FUNDAMENTALS IN NURSING (LEC) has talked with the church priest twice

REVIEWER during the hospitalization

The nurse is caring for the family of a
terminally ill client. The family members have
The nurse assesses that a client is experiencing been tearful and sad since the diagnosis was
spiritual distress. What should be the nurse’s given. What is the best nursing diagnosis
primary intervention? problem statement for this family?
Answer: Establish a trusting nurse client Answer: Anticipatory grieving
relationship
A client who was having an affair is upset and
A client who is facing a final life saving can't sleep since learning of her partner's
surgery asks the nurse to stay and pray until death. The nurse recognizes that the sleeping
the surgery begins. In which ways should the difficulty is most likely a result of which type
nurse demonstrate presencing with this client? of grief?
(Select all that apply) 1. Adjusting the
intravenous infusion 2. Talking with the client Answer: Disenfranchised
about holding area 3. Sitting next to the client The nurse determines that a terminally ill
in the holding are. 4. Praying with the client
client is nearing death. What did the nurse
for divine intervention 5. Focusing on the assess to make this clinical decision? (Select
client and fulfilling his needs all that apply) 1.Diarrhea 2.Muscle spasm
Answer: Praying with the client for divine 3.Slow,weak pulse 4.Decreased bp 5.Cyanosis
intervention and Focusing on the client and of the extremities
fulfilling his needs (4 and 5) Answer: Slow weak pulse, Decreased BP
The client being prepared for a procedure asks and Cyanosis of the extremities 3,4,5
to be allowed to wear a religious medal. The A client recovering from back surgery is upset
client states, " | have worn this medal and have after learning of the future inability to perform
not removed it since I was a teenager". What certain sports, activities, and employment
action should the nurse take? Remove the types because of the surgery. The nurse
medal and place it on head of the bed where interprets this client reaction as a response to
the client will be able to see it during the which type of loss?
procedure?
Answer: Situational loss
Answer: Tell the client that the nurse will
explain to the procedure staff about the The nurse is providing postmortem care for a
medal and will request that they allow the client whose family would like to view the
client to wear it. body before it is transported to the morgue.
What interventions are necessary for this
The nurse is determining whether preparation? (Select all that apply) 1.Provide a
interventions to address the diagnosis of total bed bath 2.Place absorbent pads beneath
Spiritual Distress for a client newly diagnosed the body 3.Remove dentures 4.Dress the client
with chronic illness have been effective. What in street clothes 5.Place a pillow under the
outcome would indicate that interventions head 6.Tape the eyelids closed
have been effective for this client? The client
states that there is nothing that can be done Answer: Place absorbent pads beneath the
spiritually to improve her current outlook on body and Place a pillow under the head (2
life and 5)
Answer: The client thanks the nurse for The nurse determines that a client, after
trying to help improve her feelings client learning of the death of a close family
member, is demonstrating normal signs of
grief. What did the nurse assess in this client? Answer: Type of surgery, Time of position
(Select all that apply) 1.Crying 2.Weakness change, Use of supportive devices and
3.Inability to sleep 4.No appetite 5.Inability to Client response to the move (2 3,4,5)
concentrate on conversations
The nurse is working on a hospital committee
Answer: Crying, Inability to sleep, No focused on preventing back injury in nurses.
appetite and Inability to concentrate on Which recommendation by this committee is
conversations (1,3,4,5 most likely to result in a decrease in back
injuries if followed?
The nurse is considering using the NANDA
nursing diagnosis Impaired Physical Mobility Answer: No solo lifting of clients is
in the care plan of a newly admitted client. In permitted in the facility
order to make this problem statement more
individual, the nurse should take which At what age does an average child begin to
action? walk indepently?

