Comprehensive

Question 1

A 38-year-old client is asking for medication for trouble falling asleep and staying asleep. The client also feels groggy and unrested during the day. What should the nurse assess for as possible etiologies? Select all that apply.
1.
Watching TV while in bed

2. Sleeping with smart phone nearby
3. Caffeine consumption
4. Current medications
5. Exercise/activities

Answer 1

1. Watching TV while in bed
2. Sleeping with smart phone nearby
3. Caffeine consumption
4. Current medications

Question 2

A client admitted with pneumonia informs the nurse of a preference for complementary medicine treatment. Which oil could the nurse suggest the family bring in for the client?

1. Geranium
2. Eucalyptus
3. Ylang Ylang
4. Peppermint

Answer 2

2.

Eucalyptus

Question 3

A client is discussing an extended family-related conflict with the nurse and states he or she is tired of the problem and does not participate in family get-togethers because of it. Which ego defense mechanism will the nurse document that the client is using?

1. Denial
2. Avoidance
3. Projection
4. Displacement

Answer 3

2.

Avoidance

Question 4

A client presents to the clinic requesting medication to help him or her sleep. The health-care provider diagnoses the client with insomnia. Which criteria would the nurse expect to be present related to this diagnosis? Select all that apply.

1. Happens three times a night
2. Happens three days per week
3. Happens for at least three months
4. Happens when unable to sleep for three hours
5. Happens from three causes: caffeine, smoking, or alcohol

Answer 4

2. Happens three days per week
3. Happens for at least three months

Question 5

A new nurse is learning how to set up telemetry monitoring for a new admission. Put the steps in the correct order.
.
Expose the client’s chest and shave the hair if dense.

Connect the lead wires to the transmitter.

Clean the client’s skin with an alcohol pad.

Remove the electrode backing.

Insert a new battery into the transmitter.

Attach the lead wires to the electrodes.

Turn on the transmitter.

Apply the electrodes to the sites.

Place the transmitter in the pouch and the pouch strings around the client’s neck.

Secure the monitoring equipment.

Answer 5

First, the nurse will insert a new battery into the transmitter and turn it on. The nurse should then connect the lead wires to the transmitter. Then the nurse exposes the client’s chest and shaves the hair if it is thick or dense. The nurse cleans the client’s skin with an alcohol pad, removes the electrode backing, and attaches the lead wires to the electrodes. The nurse applies the electrodes to the sites, secures the monitoring equipment, and places the transmitter in the pouch and the pouch strings around the client’s neck.

Question 6

A nurse is assessing a client with cardiac pain. What is the difference between cardiac pain and pleuritic pain? Select all that apply.

1. Pleuritic pain is unrelieved with nitrates.
2. Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety.
3. Pleuritic pain is the result of a pulmonary emboli.
4. Cardiac pain typically does not change with inhalation or exhalation.
5. Pleuritic pain is diagnosed with cholesterol, lipid panel, C-reactive protein, and glucose testing.

Answer 6

1. Pleuritic pain is unrelieved with nitrates.
2. Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety.
3. Cardiac pain typically does not change with inhalation or exhalation.

Question 7

A nurse is assessing an older client for orthostatic hypotension. What receptors would respond to a client’s lowering blood pressures?

1. Chemoreceptors
2. Thermoreceptors
3. Baroreceptors
4. Photoreceptors

Answer 7

3.

Baroreceptors

Question 8

A nurse is explaining to a client the differences between physiological and psychological responses to anxiety. Which statements indicate the client understands the physiological indicators? Select all that apply.1.
“My heart feels like it’s racing all the time.”

2. “I don’t know why my speech is so rapid.”
3. “I wish I could have something for this diarrhea.”
4. “My wife complains how irritable I am all the time.”
5. “When I drive in the car, I start to hyperventilate.”
6. “I have a difficult time falling asleep.”

Answer 8

“My heart feels like it’s racing all the time.”

3. “I wish I could have something for this diarrhea.”
4. “When I drive in the car, I start to hyperventilate.”
5. “I have a difficult time falling asleep.”

Question 9

A nurse is preparing to give a client an injection. As the nurse begins to give the injection, the client winces and withdraws. Which factor affecting sensory response does this demonstrate?
1.
Contrast

2. Intensity
3. Adaptation
4. Previous experience

Answer 9

4.

Previous experience

Question 10

A nurse is preparing to perform a focused assessment of a client’s respiratory system. Which aspects should the nurse include in the assessment? Select all that apply.
1.
Rate

2. Edema
3. Body position
4. Capillary refill
5. Breath sounds
6. Use of accessory muscles

Answer 10

1. Rate
2. Body position
3. Breath sounds
4. Use of accessory muscles

Question 11

A nurse is teaching a client how to promote venous circulation. Which statements by the client indicates understanding of the teaching? Select all that apply.

