NURS 10 Exam 4

A nurse is assessing a patient in a long-term care facility. The nurse notes that the patient is at risk for sensory deprivation due to limited activity related to severe rheumatoid arthritis. Which interventions would the nurse recommend based on this finding? Select all that apply.

a. Use a lower tone when communicating with the patient.
b. Provide interaction with children and pets.
c. Decrease environmental noise.
d. Ensure that the patient shares meals with other patients.
e. Discourage the use of sedatives.
f. Provide adequate lighting and clear pathways of clutter.

b. Provide interaction with children and pets.

d. Ensure that the patient shares meals with other patients.

e. Discourage the use of sedatives.

A nurse is assessing an older adult patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply.

a. The nurse asks the patient if he is bored, and if so, why.
b. The nurse asks the patient if anything interferes with the functioning of his senses.
c. The nurse asks the patient if he noticed any changes in the way he perceives his body.
d. The nurse asks the patient if he has found it difficult to communicate verbally.
e. The nurse notes if the patient withdraws from being touched.
f. The nurse notes if the patient seems unsure of his body parts or position.

c. The nurse asks the patient if he noticed any changes in the way he perceives his body.

e. The nurse notes if the patient withdraws from being touched.

f. The nurse notes if the patient seems unsure of his body parts or position.

A nurse is assessing a patient for tactile disturbances. Which question asked by the nurse would be appropriate for this assessment?

a. "Have you been experiencing any strange tastes lately?"
b. "Have you smelled odors lately that other cannot smell?"
c. "Can you tell me what I am placing in your hand right now?"
d. "Have you found it difficult to communicate verbally?"

c. "Can you tell me what I am placing in your hand right now?"

A nurse observes that a patient who has cataracts is sitting closer to the television than usual. Which alteration would the nurse suspect is causing this patient behavior?

a. Altered stimulation
b. Altered sensory reception
c. Altered nerve impulse conduction
d. Altered impulse translation

b. Altered sensory reception

Which action would be most important for a nurse to include in the care plan for a patient diagnosed with presbycusis?

a. Obtaining large-print written material
b. Speaking distinctly, using lower frequencies
c. Decreasing tactile stimulation
d. Initiating a safety program to prevent falls

b. Speaking distinctly, using lower frequencies

A patient is in the late stages of AIDS, with alterations to the brain as well as other major organ systems. The patient complains of loneliness because of friends being "afraid to visit." Based on this data, what would the nurse determine to be the least likely underlying etiology for this patient's sensory problems?

a. Stimulation
b. Reception
c. Transmission-perception-reaction
d. Emotional responses

d. Emotional responses

Which patient would a nurse assess as being at greatest risk for sensory deprivation?

a. An older adult confined to bed at home after a stroke
b. An adolescent in an oncology unit working on homework supplied by friends
c. A woman in labor
d. A toddler in a playroom awaiting same-day surgery

a. An older adult confined to bed at home after a stroke

A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 1800, 1900, and 2000. A heart monitor beeps for a patient on one side, and another patient moans frequently. Which patient assessment would the nurse make based on this data?

a. Sufficient sensory stimulation
b. Deficient sensory stimulation
c. Excessive sensory stimulation
d. Both sensory deprivation and overload

d. Both sensory deprivation and overload

A patient's spinal cord was severed, causing paralysis from the waist down. When obtaining data about this patient, which component of the sensory experience would be a priority for the nurse to assess?

a. Transmission of tactile stimuli
b. Adequate stimulation in the environment
c. Reception of visual and auditory stimuli
d. General orientation and ability to follow commands

a. Transmission of tactile stimuli

A nurse is diagnosing an 11-year-old student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Based on this assessment data, which alteration would the nurse document for this patient?

a. Self-care deficit
b. Altered Role Performance (Student)
c. Disturbed Body Image
d. Delayed Growth and Development

b. Altered Role Performance (Student)

A nurse is caring for a man with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would best prevent sensory alterations for this patient?

a. Turn the radio or television volume up very loud and close the door to his room.
b. Prevent embarrassment and emotional discomfort as much as possible.
c. Provide daily opportunity for him to participate in a social hour with 6 to 8 people.
d. Encourage daily participation in exercise and physical activity.

c. Provide daily opportunity for him to participate in a social hour with 6 to 8 people.

