Final Exam AI Practice Questions PDF

Final Exam AI Practice Questions Unit 1: **Ethical/Legal Practice Exam** **1. Which of the following statements best reflects the mission statement of PRCC ADN?** - A. To provide innovative, patient-centered care - B. To prepare students for professional nursing practice with a strong foundation in ethics - C. To focus solely on academic achievement in nursing - D. To ensure high clinical performance in hospital settings **2. Select all accrediting bodies recognized in healthcare and nursing education.** - A. The Joint Commission - B. Accreditation Commission for Education in Nursing (ACEN) - C. American Nurses Credentialing Center (ANCC) - D. Centers for Medicare & Medicaid Services (CMS) **3. Which statement best describes the purpose of the American Nurses Association (ANA) Code of Ethics for Nurses?** - A. To establish a set of guidelines for achieving organizational goals - B. To set personal standards for nurse practitioners only - C. To provide nurses with a set of ethical guidelines to support ethical decision-making - D. To regulate patient care practices **4. True or False: Ethical conflicts in healthcare can arise due to differences in values between healthcare professionals.** **5. A nurse encounters an ethical dilemma regarding patient autonomy versus beneficence. Which of the following actions would best support ethical decision-making? (Select all that apply.)** - A. Consulting the hospital ethics committee - B. Considering the patient's values and beliefs - C. Relying solely on past experience - D. Discussing options with the healthcare team **6. According to the Mississippi Nurse Practice Act, which of the following actions could lead to suspension or revocation of a nursing license?** - A. Administering prescribed medication without documenting the dose - B. Documenting patient information inaccurately - C. Violating patient confidentiality - D. Taking a day off without prior notice **7. True or False: Nurses are responsible for advocating for patient rights as outlined in the Patient Bill of Rights.** **8. The ANA Scope and Standards of Practice establishes guidelines for which of the following?** - A. Professional accountability and quality of nursing care - B. Academic standards in nursing education - C. Code of ethics for healthcare professionals - D. Documentation requirements in hospitals **9. In a legal context, an intentional tort differs from an unintentional tort in which of the following ways?** - A. Intentional torts involve negligence, while unintentional torts involve harm. - B. Intentional torts are deliberate actions causing harm; unintentional torts are accidents causing harm. - C. Both are types of negligence. - D. Unintentional torts are not prosecutable. **10. Which of the following scenarios represents malpractice?** - A. A nurse accidentally administers the wrong medication due to a physician's error in orders. - B. A nurse ignores a patient's request for assistance, resulting in a fall. - C. A nurse does not record a patient\'s vital signs due to a computer malfunction. - D. A nurse provides first aid to a stranger in a public place. **11. Which of the following is true regarding HIPAA regulations?** - A. It applies only to electronic health records. - B. It requires that only nurses maintain patient confidentiality. - C. It governs the privacy of all Protected Health Information (PHI). - D. Violating HIPAA has no legal consequences. **12. The Good Samaritan Law provides legal protection in which of the following situations?** - A. A nurse provides first aid care in an emergency outside of the hospital - B. A nurse fails to perform CPR correctly in a clinical setting - C. A nurse acts negligently while treating a patient in the hospital - D. A nurse performs surgery in a non-hospital setting **13. What are the essential elements for carrying out a healthcare provider's orders? (Select all that apply.)** - A. Checking the order for completeness and clarity - B. Consulting a senior nurse before carrying out the order - C. Ensuring the order is appropriate for the patient - D. Documenting all actions related to the order **14. True or False: Nurses are responsible for obtaining informed consent from patients before surgical procedures.** **15. When filing an incident report, which of the following actions is most appropriate?** - A. Including the report in the patient's medical chart - B. Writing only objective information about the incident - C. Sharing the report with all members of the healthcare team - D. Reporting the incident directly to the patient **16. Which of the following actions can minimize a student nurse's liability?** - A. Practicing nursing independently - B. Following instructor's guidance and hospital policies - C. Administering medications without supervision - D. Delegating tasks to other students **17. Which healthcare trend has a significant influence on nursing practice?** - A. Increased specialization in nursing roles - B. Reduced need for patient-centered care - C. Limited technology in healthcare - D. Standardized patient discharge processes **18. Scenario: A nurse is assigned to a patient who requests not to share information with family members. Which of the following actions should the nurse take?** - A. Document the patient's request and follow it strictly - B. Explain that family members have a right to know - C. Share the information only with close family members - D. Consult the physician about sharing the information **19. Select all that apply: Which of the following strategies helps nurses make ethical decisions?** - A. Self-reflection on personal biases - B. Collaboration with interdisciplinary teams - C. Ignoring patient's family input - D. Relying on ethical guidelines **20. True or False: HIPAA violations can lead to both civil and criminal penalties.** **Answer Key with Rationales** 1. **B**: This aligns with the mission of preparing nurses with an ethical foundation. 2. **A, B, D**: These are recognized accrediting bodies in healthcare and nursing. 3. **C**: The ANA Code of Ethics guides nurses in ethical decision-making. 4. **True**: Ethical conflicts often arise from value differences among professionals. 5. **A, B, D**: Consulting ethics committees, patient values, and team discussions support decision-making. 6. **C**: Breaching patient confidentiality can lead to license suspension or revocation. 7. **True**: Advocating for patient rights is a nurse\'s ethical responsibility. 8. **A**: The ANA Scope and Standards ensure professional accountability in nursing. 9. **B**: Intentional torts are deliberate; unintentional torts are accidents. 10. **B**: Ignoring a patient leading to harm is malpractice due to negligence. 11. **C**: HIPAA applies to all PHI, protecting patient confidentiality. 12. **A**: The Good Samaritan Law protects emergency responders outside of hospital settings. 13. **A, C, D**: Ensuring completeness, appropriateness, and documentation are essential. 14. **False**: The healthcare provider obtains consent; nurses confirm it is signed. 15. **B**: Incident reports should be objective and not in the patient's medical chart. 16. **B**: Following instructor guidance and policies helps minimize liability. 17. **A**: Specialization in nursing is a growing trend. 18. **A**: Respecting the patient\'s confidentiality and documenting requests is essential. 19. **A, B, D**: These strategies support ethical nursing decisions. 20. **True**: HIPAA violations may result in civil and criminal consequences. **Communication/Teamwork Practice Exam** **1. Effective communication in nursing is essential for which of the following reasons?** - A. It reduces the need for interdisciplinary collaboration. - B. It improves patient outcomes and enhances team coordination. - C. It minimizes the need for documentation. - D. It allows nurses to manage patients independently. **2. Which of the following are basic elements of the communication process? (Select all that apply.)** - A. Sender - B. Message - C. Environment - D. Interference **3. The therapeutic relationship in nursing care includes which three phases?** - A. Orientation, working, and termination phases - B. Pre-assessment, orientation, and discharge phases - C. Planning, assessment, and evaluation phases - D. Establishment, interaction, and evaluation phases **4. True or False: Interrupting a patient and offering personal advice are considered non-therapeutic communication techniques.** **5. Which of the following communication techniques are considered non-therapeutic? (Select all that apply.)** - A. Using closed-ended questions - B. Offering personal opinions - C. Asking "why" questions - D. Using silence **6. Which technique is used to facilitate therapeutic communication with a patient?** - A. Giving reassurance without assessing patient concerns - B. Validating the patient's feelings and experiences - C. Discussing personal experiences unrelated to the patient - D. Using closed body language **7. True or False: Demonstrating warmth, respect, empathy, and genuineness can improve the quality of communication between nurses and patients.** **8. A patient is visually impaired. Which communication technique is most appropriate to facilitate communication?** - A. Speaking in a louder tone - B. Using simple, clear words without excessive explanation - C. Announcing your presence and explaining procedures before touching the patient - D. Providing written instructions only **9. In a culturally diverse healthcare setting, which strategy can help promote effective communication?** - A. Assuming the patient understands English medical terms - B. Using family members as interpreters for critical information - C. Using professional interpreters for accurate translation - D. Relying on non-verbal cues instead of clarifying questions **10. Which of the following behaviors would be considered unprofessional in a nurse's relationship with the healthcare team?** - A. Openly sharing patient information with unauthorized personnel - B. Providing constructive feedback during meetings - C. Delegating tasks within scope of practice - D. Participating in team rounds **11. True or False: Assertiveness in communication means expressing needs and opinions respectfully without being aggressive.** **12. Scenario: A nurse is working with a patient who has difficulty speaking due to a stroke. Which techniques would facilitate communication? (Select all that apply.)** - A. Using a communication board - B. Allowing extra time for responses - C. Interrupting to finish the patient\'s sentences - D. Speaking slowly and clearly **13. Which of the following are phases of the therapeutic relationship where boundaries are established?