SESSION 9

1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses
this patient, the nurse is using the process of:

a. evaluation.
b. data collection.

c. problem identification.
d. testing a hypothesis.
Feedback
Assessment is the first stage of the nursing process, and is the process of gathering data to
formulate the
nursing diagnosis and care plan.

2. The nursing process organizes your approach to delivering nursing care. To provide
care to your patients, you will need to incorporate nursing process and:

a. decision making.
b. problem solving.
c. interview process.

d. intellectual standards.
Feedback
The interview process is an integral part of patient-centered care, and is continuous throughout
patient
interaction, regardless of the stage of the nursing process.

3. A patient is suffering from shortness of breath. The correct goal statement would be
written as:

a. the patient will be comfortable by the morning.

b. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.

c. the patient will not complain of breathing problems within the next 8 hours.
d. the patient will have a respiratory rate of 14 to 18 breaths per minute.
Feedback
The goal for the patient encompasses the SMART acronym. Each goal and outcome should address
only
one behavior, perception, or physiological response. Expected outcomes must also be singular.
Specificity allows you to
decide if there is a need to modify the plan of care.

4. When caring for a patient who has multiple health problems and related medical
diagnoses, nurses can best perform nursing diagnoses and nursing interventions by
developing a:
1/1
a. critical pathway.
b. nursing care plan.
c. concept map.

d. diagnostic label.
Feedback
As noted above, concept maps help the nurse organize nursing interventions for a patient with
multiple
problems.

5. Consultation occurs most often during which phase of the nursing process?
1/1
a. Assessment
b. Diagnosis
c. Planning

d. Evaluation
Feedback
When a nurse is unsure of how to proceed in the planning process, he or she will seek out another
colleague’s knowledge and experience to assist in planning interventions for the patient.

6. Concept mapping is one way to:

a. connect concepts to a central subject.

b. relate ideas to patient health problems.
c. challenge a nurse’s thinking about patient needs and problems.
d. graphically display ideas by organizing data.
e. all of the above.

Feedback
Concept mapping helps the busy nurse, with numerous patients, focus on healing patients on an
individual
basis.

7. For a student to avoid a data collection error, the student should:

a. assess the patient and, if unsure of the finding, ask a faculty member to assess the
patient.

b. review his or her own comfort level and competency with assessment skills.
c. ask another student to perform the assessment.
d. consider whether the diagnosis should be actual, potential, or risk.
Feedback
Data collection is an art that the nurse gets better at with experience, so asking for assistance from a
colleague to help with an unsure finding can ensure that the diagnostic statement is correct.

8. The nurse in charge identifies a patient’s responses to actual or potential health

problems during which step of thenursing process?

a. Assessment
b. Diagnosis

c. Planning
d. Evaluating
Feedback
The nurse identifies human responses to actual or potential health problems during the nursing
diagnoses
step of the nursing process. During the assessment step, the nurse collects data. During the
planning step, the nurse
develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse
determines the
effectiveness of the plan of care.

9. The nurse performs an assessment of a newly admitted patient. The nurse

understands that this admission assessment is conducted primarily to:

a. Diagnose if the patient is at risk for falls.

b. Ensure that the patient's skin is intact
c. Establish a therapeutic relationship
d. Identify important data
Feedback
This is the primary purpose of a nursing admission assessment.

10. The guidelines for writing an appropriate nursing diagnosis include all of the
following except:

a. State the diagnosis in terms of a problem, not a need

b. Use nursing terminology to describe the patient's response
c. Use statements that assist in planning independent nursing interventions
d. Use medical terminology to describe the probable cause of the patient's response

Feedback
A nursing diagnosis is a statement about a patient's actual or potential health problem that is within
the
scope of independent nursing intervention. Medical terminology is never part of the nursing
diagnosis.

SESSION 10

1. Nurse-initiated interventions are

a. determined by state Nurse Practice Acts.

b. supervised by the entire health care team.

c. made in concert with the plan of care initiated by the physician.
d. developed after interventions for the recent medical diagnoses are evaluated.
Feedback
Individual nurse practice acts determine nurse-initiated interventions.