Answer: Include what mobility is impaired Answer: 12 months

The nurse observes a client walking the hall.
Which element of the body movement should
The nurse is caring for a client experiencing the nurse assess in this client? (Select all that
dyspnea. In which position should the nurse apply) 1.Posture 2.Balance 3.Joint mobility
place this client? 4.Range of motion 5.Coordinated movement
Answer: Orthopneic position across the Answer: Posture, Balance, Joint mobility
overbed table and Coordinated movement (1,2,3,5)
A client with sleep apnea reports falling asleep Crawling is considered normal developmental
while driving, almost being involved in an milestone on what age?
accident, and frequent episodes of
sleepwalking. What nursing diagnosis should Answer: 6 months
be a priority for this client? Which statement made by the client would
Answer: Risk for injury related to indicate a "me centered" self concept?
somnambulism Answer: "My future is based on my
A 5 year old client has recurrent night terrors. decisions I made today"
What nursing intervention should the nurse During an assessment, the nurse notes that a
use to help alleviate this problem? client frequently refers to his cultural heritage.
Answer: Have the child empty the bladder In which way should the nurse identify the
prior to going to bed impact of the client's heritage? 

A hospitalized client is being awakened every Answer: Personal identity

hour during the night for care and procedures. An adolescent client with a rare malignancy
The nurse realizes that the lack of NREM would prefer to die to have a leg amputated.
sleep can have a physiological effect? What information should the nurse use to plan
Answer: Increase susceptibility to infection future interventions for this client?

A client recovering from surgery is turned and Answer: The knowledge that adolescents
repositioned in bed. Which should the nurse are very concerned about body image
document about positioning? (Select of that
apply) 1.Skin status 2.Type of surgery 3.Time
of position change 4.Use of supportive devices
5.Client response to the move
 The nurse suspects that a client is having 2. Reluctance to discuss sexual history
difficulty with specific self esteem. Which
client statements caused the nurse to have this 3. Utilization of birth control method that fits
concern? (Select all that apply) lifestyle

1. I hate my hair 4. Statement that there are no issues with

sexuality
2. Life is wonderful
5. Discussing sexual problems with healthcare
3. My hips are too big provider
4. I wish i had that nose job 2years ago Answer: Knowledge about sexual behavior,
Utilization of birth control method that fits
5. It is awesome that i got that promotion at lifestyle and Discussing sexual problems
work with healthcare provider (1,3,5)
Answer: I hate my hair, My hips are too big When discussing the orgasmic phase of the
and I wish I had that nose job (1,3,4) sexual response cycle, what should the nurse
Which nursing intervention would be helpful include as physiological changes that affect
when caring for client who has negative self both sexes? (Select all that apply)
esteem? 1. The respiratory rate can increase up to 40
Answer: Design a series of "small breaths per minute
successes" for the client 2. Involuntary muscle spasms occur
The 45year old married client reports having throughout the body
no interest in sex and has not had intercourse 3. The heart rate decreases to 20 beats below
in 16years. How should the nurse interpret this normal
assessment data?  
4. Systolic bp can increase 20 to 30 mmHg
Answer: The lack of sexual desire has above normal
adversely affected the spouse
5. Diastolic bp can decrease 20 to 50 mmHg
Client Dee who engages in collegiate sports below normal
asks why sexual activity must be avoided for
two days before a sport event? Which Answer: The respiratory rate can increase
response should the nurse make? up to 40 breaths per minute, Involuntary
muscle spasms occur throughout the body
Answer: As long as intercourse is not and Systolic BP can increase 20-30 mmHg
involved, there is no reason to avoid sexual above normal (1,2,4)
activity.
 A client who has been treated for diabetes
The nurse enters the room and finds the adult mellitus since childhood has a blood glucose
client masturbating. What action should the reading of 180 mg/dL. For which sensory
nurse take? disturbance should the nurse assess in this
Answer: Say "excuse me" and leave the client? 
room  Answer: Vision loss
After an assessment, the nurse determines that The nurse is assisting a visually impaired
a client has strong sexual health. What did the client with ambulation. In which way should
nurse assess in the client? (Select all that the nurse proceed with this intervention ?
apply)
Answer: Walk 1 foot in front of the client
1. Knowledge about sexual behavior 
The nurse is concerned that a client is A client is prone to developing pressure
experiencing sensory deprivation. What did injuries of the heels. Which equipment should
the nurse assess to make this clinical decision? the nurse use for this client?
(Select all that apply)
Answer: Suspension boots
1. Excessive sleeping, 2. Confusion at night, 3. A client with chronic fatigue syndrome reports
Anger over minor issues, 4. Easily distracted being too tired to exercise. Which suggestion
and 5. Sitting quietly reading a book should the nurse make?
Answer: Excessive sleeping, Confusion at Answer: Intersperse rest periods with
night, Anger over minor issues and Easily activity periods.
distracted (1,2,3,4)
The family of a client in the hospital is
concerned about the constant noise in the care The nurse teaches a client the importance of
area. Which healthcare professionals have the aerobic exercise in maintaining cardiovascular
greatest control over the level of sensory input health. Which client statement should indicate
in the hospital?  that teaching was effective?

