NCLEX PRACTICE QUESTIONS

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing?

A) Primary prevention

B) Secondary prevention

C) Tertiary prevention

D) Quaternary prevention

Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza.

A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating?

A) Primary prevention

B) Secondary prevention

C) Tertiary prevention

D) Quaternary prevention

Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration following the myocardial infarction. Tertiary-prevention activities are directed at rehabilitation rather than diagnosis and treatment. Care at this level aims to help patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning.

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!"

A) "That's fine. Exercise is bad for you anyway."

B) "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month."

C) "I understand. Can you think of one reason why being more active would be helpful for you?"

D) "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day."

The patient's response indicates that the patient is in the precontemplation stage and does not intend to change his behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with it. Asking an open-ended question may stimulate the patient to identify a reason to begin a behavior change. Nurses are challenged to motivate and facilitate change in health behavior when working with individuals.

A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise?

A) "Walking is OK. I really think running is better."

B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?"

C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables."

D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan.

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.)

A) Difficulty paying his bills

B) Seeing his pastor as a means of support

C) Family practice of not routinely seeing a health care provider

D) Stress from the divorce and the loss of a job

External factors impacting health practices include family beliefs and economic impact. How patients' families use health care services generally affects their health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system.

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow?

A) Physiological

B) Safety and security

C) Love and belonging

D) Self-actualization

The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults.

When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model?

A) Holistic

B) Health belief

C) Transtheoretical

D) Health promotion

The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care.

When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness?

A) Health belief

B) Illness behavior

C) Health promotion

D) Illness prevention

Illness behavior involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system. Personal history, social situations, social norms, and past experiences can affect illness behavior.

A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model?

A) Perceived threat of the disease

B) Likelihood of taking preventive health action

C) Analysis of perceived benefits of preventive action

D) Perceived susceptibility to the disease.

The health belief model addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how they will comply with health care therapies. In the perceived susceptibility to the disease phase, the patient recognizes the familial link to the disease.

A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take?

A) Care for the boy as she would any other patient

B) Ask the manager to talk with the father and keep him out of the unit

C) Have another nurse care for the boy because maybe that nurse will do better with the father

D) Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. If nurses are not aware of their own and other cultural patterns of behavior and language, they may not be able to recognize and understand a patient's behavior and beliefs and may have difficulty interacting with the patient.

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image?

A) "I just don't have any energy to get out of bed in the morning."

B) "I've been attending church regularly with my wife since I got out of the hospital."

C) "My wife has taken over paying the bills since I've been in the hospital."

D) "I don't go out very much because everyone stares at me."

The amputation resulted in a change in physical appearance that caused a change in body image. Reactions of patients and families to changes in body image depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available. When a change in body image such as results from a leg amputation occurs, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. The patient's statement indicates he is in the stage of withdrawal.

The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change?

A) Precontemplation

B) Contemplation

C) Preparation

D) Action

The patient is in the action stage of behavioral change. In this stage the patient is actively engaged in strategies to change behavior. This stage may last up to 6 months.

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness?

A) "I don't have time to exercise because I have to work after school every night."

B) "I'm worried about becoming overweight and getting diabetes because my father has diabetes."

C) "The statistics of how many teenagers are overweight is scary."

D) "I've decided to start a walking club at school for interested students."

The statement indicates that the patient is concerned about developing diabetes and believes that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the patient may perceive the personal risk for diabetes.

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.)

A) Sedentary lifestyle

B) Father died from CAD at age 50

C) History of hypertension

D) Eats diet high in sodium

E) Elevated cholesterol level

F) Age is 44 years

Genetic and physiological risk factors include those related to heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of coronary artery disease is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease.

Which activity represents secondary prevention?

A) A home health care nurse visits a patient's home to change a wound dressing.

B) A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked.

C) The school health nurse provides a program to the first-year students on healthy eating.

D) The patient attends cardiac rehabilitation sessions weekly.

Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities.

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective:

A) She does not touch the patients either.

B) Touch is a type of verbal communication.

C) There is never a problem with using touch.

D) Touch forms a connection between nurse and patient.

D.Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact.