2. You are writing a care plan for a newly admitted patient. Which one of these
outcome statements is written correctly?

a. The patient will eat 80% of all meals.

b. The nursing assistant will set the patient up for a bath every day.
c. The patient will have improved airway clearance by June 5.
d. The patient will identify the need to increase dietary intake of fiber by June 5.
Feedback
Outcome statements should have measurable and realistic goals. In this case, the goal is both
measurable
(will identify the need to increase dietary intake by June 5) and realistic.

3. Your patient has met the goals set for improvement of ambulatory status. You
would now:

a. modify the care plan.

b. discontinue the care plan.

c. create a new nursing diagnosis that states goals have been met.
d. reassess the patient’s response to care and evaluate the implementation step of the nursing
process.
Feedback
When goals are met, the care plan for that goal is discontinued.

4. Which of the following is an end result that translates into observable patient
behaviors that are measurable and desirable?

a. Unexpected outcome
b. Expected outcome

c. Sensitive outcome
d. Accomplished outcome
Feedback
When a nurse has an expected outcome established, it means that it is measurable. If the patient
does not
meet that outcome, the nurse should reassess and modify the care plan.

5. You have finished with several nursing interventions. To evaluate interventions, you
need to examine the:

a. appropriateness of the interventions and the correct application of the implementation

process.

b. nursing diagnoses to ensure that they are not medical diagnoses.

c. care planning process for errors in other health care team members’ judgments.
d. interventions of each nurse to enable the nurse manager to correctly evaluate performance.
Feedback
When evaluating, the nurse needs to look at the patient’s condition, the interventions used to
improve the
patient’s status, and whether or not they were appropriate.

6. Information regarding a patient’s health status may not be released to non–health

care team members because:

a. legal and ethical obligations require health care providers to keep information strictly
confidential.

b. regulations require health care institutions to document evidence of physical and emotional
well-being.
c. reimbursement issues related to patient care and procedures may be of concern.
d. fragmentation of nursing and medical care procedures may be identified.
Feedback
Under HIPAA laws, a patient’s medical information can only be released to team members, unless
express
written consent is given by the patient.

7. A nurse has just admitted a patient with a medical diagnosis of congestive heart
failure. When completing the admission paperwork, the nurse needs to record:

a. an interpretation of patient behavior.

b. objective data that are observed.

c. lengthy entry using lay terminology.

d. abbreviations familiar to the nurse.
Feedback
Objective data are part of the assessment portion of the nursing process. All data collected during
the
nursing process should be documented.

8. A nurse records that the patient stated his abdominal pain is worse now than last
night. This is an example of:

a. PIE documentation.
b. SOAP documentation.
c. narrative charting.
d. charting by exception.
Feedback
Writing subjective data, which includes the information the patient verbalizes, is written in narrative
charting.

9. A patient you are assisting has fallen in the shower. You must complete an incident
report. The purpose of an incident report is to:

a. exchange information among health care members.

b. provide information about patients from one unit to another unit.
c. ensure proper care for the patient.
d. aid in the hospital’s quality improvement program.

Feedback
Any deviation from the norm, such as a patient fall, can be used to improve quality. Incidents are
gathered
and assessed to see if there is a way to prevent it from happening again.

10. Before consulting with a physician about a female patient's need for urinary
catheterization, the nurse considers the fact that the patient has urinary retention and
has been unable to void on her own. The nurse knows that evidence for alternative
measures to promote voiding exists, but none has been effective, and that before
surgery the patient was voiding normally. This scenario is an example of which
implementation skill?

a. Cognitive

b. Interpersonal
c. Psychomotor
d. Consultative
Feedback
Cognitive skills include the critical thinking and decision-making skills described earlier. Always use
good
judgment and sound clinical decision making when performing any intervention.
SESSION 11

1. While caring for a child, you identify that additional safety teaching is needed when
a young and inexperienced mother states that:

a. that toddlers are not okay to play with small toys.

b. a 3-year-old can safely sit in the front seat of the car.

c. children need to wear safety equipment when bike riding.

d. children need to learn to swim even if they do not have a pool.
Feedback
Children ages 3 and younger should be in a child safety seat in the back seat of the car.

