1.
Mr. Mohammed is a 83-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?
Correct Answer
B. Buccal cyanosis and capillary refill greater than 3 seconds
Explanation
Buccal cyanosis and capillary refill greater than 3 seconds are signs of poor oxygenation and circulation. In a patient diagnosed with pneumonia, these symptoms indicate a potential respiratory or cardiovascular compromise. This is of greatest concern to the nurse because it suggests that the patient's condition may be deteriorating and immediate intervention may be necessary to ensure adequate oxygenation and perfusion.
2.
Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?
Correct Answer
D. Deep pain
Explanation
Deep pain refers to pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity. This type of pain is typically felt in the deeper tissues of the body, such as muscles, joints, or organs. It may be a result of injury, inflammation, or a medical condition. Unlike acute pain, which is sudden and short-lived, deep pain tends to be chronic and long-lasting.
3.
A 49-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?
Correct Answer
D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising
Explanation
Encouraging gentle range-of-motion exercises after administering aspirin and before rising is the most appropriate intervention for the 49-year-old widower with arthritis. This intervention helps to alleviate stiffness and pain in the joints by promoting blood circulation and maintaining joint flexibility. Administering aspirin before the exercises can also provide additional pain relief. It is important to note that strictly limiting movement of inflamed joints can lead to further stiffness and decreased mobility. Teaching the client's family how to transfer the client into a wheelchair or teaching the client to massage inflamed joints may not address the underlying issue of joint stiffness and pain.
4.
In planning pain reduction interventions, which pain theory provides information most useful to nurses?
Correct Answer
D. Central-control theory
Explanation
The central-control theory of pain provides the most useful information to nurses when planning pain reduction interventions. This theory suggests that pain is controlled by the central nervous system, specifically the brain and spinal cord. It emphasizes the role of psychological and cognitive factors in pain perception and modulation. Understanding this theory helps nurses in implementing interventions that target the central control of pain, such as cognitive-behavioral therapy, relaxation techniques, and distraction techniques. By addressing the central control of pain, nurses can effectively manage and reduce pain in their patients.
5.
Mr. Al Katheeri, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a chronic pain center. Which evaluation criteria would indicate the client’s successful rehabilitation?
Correct Answer
C. The client continues normal growth and development with intact support systems.
Explanation
The evaluation criteria that would indicate the client's successful rehabilitation is that the client continues normal growth and development with intact support systems. This means that despite the chronic pain, loss of self-esteem, and bodily disfigurement, the client is able to maintain a sense of normalcy in their life and has a strong support system in place. This indicates that they are able to cope with their pain, maintain their mental and emotional well-being, and continue to progress and thrive in their personal and professional life.
6.
Ahmed, a 6-year-old boy, received a small paper cut on his finger, his mother let him wash it and apply small amount of antibacterial ointment and bandage. Then she let him watch TV and eat an orange. This is an example of which type of pain intervention?
Correct Answer
C. Control and distraction
Explanation
The mother's actions of allowing Ahmed to wash his finger, apply ointment and bandage, and then distracting him by letting him watch TV and eat an orange, are aimed at diverting his attention away from the pain and providing a sense of control over the situation. This intervention falls under the category of control and distraction, as it helps to alleviate pain by shifting focus and providing a sense of empowerment.
7.
Physical assessment is being performed to Faisal by Nurse Jessy. During the abdominal examination, Jessy should perform the four physical examination techniques in which sequence?
Correct Answer
A. Auscultation immediately after inspection and then percussion and palpation
Explanation
The correct answer is auscultation immediately after inspection and then percussion and palpation. This sequence is followed during abdominal examination because it allows the nurse to first visually assess the abdomen for any abnormalities or visible signs. After inspection, auscultation is performed to listen to the bowel sounds and identify any abnormal sounds. Following auscultation, percussion is done to assess the density of underlying organs and detect any areas of tenderness. Finally, palpation is performed to further assess for any masses, tenderness, or abnormalities. This sequence ensures a systematic and thorough assessment of the abdomen.
8.
Abdullah has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
Correct Answer
D. “Is there anything else you would like to tell me?”
Explanation
The best way to end the history interview is by asking the patient if there is anything else they would like to tell the nurse. This allows the patient to share any additional information or concerns they may have that were not covered in the interview. It shows that the nurse is open to listening and ensures that the patient's needs are fully addressed.
9.
Which assessment data should the nurse include when obtaining a review of body systems?
Correct Answer
B. Client complaints of chest pain, dyspnea, or abdominal pain
Explanation
The nurse should include client complaints of chest pain, dyspnea, or abdominal pain when obtaining a review of body systems because these symptoms can provide important information about the functioning of the cardiovascular, respiratory, and gastrointestinal systems. They may indicate potential issues such as heart disease, respiratory disorders, or gastrointestinal problems. By including these complaints in the assessment data, the nurse can gather relevant information to help identify any potential health concerns and provide appropriate care.