** - A. Working phase - B. Orientation phase - C. Assessment phase - D. Termination phase **14. When working in a group, which of the following behaviors demonstrates professional and ethical practice? (Select all that apply.)** - A. Respecting others' opinions - B. Offering constructive feedback - C. Speaking over others in discussions - D. Keeping patient information confidential **15. True or False: Empathy in nursing communication involves feeling exactly what the patient feels.** **16. Which response best demonstrates empathy?** - A. "I understand; this must be very difficult for you." - B. "I think you should try to relax more." - C. "Let's just try to focus on getting you discharged." - D. "I know how you feel, I went through something similar." **17. A nurse is working with a peer who often interrupts and disregards input from team members. Which of the following is the best approach to assertively address this behavior?** - A. Ignore the behavior and focus on completing tasks - B. Inform the supervisor immediately without addressing the peer directly - C. Say, "I noticed you often speak over others; can we all have a turn to share?" - D. Avoid contributing to the discussion to prevent conflict **18. True or False: Assertiveness is essential for effective communication with all members of the healthcare team.** **19. Which of the following are key techniques to improve communication with a patient from a different cultural background? (Select all that apply.)** - A. Showing respect for cultural practices - B. Assuming they understand instructions - C. Using culturally relevant examples - D. Being patient and open to questions **20. Scenario: During a team meeting, a nurse shares that a patient's family is experiencing financial difficulties, leading to non-compliance with medication. Which response by a team member demonstrates professionalism?** - A. "That's their problem; they need to take responsibility." - B. "Perhaps we could refer them to a social worker to discuss financial resources." - C. "Let's document that they are non-compliant due to financial issues." - D. "There's nothing we can do; they need to find a way." **Answer Key with Rationales** 1. **B**: Communication enhances patient outcomes and team coordination. 2. **A, B, C, D**: These are basic elements of the communication process. 3. **A**: The three phases are orientation, working, and termination. 4. **True**: Interrupting and offering personal advice are non-therapeutic. 5. **A, B, C**: These are all non-therapeutic techniques that hinder open communication. 6. **B**: Validating a patient's feelings is a therapeutic technique. 7. **True**: Warmth, respect, empathy, and genuineness build trust and communication quality. 8. **C**: Announcing presence and explaining actions help visually impaired patients feel oriented. 9. **C**: Professional interpreters ensure accurate and unbiased communication. 10. **A**: Sharing patient information with unauthorized personnel is unprofessional and breaches confidentiality. 11. **True**: Assertiveness is about respectful, clear communication without aggression. 12. **A, B, D**: These techniques support clear and respectful communication with speech-impaired patients. 13. **B**: Boundaries are set during the orientation phase of the therapeutic relationship. 14. **A, B, D**: These actions support professional, ethical group dynamics. 15. **False**: Empathy involves understanding a patient's feelings without necessarily experiencing them. 16. **A**: This response shows understanding without judgment. 17. **C**: Assertively addressing the issue can improve teamwork and mutual respect. 18. **True**: Assertiveness helps nurses communicate effectively with patients and colleagues. 19. **A, C, D**: Respect, cultural sensitivity, and openness improve cross-cultural communication. 20. **B**: Referring the family to a social worker demonstrates professionalism and patient-centered care. **Documenting and Reporting Practice Exam** **1. What is the primary purpose of a health care record?** - A. To facilitate legal actions against healthcare providers - B. To provide accurate information about a patient\'s health history and care - C. To reduce patient interaction - D. To serve as a place for healthcare providers' personal notes **2. True or False: Electronic Health Records (EHRs) eliminate the need for narrative documentation.** **3. Which of the following are examples of documentation systems used in healthcare? (Select all that apply.)** - A. Narrative format - B. Source-oriented format - C. Charting by exception - D. Verbal communication only **4. Identify the benefits of Electronic Health Records (EHRs). (Select all that apply.)** - A. Immediate access to patient information - B. Enhanced data security - C. Reduction in potential errors - D. Elimination of HIPAA regulations **5. Which of the following is a key feature of narrative documentation?** - A. It uses a checklist format for efficiency. - B. It provides a chronological account of a patient\'s condition and care. - C. It does not allow the use of abbreviations. - D. It is used only in electronic records. **6. True or False: Accurate documentation is crucial to meet legal standards and reduce liability.** **7. Which of the following abbreviations is commonly used in documentation to indicate \"twice a day\"?** - A. QD - B. BID - C. PRN - D. TID **8. Which of the following best describes the relationship between documentation and healthcare financial reimbursement?** - A. Documentation has no effect on reimbursement. - B. Only procedures that are documented are eligible for reimbursement. - C. Documentation only affects patient satisfaction. - D. Documentation is solely the physician's responsibility. **9. Which of the following are guidelines for effective documentation? (Select all that apply.)** - A. Using only approved abbreviations - B. Documenting care promptly - C. Avoiding subjective information - D. Using correction fluid for errors **10. True or False: JCAHO standards require healthcare documentation to be complete, accurate, and timely.** **11. According to HIPAA regulations, which of the following actions should be taken when documenting patient information?** - A. Use patient names freely in public areas - B. Avoid documenting sensitive information - C. Secure electronic records and limit access - D. Include personal opinions about patient behavior **12. Which of the following information should be included in a change-of-shift report? (Select all that apply.)** - A. Patient\'s current status and plan of care - B. Any changes or updates in the patient's condition - C. Complete patient medical history - D. Family's opinion on care **13. The SBAR communication tool stands for:** - A. Situation, Background, Assessment, Recommendation - B. Symptoms, Background, Assessment, Response - C. Situation, Background, Analysis, Recommendation - D. Systematic, Brief, Analysis, Reporting **14. True or False: Technology in nursing practice has minimized the need for patient documentation.** **15. Which of the following is true regarding ISBARR?** - A. It is a variant of SBAR that includes \"Identification.\" - B. It is a method that eliminates \"Recommendation.\" - C. It stands for Identification, Safety, Background, Assessment, Response, Repeat - D. It excludes \"Assessment\" as a component **16. A nurse is documenting care on a patient\'s chart and realizes they made an error. Which action is most appropriate?** - A. Use white-out to cover the mistake and write over it - B. Draw a single line through the error, initial it, and add the correct information - C. Erase the mistake and rewrite the correct information - D. Tear out the page and start over **17. True or False: Using unauthorized abbreviations in documentation could lead to misinterpretation and errors in patient care.** **18. Scenario: A patient's family member asks to view the electronic health record (EHR) of their loved one. What is the nurse's most appropriate response?** - A. Allow the family member to review the EHR if they ask politely - B. Refer the family member to speak with the healthcare provider - C. Verify if the patient has given permission for family to access the EHR - D. Print a copy of the EHR for the family **19. Which of the following are considered appropriate uses of technology in documenting client information? (Select all that apply.)** - A. Scanning vital signs directly into the EHR - B. Using a personal device to document outside of the EHR system - C. Using secure messaging to communicate patient updates - D. Posting updates on patient condition on social media if patient consents **20. True or False: The use of technology in nursing has no impact on the accuracy of documentation.** **Answer Key with Rationales** 1. **B**: A healthcare record's purpose is to provide accurate, comprehensive information on a patient's health history. 2. **False**: EHRs often still require narrative documentation for context and clarity. 3. **A, B, C**: These are all documentation systems commonly used in healthcare. 4. **A, B, C**: EHRs provide quick access, improve security, and reduce errors, but HIPAA still applies. 5. **B**: Narrative documentation details a patient's care and condition over time. 6. **True**: Proper documentation is a legal responsibility to maintain accuracy and protect against liability. 7. **B**: BID indicates \"twice a day.\" 8. **B**: Documentation impacts reimbursement, as only documented care is billable. 9. **A, B, C**: Approved abbreviations, timely documentation, and avoiding subjective info improve clarity and accuracy. 10. **True**: JCAHO standards require documentation to be accurate and timely for patient safety. 11. **C**: HIPAA mandates security and restricted access to patient information. 12. **A, B**: Shift reports should focus on current patient status and recent changes. 13. **A**: SBAR stands for Situation, Background, Assessment, Recommendation. 14. **False**: Technology has streamlined, not eliminated, the need for documentation. 15. **A**: ISBARR adds \"Identification\" to the SBAR format. 16. **B**: Correcting errors with a line-through and initials is the standard for clarity and accountability. 17. **True**: Unauthorized abbreviations can lead to confusion and errors. 18. **C**: Verify the patient's consent before sharing EHR access with family. 19. **A, C**: These uses of technology are secure and appropriate for patient documentation. 20. **False**: Technology can improve accuracy by reducing the risk of manual errors. **Vital Signs Practice Exam** **1. Which of the following is the normal range for an adult's resting pulse rate?