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NURSING 122 EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALES 2024
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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 - Exact answer 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 - Exact answer 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." - Exact answer 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." - Exact answer 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
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 - Exact answer 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. - Exact answer 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 - Exact answer 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." - Exact answer 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
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. - Exact answer 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. 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. - Exact answer 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. - Exact answer 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 - Exact answer 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 - Exact answer 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. - Exact answer 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
D) Clear the area around the child to protect the child from injury. - Exact answer 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. - Exact answer 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)? - Exact answer 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. - Exact answer 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 - Exact answer 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 - Exact answer 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
front of the other, thus supporting the patient's body weight (see Fig. 38-5, A to C). Extend one leg and let the patient slide against it; gently lower the patient to the floor, protecting his or her head. Take the patient's blood pressure and pulse as soon as possible after incident. Which of the following best motivates a patient to participate in an exercise program? A) Giving a patient information on exercise B) Providing information to the patient when the patient is ready to change behavior C) Explaining the importance of exercise when a patient is diagnosed with a chronic disease such as diabetes D) Following up with instructions after the health care provider tells a patient to begin an exercise program - Exact answer B. Patients are more open to developing an exercise program when they are at a stage of readiness to change their behavior. Once the patient is at the stage of readiness, collaborate with him or her to develop an exercise program that fits his or her needs and provide continued follow-up support and assistance until the exercise program becomes a daily routine. Which of the following is a principle of proper body mechanics when lifting or carrying objects? A) Keep the knees in a locked position. B) Bend at the waist to maintain a center of gravity. C) Maintain a wide base of support. D) Hold objects away from the body for improved leverage. - Exact answer C. Maintaining a wide base of support allows for proper body mechanics. Locking the knees or bending at the waist causes strain on the lower back. Holding objects close to the body helps use the center of gravity for leverage. Which group of patients is at most risk for severe injuries related to falls? A) Adolescents B) Older adults C) Toddlers D) Young children - Exact answer B. Some older adults walk more slowly and are less coordinated. They also take smaller steps, keeping their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries
A nurse plans to provide education to the parents of school-aged children and includes which of the following result of children being less physically active outside of school? A) An increase in obesity B) An increase in heart disease C) Higher computer literacy D) Improved school attendance and grades - Exact answer A. It is increasingly clear that children are less active, resulting in an increase in childhood obesity. Strategies for physical activity incorporated early into a child's daily routine may provide a foundation for lifetime commitment to exercise and physical fitness. A nursing assistive personnel asks for help to transfer a patient who is 125 pounds (56.8 kg) from the bed to a wheelchair. The patient is unable to assist. What is the nurse's best response? A) "As long as we use proper body mechanics, no one will get hurt." B) "The patient only weighs 125 lb. You don't need my assistance." C) "Call the lift-team for additional assistance." D) "The two of us can easily lift the patient." - Exact answer C. Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients (see Table 38-1). Teaching the use of patient-handling equipment or the use of a lift-team in combination with proper body mechanics is more effective. You are transferring a patient who weighs 320 lb (145.5 kg) from his bed to a chair. The patient has an order for partial weight bearing as a result of bilateral reconstructive knee surgery. Which of the following is the best technique for transfer? A) Use a transfer board. B) Obtain a stand assist device. C) Implement a three-person carry. D) Use the ceiling-mounted lift. - Exact answer D. The use of patient- handling equipment helps prevent injury to health care workers and patients. Which is the correct gait when a patient is ascending stairs on crutches? A) A modified two-point gait. The affected leg is advanced between the crutches to the stairs. B) A modified three-point gait. The unaffected leg is advanced between the crutches to the stairs.
B) Notify nurse of patient complaints of increased fatigue, dizziness, light- headedness when obtaining vital signs before and/or after exercise. C) Notify nurse of vital sign values. D) Evaluate the patient's ability to use crutches properly. E) Prepare the patient for exercise by assisting in dressing and putting on shoes. - Exact answer A,B,C,E. These are all correct as they are within the nursing assistive personnel activities (e.g., notifying the nurse or completing assigned activities). Evaluation is within the scope of professional nursing practice and is not delegated. Select statements that apply to the proper use of a cane. (Select all that apply.) A) For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is divided between the cane and the stronger leg. B) A person's cane length is equal to the distance between the elbow and the floor. C) Canes provide less support than a walker and are less stable. D) The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times. - Exact answer A,C,D. A person's cane length is equal to the distance between the greater trochanter and the floor. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The patient needs to learn that two points of support (i.e., both feet or one foot and the cane) are present at all times. A patient is discharged after an exacerbation of chronic obstructive pulmonary disease (COPD). She states, "I'm afraid to go to pulmonary rehabilitation." What is your best response? A) Pulmonary rehabilitation provides a safe environment for monitoring your progress. B) You have to participate or you will be back in the hospital. C) Tell me more about your concerns with going to pulmonary rehabilitation. D) The staff at our pulmonary rehabilitation facility are professionals and will not cause you any harm. - Exact answer A. Pulmonary rehabilitation is beneficial in helping patients reach an optimal level of functioning. Some patients are fearful of participating in exercise because of the potential of
worsening dyspnea (difficulty breathing). Pulmonary rehabilitation provides a safe environment for monitoring the progress of patients. An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A) B/P = 128/ B) Respirations 26 per minute on room air C) HR 114 D) Crackles heard on auscultation E) Pain reported as 3 on scale of 0 to 10 after medication - Exact answer B,C,D. Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur. A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: A) Call the health care provider to report this change in condition. B) Give the patient a paper bag to breathe into to decrease her anxiety. C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D) Explain that this is normal after such trauma and administer the ordered pain medication. - Exact answer C. These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status. The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A) Prevent varicose veins. B) Prevent muscular atrophy. C) Ensure joint mobility and prevent contractures.
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small- bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A) Pale yellow urine B) Unilateral neglect C) Slight movement noted on the R side D) Coffee ground-like aspirate from the feeding tube - Exact answer D. When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract. A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A) The rubber mat in the walk-in shower B) The three-legged stool on wheels in the kitchen C) The braided throw rugs in the entry hallway and between the bedroom and bathroom D) The night-lights in the hallways, bedroom, and bathroom E) The cordless phone next to the patient's bed - Exact answer B,C. Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge. The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? A) Cream of broccoli soup with whole wheat crackers and tapioca for dessert B) Hamburger on soft roll with a side salad and an apple for dessert C) Low-fat turkey chili with sour cream and fresh pears for dessert D) Chicken salad on toast with tomato and lettuce and honey bun for dessert - Exact answer A. The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A) Patient's weight B) Patient's level of cooperation C) Patient's ability to assist D) Presence of medical equipment E) 24-hour calorie intake - Exact answer A,B,C,D. By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patient's ability or inability to assist you with the transfer, and the proper equipment to use for the transfer. The calorie intake for the past 24 hours does not affect safe transfer. A patient of any age can develop a contracture of a joint when: A) The adductors muscles are weakened as a result of immobility. B) The muscle fibers become shortened because of disuse. C) The calcium-to-phosphorus ratio becomes disrupted. D) There is a deficiency in vitamin D. - Exact answer B. The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent. Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A) Repositioning patient every 1 to 2 hours while awake B) Using an objective, valid scale to assess patient's risk for pressure ulcer development C) Using a device to relieve pressure when patient is seated in chair D) Teaching patient how to shift weight at regular intervals while sitting in a chair E) A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes - Exact answer B,C,D,E. Patients must be repositioned around the clock, not just when they are awake. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce his or her risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the
