Mobility/Pain
A nurse is assessing a patient who reports pain following abdominal surgery. Which statement by the patient should be considered the most reliable indicator of pain?
A. "I feel nauseous and don’t want to eat."
B. "My pain is at a 7 out of 10."
C. "My heart is racing and I’m sweating."
D. "I don’t want to get out of bed."
Correct Answer: B
Rationale: The patient’s self-report is the most reliable indicator of pain.
A nurse is assessing a patient with a suppressed immune response. Which of the following findings is most consistent with this condition?
A) Severe allergic reactions
B) Chronic wounds and fatigue
C) Increased energy and weight gain
D) Localized pain and swelling
Answer: B
Rationale: A suppressed immune response is characterized by the body's decreased ability to fight off infections and heal effectively. This can lead to symptoms like chronic wounds and fatigue.
A nurse is planning a health promotion program for a community. Which of the following is the most important initial step?
A. Implementing educational sessions.
B. Assessing the community's needs and desires.
C. Setting specific health goals for the community.
D. Securing funding for the program.
Answer: B
Rationale: The first step in planning any health promotion program, especially in a community setting, is to conduct a thorough assessment to understand the specific needs, preferences, values, and desires of the target individuals. This ensures that the program is relevant and likely to be effective.
A nurse is assessing a patient with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most consistent with this condition?
A. Increased tactile fremitus
B. Barrel chest
C. Hyperresonance on percussion
D. Vesicular breath sounds
Answer: B
Rationale: A barrel chest is a common finding in patients with COPD due to hyperinflation of the lungs. Tactile fremitus is typically decreased in COPD. Hyperresonance on percussion can be present, but barrel chest is more specific. Vesicular breath sounds are normal, not typical of COPD.
A client with hypertension is prescribed a new medication to manage their blood pressure. Which instruction is most important for the nurse to provide to the client regarding lifestyle modifications?
A) "Continue your current diet, no changes are needed."
B) "Increase your sodium intake to counteract any fluid loss from the medication."
C) "Incorporate the DASH diet into your daily eating habits."
D) "Reduce your physical activity to avoid overexertion."
Answer: C
Rationale: The DASH diet is specifically recommended for managing hypertension. It emphasizes lower sodium intake, increased potassium, calcium, and magnesium intake, and a diet low in saturated fats. Options A, B, and D are incorrect and could be detrimental to the client's health
A nurse is planning care for an older adult client with limited mobility due to osteoarthritis. Which intervention is most appropriate to prevent complications from immobility?
A. Encourage fluid restriction to avoid urinary incontinence
B. Provide passive range of motion exercises every 4 hours
C. Keep the head of the bed elevated at all times
D. Limit ambulation to once daily to reduce fall risk
Correct Answer: B
Rationale: Passive range of motion helps prevent joint stiffness and muscle atrophy in immobile patients.
A patient has developed a localized infection after a minor injury. Which of the following are characteristics of the inflammatory response at the injury site?
A) Decreased blood flow and redness
B) Swelling, warmth, and pain
C) Decreased temperature and swelling
D) Increased mobility and decreased pain
Answer: B
Rationale: Inflammation is characterized by redness, swelling, warmth, and pain due to the accumulation of immune cells and substances at the injury site.
A nurse is educating a patient about the importance of health promotion. Which statement by the patient indicates an understanding of health promotion?
A. “Health promotion focuses on avoiding disease.”
B. “Health promotion helps me control and improve my health.”
C. “Health promotion is only the responsibility of healthcare providers.”
D. “Health promotion is the same as disease prevention.
Answer: B
Rationale: Health promotion is defined as the process of enabling people to increase control over and to improve their health. While disease prevention is a component of health promotion, it is not the sole focus. Health promotion empowers individuals to take an active role in their health.
The nurse is caring for a patient receiving oxygen therapy via nasal cannula. Which action by the nurse is most appropriate?
A. Assessing the patient for skin breakdown behind the ears
B. Ensuring the oxygen flow rate is set at 10 L/min
C. Monitoring the patient for signs of oxygen toxicity
D. Encouraging the patient to breathe through their mouth
Answer: A
Rationale: Nasal cannulas can cause skin breakdown behind the ears. 10 L/min is too high for a nasal cannula. Oxygen toxicity is a concern with high concentrations, not typically nasal cannulas. Patients should breathe through their nose.
