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11/6/22, 1:13 AM Fundamentals Final Exam Practice FINAL Flashcards | Quizlet
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Fundamentals Final Exam Practice FINAL

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A nurse assesses patients in a b, e, f. Each person defines health and illness

physician's office who are
individually,
experiencing different levels of based on a number of factors. Health is more than

health and illness. Which
just the
statements best define the absence of illness; it is an active process in which a

concepts of health and illness?
person
Select all that apply.

moves toward one's maximum potential. An illness is
the
a. Health and illness are the response of the person to a disease.
same for all people.
b. Health and illness are Chapter 3

individually defined by each
person.
c. People with acute illnesses

are actually healthy.
d. People with chronic illnesses

have poor health beliefs.
e. Health is more than the

absence of illness.
f. Illness is the response of a

person to a disease.
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Fundamentals Final
The student nurse learns that Exam Practice FINAL
a, c, d. Diabetes, arthritis, and cystic fibrosis are
Study
illnesses are classified as either chronic
acute or chronic. Which are diseases because they are permanent changes
examples of chronic illnesses? caused by irreversible alterations in normal anatomy
and physiology,
and they require patient education along with a

a. Diabetes mellitus
long period of care or support. Pneumonia,
b. Bronchial pneumonia
fractures, and otitis media are acute illnesses
c. Rheumatoid arthritis
because they have a rapid onset of symptoms that
d. Cystic fibrosis
last a relatively short time.
e. Fractured hip
f. Otitis media Chapter 3
Fundamentals Final
Despite a national focus on Exam Practice FINAL
b, c, d, f. National trends in the prevention of health
Study
health promotion, nurses disparities are focused on vulnerable populations,
working with patients in inner- such as racial and ethnic minorities, those living in
city clinics continue to see poverty, women, children, older adults, rural and
disparities in health care for inner-city residents, and people with disabilities and
vulnerable populations. Which special health care needs.
patients would be considered

vulnerable populations? Select Chapter 3
all that apply.
a. A White male diagnosed with

HIV
b. An African American
teenager who is 6 months
pregnant
c. A Hispanic male who has

type II diabetes
d. A low-income family living in

rural America
e. A middle-class teacher living

in a large city
f. A White baby who was born

with cerebral palsy
A nurse has volunteered to c. Giving influenza injections is an example of

give influenza immunizations at primary health promotion and illness prevention.
a local clinic. What level of care

is the nurse demonstrating?
Chapter 3
a. Tertiary
b. Secondary
c. Primary
d. Promotive

b. When people assume the sick role, they define
Study
A nurse's neighbor tells the themselves as ill, seek validation of this experience
nurse, "I have a high from others, and give up normal activities. In stage 1:
temperature, feel awful, and I experiencing symptoms, the first indication of an
am not going to work." What illness usually is recognizing one or more symptoms
stage of illness behavior is the that are incompatible with one's personal definition
neighbor exhibiting?
of health. The stage of assuming a dependent role is
characterized by the patient's decision to accept the
a. Experiencing symptoms
diagnosis and follow the prescribed treatment plan.
b. Assuming the sick role
In the achieving recovery and rehabilitation role, the
c. Assuming a dependent role
person gives up the dependent role and resumes
d. Achieving recovery and normal activities and responsibilities.
rehabilitation
Chapter 3
Which clinic patient is most c. The physical dimension includes genetic

likely to have annual breast
inheritance, age, developmental level, race, and
examinations and gender. These components strongly influence the
mammograms based on the person's health status and health practices. A family
physical human dimension?
history of breast cancer is a major risk factor.
a. Jane, whose her best friend Chapter 3

had a benign breast lump
removed
b. Sarah, who lives in a low-

income neighborhood
c. Tricia, who has a family

history of breast cancer
d. Nancy, whose family

encourages regular physical
examinations
Fundamentals Final Exam Practice

Health promotion activities FINAL
b, c. Tertiary health promotion and disease Study
may occur on a primary, prevention begins after an illness is diagnosed and
secondary, or tertiary level. treated to reduce disability and to help rehabilitate
Which activities are considered patients to a maximum level of functioning. These
tertiary health promotion? activities include providing ROM exercises and
patient teaching for residual limb care. Providing
immunizations and teaching parents how to
a. A nurse runs an immunization childproof their homes and use an appropriate car
clinic in the inner city.
seat are primary health promotion activities.
b. A nurse teaches a patient Providing screenings is a secondary health
with an amputation how to care promotion activity.
for the residual limb.
c. A nurse provides range-of- Chapter 3

motion exercises for a
paralyzed patient.
d. A nurse teaches parents of

toddlers how to childproof
their homes.
e. A school nurse provides

screening for scoliosis for the
students.
f. A nurse teaches new parents

how to choose and use an
infant car seat.
The agent-host-environment a. The interaction of the agent, host, and

model of health and illness is environment creates risk factors that increase the
based on what concept?
probability of disease.
a. Risk factors
Chapter 3
b. Demographic variables
c. Behaviors to promote health
d. Stages of illness
Fundamentals
When providing healthFinal Exam Practice
d. Both theseFINAL
models view health as a dynamicStudy
promotion classes, a nurse uses (constantly
concepts from models of changing state).
health. What do both the

health-illness continuum and Chapter 3
the high-level wellness models
demonstrate?
a. Illness as a fixed point in time
b. The importance of family
c. Wellness as a passive state
d. Health as a constantly
changing state
A nurse follows accepted a. Good personal health enables the nurse to serve
guidelines for a healthy as a role model for patients and families.
lifestyle.
How can this promote health in Chapter 3

others?
a. By being a role model for

healthy behaviors
b. By not requiring sick days

from work
c. By never exposing others to

any type of illness
d. By spending less money on

food
Fundamentals
A female patient who isFinal Exam Practice FINAL
c. The first step when thinking critically about aStudy
receiving chemotherapy for situation is
breast
to identify the purpose or goal of your thinking.
cancer tells the nurse, "The Reassessing the patient helps to discipline thinking
treatment for this cancer is by directing all thoughts toward the goal. Once the
worse than the disease itself. problem is addressed, it is important for the nurse to
I'm not going to come for my judge the adequacy of the knowledge, identify
therapy anymore." The nurse potential problems, use helpful resources, and
responds by using critical critique the decision.
thinking skills to address this

patient problem. Which action Chapter 10
is the first step the nurse would
take in this process?
a. The nurse judges whether

the patient database is
adequate to address the
problem.
b. The nurse considers whether

or not to suggest a counseling
session for the patient.
c. The nurse reassesses the

patient and decides how best
to intervene in her care.
d. The nurse identifies several

options for intervening in the
patient's care and critiques the
merit of each option.

The nursing process ensures FINAL
b, interpersonal. All of the other options are Study
that nurses are person characteristics of the nursing process, but the
centered rather than task conversation and thinking quoted best illustrates the
centered. Rather than simply interpersonal dimension of the nursing process.
approaching a patient to take

vital signs, the nurse thinks, Chapter 10
"How is Mrs. Barclay today?
Are our nursing actions helping
her to achieve her goals? How
can we better help her?" This
demonstrates which
characteristic of the nursing
process?
a. Systematic
b. Interpersonal
c. Dynamic
d. Universally applicable in
nursing situations
Fundamentals
An experienced nurse Final
tells a Exam Practice FINAL
a. Beginning nurses must use nursing knowledge
Study
beginning nurse not to bother and scientific problem solving as the basis of care
studying too hard, since most they give; intuitive problem solving comes with
clinical reasoning becomes years of practice and observation. If the beginning
"second nature" and "intuitive" nurse has an intuition about a patient, that
once you start practicing. What information should be discussed with the faculty
thinking below should underlie member, preceptor, or supervisor. Answer b is
the beginning nurse's incorrect because there is a place for intuitive
response?
reasoning in nursing, but it will never replace
logical, scientific reasoning. Critical thinking is
a. Intuitive problem solving contextual and changes depending on the
comes with years of practice circumstances, not on personal preference.
and observation, and novice

nurses should base their care Chapter 10
on scientific problem solving.
b. For nursing to remain a

science, nurses must continue
to be vigilant about stamping
out intuitive reasoning.
c. The emphasis on logical,

scientific, evidence-based
reasoning has held nursing
back for years; it's time to
champion intuitive, creative
thinking!
d. It's simply a matter of

preference; some nurses are
logical, scientific thinkers, and
some are intuitive, creative
thinkers.

The nurse uses blended FINAL
a, d. Using critical thinking and learning medication
Study
competencies when caring for dosages are cognitive competencies. Performing
patients in a rehabilitation procedures correctly is a technical skill, helping a
facility. Which examples of patient with an informed consent form is a
interventions involve cognitive legal/ethical issue, and comforting a patient is an
skills? Select all that apply.
interpersonal skill.
a. The nurse uses critical Chapter 10

thinking skills to plan care for a
patient.
b. The nurse correctly

administers IV saline to a
patient who is dehydrated.
c. The nurse assists a patient to

fill out an informed consent
form.
d. The nurse learns the correct

dosages for patient pain
medications.
e. The nurse comforts a mother

whose baby was born with
Down syndrome.
f. The nurse uses the proper

procedure to catheterize a
female patient.

A nurse uses critical thinking FINAL
b, c, e. Critical thinking applied to clinical reasoning
Study
skills to focus on the care plan and judgment in nursing practice is guided by
of an elderly patient who has standards, policies and procedures, and ethics
dementia and needs placement codes. It is based on principles of nursing process,
in a long-term care facility. problem solving, and the scientific method. It
Which statements describe carefully identifies the key problems, issues, and
characteristics of this type of risks involved, and is driven by patient, family, and
critical thinking applied to community needs, as well as nurses' needs to give
clinical reasoning? Select all competent, efficient care. It also calls for strategies
that apply.
that make the most of human potential and
compensate for problems created by human nature.
a. It functions independently of It is constantly re evaluating, self-correcting, and
nursing standards, ethics, and striving to improve (Alfaro-LeFevre, 2014).
state practice acts.
b. It is based on the principles Chapter 10

of the nursing process,
problem solving, and the
scientific method.
c. It is driven by patient, family,

and community needs as well
as nurses' needs to give
competent, efficient care.
d. It is not designed to
compensate for problems
created by human nature, such
as medication errors.
e. It is constantly re-evaluating,
self-correcting, and striving for
improvement.
f. It focuses on the big picture

rather than identifying the key
problems, issues, and risks
involved with patient care.

A nurse is caring for a patient FINAL involves routinely updating
c. Quality improvement Study
who has complications related nursing policies and procedures. Providing patient
to type 2 diabetes mellitus. The centered care involves listening to the patient and
nurse researches new demonstrating respect and compassion. Evidence-
procedures to care for foot based practice is used when adhering to internal
ulcers when developing a plan policies and standardized skills. The nurse is
of care for this patient. Which employing informatics by using information and
QSEN competency does this technology to communicate, manage knowledge,
action represent?
and support decision making.
a. Patient-centered care
Chapter 10
b. Evidence-based practice
c. Quality improvement
d. Informatics
a. Although all the options refer to the skills used by

nurses in practice, the best choice is clinical
A nurse is assessing a 15-year-
judgment as it refers to the result or outcome of
old female patient who is
critical thinking or clinical reasoning—in this case the

diagnosed with anorexia.
recommendation to meet with a nutritionist. Clinical
Following the assessment, the
reasoning usually refers to ways of thinking about

nurse recommends that the
patient care issues (determining, preventing, and
patient meet with a nutritionist.
managing patient problems). Critical thinking is a
This action best exemplifies the
broad term that includes reasoning both outside
use of:
and inside of the clinical setting. Blended

competencies are the cognitive, technical,
a. Clinical judgment
interpersonal, and ethical/legal skills combined with

b. Clinical reasoning
the willingness to use them creatively and critically

c. Critical thinking
when working with patients.
d. Blended competencies
Chapter 10

d. Swanson (1991) identifies five caring processes
Study
and
defines caring as "a nurturing way of relating to a

valued other toward whom one feels a personal
A nurse working in a long-term sense of commitment and responsibility. Travelbee
care facility bases patient
(1971), an early nurse theorist, developed the
care on five caring processes: Human-to-Human Relationship Model and defined
knowing, being with, doing for, nursing as an interpersonal process whereby the
enabling, and maintaining professional nurse practitioner assists an individual,
belief. This approach to patient family, or community to prevent or cope with the
care best describes the theory experience of illness and suffering, and if necessary
of which theorist?
to find meaning in these experiences. Benner and
Wrubel (1989) write that caring is a basic way of
a. Travelbee
being in the world and that caring is central to
b. Watson
human expertise, curing, and healing. Watson's
c. Benner
theory is based on the belief that all humans are to
d. Swanson be valued, cared for, respected, nurtured,
understood, and assisted.
Chapter 10

The nurse practices using FINAL
c. evidence-based descriptions of behaviors that
Study
critical thinking indicators demonstrate the knowledge, characteristics, and
(CTIs)
skills that promote critical thinking in clinical
when caring for patients in the practice.
hospital setting. The best
description of CTIs is:

Chapter 10
a. Evidence-based descriptions
of behaviors that demonstrate
the knowledge that promotes
critical thinking in clinical
practice
b. Evidence-based descriptions
the knowledge and skills that
promote critical thinking in
clinical practice
c. Evidence-based descriptions
the knowledge, characteristics,
and skills that promote critical
thinking in clinical practice
d. Evidence-based descriptions
the knowledge, characteristics,
standards, and skills that
promote critical thinking in
clinical practice

The nurse practitioner is FINAL
d. Quick priority assessments (QPA) are short, Study
performing a short assessment focused, prioritized assessments nurses do to gain
of a newborn who is displaying the most important information they need to have
signs of jaundice. The nurse first. The comprehensive initial assessment is
observes the infant's skin color performed shortly after the patient is admitted to a
and orders a test for bilirubin health care agency or service. The time-lapsed
levels to report to the primary assessment is scheduled to compare a patient's
care provider. What type of current status to baseline data obtained earlier.
assessment has this nurse

performed?
Chapter 11
a. Comprehensive
b. Initial
c. Time-lapsed
d. Quick priority
Fundamentals
The nurse is admitting aFinal
35- Exam Practice FINAL
a, e, f. Medical assessments target data pointing to
Study
year-old pregnant woman to pathologic conditions, whereas nursing assessments
the hospital for treatment of focus on the patient's responses to health problems.
preeclampsia. The patient asks The initial comprehensive nursing assessment results
the nurse: "Why are you doing in baseline data that enable the nurse to make a
a history and physical exam judgment about a patient's health status, the ability
when the doctor just did one?" to manage his or her own health care and the need
Which statements best explain for nursing. It also helps nurses plan and deliver
the primary reasons a nursing individualized, holistic nursing care that draws on
assessment is performed? the patient's strengths and promotes optimum
functioning, independence, and well-being, and
enables the nurse to refer the patient to a physician
a. "The nursing assessment will or other health care professional, if indicated. The
allow us to plan and deliver fact that this is hospital policy is a secondary reason,
individualized, holistic nursing and although it may be true that a nurse may need
care that draws on your to
strengths."
develop assessment skills, it is not the chief reason
b. "It's hospital policy. I know it the nurse performs a nursing history and exam. The
must be tiresome, but I will try assessment is not performed to check the accuracy
to make this quick!"
of the medical examination.
c. "I'm a student nurse and

need to develop the skill of Chapter 11
assessing your health status
and need for nursing care."
d. "We want to make sure that

your responses to the medical
exam are consistent and that all
our data are accurate."
e. "We need to check your

health status and see what kind
of nursing care you may need."
f. "We need to see if you

require a referral to a physician
or other health care
professional.