Of the five caring processes described by Swanson, which describes "knowing the patient"?

A) Anticipating the patient's cultural preferences

B) Determining the patient's physician preference

C) Establishing an understanding of a specific patient

D) Gathering task-oriented information during assessment

C.Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help him or her. Strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise.

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?"

A) Sharing feelings about the importance of having regular woman's health examinations

B) Gaining an understanding of what a woman's health examination means to the patient

C) Recognizing that the patient is modest; obtaining gendercongruent caregiver

D) Explaining the risk factors for cervical cancer

B. You should strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care.

Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes?

A) Knowing

B) Enabling

C) Doing for

D) Being with

B. The caring behavior of enabling facilitates the other's passage through life transitions (e.g., birth, death) and unfamiliar events. When a nurse practices enabling, the patient and nurse work together to identify alternatives and resources.

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies:

A) "Spiritual care should be left to a professional."

B) "You are correct, religion is a personal decision."

C) "Nurses should not force their religious beliefs on patients."

D) "Spiritual, mind, and body connections can affect health."

D. Spirituality offers a sense of connectedness, intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power). In a caring relationship the patient and nurse come to know one another so both move toward a healing relationship.

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors?

A) Increasing the working hours of the staff

B) Increasing salary benefits of the staff

C) Creating a setting that allows flexibility and autonomy for staff

D) Encouraging increased input concerning nursing functions from physicians

C.These factors all affect nursing satisfaction. When nurses' job satisfaction is high, they have a greater connectedness with their patients and believe that caring practices are part of the nursing culture.

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of:

A) Instilling hope and faith.

B) Forming a human-altruistic value system.

C) Cultural caring.

D) Being with.

A. Instilling hope and faith helps to increase an individual's capacity to get through an event or transition and face the future with meaning.

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is:

A) Making health care decisions for patients.

B) Having family members provide a patient's total personal hygiene.

C) Injecting the nurse's perceptions about the level of care provided.

D) Asking permission before performing a procedure on a patient.

D. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members.

A nurse demonstrates caring by helping family members:

A) Become active participants in care.

B) Provide activities of daily living (ADLs).

C) Remove themselves from personal care.

D) Make health care decisions for the patient.

A. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members.

Listening is not only "taking in" what a patient says; it also includes:

A) Incorporating the views of the physician.

B) Correcting any errors in the patient's understanding.

C) Injecting the nurse's personal views and statements.

D) Interpreting and understanding what the patient means.

D. Listening is powerful. It conveys the nurse's full attention and interest. A true caring presence involves listening. Listen to what is important to another person and the meaning of a situation to that person.

A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring?

A) The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room.

B) The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat.

C) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

D) The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.

C. Attentive listening lets the nurse hear the patient's story and then correctly summarize it. It does not occur when the nurse is distracted by equipment or other personnel. The importance of listening is not to distract the patient or solve the problem, but rather to hear what the patient has to say and understand what the situation means to him.

Presence involves a person-to-person encounter that:

A) Enables patients to care for self.

B) Provides personal care to a patient.

C) Conveys a closeness and a sense of caring.

D) Describes being in close contact with a patient.

C. Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves "being there" and "being with." "Being there" is not only a physical presence but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances.

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch?

A) Caring touch

B) Protective touch

C) Task-oriented touch

D) Interpersonal touch

C. Nurses use task-orientated touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern.

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch?

A) Caring touch

B) Protective touch

C) Task-oriented touch

D) Interpersonal touch

A. Caring touch is a form of nonverbal communication. You express this in the way you hold a patient's hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally.

Match the following caring behaviors with their definitions.

A. Sustaining faith in one's capacity to get through a situation

B. Striving to understand an event's meaning for another person

C. Being emotionally there for another person

D. Providing for another as he or she would do for themselves.

Knowing

Being with

Doing for

Maintaining belief

Striving to understand an event's meaning for another person:Knowing, Being emotionally there for another person:Being with, Providing for another as he or she would do for themselves.:Doing for, Sustaining faith in one's capacity to get through a situation:Maintaining belief

The nurse's first action after discovering an electrical fire in a patient's room is to:

A) Activate the fire alarm.