** - A. 40-60 bpm - B. 60-100 bpm - C. 100-120 bpm - D. 120-140 bpm **2. True or False: A normal adult respiratory rate is between 12 and 20 breaths per minute.** **3. Factors that may require more frequent monitoring of a patient's vital signs include: (Select all that apply.)** - A. Post-operative status - B. Administration of certain medications - C. Stable and asymptomatic conditions - D. Sudden change in patient condition **4. Which of the following temperature readings is considered a fever (pyrexia) in an adult?** - A. 98.6°F - B. 100.4°F - C. 96.8°F - D. 99.0°F **5. When measuring body temperature rectally, which of the following should be considered a contraindication?** - A. Age over 50 - B. Recent cardiac surgery - C. Stable cardiac status - D. Low-grade fever **6. True or False: Tympanic temperature measurements can be affected by earwax or improper positioning.** **7. Which of the following statements about pulse characteristics is true? (Select all that apply.)** - A. The rhythm refers to the regularity of the pulse beats. - B. The amplitude describes the strength or force of the pulse. - C. Pulse rate measures the number of beats per minute. - D. Pulse amplitude indicates blood pressure measurement. **8. Which pulse site is most commonly used for routine assessments of heart rate?** - A. Femoral - B. Radial - C. Carotid - D. Apical **9. Which of the following factors can increase a patient's pulse rate?** - A. Hypothyroidism - B. Physical activity - C. Hypothermia - D. Beta-blockers **10. True or False: Respiratory rate, nature, and depth are important characteristics to assess in respiratory regulation.** **11. Scenario: A patient is on bed rest and requires assessment of peripheral pulses. Which method would be the most accurate and least invasive?** - A. Carotid pulse - B. Apical pulse - C. Femoral pulse - D. Radial pulse **12. When measuring blood pressure, which of the following describes the systolic measurement?** - A. The pressure when the heart relaxes between beats - B. The pressure when the heart contracts - C. The average of systolic and diastolic pressure - D. A measurement only used for the diastolic value **13. True or False: Pulse oximetry measures the percentage of hemoglobin that is saturated with oxygen.** **14. Which of the following oxygen saturation levels would be considered abnormal in an adult?** - A. 95% - B. 88% - C. 98% - D. 92% **15. Scenario: You measure a patient's blood pressure using the one-step method, and their reading is 145/95 mmHg. What is the appropriate classification for this reading?** - A. Normal - B. Elevated - C. Hypertension Stage 1 - D. Hypotensive **16. True or False: Documenting abnormal vital signs in the medical record should be followed by prompt communication with the healthcare provider.** **17. Which of the following best describes nursing interventions for a patient with a temperature of 102.5°F? (Select all that apply.)** - A. Encourage fluid intake - B. Administer antipyretic medications as prescribed - C. Cover the patient in multiple layers of blankets - D. Monitor for signs of infection **18. In the SBAR communication tool, where would you report a patient's abnormal pulse rate?** - A. Situation - B. Background - C. Assessment - D. Recommendation **19. Which of the following should be included in a teaching plan for patient self-assessment of blood pressure? (Select all that apply.)** - A. Choosing a blood pressure monitor with an appropriate cuff size - B. Avoiding caffeine and smoking at least 30 minutes before measurement - C. Taking blood pressure immediately after exercise for accuracy - D. Taking blood pressure at the same time each day **20. True or False: Vital signs recorded on a graphic sheet should still be charted in narrative format if abnormal.** **Answer Key with Rationales** 1. **B**: A normal adult pulse rate ranges from 60-100 bpm. 2. **True**: 12-20 breaths per minute is considered a normal adult respiratory rate. 3. **A, B, D**: These factors may require more frequent monitoring to assess for changes. 4. **B**: A fever is generally defined as a temperature above 100.4°F. 5. **B**: Rectal temperature measurements are contraindicated after recent cardiac surgery due to stimulation of the vagus nerve. 6. **True**: Tympanic readings can be affected by earwax or improper placement. 7. **A, B, C**: Rhythm, amplitude, and rate are essential pulse characteristics. 8. **B**: The radial pulse is commonly used for routine assessments of heart rate. 9. **B**: Physical activity can increase pulse rate. 10. **True**: These characteristics provide a comprehensive view of respiratory health. 11. **D**: Radial pulse is commonly used and easy to access, especially for bed rest patients. 12. **B**: Systolic pressure measures the pressure when the heart contracts. 13. **True**: Pulse oximetry indicates oxygen saturation in hemoglobin. 14. **B**: An oxygen saturation level of 88% is considered low and may require intervention. 15. **C**: A BP of 145/95 mmHg is classified as Hypertension Stage 1. 16. **True**: Documenting and promptly reporting abnormal findings are essential for timely intervention. 17. **A, B, D**: These interventions help reduce fever and monitor for underlying issues. 18. **C**: The Assessment section in SBAR is appropriate for reporting vital signs. 19. **A, B, D**: These guidelines help ensure accurate and consistent self-assessment. 20. **True**: Abnormal vitals should be documented in both graphic and narrative formats for thorough reporting. **Additional Scenario-Based Questions** **1. Scenario: You are caring for an 80-year-old patient admitted with pneumonia. When assessing their vital signs, you note a temperature of 101°F, a pulse of 92 bpm, respirations of 24 breaths per minute, and an oxygen saturation of 90% on room air. What is your priority action?** - A. Apply supplemental oxygen as ordered. - B. Encourage the patient to rest quietly. - C. Recheck the patient's temperature in 30 minutes. - D. Document the findings as expected for pneumonia. **2. Scenario: A patient reports feeling lightheaded and dizzy upon standing. When you measure their blood pressure, the reading is 105/65 mmHg while lying down and 85/55 mmHg when standing. What condition might this indicate?** - A. Hypertension - B. Orthostatic hypotension - C. Normal blood pressure - D. Hyperglycemia **3. Scenario: During a routine assessment, you notice that your patient\'s pulse is irregular. They report no symptoms and feel fine. Which of the following actions is most appropriate?** - A. Document the pulse as irregular and notify the healthcare provider immediately. - B. Count the apical pulse for one full minute to confirm the irregularity. - C. Recheck the pulse at the wrist for 15 seconds. - D. Apply a pulse oximeter and disregard the irregularity if the oxygen level is normal. **4. Scenario: You are taking an oral temperature on a patient who has just consumed hot coffee. What is the best course of action?** - A. Take the oral temperature immediately, as the coffee should not affect the reading. - B. Wait at least 15-30 minutes before taking the oral temperature. - C. Use a tympanic thermometer instead. - D. Use an axillary method to avoid delays. **5. Scenario: A patient with a suspected infection is shivering and has a temperature of 102.2°F. Which nursing intervention would be most appropriate?** - A. Place a cooling blanket on the patient to quickly lower their temperature. - B. Provide extra blankets and monitor temperature frequently. - C. Place an ice pack on the patient's neck to reduce fever. - D. Remove blankets and encourage cold fluids to reduce fever quickly. **6. Scenario: A patient's pulse oximetry reading is 88%, and they are exhibiting signs of respiratory distress, such as shallow breathing and increased effort. What is your immediate response?** - A. Encourage the patient to take deep breaths and assess again in 10 minutes. - B. Place the patient in a supine position to conserve energy. - C. Administer supplemental oxygen as prescribed. - D. Document the findings and notify the healthcare provider at the end of your shift. **7. Scenario: You measure an elderly patient's blood pressure using a standard adult cuff and record a reading of 160/95 mmHg. The patient states they have never had high blood pressure before. Which action is most appropriate?** - A. Report the high blood pressure immediately. - B. Repeat the measurement using a larger cuff if needed. - C. Wait 15 minutes, and if the reading is still high, apply a cold compress. - D. Document the high blood pressure and advise the patient to relax. **8. Scenario: A post-surgical patient's vital signs include a heart rate of 110 bpm, a blood pressure of 90/60 mmHg, respirations of 22 breaths per minute, and an oxygen saturation of 92% on room air. Which symptom is most concerning in this context?** - A. Increased heart rate - B. Lower blood pressure - C. Slightly elevated respirations - D. Oxygen saturation **9. Scenario: You are caring for a patient with congestive heart failure who is on diuretics. When you assess their vital signs, you find a blood pressure of 80/55 mmHg and a pulse of 55 bpm. What is your priority action?** - A. Encourage the patient to increase fluid intake. - B. Report the findings to the healthcare provider immediately. - C. Document the blood pressure and pulse as expected with diuretics. - D. Discontinue diuretics until blood pressure normalizes. **10. Scenario: A patient who was recently diagnosed with hypertension reports that they feel \"a bit shaky and anxious.\" When you measure their blood pressure, the reading is 130/90 mmHg. What is the most likely explanation for the symptoms?** - A. Hypertension is causing anxiety. - B. The patient may be experiencing an anxiety attack. - C. The blood pressure reading is abnormally high. - D. The patient may have side effects from new antihypertensive medications. **Answer Key with Rationales** 1. **A**: An oxygen saturation of 90% suggests hypoxia, so applying supplemental oxygen is a priority. 2. **B**: The drop in blood pressure upon standing indicates orthostatic hypotension. 3. **B**: An apical pulse for a full minute provides a more accurate measurement for irregular heart rates. 4. **B**: Waiting 15-30 minutes ensures a more accurate reading unaffected by hot coffee. 5. **B**: Providing blankets and frequent monitoring is appropriate to manage the fever safely. 6. **C**: Administering oxygen is essential to address the patient's respiratory distress. 7. **B**: A larger cuff may provide a more accurate measurement, especially for an elderly patient. 8. **B**: Hypotension (90/60 mmHg) may be indicative of bleeding or other post-surgical complications. 