2. A newly admitted patient was found wandering the hallways for the past two nights.
The most appropriate nursing interventions to prevent a fall for this patient would
include:

a. raise all four side rails when darkness falls.

b. use an electronic bed monitoring device.

c. place the patient in a room close to the nursing station.

d. use a loose-fitting vest-type jacket restraint.
Feedback
For wandering patients, an electronic monitoring device can be used to notify the nurse when the
patient is
mobile.

3. A nurse floats to a busy surgical unit and administers a wrong medication to a

patient. This error can be classified as:

a. a poisoning accident.
b. an equipment-related accident.
c. a procedure-related accident.

d. an accident related to time management.

Feedback
When an error occurs due to the actions of a healthcare provider, it is considered a procedure-
related
accident.
4. A patient is admitted to a medical unit for a home-acquired pressure ulcer. The
patient has Alzheimer’s disease and has been incontinent of urine. The nurse inserts a
Foley catheter. You will identify a link in the infection chain as:

a. restraints.
b. poor hygiene.
c. Foley catheter bag.

d. improper positioning.
Feedback
The Foley catheter bag could be both a portal of exit and portal of entry.

5. You are caring for a patient who underwent surgery 48 hours ago. On physical
assessment, you notice that the wound looks red and swollen. The patient’s WBCs are
elevated. You should:

a. start antibiotics.
b. notify the provider.

c. document the findings and reassess in 2 hours.

d. place the patient on isolation precautions.
Feedback
When a patient shows signs of infection, the nurse should notify the provider immediately to ensure
immediate treatment is given, possibly preventing a systemic infection.

6. An athletic young woman has just fractured her leg while training for a marathon.
The use of meditation has many physiological properties that will help the young
woman to:

a. raise blood pressure.

b. increase mood swings.
c. increase oxygen consumption.
d. lower muscle tension.

Feedback
Many times, a fracture comes with swelling and muscle contractions to compensate for the injury.
Meditation
may help alleviate any muscle tension this patient is experiencing.
7. You are caring for a patient who has diabetes complicated by kidney disease. You
need to make a detailed assessment when administering medications because this
patient may experience problems with:

a. absorption.
b. biotransformation.
c. distribution.
d. excretion.

Feedback
The kidneys are the main organs for medication excretion. If a patient’s renal function declines, the
kidneys
cannot excrete medications adequately.

8. A postoperative patient is receiving morphine sulfate via patient-controlled

analgesia (PCA). The nurse assesses that the patient’s respirations are depressed.
The effects of the morphine sulfate can be classified as:

a. allergic.
b. idiosyncratic.
c. therapeutic.
d. toxic.

Feedback
Toxic effects often develop after prolonged intake of a medication or when a medication
accumulates in the
blood because of impaired metabolism or excretion. Excess amounts of a medication within the body
sometimes have
lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause
severe respiratory
depression and death.

9. Nurses are legally required to document medications that are administered to

patients. The nurse is mandated to document which of the following?

a. Medication before administering it.

b. Medication after administering it.

c. Rationale for administering it.

d. Prescriber rationale for prescribing it.
Feedback
Never document that you have given a medication until you have actually given it. Document the
name of
the medication, the dose, the time of administration, and the route on the MAR. Also document the
site of any injections
and the patient’s responses to medications, either positive or negative.

10. If a nurse experiences a problem reading a physician’s medication order, the most
appropriate action will be to:

a. call the physician to verify order.

b. call the pharmacist to verify order.

c. consult with other nursing staff to verify.
d. withhold the medication until the physician makes rounds.
Feedback
It is always safe to verify an order to the health care personnel involved. With this scenario, you
should ask
the physician directly.

SESSION 12

1. You are caring for a non–English-speaking male patient. When preparing to assist
him with personal hygiene, you should:

a. use soap and water on all types of skin.

b. ensure that culture and ethnicity influence hygiene practices.

c. shave facial hair to make the patient more comfortable.

d. know that all patients need to be bathed daily.
Feedback
When caring for patients from different cultures, learn as much as possible from them or their family
about
preferred hygiene practices.

2. A young girl with long hair is experiencing a problem with matting. The most
appropriate action to take would be:

a. cutting the matted hair away.

b. braiding the hair to reduce tangles.
c. using a grease-type product to tame the hair.
d. keeping the hair oil free by applying powder every morning.
Feedback
Braiding helps to avoid repeated tangles; however, patients need to unbraid hair periodically and
comb it to
ensure good hygiene.

