NU101 Exam 4 Practice Questions

a, c, d

A nurse caring for older adults in a provider’s office researches aging theories to help determine why some people age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply.

a. Immunosenescence likely promotes the increase in infections in the older adult.

b. Free radicals have adverse effects on adjacent molecules.

c. Decreases in size and function of the thymus result in more infections.

d. Nutrition likely plays an important role in maintaining the immune response.

e. Lifespan depends to a great extent on genetic factors.

f. Organisms wear out from increased metabolic functioning.

a, b, f

A nursing student caring for older adults in a skilled nursing facility is completing an assignment identifying physical changes that are part of normal aging. What changes will the student include in this assignment? Select all that apply.

a. Fatty tissue is redistributed.

b. Skin is drier and wrinkles appear.

c. Cardiac output increases.

d. Muscle mass increases.

e. Hormone production increases.

f. Visual and hearing acuity diminishes.

b

A nurse researcher interviews adults to validate Erikson’s theory that middle-aged adults who do not achieve their developmental tasks may be in the stage of stagnation. Which patient statement will the nurse correlate to this theory?

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!”

d

A nurse providing health services for a community setting for people age 55 years and older considers health problems for these residents. Which of the following problems is most appropriate for many middle-aged adults?

a. Adequate nutrition

b. Mental health problems

c. Abuse

d. Caregiver role strain

c

The charge nurse in a long-term care facility discusses ageism with new nurse employees. Nurses are asked to intervene if they observe which of these examples demonstrating ageism?

a. The AP encourages older adults to apply makeup or aftershave to promote positive self-image.

b. The activity director explains to an older adult they could learn to use video conferencing to speak to their grandchildren.

c. A nurse colleague states that older adult should not think about having a boyfriend or girlfriend after age 70 years.

d. A nurse recognizes the patient who lost their partner of 45 years may be experiencing loneliness.

b

A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings require follow up with the health care provider?

a. Skin pigmentation caused by exposure to sun over the years

b. Thin toenails with a bluish tint to the nail beds

c. Using a walker while healing from a hip fracture related to brittle bones

d. Bruising on forearms due to fragile blood vessels in the dermis

c

A nursing instructor teaching a gerontology class to nursing students discusses myths related to the aging of adults. Which statement will the students identify as a myth about older adults?

a. Most older adults live in their own homes.

b. Healthy older adults enjoy sexual activity.

c. Aging results in mental deterioration.

d. Older adults want to be attractive to others.

c

A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. Which type of cognitive impairment is non-reversible?

a. Post-stroke speech issues

b. Malnutrition

c. Alzheimer’s disease

d. Loss of cardiac reserve

a

A nurse caring for an older adult living in a long-term care facility uses reminiscence to help the patient adapt to the changes of aging. The nurse uses which question to 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?”

b, d, f

Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply.

a. S—Senility

b. P—Problems with feeding

c. I—Irritability

d. C—Confusion

e. E—Edema of the legs

f. S—Skin breakdown

b

The nurse in a long-term care facility states in report that an older adult resident is quite frail. The oncoming caregiver prioritizes prevention of what problem?

a. Confusion

b. Falls

c. Delirium

d. Dementia

b

A patient is admitted to the acute care medical center with change in mental status, dehydration, and electrolyte imbalances. Which of these reflects a reversible cause of the changes in mental status?

a. Alzheimer’s disease

b. Delirium

c. Dementia

d. Delirium superimposed on dementia

b

A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?

Electronic Health Record: Operative Note
Splenectomy secondary to trauma
Estimated blood loss 900 mL

a. Neurologic system, ambulatory function

b. Cardiovascular system, vital signs

c. GI system, bowel function

d. Integumentary, skin breakdown

d, e

A nurse is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? Select all that apply.

a. Loss of consciousness

b. Inability to speak

c. Reduction or loss of deep tendon reflexes

d. Loss of sensation below the injection

e. Inability to move the lower extremities

f. Prolonged pain relief after other anesthesia wears off

a, b, e, f

A nurse has been asked to witness a patient signature on an informed consent form for surgery. What communication from the surgeon does the nurse expect the patient to receive before signing the form? Select all that apply.

a. Option of nontreatment

b. Underlying disease process and its natural course

c. Notice that once the form is signed, the patient cannot withdraw the consent

d. Explanation of the guaranteed outcome of the procedure or treatment

e. Name and qualifications of the provider of the procedure or treatment

f. Explanation of the risks and benefits of the procedure or treatment

a

An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?