9. **B**: The low BP and pulse may signal dehydration or an adverse effect of diuretics. 10. **D**: Shakiness and anxiety may stem from new antihypertensive medications. **Safety Practice Exam** **1. Which of the following patients is at highest risk for sensory deprivation?** - A. A 24-year-old in a long-term care facility recovering from a leg fracture - B. A 75-year-old with macular degeneration living alone - C. A 45-year-old who works in a loud, busy environment - D. A 60-year-old with minor hearing loss in one ear **2. True or False: Patients in isolation are at higher risk for sensory overload due to increased sensory stimuli.** **3. A patient with Alzheimer's disease is confused and attempting to pull out their IV line. Which nursing action is most appropriate to manage this behavior?** - A. Apply wrist restraints to prevent removal of the IV - B. Redirect the patient's attention and provide familiar objects - C. Increase sedative medications to keep the patient calm - D. Discontinue the IV to avoid complications **4. Which of the following are common emotional responses to sensory alteration? (Select all that apply.)** - A. Anxiety - B. Disorientation - C. Empowerment - D. Depression - E. Agitation **5. Which of the following interventions is most appropriate for a patient with hearing impairment to improve communication?** - A. Speaking louder so the patient can hear better - B. Facing the patient and speaking slowly and clearly - C. Using only written instructions to avoid confusion - D. Relying on family members to interpret communication **6. True or False: Bright lighting and high levels of noise can contribute to sensory overload in hospitalized patients.** **7. Scenario: A patient in a skilled nursing facility with dementia has difficulty recognizing familiar people and is easily disoriented. Which intervention would be most helpful in managing their sensory needs?** - A. Encourage social interaction with new people daily - B. Provide familiar items and personal photos in their room - C. Move the patient to a new room every week for variety - D. Limit visitors to reduce possible confusion **8. A patient who has been hospitalized for a prolonged period begins to show signs of sensory deprivation. Which nursing intervention would be appropriate to help stimulate the patient\'s senses? (Select all that apply.)** - A. Encourage family visits and bring in personal items from home - B. Turn off the lights and close the blinds during the day - C. Play soothing music during the day - D. Minimize talking to keep the environment quiet - E. Provide a variety of tactile stimuli, such as blankets or soft pillows **9. Which of the following patients is most at risk for safety issues related to their developmental age?** - A. A 30-year-old who lives alone - B. A 5-year-old exploring different rooms at home - C. A 50-year-old with controlled diabetes - D. A 70-year-old who occasionally drives **10. True or False: The application of restraints is a first-line intervention for patients who exhibit challenging behaviors that may lead to self-injury.** **11. Scenario: A patient with Parkinson's disease is at high risk for falls. Which nursing intervention would best help reduce this risk?** - A. Instruct the patient to walk quickly to maintain stability - B. Provide a walker and keep the environment clutter-free - C. Only allow the patient to ambulate under supervision - D. Keep the bed in a high position to facilitate movement **12. When caring for a patient with cognitive impairment, which of the following strategies can help promote safety and reduce agitation? (Select all that apply.)** - A. Maintain a consistent daily routine - B. Introduce new care providers daily for stimulation - C. Use calming music or soft lighting - D. Offer simple, clear instructions one step at a time - E. Avoid physical touch to prevent triggering responses **13. A patient requires a nursing care plan to address the risk of sensory overload. Which of the following would be most appropriate to include?** - A. Increase room lighting and encourage more visitors - B. Provide earplugs and reduce unnecessary noise in the room - C. Keep the television on at all times for engagement - D. Instruct the patient to focus on one activity at a time **14. True or False: A patient with visual impairment is at greater risk for falls and injury when navigating an unfamiliar environment.** **15. Scenario: A home health nurse is visiting a patient who has reduced tactile sensation in their hands and feet. Which of the following interventions should the nurse prioritize?** - A. Encourage the patient to walk barefoot to increase tactile feedback - B. Teach the patient to check water temperature with a thermometer before bathing - C. Suggest using heated blankets to keep extremities warm - D. Have the patient avoid physical activity to prevent injury **16. In an older adult patient with sensory alterations, which of the following interventions would best help prevent sensory deprivation? (Select all that apply.)** - A. Allowing frequent family visits - B. Ensuring the patient's room has a television or radio available - C. Keeping window shades closed to reduce sensory input - D. Encouraging the patient to participate in group activities **17. Scenario: A confused patient is repeatedly attempting to get out of bed without assistance. Which intervention would be the least restrictive and still help maintain patient safety?** - A. Applying a full set of bed rails - B. Keeping the patient close to the nurse's station - C. Using a vest restraint to prevent movement - D. Asking family members to stay with the patient 24/7 **18. Which of the following situations would warrant the use of a restraint?** - A. A patient is unable to sleep and is anxious - B. A patient is pulling at their IV line repeatedly - C. A patient refuses to eat and drink - D. A patient requests to be alone in their room **19. True or False: Fire hazards are best managed by keeping all electrical cords connected and accessible for staff convenience.** **20. Scenario: A patient with impaired hearing asks the nurse for clarification multiple times. Which action should the nurse take to ensure effective communication?** - A. Shout instructions more clearly - B. Write down key points and speak at a slower pace - C. Involve the family member to interpret - D. Use medical jargon to sound more authoritative **Answer Key with Rationales** 1. **B**: Elderly patients with impaired vision and who live alone are at high risk for sensory deprivation due to limited visual stimuli and lack of interaction. 2. **False**: Isolation typically reduces sensory input, which can lead to sensory deprivation, not overload. 3. **B**: Redirection and providing familiar objects can reduce anxiety and provide comfort. 4. **A, B, D, E**: Sensory alterations often lead to anxiety, disorientation, depression, and agitation. 5. **B**: Facing the patient and speaking slowly enhances communication and helps them lip-read if needed. 6. **True**: Bright lights and noise contribute to sensory overload. 7. **B**: Familiar items and photos help orient the patient, especially those with dementia. 8. **A, C, E**: These interventions provide sensory input and prevent deprivation. 9. **B**: Young children exploring their surroundings are at high risk for accidents. 10. **False**: Restraints should be a last resort, used only when other methods fail to protect the patient. 11. **B**: A walker and clutter-free environment support mobility and prevent falls in Parkinson's patients. 12. **A, C, D**: These strategies promote safety and calmness for patients with cognitive impairments. 13. **B**: Reducing noise helps prevent sensory overload. 14. **True**: Visual impairments increase fall risk, especially in unfamiliar areas. 15. **B**: Checking water temperature prevents burns due to reduced tactile sensation. 16. **A, B, D**: These prevent sensory deprivation by providing visual and social stimulation. 17. **B**: Placing the patient near the nurse's station provides close monitoring without restraints. 18. **B**: Pulling at an IV line repeatedly is a valid reason for restraint to prevent self-harm. 19. **False**: Fire safety requires checking for frayed cords and securing cables to prevent hazards. 20. **B**: Writing down key points and slowing down speech ensures the patient understands. UNIT 2 **Asepsis Practice Exam** **1. Which of the following best describes medical asepsis?** - A. A sterile technique used only in surgical procedures - B. Procedures to reduce and prevent the spread of microorganisms - C. A set of practices to maintain a completely sterile environment - D. Handwashing only, without other protective equipment **2. True or False: Surgical asepsis is necessary for any procedure that involves contact with the mucous membranes.** **3. Which of the following is the correct order of the infection cycle?** - A. Reservoir, Portal of Exit, Portal of Entry, Susceptible Host, Infectious Agent, Mode of Transmission - B. Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host - C. Portal of Entry, Susceptible Host, Mode of Transmission, Reservoir, Infectious Agent, Portal of Exit - D. Susceptible Host, Reservoir, Mode of Transmission, Portal of Entry, Infectious Agent, Portal of Exit **4. Which of the following organisms is resistant to methicillin and often associated with healthcare-acquired infections?** - A. Escherichia coli (E. coli) - B. Methicillin-resistant Staphylococcus aureus (MRSA) - C. Streptococcus pneumoniae - D. Influenza A **5. Select all that apply: Which of the following are standard precautions to prevent infection?** - A. Hand hygiene before and after patient contact - B. Wearing gloves when touching blood or body fluids - C. Using a sterile technique for all patient interactions - D. Disposing of needles and sharps in appropriate containers - E. Wearing an N95 mask for all patient contact **6. True or False: Local signs of infection include redness, swelling, and warmth at the site.** **7. Scenario: A patient presents with a high fever, malaise, and elevated white blood cell (WBC) count. What is the primary nursing action to help differentiate between a local and systemic infection?** - A. Ask the patient about any recent travel history - B. Check the patient's vital signs for blood pressure changes - C. Inspect for localized signs such as redness and swelling - D. Request a culture and sensitivity test from the laboratory **8. Which of the following best describes droplet precautions?** - A. Required for patients with infections that spread through large respiratory droplets, usually requiring a mask within three feet - B. Used for patients with diseases that spread by skin contact - C. Only needed when working with highly contagious airborne infections - D. Involves complete isolation from all hospital staff and visitors **9. What is a nosocomial infection?