When you receive the shift FINAL
d. Perform and document a focused assessment on
Study
report, you learn that your skin integrity since this is a newly identified problem.
patient has no special skin care The initial assessment stands as is and cannot be
needs. You are surprised redone or corrected. This is not a life-threatening
during the bath to observe event; therefore, there is no need for an emergency
reddened areas over bony assessment.
prominences. What action is

appropriate?
Chapter 11
a. Correct the initial assessment

form.
b. Redo the initial assessment

and document current findings.
c. Conduct and document an

emergency assessment.
d. Perform and document a

focused assessment of skin
integrity.
Fundamentals Final
A student nurse attempts to Exam Practice FINAL
b. Once you learn what constitutes the minimum
Study
perform a nursing history for data set, you can adapt this to any patient situation.
the first time. The student nurse It is not true that each assessment is the same even
asks the instructor how anyone when you are using the same minimum data set, nor
ever learns all the questions is it true that each assessment is uniquely different.
the nurse must ask to get good Nurses committed to thoughtful, person centered
baseline data. What would be practice tailor their questions to the uniqueness of
the instructor's best reply?
each patient and situation. Answer d is incorrect
because relying solely on standard agency
a. "There's a lot to learn at first, assessment tools does not allow for individualized
but once it becomes part of patient care or critical thinking.
you, you just keep asking the

same questions over and over Chapter 11
in each situation until you can
do it in your sleep!"
b. "You make the basic

questions a part of you and
then learn to modify them for
each unique situation, asking
yourself how much you need
to know to plan good care."
c. "No one ever really learns

how to do this well because
each history is different! I often
feel like I'm starting afresh with
each new patient."
d. "Don't worry about learning

all of the questions to ask.
Every agency has its own
assessment form you must use."

The nurse collects objective FINAL
a, c, d, e. Subjective data are information perceived
Study
and subjective data when only by the affected person; these data cannot be
conducting patient perceived or verified by another person. Examples
assessments. Which patient of subjective data are feeling nervous, nauseated,
conditions are examples of itchy, or chilly and experiencing pain. Objective data
subjective data? Select all that are observable and measurable data that can be
apply.
seen, heard, or felt by someone other than the
person experiencing them. Examples of objective
a. A patient tells the nurse that data are an elevated temperature reading (e.g.,
she is feeling nauseous.
101°F), edema, and vomiting.
b. A patient's ankles are

swollen.
Chapter 11
c. A patient tells the nurse that
she is nervous about her test
results.
d. A patient complains of
having a rash on her arm that is
itchy.
e. A patient rates his pain as a 7

on a scale of 1 to 10.
f. A patient vomits after eating

supper.

When a nurse enters the d. The patientFINAL
has the right to indicate whom he
Study
patient's room to begin a would like to be present for the nursing history and
nursing history, the patient's exam. You should neither presume that he wants his
wife is there. What should the wife there nor that he does not want her there.
nurse do?
Similarly, the choice belongs to the patient, not the
wife.
a. Introduce oneself and thank

the wife for being present.
Chapter 11
b. Introduce oneself and ask
the wife if she wants to remain.
c. Introduce oneself and ask

the wife to leave.
d. Introduce oneself and ask

the patient if he would like the
wife to stay.
Fundamentals Final
A nurse is performing an initial Exam Practice FINALhealth patterns begin with
b. Gordon's functional the
Study
comprehensive assessment of patient's perception of health and well-being and
an 84-year-old male patient progress to data about nutritional-metabolic
admitted to a long-term care patterns, elimination patterns, activity, sleep/rest,
facility from home. The nurse self-perception, role relationship, sexuality, coping,
begins the assessment by and values/beliefs. Maslow's model is based on the
asking the patient, "How would human needs hierarchy. Human responses include
you describe your health status exchanging, communicating, relating, valuing,
and well-being?" The nurse choosing, moving, perceiving, knowing, and feeling.
also asks the patient, "What do The body system model is based on the functioning
you do to keep yourself of the major body systems.
healthy?" Which model for

organizing data is this nurse Chapter 11
following?
a. Maslow's human needs
b. Gordon's functional health

patterns
c. Human response patterns
d. Body system model
The nurse is surprised to detect c. The nurse should first validate the finding if it is
an elevated temperature unusual, deviates from normal, and is unsupported
(102°F) in a patient scheduled by other data. Should the initial recording prove to
for surgery. The patient has be in error, it would have been premature to notify
been afebrile and shows no the charge nurse or the surgeon. The nurse should
other signs of being febrile. be sure that all data recorded are accurate, thus all
What is the first thing the nurse data should be validated before documentation if
should do?
there are any doubts about accuracy.
a. Inform the charge nurse
Chapter 11
b. Inform the surgeon
c. Validate the finding
d. Document the finding

A student nurse tells the FINAL
a. The instructor is most likely to challenge theStudy
instructor that a patient is fine inference that the patient is "fine" simply because
and has "no complaints." What she is telling you that she has no problems. It is
would be the instructor's best appropriate for the instructor to ask how the student
response?
nurse validated this inference. Jumping to the
conclusion that the patient does not trust the
a. "You made an inference that student nurse is premature and is an invalidated
she is fine because she has no inference.
complaints. How did you Answer c is wrong because it accepts the

validate this?"
invalidated
b. "She probably just doesn't inference. Answer d is wrong because it is possible

trust you enough to share what that the condition is resolving.
she is feeling. I'd work on

developing a trusting Chapter 11
relationship."
c. "Sometimes everyone gets

lucky. Why don't you try to help
another patient?"
d. "Maybe you should reassess

the patient. She has to have a
problem—why else would she
be here?"
Fundamentals Final
A registered nurse is writing a Exam Practice FINAL
b, d, f. The purposes of diagnosing are to identify
Study
diagnosis for a 28-year-old how an individual, group, or community responds to
male patient who is in traction actual or potential health and life processes; identify
due to multiple fractures from a factors that contribute to or cause health problems
motor vehicle accident. Which (etiologies); and identify resources or strengths the
nursing actions are related to individual, group, or community can draw on to
this step in the nursing prevent or resolve problems. In the diagnosing step
process? Select all that apply.
of the nursing process, the nurse interprets and
analyzes data gathered from the nursing
a. The nurse uses the nursing assessment, identifies patient strengths, and
interview to collect patient identifies resources the patient can use to resolve
data.
problems. The nurse assesses and collects patient
b. The nurse analyzes data data in the assessment step and develops a care
collected in the nursing plan in the planning step of the nursing process.
assessment.
c. The nurse develops a care Chapter 12

plan for the patient.
d. The nurse points out the

patient's strengths.
e. The nurse assesses the

patient's mental status.
f. The nurse identifies

community resources to help
his family cope.
Fundamentals
A nurse is caring for anFinal
older Exam Practice FINAL
b, c, f. Nursing diagnoses are actual or potential
Study
adult patient who presents with health
labored respirations, problems that can be prevented or resolved by

productive cough, and fever. independent nursing interventions, such as impaired
What would be appropriate gas exchange, ineffective airway clearance, or risk
nursing diagnoses for this for septic shock. Bronchial pneumonia and infection
patient? Select all that apply.
are medical diagnoses, and "potential complication:
sepsis" is a collaborative problem.
a. Bronchial pneumonia
b. Impaired gas exchange

Chapter 12
c. Ineffective airway clearance
d. Potential complication:
sepsis
e. Infection related to
pneumonia
f. Risk for septic shock
After assessing a patient who is b. When a possible problem exists, such as

recovering from a stroke in a situational low self-esteem related to effects of
rehabilitation facility, a nurse stroke, the nurse must collect more data to confirm
interprets and analyzes the or disprove the suspected problem. The conclusion
patient data. Which of the four "no problem" means no nursing response is
basic conclusions has the nurse indicated. When an actual problem exists, the nurse
reached when identifying the begins planning, implementing, and evaluating care
need to collect more data to to prevent, reduce, or resolve the problem. A
confirm a diagnosis of clinical problem other than nursing diagnosis
situational low self-esteem?
requires that the nurse consult with the appropriate
health care professional to work collaboratively on
a. No problem
the problem.
b. Possible problem
c. Actual nursing diagnosis

Chapter 12
d. Clinical problem other than
nursing diagnosis
Fundamentals Final
A nurse assesses a patient and Exam Practice
b."Related to FINAL
prescribed bedrest" is the etiology of
Study
formulates the following the statement. The etiology identifies the
nursing diagnosis: Risk for contributing or causative factors of the problem.
Impaired Skin Integrity related "Risk for Impaired Skin Integrity" is the problem, and
to prescribed bedrest as "as evidenced by reddened areas of skin on the
evidenced by reddened areas heels and back" are the defining characteristics of
of skin on the heels and back. the problem.
Which phrase represents the

etiology of this diagnostic Chapter 12
statement?
a. Risk for Impaired Skin

Integrity
b. Related to prescribed
bedrest
c. As evidenced by
d. As evidenced by reddened
areas of skin on the heels and
back.
Fundamentals
A nurse is counseling aFinal
d. Nursing Problem, because it describes a problem
Study
year-old female patient who
that can be treated by nurses within the scope of
refuses to look at or care for a independent nursing practice. Collaborative and
new colostomy. She tells the interdisciplinary problems require a teamwork
nurse, "I don't care what I look approach with other health care professionals to
like anymore, I don't even feel resolve the problem. A medical problem is a
like washing my hair, let alone traumatic or disease condition validated by medical
changing this bag." The nurse diagnostic studies.
diagnoses Altered Health

Maintenance. This is an Chapter 12
example of what type of
problem?
a. Collaborative problem
b. Interdisciplinary problem
c. Medical problem
d. Nursing problem
To determine the significance a. A standard, or a norm, is a generally accepted

of a blood pressure reading of rule, measure, pattern, or model to which data can
148/100, it is first necessary for be compared in the same class or category. For
the nurse to:
example, when determining the significance of a
patient's blood pressure reading, appropriate
a. Compare this reading to standards include normative values for the patient's
standards.
age group, race, and illness category. Deviation
b. Check the taxonomy of from an appropriate norm may be the basis for
nursing diagnoses for a writing a diagnosis.
pertinent label.
c. Check a medical text for the Chapter 12

signs and symptoms of high
blood pressure.
d. Consult with colleagues.
Fundamentals
When the initial nursingFinal Exam Practice FINAL
a. A data cluster is a grouping of patient data or
Study
assessment revealed that a cues that points to the existence of a patient health
patient had not had a bowel problem. Nursing diagnoses should always be
movement for 2 days, the derived from clusters of significant data rather than
student nurse wrote the from a single cue. There may be a reason for the
diagnostic label "constipation." lack of a bowel movement for 2 days, or it might be
Which of the following this individual's normal pattern.
comments is the nurse most
likely to hear from the Chapter 12
instructor?
a. "Hold on a minute . . .
Nursing diagnoses should
always be derived from
clusters of significant data
rather than from a single cue."
b. "Job well done . . . you've

identified this problem early
and we can manage it before it
becomes more acute."
c. "Is this an actual or a possible

diagnosis?"
d. "This is a medical, not a
nursing problem."
Fundamentals
A nurse makes a clinicalFinal Exam Practice FINALthat an individual, family,Study
b. A clinical judgment or
judgment that an African community is more vulnerable to develop the
American male patient in a problem than others in the same or similar situation
stressful job is more vulnerable is a Risk nursing diagnosis.
to developing hypertension
than White male patients in the Chapter 12
same or similar situation. The
nurse has formulated what type
of nursing diagnosis?
a. Actual
b. Risk
c. Possible
d. Wellness

A nurse is writing nursing d. Each of theFINAL
four diagnoses is a correctly written
Study
diagnoses for patients in a two-part diagnostic statement that includes the
psychiatrist's office. Which problem or diagnostic label and the etiology or
nursing diagnoses are correctly cause.
written as two-part nursing

diagnoses?
Chapter 12
(1) Ineffective Coping related

to inability to maintain
marriage
(2) Defensive Coping related to

loss of job and economic
security
(3) Altered Thought Processes

related to panic state
(4) Decisional Conflict related

to placement of parent in a
long-term care facility
a. (1) and (2)
b. (3) and (4)
c. (1), (2), and (3)
d. All of the above
Fundamentals
A nurse writes nursing Final Exam Practice FINAL
b. (1) is a two-part diagnosis, (3) is written in terms
Studyof
diagnoses for patients and their needs and not an unhealthy response, and (5) is a
families visiting a community legally inadvisable statement.
health clinic. Which nursing

diagnoses are correctly written Chapter 12
as three-part nursing
diagnoses?
(1) Disabled Family Coping

related to lack of knowledge
about home care of child on
ventilator
(2) Imbalanced Nutrition: Less

Than Body Requirements
related to inadequate caloric
intake while striving to excel in
gymnastics as evidenced by
20-pound weight loss since
beginning the gymnastic
program, and greatly less than
ideal body weight when
compared to standard height
weight charts
(3) Need to learn how to care

for child on ventilator at
home related to unexpected

discharge of daughter after 3-
month hospital stay as
evidenced by repeated
comments "I cannot do this," "I
know I'll harm her because I'm
not a nurse," and "I can't do
medical things"
(4) Spiritual Distress related to

inability to accept diagnosis of
terminal illness as evidenced
by multiple comments such as
"How could God do this to

