The nurse recognizes that the concept of prevention in describing health is essential because:
The nurse recognizes that the concept of prevention in describing health is essential because:
Disease can be prevented by treating the external environment.
The majority of deaths among Americans under age 65 years are not preventable.
Prevention places the emphasis on the link between health and personal behavior.
The means to prevention is through treatment provided by primary health care practitioners.
Question 2 The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
Establish priorities.
Identify expected outcomes.
Evaluate the individual’s condition, and compare actual outcomes with expected outcomes.
Interpret data, and then identify clusters of cues and make inferences.
Question 3 During a visit to the clinic, a patient states, “The doctor just told me he thought I ought to stop smoking. He doesn’t understand how hard I’ve tried. I just don’t know the best way to do it. What should I do?” The nurse’s most appropriate response in this case would be:
“I’d quit if I were you. The doctor really knows what he is talking about.”
“Would you like some information about the different ways a person can quit smoking?”
“Stopping your dependence on cigarettes can be very difficult. I understand how you feel.”
“Why are you confused? Didn’t the doctor give you the information about the smoking cessation program we offer?”
Question 4 A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Collect history information first, then perform the physical examination and institute life-saving measures.
Simultaneously ask history questions while performing the examination and initiating life-saving measures.
Collect all information on the history form, including social support patterns, strengths, and coping patterns.
Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
Question 5 Put the following patient situations in order according to the level of priority.
• A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
• A teenager who was stung by a bee during a soccer match is having trouble breathing.
• An older adult with a urinary tract infection is also showing signs of confusion and agitation.
Question 6 A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?
Alcohol
Heroin
Crack cocaine
Sedatives
Question 7 A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to “warm up” and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Tickle the toddler, and get her to laugh.
Stoop down to her level, and ask her about the toy she is holding.
Continue to ignore her until it is time for the physical examination.
Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.
Question 8 A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, and sleep
Breathing, sleep, and pain
Sleep, breathing, and pain
Sleep, pain, and breathing
Question 9 A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop “cold turkey.” He asks the nurse, “What symptoms can I expect if I do this?” Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply.
Headaches
Hunger
Sleepiness
Restlessness
Nervousness
Sweating
Question 10 During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
Certain drugs can affect the metabolism of nutrients.
The nurse needs to assess the patient for allergic reactions.
Medications need to be documented in the record for the physician’s review.
Medications can affect one’s memory and ability to identify food eaten in the last 24 hours.
Question 11 The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.
Open-ended questions elicit cold facts.
They allow for self-expression.
Open-ended questions build and enhance rapport.
They leave interactions neutral.
Open-ended questions call for short one- to two-word answers.
They are used when narrative information is needed.
Question 12 When observing a patient’s verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
Ask someone who knows the patient well to help interpret this discrepancy.
Focus on the patient’s verbal message, and try to ignore the nonverbal behaviors.
Try to integrate the verbal and nonverbal messages and then interpret them as an average.
Focus on the patient’s nonverbal behaviors, because these are often more reflective of a patient’s true feelings.
Question 13 In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
This information is necessary to determine the patient’s reliability.
Alcohol can interact with all medications and can make some diseases worse.
The nurse needs to be able to teach the patient about the dangers of alcohol use.
This information is not necessary unless a drinking problem is obvious.
Question 14 The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
Inspiratory wheezes noted in left lower lobes
Hypoactive bowel sounds
Nonproductive cough
Edema, +2, noted on left hand
Patient reports dyspnea upon exertion
Rate of respirations 16 breaths per minute
Question 15 A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, “You don’t smoke, drink, or take drugs, do you?” This question is an example of:
Talking too much.
Using confrontation.
Using biased or leading questions.
Using blunt language to deal with distasteful topics.
Question 16 The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply.
“Where is the headache pain?”
“Did you have these headaches as a child?”
“On a scale of 1 to 10, how bad is the pain?”
“How often do the headaches occur?”
“What makes the headaches feel better?”
“Do you have any family history of headaches?”
Question 17 During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son’s treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
Simply changing positions.
More comfortable in this position.
Tired and needs a break from the interview.
Uncomfortable talking about his son’s treatment.
Question 18 The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?
29-year-old woman whose waist measures 33 inches and hips measure 36 inches
32-year-old man whose waist measures 34 inches and hips measure 36 inches
38-year-old man whose waist measures 35 inches and hips measure 38 inches
46-year-old woman whose waist measures 30 inches and hips measure 38 inches
Question 19 The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
Emphysema.
Head trauma.
Mental illness.
Fractured bones.
Question 20 The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
Patient with postoperative pain
Newly diagnosed patient with diabetes who needs diabetic teaching
Individual with a small laceration on the sole of the foot
Individual with shortness of breath and respiratory distress
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