** - A. An infection acquired in the community - B. An infection acquired in the hospital setting - C. An infection spread by vectors such as insects - D. An infection caused by improper hand hygiene **10. Which laboratory test would be most helpful to identify the appropriate antibiotic for treating a patient's infection?** - A. Complete Blood Count (CBC) with differential - B. Urinalysis - C. Culture and sensitivity test - D. Blood glucose test **11. True or False: Transmission-based precautions apply to all patients, regardless of their infection status.** **12. Scenario: A patient has been placed on contact precautions due to a Clostridium difficile infection. Which personal protective equipment (PPE) should the nurse use?** - A. Gloves and gown only - B. Gloves, gown, and N95 respirator mask - C. Gloves, gown, and surgical mask - D. Gloves only **13. A nurse is teaching a family about preventing the spread of infection at home. Which instructions should be included in the teaching? (Select all that apply.)** - A. Wash hands frequently and thoroughly - B. Disinfect surfaces regularly - C. Reuse disposable gloves to reduce waste - D. Avoid sharing personal items such as towels - E. Always use hand sanitizer in place of soap and water **14. True or False: Airborne precautions are needed for diseases such as tuberculosis (TB) and measles.** **15. Scenario: A nurse accidentally sticks themselves with a contaminated needle. What is the first action they should take?** - A. Report the incident to the infection control nurse - B. Wash the affected area immediately with soap and water - C. Complete an incident report - D. Begin post-exposure prophylaxis (PEP) **16. Which of the following are examples of appropriate nursing interventions for a patient on transmission-based precautions? (Select all that apply.)** - A. Explaining the reason for isolation to the patient and family - B. Avoiding all patient contact to prevent self-contamination - C. Wearing required PPE for each entry into the patient's room - D. Providing opportunities for social interaction if safe and possible - E. Using disposable equipment to avoid cross-contamination **17. What is the primary role of the infection control nurse?** - A. Supervising all nursing staff in daily patient care - B. Educating staff on infection prevention and control practices - C. Diagnosing infections in hospitalized patients - D. Providing direct care to patients with infectious diseases **18. Which statement best describes an appropriate teaching plan for a patient with an infection?** - A. "You should complete the entire course of antibiotics, even if you feel better." - B. "You may stop taking your antibiotics once your fever goes down." - C. "Do not worry about hand hygiene at home if you're on antibiotics." - D. "Only use hand sanitizer if soap and water are not available." **19. True or False: Psychological effects of isolation can include loneliness, depression, and anxiety.** **20. Scenario: A patient diagnosed with influenza has been placed on droplet precautions. Which actions are correct for the healthcare team to follow? (Select all that apply.)** - A. Wear a mask when within 3 feet of the patient - B. Use only gloves without a mask - C. Wear gloves, gown, and goggles whenever entering the room - D. Place a mask on the patient if they are transported out of the room - E. Maintain a distance of at least 6 feet without a mask **Answer Key with Rationales** 1. **B**: Medical asepsis includes practices to reduce the spread of microorganisms, such as hand hygiene and barrier techniques. 2. **False**: Surgical asepsis is required for invasive procedures or contact with sterile areas, not specifically mucous membranes. 3. **B**: This sequence follows the infection cycle accurately. 4. **B**: MRSA is resistant to methicillin and is commonly associated with HAIs. 5. **A, B, D**: Standard precautions include hand hygiene, appropriate PPE, and safe disposal of sharps. 6. **True**: Local signs of infection typically include redness, swelling, and warmth. 7. **C**: Inspecting for localized signs can help distinguish local from systemic infections. 8. **A**: Droplet precautions involve wearing a mask within close range of the patient. 9. **B**: Nosocomial infections, also known as healthcare-associated infections (HAIs), are acquired in healthcare facilities. 10. **C**: Culture and sensitivity tests determine the most effective antibiotic. 11. **False**: Transmission-based precautions are specific to patients with known or suspected infections. 12. **A**: Gloves and gowns are standard for contact precautions, especially for C. difficile. 13. **A, B, D**: Frequent handwashing, disinfecting surfaces, and not sharing personal items help prevent infection spread. 14. **True**: Airborne precautions are required for TB and measles due to the airborne nature of these pathogens. 15. **B**: Washing the area immediately is the first response to a needlestick. 16. **A, C, D, E**: Educating, following PPE guidelines, providing social interaction, and using disposable equipment are appropriate. 17. **B**: The infection control nurse educates and implements infection prevention protocols. 18. **A**: Completing the full course of antibiotics prevents resistance and ensures infection clearance. 19. **True**: Isolation can have significant psychological effects, such as loneliness and anxiety. 20. **A, D**: Droplet precautions include wearing a mask within close proximity and placing a mask on the patient during transport. **Hygiene Practice Exam** **1. Which of the following is most important when assessing a patient's hygiene practices?** - A. Ensuring the patient receives a daily bath - B. Understanding the patient's cultural beliefs regarding hygiene - C. Scheduling hygiene care based on hospital protocol - D. Asking the family members about the patient\'s hygiene habits **2. True or False: Nurses should adapt personal hygiene routines to accommodate the cultural preferences of the patient.** **3. Which layer of the skin contains blood vessels and nerve endings?** - A. Epidermis - B. Dermis - C. Subcutaneous tissue - D. Stratum corneum **4. When providing hygiene care to a patient with dentures, which of the following actions is correct?** - A. Use hot water to rinse the dentures - B. Place a towel in the sink to protect dentures if dropped - C. Use alcohol-based cleaner for denture care - D. Place dentures on the bedside table without covering **5. Select all that apply: Which of the following types of baths are used in clinical care?** - A. Complete bed bath - B. Sponge bath - C. Therapeutic bath - D. Sitz bath - E. Open bath **6. Scenario: A nurse is caring for a patient with a Foley catheter. Which of the following steps should the nurse include in hygiene care? (Select all that apply.)** - A. Clean the catheter tubing from the insertion site outward - B. Use antiseptic wipes around the insertion site - C. Change the catheter daily to prevent infection - D. Secure the catheter tubing to the patient's leg to prevent pulling **7. Which of the following types of baths is best suited for patients with mobility limitations who need assistance but prefer to bathe independently?** - A. Complete bed bath - B. Partial bath - C. Therapeutic bath - D. Sponge bath **8. True or False: It is acceptable to perform oral care for a patient with a nasogastric (NG) tube only once daily to avoid disturbing the patient.** **9. When caring for a patient with an oxygen mask, what precautions should the nurse take during hygiene care? (Select all that apply.)** - A. Monitor for dryness around the nasal area - B. Cleanse the area around the mask every shift - C. Remove the oxygen mask during hygiene care to make the patient more comfortable - D. Apply petroleum jelly around the nose to prevent skin breakdown **10. A nurse is preparing to give a bed bath to a patient who practices modesty in accordance with their culture. What is the nurse's best approach?** - A. Proceed with the bed bath as usual - B. Ask the patient if they would prefer a family member to assist with the bath - C. Limit the bath to only exposed areas of the patient's body - D. Avoid discussing the patient's cultural needs to avoid discomfort **11. Which of the following is a closed bed?** - A. A bed that is ready for a new patient admission - B. A bed made with the sheets turned down - C. A bed prepared for a postoperative patient - D. A bed that is occupied by a patient **12. Which of the following actions demonstrates correct procedure when making an occupied bed?** - A. Remove all bed linens at once - B. Roll the patient from side to side to remove and replace linens - C. Leave the top sheet off to keep the patient cool - D. Leave the bed in a high position while changing linens **13. True or False: Perineal care should be performed in a way that maintains patient dignity and respects cultural preferences.** **14. Scenario: A nurse notices that a patient has foot calluses and dryness. What should the nurse consider before providing foot care?** - A. Calluses are a normal finding and do not require attention - B. Check if the patient has diabetes, as this will influence foot care - C. Apply lotion liberally to soften the calluses - D. Remove the calluses using an emery board **15. When providing eye care for a comatose patient, the nurse should:** - A. Use soap and water to clean the eye area - B. Use only a dry cotton ball - C. Moisten a cotton ball with saline to cleanse the eye - D. Avoid any eye care unless discharge is present **16. Scenario: A patient with impaired mobility has limited ability to perform personal hygiene independently. The nurse can best support this patient by:** - A. Performing all hygiene tasks for the patient - B. Allowing the patient to do as much as possible independently - C. Encouraging the patient to rest and conserve energy - D. Providing hygiene care only when the patient requests assistance **17. Which of the following hygiene interventions is appropriate for a patient with sensory deficits? (Select all that apply.)** - A. Speak clearly and face the patient when communicating - B. Ensure the patient is positioned comfortably for self-care - C. Assume the patient cannot perform hygiene care independently - D. Provide a well-lit environment to promote self-care **18. True or False: The nurse should use firm, brisk strokes when performing a back rub on a frail elderly patient.** **19. Scenario: A nurse is caring for a patient who requires daily oral care. The patient has dentures and insists on wearing them at night. What should the nurse do?