10.
When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?
Correct Answer
A. The client distracts himself during pain episodes.
Explanation
The behavior of distracting oneself during pain episodes indicates appropriate adaptation to pain. This suggests that the client is actively trying to cope with the pain by redirecting their attention and focusing on other activities or thoughts. This can help them manage their pain more effectively and prevent it from negatively impacting their daily functioning.
11.
Nurse Jane is acquiring information from a client. Which is an example of biographic information that may be obtained during a health history?
Correct Answer
D. Location of an advance directive
Explanation
During a health history, biographic information refers to personal details about the client. The location of an advance directive is an example of biographic information as it provides insight into the client's preferences for medical treatment in the event that they are unable to communicate their wishes. It is important for nurses to know the location of an advance directive to ensure that the client's wishes are respected and followed.
12.
Abdul Salam is diagnosed with dehydration and underwent series of tests. Which laboratory result would warrant immediate intervention by the nurse?
Correct Answer
B. Serum potassium level of 3.1 mEq/L
Explanation
A serum potassium level of 3.1 mEq/L is considered low (hypokalemia). Hypokalemia can cause muscle weakness, fatigue, and cardiac arrhythmias, which can be life-threatening. Therefore, it would warrant immediate intervention by the nurse to prevent any potential complications.
13.
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
Correct Answer
D. Palpating the pedal pulses
Explanation
To assess arterial function in the lower extremities, the nurse should palpate the pedal pulses. Palpating the pedal pulses allows the nurse to evaluate the strength, rate, and regularity of the pulses, which can indicate the presence or absence of arterial blood flow. This intervention helps in detecting any abnormalities or signs of peripheral arterial disease. Assessing the medial malleoli for pitting edema, performing Allen's test, and assessing Homans' sign are not specific interventions for evaluating arterial function.
14.
A 12-year-old, Fatima, fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?
Correct Answer
A. Type A-delta fibers
Explanation
Based on the given information, Fatima is experiencing sharp pain in her wrist after falling off the stairs. This type of pain is typically caused by fast-conducting nerve fibers known as Type A-delta fibers. These fibers transmit sharp, localized pain sensations from the injured area to the spinal cord. Autonomic nerve fibers are responsible for regulating involuntary bodily functions and are not directly related to pain perception. Type C fibers are slow-conducting fibers that transmit dull, aching pain sensations. Somatic efferent fibers are responsible for transmitting motor signals from the spinal cord to the muscles and are not involved in pain perception.
15.
Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?
Correct Answer
D. Using transcutaneous electric nerve stimulation
Explanation
Using transcutaneous electric nerve stimulation (TENS) is a nonpharmacologic pain-relief intervention for chronic pain. TENS involves the use of a small device that delivers low-voltage electrical currents to the skin through electrodes. These electrical currents stimulate the nerves and help to block pain signals from reaching the brain. TENS is a safe and effective method for managing chronic pain without the use of medication.
16.
Nashreen, a 20 year old lady, should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?
Correct Answer
B. The tail of Spence area must be included in self-examination
Explanation
The nurse should remember that the tail of Spence area must be included in self-examination. The tail of Spence is an extension of breast tissue into the axilla (armpit), and it is an important area to examine for any abnormalities or changes. Including this area in self-examination increases the chances of detecting any potential breast issues, including breast cancer. Therefore, it is crucial for Nashreen to be aware of this and include the tail of Spence area in her self-examination routine.
17.
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
Correct Answer
D. 5 minutes
Explanation
The nurse would notify the health care provider if the client had no bowel sounds for 5 minutes. This is because the absence of bowel sounds for an extended period of time may indicate a bowel obstruction or other serious gastrointestinal issue. It is important for the nurse to notify the healthcare provider so that appropriate interventions can be implemented to prevent further complications.
18.
You are currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?
Correct Answer
B. Pain sensation is affected by a client’s anticipation of pain
Explanation
The correct answer indicates that the individual understands the concept of pain because it recognizes that a client's anticipation of pain can have an impact on their pain sensation. This understanding aligns with the idea that psychological factors, such as anticipation and perception, can influence the experience of pain.
19.
Saleh, who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?
Correct Answer
A. Assessing the client to rule out possible complications secondary to surgery
Explanation
The nurse should assess the client to rule out possible complications secondary to surgery as the first intervention. This is because the client's sharp, throbbing abdominal pain that ranks 8 on a scale of 1 to 10 could indicate a potential complication. By assessing the client, the nurse can gather more information about the pain, such as its location, intensity, and any associated symptoms, which can help identify if there is a complication that needs immediate attention. This assessment will guide further interventions and ensure the client's safety and well-being.
20.
Abdella underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
Correct Answer
D. Left foot cold to touch; no palpable pedal pulse
Explanation
The client underwent a surgical procedure on the left hip, and one day after the operation, they are complaining of pain. While the other data suggests stability and normal vital signs, the fact that the left foot is cold to touch and there is no palpable pedal pulse indicates a potential issue with circulation. This could be a sign of compromised blood flow to the foot, which is a serious concern and should be reported to the healthcare provider immediately.