In a group home in which most patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns?

a. Maintaining safety and preventing sensory deterioration
b. Insisting that every patient participate in as many self-care activities as possible
c. Emphasizing and reinforcing individual patient strengths
d. Encouraging reminiscence and life review in groups

a. Maintaining safety and preventing sensory deterioration

A nurse assessing an 8-month-old infant suspects the infant is experiencing sensory deprivation related to inadequate parenting. Since this assessment, both parents have attended parenting classes. However, both parents work while the infant stays with a grandparent, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor, rocking back and forth and has a dull facial expression with few vocalizations. Which nursing action would be appropriate for this patient and family?

a. Explore why the infant's parents lack motivation to provide necessary stimulation.
b. Remove the infant from the grandmother's care as the child has not progressed.
c. Suggest counseling since the infant's sensory deprivation is still severe.
d. No action is needed, as this is normal behavior for an 11-month-old infant.

c. Suggest counseling since the infant's sensory deprivation is still severe.

An older adult in a long-term care facility walked out the door unobserved and was lost for several hours. Upon assessment, the nurse notes that the patient is confused and documents: chronic sensory deprivation related to the effects of aging. Which interventions would be most effective for this patient? Select all that apply.

a. Ignore the patient's confusion, or go along with it to prevent embarrassment.
b. Reduce the number and type of stimuli in the patient's room.
c. Orient the patient to time, place, and person frequently.
d. Provide daily contact with children, community people, and pets.
e. Decrease background or loud noises in the environment.
f. Provide a radio and television in the patient's room.

c. Orient the patient to time, place, and person frequently.
d. Provide daily contact with children, community people, and pets.
f. Provide a radio and television in the patient's room.

An older patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient?

a. Assist the patient to ambulate by walking slightly behind her and grasping the arm.
b. Concentrate on the patient's sense of sight and limit diversions that involve other senses.
c. Stay outside of the patient's field of vision when performing personal hygiene for her.
d. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.

d. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required?

a. "I can expect my newborn to sleep an average of 16 to 24 hours a day."
b. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician."
c. "I will place my infant on his back to sleep."
d. "I will not place pillows or blankets in the crib to prevent suffocation."

b. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician."

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action?

a. No action is necessary as this is a normal finding during sleep.
b. Call the primary care provider to report possible neurologic deficit.
c. Lower the temperature in the patient's room.
d. Awaken the patient as this is an indication of night terrors.

a. No action is necessary as this is a normal finding during sleep.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply.

a. He is aware of his surroundings at this point.
b. He is in delta sleep at this time.
c. It would be most difficult to awaken him at this time.
d. This is most likely an NREM stage.
e. This stage constitutes around 20% to 25% of total sleep.
f. The muscles are relaxed in this stage.

c. It would be most difficult to awaken him at this time.
e. This stage constitutes around 20% to 25% of total sleep.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply.

a. REM sleep constitutes much of the sleep cycle of a preschool child.
b. By the age of 8 years, most children no longer take naps.
c. Sleep needs usually decrease when physical growth peaks.
d. Many adolescents do not get enough sleep.
e. Total sleep decreases in adults with a decrease in stage IV sleep.
f. Sleep is less sound in older adults and stage IV sleep may be absent.

a. REM sleep constitutes much of the sleep cycle of a preschool child.
b. By the age of 8 years, most children no longer take naps.
c. Sleep needs usually decrease when physical growth peaks.

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include?

a. Drinking a cup of regular tea at night induces sleep.
b. Using alcohol moderately promotes a deep sleep.
c. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep.
d. Exercising right before bedtime can hinder sleep.

c. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep.