** - A. Respect the patient's decision to wear dentures at night - B. Insist the patient remove the dentures to prevent oral infections - C. Soak the dentures in water overnight without the patient's permission - D. Document the patient's noncompliance with oral hygiene standards **20. A nurse is teaching a patient about personal hygiene practices at home. Which of the following should be included in the teaching? (Select all that apply.)** - A. Change bed linens once per week - B. Wash hands before eating and after bathroom use - C. Use antiseptic mouthwash daily - D. Regularly clean dentures and store them in water when not in use - E. Apply lotion between toes to prevent dryness **Answer Key with Rationales** 1. **B**: Understanding a patient\'s cultural beliefs is essential for assessing and providing appropriate hygiene care. 2. **True**: Nurses should adapt hygiene routines to the cultural practices and preferences of each patient. 3. **B**: The dermis contains blood vessels, nerve endings, and connective tissue. 4. **B**: Placing a towel in the sink prevents damage if dentures are dropped. 5. **A, B, C, D**: Complete, sponge, therapeutic, and sitz baths are common in clinical care. 6. **A, B, D**: Cleaning from the insertion site outward, using antiseptic wipes, and securing tubing prevent infection. 7. **B**: A partial bath allows independence with minimal assistance for patients with limited mobility. 8. **False**: Oral care should be provided frequently for NG tube patients to prevent dryness and infection. 9. **A, B**: Monitoring dryness and cleansing the nasal area prevent irritation and breakdown. 10. **B**: Involving a family member can support cultural sensitivity and comfort during the bed bath. 11. **A**: A closed bed is prepared for a new patient and kept ready until admission. 12. **B**: Rolling the patient from side to side allows for safe linen changes without full movement. 13. **True**: Perineal care should be respectful and maintain patient dignity and comfort. 14. **B**: Checking for diabetes is essential, as it impacts foot care practices to avoid complications. 15. **C**: Saline is gentle and appropriate for cleansing a comatose patient's eyes. 16. **B**: Encouraging independence as much as possible maintains the patient's dignity and self-care ability. 17. **A, B, D**: Clear communication, comfortable positioning, and a well-lit environment assist patients with sensory deficits. 18. **False**: Frail elderly patients may bruise easily; gentle strokes are more appropriate. 19. **A**: The patient's preference should be respected; document the choice rather than forcefully removing dentures. 20. **B, D**: Handwashing and proper denture care are essential components of personal hygiene at home. **Mobility Practice Exam** **1. Which of the following is a key principle of body mechanics for nurses?** - A. Lifting with the back instead of the legs - B. Twisting the torso when turning - C. Maintaining a wide base of support - D. Keeping feet close together for stability **2. True or False: Proper body alignment in bed promotes optimal lung expansion and reduces the risk of pressure ulcers.** **3. Which patient is most at risk for complications from prolonged bed rest?** - A. A 30-year-old with a sprained ankle - B. A 65-year-old with a fractured hip - C. A 40-year-old with acute bronchitis - D. A 50-year-old post-cholecystectomy **4. Which of the following is a structural abnormality that affects body alignment?** - A. Scoliosis - B. Edema - C. Torticollis - D. Obesity **5. Select all that apply: Which nursing interventions can help prevent complications of immobility in bed-ridden patients?** - A. Encouraging deep breathing exercises - B. Repositioning every 2 hours - C. Applying compression stockings - D. Limiting fluid intake to prevent edema **6. Scenario: A nurse is caring for a patient with limited mobility due to a stroke. Which nursing intervention is appropriate to address the patient's risk of muscle atrophy?** - A. Assisting with active range of motion (ROM) exercises daily - B. Keeping the patient in a supine position to prevent falls - C. Increasing the patient's caloric intake - D. Encouraging the patient to lie still to conserve energy **7. During passive range of motion exercises, what should the nurse ensure to avoid causing injury?** - A. Moving each joint to the point of slight discomfort - B. Extending each joint beyond its normal range of motion - C. Moving the joints slowly and supporting the extremity - D. Focusing only on major joints, such as shoulders and knees **8. True or False: Passive ROM exercises are beneficial for patients who are unable to move their joints independently.** **9. Which is the best intervention to prevent joint contractures in an immobile patient?** - A. Turning the patient every 4 hours - B. Performing passive ROM exercises regularly - C. Keeping the patient's joints in a fixed position - D. Applying splints to all major joints **10. Scenario: A nurse observes a patient using a cane. Which of the following actions indicates the correct technique?** - A. The patient holds the cane on the affected side - B. The patient moves the cane forward with the affected leg - C. The patient uses the cane on the unaffected side for support - D. The patient advances the cane 12-18 inches with each step **11. When helping a patient transfer from the bed to a wheelchair, which of the following actions should the nurse take?** - A. Place the wheelchair parallel to the bed - B. Lock the wheels on the wheelchair - C. Instruct the patient to push up on the wheelchair armrests - D. Allow the patient to twist to reach the wheelchair **12. Select all that apply: Which physiological effects can be consequences of immobility?** - A. Decreased cardiac output - B. Increased risk for kidney stones - C. Improved muscle tone - D. Increased risk of pressure ulcers **13. Which developmental change commonly affects the mobility of older adults?** - A. Increased bone density - B. Greater joint flexibility - C. Reduced muscle strength - D. Increased endurance **14. True or False: Active range of motion (ROM) exercises are performed by the nurse without any assistance from the patient.** **15. A nurse is assessing a patient's body alignment in a chair. Which of the following indicates proper alignment?** - A. The patient's back is slouched to one side - B. Both feet are flat on the floor - C. The knees are higher than the hips - D. The patient's shoulders are leaning forward **16. Scenario: A nurse is teaching a patient how to use crutches. Which of the following instructions is correct?** - A. Place weight on the axillae when using crutches - B. Keep crutches at least 12 inches from the feet when walking - C. Move the crutches and affected leg forward together - D. Use a \"swing-to\" gait for increased speed **17. Which of the following assessments is most important for a patient with impaired mobility?** - A. Respiratory rate and depth - B. Skin condition over bony prominences - C. Urinary output - D. Appetite and caloric intake **18. Scenario: A patient is recovering from surgery and needs assistance ambulating with a walker. Which is the correct sequence of actions?** - A. Move the walker forward, step with the affected leg, then the unaffected leg - B. Move the unaffected leg first, followed by the walker - C. Move the walker forward and step with both legs at the same time - D. Step forward with both legs, then move the walker **19. True or False: It is safer to lift a patient by bending at the waist rather than using the legs.** **20. A nurse is planning a discharge referral for a patient who has significant mobility limitations. Which of the following referrals is most appropriate?** - A. Dietary specialist - B. Occupational therapist - C. Respiratory therapist - D. Audiologist **Answer Key with Rationales** 1. **C**: Maintaining a wide base of support provides stability during patient handling. 2. **True**: Proper body alignment in bed aids in lung expansion and prevents skin breakdown. 3. **B**: Older adults with fractures or mobility restrictions are at greater risk of bedrest complications. 4. **A**: Scoliosis is a spinal deformity that disrupts normal body alignment. 5. **A, B, C**: Deep breathing, repositioning, and compression stockings prevent complications of immobility. 6. **A**: Active ROM exercises help reduce the risk of muscle atrophy in patients with limited mobility. 7. **C**: Moving joints slowly with support prevents injury during passive ROM exercises. 8. **True**: Passive ROM is beneficial for patients who cannot move joints independently. 9. **B**: Passive ROM helps prevent joint contractures by promoting movement and flexibility. 10. **C**: The cane should be used on the unaffected side for proper balance and support. 11. **B**: Locking the wheelchair wheels prevents the chair from moving during the transfer. 12. **A, B, D**: Immobility reduces cardiac output, increases risk for kidney stones, and leads to pressure ulcers. 13. **C**: Reduced muscle strength is common in older adults and affects mobility. 14. **False**: Active ROM involves patient participation, while passive ROM is performed by the nurse. 15. **B**: Feet flat on the floor ensures proper alignment and balance when sitting. 16. **C**: Moving crutches and the affected leg together helps stabilize the patient. 17. **B**: Skin assessment over bony prominences is essential to prevent pressure ulcers in immobile patients. 18. **A**: Moving the walker first, followed by the affected leg, is the correct sequence. 19. **False**: Bending at the waist strains the back; lifting with the legs is safer. 20. **B**: An occupational therapist can assist with home adaptations and activities of daily living (ADLs) for mobility support. Unit 3 **Physical Assessment Practice Exam** **1. What is the primary purpose of a health assessment?** - A. To develop a treatment plan - B. To gather subjective and objective data - C. To perform diagnostic procedures - D. To validate a patient\'s treatment preferences **2. Select all that apply: Which types of assessments are commonly included in a comprehensive physical assessment?** - A. Health history - B. Medication list - C. Immunization record - D. Review of systems **3. True or False: The environment should be well-lit, private, and comfortable to ensure accurate assessment and patient comfort.** **4. Which action is most appropriate when preparing a patient for a physical assessment?** - A. Ask the patient to sit upright at all times - B. Ensure the patient is fully clothed - C. Explain each step of the assessment to the patient - D. Skip uncomfortable questions to ensure patient privacy **5. Which assessment technique involves using the sense of smell to identify potential health issues?