Fundamentals Final
me?," "I don't deserve this," "I Exam Practice FINAL Study
don't understand. I've tried to

live my life well," and "How
could God make me suffer this
way?"
(5) Caregiver Role Strain

related to failure of home
health aides to appropriately

diagnose needs of family
caregivers and initiate a plan to

facilitate coping as
evidenced by caregiver's loss

of weight and clinical
depression
a. (1) and (3)
b. (2) and (4)
c. (1), (2), and (3)
d. All of the abo
Fundamentals Final
A nurse is planning care for a Exam Practice
b, c, d. DuringFINAL
the outcome identification and Study
male adolescent patient who is planning step of the nursing process, the nurse
admitted to the hospital for works in partnership with the patient and family to
treatment of a drug overdose. establish priorities, identify and write expected
Which nursing actions are patient outcomes, select evidence-based nursing
related to the outcome interventions, and communicate the plan of nursing
identification and planning step care. Although all these steps may overlap,
of the nursing process? Select formulating and validating nursing diagnoses occurs
all that apply.
most frequently during the diagnosing step of the
nursing process. Assessing mental status is part of
a. The nurse formulates nursing the assessment step, and evaluating patient
diagnoses.
outcomes occurs during the evaluation step of the
b. The nurse identifies nursing process.
expected patient outcomes.
c. The nurse selects evidence- Chapter 13

based nursing interventions.
d. The nurse explains the

nursing care plan to the
patient.
e. The nurse assesses the

patient's mental status.
f. The nurse evaluates the

patient's outcome achievement.
Fundamentals Final
A nurse on a busy surgical unit Exam Practice FINAL
b, d, e. Informal planning is a link between Study
relies on informal planning to identifying a patient's strength or problem and
provide appropriate nursing providing an appropriate nursing response. This
responses to patients in a occurs, for example, when a busy nurse first
timely manner. What are recognizes postpartum depression in a patient,
examples of this type of takes time to assess a patient who received bad
planning? Select all that apply.
news about tests, or reassesses a patient for pain.
Formal planning involves prioritizing diagnoses,
a. A nurse sits down with a formally planning interventions, and coordinating
patient and prioritizes existing the home care of a patient being discharged.
diagnoses.
b. A nurse assesses a woman Chapter 13

for postpartum depression
during routine care.
c. A nurse plans interventions

for a patient who is diagnosed
with epilepsy.
d. A busy nurse takes time to

speak to a patient who
received bad news.
e. A nurse reassesses a patient

whose PRN pain medication is
not working.
f. A nurse coordinates the

home care of a patient being
discharged.
Fundamentals Final Exam Practice FINALis problem oriented and Study

c. Ongoing planning has as
its purpose keeping the plan up to date as new
actual or potential problems are identified. Initial
When helping a patient turn in
planning addresses each problem listed in the
bed, the nurse notices that his
prioritized nursing diagnoses and identifies
heels are reddened and plans
appropriate patient goals and the related nursing
to place him on precautions for
care. Standardized care plans are prepared plans of
skin breakdown. This is an
care that identify the nursing diagnoses, outcomes,
example of what type of
and related nursing interventions common to a
planning?
specific population or health problem. During

discharge planning, the nurse uses teaching and
a. Initial planning
counseling skills effectively to help the patient and

b. Standardized planning
family develop sufficient knowledge of the health

c. Ongoing planning
problem and the therapeutic regimen to carry out

d. Discharge planning
necessary self-care behaviors competently at home.
Chapter 13

A nurse is prioritizing the FINAL
a. 2, 4, 1, 3. Because basic needs must be met before
Study
following patient diagnoses a person can focus on higher ones, patient needs
according to Maslow's may be prioritized according to Maslow's hierarchy:
hierarchy of human needs:
(1) physiologic needs, (2) safety needs, (3) love and
belonging needs, (4) self esteem needs, and (5)
(1) Disturbed Body Image
self-actualization needs. #2 is an example of a
(2) Ineffective Airway physiologic need, #4 is an example of a love and
Clearance
belonging need, #1 is an example of a self-esteem
(3) Spiritual Distress
need, and #3 is an example of a self-actualization
(4) Impaired Social Interaction
need.
Which answer choice below

lists the problems in order of Chapter 13
highest priority to lowest
priority based on Maslow's
model?
a. 2, 4, 1, 3
b. 3, 1, 4, 2
c. 2, 4, 3, 1
d. 3, 2, 4, 1
Fundamentals
A nurse is using criticalFinal Exam Practice
a, c. A criticalFINAL
pathway represents a sequential,Study
pathway methodology for interdisciplinary, minimal practice standard for a
choosing interventions for a specific patient population that provides flexibility
patient who is receiving to alter care to meet individualized patient needs. It
chemotherapy for breast also offers the ability to measure a cause-and-effect
cancer. Which nursing actions relationship between pathway and patient
are characteristics of this outcomes. An algorithm is a binary decision tree that
system being used when guides stepwise assessment and intervention with
planning care? Select all that intense specificity and no provider flexibility.
apply.
Guidelines are broad, research-based practice
recommendations that may or may not have been
a. The nurse uses a minimal tested in clinical practice, and an order set is a
practice standard and is able to preprinted provider order used to expedite the
alter care to meet the patient's order process after a practice standard has been
individual needs.
validated through analytical research.
b. The nurse uses a binary

decision tree for stepwise
Chapter 13
assessment and intervention.
c. The nurse is able to measure

the cause-and-effect
relationship between pathway

and patient outcomes.
d. The nurse uses broad,

research-based practice
recommendations that may or
may not have been tested in
clinical practice.
e. The nurse uses preprinted

provider orders used to
expedite the order process
after a practice standard has
been validated through
research.
f. The nurse uses a decision tree

that provides intense specificity
and no provider flexibility.

A nurse is identifying outcomes FINALdescribe changes in patient
d. Affective outcomes Study
for a patient who has a leg values, beliefs, and attitudes. Cognitive outcomes
ulcer related to diabetes. An (a) describe increases in patient knowledge or
example of an affective intellectual behaviors; psychomotor outcomes (b)
outcome for this patient is:
describe the patient's achievement of new skills. c is
an outcome describing a physical change in the
a. Within 1 day after teaching, patient.
the patient will list three

benefits of continuing to apply Chapter 13
moist compresses to leg ulcer
after discharge.
b. By 6/12/15, the patient will

correctly demonstrate
application of wet-to-dry
dressing on leg ulcer.
c. By 6/19/15, the patient's ulcer

will begin to show signs of
healing (e.g., size shrinks from
″
3 to 2.5 ).
″
d. By 6/12/15, the patient will
verbalize valuing health
sufficiently to practice new
health behaviors to prevent
recurrence of leg ulcer.

A nurse is preparing a clinical FINAL
a. Clinical outcomes describe the expected status
Studyof
outcome for a 32-year-old health issues at certain points in time, after treatment
female runner who is is complete. Functional outcomes (b) describe the
recovering from a stroke that person's ability to function in relation to the desired
caused right-sided paresis. An usual activities. Quality-of-life outcomes (c) focus on
example of this type of key factors that affect someone's ability to enjoy life
outcome is:
and achieve personal goals. Affective outcomes (d)
describe changes in patient values, beliefs, and
a. After receiving 3 weeks of attitudes.
physical therapy, patient will

demonstrate improved Chapter 13
movement on the right side of
her body.
b. By 8/15/15, patient will be

able to use right arm to dress,
comb hair, and feed herself.
c. Following physical therapy,

patient will begin to gradually
participate in walking/running
events.
d. By 8/15/15, patient will

verbalize feeling sufficiently
prepared to participate in
running events.
Fundamentals
elderly Exam Practice FINAL
b. The outcomes in a and c make the error of Study
male patient who is receiving expressing the patient goal as a nursing
fluids for dehydration. Which intervention. Incorrect: "Offer the patient 60 mL fluid
outcome for this patient is every 2 hours while awake." Correct: "The patient
correctly written?
will drink 60 mL fluid every 2 hours while awake,
beginning 1/3/15." The outcome in d makes the error
a. Offer the patient 60 mL fluid of using verbs that are not observable and
every 2 hours while awake.
measurable. Verbs to be avoided when writing
b. During the next 24-hour goals include "know," "understand," "learn," and
period, the patient's fluid intake "become aware."
will total at least 2,000 mL.
c. Teach the patient the Chapter 13

importance of drinking enough
fluids to prevent dehydration
by 1/15/15
d. At the next visit, 12/23/15, the

patient will know that he should
drink at least 3 liters of water
per day.
b. An intervention for a possible diagnosis is to

A nurse is collecting more
collect more patient data to confirm or rule out the
patient data to confirm a
problem. An intervention for an actual diagnosis is
diagnosis of emphysema for a
to reduce or eliminate contributing factors to the
68-year-old male patient. What
diagnosis. Interventions for a risk diagnosis focus on
type of diagnosis does this
reducing or eliminating risk factors, and
intervention seek to confirm?
interventions for collaborative problems focus on

monitoring for changes in status and managing
a. Actual
these changes with nurse and physician-prescribed

b. Possible
interventions.
c. Risk
d. Collaborative
Chapter 13

A nurse is caring for a patient FINAL
d. This statement lacks sufficient detail to effectively
Study
who is diagnosed with guide nursing intervention. The set of nursing
congestive heart failure. Which interventions written to assist a patient to meet an
statement below is not an outcome must be comprehensive. Comprehensive
example of a well-stated nursing interventions specify what observations
nursing intervention?
(assessments) need to be made and how often,
what nursing interventions need to be done and
a. Offer patient 60 mL water or when they must be done, and what teaching,
juice (prefers orange or
counseling, and advocacy needs patients and
cranberry juice) every 2 hours families may have.
while awake for a total
minimum PO intake of 500 mL.

Chapter 13
b. Teach patient the necessity
of carefully monitoring fluid
intake and output; remind
patient each shift to mark off
fluid intake on record at
bedside.
c. Walk with patient to

bathroom for toileting every 2
hours (on even hours) while
patient is awake.
d. Manage patient's pain.
Fundamentals
A school nurse noticesFinal
that a Exam Practice
a. PerformingFINAL
a focused assessment is an Study
female adolescent student is independent nurse- initiated intervention, thus the
losing weight and decides to nurse does not need an order from the physician or
perform a focused assessment the nutritionist.
of her nutritional status to

determine if she has an eating Chapter 14
disorder. How should the
nurse proceed?
a. Perform the focused

assessment. This is an
independent nurse-initiated
intervention.
b. Request an order from Jill's

physician since this is a
physician-initiated intervention.
c. Request an order from Jill's

physician since this is a
collaborative intervention.
d. Request an order from the

nutritionist since this is a
collaborative intervention.
Fundamentals
A nurse is using the Final Exam Practice
a, d, f. DuringFINAL
the implementing step of the nursing
Study
implementation step of the process, nursing actions planned in the previous
nursing process to provide step are carried out. The purpose of implementation
care for patients in a busy is to assist the patient in achieving valued health
hospital setting. Which nursing outcomes: promote health, prevent disease and
actions best represent this illness, restore health, and facilitate coping with
step? Select all that apply.
altered functioning. Assessing a patient for
nutritional status or insurance coverage occurs in
a. The nurse carefully removes the assessment step, and formulating nursing
the bandages from a burn diagnoses occurs in the diagnosing step.
victim's arm.
b. The nurse assesses a patient Chapter 14

to check nutritional status.
c. The nurse formulates a

nursing diagnosis for a patient
with epilepsy.
d. The nurse turns a patient in

bed every 2 hours to prevent
pressure ulcers.
e. The nurse checks a patient's

insurance coverage at the initial
interview.
f. The nurse checks for

community resources for a
patient with dementia.
Fundamentals
Nurses use the NursingFinal Exam Practice FINAL
b. The Nursing Interventions Classification Taxonomy
Study
Interventions Classification lists nursing interventions, each with a label, a
Taxonomy structure as a definition, a set of activities that a nurse performs to
resource when planning carry it out, and a short list of background readings.
nursing care for patients. What It does not contain case studies, diagnoses, or
information would be found in charges.
this structure?
Chapter 14
a. Case studies illustrating a
complete set of activities that a
nurse performs to carry out
nursing interventions
b. Nursing interventions, each

with a label, a definition, and a
set of activities that a nurse
performs to carry it out, with a
short list of background
readings
c. A complete list of nursing

diagnoses, outcomes, and
related nursing activities for

each nursing intervention
d. A complete list of
reimbursable charges for each
nursing intervention
Fundamentals Final
A new RN is being oriented to Exam Practice FINAL
c. The nurse should not delegate this nursing Study
a nursing unit that is currently admission assessment because only nurses can
understaffed and is told that perform this intervention. The nurse should seek
the UAPs have been trained to clarification for this policy from the nursing
obtain the initial nursing administration.
assessment. What is the best

response of the RN?
Chapter 14
a. Allow the UAPs to do the

admission assessment and
report the findings to the RN.
b. Do his or her own admission

assessments but don't interfere
with the practice if other
professional RNs seem
comfortable with the practice.
c. Tell the charge nurse that he

or she chooses not to delegate
the admission assessment until
further clarification is received
from administration.
d. Contact his or her labor

representative and complain
about this practice.

A nurse performs nurse- FINALinterventions, or independent
c, d, f. Nurse-initiated Study
initiated nursing actions when nursing actions, involve carrying out nurse-
caring for patients in a skilled prescribed interventions resulting from their
nursing facility. Which are assessment of patient needs written on the nursing
examples of these types of plan of care, as well as any other actions that nurses
interventions? Select all that initiate without the direction or supervision of
apply.
another health care professional. Protocols and
standard orders empower the nurse to initiate
a. A nurse administers 500 mg actions that ordinarily require the order or
of ciprofloxacin to a patient supervision of a physician. Consulting with a
with pneumonia.
psychiatrist is a collaborative intervention.
b. A nurse consults with a

psychiatrist for a patient who Chapter 14
abuses pain killers.
c. A nurse checks the skin of

bedridden patients for skin
breakdown.
d. A nurse orders a kosher meal

for an orthodox Jewish patient.
e. A nurse records the I&O of a

patient as prescribed by his
physician.
f. A nurse prepares a patient for

minor surgery according to
facility protocol.
Fundamentals Final
A nurse is about to perform pinExam Practice FINAL any nursing action, theStudy
b. Before implementing
site care for a patient who has nurse should reassess the patient to determine
a halo traction device installed. whether the action is still needed. Then the nurse
What is the first nursing action may collect the equipment, explain the procedure,
that should be taken prior to and if necessary administer pain medications.
performing this care?
Chapter 14
a. Administer pain medication.
b. Reassess the patient.
c. Prepare the equipment.
d. Explain the procedure to the

patient.
Fundamentals
A student nurse is on aFinal
clinical Exam Practice FINAL
a. Student nurses should notify their nursing Study
rotation at a busy hospital unit. instructor or nurse mentor if they believe they lack
The RN in charge tells the any competencies needed to safely implement the
student to change a surgical plan of care. It is within the realm of a student nurse
dressing on a patient while she to change a dressing if he or she is technically
takes care of other patients. prepared to do so.
The student has not changed

dressings before and does not Chapter 14
feel confident with the
procedure. What would be the
student's best response?
a. Tell the RN that he or she

lacks the technical
competencies to change the
dressing independently.
b. Assemble the equipment for

the procedure and follow the
steps in the procedure manual.
c. Ask another student nurse to

work collaboratively with him
or her to change the dressing.
d. Report the RN to his or her

instructor for delegating a task
that should not be assigned to
student nurses.