Answer: Nurse Answer: Engage in daily exercise.

A client can be aroused only with extreme or A client is prescribed isotonic exercises.
repeated stimuli. How should the nurse Which client activity should the nurse
document this client's behavior? encourage?

Answer: Semicomatose Answer: Use a trapeze to lift the body off of

the bed
A client experiences pallor, diaphoresis,
tachycardia, and dizziness when moving from A client reports going for a long run every
a lying to sitting position. For which health night after dinner. Which assessment finding
problem should the nurse plan care for should the nurse expect?
this client? Answer: Insomnia
Answer: Orthostatic hypotension A client is being treated for diabetic
The family is being instructed to turn and ketoacidosis. For which potential health
reposition a client. Which action should the problem should the nurse plan care for this
nurse take to ensure the family's client?
comprehension of the procedure?
Answer: Hypersomnia
Answer: Ask the family to demonstrate the A preschool-age client has a history of night
procedure. terrors. Which action should the nurse take to
The nurse assesses a client who engages in help this client?
athletic activities. Which fluid replacement Answer: Toilet the client before bedtime.
should the nurse suggest to maintain metabolic
processes? The nurse prepares teaching about the
restorative aspects of sleep. Which
Answer: Osteoporosis information should the nurse include?
A client experiences chronic pain with
mobility. For which health problem should the Answer; During sleep the body clears itself
nurse assess this client?  of adenosine.

Answer: Altered self-esteem An older client reports a sleep disturbance. For

which health problem should the nurse assess
the client?
Answer: Gastric reflux disease Answer: Polyuria

A female client experiences incontinence

The nurse has worked 24 hours to help staff because of chronic urinary tract infections.
the hospital after a major community disaster. Which advice should the nurse provide this
Which action should the nurse take? client?
Answer: Ask a friend for a ride home. Answer: Perform pelvic floor muscle
  exercises.
An adolescent client experiences a sleep  
disturbance. Which suggestion should the The nurse is planning care for a client with
nurse make? dementia. Which toileting schedule should the
Answer: Do not sleep with the smartphone nurse implement for the client?
in the bedroom. Answer: Every 2 hours
   
A parent reports having a toddler who The nurse prepares to irrigate a client's
constantly refuses to go to sleep. Which bladder. Which action should the nurse take
suggestion should the nurse make? first?
Answer: Implement a regular sleep routine. Answer: Review the client record for recent
fluid intake and output (I&O).
A client is diagnosed with hyperthyroidism.  
Which should the nurse expect when assessing A client who has been treated for diabetes
this client? mellitus since childhood has a blood glucose
Answer: Lengthened presleep cycle reading of 180 mg/dl. For which sensory
disturbance should the nurse assess in this
A client reports having difficulty stimulating client?
the micturition reflex. Which suggestion Answer: Vision loss
should the nurse make?  
Answer: Turn on running water. The nurse is assigning support personnel to
assist the families of clients who have died in
A 3-year-old client is not completely toilet dealing with the stress related to the loss of
trained which causes the parent concern. their family members. For which client should
Which information should the nurse provide to the nurse screen the family as being at the
the parent? highest risk for complicated grief?
  Answer: Client was killed in the robbery of
Answer: Full urinary control occurs at age a bank.
4 or 5
The nurse is caring for the family of a
An older client is experiencing nocturia. terminally ill client. The family members have
Which factor should the nurse expect is the been tearful and sad since the diagnosis was
cause of this client's symptom? given. What is the best nursing diagnosis
Answer: Diminished bladder muscle tone problem statement for this family?
Answer: Anticipatory Grieving
An adolescent's daily urine output is 1500 mL.
Which action should the nurse take? How should the nurse document the clients
Answer: Document the finding in the behavior?
client's medical record. Answer: Semi-Comatose
 