** - A. Inspection - B. Olfaction - C. Percussion - D. Palpation **6. Scenario: A nurse is taking a patient\'s health history. Which question best assesses the patient's mental status?** - A. \"What medications are you taking?\" - B. \"Can you tell me what day it is today?\" - C. \"Do you have any allergies?\" - D. \"Do you have any pain right now?\" **7. Which order of techniques is correct for an abdominal physical assessment?** - A. Inspection, auscultation, palpation, percussion - B. Inspection, palpation, percussion, auscultation - C. Auscultation, inspection, palpation, percussion - D. Percussion, inspection, palpation, auscultation **8. During auscultation of the heart, where should the nurse place the stethoscope to best hear the apical pulse?** - A. Fifth intercostal space, left midclavicular line - B. Second intercostal space, right sternal border - C. Third intercostal space, left sternal border - D. Fourth intercostal space, mid-axillary line **9. True or False: Palpation should always be performed before auscultation in all physical assessments.** **10. Select all that apply: Which are key expected findings during a normal lung assessment?** - A. Regular, clear breath sounds bilaterally - B. No adventitious sounds such as crackles or wheezes - C. Muffled heart sounds heard over the lungs - D. Vesicular sounds heard over most lung fields **11. A nurse is preparing to perform an assessment on an older adult. Which modification is appropriate?** - A. Conducting the assessment as quickly as possible - B. Speaking loudly to ensure the patient hears - C. Allowing extra time for responses - D. Avoiding questions about sexual health **12. Which of the following best describes the purpose of palpation?** - A. To listen to internal sounds - B. To feel texture, temperature, and size - C. To observe skin color - D. To strike body parts to elicit sounds **13. True or False: Light palpation is generally done to detect surface characteristics, while deep palpation is used for underlying organs.** **14. Scenario: A patient reports sudden chest pain and shortness of breath. Which priority assessment should the nurse perform?** - A. Head-to-toe assessment - B. Focused cardiovascular and respiratory assessment - C. Full review of systems - D. Detailed medication history **15. When using the stethoscope, the nurse hears a high-pitched sound over the carotid artery. What does this most likely indicate?** - A. Normal blood flow - B. Murmur - C. Bruit - D. Crackles **16. True or False: Percussion over a normal lung field produces a dull sound.** **17. Which is an appropriate way to assess skin turgor?** - A. Palpate the forearm for moisture - B. Pinch the skin over the clavicle - C. Inspect for pallor - D. Measure skin elasticity on the wrist **18. During a neurological assessment, the nurse asks the patient to identify different smells. This assesses which cranial nerve?** - A. CN I - Olfactory - B. CN II - Optic - C. CN V - Trigeminal - D. CN VII - Facial **19. Select all that apply: Which are characteristics of a therapeutic communication approach in a health history interview?** - A. Using open-ended questions - B. Giving medical advice directly - C. Maintaining eye contact - D. Listening actively and avoiding interruptions **20. Scenario: While performing an abdominal assessment, the nurse notices tenderness in the right lower quadrant. Which condition might this finding suggest?** - A. Appendicitis - B. Cholecystitis - C. Gastritis - D. Nephritis **21. A nurse is documenting findings from a head-to-toe assessment. Which of the following documentation entries is correct?** - A. \"Breath sounds normal.\" - B. \"Patient is stable.\" - C. \"Lungs clear to auscultation bilaterally.\" - D. \"Heart sounds present.\" **22. True or False: Documentation of assessment findings should always include subjective and objective data.** **23. Scenario: A nurse is assessing a toddler. Which approach is best to establish rapport?** - A. Approach the child quickly and explain the procedure to the parent - B. Talk to the parent and ignore the child's responses - C. Play with the child or engage them in a conversation - D. Perform a head-to-toe assessment immediately **24. Which part of the stethoscope is best for listening to low-pitched sounds like heart murmurs?** - A. Bell - B. Diaphragm - C. Earpiece - D. Tubing **25. In which situation should the nurse prioritize olfaction during an assessment?** - A. When assessing skin temperature - B. During lung auscultation - C. When evaluating for the presence of infection - D. During visual inspection **26. True or False: A comprehensive physical assessment must be conducted in every encounter with a patient.** **27. Scenario: A nurse observes a patient's gait and posture. Which system is the nurse assessing?** - A. Cardiovascular - B. Neurological - C. Musculoskeletal - D. Gastrointestinal **28. When conducting a cultural assessment, the nurse should:** - A. Assume that all patients from the same culture have the same beliefs - B. Avoid asking questions about cultural beliefs to prevent discomfort - C. Ask open-ended questions about cultural practices and preferences - D. Only consider culture in the context of dietary habits **29. Select all that apply: Which findings are considered normal when assessing a patient's level of consciousness?** - A. Alert and oriented to person, place, time - B. Unresponsive without stimuli - C. Follows commands appropriately - D. Drowsy but responsive to verbal stimuli **30. Scenario: A nurse is performing a respiratory assessment on a patient. Which finding requires immediate intervention?** - A. Clear, bilateral breath sounds - B. Respiratory rate of 16 breaths per minute - C. Audible wheezing during exhalation - D. Resonant sounds upon percussion of the lungs **Answer Key with Rationales** 1. **B**: Health assessment's primary purpose is to gather subjective and objective data. 2. **A, B, D**: Health history, medication list, and review of systems are parts of a comprehensive assessment. 3. **True**: A private, comfortable, well-lit environment helps accuracy. 4. **C**: Explaining steps ensures comfort and cooperation. 5. **B**: Olfaction uses smell to identify health indicators. 6. **B**: Orientation questions assess mental status. 7. **A**: Abdomen order is inspection, auscultation, palpation, percussion. 8. **A**: Apical pulse is best heard at the fifth intercostal space. 9. **False**: For the abdomen, auscultation precedes palpation. 10. **A, B, D**: Clear sounds, absence of adventitious sounds, and vesicular sounds are normal lung findings. 11. **C**: Allowing time respects older adults' pace. 12. **B**: Palpation feels for texture, size, temperature. 13. **True**: Light palpation assesses surface; deep is for organs. 14. **B**: Cardiovascular and respiratory are priority in chest pain. 15. **C**: A bruit suggests 16. **False**: Percussion over a normal lung field produces a resonant sound, not a dull one. Dullness suggests fluid or a mass. 17. **B**: To assess skin turgor, the nurse should pinch the skin over the clavicle, as it gives a quick indication of hydration status. 18. **A**: Cranial Nerve I (Olfactory) is responsible for the sense of smell. 19. **A, C, D**: Therapeutic communication involves open-ended questions, active listening, and eye contact (when culturally appropriate). 20. **A**: Right lower quadrant tenderness often suggests appendicitis, especially with associated symptoms like fever or elevated white blood cell count. 21. **C**: Documentation should be specific and descriptive, such as "Lungs clear to auscultation bilaterally." 22. **True**: Both subjective (what the patient describes) and objective (what the nurse observes) data are essential for a complete documentation. 23. **C**: Engaging the child through play helps build rapport and reduces fear in young children during assessment. 24. **A**: The bell of the stethoscope is best for low-pitched sounds, like heart murmurs and some vascular sounds. 25. **C**: Olfaction can help detect infection, as certain infections produce distinctive odors. 26. **False**: A comprehensive assessment is not required at every encounter; focused assessments may be more appropriate depending on the situation. 27. **C**: Observing gait and posture assesses the musculoskeletal system, as it involves movement, alignment, and muscle tone. 28. **C**: Open-ended questions allow the nurse to understand the patient's unique cultural beliefs and practices without making assumptions. 29. **A, C, D**: Being alert and oriented, following commands, and responding to verbal stimuli are normal signs of consciousness. 30. **C**: Audible wheezing suggests airway constriction or obstruction, requiring immediate intervention to prevent further respiratory distress. **Wellness/Illness & Nursing Process/CJMCP Practice Test** **1. The three levels of preventive care include which of the following? *(Select all that apply)*** - A\) Primary Prevention - B\) Secondary Prevention - C\) Tertiary Prevention - D\) Quaternary Prevention **2. Which of the following are considered basic human needs according to Maslow's Hierarchy?** - A\) Safety and security - B\) Self-actualization - C\) Esteem - D\) All of the above **3. True or False: The goal of tertiary prevention is to prevent the initial occurrence of illness.** **4. The Healthy People 2030 public health initiative primarily aims to:** - A\) Promote health literacy exclusively for health professionals. - B\) Eliminate disparities in access to healthcare services. - C\) Prioritize individual health over community health. - D\) Promote disease treatment over prevention. **5. A nurse is assessing a patient's psychosocial well-being. Which of the following are components of psychosocial health? *(Select all that apply)*** - A\) Self-esteem - B\) Spirituality - C\) Physical endurance - D\) Family relationships **6. Which of the following variables may influence a patient's health beliefs and practices?** - A\) Financial resources - B\) Cultural background - C\) Access to healthcare - D\) All of the above **7. True or False: Maslow's Hierarchy of Needs suggests that individuals must meet lower-level needs before they can achieve higher-level goals like self-actualization.\*\*** **8. The Clinical Judgment Model (CJMCP) emphasizes which of the following in clinical decision-making?** - A\) Completing tasks quickly - B\) Relying only on intuition - C\) Recognizing patient cues and analyzing data - D\) Following general care guidelines without modification **9. Which of the following nursing diagnoses would be appropriate for a patient experiencing shortness of breath?