A nurse develops a detailed FINAL
c. When a patient does not follow the plan of care
Study
plan of care for a 16-year-old despite your best efforts, it is time to reassess
female who is a new single strategy. The first objective is to identify why the
mother of a premature infant. patient is not following the therapy. If the nurse
The plan includes collaborative determines, however, that the plan of care is
care measures and home adequate, the nurse must identify and remedy the
health care visits. When factors contributing to the patient's noncompliance.
presented with the plan, the

patient states, "We will be fine Chapter 14
on our own. I don't need any
more care." What would be the
nurse's best response?
a. "You know your personal

situation better than I do, so I
will respect your wishes."
b. "If you don't accept these

services, your baby's health will
suffer."
c. "Let's take a look at the plan

again and see if we can adjust
it to fit your needs."
d. "I'm going to assign your

case to a social worker who
can explain the services
better."

An RN working on a busy FINAL
b, c, e, f. Performing the initial patient assessment
Study
hospital unit delegates patient and administering medications are the responsibility
care to unlicensed assistive of the registered nurse. In most cases, patient
personnel (UAPs). Which hygiene, bed-making, ambulating patients, and
patient care could the nurse helping to feed patients can be delegated to a UAP.
most likely delegate to a UAP

safely? Select all that apply.
Chapter 14
a. Performing the initial patient

assessments b. Making patient
beds
c. Giving patients bed baths
d. Administering patient
medications
e. Ambulating patients
f. Assisting patients with meals

A student nurse is organizing d. As long as FINAL
time constraints permit, the mostStudy
clinical responsibilities for an important priorities when scheduling nursing care
84-year-old female patient are priorities identified by the patient as being
who is diabetic and is being most important. In this case, washing the patient's
treated for foot ulcers. The hair and assisting with hygiene puts the patient first
patient tells the student, "I and sets the tone for an effective nurse- patient
need to have my hair washed partnership.
before I can do anything else

today; I'm ashamed of the way Chapter 14
I look." The patient's needs
include diagnostic testing,
dressing changes, meal
planning and counseling, and
assistance with hygiene. How
would the nurse best prioritize
this patient's care?
a. Explain to the patient that

there is not enough time to
wash her hair today because of
her busy schedule.
b. Schedule the testing and

meal planning first and
complete hygiene as time
permits.
c. Perform the dressing

changes first, schedule the
testing and counseling, and
complete hygiene last.
d. Arrange to wash the patient's

hair first, perform hygiene, and
schedule diagnostic testing
and counseling.
Fundamentals
A nurse is documentingFinal
patientExam Practice FINAL
c, d, f. The nurse should enter information in a Study
data in the medical record of a complete, accurate, concise, current, and factual
patient admitted to the hospital manner and indicate in each entry the date and
with a diagnosis of appen- both the time the entry was written and the time of
dicitis. The physician has pertinent observations and interventions. When
ordered 10 mg morphine IV charting, the nurse should avoid the use of
every 3 to 4 hours. Which stereotypes or derogatory terms as well as
examples of documentation of generalizations such as "seems comfortable today."
care for this patient follows The nurse should never document an intervention
recommended guidelines? before carrying it out.
Chapter 16
a. 6/12/15 0945 Morphine 10
mg administered IV. Patient's
response to pain appears to be
exaggerated. M. Patrick, RN
b. 6/12/15 0945 Morphine 10

mg administered IV. Patient
seems to be comfortable. M.
Patrick, RN
c. 6/12/15 0945 30 minutes

following administration of
morphine 10 mg IV patient
reports pain as 2 on a scale of 1
to 10. M. Patrick, RN
d. 6/12/15 0945 Patient reports

severe pain in right lower
quadrant. M. Patrick, RN
e. 6/12/15 0945 Morphine IV 10

mg will be administered to
patient every 3 to 4 hours. M.
Patrick, RN
f. 6/12/15 0945 Patient states

she does not want pain
medication despite return of
pain. After discussing situation,
patient agrees to medication

Fundamentals
administration. Final Exam Practice FINAL Study
A nurse is documenting the b. The nurse should not use dittos, erasures, or
care given to a 56-year-old correcting fluids. A single line should be drawn
patient diagnosed with an through an incorrect entry, and the words "mistaken
osteosarcoma, whose right leg entry" or "error in charting" should be printed above
was amputated. The nurse or beside the entry and signed. The entry should
accidentally documents that a then be rewritten correctly.
dressing changed was

performed on the left leg. Chapter 16
What would be the best action
of the nurse to correct this
documentation?
a. Erase or use correcting fluid

to completely delete the error.
b. Draw a single line through

the entry and rewrite it above
or beside it.
c. Use a permanent marker to

block out the mistaken entry
and rewrite it.
d. Remove the page with the

error and rewrite the data on
that page correctly
Fundamentals
A nurse is discharging aFinal
patientExam Practice
d. According FINAL
to HIPAA, patients have a right toStudy
see
from the hospital following a and copy their health record; update their health
heart stent procedure. The record; get a list of the disclosures a health care
patient asks to see and copy institution has made independent of disclosures
his medical record. What is the made for the purposes of treatment, payment, and
health care operations; request a restriction on
certain uses or disclosures; and choose how to
a. "I'm sorry, but patients are receive health information. The nurse should be
not allowed to copy their aware of agency policies regarding the patient's
medical records."
right to access and copy records.
b. "I can make a copy of your

record for you right now."
Chapter 16
c. "You can read your record
while you are still a patient, but
copying records is not
permitted according to HIPAA
rules."
d. "I will need to check with our

records department to get you
a copy."

According to the Health FINAL is not required for tracking
b, c, d, e. Authorization Study
Insurance Portability and disease outbreaks, providing PHI to a coroner,
Account- ability Act of 1996, if a reporting incidents of child abuse, or facilitating
health institution wants to organ donations. Under no circumstance can a
release a patient's health nurse provide information to a news reporter
information (PHI) for purposes without the patient's express authorization. An
other than treatment, payment, authorization form is still needed to provide PHI for
and routine health care a patient who has Alzheimer's disease.
operations, the patient must be

asked to sign an authorization. Chapter 16
The nurse is aware that there
are exceptions to this
requirement. In which of the
following cases is an
authorization form not
needed? Select all that apply.
a. News media are preparing a

report on the condition of a
public figure.
b. Data are needed for the

tracking and notification of
disease outbreaks.
c. Protected health information

is needed by a coroner.
d. Child abuse and neglect are

suspected.
e. Protected health information

is needed to facilitate organ
donation.
f. The sister of a patient with

Alzheimer's wants to help
provide care.
Fundamentals
A friend of a nurse callsFinal
and Exam Practice FINAL
b. The nurse should immediately clarify what he or
Study
asks if she is still working at she can and cannot do. Since the primary reason for
Memorial Hospital. The nurse refusing to help is linked to the responsibility to
replies, "Yes." The friend tells protect patient privacy and confidentiality, the nurse
the nurse that his girlfriend's should not begin by mention- ing the real penalties
father was just admitted as a linked to abuses of privacy. Finally, it is appropriate
patient and he wants the nurse to ask about Sue and her worries, but this should be
to find out how he is. The friend done after the nurse clarifies what he or she is able
states, "Sue seems unusually to do.
worried about her dad, but she

won't talk to me and I want to Chapter 16
be able to help her." What is
the best initial response the
nurse should make?
a. "You shouldn't be asking me

to do this. I could be fined or
even lose my job for disclosing
this information."
b. "Sorry, but I'm not able to

give information about patients
to the public—even when my
best friend or a family mem-
ber asks."
c. "Because of the Health

Insurance Portability and
Account- ability Act, you
shouldn't be asking for this
information unless the patient
has authorized you to receive
it! This could get you in
trouble!"
d. "Why do you think Sue isn't

talking about her worries?"
Fundamentals
A patient has an order Final
for an Exam Practice
d. PRN meansFINAL
"as needed."
Study
analgesic medication to be
given PRN. When would the Chapter 16
nurse administer this
medication?
a. Every three hours
b. Every four hours
c. Daily
d. As needed
Fundamentals Final
A resident who is called to see Exam Practice FINAL
c. In most agencies, the only circumstance in which
Study
a patient in the middle of the an attending physician, nurse practitioner, or house
night is leaving the unit but officer may issue orders verbally is in a medical
then remembers that he forgot emergency, when the physician/nurse practitioner is
to write a new order for a pain present but finds it impossible, due to the
medication a nurse had emergency situation, to write the order.
requested for another patient.

Tired and already being paged Chapter 16
to another unit, he verbally
tells the nurse the order and
asks the nurse to document it
on the physician's order sheet.
The nurse's best response is:
a. "Thank you for taking care of

this!"
b. Get a second nurse to listen

to the order, and after writing
the order on the physician
order sheet, have both nurses
sign it.
c. "I am sorry, but verbal orders

can only be given in an
emergency situation that

prevents us from writing them
out. I'll bring the chart and we
can do this quickly."
d. Try calling another resident

for the order or wait until the
next shift.
Fundamentals Finalin Exam Practice

A nurse is looking for trends d. While one FINAL
recording of vital signs should appear
Study
a postoperative patient's vital on the admission nursing assessment, the best place
signs. Which documents would to find sequential recordings that show a pattern
the nurse consult first?
or trend is the graphic record. The admission sheet
does not include vital sign documentation, and
a. Admission sheet
neither does the activity flow sheet.
b. Admission nursing
assessment
Chapter 16
c. Activity flow sheet
d. Graphic record
A nurse is using the SOAP a. When using the SOAP format, the problem list at
format of documentation to the front of the chart alerts all caregivers to patient
document care of a patient priorities. Narra- tive notes allow nurses to describe
who is diagnosed with type 2 a condition, situation, or response in their own
diabetes. Which source of terms. Abnormal status can be seen immediately
information would be the when using charting by exception, and planned
nurse's focus when completing interventions and patient expected outcomes are
this documentation?
the focus of the case management model.
a. A patient problem list

Chapter 16
b. Notes describing the
patient's condition
c. Overall trends in patient

status
d. Planned interventions and

patient outcomes

A nurse is using the ISBARR d, a, e, b, f, c. FINAL
The order for ISBARR is: Study
physician reporting system to identity/introduction, situation, background,
report the deteriorating mental assessment, recommendation, and read-back.
status of Mr. Sanchez, a male

patient who has been Chapter 16
prescribed morphine via a
patient- controlled analgesia
pump (PCA) for pain related to
pancreatic cancer. Place the
following nursing statements
related to this call in the order
in which they should be
performed.
a. "I am calling about Mr.

Sanchez in Room 202 who is
receiving morphine via a PCA
pump for pancreatic cancer."
b. "Mr. Sanchez has been

difficult to arouse and his
mental status has changed over
the past 12 hours since using
the pump."
c. "You want me to discontinue

the PCA pump until you see
him tonight at patient rounds."
d. "I am Rosa Clark, an RN

working on the second floor of
South Street Hospital."
e. "Mr. Sanchez was admitted

two days ago following a
diagnosis of pancreatic
cancer."
f. "I think the dosage of

morphine in Mr. Sanchez's PCA
pump needs to be lowered."
Fundamentals Final
A nurse caring for adults in a Exam Practice FINAL
c, d. The immunity theory of aging focuses on the
Study
physician's office notes that functions of the immune system and states that the
some patients age more immune response declines steadily after younger
rapidly that other patients of adulthood as the thymus loses size and function,
the same age. The nurse causing more infections. There is much interest in
researches aging theories that vitamin supplements (such as vitamin E) to improve
attempt to describe how and immune function. In the cross-linkage theory, cross-
why aging occurs. Which linkage is a chemical reac- tion that produces
statements apply to the damage to the DNA and cell death. The free radical
immunity theory of aging? theory states that free radicals, formed during
cellular metabolism, are molecules with separated
high-energy electrons, which can have adverse
a. Chemical reactions in the effects on adjacent molecules. The genetic theory
body produce damage to the of aging holds that lifespan depends to a great
DNA.
extent on genetic factors. According to the wear-
b. Free radicals have adverse and-tear theory, organisms wear out from increased
effects on adjacent molecules.
metabolic functioning, and cells become exhausted
c. Decrease in size and from continual energy depletion from adapting to
function of the thymus causes stressors (Eliopoulos, 2010).
infections.
d. There is much interest in the Chapter 19

role of vitamin
supplementation.
e. Lifespan depends on a great

extent to genetic factors.
f. Organisms wear out from

increased metabolic
functioning.
Fundamentals Final
A nurse caring for older adults Exam Practice FINAL
a, b, f. Physical changes occurring with aging Study
in a long-term care facility include these: fatty tissue is redistributed, the skin is
knows that several physical drier and wrinkles appear, and visual and hearing
changes occur in the aging acuity diminishes. Cardiac output decreases, muscle
adult. Which characteristics mass decreases, and hormone production
best describe these changes? decreases, causing menopause or andropause.
Chapter 19
a. Fatty tissue is redistributed.
b. The skin is drier and wrinkles

appear.
c. Cardiac output increases.
d. Muscle mass increases.
e. Hormone production
increases.
f. Visual and hearing acuity

diminishes.