21.
Nurse Ryan is about to perform Romberg’s test to Hamood. To ensure the latter’s safety, which intervention should nurse Ryan implement?
Correct Answer
D. Standing close to provide support
Explanation
Nurse Ryan should stand close to provide support during Romberg's test to ensure Hamood's safety. Romberg's test is a neurological examination that assesses a person's ability to maintain balance with their eyes closed. By standing close to Hamood, Nurse Ryan can quickly provide support if he starts to lose balance or fall. This intervention is important to prevent any potential injuries and ensure the safety of the client during the test.
22.
Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?
Correct Answer
C. These measures potentiate the effects of analgesics.
Explanation
Noninvasive and non-pharmacologic pain-control measures can enhance the effectiveness of analgesics. By using these measures in conjunction with other pain-control measures, such as medication, the overall pain relief can be improved. This suggests that the noninvasive and non-pharmacologic measures have a synergistic effect with analgesics, making them more potent when used together.
23.
During the nursing assessment, which data represent information concerning health beliefs?
Correct Answer
C. Promotive, preventive, and restorative health practices
Explanation
Promotive, preventive, and restorative health practices represent information concerning health beliefs during a nursing assessment. These practices indicate the individual's beliefs and actions towards maintaining and improving their health. Understanding a person's approach to promoting, preventing, and restoring health can provide valuable insights into their overall health beliefs and behaviors. Family role and relationship patterns, educational level and financial status, and use of medications may provide additional information about the individual's health, but they do not specifically address their health beliefs.
24.
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?
Correct Answer
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal
Explanation
Inserting the otoscope superiorly into the proximal two-thirds of the external canal should be avoided during an otoscopic examination to prevent discomfort and injury to the client. This action can cause pain and potentially damage the delicate structures of the ear. It is important to insert the otoscope gently and carefully, following the natural curve of the ear canal.
25.
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?
Correct Answer
D. Mitral area
Explanation
The mitral area is the best area for auscultating the apical pulse. This is because the mitral area is located at the apex of the heart, where the mitral valve is located. The apical pulse is the pulsation felt at the apex of the heart, which corresponds to the mitral area. By auscultating the apical pulse in the mitral area, healthcare professionals can accurately assess the heart's function and detect any abnormalities or irregularities.
26.
Majedah who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?
Correct Answer
A. Referring the client for counseling and occupational therapy
Explanation
Referring the client for counseling and occupational therapy is the most appropriate intervention for Majedah. Since she is expressing concerns about job-performance abilities and physical disfigurement, counseling can help her address and cope with the emotional and psychological impact of her burns. Occupational therapy can assist her in regaining and improving her job-related skills and abilities, as well as providing support in adapting to any physical limitations or changes in appearance. This intervention focuses on both the psychological and practical aspects of Majedah's recovery, ensuring a holistic approach to her rehabilitation.
27.
Which term would the nurse use to document pain at one site that is perceived in other site?
Correct Answer
A. Referred pain
Explanation
Referred pain is the term used to describe pain that is perceived in a location different from the actual site of the injury or problem. This occurs because the nerves that carry pain signals from different areas of the body may share common pathways, causing the brain to interpret the pain as originating from a different location.
28.
Salama was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?
Correct Answer
B. Resonance
Explanation
When percussing the client's chest during a physical assessment, the nurse would expect to find resonance as a normal sign over the lungs. Resonance is the expected sound heard when percussing healthy lung tissue, indicating that the lungs are filled with air and functioning properly. Dullness may indicate consolidation or fluid in the lungs, hyperresonance may suggest hyperinflation or trapped air, and tympany may indicate air in the pleural space. Therefore, resonance is the expected normal finding during chest percussion.
29.
Newly hired nurse Lara is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Lara to wear gloves?
Correct Answer
D. Oral
Explanation
During an oral assessment, the nurse needs to wear gloves to maintain proper hygiene and prevent the transmission of any potential infections or diseases. This is because the oral cavity contains various microorganisms that can be easily transmitted through contact. Wearing gloves ensures the safety of both the nurse and the client during the examination.
30.
Salem complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)
Correct Answer(s)
A. Assessing the client’s bowel sounds
B. Taking the client’s blood pressure and apical pulse
E. Determining the last time the client received pain medication
Explanation
The correct interventions to implement in this situation are assessing the client's bowel sounds, taking the client's blood pressure and apical pulse, and determining the last time the client received pain medication. These interventions are important in assessing the client's condition and determining the possible causes of the abdominal pain. Assessing bowel sounds can help identify any abnormalities in the gastrointestinal tract. Taking the client's blood pressure and apical pulse can provide information about the client's cardiovascular status. Determining the last time the client received pain medication is crucial in determining if the current pain is related to inadequate pain relief.