Examsrevision

MULTIPLE CHOICE 1. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures. ANS: D The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more abl...

MULTIPLE CHOICE 1. A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene? a. Mechanical lifts are in a locked closet. b. Algorithms for patient handling are available. c. Ergonomic assessment protocols are being followed. d. A no-lift policy is in place with adherence by all staff. ANS: A The nurse will follow up when lifts are not kept in convenient locations. Comprehensive safe patient-handling ...

MULTIPLE CHOICE 1. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the ostomy is physically unattractive. Which initial nursing intervention will be most effective in helping this patient resume sexual activity? a. Inform the patient about a support group for people with colostomies. b. Reassure the patient that lots of people r...

MULTIPLE CHOICE 1. A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient? a. Writing in a journal b. Drinking a little alcohol to go to sleep c. Exercising vigorously rather than sleeping d. Avoiding talking about the deaths with friends ANS: A Coping strategies may be healthy and effective like talking, journaling, and sharing emotions with others. They may also be unhealthy and ineffective...

MULTIPLE CHOICE 1. The nurse and the patient have the same religious affiliation. Which action will the nurse take to support the patient spiritually? a. Must use a formal assessment tool to determine patient’s beliefs. b. Assume that both have the same spiritual beliefs. c. Do not impose personal values on the patient. d. Skip the spiritual belief assessment. ANS: C It is important not to impose personal value systems on the patient. This is particularly true when the patient’s...

MULTIPLE CHOICE 1. A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful? a. “I should let the medication dissolve completely.” b. “I will place the medication in the same location.” c. “I can only drink water, not juice, with this medication.” d. “I better chew my medication first for faster distribution.” ANS: A Buccal medications should be placed in the side of the cheek and...

MULTIPLE CHOICE 1. Which individual is most likely to need the nurse’s assistance in coping with identity confusion? a. A 49-year-old male with stable employment b. A 35-year-old recently divorced mother of twins c. A 22-year-old in the third year of college d. A 50-year-old self-employed woman ANS: B Identity confusion results when people do not maintain a clear, consistent, and continuous consciousness of personal identity. A newly divorced woman would be trying to adapt to a ne...

MULTIPLE CHOICE 1. A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? a. Shaman b. Vitalist c. Ayurvedic d. Curanderismo ANS: A Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness a...

Chapter 26: Informatics and Documentation Chapter 27: Patient Safety and Quality Chapter 28: Infection Prevention and Control Chapter 29: Vital Signs Chapter 30: Health Assessment and Physical Examination

MULTIPLE CHOICE 1. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a. Touching clean protective eyewear b. Standing with hands above waist area c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open ANS: A Touching nonsterile (clean) protective eyewear once gowned and gloved wi...

MULTIPLE CHOICE 1. A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment? a. Assess the area that is most tender first. b. Ask the patient about the color of her stools. c. Recommend that the patient take more laxatives. d. Avoid sexual references such as possible pregnancy. ANS: B Abdominal pain can be related to bowels. If stools are black or tarry (melena), this may i...

Chapter 21: Managing Patient Care Chapter 22: Ethics and Values Chapter 23: Legal Implications in Nursing Practice Chapter 24: Communication Chapter 25: Patient Education

MULTIPLE CHOICE 1. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions. ANS: D Negative chronotropic drugs such as di...

MULTIPLE CHOICE 1. A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority to assist learning? a. Assess laboratory results for high cholesterol and other data. b. Identify that teaching is the same as the nursing process. c. Perform nursing care therapies to address hypertension. d. Focus on a patient’s learning needs and objectives. ANS: D The teaching process focuses on the patient’s learning needs, mo...

MULTIPLE CHOICE 1. Which activity will increase the need for the nurse to monitor for equipment-related accidents? a. Using a patient-controlled analgesic pump b. Making an entry in a computer-based documentation record c. Using a plastic measuring device to accurately measure urine d. Removing medications from a manual medication-dispensing device ANS: A Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard....

MULTIPLE CHOICE 1. A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Clinical decision support system b. Admission nursing history c. Mode of transportation d. SOAP notes ANS: C List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary...

MULTIPLE CHOICE 1. A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics ANS: D Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is ignored or invisible. Deontology refers to making decisions or “right-making charact...

MULTIPLE CHOICE 1. A patient was admitted 2 days ago with a diagnosis of pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for “B” when using SBAR? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S)...

Chapter 16: Nursing Assessment Chapter 17: Analysis and Nursing Diagnosis Chapter 18: Planning and Outcomes Identification in Nursing Care Chapter 19: Implementing Nursing Care Chapter 20: Evaluation

MULTIPLE CHOICE 1. While recovering from a severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. Which response by the nurse is most appropriate? a. “Check with your admitting health care provider whether a copy is on your chart.” b. “Let me check with someone here in the hospital who can assist you.” c. “You are not allowed to ever change a living will after signing it.” d. “Your living will can be changed only once each calend...