Based on Erikson's theory, FINAL
b. Middle adults who do not reach generativityStudy
tend
middle adults who do not to become overly concerned about their own
achieve their developmental physical and emotional health needs.
tasks may be considered to be

in stagna- tion. Which Chapter 19
statement is one example of
this finding?
a. "I am helping my parents

move into an assisted-living
facility."
b. "I spend all of my time going

to the doctor to be sure I am
not sick."
c. "I have enough money to

help my son and his wife when
they need it."
d. "I earned this gray hair and I

like it!"
Which of the following nursing d. Many middle adults help care for aging parents
diagnoses would be appropri- and have concerns about their own health and
ate for many middle adults?
ability to continue to care for an older family
member. Caregivers often face 24-hour care
a. Risk for Imbalanced responsibilities for extended periods of time, which
Nutrition: Less Than Body creates physical and emotional problems for the
Requirements
caregiver.
b. Delayed Growth and

Development
Chapter 19
c. Self-Care Deficit
d. Caregiver Role Strain
Fundamentals
An experienced nurse Final
tells a Exam Practice
d. Ageism is aFINAL
form of prejudice in which olderStudy
younger nurse who is working adults are stereotyped by characteristics found in
in a retirement home that older only a few members of their age group. Harassment
adults are different and do not occurs when a dominant person takes advantage
have the same desires, needs, of or overpowers a less dominant person (may
and concerns as other age involve sexual harassment or power struggles).
groups. The nurse also Whistle blowing involves reporting illegal or
comments that most older unethical behavior in the workplace. Racism is
adults have "outlived their prejudice against other races and ethnic groups.
usefulness." What is the term

for this type of prejudice?
Chapter 19
a. Harassment
b. Whistle blowing
c. Racism
d. Ageism
Fundamentals Final
A nurse who is caring for older Exam Practice FINAL
b, d, e. Exposure to sun over the years can cause a
Study
adults in a senior daycare patient's skin to be pigmented. Bone
center documents findings as demineralization occurs with aging, causing bones
related to which normal aging to become porous and brittle, making fractures
process? Select all that apply.
more common. The blood vessels in the dermis
become more fragile, causing an increase in
a. A patient's increased skin bruising and purpura. Wrinkling and sagging of skin
elasticity causes wrinkles on occur with decreased skin elasticity. A patient's
the face and arms.
toenails may become thicker, with a yellowish tint to
b. Exposure to sun over the the nail beds. Bladder capacity decreases by 50%,
years causes a patient's skin to making voiding more frequent; two or three times a
be pigmented.
night is usual.
c. A patient's toenails have

become thinner with a bluish Chapter 19
tint to the nail beds.
d. A patient experiences a hip

fracture due to porous and
brittle bones.
e. Fragile blood vessels in the

dermis allow for more easy
bruising of a patient's forearm.
f. Increased bladder capacity

causes decreased voiding in an
older patient.

A nursing instructor teaching FINALtime may be longer,
c. Although response Study
classes in gerontology to nurs- intelligence does not normally decrease because of
ing students discusses myths aging. Most older adults own their own homes, and
related to the aging of adults. although sexual activity may be less frequent, the
Which statement is a myth ability to perform and enjoy sexual activity lasts well
about older adults?
into the 90s in healthy older adults. Older adults
want to be attractive to others.
a. Most older adults live in their

own homes.
Chapter 19
b. Healthy older adults enjoy
sexual activity.
c. Old age means mental

deterioration.
d. Older adults want to be

attractive to others.
What is the leading cause of c. Alzheimer disease is the most common

cognitive impairment in old degenerative neurologic illness and the most
age?
common cause of cognitive impairment. It is
irreversible, progressing from deficits in memory
a. Stroke
and thinking skills to an inability to perform even the
b. Malnutrition
simplest of tasks.
c. Alzheimer disease
d. Loss of cardiac reserve Chapter 19
Fundamentals
a. Asking questions about events in the past can
Study
year-old female patient who is encourage the older adult to relive and restructure
living in a long-term care life experiences.
facility. To help this patient

adapt to her present Chapter 19
circumstances, the nurse is
using reminiscence as therapy.
Which question would
encourage reminiscence?
a. "Tell me about how you

celebrated Christmas when
you were young."
b. "Tell me how you plan to

spend your time this weekend."
c. "Did you enjoy the choral

group that performed here
yesterday?
d. "Why don't you want to talk

about your feelings?"
Following a fall that left an b, d, f. The SPICES acronym is used to identify

elderly male patient common problems in older adults and stands for:
temporarily bedridden, the

nurse is using the SPICES S - Sleep disorders
assessment tool to evaluate P - Problems with eating or feeding
him for cascade iatrogenesis. I - Incontinence
Which are correct aspects of C - Confusion
this tool? Select all that apply.

E - Evidence of falls
S - Skin breakdown (Fulmer & Wallace, 2012).
a. S - Senility
b. P - Problems with feeding

Chapter 19
c. I - Irritableness
d. C - Confusion
e. E - Edema of the legs
f. S - Skin breakdown
Fundamentals Final
During rounds, a charge nurse Exam Practice
d. The chargeFINAL
nurse should direct the patient care
Study
hears the patient care techni- techni- cian to determine the patient's safety. Then
cian yelling loudly to a patient the nurse should address any concerns regarding
regarding a transfer from the the patient care technician's communication
bed to chair. When entering techniques privately. The nurse should direct the
the room, what is the nurse's patient care technician on aspects of therapeutic
best response?
communication.
a. "You need to speak to the Chapter 20

patient quietly. You are
disturbing the patient."
b. "Let me help you with your

transfer technique."
c. "When you are finished, be

sure to apologize for your
rough demeanor."
d. "When your patient is safe

and comfortable, meet me at
the desk."
A public health nurse is leaving a. The nurse must maintain confidentiality when
the home of a young mother providing care. The statement "New mothers need
who has a special needs baby. support" is a general statement that all new parents
The neighbor states, "How is need help. The statement is not judgmental of the
she doing, since the baby's family's roles.
father is no help?" What is the

nurse's best response to the Chapter 20
neighbor?
a. "New mothers need

support."
b. "The lack of a father is

difficult."
c. "How are you today?"
d. "It is a very sad situation."

A 3-year-old child is being d. The use of FINAL
the clarifying question or comment
Study
admitted to a medical division allows the nurse to gain an understanding of a
for vomiting, diarrhea, and patient's comment. When used properly, this
dehydration. During the admis- technique can avert possible misconcep- tions that
sion interview, the nurse should could lead to an inappropriate nursing diagnosis.
implement which commu- The reflective question technique involves repeating
nication techniques to elicit the what the person has said or describing the person's
most information from the feelings. Open- ended questions encourage free
parents?
verbalization and expression of what the parents
believe to be true. Assertive behavior is the ability to
a. The use of reflective stand up for oneself and others using open, hon-
questions
est, and direct communication.
b. The use of closed questions
c. The use of assertive Chapter 20

questions
d. The use of clarifying

questions
A nurse enters a patient's room d. The nurse should identify himself, be sure the
and examines the patient's IV patient knows what will be happening, and the time
fluids and cardiac monitor. The period he will be with his patient.
patient states, "Well, I haven't

seen you before. Who are Chapter 20
you?" What is the nurse's best
response?
a. "I'm just the IV therapist

checking your IV."
b. "I've been transferred to this

division and will be caring for
you."
c. "I'm sorry, my name is John

Smith and I am your nurse."
d. "My name is John Smith, I am

your nurse and I'll be caring for
you until 11 p.m."
Fundamentals Final
A nurse enters the room of a Exam Practice
d. The use of FINAL
touch conveys acceptance, and the
Study
patient with cancer. The patient implementation of an open-ended question allows
is crying and states, "I feel so the patient time to verbalize freely.
alone." Which statement is the

most therapeutic?
Chapter 20
a. The nurse stands at the

patient's bedside and states, "I
understand how you feel. My
mother said the same thing
when she was ill."
b. The nurse places a hand on

the patient's arm and states,
"You feel so alone."
c. The nurse stands in the

patient's room and asks, "Why
do you feel so alone? Your wife
has been here every day."
d. The nurse holds the patient's

hand and asks, "What makes
you feel so alone?"

A nurse caring for a patient FINAL
a. The termination phase occurs when the Study
who is hospitalized following a conclusion of the initial agreement is
double mastectomy is acknowledged. Discharge planning coordinates
preparing a discharge plan for with the termination phase of a helping relationship.
the patient. Which action The nurse should determine the progress made in
should be the focus of this achieving the goals related to the patient's care.
termination phase of the

helping relationship?
Chapter 20
a. Determining the progress

made in achieving established
goals
b. Clarifying when the patient

should take medications c.
Reporting the progress made
in teaching to the staff d.
Including all family members in
the teaching session

A nursing student is nervous FINAL
c. By engaging in self-talk, or intrapersonal Study
and concerned about the work communication, the nursing student can plan her
she is about to do at the clinical day and enhance her clinical performance to
facility. To allay anxiety and be decrease fear and anxiety.
successful in her provision of

care, it is most important for Chapter 20
her to:
a. Determine the established

goals of the institution
b. Be sure her verbal and

nonverbal communication is
congruent
c. Engage in self-talk to plan

her day and decrease her fear
d. Speak with her fellow

colleagues about how they feel

A nurse in the rehabilitation FINAL
b. Effective communication by the sender involves
Study
division states to her head the implementation of nonthreatening information
nurse, Mr. Tyler, "I need the day by showing respect to the receiver. The nurse
off and you didn't give it to should identify the subject of the meeting and be
me!" The head nurse replies, sure it occurs at a mutually agreed upon time.
"Well, I wasn't aware you

needed the day off, and it isn't Chapter 20
possible since staffing is so
inadequate." Instead of this
exchange, what communication
by the nurse would have been
more effective?
a. "Mr. Tyler, I placed a request

to have August 8th off, but I'm
working and I have a doctor's
appointment."
b. "Mr. Tyler, I would like to

discuss my schedule with you. I
requested the 8th of August off
for a doctor's appointment.
Could I make an
appointment?"
c. "Mr. Tyler, I will need to call

in on the 8th of August
because I have a doctor's
appointment."
d. "Mr. Tyler, since you didn't

give me the 8th of August off,
will I need to find someone to
work for me?"

During a nursing staff meeting, FINAL
a, d, e, f. Solving problems involves group decision
Study
the nurses resolve a problem making; ascertaining that the staff completes a task
of delayed documentation by on time and that all members agree the task is
agreeing unanimously that they important is a characteristic of group identity; group
will make sure all vital signs are patterns of interaction involve honest
reported and charted within 15 communication and member support; and
minutes following assessment. cohesiveness occurs when members generally trust
This is an example of which each other, have a high commitment to the group,
characteristics of effective and a high degree of cooperation. Group leadership
communication? Select all that occurs when groups use effective styles of
apply.
leadership to meet goals; with group power,
sources of power are recognized and used
a. Group decision making b. appropriately to accomplish group outcomes.
Group leadership
c. Group power
Chapter 20
d. Group identity
e. Group patterns of interaction

f. Group cohesiveness
A nurse sees a patient walking a. A patient who presents with nonverbal

to the bathroom with a communication of a stooped gait, facial grimacing,
stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain.
and gasping sounds. It is The nurse should clarify this nonverbal behavior.
important that the nurse assess

the patient for:
Chapter 20
a. Pain
b. Anxiety
c. Depression
d. Fluid volume deficit

A nursing student is preparing FINAL
b. The nurse should ask permission to assist theStudy
to administer morning care to a patient with a bath. This allows for consent to assist
patient. What is the most the patient with care that invades the patient's
important question that the private zones.
nursing student should ask

the patient about personal Chapter 20
hygiene?
a. "Would you prefer a bath or

a shower?"
b. "May I help you with a bed

bath now or later this
morning?"
c. "I will be giving you your

bath. Do you use soap or
shower gel?"
d. "I prefer a shower in the

evening. When would you like
your bath?"
A nurse is providing instruction b. The patient's question allows the nurse to clarify
to a patient regarding the information that is new to the patient or that
procedure to change his requires further explanation.
colostomy bag. During the

teaching session, he asks, Chapter 20
"What type of foods should I
avoid to prevent gas?" The
patient's question allows for
what type of communication?
a. A closed-ended answer
b. Information clarification
c. The nurse to give advice
d. Assertive behavior
Fundamentals
When interacting with aFinal
patient,Exam Practice FINAL
a. Telling a patient that everything is going to be all
Study
the nurse answers, "I am sure right is a cliché. This statement gives false assurance
everything will be fine. You and gives the patient the impression that the nurse is
have nothing to worry about." not interested in the patient's condition.
This is an example of what type

of inappropriate com- Chapter 20
munication technique?
a. Cliché
b. Giving advice
c. Being judgmental
d. Changing the subject
A 76-year-old patient states, "I d. Requesting specific information regarding

have been experiencing com- complications of diabetes will elicit specific
plications of diabetes." The information to guide the nurse in further interview
nurse needs to direct the questions and specific assessment techniques.
patient to gain more

information. What is the most Chapter 20
appropriate comment or
question to elicit additional
information?
a. "Do you take two injections

of insulin to decrease the
complications?"
b. "Most physicians
recommend diet and exercise
to regulate blood sugar."
c. "Most complications of
diabetes are related to
neuropathy."
d. "What specific complications

have you experienced?"
Fundamentals Final
During an interaction with a Exam Practice FINAL
c, d, e. The nurse can use silence appropriatelyStudy
by
patient diagnosed with taking the time to wait for the patient to initiate or to
epilepsy, a nurse notes that the continue speak- ing. During periods of silence, the
patient is silent after she nurse should reflect on what has already been
communicates the plan of care. shared and observe the patient without having to
What would be appropriate concentrate simultaneously on the spoken word. In
nurse responses in this due time, the nurse might discuss the silence with
situation? Select all that apply.
the patient in order to understand its meaning. Also,
the patient's culture may require longer pauses
a. Fill the silence with lighter between verbal communication. Fear of silence
conversation directed at the sometimes leads to too much talking by the nurse,
patient.
and excessive talking tends to place the focus on
b. Use the time to perform the the nurse rather than on the patient. The nurse
care that is needed uninter- should not assume silence requires a consult with a
rupted.
counselor.
c. Discuss the silence with the

patient to ascertain its mean- Chapter 20
ing.
d. Allow the patient time to

think and explore inner
thoughts.
e. Determine if the patient's

culture requires pauses
between
conversation.
f. Arrange for a counselor to

help the patient cope with
emotional issues.