B) Confine the fire by closing all doors and windows.

C) Remove all patients in immediate danger.

D) Extinguish the fire by using the nearest fire extinguisher.

C. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

A) Give the child milk.

B) Give the child syrup of ipecac.

C) Call the poison control center.

D) Take the child to the emergency department.

C. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

A) Activity intolerance

B) Impaired bed mobility

C) Acute pain

D) Risk for falls

D. For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

A) Home accidents

B) Physiological changes of aging

C) Poisoning and child abduction

D) Automobile accidents, suicide, and substance abuse

D. Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

A) Insert a urinary catheter.

B) Leave a night light on in the bathroom.

C) Ask the physician to order a restraint.

D) Keep the bed in low position with upper and lower side rails up.

E) Assign a staff member to stay with the patient.

F) Provide scheduled toileting during the night shift.

G) Keep the pathway from the bed to the bathroom clear.

B,F,G. Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

A) Contact the nursing supervisor.

B) Restrict the family's visiting privileges.

C) Ask the family to stay with the patient.

D) Inform the family of the risks associated with side-rail use.

E) Thank the family for being conscientious and put the four rails up.

F) Discuss alternatives with the family that are appropriate for this patient.

C,D,F. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order.

___ 1. Explain what you plan to do.

___ 2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure.

___ 3. Determine that restraint alternatives fail to ensure patient's safety.

___ 4. Identify the patient using proper identifier.

___ 5. Pad the patient's wrist.

3,4,1,5,2.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?

A) Begin cardiopulmonary respiration.

B) Restrain the child to prevent injury.

C) Place a tongue blade over the tongue to prevent aspiration.

D) Clear the area around the child to protect the child from injury.

D. Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

A) A safe environment promotes patient activity.

B) Assessment focuses on environmental factors only.

C) Teaching home safety is difficult to do in the hospital setting.

D) Most accidents in the older adult are caused by lifestyle factors.

A. Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

A fragile, 87-year-old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse give to nursing assistive personnel (NAP)?

The use of restraints is associated with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. The restraint itself could injure the underlying skin. Routine checks are required to prevent or decrease these complications. The NAP needs to notify the nurse if there is a change in skin integrity, circulation, or patient's breathing and provide range of motion, nutrition and hydration, skin care, toileting, and opportunities for socialization at least every 2 hours.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

A) Place a bed alarm device on the bed.

B) Place the patient in a belt restraint.

C) Provide one-on-one observation of the patient.

D) Apply wrist restraints.

A. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.)

A) Smoking is prohibited around oxygen.

B) Demonstrate how to adjust the oxygen flow rate based on patient symptoms.

C) Do not use electrical equipment around oxygen.

D) Special precautions may be required when traveling with oxygen

A,C,D. When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen

How does the nurse support a culture of safety? (Select all that apply.)

A) Completing incident reports when appropriate

B) Completing incident reports for a near miss

C) Communicating product concerns to an immediate supervisor

D) Identifying the person responsible for an incident

A,B,C. Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

A) Smokes a pack a day

B) Used a cane to walk at home

C) Takes antihypertensive and diuretics

D) History of recent fall

E) Neglect, spatial and perceptual abilities, impulsive

F) Requires assistance with activity, unsteady gait

G) IV line, urinary catheter

C,D,E,F,G. Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?

A) Prepare for an influx of patients

B) Contact the American Red Cross

C) Determine how to restore essential services

D) Evacuate patients per the disaster plan

A. The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

The Collins family includes a mother, Jean; stepfather, Adam; two teenage biological daughters of the mother, Lisa and Laura; and a biological daughter of the father, 25-year-old Stacey. Stacey just moved home following the loss of her job in another city. The family is converting a study into Stacey's bedroom and is in the process of distributing household chores. When you talk to members of the family, they all think that their family can adjust to lifestyle changes. This is an example of family:

A) Diversity.

B) Durability.

C) Resiliency.

D) Configuration.

C. Resiliency is the ability of the family to cope with the unexpected. In this scenario the family used resources to provide some short-term solutions for the adult child's return home.

The most common reason grandparents are called on to raise their grandchildren is because of:

A) Single parenthood.

B) Legal interventions.

C) Dual-income families.