3. The nursing assistant asks you the difference between a wound that heals by
primary or secondary intention. You willreply that a wound heals by primary intention
when the skin edges:

a. are approximated.

b. migrate across the incision.

c. appear slightly pink.
d. slightly overlap each other.
Feedback
A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals
by
primary intention. The skin edges are approximated, or closed, and the risk of infection is low.

4. A postoperative patient arrives at an ambulatory care center and states, “I am not

feeling good.” Upon assessment,you note an elevated temperature. An indication that
the wound is infected would be:

a. it has no odor.
b. a culture is negative.
c. the edges reveal the presence of fluid.
d. it shows purulent drainage coming from the incision site.

Feedback
Note the amount, color, odor, and consistency of drainage. The amount of drainage depends on the
type of
wound. Types of drainage include serous, sanguineous, serosanguineous, and purulent. If the
drainage has a pungent or
strong odor, you should suspect an infection.
5. A surgical wound requires a Hydrogel dressing. The primary advantage of this type
of dressing is that it provides:

a. an absorbent surface to collect wound drainage.

b. decreased incidence of skin maceration.
c. protection from the external environment.
d. moisture needed for wound healing.

Feedback
Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based
amorphous gel.
This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings
are for
partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds,
burns, and
radiation-damaged skin.

6. Match the pressure ulcer categories/stages with the correct definition. I.

Category/stage I II. Category/stage II III. Category/stage III IV. Category/stage IV
I. Category/stage I
II. Category/stage II
III. Category/stage III
IV. Category/stage IV
Score
A. Non - blanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be
present- I. Category/stage I

b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining .- III.
Category/stage III

c. Full thickness tissue loss; muscle and bone visible. May include undermining. - IV.
Category/stage IV

d. Partial-thickness skin loss or intact blister with serosanguinous fluid.- II. Category/stage II

a. MATCH THE PRESSURE ULCER CATEGORIES/STAES WITH THE

CORRECT DEFINITION. (RATIONALE ONLY)
Pressure ulcers are also known as bedsores and decubitus ulcers. They range from closed to
open wounds and are classified into a series of four stages based on how deep the wound is:
Stage 1 ulcers have not yet broken through the skin. Stage 2 ulcers have a break in the top two
layers of skin.
Feedback
Stage 1 - Intact skin with non- blanchable redness; Stage 2 - Partial-thickness skin loss involving
epidermis,
dermis, or both; Stage 3 - Full-thickness tissue loss with visible fat; Stage 4 - Full-thickness tissue
loss with exposed bone,
muscle, or tendon.

7. Which of the following are measures to reduce tissue damage from shear? (Select
all that apply.)

a. Use a transfer device (e.g., transfer board)

b. Have head of bed elevated when transferring patient

c. Have head of bed flat when repositioning patient

d. Raise head of bed 60 degrees when patient positioned supine

e. Raise head of bed 30 degrees when patient positioned supine

Feedback
Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of
the bed
to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces.
Consider repositioning
the patient at least every 2 hours if allowed by their overall condition. When repositioning, use
positioning devices to
protect bony prominences. The WOCN guidelines (2010) recommend a 30-degree lateral position,
which should prevent
positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer
device to lift rather
than drag the patient when changing positions. After repositioning the patient, reassess the skin.
Never massage
reddened areas. Massaging reddened areas increases the breakdown of the capillaries in the
underlying tissues and
leads to the risk of tissue injury and pressure ulcer formation.

8. When obtaining a wound culture to determine the presence of a wound infection,

from where should the specimen be taken?

a. Necrotic tissue
b. Wound drainage
c. Wound circumference
d. Cleansed wound
Feedback
Never collect a wound culture sample from old drainage. Clean a wound first with normal saline to
remove
skin flora.

9. What is the correct sequence of steps when performing wound irrigation to a large
open wound? a. Use slow, continuous pressure to irrigate wounds. b. Attach a 19-
gauge angiocatheter to syringe. c. Fill the syringe with irrigation fluid. d. Place a
waterproof bag near bed .e. Position angiocatheter over wound.