b. Teaching first aid is a function of the goal toStudy
prevent illness. Promoting health involves helping
A nurse is teaching first aid to
patients to value health and develop specific health
counselors of a summer camp
practices that promote wellness. Restoring health
for children with asthma. This is
occurs once a patient is ill, and teaching focuses on
an example of what aim of
developing self-care practices that promote
health teaching?
recovery. When facilitating coping, nurses help

patients come to terms with whatever lifestyle
a. Promoting health
modification is needed for their recovery or to

b. Preventing illness
enable them to cope with permanent health

c. Restoring health
alterations.
d. Facilitating coping
Chapter 21
Fundamentals Final
A nurse is teaching patients of Exam Practice FINAL
c, d, e. Successful teaching plans for older adults
Study
all ages in a hospital setting. incorpo- rate extra time, short teaching sessions,
Which examples demonstrate accommodation for sensory deficits, and reduction
teaching that is appropriately of environmental distractions. Older adults also
based on the patient's benefit from instruction that relates new information
developmental level? Select all to familiar activities or information. School-
that apply.
aged children are capable of logical reasoning and
should be included in the teaching-learning process
a. The nurse plans long whenever possible; they are also open to new
teaching sessions to discuss learning experiences but need learning to be
diet modifications for an older reinforced by either a parent or health care provider
adult diagnosed with type 2 as they become more involved with their friends and
diabetes.
school activities. Teaching strategies designed for an
b. The nurse recognizes that a adolescent patient should recognize the
female adolescent diagnosed adolescent's need for independence, as well as
with anorexia is still dependent the need to establish a trusting relationship that
on her parents and includes demonstrates respect for the adolescent's opinions.
them in all teaching sessions.
c. The nurse designs an Chapter 21

exercise program for a
sedentary older adult male
patient based on the activities
he prefers.
d. The nurse includes an 8-

year-old patient in the teaching
plan for managing cystic
fibrosis.
e. The nurse demonstrates how

to use an inhaler to an 11-year-
old male patient and includes
his mother in the session to
reinforce the teaching.
f. The nurse continues a

teaching session on STIs for a
sexu- ally active male
adolescent despite his protest
that "I've heard enough

Fundamentals
already!" Final Exam Practice FINAL Study
c. The teach-back tool is a method of assessing

literacy and confirming that the learner understands
A nurse is teaching a 50-year- health informa-
old male patient how to care tion received from a health professional. The Ask Me
for his new ostomy appliance. 3 is a brief tool intended to promote understanding
Which teaching aid would be and improve communication between patients and
most appropriate to confirm their providers. The Newest Vital Sign (NVS) is a
that the patient has learned the reliable screening tool to assess low health literacy,
information?
developed to improve communications between
patients and providers. The TEACH acronym is used
a. Ask Me 3
to maximize the effectiveness of patient teaching by
b. Newest Vital Sign
tuning into the patient, editing patient information,
c. Teach-back tool
acting on every teaching moment, clarifying often,
d. TEACH acronym and honoring the patient as a partner in the process.
Chapter 21

A nurse is planning teaching FINAL
b, d, f. Affective learning includes changes in Study
strategies for patients addicted attitudes, values, and feelings (e.g., the patient
to alcohol, in the affective expresses renewed self-confidence to be able to
domain of learning. What are give up drinking). Cognitive learning involves the
examples of strategies storing and recalling of new knowledge in the brain,
promoting behaviors in this such as the learning that occurs during a lecture or
domain? Select all that apply.
by using a pamphlet for teaching. Learning a
physical skill involving the integration of mental and
a. The nurse prepares a lecture muscular activity is called psychomotor learning,
on the harmful long-term which may involve a return demonstration of a skill.
effects of alcohol on the body.
b. The nurse explores the Chapter 21

reasons alcoholics drink and
promotes other methods of
coping with problems.
c. The nurse asks patients for a

return demonstration for using
relaxation exercises to relieve
stress.
d. The nurse helps patients to

reaffirm their feelings of self-
worth and relate this to their
addiction problem.
e. The nurse uses a pamphlet to

discuss the tenants of the
Alcoholics Anonymous
program to patients.
f. The nurse reinforces the

mental benefits of gaining self-
control over an addiction.

a. Demonstration of techniques, procedures, Study
exercises, and the use of special equipment is an
A nurse is preparing to teach a effective patient teaching strategy for a skill. Lecture
45-year-old male patient with can be used to deliver information to a large group
asthma how to use his inhaler. of patients but is more effective when the session is
Which teaching tool is one of interactive; it is rarely used for individual instruc-
the best methods to teach the tion, except in combination with other strategies.
patient this skill?
Discovery is a good method for teaching problem-
solving techniques and independent thinking. Panel
a. Demonstration
discussions can be used to impart factual material
b. Lecture
but are also effective for sharing experiences and
c. Discovery
emotions.
d. Panel session
Chapter 21
A nurse has taught a diabetic b. The nurse cannot assume that the patient has
patient how to administer his actually learned the content unless there is some
daily insulin. The nurse should type of proof of learning. The key to evaluation is
evaluate the teaching-learning meeting the learner outcomes stated in the
process by:
teaching plan.
a. Determining the patient's Chapter 21

motivation to learn
b. Deciding if the learning

outcomes have been achieved
c. Allowing the patient to

practice the skill he has just
learned
d. Documenting the teaching

session in the patient's medical
record
Fundamentals Final
A registered nurse assumes theExam Practice FINAL
a. A nurse coach establishes a partnership withStudy
a
role of nurse coach to provide patient and, using discovery, facilitates the
teaching to patients who are identification of the patient's personal goals and
recovering from strokes. One agenda to lead to change rather than using teaching
example of an intervention the and education strategies with the nurse as the
nurse may provide related to expert. A nurse coach explores the patient's
this role is:
readiness for coaching, designs the structure of a
coaching session, supports the achievement of the
a. The nurse uses discovery to patient's desired goals, and with the patient
identify the patients' personal determines how to evaluate the attainment of
goals and create an agenda patient goals.
that will result in change.
b. The nurse is the expert in Chapter 21

providing teaching and
education strategies to provide
dietary and activity
modifications.
c. The nurse becomes a mentor

to the patients and encour-
ages them to create their own
fitness programs.
d. The nurse assumes an

authoritative role to design the
structure of the coaching
session and support the
achievement of patient goals.
Fundamentals
A nurse is counseling aFinal
19-year-Exam Practice
d. This answerFINAL
communicates respect and sensitivity
Study
old male athlete who had his to the patient's needs and offers an opportunity to
right leg amputated below the discuss his feelings with the nurse or another
knee following a motorcycle health care professional. The other answers do not
accident. During the allow the patient to express his feelings and receive
rehabilitation process, the the counseling he needs.
patient refuses to eat or get up

to ambulate on his own. He Chapter 21
says to the nurse, "What's the
point. My life is over now and
I'll never be the football player
I dreamed of becoming." What
is the nurse counselor's best
response to this patient?
a. "You're young and have your

whole life ahead of you. You
should focus on your
rehabilitation and make
something of your life."
b. "I understand how you must

feel. I wanted to be a famous
singer, but I wasn't born with
the talent to be successful at it."
c. "You should concentrate on

other sports that you could
play even with a prosthesis."
d. "I understand this is difficult

for you. Would you like to talk
about it now or would you
prefer me to make a referral
to someone else?"

A nurse is caring for a 42-year- b. Short-termFINAL
counseling might be used during a
Study
old male patient who is situational crisis, which occurs when a patient faces
admitted to the hospital with an event or situation that causes a disruption in life,
injuries sustained in a motor such as a flood. Long-term counseling extends over
vehicle accident. While he is in a prolonged period; a patient experiencing a
the hospital, his wife tells him developmental crisis, for example, might need long-
that the bottom level of their term counseling. Motivational interviewing is an
house flooded, damaging their evidence- based counseling approach that involves
belongings. When the nurse discussing feelings and incentives with the patient. A
enters his room, she notes that caring nurse can motivate patients to become
the patient is visibly upset. The interested in promoting their own health.
nurse is aware that the patient

will most likely be in need of Chapter 21
which type of counseling?
a. Long-term developmental
b. Short-term situational
c. Short-term motivational
d. Long-term motivational
Fundamentals Final
A nurse who is caring for a Exam Practice FINAL
b. A contractual agreement is a pact two people
Study
morbidly obese male teenager make setting out mutually agreed-on goals.
forms a contractual agreement Contracts are usually informal and not legally
with him to achieve his weight binding. When teaching a patient, such an
goals. Which statement best agreement can help motivate both the patient and
describes the nature of this the teacher to do what is necessary to meet the
agreement?
patient's learning outcomes. The agreement notes
the responsibilities of both the teacher and the
a. "This agreement forms a learner, emphasizing the importance of the mutual
legal bond between the two of commitment.
us to achieve your weight

goals."
Chapter 21
b. "This agreement will motivate
the two of us to do what is
necessary to meet your weight
goals."
c. "This agreement will help us

determine what learning
outcomes are necessary to
achieve your weight goals."
d. "This agreement will limit the

scope of the teaching session
and make stated weight goals
more attainable."
Fundamentals
A nurse is following theFinal Exam Practice
c. According FINAL
to the principles of medical asepsis,
Study
principles of medical asepsis the nurse should move equipment away from the
when performing patient care body when brush- ing, scrubbing, or dusting articles
in a hospital setting. Which to prevent contaminated particles from settling on
nursing action performed by the hair, face, or uniform. The nurse should carry
the nurse follows these soiled items away from the body to prevent them
recommended guidelines?
from touching the clothing. The nurse should not
put soiled items on the floor, as it is highly
a. The nurse carries the contaminated. The nurse should also clean the least
patients' soiled bed linens soiled areas first and then move to the more soiled
close to the body to prevent ones to prevent having the cleaner areas soiled by
spreading microorganisms into the dirtier areas.
the air.
b. The nurse places soiled bed Chapter 23

linens and hospital gowns on
the floor when making the bed.
c. The nurse moves the patient

table away from the nurse's
body when wiping it off after a
meal.
d. The nurse cleans the most

soiled items in the patient's
bathroom first and follows with
the cleaner items.

A school nurse is performing b. During theFINAL
prodromal stage, the person hasStudy
an assessment of a student vague signs and symptoms, such as fatigue and a
who states: "I'm too tired to low-grade fever. There are no obvious symptoms of
keep my head up in class." The infection during the incubation period, and they are
student has a low-grade fever. more specific during the full stage of illness,
The nurse would interpret before disappearing by the convalescent period.
these findings as indicating

which stage of infection?
Chapter 23
a. Incubation period
b. Prodromal stage
c. Full stage of illness
d. Convalescent period

A nurse is caring for patients FINAL
a, c, d, f. It is recommended to use an alcohol-based
Study
an isolation ward. In which handrub in the following situations: before direct
situations would the nurse contact with patients; after direct contact with
appropriately use an alcohol- patient skin; after contact with body fluids if hands
based handrub to are not visibly soiled; after removing gloves;
decontaminate the hands? before inserting urinary catheters, peripheral
vascular catheters, or invasive devices that do not
require surgical placement; before donning sterile
a. The nurse is providing a bed gloves prior to an invasive procedure; if moving
bath for a patient. from a contaminated body site to a clean body site;
b. The nurse has visibly soiled and after contact with objects contaminated by
hands after changing the the patient.
bedding of a patient.
c. The nurse removes gloves Chapter 23

when patient care is
completed.
d. The nurse is inserting a

urinary catheter for a female
patient.
e. The nurse is assisting with a

surgical placement of a
cardiac stent.
f. The nurse removes old

magazines from a patient's
table.

A nurse is performing hand b, e, f. ProperFINAL
hand hygiene includes removingStudy
hygiene after providing patient jewelry with the exception of a plain wedding band,
care. The nurse's hands are not wetting the hands and wrist area with the hands
visibly soiled. Which steps in lower than the elbows, using about one teaspoon of
this procedure are performed liquid soap, using friction motion for at least 15
correctly? Select all that apply.
seconds, washing to one inch above the wrists with
a friction motion for at least 15 seconds, and
a. The nurse removes all rinsing thoroughly with water flowing toward
jewelry including a platinum fingertips.
wedding band.
b. The nurse washes hands to Chapter 23

one inch above the wrists.
c. The nurse uses

approximately two teaspoons
of liquid soap.
d. The nurse keeps hands

higher than elbows when
placing under faucet.
e. The nurse uses friction

motion when washing for at
least 15 seconds.
f. The nurse rinses thoroughly

with water flowing toward
fingertips.
Fundamentals
The nurse has opened Final
the Exam Practice FINAL
d. Considering the outer inch of a sterile field Study
as
sterile supplies and put on two contaminated is a principle of surgical asepsis.
sterile gloves to complete a Moisture such as from splashes contaminates the
sterile dressing change, a sterile field, and sneezing would contaminate the
procedure that requires sterile gloves. Forceps soaked in disinfectant are not
surgical asepsis. The nurse considered sterile.
must:
Chapter 23
a. Keep splashes on the sterile
field to a minimum.
b. Cover the nose and mouth

with gloved hands if a sneeze is
imminent.
c. Use forceps soaked in a

disinfectant.
d. Consider the outer 1 inch of

the sterile field as
contaminated.
The nurse caring for patients in d. Standard precautions apply to all patients
a hospital setting institutes receiving care in hospitals, regardless of their
CDC standard precaution diagnosis or possible infection status. These
recommendations for which recommendations include blood; all body fluids,
category of patients?
secretions, and excretions except sweat; nonintact
skin; and mucous membranes.
a. Only patients with diagnosed

infections
Chapter 23
b. Only patients with visible
blood, body fluids, or sweat
c. Only patients with nonintact

skin
d. All patients receiving care in
hospitals
Fundamentals
In addition to standardFinal Exam Practice FINAL
a, b, f. Rubella, diphtheria, and adenovirus infection
Study
precautions, the nurse would are illnesses transmitted by large-particle droplets
initiate droplet precautions and require droplet precautions in addition to
for which patients? Select all standard precautions. Air- borne precautions are
that apply.
used for patients who have infections spread
through the air with small particles, for example,
a. A patient diagnosed with tuberculosis, varicella, and rubeola. Contact
rubella
precautions are used for patients who are infected
b. A patient diagnosed with or colonized by a multidrug-resistant organism
diptheria
(MDRO), such as MRSA.
c. A patient diagnosed with

varicella
Chapter 23
d. A patient diagnosed with
tuberculosis
e. A patient diagnosed with

