. Alzheimer's disease
D. Multi-infarct dementia
B. Parkinson's disease
C. Alzheimer's disease
ANSWER: C
D. Multi-infarct dementia
The nurse caring for an older adult patient with early signs
A. Altered nutrition, less than nutritional requirements
of dementia incorporates which priority nursing diagnosis
B. Altered nutrition, greater than nutritional requirements
into the plan of care?
C. Risk for injury
A. Altered nutrition, less than nutritional requirements
, B. Altered nutrition, greater than nutritional require-
D. Activity intolerance
ments
C. Risk for injury
ANSWER: C
D. Activity intolerance
While assisting family members in finding resources to
A. Medicare
care for their father, the nurse is aware that this agency
B. Social Security Administration
can provide assistance with nursing home costs.
C. Medicaid
A. Medicare
D. Department of Health and Human Services
B. Social Security Administration
C. Medicaid
ANSWER: C
D. Department of Health and Human Services
The nurse is screening patients for their risk of developing A. Patient with CHF
aspiration. The nurse should consider which patient at B. Patient with type 2 diabetes mellitus
greatest risk? C. Patient receiving tube feedings
A. Patient with CHF D. Patient with COPD
B. Patient with type 2 diabetes mellitus
C. Patient receiving tube feedings ANSWER:
D. Patient with COPD C
The nurse knows that decreased vitamin D absorption A. Skin dryness
predisposes a patient to: B. Gastric ulcers
A. Skin dryness C. Osteoporosis
B. Gastric ulcers D. Venous stasis
C. Osteoporosis
D. Venous stasis ANSWER: C
The nurse monitors for which clinical manifesta- tions of A. Somnolence and fever
the older adult patient diagnosed with delirium? B. Abrupt onset of confusion and hallucinations
A. Somnolence and fever C. Feelings of hopelessness and early morning wakening
B. Abrupt onset of confusion and hallucinations D. Disorientation and word-finding diflculty
C. Feelings of hopelessness and early morning wakening
D. Disorientation and word-finding diflculty ANSWER: B
a. circumscribed, flat, non palpable and less than 1 cm
(THIS IS MACULE)
Which patient is most likely to have a nodule type of lesion, b. circumscribed, elevated, palpable, 1 to 2 cm (THIS IS
based on the assessment findings in the chart? NODULE)
a. circumscribed, flat, non palpable and less than 1 cm c. irregularly shaped, elevated, solid, pale, red in color
b. circumscribed, elevated, palpable, 1 to 2 cm (THIS IS WHEAL)
c. irregularly shaped, elevated, solid, pale, red in color d. flat, elevated, rough to touch, and larger than 1 cm (THIS
d. flat, elevated, rough to touch, and larger than 1 cm IS PLAQUE)
answer: B
The home care nurse assesses a stage I pressure injury
on an older adult patient who has limited mobility from a A. Deliver high protein shakes twice a day
stroke. What should the nurse include when educating the b. exercise extremities every 4 hours
patient's daughter about her care? Select all that apply. c. be sure position is changed at least every 2 hours
A. Deliver high protein shakes twice a day d. keep skin moist and layer sacral area with extra sheet
b. exercise extremities every 4 hours e. use pillows to pad all bony prominences
c. be sure position is changed at least every 2 hours
d. keep skin moist and layer sacral area with extra sheet answer: a, b, c, e
e. use pillows to pad all bony prominences
which is true regarding autolytic wound debridement on a. this method can be used for larger debridement
a wound? select all that apply b. this method can increase the risk of maceration to the
a. this method can be used for larger debridement adjacent skin
b. this method can increase the risk of maceration to the c. this method can be performed in any type of setting
adjacent skin d. this method can be performed on patients who require
c. this method can be performed in any type of setting fast debridement
d. this method can be performed on patients who require e. this method does not cause pain if the dressing is in
fast debridement place
e. this method does not cause pain if the dressing is in
place answer: B, C, E
1. wash hands and apply clean gloves
2. remove soiled
,Arrange the steps to be followed by a nurse when cleaning
wound dressing and discard
and preparing a wound.
