- Evidence that a sitz bath has been effective would be if the patient reports:
Your answer:
decreased flatulence
decreased bleeding from the area
decreased pain in the immediate area
decreased circulation to the area
- A patient attached to several invasive monitoring devices screams, "This has got to stop. I just have had enough." The most likely cause for this outburst is:
Your answer:
deterioration in patient's condition
impaired oxygenation
drug reaction
sensory overload
- Which statement would be evidence that a 16 year old was experiencing diversional activity deficit?
Your answer:
If I see sliced peaches on my dinner tray one more time, I'm going to scream!
I miss going to the football games with my friends.
I'm bored. There's nothing to do here.
I hope I don't fall too far behind in school.
- A patient who speaks very little English has just been admitted. The most appropriate nursing diagnosis would be:
Your answer:
anxiety related to unfamiliar environment
knowledge deficit related to inability to read written instructions
impaired communication related to language barrier
impaired social interactions related to language barrier
- Why should the nurse bend her knees before lifting or moving a patient?
Your answer:
prevent strain on the knees during lifting
lower the center of gravity
increase strength for movement
provide wider base of support
- Your patient has recently been diagnosed as having a hearing impairment. The family should be instructed to:
Your answer:
whisper in his better ear
speak loudly, using very simple direct instructions
speak clearly in short, clear sentences
write down all communications
- A child, suffering from a sleep pattern disturbance, is being discharged from the hospital. It is most important to teach the child and the parents that it is important to:
Your answer:
adhere closely to established bedtime rituals
get regular exercise
plan bedtime snacks which contain a warm beverage
allow the child to take naps as needed
- Which of the following nursing techniques requires strict surgical aseptic technique?
Your answer:
administration of gastric lavage
removal of the old dressing from a draining wound
instillation of a tube feeding by gravity
insertion of an intravenous catheter
- What is the best nursing intervention to prevent foot drop in a bedfast patient?
Your answer:
foot board
range of motion
bed cradle
knee gatch
- When positioning a patient in the right lateral Sim's position, where should pillows be placed?
Your answer:
under the head and left knee
under the head, left arm and left knee
under the head and left arm
under the head
- Which position is best for a comatose patient?
Your answer:
side-lying
prone
trendelenburg
supine
- As a nurse, you know that:
Your answer:
seizures in a small child can usually be well controlled by Dilantin (phenytoin)
epilepsy is the usually the underlying cause of seizures in a small child
an elevating temperature can lead to seizures in a small child
children who have seizures usually have seizures as an adult
- The most reliable indicator of a patient's true feelings is:
Your answer:
nonverbal clues (body language)
what he tells the nurse
the order in which he lists his complaints
what he tells the doctor
- The most common symptom of sleep apnea is:
Your answer:
loud snoring
frequent awakening during the night
rapid, shallow respirations followed by periods of apnea
fear of falling asleep
- Which physiologic change would you most expect to happen under stress?
Your answer:
urinary output is increased
blood pressure decreases
heart rate increases
pupils constrict
- A 17 year old girl was in a car accident and is hospitalized 80 miles from home. Six of her girlfriends have driven to visit her but there is only five minutes left before visiting hours end. What do you, as her nurse, do?
Your answer:
let them all visit for 30 minutes as long as they keep the door closed.
let them all visit for the last five minutes.
tell them he is too sick to have visitors.
only let one friend visit.
- Parents should be taught to administer ear drops to a three year old by:
Your answer:
pull the ear up and forward
pull the ear down and back
pull the ear down and forward
pull the ear up and back
- When administering eye drops, why is slight pressure applied to the lower conjunctiva?
Your answer:
to keep the medication out of the pupil
to enhance absorption
to close the nasolacrimal duct and keep the medication from running out of the eye and down the duct.
to press the medication into the scleral sac
- Which statement is evidence that your patient teaching has been effective regarding administration of eye ointments?
Your answer:
"I will discard the first bead of eye ointment before applying the dose."
"I will firmly squeeze my eye shut immediately after applying the ointment."
"I will apply the ointment starting from the outer edge of my eye in to toward my nose."
"I will rest the tip of the tube on my lower eye lid to make sure the ointment goes into the proper location."
- After successfully coping with a stressful event, glucose level usually:
Your answer:
remain the same because the glucose level is unaffected by stress
stays increased for about 24 hours
is below normal for 8-12 hours
returns to normal
- During stress, what typically happens to your glucose level?
Your answer:
decreased slightly
increased slightly
not affected by stress
decreases significantly
- Which chemical is released during an inflammatory response?
Your answer:
histamine
dopamine
antihistamine
chemotaxis
- An undesirable side effect from taking anti-inflammatory medications is:
Your answer:
decreased immune response
increased appetite
nervousness and irritability
antipyretic
- Prolonged and/or severe stress can lead to which serious complication?
Your answer:
diaphoresis
increased heart rate
decreased urinary output
decreased immune response
- A six month old would most likely be working on which motor activity?
Your answer:
walking with assistance
holding head erect
sitting up
grasping tiny objects between thumb and forefinger
- The best way to determine the religious and cultural preferences of a patient is to:
Your answer:
ask him
ask his spouse or family members
ask a chaplain to visit
ask a co-worker of the same faith
- What is the best source of patient history information?
Your answer:
patient's medical record
patient's family
patient himself
patient's physician
- Which statement reflects that your patient teaching regarding safety recommendations about caring for an elderly person has been ineffective?
Your answer:
"I have put throw rugs down on all the bare floors of mother's apartment to keep her feet warm this winter."
"I have purchased a pair of slippers with rubber soles for Mother."