The nurse is assessing a client for risk factors of impaired tissue perfusion. Which of the following factors would the nurse identify as a modifiable risk factor?
A) Age
B) Family history
C) Obesity
D) Race
Answer: C
Rationale: Modifiable risk factors are those that can be changed. Obesity is a modifiable risk factor. Age, family history, and race are nonmodifiable risk factors.
A nurse is assessing an older adult with dementia who recently underwent hip replacement. The client is nonverbal and shows restlessness and facial grimacing when moved. What is the best initial nursing action?
A. Request a psychiatric consult
B. Ask the family if the patient is acting normal
C. Administer a prescribed PRN analgesic
D. Document the behavior and reassess in 1 hour
Correct Answer: C
Rationale: Nonverbal signs like restlessness and facial grimacing can indicate pain, especially in nonverbal patients. Pharmacologic intervention is appropriate based on assessment
A nurse is teaching a patient about measures to prevent infection. Which of the following statements by the patient indicates a need for further teaching?
A) "I should get vaccinated according to the recommended schedule."
B) "Proper hand hygiene is important to prevent infection."
C) "I don't need to worry about food hygiene since I eat at restaurants."
D) "If I'm in a high-risk group, I should get screened for infections."
Answer: C
Rationale: Food hygiene is a crucial component of infection prevention. Patients need to be educated on safe food handling and preparation, regardless of where they eat.
A nurse is working with a patient who is struggling to incorporate healthy behaviors into their lifestyle. Which factor should the nurse prioritize when addressing this issue?
A. The patient's literacy level.
B. The patient's motivation.
C. The patient's cultural background.
D. The patient's access to healthcare resources.
Answer: B
Rationale: Motivation is essential for incorporating health promotion strategies into lifestyles. Without motivation, the patient is unlikely to make sustained behavioral changes, regardless of other factors. While literacy, culture, and resources are important considerations in patient education and health promotion, motivation is the foundational element for change.
A patient is admitted with suspected obstructive sleep apnea (OSA). Which assessment findings would the nurse expect to see?
A. Decreased daytime sleepiness
B. Loud snoring
C. Increased concentration
D. Morning headaches
Answer: B, D
Rationale: OSA is characterized by disrupted sleep, leading to daytime sleepiness and decreased concentration, not the opposite. Loud snoring and morning headaches are common symptoms.
A client is admitted with a diagnosis of coronary artery disease (CAD). Which laboratory finding would the nurse expect to see?
A) Cholesterol 120 mg/dL
B) Triglycerides 168 mg/dL
C) HDLs 60 mg/dL
D) CRP 0.5 mg/dL
Answer: B
Rationale: Elevated triglycerides are a risk factor for CAD. Low HDL levels are also a risk factor for CAD. Cholesterol of 120 mg/dL and CRP of 0.5 mg/dL are within normal limits.
The nurse is educating a group of older adults about risk factors for impaired mobility. Which of the following are common risk factors in this population?
A. Chronic neurological conditions
B. Recent traumatic injury
C. Use of assistive devices
D. Age-related muscle loss
Correct Answers: A, B, D
Rationale: Older adults are at risk due to chronic conditions, injuries, and sarcopenia (age-related muscle loss). Use of assistive devices is a response, not a risk factor; high-protein diets can help prevent muscle loss.
Which of the following factors can increase an individual's risk for infection?
A) Young age
B) Vaccinations
C) Crowded living conditions
D) Being uninsured
Answer: A, C, and D
Rationale: Very young age, crowded living conditions, and being uninsured are risk factors for infection. Proper nutrition and vaccinations help prevent infection
A nurse is developing a patient education plan for a patient with newly diagnosed diabetes. Which of the following should the nurse include in the plan? (Select all that apply)
A. Information on self-monitoring blood glucose.
B. The importance of adhering to the prescribed medication regimen.
C. Strategies for coping with the emotional aspects of the diagnosis.
D. Detailed pathophysiology of diabetes.
Answer: A, B, and C
Rationale: Patient education should include teaching patients how to perform specific tasks (like self-monitoring blood glucose), the importance of adherence to treatment plans, and addressing the affective domain by providing support for coping with emotional aspects of their condition. While understanding the disease process can be helpful, detailed pathophysiology is less crucial than practical skills and emotional support for incorporating new behaviors into everyday life.
