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Documentation
Teaching and Learning
Nursing Process
Communication/Caring
100
The practical nurse is assisting with data collection on a new admission to the rehabilitation unit. The practical nurse reviews the data collected and determines the highest priority would be: a. The client’s report of anxiety regarding the ability of treatment to return them to normal functioning level b. Report by the client of having skipped breakfast this morning c. Oral temperature measured at 99.2 degrees Fahrenheit d. New onset of tingling and weakness in the left arm
Answer: d Rationale: When considering the client’s reported anxiety, this would be considered a normal response to the scenario. While a skipped breakfast may be important information if the client reported being diabetic, don’t read more into the scenario than what is presented. While the client has a low grade fever, by far the most critical and highest priority data collected is the new onset of weakness and tingling in the left arm and should be immediately reported to the nursing supervisor or physician.
100
A postmenopausal client is just learning to do breast self examination (BSE). To aid in remembering to perform the procedure, at which of the following times should the nurse recommended that the client perform BSE? a. Weekly just before grocery shopping b. On a random day once each month according to convenience c. Once a month on a standard day that that the client can remember d. Just prior to each 6-month check-up for another health problem
Answer: c Rationale: The client needs to perform BSE once per month, on the same day each month. The client is encouraged to associate performing BSE with another monthly activity, such as paying bills, or to do it on the same calendar date each month (such as the first). The other statements represent incorrect timeframes.
100
An older adult female client has osteoporosis. In counseling the client about the best form of exercise, the nurse would recommend which of the following: a. Swimming b. Jogging c. Cycling on a stationary bicycle d. Walking
Answer: d Rationale: Although all of the exercises listed are aerobic and therefore beneficial, the older adult client with osteoporosis needs to select an exercise that has a weight-bearing component and yet does not stress the joints. Such an activity will help retain calcium in bone and reduce the rate of bone loss to osteoporosis. Walking is an aerobic exercise that does not stress the joints of the legs. Swimming and stationary cycling are not weight-bearing exercises. Jogging could harm the knee and ankle joints and is not a preferred method of exercise for this client.
100
A client asks about a new diagnostic test with which the nurse is unfamiliar. What is the best nursing response? a. "I don't know much bout the procedure, but i will find out and bring the information about it" b. "The technicians in the radiology department will explain the procedure to you when you go for the test" c. "It is your doctor's responsibility to explain that procedure to you. Would you like me to telephone the doctor?" d. "I can't explain hat now, but I'll get back to you later after all the morning medications are distributed"
Answer: a Rationale: Option 1 demonstrates honesty and openness between the client and the nurse. It also address the clients need for information. Options 2, 3, and 4 are incorrect because they put eh clients information needs on hold and to not represent a candid response by the nurse. The correct answer to communication question is the one that best acknowledges the client and utilizes therapeutic communication techniques.
200
The nurse unexpectedly notes, during a routine screening examination, that the client has a thready pulse. In what other way could this finding be documented? a. A 2+ pulse b. Pulse rate irregular and forceful c. Pulse difficult to palpate and easy to obliterate d. Pressure with the index finger causes pulsation
Answer: c Rationale: A weak, thready pulse is one that is difficult to palpate and easily diminished by slight pressure. A 2+ pulse indicates one that is easily palpable and normal. A forceful pulse and a pulsation felt with pressure from the index finger may be labeled as “full” or “bounding.”
200
The nurse is participating in a health promotion fair. When discussing aerobic exercise, the nurse should include which of the following points? a. Exercise should be done a minimum of 5 days per week. b. Fast walking is a good form of aerobic exercise c. If one cannot talk when exercising, then the appropriate level of energy is being used. d. Each exercise session should last for at least 45 minutes, and preferably 60
Answer: b Rationale: Each client should exercise at least 3 days per week for a minimum of 30 minutes in order for exercise to be effective. Fast walking is a good form of aerobic exercise. If one cannot speak when exercising, it it too strenuous and should be decreased in speed and amount.