a. Anticoagulants

b. Antacids

c. Laxatives

d. Sedatives

b

A nurse is caring for a patient who is obese and has had abdominal surgery. The nurse prioritizes a plan to prevent what postoperative complication?

a. Anesthetic interactions

b. Impaired wound healing

c. Weight gain

d. Flatulence

b

When caring for a patient who returned from the operating room 8 hours ago, which finding requires follow-up assessment by the nurse?

a. Patient reports discomfort at surgical site, scale of 5/10

b. Patient voids small amounts every 20–30 minutes

c. Patient is sleepy and awakens only to touch

d. Patient reports thirst and dry mouth

d

A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery?

a. Lecture

b. Discussion

c. Audiovisuals

d. Written instructions

b

An adult patient awaiting surgery says to the nurse, “I am so frightened—what if I don’t wake up?” What is the nurse’s best response?

a. “Are you worried about the anesthesia?”

b. “Tell me what concerns you most.”

c. “Your surgeon is great; she operated on my aunt!”

d. “Many people are anxious before surgery.”

d

During preoperative teaching about pain management, the patient asks the nurse to explain how a PCA pump works. What will the nurse teach the patient about PCA?

a. “It allows the patient to be completely free of pain during the postoperative period.”

b. “It allows the patient to take unlimited amounts of medication as needed.”

c. “It allows the patient to choose the type of medication given postoperatively.”

d. “It permits the patient to self-administer limited doses of pain medication.”

a

A nurse is planning caring for a patient who had thoracic surgery. Which nursing interventions are most appropriate for patients undergoing this type of surgery?

a. Observing for incisional wound healing

b. Monitoring vital signs, especially pulse and blood pressure

c. Instructing the patient on the proper use of the incentive spirometer

d. Applying antiembolism stockings

a, c, d

While assessing a patient in the PACU following abdominal surgery, a nurse promptly contacts the surgeon for which of these findings? Select all that apply.

Electronic Health Record
Vital signs
1200: T 97.4, P-89, RR 12, BP/102/70
1215: T 97.4, P-92, RR 12, BP/100/68
1230: T 97.2, P-112, RR 12, BP/98/60

Intake Output/Hemovac
1200: 200 mL 0.9% saline infused 30 mL sanguineous material
1215: IV NSS 25 mL 45 mL serosanguineous material
1230: IV NSS 25 mL 250 mL bright red blood

a. Tachycardia

b. IV with normal saline solution

c. Wound drainage

d. Patient restless

e. Patient reports incisional pain 8/10

d

A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? Select all that apply.

a. Administering analgesics

b. Documenting daily calf circumference

c. Assessing vital signs every 4 hours

d. Encouraging ambulation

e. Applying intermittent pneumatic compression devices (IPCDs)

f. Providing education on pain management

a, b

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply.

a. Maintaining sterile technique

b. Draping and handling instruments and supplies

c. Identifying and assessing the patient on admission

d. Integrating case management

e. Preparing the skin at the surgical site

f. Providing exposure of the operative area

b

A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?

a. Taking and recording vital signs every shift

b. Turning, coughing, and deep breathing every 4 hours

c. Encouraging increased intake of oral fluids

d. Assessing bowel sounds daily

d

A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient?

a. Improves respiratory function

b. Maintains functional abilities

c. Provides diversional activities

d. Increases venous return

b

A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately?

a. Asking how long after the surgery they can leave the hospital

b. Received an oral anticoagulant last night

c. Surgeon has not yet filled out the consent form

d. Blood pressure is 142/86

b, c, f

During postconference, nursing students are exploring definitions of pain and its nature. Which statements should be included in this discussion? Select all that apply.

a. “It is whatever the health care provider treating the pain says it is.”

b. “Pain exists whenever the person experiencing it says it is present.”

c. “It is an emotional and sensory reaction to tissue damage.”

d. “Pain is a simple, universal, and easy-to-describe phenomenon.”

e. “When a cause cannot be identified, pain is psychological in nature.”

f. “It is classified by duration, location, source, transmission, and etiology.”

a, d, e

A nurse in a rehabilitation facility is evaluating patients with chronic pain to develop an interprofessional plan of care. Which patients would the nurse identify who could benefit from a multimodal approach to pain management? Select all that apply.