1. “I will keep my legs elevated when I am sitting in the recliner.”
2. “I will take a walk around the block in the morning and afternoon.”
3. “I will only be able to perform range-of-motion exercises once per week”
4. “It’s ok if I sit with my legs crossed in the car.”
5. “I will drink at least six 8-ounce glasses of water every day.”

6. 
“I will attend a smoking cessation class at the YMCA.”

Answer 11

1. “I will keep my legs elevated when I am sitting in the recliner.”
2. “I will take a walk around the block in the morning and afternoon.”
3. “I will drink at least six 8-ounce glasses of water every day.”

6. 
“I will attend a smoking cessation class at the YMCA.”

Question 12

A nurse notes a history of peripheral neuropathy in the medical record of a client. What should the nurse include in the assessment of this client? Select all that apply.

1. Deep diffuse pain
2. Numbness of the feet
3. Cramping and achiness
4. Feeling of pins and needles
5. Itching on the soles of the feet

Answer 12

2. Numbness of the feet
3. Feeling of pins and needles
4. Itching on the soles of the feet

Question 13

According to the gate-control theory of pain, which type of fibers inhibit the client’s perception of pain?1.
Mu fibers

2. A-delta fibers
3. Alpha fibers
4. Sigma fibers

Answer 13

2.

A-delta fibers

Question 14

Clients who experience anxiety may use defense mechanisms to cope. The nurse knows that a common defense mechanism is denial. What is denial?

1. Refusing to acknowledge reality or associated feelings
2. Transferring feelings from one object or person to another
3. Attempting to pattern or resemble the personality of an admired person
4. Attributing one’s own unacceptable feelings and thoughts to others

Answer 14

1.

Refusing to acknowledge reality or associated feelings

Question 15

Conditions that beta blockers treat

Answer 15

1. Angina
2. Congestive heart failure
3. Acute myocardial infarction

Question 16

he nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen?

1. Inflammatory phase
2. Maturation phase
3. Proliferative phase
4. Tertiary phase

Answer 16

1.

Inflammatory phase

Question 17

How is homeostasis defined?

1. When a person makes changes to cope with a situation
2. A disturbance in a person’s normal balanced state
3. When a person’s internal and external equilibria are maintained
4. Adapting to the changes and stressors of illness and caregiving

Answer 17

3.

When a person’s internal and external equilibria are maintained

Question 18

How often should the nurse provide tracheostomy care?

1. Every 8 hours
2. Every 24 hours
3. Every other day
4. Every week

Answer 18

1.

Every 8 hours

Question 19

In which sleep stage would a client’s EEG show beta waves?

1. Drowsy stage
2. In periods of wakefulness
3. Earlier phase of NREM
4. When transitioning to deep sleep

Answer 19

2.

In periods of wakefulness

Question 20

In which way is pain positive?

1. Keeps the person having pain more alert
2. Warns of bodily injury
3. May diminish over time
4. May interfere with quality of life

Answer 20

2.

Warns of bodily injury

Question 21

Place in order the neuroendocrine responses that occur during the fight-or-flight response?
1.
2.
3.
4.
5.
6.
Thyroid-stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy.
Corticotropin-releasing hormone (CRH) is released from the hypothalamus.
Endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well-being and reducing pain.
Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
Antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water.
Corticotropin-releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH).

Answer 21

Corticotropin-releasing hormone (CRH) is released from the hypothalamus.

Corticotropin-releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH).

Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone).

Antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water.

Endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well-being and reducing pain.

Thyroid-stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy.

Question 22

The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use. Which medication may have caused this sensory loss?

1. Lisinopril (Zestril)
2. Vinblastine (Velban)
3. Atorvastatin (Lipitor)
4. Gentamicin (Garamycin)

Answer 22

4.

Gentamicin (Garamycin)

Question 23

The nurse is performing passive range of motion for a client with osteoarthritis and feels a grating sound in the left knee. How would the nurse document this finding?

1. Edema
2. Friction
3. Shearing
4. Crepitus

Answer 23

4.

Crepitus

Question 24

The nurse is preparing to interview a 25-year-old client who reports having problems at work. Which skills should the nurse incorporate into the interview to promote open communication with the client? Select All That Apply.