A, B, C, D, E

10. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which
wound-care product helps prevent edema formation, control bleeding, and anesthetize
the body part?

a. Binder
b. Ice bag

c. Elastic bandage
d. Absorptive dressing
Feedback
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, or who has undergone
dental
surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body
part.

11. You notice a respiratory change in your immobilized postoperative patient. The
change you note is most consistent with:

a. atelectasis.

b. hypertension.
c. orthostatic hypotension.
d. coagulation of blood.
Feedback
Atelectasis is the collapse of alveoli.
12. During rounds on the night shift, you note that a patient stops breathing for 1 to 2
minutes several times during the shift. This condition is known as:

a. cataplexy.
b. insomnia.
c. narcolepsy.
d. sleep apnea.

Feedback
Sleep apnea is a disorder characterized by lack of airflow through the nose and mouth for periods of
10
seconds or longer during sleep.

13. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best
action to take would be:

a. adding a daytime nap.

b. allowing the child to sleep longer in the morning.
c. maintaining the child’s home sleep routine.

d. offering the child, a bedtime snack.

Feedback
Sleep routine would help the child to know the difference between day and night, if it’s time to sleep.
If the
routine is disrupted, it can generally lead to sleep problems. So the focus of intervention must be on
controlling factors in
the environment and providing uninterrupted rest and sleep periods.

14. A patient suffers from sleep pattern disturbance. To promote adequate sleep, most
important nursing intervention is:

a. administering a sleep aid.

b. synchronizing the medication, treatment, and vital signs schedule.

c. encouraging the patient to exercise immediately before sleep.

d. discussing with the patient the benefits of beginning a long-term night time medication
regimen.
Feedback
Patients in acute care settings have their normal rest and sleep routine disrupted, which generally
leads to
sleep problems. In this setting, nursing interventions focus on controlling factors in the environment
that disrupt sleep,
relieving physiological or psychological disruptions to sleep, and providing for uninterrupted rest and
sleep periods for the
patient.

15. A 72-year-old patient asks the nurse about using an over-the-counter

antihistamine as a sleeping pill to help her get tosleep. What is the nurse's best
response?
1/1
a. “Antihistamines are better than prescription medications because these can cause a lot of
problems.”
b. “Antihistamines should not be used because they can cause confusion and increase
your risk of falls.”

c. “Antihistamines are effective sleep aids because they do not have many side effects.”
d. “Over-the-counter medications when combined with sleep hygiene measures are a good plan
for sleep.”
Feedback
Confusion is one of the side effects of antihistamine that may increase the risk of falls.

16. The school nurse is teaching health-promoting behaviors that improve sleep to a
group of high school students. Which points should be included in the education?
(Select all that apply.)

a. Go to bed at the same time each night.

b. Study in your bedroom to have a quiet place.

c. Turn on the television to help you fall asleep.
d. Avoid drinking coffee or soda before bedtime.

e. Turn off your cell phone at bedtime.

Feedback
Sleep routines help you get into sleep better and faster. Coffee contains caffeine that gives you
energy and
stays awake. Cell phones have radiation that could disrupt your sleep, according to research.
17. Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing
assistant? (Select all that apply.)

a. Giving the patient a backrub

b. Turning on quiet music

c. Dimming the lights in the patient's room

d. Giving a patient a cup of coffee

e. Monitoring for the effect of the sleeping medication that was given

Feedback
All choices except D and E can be delegated to a nursing assistant. You must avoid giving a cup of
coffee
before bedtime and giving and monitoring the effects of a medication is part of the nurses’ roles and
responsibilities.

18. Which statement made by the parent of a school-age child requires follow-up by
the nurse?

a. “I encourage evening exercise about an hour before bedtime.”

b. “I offer my daughter glass warm milk before bedtime.”

c. “I make sure that the room is dark and quiet at bedtime.”
d. “We use quiet activities such as reading a book before bedtime.”
Feedback
All but A helps a school-age child sleep faster and better. Exercise before sleep is neither
recommended nor
necessary for this age.

19. The nurse is developing a plan of care for a patient experiencing obstructive sleep
apnea (OSA). Which intervention is appropriate to include on the plan?

a. Instruct the patient to sleep in a supine position.

b. Have the patient limit fluid intake 2 hours before bedtime.
c. Elevate head of bed and assume a side or prone position.

d. Encourage patients to take an over-the-counter sleep aid.