MRSA
f. An infant diagnosed with

adenovirus infection

A nurse is preparing a sterile FINAL
c. If the patient touches a sterile field, the nurse
Study
field using a packaged sterile should discard the supplies and prepare a new
drape for a confused patient sterile field. If the patient is confused, the nurse
who is scheduled for a surgical should have someone assist by holding the patient's
procedure. When setting up hand and reinforcing what is happening.
the field, the patient

accidentally touches an Chapter 23
instrument in the sterile field.
What is the appropriate
nursing action in this situation?
a. Ask another nurse to hold

the hand of the patient and
continue setting up the field.
b. Remove the instrument that

was touched by the patient and
continue setting up the sterile
field.
c. Discard the supplies and

prepare a new sterile field with
another person holding the
patient's hand.
d. No action is necessary since

the patient has touched his or
her own sterile field.
Fundamentals
A nurse who created a Final
sterile Exam Practice FINAL
d. To add a sterile solution to a sterile field, theStudy
field for a patient is adding a nurse would open the solution container according
sterile solution to the field. to directions and place the cap on the table away
What is an appropriate action from the field with the edges up. The nurse would
when performing this task?
then hold the bottle outside the edge of the sterile
field with the label side facing the palm of the hand
a. Place the bottle cap on the and prepare to pour from a height of 4 to 6 inches
table with the edges down.
(10 to 15 cm).
b. Hold the bottle inside the

edge of the sterile field.
Chapter 23
c. Hold the bottle with the
label side opposite the palm of
the hand.
d. Pour the solution from a

height of 4 to 6 inches (10 to 15
cm).
A nurse is finished with patient c. If an impervious gown has been tied in front of
care. How would the nurse the body at the waist, the nurse should untie the
remove PPE when leaving the waist strings before removing gloves. Gloves are
room?
always removed first because they are most likely to
be contaminated, followed by the goggles, gown,
a. Remove gown, goggles, and mask, and hands should be washed thoroughly
mask, gloves, and exit the after the equipment has been removed and before
room.
leaving the room.
b. Remove gloves, perform

hand hygiene, then remove Chapter 23
gown, mask, and goggles.
c. Untie gown waiststrings,

remove gloves, goggles, gown,
mask; perform hand hygiene.
d. Remove goggles, mask,

gloves, gown, and perform
hand hygiene
Fundamentals Final
A nurse who is caring for a Exam Practice FINALinjury occurs, the nurse Study
b. When a needlestick
patient diagnosed with should wash the exposed area immediately with
HIV/AIDS incurs a needlestick warm water and soap, report the incident to the
injury when administering the appropriate person and complete an incident injury
patient's medications. What report, consent to and await the results of blood
would be the priority action of tests, consent to postexposure prophylaxis, and
the nurse following the attend counseling sessions regarding safe practice
exposure?
to protect self and others.
a. Report the incident to the Chapter 23

appropriate person and file an
incident report.
b. Wash the exposed area with

warm water and soap.
c. Consent to postexposure
prophylaxis at appropriate
time.
d. Set up counseling sessions

regarding safe practice to
protect self.
Fundamentals Final
The nurse assesses patients to Exam Practice
c. Indwelling FINAL
urinary catheters have been implicated
Study
determine their risk for health in most health care-associated infections. Cigarette
care-associated infections. smoking, a normal white blood cell count, and a
Which hospitalized patient is vegetarian diet have not been implicated as risk
most at risk for developing this factors for HAIs.
type of infection?
Chapter 23
a. A 60-year-old patient who
smokes two packs of cigarettes
daily
b. A 40-year-old patient who

has a white blood cell count of
6,000/mm3
c. A 65-year-old patient who

has an indwelling urinary
catheter in place
d. A 60-year-old patient who is

a vegetarian and slightly
underweight
Fundamentals
obese Exam Practice
d. The priorityFINAL
diagnosis in this situation is the Study
62-year-old patient with arthri- possibility of an infection developing in the open
tis who has developed an open skin area. The others may be potential or probable
reddened area over his sacrum. diagnoses for this patient and may also require
What is a priority nursing nursing interventions after the first diagnosis is
diagnosis for this patient?
addressed.
a. Imbalanced Nutrition: More Chapter 23

Than Body Requirements
related to immobility
b. Impaired Physical Mobility

related to pain and discomfort
c. Chronic Pain related to

immobility
d. Risk for Infection related to

altered skin integrity
A nurse teaches a patient at b. In the home setting, where the patient's

home to use clean technique environment is more controlled, medical asepsis is
when changing a wound usually recommended, with the exception of self-
dressing. This practice is injection. This is the appropriate procedure for the
considered:
home and is neither unethical nor grossly negligent.
a. The nurse's preference

Chapter 23
b. Safe for the home setting
c. Unethical behavior
d. Grossly negligent

A nurse is using personal b. When usingFINAL
PPE, the nurse should work from
Study
protective equipment (PPE) "clean" areas to "dirty" ones, put on PPE before
when bathing a patient entering the patient room, always use goggles
diagnosed with C. difficile instead of personal glasses, and remove PPE in the
infection. Which nursing action doorway or anteroom.
related to this activity promotes

safe, effective patient care?
Chapter 23
a. The nurse puts on PPE after

entering the patient room.
b. The nurse works from "clean"

areas to "dirty" areas during
bath.
c. The nurse personalizes the

care by substituting glasses for
goggles.
d. The nurse removes PPE prior

to leaving the patient room.
A nurse assesses an oral d. Afebrile means without fever. This temperature is

temperature for an adult within the normal range for an adult. Fever (pyrexia)
patient. The patient's is an elevation of body temperature; a person with
temperature is 37.5°C (99.5°F). fever is said to be febrile. Hypothermia is a low
What term would the nurse use body temperature and hyperthermia is a high body
to report this temperature?
temperature.
a. Febrile
Chapter 24
b. Hypothermia
c. Hypertension
d. Afebrile
Fundamentals
A nurse is assessing theFinal
vital Exam Practice FINAL
a, d, e, f. The normal temperature range for infants
Studyis
signs of patients who 37.1°C to 38.1°C (98.7°F-100.5°F). The normal pulse
presented at the emergency rate for an adolescent is 55 to 105. The normal
department. Based on the respiratory rate for an adult is 12 to 20 bpm and the
knowledge of age-related normal pulse for an older adult is 40 to 100 bpm.
variations in normal vital signs, The normal blood pressure for a toddler is 89/46
which patients would the nurse and the normal temperature for a child is 36.8°C to
document as having a normal 37.8°C (98.2°F-100°F; refer to Table 24-1, Age-
vital sign? Select all that apply.
Related Variations in Normal Vital Signs).
a. A 4-month old infant whose Chapter 24

temperature is 38.1°C (100.5°F)
b. A 3-year old whose blood

pressure is 118/80
c. A 9-year old whose

temperature is 39°C (102.2°F)
d. An adolescent whose pulse

rate is 70 bpm
e. An adult whose respiratory

rate is 20 bpm
f. A 72-year old whose pulse

rate is 42 bpm
a. Evaporation is the conversion of a liquid to a

A patient who is febrile may vapor as occurs when body fluid in the form of
lose body heat through perspiration is vapor- ized from the skin. With
perspiration. The nurse convection, the heat is disseminated by motion
recognizes that this is an between areas of unequal density, for example, the
example of what mechanism of action of a fan blowing cool air over the body. An
heat loss?
example of radiation (diffusion of heat by
electromagnetic waves) is the body giving off heat
a. Evaporation
from uncovered areas. In conduction, the heat is
b. Convection
transferred to another object during direct contact,
c. Radiation
for example, body heat melting an ice pack.
d. Conduction
Chapter 24
Fundamentals
The rectal temperature,Final
a core Exam Practice
a, c, d, e. The FINAL
rectal site should not be used in Study
temperature, is considered to newborns, children with diarrhea, and in patients
be one of the most accurate who have undergone rectal surgery. The insertion of
routes. In which cases would the thermometer can slow the heart rate by
taking a rectal temperature be stimulating the vagus nerve, thus patients post-MI
contraindicated? Select all that should not have a rectal temperature taken.
apply.
Assessing a rectal temperature is also
contraindicated in patients who are neutropenic
a. A newborn who has (have low white blood cell counts, such as in
hypothermia
leukemia), in patients who have certain neurologic
b. A child who has pneumonia
disorders, and in patients with low platelet counts.
c. An older patient who is post

myocardial infarction
Chapter 24
(heart attack)
d. A teenager who has

leukemia
e. A patient receiving
erythropoietin to replace red
blood cells
f. An adult patient who is newly

diagnosed with pancreatitis
While taking an adult patient's d. A rate of 140 beats/min in an adult is an abnormal

pulse, a nurse finds the rate to pulse and should be reported to the primary care
be 140 beats/min. What should provider or the nurse in charge of the patient.
the nurse do next?
a. Check the pulse again in 2 Chapter 24

hours.
b. Check the blood pressure.
c. Record the information.
d. Report the rate to the

primary care provider.
Fundamentals
A patient complains of Final
severe Exam Practice FINAL
a, e. The pulse often increases when a person Study
is
abdominal pain. When assess- experiencing pain. Pain does not affect body
ing the vital signs, the nurse temperature and may increase (not decrease) blood
would not be surprised to find pressure. Acute pain may increase respiratory rate
what assessments? Select all but decrease respiratory depth.
that apply.
Chapter 24
a. An increase in the pulse rate
b. A decrease in body
temperature
c. A decrease in blood
pressure
d. An increase in respiratory
depth
e. An increase in respiratory
rate
f. An increase in body
temperature
Two nurses are taking an a. The difference between the apical and radial
apical-radial pulse and note a pulse rate is called the pulse deficit.
difference in pulse rate of 8

beats per minute. The nurse Chapter 24
would document this
difference as which of the
following?
a. Pulse deficit
b. Pulse amplitude
c. Ventricular rhythm
d. Heart arrhythmia

The nurse instructor is teaching FINAL
b, c, e, f. Blood pressure increases with age due to a
Study
student nurses about the decreased elasticity of the arteries, increasing
factors that may affect a peripheral resistance. Blood pressure is usually
patient's blood pressure. Which lowest on arising in the morning. Women usually
statements accurately have lower blood pressure than men until
describe these factors? Select menopause occurs. Blood pressure increases after
all that apply.
eating food. Blood pressure tends to be lower in the
prone or supine position. Increased blood pressure
a. Blood pressure decreases is more prevalent and severe in Afri- can American
with age.
men and women.
b. Blood pressure is usually

lowest on arising in the Chapter 24
morning.
c. Women usually have lower

blood pressure than men until
menopause.
d. Blood pressure decreases

after eating food.
e. Blood pressure tends to be

lower in the prone or supine
position.
f. Increased blood pressure is

more prevalent in African
Americans.
A patient is having dyspnea. b. Elevating the head of the bed allows the
What would the nurse do first?
abdominal organs to descend, giving the diaphragm
greater room for expansion and facilitating lung
a. Remove pillows from under expansion.
the head
b. Elevate the head of the bed

Chapter 24
c. Elevate the foot of the bed
d. Take the blood pressure
Fundamentals Final
A student nurse is learning to Exam Practice FINAL
b. Blood pressure is the measurement of the force
Study
assess blood pressure. What of blood against arterial walls.
does the blood pressure

measure?
Chapter 24
a. Flow of blood through the

circulation
b. Force of blood against

arterial walls
c. Force of blood against

venous walls
d. Flow of blood through the

heart
Fundamentals
Prioritization: Place theFinal Exam Practice FINAL
d, a, b, e, c. Phase I is characterized by the firstStudy
following descriptions of the appearance of faint but clear tapping sounds that
phases of Korotkoff sounds in gradually increase in intensity; the first tapping
order from Phase I to Phase V.
sound is the systolic pressure. Phase II is
characterized by muffled or swishing sounds, which
a. Characterized by muffled or may temporarily disappear, especially in
swishing sounds that may hypertensive people; the disappearance of the
temporarily disappear; also sound during the latter part of phase I and during
known as the auscultatory gap
phase II is called the auscultatory gap. Phase III is
b. Characterized by distinct, characterized by distinct, loud sounds as the blood
loud sounds as the blood flows flows relatively freely through an increasingly
relatively freely through an open artery. Phase IV is characterized by a distinct,
increasingly open artery
abrupt, muffling sound with a soft, blowing quality;
c. The last sound heard before in adults, the onset of this phase is considered to be
a period of continuous silence, the first diastolic pressure. Phase V is the last sound
known as the second diastolic heard before a period of continuous silence; the
pressure
pressure at which the last sound is heard is the
d. Characterized by the first second diastolic pressure.
appearance of faint but clear

tap ping sounds that gradually Chapter 24
increase in intensity; known as
the systolic pressure
e. Characterized by a distinct,
abrupt, muffling sound with a
soft, blowing quality;
considered to be the first
diastolic pressure

A patient has a blood pressure FINAL
a. A single blood pressure reading that is mildly
Study
reading of 130/90 mm Hg when elevated is not significant, but the measurement
visiting a clinic. What would the should be taken again over time to determine if
nurse recommend to the hypertension is a problem. The nurse would
patient?
recommend a return visit to the clinic for a recheck.
a. Follow-up measurements of
blood pressure
Chapter 24
b. Immediate treatment by a
physician
c. No action, because the nurse

considers this reading is due to
anxiety
d. A change in dietary intake
A nurse is documenting a c.Thesystolicpressureis120mmHg.Thediastolicpressur

blood pressure of 120/80 mm eis 80 mm Hg, the lowest pressure present on
Hg. The nurse interprets the 120 arterial walls when the heart rests between beats.
to represent:
The difference between the systolic and diastolic
pressures is called the pulse pressure. The rhythmic
a. The rhythmic distention of distention of the arterial walls as a result of
the arterial walls as a result of increased pressure due to surges of blood with
increased pressure due to ventricular contraction is the pulse.
surges of blood with

ventricular contraction
Chapter 24
b. The lowest pressure present
on arterial walls while the
ventricles relax
c. The highest pressure present

on arterial walls while the
ventricles contract
d. The difference between the

pressure on arterial walls with
ventricular contraction and
relaxation

It is important to have the FINAL
a. A blood pressure cuff that is not the right size may
Study
appropriate cuff size when cause an incorrect reading.
taking the blood pressure.