1. Allowing emotions to show
2. Maintaining the focus on the client
3. Incorporating open-ended questions
4. Being respectful of cultural details
5. Being cognizant of self-imposed biases
6. Permitting the client to control the interview direction

Answer 24

2. Maintaining the focus on the client
3. Incorporating open-ended questions
4. Being respectful of cultural details
5. Being cognizant of self-imposed biases
6. Permitting the client to control the interview direction

Question 25

The nurse is reviewing the structures of the heart. Which part is the pericardium? 1. Two thin-walled muscles that receive blood into the heart 2. A sac of connective tissue that encases the heart 3. Two thick-walled muscles that pump blood out of the heart 4. The nerve tissue that acts as the pacemaker

Answer 25

2. | A sac of connective tissue that encases the heart

Question 26

The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity. Which clinical manifestations should the nurse instruct the family to report? Select all that apply. 1. Withdrawal 2. Depression 3. Aggression 4. Combative 5. Hallucinations 6. Social isolation

Answer 26

1. Withdrawal 2. Depression 5. Hallucinations 6. Social isolation

Question 27

The nurse recognizes his coworker has been working 12 hour shifts and picking up extra shifts in between on different units. Lately, she has experienced several clients who have expired or have been diagnosed with late stage cancers. He notices the coworker has made several mistakes when conducting inventory on the meds cabinet and has been extremely fatigued, forgetful, and has been preoccupied. What should the nurse do to help prevent burnout in the coworker? 1. Offer support to help with tasks or with their feelings and suggest speaking with supervisor. 2. Be proactive about the things you can change and accept the things that you cannot change. 3. Join and support professional organizations that address workplace issues. 4. Seek help from others; don’t be afraid to ask for help.

Answer 27

Offer support to help with tasks or with their feelings and suggest speaking with supervisor.

Question 28

The nursing manager of an intensive care unit is worried about staff burnout. Which behaviors of the nurses may indicate this problem? Select All That Apply. 1. Increased client acuity 2. Nurses being floated to other units 3. Increased ability to delegate nursing responsibilities 4. Decreased staff nurse-to-client ratio assignments 5. Management bringing in food to help nurses who work through extra shifts

Answer 28

1. Increased client acuity 2. Nurses being floated to other units

Question 29

What are primary causes of maceration? Select all that apply. 1. Fever 2. Incontinence 3. Bowel incontinence 4. Infection 5. Tanning

Answer 29

1. Fever 2. Incontinence

Question 30

What are the functions of the stratum corneum layer of the skin? Select all that apply. 1. Prevents water loss 2. Eliminates foreign material 3. Protects from ultraviolet light 4. Functions as a protective barrier 5. Stops chemicals from entering the body

Answer 30

Prevents water loss 4. Functions as a protective barrier 5. Stops chemicals from entering the body

Question 31

What is important to remember when conducting perineal care for a client? 1. Drape the client appropriately to protect modesty. 2. A nurse/NAP of the same gender should conduct perineal care. 3. Clients should be facing the opposite direction to avoid embarrassment. 4. A family member must be present to ensure client comfort.

Answer 31

1. | Drape the client appropriately to protect modesty.

Question 32

What is missing from the documentation regarding the emptying of drainage from a wound? 03/12/20160750Hemovac drained serosangiuneous fluid over 12 hours. No odor or purulent material noted at drainage site………………………N. Signature RN 1. Amount drained 2. a. m. or p.m. 3. Description of color of drainage site 4. Materials used

Answer 32

1. | Amount drained

Question 33

What is the hormone that naturally controls sleep? 1. Melatonin 2. L-tryptophan 3. Progesterone 4. Testosterone

Answer 33

1. | Melatonin

Question 34

What is the most common cause of infectious pharyngitis?1. Streptococcal pyogenes 2. Staphylococcus aureus 3. Influenza virus 4. Respiratory syncytial virus

Answer 34

1. | Streptococcal pyogenes

Question 35

What priority nursing intervention does the nurse incorporate into a plan of care to promote sleep for a hospitalized client? 1. Schedule nursing care to avoid interrupting sleep. 2. Promote good body alignment to facilitate relaxation. 3. Control the temperature of the room and provide good ventilation. 4. Offer cool cloths or a back massage.

Answer 35

1. | Schedule nursing care to avoid interrupting sleep.

Question 36

What questions would best address sleep changes and problems when assessing a client’s sleep history? Select all that apply. 1. How often do you experience difficulty falling asleep? 2. Do you ever experience an unpleasant creeping feeling, crawling, or tingling, relieved only by moving the legs at night? 3. Do you snore? 4. Do you grind your teeth while you sleep? 5. Do you take any sleep medications or other drugs?

Answer 36

1. How often do you experience difficulty falling asleep? 2. Do you ever experience an unpleasant creeping feeling, crawling, or tingling, relieved only by moving the legs at night? 3. Do you snore? 4. Do you grind your teeth while you sleep?