D) Increased divorce rate.

B. This new parenting responsibility is caused by a number of societal factors: the increase in the divorce rate, dual-income families, and single parenthood. But most often it is a consequence of legal intervention when parents are unfit or renounce their parental obligations.

A family's access to adequate health care, opportunity for education, sound nutrition, and decreased stress is affected by:

A) Development.

B) Family function.

C) Family structure.

D) Economic stability.

D. The ability of families to meet health care, education, and basic needs is often affected by the economic resources of the family

David Singer is a single parent of a 3-year-old boy, Kevin. Kevin has well-managed asthma and misses day care infrequently. David is in school studying to be an information technology professional. His income and time are limited, and he admits to going to fast-food restaurants frequently for dinner. However, he and his son spend a lot of time together. David receives state-supported health care for his son, but he does not have health insurance or a personal physician. He has his son enrolled in a government-assisted day care program. Which of the following are risks to this family's level of health? (Select all that apply.)

A) Economic status

B) Chronic illness

C) Underinsured

D) Government-assisted day care

A,C. David's economic status is stretched. He has multiple resources for his son, but he is not insured. Thus, as a result, there is a potential that David does not follow through with personal health promotion activities. Although asthma is a chronic illness, this is well managed, and there is adequate health care for his son.

The Cleric family, which includes a mother, stepfather, two teenage biological daughters of the mother, and a biological daughter of the father is an example of a(n):

A) Nuclear family.

B) Blended family.

C) Extended family.

D) Alternative family

B. Blended families result when two people who have children from a previous marriage/relationship marry.

Which of the following are possible outcomes with clear family communication? (Select all that apply.)

A) Family goals

B) Decision making

C) Methods of discipline

D) Impaired coping

A,B,C. Clear and direct family communication assists the family in creating goals, decision making, progressing through the family development cycle, and coping with stressors.

Communication among family members is an example of family:

A) Attributes.

B) Function.

C) Structure.

D) Development

B. Communication is a component of family functioning, whether that be setting goals, coping, or establishing discipline. Family functioning is what the family does, and communication is an important component of function

Which of the following contribute to family hardiness? (Select all that apply.)

A) Family meetings

B) Established family roles

C) Willingness to change in time of stress

D) Passive orientation to life

A,B,C. Family hardiness is the internal strengths and durability of the family unit. It includes a sense of control over the outcome of life, a view of change as beneficial and growth producing, and an active orientation (such as family meetings) rather than passive orientation in adapting to stressful events. Family meetings, understanding of roles, and adaptation to stressors along with a willingness to change affect family hardiness.

Which of the following demonstrate family resiliency? (Select all that apply.)

A) Resuming full-time work when spouse loses job

B) Arguing ways to deal with problems among siblings

C) Developing hobbies when children leave home

D) Placing blame on family members

A,C. Family resiliency is the ability to cope with expected and unexpected stressors. Resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events.

When nurses view the family as context, their primary focus is on the:

A) Family members within a system.

B) Family process and relationships.

C) Family relational and transactional concepts.

D) Health needs of an individual member.

D. When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). Although the focus is on the individual's health status, assess how much the family provides the individual's basic needs.

Diane is a hospice nurse who is caring for the Robinson family. This family is providing end-of-life care for their grandmother, who has terminal breast cancer. When Diane visits the home 3 times a week, she focuses on symptom management for the grandmother and assists the family with coping skills. Diane's approach is an example of which of the following?

A) Family as context

B) Family as patient

C) Family as system

D) Family as structure

B. When the family as patient is the approach, family processes and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care.

Which of the following are included in a family function assessment? (Select all that apply.)

A) Cultural practices

B) Decision making

C) Rituals and celebrations

D) Neighborhood crime data

A,B,C. Cultural practices help identify culturally related health practices, diets, and religious practices. Decision making provides information as to how the family copes and meets challenges related to changes in family life or dynamics. Rituals and celebrations address how a family celebrates accomplishments and how they deal with challenges. Neighborhood crime data are relevant for community assessment, but they do not give sufficient information about family function.