Feedback
OSA occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper
airway
becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea)
for as long as 30
seconds. This position is best for OSA to help not to block the airway.

20. The effects of immobility on the cardiac system include which of the following?
(Select all that apply.)

A. Thrombus formation

B. Increased cardiac workload

C. Weak peripheral pulses

D. Irregular heartbeat
E. Orthostatic hypotension

SESSION 13

1. When a smiling and cooperative patient complains of discomfort, nurses caring for
this patient often harbormis conceptions about the patient's pain. Which of the
following is true?

a. Chronic pain is psychological in nature.

b. Patients are the best judges of their pain.

c. Regular use of narcotic analgesics leads to drug addiction.

d. Amount of pain is reflective of actual tissue damage.
Feedback
Pain is a subjective data that the patient can only feel.

2. A patient who has just undergone recommendation would be an appendectomy.

When discussing with the patientseveral pain-relief interventions, the most appropriate

a. adjunctive therapy.
b. non-opioids.
c. NSAIDs.
d. PCA pain management.

Feedback
There are many benefits to PCA use. The patient gains control over pain, and pain relief does not
depend
on nurse availability. Patients also have access to medication when they need it. This decreases
anxiety and leads to
decreased medication use. Small doses of medications are delivered at short intervals, stabilizing
serum drug
concentrations for sustained pain relief.

3. A postoperative patient is using PCA. You will evaluate the effectiveness of the
medication when:

a. you compare assessed pain w/baseline pain.

b. body language is incongruent with reports of pain relief.

c. family members report that pain has subsided.
d. vital signs have returned to baseline.
Feedback
Evaluating the effectiveness of a pain intervention

4. A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct
quantities of nutrients. Which statement reflects that she understands the dietary
guidelines?

a. “I am not concerned with what I am eating.”

b. “I am taking vitamin doses based on TV.”
c. “I am taking a daily MVI.”
d. “I am making eating choices according to the recommended dietary allowances.”

Feedback
This statement shows that the mother knows the importance of following the recommended dietary
allowances since she is breastfeeding, which is beneficial to the infant.

5. You receive an order to begin enteral tube feedings. The first step is to:

a. place the patient in a prone position.

b. irrigate the tube with normal saline.
c. check to see that the tube is properly placed.
d. introduce a small amount of fluid into the tube before feeding.

Feedback
Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of
water
to ensure that the tube is clear and patent.

6. A patient with a long-standing history of diabetes mellitus is voicing concerns about

kidney disease. The patient asks the nurse where urine is formed in the kidney. The
nurse’s response is the:

a. bladder.
b. kidney.
c. nephron.

d. ureter.
Feedback
Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major
role in
the regulation of fluid and electrolyte balance. The normal range of urine production is 1 to 2 L/day.
Nephrons are part of
the kidney where urine is being formed.

7. A health care provider may suspect that a patient is experiencing urinary retention
when the patient has:

a. large amounts of voided cloudy urine.

b. pain in the suprapubic region.
c. spasms and difficulty during urination.
d. small amounts of urine voided two to three times per hour.

Feedback
Urinary retention is the inability to partially or completely empty the bladder. Patients may have no
urine
output over several hours and in some cases experience frequency, urgency, small-volume voiding,
or incontinence of
small volumes of urine.
8. A young girl is having problems urinating postoperatively. You remember that
children may have trouble voiding:

a. in bathrooms other than their own.

b. in a urinal.
c. while lying in bed.
d. in the presence of a person other than one of their parents.

Feedback
Create as much privacy as possible by closing the door and bedside curtain; asking visitors to leave
a room
when a bedside commode, bedpan, or urinal is used; and masking the sounds of voiding with
running water.

9. A newly admitted patient states that he has recently had a change in medications
and reports that stools are now dry and hard to pass. This type of bowel pattern is
consistent with:

a. abnormal defecation.
b. constipation.

c. fecal impaction.
d. fecal incontinence.
Feedback
Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation.
When
intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most
of the fecal water
content is absorbed. Little water is left to soften and lubricate the stool. Constipation is a significant
source of discomfort
and the nurse should assess the need for intervention before the defecation becomes painful or the
stool is impacted.