A client reports drinking several caffeinated The nurse concern that the hospitalized client
drinks each day. Which should the nurse is experiencing sensory overload. What is the
expect when assessing this client?
nurse assess to come to this conclusion? Answer: Puckering of the skin, flattening of
(select all that apply) the breast from the side view, and change in
Answer: -, Anxiety, and Raising thoughts shape. (1,2, and 5)
(1,2, and 4)
The nurse uses the PLISSIT format in helping
The nurse suspect that the client having clients who have sexual dysfunction. Which
difficulty with specific self-esteem. Which action by the nurse best reflects the SS section
client treatment cause the nurse to have this of this format?
concern? (Select all that apply) Answer: Use the nurses knowledge about
Answer: I hate my hair, My hips are too how disease affects sexuality to offer
big, and I wish I had that nose job 2 years specific suggestions for the client.
ago. (1,3, and 4)
In discussion with teenagers, the nurse
The nurse is preparing an educational session chooses to use the term sexually transmitted
on the sexual response cycle. What should be infection rather than sexually transmitted
included when discussing the psychological or disease. What is the rationale for this choice?
the physiological changes during the Answer: The word disease may elicit guilt,
excitement phase? (Select all that apply) shame, and fear in the client.
Answer: Erection of the clitoris, the breasts
enlarge, and the uterus elevates. (3,4 and 5) The nurse uses the PLISSIT format in helping
clients who have sexual dysfunction. Which
A client speaks about an adult son who is a action by the nurse best reflects the LI section
practicing homosexual and expresses concern of this format?
by stating: I am so worried about him and I Answer: Give the client accurate but
know he is going to hell. What is the most concise information in regard to any sexual
important fact for the nurse to consider in questions that might be asked.
formulating a response to this clients concern?
Answer: What constitutes normal sexual The nurse uses the PLISSIT format in helping
expression varies among cultures and clients who have sexual dysfunction. Which
religions. action by the nurse best reflects the P section
of this format?
The nurse is developing strategies for the Answer: Acknowledge the clients spoken
relief of menstrual cramping to teach a group and unspoken sexual concerns when
of young clients. What should be the focus of providing care.
these strategies?
Answer: Increase of blood flow to the The nurse enters the room and finds the adult
uterine muscle client masturbating. What action should the
nurse take?
Which statement, made by a postmenopausal Answer: Say excuse me and leave the room.
client, would the nurse evaluate as indicating
the need for further assessment? The female client has experienced recurrent
Answer: I am so glad that I dont need to candidiasis with intense vaginal itching and
worry about sex anymore. excoriation. After treatment the client is
reexamined, and the nurse practitioner finds
The nurse who is teaching a client breast self- presence of a white, cheesy discharge. What
examination describes inspection of the recommendation is necessary?
breasts before a mirror. Which findings should Answer: Examination and treatment of
the nurse tell the client should be evaluated by sexual partner
a healthcare provider?
After an assessment, the nurse determines that When gathering the sexual history for this
a client has strong sexual health. What did the client, what question should the nurse ask?
nurse assess in the client? Answer: Have there been any changes in
Answer: Knowledge about sexual behavior, your sexual functioning that might be
utilization of birth control method that fits related to your illness or the medications
lifestyle, and discussing sexual problems you take?
with healthcare provider. (1,3, and 5)
The 45-year-old client reports that she has no
The nurse is preparing to assess a clients interest in sex and that she and her husband
sexual health. What will the nurse include in have not had intercourse in 16 years. How
this assessment? does the nurse interpret these assessment data?
Answer: Sexual self-concept, body image, Answer: If both partners share the same
and gender identity. (1,2, and 3) lack of desire, there is often not a problem.