200
A 4 year-old client is coming to the health care provider's office for a well child visit. whichs f the following routine screenings does the nurse anticipated? select all that apply a. Blood pressure b. Vision c. Urinalysis d. Lead screening e. Hearing
Answer: a, b, e Rationale: Blood pressure and vision screening are stared at age 3 and continue with each visit. Hearing screening begins at age 4. Lead screening would only be done on an as-needed basis for a 4 year old. Hemoglobin and hematocrit are done at 12 months and needed. Urinalysis is done at age 5, in adolescence, and otherwise only as indicated.
200
Which of the following is the best approach for a nurse to use to encourage a client to express feelings and to develop increase awareness about what those feeling are? a. Challenge the client b. Offer reassurance c. Suggest coping strategies d. Offer empathy
Answer: d Rationale: Empathy is the ability of the nurse to see the clients perception of the world. Challenging clients forces them to defend themselves from what appears to be an attach by the nurse (Option1 ). False reassurance (Option2 ) is another way of telling clients how to feel and ignoring their distress. Advising (Option 3) occurs when the nurse tells clients what to do, preventing them form exploring problems and using the problem-solving process to find solutions.
300
When documenting the findings of the health history, the nurse should do which of the following? a. Wait until the client has left the area b. Write the findings immediately on the appropriate form c. Abbreviate the data whenever possible to save time d. Ask the client to confirm that the documentation is accurate
Answer: b Rationale: The information extrapolated from the health history should be documented in the client’s medical record in a timely manner. If the nurse does not write the information down, the data could be forgotten or omitted from the record. The nurse should not wait until the client has left the area to document information unless there is an emergency. Standard abbreviations should be used in the char. Asking the client to review the documentation is not required.
300
The nurse selects which of the following as the most appropriate dietary menu items for a client with iron-deficiency anemia? a. Salad with lettuce, fruit, and nuts b. Roast beef and broccoli c. Lasagna with tomato sauce and steamed carrots d. Mixed green salads topped with tuna fish
Answer: b Rationale: With iron-deficiency anemia, it is important to select dietary items that are high in iron to counteract the deficit. Red meat tens to be high in iron, as do some green, leafy vegetables. Although options a and d contain salad greens, the other components of these meals are not as high in iron.
300
A nurse is teaching a class about aging at a senior citizen center. The nurse would know that a client needed further instruction if he or she make which of the following statements? a. "Through nutrition and exercise, we can modify the rate of aging." b. "Free radicals influence the quality of growing old" c. "Some of the physical changes within our bodies are the result of disuse" d. "Deterioration of body systems occurs at the same rate"
Answer: d Rationale: Options 1, 2, and 3 are true statements. Each physiologic system of a person ages at different rate
300
A client can understand only minimal English, and no interpreter is available. What alternative measures can the nurse use to enhance communication? a. Speak loudly to the client. b. Use a paper and pencil to write questions and information. c. Use pictures and nonverbal cues to communicate d. Speak more slowly and face the client
Answer: c Rationale: Because the clients does not speak English, the nurse must utilize nonverbal communication. Wit this in mind, option 3 is the one that takes this need into account. Option 1 are 4 are helpful when the nurse is working with a client who is hearing impaired. Option 2 would be useful for the aphasic client who has use of the dominant hand, such as after a CVA.
400
Which of the following is the most important data for the nurse to obtain regarding the family history of a client? a. Quality of emotional support provided by family b. Dates of immunizations and vaccines received c. Number and ages of client's siblings d. Major diseases of close family members
Answer: d Rationale: Major diseases such as diabetes, hypertension, arteriosclerosis, and cancer often have a genetic disposition and put the client at greater risk for developing them. The number and ages of siblings is a component of the family history, as well as inquiring about the clients support network. Vaccines and immunizations would be covered in the section known as past history
400
The pediatric clinic nurse has just administered a dose of Haemophilus influenzae type B (Hib) vaccine to a child. The nurse explains to the parents that they can expect which of the following local reactions following the injection? a. Mild to moderate fever b. Pain or redness at site c. Irritability d. Decreased appetite
Answer: b Rationale: The parents should be taught to expect pain and redness at the site as possible local reactions. Fever, irritability , and decreased appetite are some side effects of the heptavalent pneumococcal conjugate vaccine (PCV)
400
Which of these instructions, if included in the care plan for an older adult who has "leaking urine," would be most effective in strengthening pelvic muscles? a. When coughing, bear down in the standing positions. b. Percuss the lower abdomen for dull sounds, indicating a distended bladder c. Observe for fullness immediately after urinating d. Stop the steam of urine during the middle of urination
Answer: d Rationale: Interrupting the flow of urine assists the external urethra to contract and strengthens pelvic floor muscles. Other actions involve assessment activities.