A nurse is teaching a patient about risk factors for impaired gas exchange. Which factors should the nurse include?
A. Age
B. Smoking
C. Regular exercise
D. Chronic medical conditions
Answer: A, B, D
Rationale: Age, smoking, and chronic medical conditions like COPD are risk factors for impaired gas exchange. Regular exercise promotes gas exchange.
The nurse is teaching a client about hypertension. Which of the following statements should be included in the teaching? (Select all that apply)
A) "Hypertension is defined as a systolic blood pressure greater than 140 mmHg or a diastolic blood pressure greater than 90 mmHg."
B) "Reducing sodium intake can help manage your blood pressure."
C) "Hypertension primarily affects older adults."
D) "Regular aerobic exercise is beneficial for lowering blood pressure."
Answer: A, B, D
Rationale: Hypertension is defined as a systolic BP > 140 mmHg or a diastolic BP > 90 mmHg. Reducing sodium intake and regular aerobic exercise are recommended lifestyle modifications for managing hypertension. While hypertension is more common in older adults, it can affect people of all ages.
The nurse is caring for a client with chronic musculoskeletal pain. Which of the following nonpharmacological interventions should be included in the plan of care? Select all that apply.
A. Cognitive-behavioral therapy
B. Opioid administration
C. Use of heat therapy
D. Guided imagery
Correct Answers: A, C, D
Rationale: Cognitive-behavioral therapy, heat therapy, and guided imagery are nonpharmacological methods proven to assist in managing chronic pain. Opioid administration is a pharmacologic intervention and therefore not included in this category.
A nurse is assessing a patient for signs of altered immunity. Which of the following findings could indicate an altered immune response?
A) Report of frequent infections
B) Enlarged lymph nodes
C) Normal wound healing
D) Allergic symptoms
Answer: A, B, and D
Rationale: Frequent infections and enlarged lymph nodes can indicate a suppressed immune response, while allergic symptoms indicate an exaggerated immune response. Normal wound healing and weight gain are not typically associated with altered immunity.
A community health nurse is implementing a health promotion program. Which of the following strategies should the nurse include to ensure the program's success? (Select all that apply)
A. Focus on community values and norms.
B. Ensure active participation of community leadership.
C. Implement planned changes controlled by community members.
D. Prioritize individual behavior change over environmental changes.
Answer: A, B, and C
Rationale: Community-focused health promotion models emphasize the importance of aligning with community values and norms, involving community leadership, and ensuring community members have control over planned changes. Focusing solely on individual behavior change over environmental changes is not a hallmark of community health promotion models.
The nurse is assessing a patient with a chest tube. Which findings require immediate intervention?
A. Continuous bubbling in the water seal chamber
B. Chest tube insertion site with intact dressing
C. Drainage in the collection chamber
D. Sudden cessation of chest tube drainage
Answer: A, D
Rationale: Continuous bubbling in the water seal chamber indicates an air leak and requires intervention. Drainage in the collection chamber is expected. A sudden cessation of chest tube drainage could indicate a blockage and requires assessment.
(This one is hard, sorry guys)
The nurse is assessing a client for impaired clotting. Which assessment findings are indicative of a clotting issue? (Select all that apply)
A) Petechiae
B) Hemarthrosis
C) Pallor
D) Bradycardia
Answer: A, B, C
Rationale: Petechiae, hemarthrosis, and pallor can be signs of impaired clotting. Petechiae are small, pinpoint-sized red or purple spots on the skin caused by bleeding. Hemarthrosis is bleeding into joint spaces. Pallor, or paleness, can indicate reduced blood flow or anemia related to clotting issues. Bradycardia (slow heart rate) is not typically a direct indicator of a clotting disorder.