a. Patient receiving chemotherapy for bladder cancer

b. Adolescent who had an appendectomy

c. Patient who is experiencing a ruptured aneurysm

d. Patient with fibromyalgia requesting pain medication

e. Patient having back pain related to an accident that occurred last year

f. Patient experiencing pain from second-degree burns

b

A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain?

a. Cutaneous

b. Visceral

c. Superficial

d. Somatic

d

Which question by the nurse will be most helpful in determining whether a patient who is experiencing a myocardial infarction has referred pain?

a. “Did your chest pain last 2 minutes or less?

b. “Was the pain on the surface of your chest?”

c. “Is this pain in your residual limb shooting or burning?”

d. “Are you having any arm or shoulder pain?”

a, b, f

A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply.

a. Cradling a wrist that was injured in a car accident

b. Moaning and crying from abdominal pain

c. Increasing pulse following a myocardial infarction

d. Striking out at a nurse who attempts to provide a bath

e. Acting depressed and withdrawn while experiencing chronic cancer pain

f. Pulling away from a nurse trying to give an injection

a

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors?

a. Older adult on bedrest following cervical spine surgery

b. Patient with a severe sunburn being treated for dehydration

c. Industrial worker who has burns caused by a caustic acid

d. Patient experiencing cardiac disturbances from an electrical shock

c

A nurse plans to promote a patient’s natural pain mediators by using a whirlpool following intensive physical therapy to the legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques?

a. Prostaglandins

b. Substance P

c. Endorphins

d. Serotonin

d

A postoperative patient asks the nurse about pain management following surgery. What teaching will the nurse provide?

a. “Avoid asking for pain medication often, as it can be addictive.”

b. “It is better to wait until the pain is severe before asking for pain medication.”

c. “It’s natural to have pain after surgery; it will lessen in intensity in a few days.”

d. “You will be more comfortable if you take the medication at regular intervals.”

b

The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by “closing the gate”?

a. Encouraging regular use of analgesics

b. Applying moist heat to the area at intervals

c. Reviewing the pain experience with the patient

d. Ambulating the patient after administering medication

a

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?

a. CRIES

b. COMFORT

c. FLACC

d. FACES

a, b, c, d

When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse received in shift report that the patient has consistently refused pain medication. To help promote comfort, which additional data will the nurse gather? Select all that apply.

a. Patient’s understanding of or fear of taking prescribed analgesics

b. Assessment of any current pain

c. Presence of anxiety or additional stressors

d. Assessment of the surgical incision for infection

e. What the patient has eaten to this point

f. Whether the patient is using the incentive spirometer

c

When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method?

a. Providing the highest effective dose of an opioid on a PRN (as needed) basis

b. Using nonopioid drugs conservatively

c. Applying multimodal nonpharmacologic and nonopioid pharmacologic therapies

d. Administering a continuous intravenous infusion on a regular basis

b

When assessing pain in a child, the nurse needs to be aware of what considerations?

a. Immature neurologic development results in reduced pain sensation

b. Inadequate or inconsistent relief of pain is widespread

c. Reliable assessment tools are currently unavailable

d. Narcotic analgesic use should be avoided

d

A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize?

a. Pruritus

b. Urinary retention

c. Vomiting

d. Respiratory depression

b

A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider?

a. A respiratory rate of 11/min with normal depth

b. A sedation level of 4

c. Mild forgetfulness

d. Reported constipation

b

A patient is receiving a multimodal medication regimen as part of the treatment plan for neuropathic phantom limb pain. When the patient reports a bloody bowel movement, which medication prescription requires notification of the provider?

a. Acetaminophen

b. Nonsteroidal antiinflammatory

c.Opioid medication

d. Antianxiety medication

b

A nurse on an adult surgical floor enters a patient room and observes a family member pressing the button to administer a dose of PCA via the infusion pump. What response by the nurse is most appropriate?

a. “That dose will sure be helpful after their type of surgery.”

b. “Having only the patient use the pump prevents respiratory complications.”

c. “If the patient asked you to press the button, then it’s OK.”

d. “Since the pump has built in safeguards, you can help with pain management.”

c

Students in a leadership class are discussing how social determinants of health affect pain management. Which statement is correct and should be included in the discussion?

a. “Outcomes of pain management are generally satisfactory regardless of income.”

b. “Minority patients often receive excess medication.”

c. “Patients from minority groups often wait a long time before seeking treatment for pain.”

d. “Social determinants of health are unrelated to pain management.”