3. remove the gloves and wash hands
wash hands and apply clean gloves
4. apply clean gloves and irrigate the wound thoroughly
remove soiled wound dressing and discard
with saline
wipe the surface of the wound with a sterile gauze
5. wipe the surface of the wound with a sterile gauze
remove the excess saline from the wound
6. remove the excess saline from the wound
assess and measure the wound
7. assess and measure the wound
apply clean gloves and irrigate the wound thoroughly with
saline
correct order
remove the gloves and wash hands
The nurse is inspecting the skin and nails of a newly
a. back for acne
admitted patient. Which assessment is priority during ad-
b. scalp for lesions
mission and routinely?
c. pressure points for redness
a. back for acne
d. nails for cleanliness
b. scalp for lesions
c. pressure points for redness
answer: c
d. nails for cleanliness
The nurse is discharging a patient with a wound. What
A. Iron
dietary changes should the nurse suggest be increased
b. B vitamins
to improve wound healing? Select all that apply
c. protein
A. Iron
d. zinc
b. B vitamins
e. vitamin c
c. protein
d. zinc
answer: A, B, C, D, E
e. vitamin c
the nurse is teaching an 80-year-old patient about skin
a. " i should bathe for at least 20 minutes"
care. Which statement made by the patient indicates the
b. "i should use pH balanced soap for cleansing"
need for further learning? Select all that apply.
c. "i should apply moisturizer every other day"
a. " i should bathe for at least 20 minutes"
d. "i should clean the skin immediately after incontinence"
b. "i should use pH balanced soap for cleansing"
e. "i should use skin barrier creams to prevent exposure
c. "i should apply moisturizer every other day"
,d."i should clean the skin immediately after inconti-
to moisture"
nence"
e. "i should use skin barrier creams to prevent exposure
answer: a, c
to moisture"
The nurse is preparing a discharge plan for a 78 year
A. The patient will drive herself home.
old woman. Which likely scenario should the nurse antic-
B. The patient lives in a homeless shelter.
ipate?
C. The patient is a widow and lives alone.
A. The patient will drive herself home.
D. The patient receives a government pension.
B. The patient lives in a homeless shelter.
C. The patient is a widow and lives alone.
answer: c
D. The patient receives a government pension.
The nurse is performing a cardiovascular assessment on
A. Irregular pulse and diminished lung sounds
an older adult patient. Which physical signs of normal
B. Heart rate of 88 bpm and a heart murmur
aging can be expected?
C. Systolic blood pressure of 150 mm Hg and a fourth
A. Irregular pulse and diminished lung sounds
heart sound
B. Heart rate of 88 bpm and a heart murmur
D. Productive cough and hoarseness
C. Systolic blood pressure of 150 mm Hg and a fourth
heart sound
ANSWER: C
D. Productive cough and hoarseness
When assessing the patient with cognitive impairment,
A. Vascular dementia
the nurse should be aware that this is the most common
B. Parkinson's disease
cause of dementia:
A. Vascular dementia C. Alzheimer's disease
D. Multi-infarct dementia
B. Parkinson's disease
C. Alzheimer's disease
ANSWER: C
D. Multi-infarct dementia
The nurse caring for an older adult patient with early signs
A. Altered nutrition, less than nutritional requirements
of dementia incorporates which priority nursing diagnosis
B. Altered nutrition, greater than nutritional requirements
into the plan of care?
C. Risk for injury
A. Altered nutrition, less than nutritional requirements
, B. Altered nutrition, greater than nutritional require-
D. Activity intolerance
ments
C. Risk for injury
ANSWER: C
D. Activity intolerance
While assisting family members in finding resources to
A. Medicare
care for their father, the nurse is aware that this agency
B. Social Security Administration
can provide assistance with nursing home costs.
C. Medicaid
A. Medicare
D. Department of Health and Human Services
B. Social Security Administration
C. Medicaid
ANSWER: C
D. Department of Health and Human Services
The nurse is screening patients for their risk of developing A. Patient with CHF
aspiration. The nurse should consider which patient at B. Patient with type 2 diabetes mellitus
greatest risk? C. Patient receiving tube feedings
A. Patient with CHF D. Patient with COPD
B. Patient with type 2 diabetes mellitus
C. Patient receiving tube feedings ANSWER:
D. Patient with COPD C
The nurse knows that decreased vitamin D absorption A. Skin dryness
predisposes a patient to: B. Gastric ulcers
A. Skin dryness C. Osteoporosis
B. Gastric ulcers D. Venous stasis
C. Osteoporosis
D. Venous stasis ANSWER: C
The nurse monitors for which clinical manifesta- tions of A. Somnolence and fever
the older adult patient diagnosed with delirium? B. Abrupt onset of confusion and hallucinations
A. Somnolence and fever C. Feelings of hopelessness and early morning wakening
B. Abrupt onset of confusion and hallucinations D. Disorientation and word-finding diflculty
C. Feelings of hopelessness and early morning wakening
D. Disorientation and word-finding diflculty ANSWER: B