Karen Johnson is a single mother of a school-age daughter. Linda Brown is also a single mother of two teenage daughters. Karen and Linda are active professionals, have busy social lives, and date occasionally. Three years ago they decided to share a house and housing costs, living expenses, and child care responsibilities. The children consider one another as their family. This family form is considered a(n):

A) Diverse family relationship.

B) Blended family relationship.

C) Extended family relationship.

D) Alternative family relationship.

D. This relationship includes multiadult households, "skip-generation" families, communal groups with children, "nonfamilies," cohabitating partners, and homosexual couples.

During a visit to a family clinic the nurse teaches the mother about immunizations, car seat use, and home safety for an infant and toddler. Which type of nursing interventions are these?

A) Health promotion activities

B) Acute care activities

C) Restorative care activities

D) Growth and development-care activities

A. Health promotion activities focus on interventions designed to maintain the physical, social, emotional, and spiritual health of the family unit. They can include information about specific health behaviors, family coping techniques, and growth and development.

Which best defines family caregiving? (Select all that apply.)

A) Designing a nurturing family to raise children

B) Providing physical and emotional care for a family member

C) Establishing a safe physical environment for a family

D) Monitoring for side effects of illness and treatments

B,C,D. Family caregiving involves the routine provision of services and personal care activities for a family member by spouses, siblings, or parents. Caregiving activities include finding resources, personal care (bathing, feeding, or grooming), monitoring for complications or side effects of illness and treatments, providing instrumental activities of daily living (shopping or housekeeping), and the ongoing emotional support and decision making that is necessary.

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of:

A) Logical reasoning.

B) Egocentrism.

C) Concrete thinking.

D) Animism.

D. This is the belief that inanimate objects have lifelike qualities; it is a component of magical thinking evident in preoperational thought

An 18-month-old child is noted by the parents to be "angry" about any change in routine. This child's temperament is most likely to be described as:

A) Slow to warm up.

B) Difficult.

C) Hyperactive.

D) Easy.

B. Children described as "difficult" adapt slowly to new routines and express their emotions forcefully; they like consistent structure.

Nine-year-old Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in:

A) A sense of guilt.

B) A poor sense of self.

C) Feelings of inferiority.

D) Mistrust.

C. School-age children need to feel real accomplishment and be accepted by peers to develop a sense of industry.

The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson's stages of development?

A) Trust versus mistrust

B) Initiative versus guilt

C) Industry versus inferiority

D) Autonomy versus sense of shame and doubt

B. Toddlers are learning that parents and society have expectations about behaviors and that they must learn to control their behavior.

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of:

A) Object permanence.

B) Sensorimotor play.

C) Schemata.

D) Magical thinking.

A. He is now in Piaget's later stage of sensorimotor thought and has learned that objects exist even though he cannot see or touch them.

When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use?

A) Allowing the child to watch another child undergoing the same procedure

B) Showing the child pictures of what he or she will experience

C) Talking to the child in simple terms about what will happen

D) Preparing the child through play with a doll and toy medical equipment

D. Preschoolers are in the preoperational stage of cognitive development and learn more easily when play is used to teach

A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. She is using which form of cognitive development?

A) Conventional reasoning

B) Formal operations

C) Integrity versus despair

D) Postformal thought

D. Adults recognize that there are various solutions to problems and that different situations demand different solutions.

You are caring for a recently retired man who appears withdrawn and says he is "bored with life." Applying the work of Havinghurst, you would help this individual find meaning in life by:

A) Encouraging him to explore new roles.

B) Encouraging relocation to a new city.

C) Explaining the need to simplify life.

D) Encouraging him to adopt a new pet.

A. The activity theory states that continuing an active, involved lifestyle results in greater satisfaction and well-being.

Place the following stages of Freud's psychosexual development in the proper order by age progression.

1. Oedipal

2. Latency

3. Oral

4. Genital

5. Anal

3, 5, 2, 1, 4

According to Piaget's cognitive theory, a 12-year-old child is most likely to engage in which of the following activities?

A) Using building blocks to determine how houses are constructed

B) Writing a story about a clown who wants to leave the circus

C) Drawing pictures of a family using stick figures

D) Writing an essay about patriotism

B. As adolescents mature, their thinking moves to abstract and theoretical subjects. They have the capacity to reason with respect to possibilities.

