Concept-Based Assessment Online Practice A Level 2
1. A hospice nurse is caring for a preschooler who has a terminal illness. One of the
child's parents tells the nurse that it is too difficult to cope any longer and has
decided to move out of the house. Which of the following responses should the nurse
make Ans: A: "Let's talk about a few ways you have dealt with stress in the past."
Rationale:This statement by the nurse combines two therapeutic responses, active listening
and focusing. Used together, these techniques facilitate communication by letting the
parent know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
2. A nurse is teaching a client ways to prevent osteoporotic fractures due to
osteoporosis. Which of the following information should the nurse include in the
teaching Ans: A: "Maintain bone health by eating fruits, vegetables, and protein."
Rationale: The nurse should instruct the client that the best way to maintain bone health
and bone remodeling is by eating fruits, vegetables, and protein.
3. A nurse is teaching a client who has hypothyroidism about taking levothy- roxine.
Which of the following statements should the nurse make Ans: B: "This medication
causes adverse effects if the dosage is too high or too low." Rationale: The nurse should
instruct the client that levothyroxine, in the right dosage, does not typically cause adverse
,effects. If the dosage is too low, the manifestations of hypothyroidism will recur. If the
dosage is too high, the manifestations of hyperthy- roidism will occur.
4. A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic
IV fluids. Which of the following findings should the nurse identify as an indication
that the treatment is effective Ans: D: Brisk skin turgor Rationale: The nurse should
expect the child to have brisk skin turgor if fluid replacement therapy is effective.
5. A nurse is caring for a client who has left hemiparesis following a stroke. Which of
the following actions should the nurse take Ans: B: Encourage the client to use wide-
grip utensils when eating with the right hand. Rationale: The nurse should encourage the
client who has hemiparesis to use wide-grip utensils when eating with the right hand,
which can accommodate a weak grasp and encourage independence in eating.
6. A nurse is teaching about herbal supplements with a group of newly li- censed
nurses. Which of the following herbal supplements should the nurse include in the
teaching for treating hyperlipidemia Ans: D: Garlic Rationale: The nurse should include
that garlic can help improve cholesterol levels, which then helps
,to reduce the buildup of plaque in the arteries. For some clients, it can also help lower
blood pressure
7. A nurse is admitting a client who has an acute bacterial wound infection and a
temperature of 39.8° C (103.6° F). Which of the following actions should the nurse
take Ans: D: Set the temperature of the client's room to 22.2° C (72°). Rationale: The nurse
should set the temperature of the client's room at 21° C to 27° C (70° F to 80° F). This
promotes a reduction in the client's fever without causing shivering. By combining
nonpharmacological interventions with antipyretics, the nurse can reduce the client's fever.
8. A nurse is planning care for a client who had surgery for osteomyelitis from a past
musculoskeletal trauma to the lower leg. Which of the following inter- ventions
should the nurse include in the plan of care Ans: C: Check for paresthesia of the affected
leg. Rationale: The nurse should include in the interventions to check for paresthesia, such
as a tingling sensation of the leg and foot, which can indicate manifestations of
neurovascular compromise or compartment syndrome.
9. A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider Ans: - B:
Presence of strabismus Rationale: The nurse should recognize that the presence of
strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not
corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report
, this finding to the provider.
10. A nurse is teaching a client who has atherosclerosis about self-care.Which of the
following instructions should the nurse include in the teaching Ans: C: Increase fiber
intake to at least 30 g per day. Rationale: The nurse should instruct the client to increase
daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the
development of atherosclerosis.
11. A nurse is assessing a client who has as an ulcer due to peripheral vascular
disease. Which of the following findings should the nurse identify as an indication that
the client has a venous ulcer rather than an arterial ulcer Ans: B: Discoloration and
edema of the right ankle Rationale: The nurse should identify that manifestations of
peripheral venous disease include discoloration and edema of the ankle, resulting from
venous hypertension.
12. A nurse is providing discharge teaching to a client who is postoperative fol- lowing a
transurethral resection of the prostate (TURP) for treatment of benign prostatic
hyperplasia. Which of the following instructions should the nurse include in the
teaching Ans: D: "Perform Kegel exercises several times throughout the day." Rationale:
The nurse should instruct the client on the performance of Kegel exercises, or tightening and
then relaxing the urinary sphincter, to assist the client in
1. A hospice nurse is caring for a preschooler who has a terminal illness. One of the
child's parents tells the nurse that it is too difficult to cope any longer and has
decided to move out of the house. Which of the following responses should the nurse
make Ans: A: "Let's talk about a few ways you have dealt with stress in the past."