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply.

a. A patient who has uncontrolled hypothyroidism.
b. A patient with coronary artery disease.
c. A patient who has GERD.
d. A patient who is HIV positive.
e. A patient who is taking corticosteroids for arthritis.
f. A patient with a urinary tract infection.

a. A patient who has uncontrolled hypothyroidism.
b. A patient with coronary artery disease.
c. A patient who has GERD.

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply.

a. A patient who is taking iron supplements for anemia.
b. A patient with Parkinson's disease who is taking dopamine.
c. An older adult taking diuretics for congestive heart failure.
d. A patient who is taking antibiotics for an ear infection.
e. A patient who is prescribed antidepressants.
f. A patient who is taking low-dose aspirin prophylactically.

b. A patient with Parkinson's disease who is taking dopamine.
c. An older adult taking diuretics for congestive heart failure.
e. A patient who is prescribed antidepressants.

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform?

a. Preparing the family for a diagnosis of insomnia and related treatments.
b. Preparing the family for a diagnosis of narcolepsy and related treatments.
c. Anticipating the scheduling of polysomnography to confirm OSA.
d. No action would be taken, as this is a normal finding for hospitalized children.

c. Anticipating the scheduling of polysomnography to confirm OSA.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder?

a. Circadian rhythm sleep-wake disorder
b. Narcolepsy
c. Enuresis
d. Sleep apnea

b. Narcolepsy

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply.

a. Daily mental activities
b. Daily physical activities
c. Morning and evening body temperature
d. Daily measurement of fluid intake and output
e. Presence of anxiety or worries affecting sleep
f. Morning and evening blood pressure readings

a. Daily mental activities
b. Daily physical activities
e. Presence of anxiety or worries affecting sleep

To promote sleep in a patient, a nurse suggests what intervention?

a. Follow the usual bedtime routine if possible.
b. Drink two or three glasses of water at bedtime.
c. Have a large snack at bedtime.
d. Take a sedative-hypnotic every night at bedtime.

a. Follow the usual bedtime routine if possible.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply.

a. Arrange for assessment for depression and treatment.
b. Discourage napping during the day.
c. Decrease fluids during the evening.
d. Administer diuretics in the morning.
e. Encourage patient to engage in some type of physical activity.
f. Assess medication for side effects of sleep pattern disturbances.

a. Arrange for assessment for depression and treatment.
b. Discourage napping during the day.
e. Encourage patient to engage in some type of physical activity.
f. Assess medication for side effects of sleep pattern disturbances.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient?

a. The use of a central nervous system stimulant
b. Continuous positive airway pressure machine (CPAP)
c. Chronotherapy
d. The application of heat or cold therapy to promote sleep

c. Chronotherapy

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep?

a. Keep the room light dimmed during the day.
b. Keep the room cool.
c. Keep the door of the room open.
d. Offer a sleep aid medication to patients on a regular basis.

b. Keep the room cool.

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults.
Which action is recommended for these patients?

a. Increase physical activities during the day.
b. Encourage short periods of napping during the day.
c. Increase fluids during the evening.
d. Dispense diuretics during the afternoon hours.

a. Increase physical activities during the day.

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply.

a. Changes in appetite
b. Changes in elimination patterns
c. Decreased pulse and respirations
d. Use of ineffective coping mechanisms
e. Withdrawal
f. Attention-seeking behaviors

a. Changes in appetite
b. Changes in elimination patterns

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management?

a. The nurse teaches a patient rhythmic breathing to perform prior to the procedure.
b. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out.
c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it.
d. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it.