"I have tightened the hand rails in the bathroom beside the toilet and in the bathtub."
"I have installed a night light in the hallway and in the bathroom."
- Your patient states, "I've been independent all my life. I don't want to be a burden to anyone." She is experiencing:
Your answer:
anger
conflict resolution
depression
anticipatory grieving
- Your patient, an elderly woman, is preparing to be transferred to a nursing home. She says "I don't feel all that bad. All I want to do is just go home." Your most therapeutic response would be:
Your answer:
"You'll meet lot's of nice new friends there. You'll see."
"You can't go home right now and you know it. It's for the best."
"The nursing home will take good care of you."
"You must be feeling very stressed right now."
- A man reveals to the nurse that he has been cheating on his wife for the past five years. He says, "Should I tell my wife?" The most non-therapeutic answer you can give is:
Your answer:
"Yes, you should tell your wife. Lying in marriage is never a good thing."
"You are considering telling your wife?"
"Have you discussed this situation with your pastor or a trusted friend?"
"Considering a decision like that must be very difficult for you."
- The purpose of a directive interview is intended to:
Your answer:
get answers to a specific set of questions.
determine the underlying cause of the present illness.
assist the patient to get in touch with his inner feelings.
obtain the patient's perspective regarding his symptoms and his present illness.
- The purpose of the working phase of nurse relationship is primarily to:
Your answer:
to set realistic goals and initiate a plan of action
minimize the guilt and fear of terminating the relation ship
establish a relationship and set boundaries
try out new ideas and possibilities for solutions to problems
- Which of the following should happen in the orientation phase of the nurse/client relationship?
Your answer:
the nurse should define her role
coping measures should be re-evaluated
patient should try on various "roles" to determine the most effective one
new ideas should be tested
- A patient has been in a working relationship with a nurse during his week's hospitalization. The statement best reflects that the patient has successfully progressed past the termination phase of the relationship?
Your answer:
No one in my family will ever be able to replace you.
I just hope I will be able to get by without talking to you every day.
I will be back to see you next Saturday.
Thank you for all your help. I really appreciate it.
- The method that is most effective at promoting communication when dealing with a patient with speech impairment is:
Your answer:
do not interrupt him as he attempts to speak
minimize background noise
finish words and thoughts for him to minimize frustration
talk loudly, clearly and distinctly to promote understanding
- Which hospitalized patient is most at risk for physical injury?
Your answer:
40 year old with no side rails up
75 year old with two side rails up
6 mo old in a crib
2 year old in a crib
- Your 75 year old male patient begins to hyperventilate and experiences tachycardia after the doctor has been in to visit him. The most therapeutic intervention you could initiate would be to:
Your answer:
notify the physician and ask for an order for a sedative.
promote a diversional activity to help him to redirect the focus of his attention.
offer to call a family member or his pastor.
talk with him and encourage him to express his feelings.
- Which type of soak would you expect to put on an open, draining wound?
Your answer:
hot, dry
cool, dry
warm, moist
cool, moist
- Your patient is being discharged with a prescription for a sedative. What information should you include in your discharge instructions?
Your answer:
only take the medication if all other coping measures have failed
sedatives can be addictive and should be discontinued as soon as possible
if drowsiness occurs, the physician should be notified
do not drink alcohol
- Your patient is being discharged to home even though his has not quite healed. It would be most important to include information about:
Your answer:
alternative methods for pain relief.
exercises to promote return of normal bowel function.
sources from which he can purchase necessary dressing supplies.
symptoms of infection.
- As you walk into the room, the patient angrily screams, "No one has been in here to check on me for over 30 minutes. I could have died." You know that this outburst is most likely:
Your answer:
a direct attack on the nurse's professional abilities.
a side effect from medications.
an expression of assertive behavior.
an expression of feelings of helplessness.
- You have been counseling a patient with a sleep disturbance. Which statement is evidence that your counseling has not been successful?
Your answer:
"I have increased the amount of daily exercise I get."
"I sleep long hours on my day off."
"I drink warm milk before I go to bed."
"I use relaxation techniques every night."
- Drinking warm milk at night is a natural aid to promote sleep because:
Your answer:
warm fluid minimizes the action of the gastrointestinal tract, promoting sleep.
the warmth promotes relaxation.
warm milk stimulates the release of the amino acid tryptophan.
it stimulates the release of natural endorphins which cause drowsiness.
- Administration of an antipyretic drug given for hyperpyrexia has been effective if which finding is present?
Your answer:
respirations are easy and quiet
normal body temperature
flatulence is reduced
normal heart rate
- Which statement best explains the theoretical basis for obtaining a CBC with a differential count?
Your answer:
The type of infecting agent can be determined.
The antibiotic to which the infecting agent is most sensitive can be determined.
The number of each variety of red blood cells sometimes can offer clues to a diagnosis.
The number of each variety of leukocytes sometimes can offer clues to a diagnosis.
- Which of the following would be evidence of a systemic infection?
Your answer:
erythema
localized edema
pain at the site of infection
increased body temperature
- The nursing diagnosis of impaired skin integrity would be most appropriate for a patient with which finding?
Your answer:
excoriation under the breast
inflammation of the ischial spines
edema of the coccyx
erythema of the scapulae
- Increased serum calcium levels in an immobile patient are most likely the result of:
Your answer:
bone demineralization
disruption of normal kidney function
decreased intake of vitamin D
increased intake of milk and milk products
- Which statement is true regarding sedimentation rate?
Your answer:
increases in sedimentation rate may indicate congenital heart disease
increases in sedimentation rate may indicate inflammation
decreases in sedimentation rate may indicate infection
decreases in sedimentation rate indicate improvement in polycythemia