400
Which of the following would be the most appropriate time for the use of confrontation as a therapeutic technique in communication with an assigned client? a. When a good relations exists and the clients anxiety level is low b. During periods when the client is non compliant c. After the client has had time to reflect on his or her behavior d. Immediately after a negative behavior has occurred.
Answer: a Rationale: Confrontation should not e be used a therapeutic communication techniques unless trust has been establish in the nurse-client relatinoshi9p. Because confrontation can be uncomfortable for the client, it is important for the nurse and client to have a trusting relationship as a foundation. The others represent situations in which the nurse might like to use confrontation but that are not appropriate for this communication technique .
500
After examining the clients pupils with a penlight for reaction, roundness, symmetry, and accommodation, the nurse can document normal findings as which of the following? a. PARL b. PERRLA c. PRLE d. PLRAE
Answer: b Rationale: The correct abbreviation for pupils that are equal, round, and responsive to light and accommodation is PERRLA.
500
A child stepped on a rusty nail and is brought to the emergency department. If the child was not adequately immunized against tetanus according to the immunization schedule, what would the emergency department nurse anticipate will be ordered to treat this child? a. Diphtheria, tetanus, and pertussis vaccine b. Tetanus immune globulin c. A broad-spectrum antibiotic d. Tetanus toxoid
Answer: b Rationale: When there is accidental exposure and inadequate vaccination, passive immunity with tetanus immune globulin is indicated for immediate protection from the bacterial spores in the nail. Options a and d provide active immunity and option c in inadequate.
500
When discharging a client on oral anticoagulant therapy, the nurse would include fuhrer teaching for the client who has a lifestyle that includes which of the following? a. Growing green vegetables b. Walking one mile a day c. Living in a rural setting d. Spending most of the time alone
Answer: a Rationale: The oral anticoagulant drug is sodium warfarin (Coumadin), and its action can be limited by excessive intake of foods, containing vitamin K. Since, green, leafy vegetables are high in vitamin K, the nurse needs to counsel this client about the possible antagonistic effect of these foods with the medication. Walking, rural living, and spending time alone pose no particular risk to the client.
500
A Client has been on the nursing unit for a few weeks because of complications ofter surgery, including the needs for extensive would care. During the last dressing change before discharge to home with home health services, the client becomes angry with the nurse and says, "You don't have to be do careful. I'm being sent home anyway!" Which of the following responses by the nurse would be therapeutic? Select all that apply? a. "I hear frustration or perhaps anger in your voice. can you tell me more about how you are feeling right now?" b. "Many people who have been in the hospital for an extended periods have mixed feelings about going home. Can you tell me how you are feeling about discharge?" c. "It sounds as though you're nervous about going home, but the wound care nurse who will see you also uses excellent technique. I'm sure your would will continue to heal" d. "Just because you are going home doesn't mean that your wound doesn't still require strict technique during a dressing change. Do you have any questions about your would care after discharge?" e. "Do you have any concerns about what will happen after discharge that you would like to talk about?"
Answer: a, b, e Rationale: The correct answers to communication questions are those that utilize therapeutic communication techniques and avoid communication blocks. Options a, b, and e utilize these techniques, while options c and d use the communication blocks and false reassurance (option c), challenging the client (option d). Another block would be putting the clients feelings on hold.