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply.

a. Increased heart rate
b. Decreased muscle strength
c. Increased mental alertness
d. Increased blood glucose levels
e. Decreased cardiac output
f. Decreased peristalsis

a. Increased heart rate
c. Increased mental alertness
d. Increased blood glucose levels

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress?

a. An infant who learns to turn over
b. A school-aged child who learns how to add and subtract
c. An adolescent who is a "loner"
d. A young adult who has a variety of friends

c. An adolescent who is a "loner"

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient?

a. Monitoring food and drink temperatures to prevent burns
b. Providing adequate pain relief measures to reduce stress
c. Monitoring for depression related to social isolation
d. Providing meals high in carbohydrates to promote healing

a. Monitoring food and drink temperatures to prevent burns

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected?

a. Decreasing pulse
b. Increasing sleepiness
c. Increasing energy levels
d. Decreasing respirations

c. Increasing energy levels

A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document?

a. "Patient displays moderate anxiety related to her situation."
b. "Patient manifests panic related to feelings of impending doom."
c. "Patient describes severe anxiety related to her situation."
d. "Patient expresses fear of her husband."

d. "Patient expresses fear of her husband."

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations?

a. "Are you worried about failing your exams?"
b. "Have you been staying up late studying?"
c. "Are you using any recreational drugs?"
d. "Do you have trouble managing your time?"

a. "Are you worried about failing your exams?"

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating?

a. Projection
b. Denial
c. Displacement
d. Repression

b. Denial

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family?

a. Arrange to have the infant removed from the home.
b. Inform other members of the family of the situation.
c. Increase the number of visits by the visiting nurse.
d. Notify the care provider and recommend respite care for the mother.

d. Notify the care provider and recommend respite care for the mother.

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching?

a. "I must breathe in and out in rhythm."
b. "I should take my pulse and expect it to be faster."
c. "I can expect my muscles to feel less tense."
d. "I will be more relaxed and less aware."

b. "I should take my pulse and expect it to be faster."

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply.

a. Progressive muscle relaxation
b. Meditation
c. Anticipatory socialization
d. Biofeedback
e. Rhythmic breathing
f. Guided imagery

a. Progressive muscle relaxation
b. Meditation
e. Rhythmic breathing
f. Guided imagery

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process?

a. "I need to identify the problem first."
b. "Listing alternatives is the initial step."
c. "I will list alternatives after I develop the plan."
d. "I do not need to evaluate the outcome of my plan."

a. "I need to identify the problem first."

A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient?

a. Ineffective Coping related to the new parenting role
b. Ineffective Denial related to ability to care for a newborn
c. Anxiety related to change in role status
d. Situational Low Self-Esteem related to fear of parenting

c. Anxiety related to change in role status

A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients?

a. Discouraging oververbalization of fears and anxieties
b. Focusing on the outcome as opposed to the details of the surgery
c. Providing time alone for reflection on personal strengths and weaknesses
d. Mutually determining expected outcomes of the care plan

d. Mutually determining expected outcomes of the care plan

A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply.

a. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'."
b. "I should wean my infant by 4 months and encourage him to use a sippy cup."
c. "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body."
d. "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears."
e. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases."
f. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

a. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'."

b. "I should wean my infant by 4 months and encourage him to use a sippy cup."

e. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases."

f. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address?

a. "We're at the age when we should consider ceasing sexual activity."
b. "We need more time for sexual stimulation than we used to."
c. "If we are unable to have sex we can still have an intimate relationship."
d. "If we change our position we can still have sex and be more comfortable."

a. "We're at the age when we should consider ceasing sexual activity."

A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply.

a. A 72-year-old man with a history of diabetes
b. A 78-year-old man who has a new partner
c. A 75-year-old man who has Parkinson's disease
d. An 80-year-old man who is an alcoholic
e. An 85-year-old man who takes antihypertensive medication
f. A 76-year-old man who smokes tobacco

a. A 72-year-old man with a history of diabetes
d. An 80-year-old man who is an alcoholic
e. An 85-year-old man who takes antihypertensive medication

A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning?

a. "Each person is born with a certain amount of sexual drive, which can be depleted in later years."
b. "If you want to be a great athlete, sexual abstinence is necessary when you are training."
c. "If you have a nocturnal emission (wet dream), it is an indicator of a sexual disorder."
d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern?

a. "Children should be taught not to masturbate because most people believe self-stimulation is wrong."
b. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty."
c. "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children."
d. "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

b. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty."