Rationale:This statement by the nurse combines two therapeutic responses, active listening
and focusing. Used together, these techniques facilitate communication by letting the
parent know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
2. A nurse is teaching a client ways to prevent osteoporotic fractures due to
osteoporosis. Which of the following information should the nurse include in the
teaching Ans: A: "Maintain bone health by eating fruits, vegetables, and protein."
Rationale: The nurse should instruct the client that the best way to maintain bone health
and bone remodeling is by eating fruits, vegetables, and protein.
3. A nurse is teaching a client who has hypothyroidism about taking levothy- roxine.
Which of the following statements should the nurse make Ans: B: "This medication
causes adverse effects if the dosage is too high or too low." Rationale: The nurse should
instruct the client that levothyroxine, in the right dosage, does not typically cause adverse
,effects. If the dosage is too low, the manifestations of hypothyroidism will recur. If the
dosage is too high, the manifestations of hyperthy- roidism will occur.
4. A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic
IV fluids. Which of the following findings should the nurse identify as an indication
that the treatment is effective Ans: D: Brisk skin turgor Rationale: The nurse should
expect the child to have brisk skin turgor if fluid replacement therapy is effective.
5. A nurse is caring for a client who has left hemiparesis following a stroke. Which of
the following actions should the nurse take Ans: B: Encourage the client to use wide-
grip utensils when eating with the right hand. Rationale: The nurse should encourage the
client who has hemiparesis to use wide-grip utensils when eating with the right hand,
which can accommodate a weak grasp and encourage independence in eating.
6. A nurse is teaching about herbal supplements with a group of newly li- censed
nurses. Which of the following herbal supplements should the nurse include in the
teaching for treating hyperlipidemia Ans: D: Garlic Rationale: The nurse should include
that garlic can help improve cholesterol levels, which then helps
,to reduce the buildup of plaque in the arteries. For some clients, it can also help lower
blood pressure
7. A nurse is admitting a client who has an acute bacterial wound infection and a
temperature of 39.8° C (103.6° F). Which of the following actions should the nurse
take Ans: D: Set the temperature of the client's room to 22.2° C (72°). Rationale: The nurse
should set the temperature of the client's room at 21° C to 27° C (70° F to 80° F). This
promotes a reduction in the client's fever without causing shivering. By combining
nonpharmacological interventions with antipyretics, the nurse can reduce the client's fever.
8. A nurse is planning care for a client who had surgery for osteomyelitis from a past
musculoskeletal trauma to the lower leg. Which of the following inter- ventions
should the nurse include in the plan of care Ans: C: Check for paresthesia of the affected
leg. Rationale: The nurse should include in the interventions to check for paresthesia, such
as a tingling sensation of the leg and foot, which can indicate manifestations of
neurovascular compromise or compartment syndrome.
9. A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider Ans: - B:
Presence of strabismus Rationale: The nurse should recognize that the presence of
strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not
corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report
, this finding to the provider.
10. A nurse is teaching a client who has atherosclerosis about self-care.Which of the
following instructions should the nurse include in the teaching Ans: C: Increase fiber
intake to at least 30 g per day. Rationale: The nurse should instruct the client to increase
daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the
development of atherosclerosis.
11. A nurse is assessing a client who has as an ulcer due to peripheral vascular
disease. Which of the following findings should the nurse identify as an indication that
the client has a venous ulcer rather than an arterial ulcer Ans: B: Discoloration and
edema of the right ankle Rationale: The nurse should identify that manifestations of
peripheral venous disease include discoloration and edema of the ankle, resulting from
venous hypertension.
12. A nurse is providing discharge teaching to a client who is postoperative fol- lowing a
transurethral resection of the prostate (TURP) for treatment of benign prostatic
hyperplasia. Which of the following instructions should the nurse include in the
teaching Ans: D: "Perform Kegel exercises several times throughout the day." Rationale:
The nurse should instruct the client on the performance of Kegel exercises, or tightening and
then relaxing the urinary sphincter, to assist the client in