Allison, age 15 years, calls her best friend Laura and is crying. She has a date with John, someone she has been hoping to date for months, but now she has a pimple on her forehead. Laura firmly believes that John and everyone else will notice the blemish right away. This is an example of the:

A) Imaginary audience.

B) False-belief syndrome.

C) Personal fable.

D) Personal absorption syndrome.

A. Adolescents are quite egocentric and have the belief that everyone is focused on them and sees all of their flaws.

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent:

A) Imaginary audience.

B) False-belief syndrome.

C) Personal fable.

D) Sense of invulnerability

D. Adolescents can be risk takers and believe that they are immune to the negative consequences of behaviors; they are just beginning to be future oriented in their thought process and see everything as black or white

Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state is an example of ____________, which aids cognitive performance by using new approaches.

A) Cognitive development

B) Activity theory

C) Selective optimization with compensation

D) Formal operations

C. As adults age, they put more of their energies into activities associated with meaningful relationships

Dave reports being happy and satisfied with his life. What do we know about Dave?

A) He is in one of the later developmental periods, concerned with reviewing his life.

B) He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives.

C) He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships.

D) It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages

D. Each of the life stages can be achieved successfully and result in satisfaction, including old age

You are working in a clinic that provides services for homeless people. The current local regulations prohibit providing a service that you believe is needed by your patients. You adhere to the regulations but at the same time are involved in influencing authorities to change the regulation. This action represents which stage of moral development?

A) Instrumental relativist orientation

B) Social contract orientation

C) Society-maintaining orientation

D) Universal ethical principle orientation

B. At this stage the individual recognizes that at times the law must be changed to meet the needs of society and that all people have basic rights, regardless of their social group.

In an interview with a pregnant patient, the nurse discussed the three risk factors that have been cited as having a possible effect on prenatal development. They are:

A) Nutrition, stress, and mother's age.

B) Prematurity, stress, and mother's age.

C) Nutrition, mother's age, and fetal infections.

D) Fetal infections, prematurity, and placenta previa.

A. The woman's diet before and during pregnancy has a significant effect on fetal development; the mother's age may contribute to a risk for chromosomal defects (older mothers) or the lack of prenatal care (adolescent mothers); pregnancy is often accompanied by stress because of all of the developmental changes, and it is important to know whether or not the mother has an effective support system.

A parent has brought her 6-month-old infant in for a well-child check. Which of her statements indicates a need for further teaching?

A) "I can start giving her whole milk at about 12 months."

B) "I can continue to breastfeed for another 6 months."

C) "I've started giving her plenty of fruit juice as a way to increase her vitamin intake."

D) "I can start giving her solid food now."

C. Breast milk or formula is recommended at this time; fruit juice is not considered a nutritive addition.

The type of injury a child is most vulnerable to at a specific age is most closely related to which of the following?

A) Provision of adult supervision.

B) Educational level of the parent

C) Physical health of the child

D) Developmental level of the child

D. The child's cognitive and physical development need to be considered initially when assessing the potential risk for injury.

Which approach would be best for the nurse to use with a hospitalized toddler?

A) Always give several choices.

B) Set few limits to allow for open expression.

C) Use noninvasive methods when possible.

D) Gain cooperation before attempting treatment.

D. Toddlers are learning to become independent and frequently display negative behavior if an effort to gain their trust is not provided initially. Providing too many choices does not support their efforts to gain control.

The nurse is providing information on prevention of sudden infant death syndrome (SIDS) to the mother of a young infant. Which of the following statements indicates that the mother has a good understanding?

A) "I won't use a pacifier to help my baby sleep."

B) "I'll be sure my baby does not spend any time on her abdomen."

C) "I'll place my baby on her back for sleep."

D) "I'll be sure to keep my baby's room cold."

C,D. The American Academy of Pediatrics has clearly recommended that infants be placed on their backs for sleep to help prevent SIDS. Keeping the room cool is also important.

In evaluating the gross-motor development of a 5-month-old infant, which of the following would the nurse expect the infant to do?