A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend?

a. Diaphragm
b. Oral contraceptive pills
c. Depo-Provera
d. Evra patch

a. Diaphragm

A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED, but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority?

a. Getting the patient into a safe environment and mobilizing support for her
b. Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped
c. Convincing the student to be assessed for pregnancy, STIs, or other complications
d. Convincing the student to tell her parents so that she can receive their support

a. Getting the patient into a safe environment and mobilizing support for her

A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching?

a. "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period."
b. "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus."
c. "Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs."
d. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

d. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

A nurse is assessing a patient who is visiting her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect?

a. Human papillomavirus (HPV)
b. Syphilis
c. Trichomoniasis
d. Herpes simplex virus

c. Trichomoniasis

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include?

a. "HPV causes genital warts and cervical and other genital cancers."
b. "HPV causes a single painless genital lesion and can lead to sterility."
c. "50% of women between the ages of 14 and 19 are infected with HPV."
d. "The HPV vaccination is only recommended for the female population."

a. "HPV causes genital warts and cervical and other genital cancers."

A patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. How would the nurse document this data?

a. Masochism
b. Pedophilia
c. Voyeurism
d. Sadism

c. Voyeurism

An 18-year-old presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate?

a. "Vaginal intercourse is most commonly performed in the missionary position."
b. "The side-by-side position achieves better clitoral stimulation than the missionary position."
c. "Achieving simultaneous orgasms is the goal of vaginal intercourse."
d. "The period after coitus is just as significant as the events leading up to it."

c. "Achieving simultaneous orgasms is the goal of vaginal intercourse."

Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply.

a. A patient who is breast-feeding
b. A patient who is diagnosed with anorexia
c. A patient who chooses to abstain from sexual intercourse
d. A patient who has pelvic inflammatory disease
e. A patient who is obsessed with exercising
f. A patient who has a spinal cord injury

a. A patient who is breast-feeding
b. A patient who is diagnosed with anorexia
d. A patient who has pelvic inflammatory disease
e. A patient who is obsessed with exercising

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia?

a. "Do you currently have a new partner?"
b. "Have you been diagnosed with a neurologic disorder?"
c. "Do you take antihypertensive medication?"
d. "Do you use antihistamines?"

d. "Do you use antihistamines?"

A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply.

a. LGBT youth are four times more likely to attempt suicide.
b. LGBT youth are more likely to be homeless.
c. Lesbians are less likely to get preventive services for cancer.
d. Lesbians and bisexual females are more likely to be underweight.
e. Transgender people have a high prevalence of HIV and sexually transmitted infections.
f. LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

b. LGBT youth are more likely to be homeless.
c. Lesbians are less likely to get preventive services for cancer.
e. Transgender people have a high prevalence of HIV and sexually transmitted infections.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply.

a. Actual
b. Perceived
c. Psychological
d. Anticipatory
e. Physical
f. Maturational

a. Actual
b. Perceived
c. Psychological

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply.

a. The family arranges for a funeral for their loved one.
b. The family arranges for a memorial scholarship for their loved one.
c. The coroner pronounces the patient's death.
d. The family arranges for hospice for their loved one.
e. The patient is diagnosed with terminal cancer.
f. The patient's daughter writes a poem expressing her sorrow.

a. The family arranges for a funeral for their loved one.
b. The family arranges for a memorial scholarship for their loved one.
f. The patient's daughter writes a poem expressing her sorrow.

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing?

a. Somatic grief
b. Anticipatory grief
c. Unresolved grief
d. Inhibited grief

c. Unresolved grief

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying?

a. Acceptance
b. Anger
c. Bargaining
d. Denial

a. Acceptance

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the nurse would be most appropriate?

a. "You can't be feeling this way. You know you are going to die."
b. "It does seem unfair. Tell me more about how you are feeling."
c. "You'll be all right; who knows how much time any of us has."
d. "Tell me about your pain. Did it keep you awake last night?"

b. "It does seem unfair. Tell me more about how you are feeling."