What error may result from a Chapter 24
cuff that is too large or too
small?
a. An incorrect reading
b. Injury to the patient
c. Prolonged pressure on the

arm
d. Loss of Korotkoff sounds
A patient has intravenous fluids b. The blood pressure should be taken in the arm
infusing in the right arm. When opposite the one with the infusion.
taking a blood pressure on this

patient, what would the nurse Chapter 24
do in this situation?
a. Take the blood pressure in

the right arm
b. Take the blood pressure in

the left arm
c. Use the smallest possible

cuff
d. Report inability to take the

blood pressure

The nurse caring for patients FINAL
b, d, f. Risk factors for falls include age over 65Study
a long-term care facility knows years, docu- mented history of falls, postural
that there are factors that place hypotension, and unfamiliar environment. A
certain patients at a higher risk medication regimen that includes diuretics,
for falls. Which patients would tranquilizers, sedatives, hypnotics, or analgesics is
the nurse consider to be in this also a risk factor, not chemotherapy or antibiotics.
category? Select all that apply.
Chapter 26
a. A patient who is older than
60 years
b. A patient who has already

fallen twice
c. A patient who is taking

antibiotics
d. A patient who experiences

postural hypotension
e. A patient who is
experiencing nausea from
chemotherapy
f. A 70-year old patient who is

transferred to long-term care

A school nurse is teaching c, d, e. Of all FINAL
fire deaths in the United States, 85%
Study
parents about home safety and occur in the home (CDC, 2011a). Most fatal home
fires. What information would fires occur while people are sleeping, and most
be accurate to include in the people who die in house fires die of smoke
teaching plan? Select all that inhalation rather than burns. More than one-third of
apply.
home fire deaths occur in a home without a smoke
detector (CDC, 2011a). People with limited financial
a. 60% of U.S. fire deaths occur resources should be asked about how they heat
in the home.
their house because the electricity or gas may have
b. Most fatal fires occur when been turned off and space or kerosene heaters,
people are cooking.
wood stoves, or a fireplace may be the sole source
c. Most people who die in fires of heat. Being a single parent is not a risk factor for
die of smoke inhalation. fire occurrences.
d. Over 1/3 of fire deaths occur

in a home without a smoke Chapter 26
detector.
e. Fires are more likely to occur

in homes without electricity or
gas.
f. More fires occur in homes

occupied by single parents.
Fundamentals
A nurse is assessing theFinal Exam Practice FINAL
a. A young child may place small or loose parts in
Study
following children. Which child the mouth; a toy that is safe for a 9-year-old could
would the nurse identify as kill a toddler. An infant sleeping in a crib without a
having the greatest risk for pillow or large blanket and a 3-year-old and a 4-
choking and suffocating?
year-old drinking juice and eating yogurt are not
particular safety risks.
a. A toddler playing with his 9-

year-old brother's
Chapter 26
construction set
b. A 4-year-old eating yogurt

for lunch
c. An infant covered with a

small blanket and asleep in the
crib
d. A 3-year-old drinking a glass

of juice
While discussing home safety c. Because Mrs. Fuller is not aware that smoking in
with the nurse, a patient admits bed is extremely dangerous, she is at risk for
that she always smokes a suffocation from fire. The other three nursing
cigarette in bed before falling diagnoses are correctly stated but are not a priority
asleep at night. Which nursing in this situation.
diagnosis would be the priority

for this patient?
Chapter 26
a. Impaired Gas Exchange

related to cigarette smoking
b. Anxiety related to inability to

stop smoking
c. Risk for Suffocation related

to unfamiliarity with fire
prevention guidelines
d. Deficient Knowledge related

to lack of follow-through of
recommendation to stop
smoking

A nurse working in a busy FINAL
d. For the ingestion of drain opener, the nurseStudy
emergency department is should never induce vomiting; instead, the poison
caring for a teenage patient should be diluted with milk or water and the primary
who presents with a burning care provider should be called. For vitamin
pain in his mouth, edema of the preparations, stomach lavage is used to remove
lips, vomiting, and hemoptysis. undigested pills and for acetaminophen poisoning,
The teen admits that he was activated charcoal may be used.
playing a dare game with

friends and was forced to Chapter 26
swallow a drain opener
preparation. What would be
the nurse's priority
intervention?
a. Induce vomiting and call the

primary care provider.
b. Perform stomach lavage and

call the poison control
center.
c. Give activated charcoal

orally and call the physician.
d. Dilute the poison with milk

and call the primary care
provider.
Fundamentals Final
A nurse is teaching parents in a Exam Practice FINAL
a. Booster seats should be used for children until
Study
parenting class about the use ′ ′′
they are 4 9 tall and weigh between 80 and 100
of car seats and restraints for pounds. All 50 U.S. states mandate the use of infant
infants and children. Which car seats and carriers when transporting a child in a
information is accurate and motor vehicle. Infants and toddlers up to 2 years of
should be included in the age (or up to the maximum height and weight for
teaching plan?
the seat) should be in a rear-facing safety seat.
Many children older than 6 years should still be in a
a. Booster seats should be booster seat.
used for children until they are

′ ′′
4 9 tall and weigh between 80 Chapter 26
and 100 pounds.
b. Most U.S. states mandate the

use of infant car seats and
carriers when transporting a
child in a motor vehicle.
c. Infants and toddlers up to 2

years of age (or up to the
maximum height and weight for
the seat) should be in a front-
facing safety seat.
d. Children older than 6 years

may be restrained using a car
seat belt in the back seat.
Fundamentals
A nurse working with Final Exam Practice FINAL
a, c, d. Each year, underage drinking claims theStudy
lives
adolescents in a juvenile of approximately 5,000 people under the age of 21.
detention center teaches The CDC (2012j) lists motor vehicle accidents as the
parents about behaviors that number one cause of death for adolescents.
place adolescents at high risk Marijuana use among teenagers has been on the
for injury. Which statements increase and the abuse of prescription medication
accurately describe these and OTC drugs has remained at a high level.
risks? Select all that apply.
Approximately one in five (20%) high school
students reported using some type of tobacco
a. Each year, underage drinking product. Homicide rates for youths using firearms
claims the lives of are higher than any other age group and the most
approximately 5,000 recent statistics indicate that youths aged 10-19
individuals under the age of 21.
years committed almost 1,500 suicides using
b. Approximately one in three firearms (Kagler, Annest, Kresnow & Mercy, 2011).
high school students reported According to the American Acad- emy of Child &
using some type of tobacco Adolescent Psychiatry, as many as 50% of children
product.
are bullied during their school years and some
c. The CDC (2012i) lists motor experts believe that cyber bullying is more
vehicle accidents as the
dangerous and damaging to children than bullying
number-one cause of death for that occurs in the schoolyard.
adolescents.
d. Marijuana use among Chapter 26

teenagers has been on the
increase and the abuse of
prescription medication and
OTC drugs has remained at a
high level.
e. Homicide rates for

adolescents are high, and
youths
aged 10-19 years committed

almost 500 suicides using
firearms.
f. As many as 30% of children

are bullied during their
school years and cyber
bullying is even more

Fundamentals
damaging to children. Final Exam Practice FINAL
Study
When describing safety issues d. Falls among older adults are the most common
and related mortality to a local cause of hospital admissions for trauma. Fires and
senior citizens group, what temperature extremes are also significant hazard for
would the nurse identify as the older adults but are not the most common cause of
leading cause of hospital trauma admissions. Intimate partner violence occurs
admissions for trauma in older more frequently in adults as opposed to older
adults?
adults.
a. Fires
Chapter 26
b. Exposure to temperature
extremes
c. Intimate partner violence
d. Falls
What consideration should the d. Studies of restraint-related deaths have shown

nurse keep in mind regarding that people of small stature are more likely to slip
the use of side rails for a through or between the side rails. The desire to
confused patient?
prevent a patient from wandering is not sufficient
reason for the use of side rails. Creative use of
a. They prevent confused alternative measures indicates respect for the
patients from wandering.
patient's dignity and may in fact prevent more
b. A history of a previous fall serious fall-related injuries.
from a bed with raised side A history of falls from a bed with raised side rails
rails is insignificant.
carries a significant risk for a future serious incident.
c. Alternative measures are

ineffective to prevent Chapter 26
wandering.
d. A person of small stature is

at increased risk for injury from
entrapment.
Fundamentals
When a fire occurs in aFinal
patient'sExam Practice FINAL
a. The patient's safety is always the priority. Study
room, what would be the Sounding the alarm and extinguishing the fire are
nurse's priority?
important after the patient is safe. Calling for help, if
possible, rather than running for assistance, allows
a. Rescue the patient.
you to remain with your patient and is more
b. Extinguish the fire.
appropriate.
c. Sound the alarm.
d. Run for help. Chapter 26
When completing a safety d. A safety event report is a legal document, which

event report, the nurse should:
must be as objective and complete as possible. It is
not a collaborative effort with the patient, and any
a. Include suggestions on how suggestions to prevent the occurrence from
to prevent the incident from happening again should be discussed at a
recurring.
postincident conference.
b. Provide minimal information

about the incident.
Chapter 26
c. Discuss the details with the
patient before documenting
them.
d. Objectively describe the

incident in detail.

When discussing emergency FINAL
d. Blast lung injury is a recognized consequence
Study
preparedness with a group of following exposure to an explosive device. The CDC
first responders, what is the federal agency that has collaborated with the
information would be pharmaceutical companies to stockpile drugs for
important to include about an emergency. A high dose of radiation exposure
preparation for a terrorist can result in bone marrow depression and cancer.
attack?
Most survivors of a terrorist event will experience
stress and some (possibly one-third of survivors)
a. Posttraumatic stress may exhibit posttraumatic stress disorder.
disorders can be expected in

most survivors of a terrorist Chapter 26
attack.
b. The FDA has collaborated

with drug companies to create
stockpiles of emergency drugs.
c. Even small doses of radiation

result in bone marrow
depression and cancer.
d. Blast lung injury is a serious

consequence following
detonation of an explosive
device.
Fundamentals
An older resident who Final
is Exam Practice
d. This allowsFINAL
the resident to be on the move and be
Study
disoriented likes to wander the more likely to find his room when he wants to return.
halls of his long-term care The alternative would be to not allow him to
facility. Which action would be wander. Many facilities use this kind of approach.
most appropriate for the nurse Identifying his door with his picture and a balloon
to use as an alternative to may work as an alternative to restraints. Using the
restraints?
geriatric chair and sheets are forms of physical
restraint. Leaving the bed in the high position is a
a. Sitting him in a geriatric chair safety risk and would probably result in a fall.
near the nurses' station
b. Using the sheets to secure Chapter 26

him snugly in his bed
c. Keeping the bed in the high

position
d. Identifying his door with his

picture and a balloon

The Joint Commission issues FINAL
b. The nurse should be able to place two fingers
Study
guidelines regarding the use of between the restraint and a patient's wrist or ankle.
restraints. In which case is a The patient should not be put in a supine position
restraint properly used?
with restraints due to risk of aspiration. Due to the IV
in the right wrist, alternative forms of restraints
a. The nurse positions a patient should be tried, such as a cloth mitt or an elbow
in a supine position prior to restraint. Securing the restraint to a side rail may
applying wrist restraints.
injure the patient when the side rail is lowered.
b. The nurse ensures that two

fingers can be inserted Chapter 26
between the restraint and
patient's ankle.
c. The nurse applies a cloth

restraint to the left hand of a
patient with an IV catheter in
the right wrist.
d. The nurse ties an elbow

restraint to the raised side rail
of a patient's bed.
A nurse orients an older patient d. Knowing how to use the call bell is a safety
to the safety features in her priority; knowing how to use the phone, meeting the
hospital room. What is a roommate, and knowledge of visiting hours will not
priority component of this necessarily prevent an accidental injury.
admission routine?
Chapter 26
a. Explain how to use the
telephone.
b. Introduce the patient to her

roommate.
c. Review the hospital policy

on visiting hours.
d. Explain how to operate the

call bell.

At a follow-up visit, a patient b. Kripaula, orFINAL
"gentle yoga," focuses on relaxation
Study
recovering from a myocardial and coming into balance. Ashtanga focuses on
infarction tells the nurse: "I feel synchronizing breath with a fast-paced series of
like my life is out of control postures. The nurse should not discourage the use
ever since I had the heart of yoga in patients who are healthy enough to
attack. I would like to sign up participate. Yoga is not contraindicated in patients
for yoga, but I don't think I'm with controlled high blood pressure.
strong enough to hold poses

for long." What would be the Chapter 27
a. "Right now you should

concentrate on relaxing and
taking your blood pressure
medicine regularly, instead of
worry- ing about doing yoga."
b. "There is a slower-paced
yoga called Kripaula that
focuses on coming into
balance and relaxation that you
could look into."
c. "Ashtanga yoga is a
gentlepaced yoga that would
help with your breathing and
blood pressure."
d. "Yoga is contraindicated for

patients who have had a heart
attack."

A nurse is providing a lecture FINAL
c. Many nurses are expanding their clinical practice
Study
on CAT to a group of patients by incorporating CAT. Although CAT may seem
in a rehabilitation facility. Which totally safe, some therapies have led to harmful and
teaching point should the at times lethal outcomes. Many patients use these
nurse include?
types of therapies as outpatients and want to
continue their use as inpatients. Although the use of
a. CAT is a safe intervention most complementary and alternative therapies
used to supplement traditional predates modern medicine, it was not until recently
care.
that nursing and medical schools began to teach
b. Many patients use CAT as about their use.
outpatients, but do not wish to

continue as inpatients.
Chapter 27
c. Many nurses are expanding
their clinical practice by
incorporating CAT to meet the
demands of patients.
d. Most complementary and

alternative therapies are
relatively new and their
efficacy has not been
established.

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11/6/22, 1:13 AM Fundamentals Final Exam Practice FINAL Flashcards | Quizlet

Fundamentals Final Exam Practice FINAL Study

Fundamentals Final Exam Practice FINAL

Terms in this set (382)

A nurse assesses patients in a b, e, f. Each person defines health and illness

experiencing different levels of based on a number of factors. Health is more than

statements best define the absence of illness; it is an active process in which a

Select all that apply.

a. Health and illness are the response of the person to a disease.

same for all people.

b. Health and illness are Chapter 3

c. People with acute illnesses

d. People with chronic illnesses

e. Health is more than the

f. Illness is the response of a

and they require patient education along with a

f. Otitis media Chapter 3

patients would be considered

a. A White male diagnosed with

c. A Hispanic male who has

d. A low-income family living in

e. A middle-class teacher living

f. A White baby who was born

A nurse has volunteered to c. Giving influenza injections is an example of

a local clinic. What level of care

Fundamentals Final Exam Practice FINAL

Which clinic patient is most c. The physical dimension includes genetic

a. Jane, whose her best friend Chapter 3

b. Sarah, who lives in a low-

c. Tricia, who has a family

d. Nancy, whose family

Fundamentals Final Exam Practice

for the residual limb.

c. A nurse provides range-of- Chapter 3

d. A nurse teaches parents of

e. A school nurse provides

f. A nurse teaches new parents

infant car seat.

The agent-host-environment a. The interaction of the agent, host, and

c. Behaviors to promote health

concepts from models of changing state).

health. What do both the

a. Illness as a fixed point in time

b. The importance of family

c. Wellness as a passive state

How can this promote health in Chapter 3

a. By being a role model for

b. By not requiring sick days

c. By never exposing others to

d. By spending less money on

thinking skills to address this

a. The nurse judges whether

b. The nurse considers whether

c. The nurse reassesses the

d. The nurse identifies several

Fundamentals Final Exam Practice

approaching a patient to take

and observation, and novice

b. For nursing to remain a

c. The emphasis on logical,

d. It's simply a matter of

Fundamentals Final Exam Practice

a. The nurse uses critical Chapter 10