10. To maintain normal elimination patterns in the hospitalized patient, you should
instruct the patient to defecate 1 hour after meals because:

a. the presence of food stimulates peristalsis.

b. mass colonic peristalsis occurs at this time.

c. irregularity helps to develop a habitual pattern.

d. neglecting the urge to defecate can cause diarrhea.
Feedback
Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only
three or
four times daily, with the strongest during the hour after mealtime.

SESSION 14
1. A patient complains of chest pain. When assessing the pain, you decide that its
origin is cardiac—rather than respiratory or gastrointestinal—when it:

a. does not occur with respiratory variations.

b. is peripheral and may radiate to the scapular region.

c. is aggravated by inspiratory movements.
d. is non-radiating and occurs during inspiration.
Feedback
In order to differentiate between the chest pain caused by cardiac reason and respiratory cause,
make sure
that the respiratory variations are not present. Predictability of the respiratory variation of stroke
volume varies according
to the definition of fluid responsiveness.

2. A patient with a tracheostomy has thick tenacious secretions. To maintain the

airway, the most appropriate action for the nurse includes:

a. tracheal suctioning.

b. oropharyngeal suctioning.
c. nasotracheal suctioning.
d. orotracheal suctioning.
Feedback
Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway
that you
are not able to clear by coughing. Suctioning is done when you wake up in the morning and right
before you go to bed in
the evening. Suctioning is also done after any respiratory treatments.

3. When evaluating a post-thoracotomy patient with a chest tube, the best method to
properly maintain the chest tube would be to:
a. strip the chest tube every hour to maintain drainage.
b. place the device below the patient’s chest.

c. double clamp the tube except during assessment.

d. remove the tubing from the drainage device to check for proper suctioning.
Feedback
This is in consideration with the concept of gravity - draining the lung contents by placing the device
below
the chest.

4. A patient is diaphoretic and has an oral temperature of 104° F. These are classic
signs of:

a. ADH deficit.
b. extracellular fluid loss.
c. insensible water loss.
d. sensible water loss.

Feedback
Sensible water loss is a measurable loss of body fluid, e.g., blood, diarrhea, urine, vomit. If sensible
losses
consistently exceed fluid intake, dehydration may result.

5. The body’s fluid and electrolyte balance is maintained partially by hormonal

regulation. Which of the following statements shows an understanding of this
mechanism?

a. “The pituitary secretes aldosterone.”

b. “The kidneys secrete antidiuretic hormone.”
c. “The adrenal cortex secretes antidiuretic hormone.”
d. “The pituitary gland secretes antidiuretic hormone.”

Feedback
Antidiuretic hormone, also known as vasopressin is a hormone released by the posterior pituitary. It
is
important mainly for its actions on the kidneys where it increases the reabsorption of water.
Vasopressin is also a powerful
vasoconstrictor.
6. A senior student nurse delegates the task of intake and output to a new nursing
assistant. The student will verify that the nursing assistant understands the task of I&O
when the nursing assistant states,

a. “I will record the amount of all voided urine.”

b. “I will not count liquid stools as output.”

c. “I will not record a café mocha as intake.”
d. “I will notate perspiration and record it as a small or large amount.”
Feedback
Intake and output record template is a template to record any fluid taken by any patients regularly for
specific health evaluation. Recording intake and output tends to be the primary activity to be done at
the bedside and is
used together with certain laboratory reports to set required fluid intake levels. Accuracy of this
activity is vital to facilitate
correct prescribing of intravenous and subcutaneous fluids.

SESSION 15

1. You are a nurse working in the college student health center. You receive a call that
an athlete has just fallen and has been injured. You know that according to the
general adaptation syndrome, the athlete will be exhibiting:

a. an increased appetite.
b. an increased heart rate.

c. a decrease in perspiration.
d. a decrease in respiratory rate.
Feedback
The alarm reaction stage of GAS refers to the initial symptoms the body experiences when under
stress.
You may be familiar with the “fight-or-flight” response, which is a physiological response to stress.
This natural reaction
prepares you to either flee or protect yourself in dangerous situations. Your heart rate increases,
your adrenal gland
releases cortisol (a stress hormone), and you receive a boost of adrenaline, which increases energy.
This fight-or-flight
response occurs in the alarm reaction stage.
2. A patient comes into the emergency department complaining of chest pain. When
discussing possible reasons why the chest pain has occurred, the nurse learns that
the patient is depressed because of the loss of a job. This type of crisis can be
classified as

a. maturational.
b. situational.

c. sociocultural.
d. posttraumatic.
Feedback
External sources such as a job change, a motor vehicle crash, a death, or severe illness provoke
situational
crises.