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate?

a. "Oh, don't worry about that now. You need to sleep."
b. "What seems to be concerning you the most?"
c. "I have talked to your wife and she told me she will be fine."
d. "I'm not qualified to advise you, I suggest you discuss this with your wife."

b. "What seems to be concerning you the most?"

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare?

a. POLST form
b. Durable power of attorney for health care
c. Living will
d. Allow Natural Death (AND) form

b. Durable power of attorney for health care

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide?

a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death.
b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses.
c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die."
d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death.

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife's health care provider about which type of order?

a. Comfort Measures Only
b. Do Not Hospitalize
c. Do Not Resuscitate
d. Slow Code Only

a. Comfort Measures Only

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply.

a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support.
b. Explain to the family what will happen at each phase of the weaning and offer support.
c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.
d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator.
e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider.
f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support.
b. Explain to the family what will happen at each phase of the weaning and offer support.
c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document?

a. Grieving
b. Ineffective Coping
c. Caregiver Role Strain
d. Powerlessness

c. Caregiver Role Strain

A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care?

a. To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient.
b. The nurse sits on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient.
c. The nurse refers to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father.
d. The nurse tells a dying patient to sit back and relax and performs patient hygiene for the patient because it is easier than having the patient help.

b. The nurse sits on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy?

a. The nurse leaves the patient in a sitting position while the family visits.
b. The nurse places identification tags on both the shroud and the ankle.
c. The nurse removes soiled dressings and tubes.
d. The nurse makes sure a death certificate is issued and signed.

a. The nurse leaves the patient in a sitting position while the family visits.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate?

a. Inform the family that there is no need for them to wash the body since the mortician typically does this.
b. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel.
c. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens.
d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker?

a. The patient
b. The patient's daughter
c. The patient's health care provider
d. The ethics consult team

a. The patient

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient?

a. Give the patient a hug and tell him that his life still has meaning.
b. Arrange for a spiritual adviser to visit the patient.
c. Ask if the patient would like to talk about his feelings.
d. Call in a close friend or relative to talk to the patient.

c. Ask if the patient would like to talk about his feelings.

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also from God—if there is a God." Analysis of these data reveals which unmet spiritual need?

a. Need for meaning and purpose
b. Need for forgiveness
c. Need for love and relatedness
d. Need for strength for everyday living

c. Need for love and relatedness

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs?

a. Can you describe your usual spiritual practices and how you maintain them daily?
b. Are your spiritual beliefs causing you any concern?
c. How can I and the other nurses help you maintain your spiritual practices?
d. How do your religious beliefs help you to feel at peace?

c. How can I and the other nurses help you maintain your spiritual practices?

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding?

a. The nurse should have ordered kosher dishes also.
b. The staff must have behaved condescendingly or critically.
c. Mr. Goldstein is a problem patient and difficult to satisfy.
d. Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

d. Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery?

a. A patient of the Adventist faith
b. A patient who practices Buddhism
c. A patient who is a Jehovah's Witness
d. A patient who is an Orthodox Jew

c. A patient who is a Jehovah's Witness

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed?

a. Baptism frequently postpones or prevents death or suffering.
b. It is legally required that nurses provide for this care when the family makes this request.
c. It is a nursing function to assure the salvation of the baby.
d. Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

d. Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply.

a. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days.
b. A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures.
c. A nurse administering medications to a Muslim patient avoids touching the patient's lips
d. A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday.
e. The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient.
f. The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

a. The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days.
b. A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures.
d. A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday.
f. The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality?

a. The child's church or religious organization
b. What parents say about God and religion
c. How parents behave in relationship to one another, their children, others, and to God
d. The spiritual adviser for the family

c. How parents behave in relationship to one another, their children, others, and to God

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation?

a. Patients usually want to conceal information about their spiritual needs.
b. Patients are not concerned about spiritual needs until after their spiritual adviser visits.
c. Family members and close friends often initiate spiritual concerns.
d. Illness increases spiritual concerns, which may be difficult for patients to express in words.

d. Illness increases spiritual concerns, which may be difficult for patients to express in words.