During an assessment, a client tells the nurse The nurse is conducting a sexual health history
of a desire to wear clothing that is typically with a client. What questions should the nurse
associated with the opposite sex. The nurse ask during this history?
realizes this client is describing which gender Answer: Are you currently sexually active?,
identity? do you experience any pain with sexual
Answer: Cross-dressing. interaction?, and do you have difficulty
with sexual desire? (2,3, and 4)
During a sexual assessment, a client tells the
nurse about a preference for oralgenital sex. The nurse is preparing educational materials to
How should the nurse instruct this client? be used when instructing clients on testicular
Answer: The need to follow safe sex and breast self-examination. What would be
practices. applicable for both sets of instructions?
Answer: Perform palpation in the shower.
The mother of a 5-year-old tells the nurse that
her daughter has always been closer to her The nurse is conducting a health history with
than to her husband. The mother expresses an older client with arthritis and heart disease.
concern that, over the last 2 months, the little When gathering the sexual history for this
girl wants to spend all of her time with her client, what question should the nurse ask?
father instead of with the mother. The nurse Answer:
recognizes that this behavior:
Answer: Is a normal expectation of a The nurse attends a continuing education
preschooler developing sexuality. program to learn about the latest cardiac
catheterization care. Which type of credential
When discussing the orgasmic phase of the should the nurse expect to earn after attending
sexual response cycle, which of the following this program?
will the nurse include as physiological changes Answer: Certificate of completion
that affect both sexes?
Answer: The respiratory rate can increase The nurse wants to earn a master's degree in
up to 40 breaths per minute, involuntary nursing. On which content should the nurse
muscle spasms throughout the body, and expect the program's curriculum to focus?
systolic blood pressure can increase 2030 Answer: Advanced leadership roles
mm Hg above normal (1,2, and 4)
The nurse coordinates the care and consults
The nurse is conducting a health history with with interdisciplinary team members about the
an older client with arthritis and heart disease. needs of a client receiving hemodialysis. In
which way should this  nurse's role be
described?
Answer: Specialist

A group of nurses are discussing the changes

in nursing education curricula. Which societal
factor should be identified that has influenced
nursing education curricula? (Select all that
apply.)
Answer: Political climate, new scientific
knowledge, cultural changes, and
technological advances. (1,2,4, and 5)

The nurse learns of receiving licensure as a

practical nurse. To which setting should the
nurse apply for  employment? (Select all that
apply.)
Answer: Hospice, home health agency,
nursing home and hospital. (2,3,4 and 5)
 FUNDAMENTALS IN NURSING Answer: decline in liver function in
(SKILLS) REVIEWER production of enzymes needed for drug
metabolism
Which of the following actions would the nurse
expect it to perform when instilling eardrops A patient tells the nurse this field is different
correctly? color than the other that I usually play at home
Answer: Strengthen the auditory canal by which is the best response by the nurse?
pulling the cartilaginous portion of the pinna Answer: I will recheck your medication
up and back in an adult and down and back orders
in an infant or child under 3 years
Most drugs are excreted through which of the
Which of the following actions would the nurse following organs?
expect it to perform when instilling eardrops Answer: kidneys
correctly?
Answer: Place the thumb near the margin of Which of the following types of medication
the lower eyelid and exert pressure upward orders with a position prescribe for “as needed”
over the bony prominence of the cheek. pain medication?
Answer: PRN order
Which of the following sites is recommended
for adults as a safe site for the majority of Before administering a drug for a patient, the
intramuscular injections nurse should identify the patient by doing which
Answer: ventrogluteal site of the following?
Answer: check the patient’s ID bracelet
When giving an intramuscular injection using
the z-track technique the nurse should consider The nurse is experiencing a Compazine
which of the following? injection to be given to a client. Which of the
Answer: do not massage the site because it following statements is correct?
may cause irritation Answer: when handling a syringe, the nurse
may touch the outside of the barrel, and the
A patient weighs 110 LB. what is the correct handle of the plunger
kilograms I’m on a nurse should calculate if he
or she understand how to convert pounds to
kilograms? A client in the emergency department is to
Answer: 50 kg receive a rectal suppository which of the
following nursing action is not correct for
Which means of drug administration would be administering a rectal suppository?
used in an emergency to achieve rapid Answer:
absorption, and quicker results
Answer: injection A nurse is evaluating a nursing student’s
transdermal patch application to a comatose
Mr. Harris is a 78 year old women admitted to client. Which of the following options
your unit after experiencing symptoms of stroke demonstrate a need for further teaching? The
when administering the medication prescribed student:
OK the nurse should be aware that this patient Answer: holes the patch by touching the
has an increase possibility of drug toxicity due adhesive edges.
to which of the following age related factors?
Erythromycin 500 mg is ordering it is supplied
in a liquid form containing 250 mg in 5 mL.
How many milliliters would the nurse
administer?
Answer: 10