Question 37

What would the nurse assess for in a client with stable angina? Select all that apply. 1. Chest pain relieved by rest 2. Chest pain unrelieved by medication 3. Chest pain caused by cigarette smoking 4. Chest pain that gets worse without relief 5. Chest pain that leads to a myocardial infarction

Answer 37

1. Chest pain relieved by rest 3. Chest pain caused by cigarette smoking

Question 38

Which anticoagulants do not require blood testing to monitor blood levels? Select all that apply. 1. Heparin 2. Warfarin 3. Apixaban 4. Dabigatran 5. Rivaroxaban

Answer 38

3. Apixaban 4. Dabigatran 5. Rivaroxaban

Question 39

Which are issues a nurse should be aware of when assessing anxiety and ego defense mechanisms? Select All That Apply. 1. When used sparingly, defense mechanisms can be helpful. 2. When overused, defense mechanisms become habits that appear as if we are coping. 3. If defense mechanisms are inadequate to diminish perceived threats and restore equilibrium, anxiety disorders may develop. 4. When stressors cannot be controlled an individual may become apprehensive and respond with anger. 5. If left without intervention, hostility can develop along with destructive behavior.

Answer 39

1. When used sparingly, defense mechanisms can be helpful. 2. When overused, defense mechanisms become habits that appear as if we are coping. 3. If defense mechanisms are inadequate to diminish perceived threats and restore equilibrium, anxiety disorders may develop.

Question 40

Which are the main premises of hospice care? Select all that apply. 1. Quality of life is as important as the length of life. 2. All illnesses should be treated aggressively. 3. Lifesaving measures should always be implemented, even if the illness is not curable. 4. Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones. 5. No efforts will be made to treat or reduce symptoms of illness.

Answer 40

1. Quality of life is as important as the length of life. 4. Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones.

Question 41

Which areas of the brain are stimulated by the hypothalamus when a person experiences pain? Select all that apply. 1. Parietal lobe 2. Limbic system 3. Frontal cortex 4. Occipital lobe 5. Somatosensory cortex

Answer 41

2. Limbic system 3. Frontal cortex 5. Somatosensory cortex

Question 42

Which best describes a client who is obtunded? 1. A client whose speech and actions are inappropriate 2. A client whose processes and movements are sluggish 3. A client with a low level of awareness to his or her environment 4. A client with no spontaneous movement or verbalization present

Answer 42

3. | A client with a low level of awareness to his or her environment

Question 43

Which chronic diseases or conditions can have a direct impact on nutritional needs? Select all that apply. 1. Traumatic injury 2. Alcoholism 3. Degenerative joint disease 4. Viral illness 5. Cognitive function

Answer 43

1. Traumatic injury 2. Alcoholism 5. Cognitive function

Question 44

Which classification of medications removes excess fluid from body tissues? Diuretics 2. Calcium channel blockers 3. Positive inotropic agents 4. Beta-adrenergic blockers

Answer 44

Diuretics

Question 45

Which concept involves the movement of air in and out of the lungs through the act of breathing? 1. Inhalation 2. Ventilation 3. Respiration 4. Oxygenation

Answer 45

2. | Ventilation

Question 46

Which describes the updated revision of vitamins, minerals, proteins, and total calories that are thought to meet the needs of about 98% of a particular group? 1. Daily Reference Intake 2. Recommended Daily Allowance 3. Adequate Intakes 4. Standards

Answer 46

2. | Recommended Daily Allowance

Question 47

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply. 1. Weather 2. Pollutants 3. Financial strains 4. Medical diseases 5. Congenital disorders

Answer 47

1. Weather 2. Pollutants 3. Financial strains

Question 48

Which factors affect how a person responds to a stimulus? Select all that apply. 1. Intensity 2. Contrast 3. Adaptation 4. Previous experience 5. Number of receptors activated 6. Presence of specialized receptors

Answer 48

1. Intensity 2. Contrast 3. Adaptation 4. Previous experience

Question 49

Which factors affect the perception of a stimulus? Select all that apply. 1. Position of the stimulus 2. Prior stimuli experience 3. Location of the receptors 4. Number of receptors activated 5. Frequency of action potentials generated 6. Changes in frequency, location, and number of stimuli

Answer 49

3. Location of the receptors 4. Number of receptors activated 5. Frequency of action potentials generated 6. Changes in frequency, location, and number of stimuli

Question 50

Which factors can decrease cardiac tissue perfusion? Select all that apply. 1. Pregnancy 2. Hypovolemia 3. Hyperlipidemia 4. Substance abuse 5. Birth control pills