3. You are caring for a patient who is depressed because the only child has gone
away to college. The nurse will assess this type of depression as:

a. actual loss.
b. perceived loss.
c. situational loss.
d. maturational loss.

Feedback
When life keeps moving, such as kids growing up and moving away, it is considered maturational
loss.

4. As a first-year nursing student, you are assigned to care for a dying patient. To best
prepare you for this assignment, you will want to:

a. complete a course on death and dying.

b. control your emotions about death and dying.
c. compare this experience to the death of a family member.
d. develop a personal understanding of your own feelings about grief and death.

Feedback
The nurse cannot provide patient-centered nursing if the nurse does not understand his or her own
feelings
about death and dying.
SESSION 16

1. An elderly patient who lives in an adult assisted-living facility mentions that he is

experiencing hearing and vision changes. During your assessment, you would
associate this type of sensory deprivation with:
1/1
a. stable affect.
b. altered perception.

c. improved task completion.

d. increased need for social interaction.
Feedback
The mental process of becoming aware of or recognizing an object or idea; primarily cognitive rather
than
affective or conative, although all three aspects are manifested, are altered.

2. A patient with glaucoma is being discharged from the hospital. When teaching the
patient and family ways to improve home safety, the nurse tells the family to:

a. use throw rugs to prevent tripping.

b. paint the floor black and white to improve perception.
c. install extra incandescent lighting.

d. install handrails painted the same color as the walls.

Feedback
Light sensitivity (or photophobia) and glare are common problems for glaucoma patients, often
making
outdoor activities and driving more difficult. Light sensitivity is a result of the pressure build-up in the
eyes that is
characteristic of glaucoma. Patients who experience light sensitivity typically feel discomfort from
sunlight, incandescent
lights, and/or fluorescent lights. Halogen lights, like those used in car headlights, and fluorescent
store lighting or fixtures
can cause an uncomfortable glare for those with glaucoma, as well. Though low light is better for
watching TV and
reading, bright lighting in the home helps people do other tasks with ease. Use suitable lighting for
the things they should
be used for.

3. Which of the following populations have the highest incidence of STI? (Select all
that apply.)
a. Hispanic women age 15 to 24 years

b. African-American men age 15 to 24 years

c. Caucasian men age 50 to 58 years

d. Caucasian women age 42 to 53 years
Feedback
The highest incidence of STI occurs in the 15-to-24-year-old age group and in Hispanic and African
American populations.

4. Upon admission, when gathering a patient’s sexual history, nurses should:

a. focus only on physical factors that affect sexual functioning.

b. discuss sexual concerns only if the patient raises questions or concerns.
c. use emotionally laden terms when discussing sexual concepts.
d. include questions related to sexual function.

Feedback
Sexual function is an important part of taking a sexual history, as it can indicate other problems the
patient
may be having.

5. When caring for patients, the nurse must understand the difference between
religion and spirituality. Religious care helps individuals:

a. maintain their belief systems and worship practices.

b. develop a relationship with a higher being.

c. establish a cultural connectedness with the purpose of life.
d. achieve the balance needed to maintain health and well-being.
Feedback
Religion is associated with the “state of doing,” or a specific system of practices associated with a
particular
denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person
practices to
outwardly express spirituality. Religious care helps patients maintain their faithfulness to their belief
systems and worship
practices. Spiritual care helps people identify meaning and purpose in life, look beyond the present,
and maintain personal
relationships and a relationship with a higher being or life force.

6. To assess, evaluate, and support a patient’s spirituality, the best action a nurse can
take is to:

a. assist the patient to use faith to get well.

b. refer the patient to the health care facility chaplain.
c. provide the patient with a variety of religious literature.
d. determine the patient’s perceptions and belief system.

Feedback
By understanding the patient’s perceptions and belief system, the nurse is able to provide patient-
centered
care for the patient.