A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients?

a. Calling the patient's own spiritual adviser first
b. Asking whether the patient has a spiritual adviser the patient wishes to consult
c. Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser
d. Advising the patient and spiritual adviser concerning health options and the best choices for the patient

b. Asking whether the patient has a spiritual adviser the patient wishes to consult

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing?

a. Spiritual Alienation
b. Spiritual Despair
c. Spiritual Anxiety
d. Spiritual Pain

a. Spiritual Alienation

A patient states she feels so isolated from her family and church, and even from God, "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress?

a. The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living.
b. The patient will identify spiritual beliefs that meet her need for meaning and purpose.
c. The patient will express peaceful acceptance of limitations and failings.
d. The patient will identify spiritual supports available to her in this medical center.

d. The patient will identify spiritual supports available to her in this medical center.

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan?

a. Ask the patient which spiritual adviser he would like you to call.
b. Recommend that the patient read spiritual biographies or religious books.
c. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past.
d. Introduce the belief that God is a loving and personal God.

c. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past.

After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem?

a. Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands."
b. Patient has slept from 10 PM to 6 AM for three consecutive nights without medication.
c. Patient has developed mutually caring relationships with two women and one man.
d. Patient has identified several spiritual beliefs that give purpose to her life.

a. Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands."

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness?

a. Assure Mr. Brown that many parents feel the same way.
b. Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass.
c. Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive.
d. Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

c. Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive.

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply.

a. People are born with values.
b. Values act as standards to guide behavior.
c. Values are ranked on a continuum of importance.
d. Values influence beliefs about health and illness.
e. Value systems are not related to personal codes of conduct.
f. Nurses should not let their values influence patient care.

b. Values act as standards to guide behavior.
c. Values are ranked on a continuum of importance.
d. Values influence beliefs about health and illness.

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission?

a. Modeling
b. Moralizing
c. Laissez-faire
d. Rewarding and punishing

d. Rewarding and punishing

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply.

a. A patient decides to quit smoking following a diagnosis of lung cancer.
b. A patient shows off a new outfit that she is wearing after losing 20 pounds.
c. A patient chooses to work fewer hours following a stress-related myocardial infarction.
d. A patient incorporates a new low-cholesterol diet into his daily routine.
e. A patient joins a gym and schedules classes throughout the year.
f. A patient proudly displays his certificate for completing a marathon.

b. A patient shows off a new outfit that she is wearing after losing 20 pounds.
f. A patient proudly displays his certificate for completing a marathon.

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice?

a. Altruism
b. Autonomy
c. Human dignity
d. Integrity

d. Integrity

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute?

a. Providing honest information to patients and the public
b. Promoting universal access to health care
c. Planning care in partnership with patients
d. Documenting care accurately and honestly

b. Promoting universal access to health care

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development?

a. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code."
b. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!"
c. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had."
d. "I agree! It's impossible to be ethical when working in a practice setting like this!"

a. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code."

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics?

a. Autonomy
b. Beneficence
c. Justice
d. Fidelity
e. Nonmaleficence

e. Nonmaleficence

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy?

a. The nurse helps the patient prepare a durable power of attorney document.
b. The nurse gives the patient undivided attention when listening to concerns.
c. The nurse keeps a promise to provide a counselor for the patient.
d. The nurse competently administers pain medication to the patient.

a. The nurse helps the patient prepare a durable power of attorney document.

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing?

a. Ethical uncertainty
b. Ethical distress
c. Ethical dilemma
d. Ethical residue

b. Ethical distress

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply.

a. Advocacy is the protection and support of another's rights.
b. Patient advocacy is primarily performed by nurses.
c. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities.
d. Nurse advocates make good health care decisions for patients and residents.
e. Nurse advocates do whatever patients and residents want.
f. Effective advocacy may entail becoming politically active.

a. Advocacy is the protection and support of another's rights.
c. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities.
f. Effective advocacy may entail becoming politically active.