Answer 50

3. Hyperlipidemia 4. Substance abuse 5. Birth control pills

Question 51

Which factors could cause a person to develop a partial seizure? Select all that apply. 1. Meningitis 2. Head trauma 3. Brain tumors 4. Sleep deprivation 5. Hereditary factors 6. High levels of anticonvulsants

Answer 51

1. Meningitis 2. Head trauma 3. Brain tumors 4. Sleep deprivation

Question 52

Which finding would the nurse expect when assessing a client with pulmonary edema? 1. Black sputum 2. Green sputum 3. Foul-smelling sputum 4. Pink and frothy sputum

Answer 52

4. | Pink and frothy sputum

Question 53

Which high-amplitude brain waves found during sleep are common in children but rare in adults? 1. Beta 2. Alpha 3. Theta 4. Delta

Answer 53

3. | Theta

Question 54

Which is likely to happen in a person who has long-term blindness? 1. Other senses will gradually diminish. 2. Other senses will likely sharpen. 3. The person may suffer from sensory deprivation. 4. Over time, anxiety will develop.

Answer 54

2. | Other senses will likely sharpen.

Question 55

Which is proven to release endorphins, relieve stress, oxygenate the blood, and suppress stress-related hormone release? 1. Humor 2. Music 3. Journaling 4. Sleep

Answer 55

1. | Humor

Question 56

Which is the most prevalent type of degenerative disease that can severely limit a person’s ability to perform physical activity? 1. Osteoarthritis 2. Rheumatoid arthritis 3. Gout 4. Osteomyelitis

Answer 56

1. | Osteoarthritis

Question 57

Which lifestyle choices can lead to alterations in skin integrity? Select all that apply. 1. Smoking 2. Tanning 3. Exercise 4. Daily bathing 5. Adequate nutrition

Answer 57

1. Smoking 2. Tanning

Question 58

Which neurotransmitters are related to excitatory and inhibitory sleep mechanisms? Select all that apply.Glycine 2. Aspartate 3. Serotonin 4. Histamine 5. Prostaglandins 6. Acetylcholine

Answer 58

3. Serotonin 4. Histamine 5. Prostaglandins 6. Acetylcholine

Question 59

Which one of the following statements made by a client would indicate a beginning level of acceptance of a change in body image? A client who is 2 days postoperative with a left BKA and states a desire to look at the stump and learn how to change the dressing 2. A teenager with severe facial burns who doesn’t want any visitors 3. A pregnant woman at 33 weeks who asks if she looks fat 4. A client receiving chemotherapy and has alopecia refuses to look in a mirror because he or she feels “ugly”

Answer 59

A client who is 2 days postoperative with a left BKA and states a desire to look at the stump and learn how to change the dressing

Question 60

Which part of the brain controls circadian rhythms? 1. Thalamus 2. Cerebellum 3. Pituitary gland 4. Hypothalamus

Answer 60

4. | Hypothalamus

Question 61

Which part of the ECG complex represents the SA node firing and conducting the impulse through the atria? 1. P wave 2. QRS complex 3. T wave 4. U wave

Answer 61

1. | P wave

Question 62

Which relaxation techniques would the nurse instruct a client to incorporate into his or her life in order to decrease anxiety? Select All That Apply. 1. Exercise 2. Meditation 3. Visualization 4. Video gaming 5. Acupuncture

Answer 62

1. Exercise 2. Meditation 3. Visualization 5. Acupuncture

Question 63

Which source of energy is butter? 1. Simple carbohydrate 2. Lipid 3. Complete protein 4. Incomplete protein

Answer 63

2. | Lipid

Question 64

Which theorist focused research on identifying developmental stages according to tasks that one is able to complete? 1. Erikson 2. Kolb 3. Maslow 4. Bloom

Answer 64

1. | Erikson

Question 65

Which type of joint is a synovial joint? 1. The cranium 2. The vertebrae 3. The knee joints 4. The pubic bones

Answer 65

3. | The knee joints

Question 66

While administering nutrition through a gastric tube, the client complains of feeling full and nauseated. What should the nurse do at this point? 1. Stop the feeding, assess the client, flush the tube, wait an hour, then measure gastric contents and restart the feeding at a slower rate. 2. Cuff the tracheostomy tube and keep inflated for at least 15 minutes afterward to prevent aspiration. 3. Remove any enteral feeding solution remaining in the tube. Try instilling 5 mL of warm water into the tube and clamping the tube for 5 minutes. 4. Turn the client onto his or her left side.

Answer 66

Stop the feeding, assess the client, flush the tube, wait an hour, then measure gastric contents and restart the feeding at a slower rate.