A) Roll from abdomen to back

B) Move from prone to sitting unassisted

C) Sit upright without support

D) Turn completely over

A. The 5-month-old infant should be able to turn from abdomen to back.

Parents are concerned about their toddler's negativism and ask the nurse for guidance. Which is the most appropriate recommendation?

A) Provide more attention.

B) Reduce opportunities for a "no" answer.

C) Be consistent with punishment.

D) Provide opportunities for the toddler to make decisions.

B. Giving toddlers realistic choices reduces the opportunity for a negative response and helps support their need for control.

When nurses are communicating with adolescents, they should:

A) Be alert to clues to their emotional state.

B) Ask closed-ended questions to get straight answers.

C) Avoid looking for meaning behind adolescents' words or actions.

D) Avoid discussing sensitive issues such sex and drugs.

A. Adolescents are searching for their identity and trying to become emotionally independent from parents while maintaining family ties. Depression, substance abuse, and violence are all real concerns during this period; thus the nurse must be aware of the adolescent's emotional state.

Which of the following statements is most descriptive of the psychosocial development of school-age children?

A) Boys and girls play equally with each other.

B) Peer influence is not yet an important factor to the child.

C) They like to play games with rigid rules.

D) Children frequently have "best friends."

D. Peer relationships become very important to school-age children, and they usually develop close friendships.

You are caring for a 4-year-old child who is hospitalized for an infection. He tells you that he is sick because he was "bad." Which is the most correct interpretation of his comment?

A) Indicative of extreme stress

B) Representative of his cognitive development

C) Suggestive of excessive discipline at home

D) Indicative of his developing sense of inferiority

B. Preschoolers exhibit "egocentric" thought, meaning that they truly believe that their thinking is shared by others and that they can control their environment by their thoughts.

At a well-child examination, the mother comments that her toddler eats little at mealtime, will only sit briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend?

A) Provide nutritious snacks.

B) Offer rewards for eating at mealtimes.

C) Avoid snacks so she is hungry at mealtime.

D) Explain to her firmly why eating at mealtime is important.

A. Toddlers are not growing as quickly as they did during infancy and thus eat smaller meals; nutritious snacks can help to ensure that they gain the nutrients they need.

An 8-year-old child is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which of the following will most help her adjust to the hospital?

A) Explain hospital routines such as meal times to her.

B) Use terms such as "honey" and "dear" to show a caring attitude.

C) Explain when her parents can visit and why siblings cannot come to see her.

D) Since she is young, orient her parents to her room and hospital facility.

A. School-age children are able to think logically and can classify objects or routines; having an understanding of what to expect can help them cope with a new experience.

The school nurse is counseling an obese 10-year-old child. What factor would be important to consider when planning an intervention to support the child's health?

A) Concentrate on the child only rather than the family since it is the child's responsibility.

B) Consider the use of medications to suppress the appetite.

C) First plan for weight loss through dieting and then add activity as tolerated.

D) Plan food intake to allow for growth

D. Although growth slows down during the school-age years, it is still important that appropriate nutrients be provided to promote growth. Children need adequate caloric intake along with activity for gross-motor development. Dieting might not provide the intake necessary.

You are working in an adolescent health center when a 15-yearold patient shares with you that she thinks she is pregnant and is worried that she may now have a sexually transmitted infection (STI). Her pregnancy test is negative. What is your next priority of care?

A) Contact her parents to alert them of her need for birth control.

B) Refer her to a primary health care provider to obtain a prescription for birth control.

C) Counsel her on safe sex practices.

D) Ask her to have her partner come to the clinic for STI testing.

C. Adolescent pregnancy and STIs are concerns that should be addressed by the nurse to support health care.

While working in the high-school clinic, one of the students tells you that she is worried about her friend who has started to refuse to participate in group activities, no longer cares about how she looks at school, and is not going to all of her classes. Your assessment of these symptoms may indicate that:

A) She has just broken up with her boyfriend and time will heal all.

B) You will need to observe her over time to see if symptoms persist.

C) School may be too difficult for her right now.

D) She may be at increased risk for suicide.

D. Depression is a major health concern for adolescents and can be triggered by many factors; the symptoms that are listed indicate increased risk.

With the exception of pregnant or lactating women, the young adult has usually completed physical growth by the age of:

A) 18.

B) 20.

C) 25.

D) 30.

B. Physical growth in the young adult is usually completed by the age of 20.

The nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to:

A) Instructing him to return in 2 years.

B) Instructing him in secondary prevention.

C) Instructing him in health promotion activities.

D) Implementing primary prevention with vaccines

C. Although young adults generally have a minimum of major health problems, lifestyles such as tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical activity put them at risk for health problems. Instructing them in health-promotion activities can decrease lifestyle-related health issues.

When determining the amount of information that a patient needs to make decisions about the prescribed course of therapy, many factors affect the patient's compliance with the regimen, including educational level and socioeconomic factors. Which additional factor affects compliance?

A) Gender

B) Lifestyle

C) Motivation

D) Family history

C. Motivation plays a key role in compliance with a prescribed course of therapy. However, motivation can be influenced by a variety of factors, including age, experience, family history, social support, and pressure from health care providers.

A patient is laboring with her first baby, which is coming 2 weeks early. Her husband is in the military and might not get back in time, and both families are unable to be with her during labor. The doctor decides to call in which of the following people employed by the birthing area to be a support person to be present during labor?

A) Nurse

B) Midwife

C) Assistant

D) Lay doula

D. Although a nurse and midwife would be supportive during labor, the scope of practice for nurses and midwives far exceeds that of a support person present during labor. An assistant is incorrect. This woman has no family available to support her during the laboring process and delivery. A lay doula is a support person who is present during labor to assist women who have no other source of support.

A single young adult female interacts with a group of close friends from college and work. They celebrate birthdays and holidays together. In addition, they help one another through many stressors. She views these individuals as:

A) Family.

B) Siblings.

C) Substitute parents.

D) Alternative family structure.

A. Families can be defined biologically, legally, or as a social network with personally constructed ties and ideologies

Sharing eating utensils with a person who has a contagious illness increases the risk of illness. This type of health risk arises from:

A) Lifestyle.

B) Community.

C) Family history.

D) Personal hygiene habits.

D. In all age-groups personal hygiene habits can be risk factors for the spread of contagious diseases. Sharing eating utensils with a person who has a contagious illness increases the risk of illness.

A 50-year-old woman has elevated cholesterol profile values that increase her cardiovascular risk factor. One method to control this risk factor is to identify current diet trends and describe dietary changes to reduce the risk. This nursing activity is a form of:

A) Referral.

B) Counseling.

C) Health education

D) Stress management techniques.

C. The nurse is engaged in health teaching as she offers dietary information to the woman to enable her to make decisions about her dietary health practices in an attempt to lower her cholesterol.

A 34-year-old female executive has a job with frequent deadlines. She notes that, when the deadlines appear, she has a tendency to eat high-fat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. The nurse provides a number of options for the executive, and she chooses yoga. In this scenario yoga is used as a(n):

A) Outpatient referral.

B) Counseling technique.

C) Health promotion activity.

D) Stress-management technique.

D. Relaxation techniques such as imagery, biofeedback, and yoga help recondition the patient's response to stress. Yoga is an ancient practice of controlling body and mind through physical and mental harmony. It is frequently used as an effective intervention for stress and stress-related physical symptoms.

A 50-year-old male patient is seen in the clinic. He tells the nurse that he has recently lost his job and his wife of 26 years has asked for a divorce. He has a flat affect. Family history reveals that his father committed suicide at the age of 53. The nurse should assess for the following:

A) Cardiovascular disease

B) Depression

C) Sexually transmitted infection

D) Iron deficiency anemia

B. Depression is common among middle-age adults and has a variety of causes. Risk factors for depression include disappointments or losses at work, at school, or in family relationships and family history.

Middle-age adults frequently find themselves trying to balance responsibilities related to employment, family life, care of children, and care of aging parents. People finding themselves in this situation are frequently referred to as being a part of:

A) The sandwich generation.

B) The millennial generation.

C) Generation X.

D) Generation Y.

A. The sandwich generation is a generation of people who care for their aging parents while supporting their own children. According to the Pew Research Center, just over one in every eight Americans ages 40 to 60 is both raising a child and caring for a parent.