** - A\) Activity intolerance - B\) Risk for infection - C\) Fluid volume overload - D\) Hyperthermia **10. The purpose of establishing expected outcomes in the nursing process is to:** - A\) Predict the exact timeline for patient recovery. - B\) Guide the planning of nursing interventions. - C\) Limit the range of potential nursing diagnoses. - D\) Ensure the patient receives a minimum standard of care. **11. True or False: Nursing diagnoses focus on identifying medical conditions rather than the patient's response to health conditions.\*\*** **12. The primary purpose of collecting data during the assessment phase is to:** - A\) Ensure the patient is comfortable. - B\) Identify specific cues relevant to the patient's condition. - C\) Establish rapport with family members. - D\) Develop a medical treatment plan. **13. A patient with impaired mobility related to a recent stroke would benefit from which types of nursing interventions? *(Select all that apply)*** - A\) Range-of-motion exercises - B\) Referral to physical therapy - C\) Administration of IV antibiotics - D\) Assistive devices for ambulation **14. True or False: A nursing care plan should remain the same even if a patient's condition changes to maintain continuity.\*\*** **15. When differentiating between medical and nursing diagnoses, which of the following best describes a nursing diagnosis?** - A\) Identifies the primary illness. - B\) Focuses on the treatment plan. - C\) Describes the patient\'s response to illness. - D\) Includes medications for management. **16. In creating a culturally sensitive nursing care plan, a nurse should first:** - A\) Ask the patient about their cultural preferences and beliefs. - B\) Consult with family members without asking the patient. - C\) Implement standard care procedures. - D\) Only consider physical needs. **17. The final phase of the nursing process, which involves determining if patient outcomes are met, is known as:** - A\) Diagnosis - B\) Evaluation - C\) Implementation - D\) Planning **18. Which of the following interventions is considered independent for a nurse to perform?** - A\) Prescribing medication for pain - B\) Administering a prescribed medication - C\) Providing patient education on diet - D\) Ordering laboratory tests **19. When assessing oxygenation as a basic need, which of the following data should the nurse consider?** - A\) Breath sounds - B\) Oxygen saturation - C\) Patient's respiratory rate - D\) All of the above **20. A nursing student is creating a nursing care plan for a patient with impaired nutrition. Which of the following would be an appropriate goal for this patient?** - A\) \"Patient will consume 75% of meals within 3 days.\" - B\) \"Patient will decrease meal intake to reduce weight.\" - C\) \"Patient will have no more than one meal per day.\" - D\) \"Patient will limit fluids to decrease bloating.\" **Answer Key and Rationales** **1.** A, B, C\ **Rationale:** The three levels of prevention include primary (preventing disease), secondary (early detection and treatment), and tertiary (reducing complications). **2.** D\ **Rationale:** All listed components are part of Maslow\'s Hierarchy and contribute to overall wellness. **3.** False\ **Rationale:** Tertiary prevention aims to manage and reduce complications of existing diseases. **4.** B\ **Rationale:** Healthy People 2030 prioritizes reducing health disparities and improving access. **5.** A, B, D\ **Rationale:** Psychosocial health includes self-esteem, spirituality, and relationships with others. **6.** D\ **Rationale:** Health beliefs and practices can be affected by a variety of individual and external factors. **7.** True\ **Rationale:** According to Maslow, basic needs must be met before reaching higher-level needs. **8.** C\ **Rationale:** The Clinical Judgment Model focuses on observing cues and analyzing data for decision-making. **9.** A\ **Rationale:** \"Activity intolerance\" is a nursing diagnosis for patients with difficulty in performing activities due to symptoms like shortness of breath. **10.** B\ **Rationale:** Expected outcomes guide nursing interventions and provide goals for patient care. **11.** False\ **Rationale:** Nursing diagnoses address the patient's responses rather than the medical condition itself. **12.** B\ **Rationale:** The purpose of assessment is to recognize and identify cues that inform the plan of care. **13.** A, B, D\ **Rationale:** ROM exercises, physical therapy, and assistive devices help manage impaired mobility. **14.** False\ **Rationale:** A nursing care plan should be revised based on changes in the patient's condition. **15.** C\ **Rationale:** Nursing diagnoses identify patient responses to illness, not the illness itself. **16.** A\ **Rationale:** Understanding a patient's cultural preferences is essential for providing personalized care. **17.** B\ **Rationale:** Evaluation determines if goals were met and guides the next steps in care. **18.** C\ **Rationale:** Patient education is an independent nursing intervention. **19.** D\ **Rationale:** All of these data points provide information on oxygenation status. **20.** A\ **Rationale:** This goal is measurable, realistic, and tailored to improving nutrition. **Patient Education Practice Test** **1. The primary purpose of patient education is to:** - A\) Increase the length of hospital stays - B\) Improve patient health outcomes and promote self-care - C\) Focus on educating family members exclusively - D\) Ensure patients follow hospital policies **2. True or False: The nurse\'s role in health promotion includes educating patients to take control of their own health.** **3. Which of the following are Bloom's three domains of learning? *(Select all that apply)*** - A\) Cognitive - B\) Psychomotor - C\) Spiritual - D\) Affective **4. A nurse is planning patient education. Which of the following would be a factor that could facilitate learning?** - A\) Patient experiencing acute pain - B\) Quiet, well-lit environment - C\) Use of complex medical terminology - D\) Patient's anxiety about diagnosis **5. True or False: The nursing process and the teaching-learning process are similar, as both require assessment, planning, intervention, and evaluation.\*\*** **6. When educating a patient, which of the following principles of effective teaching should a nurse follow? *(Select all that apply)*** - A\) Tailor information to the patient's educational level - B\) Use medical jargon to increase professionalism - C\) Encourage patient questions to gauge understanding - D\) Use a monotone voice to avoid distracting the patient **7. A good learning environment should have which of the following characteristics?** - A\) High noise level - B\) Ample distractions - C\) Comfortable temperature - D\) Limited lighting **8. The affective domain of learning primarily involves:** - A\) Physical skills - B\) Attitudes, values, and emotions - C\) Knowledge and comprehension - D\) Problem-solving abilities **9. When educating a patient with different cultural beliefs, the nurse should:** - A\) Ignore cultural beliefs to ensure the patient understands Western medicine - B\) Use interpreters or culturally appropriate materials if needed - C\) Only provide written materials in English - D\) Assume the patient has the same learning preferences as other patients **10. True or False: An essential principle in effective teaching is avoiding overwhelming the patient with too much information at once.\*\*** **11. When teaching a patient about insulin injections, the nurse demonstrates the technique first and then asks the patient to perform the task. Which domain of learning is the nurse primarily addressing?** - A\) Cognitive - B\) Psychomotor - C\) Affective - D\) Cultural **12. Which of the following nursing interventions could improve patient compliance with their care plan? *(Select all that apply)*** - A\) Simplifying instructions - B\) Involving family members in education - C\) Providing all instructions in one session - D\) Using visual aids when explaining complex concepts **13. The teaching-learning process differs from the nursing process because it specifically focuses on:** - A\) Problem-solving abilities - B\) Creating an individualized care plan - C\) Assessing patient understanding and promoting behavioral changes - D\) Managing physical symptoms **14. Which of the following would indicate that patient education was effective?** - A\) The patient can repeat all instructions word-for-word - B\) The patient demonstrates the skill correctly - C\) The patient avoids asking questions - D\) The patient does not remember key points after a day **15. The nurse observes a patient giving themselves a subcutaneous injection after instruction. This is an example of evaluation in which domain?** - A\) Cognitive - B\) Psychomotor - C\) Affective - D\) None of the above **16. Resources available to meet a patient's learning needs may include: *(Select all that apply)*** - A\) Educational videos and booklets - B\) Professional translators or interpreters - C\) Family members - D\) All of the above **17. True or False: A supportive and collaborative nurse-patient relationship is essential for effective patient education.\*\*** **18. To ensure a patient's understanding, the nurse should evaluate learning by:** - A\) Asking the patient to explain or demonstrate what they learned - B\) Repeating the instructions multiple times without confirmation - C\) Completing the teaching session without patient feedback - D\) Avoiding follow-up to allow the patient to reflect **19. When educating a patient with a language barrier, the best approach is to:** - A\) Speak more slowly and louder in English - B\) Use hand gestures only - C\) Arrange for a professional interpreter - D\) Use the patient's family as the primary translator without verifying accuracy **20. Which of the following reflects the cognitive domain in patient education?** - A\) Patient verbalizes understanding of diabetes management - B\) Patient demonstrates how to use an inhaler - C\) Patient expresses fear about surgery - D\) Patient accepts the need for medication compliance **Answer Key and Rationales** **1.** B\ **Rationale:** Patient education aims to improve health outcomes by enabling patients to care for themselves effectively. **2.** True\ **Rationale:** Nurses play a critical role in promoting health literacy, which encourages patients to take control of their health. **3.** A, B, D\ **Rationale:** Bloom\'s domains include cognitive (knowledge), psychomotor (physical skills), and affective (attitudes). **4.** B\ **Rationale:** A quiet, well-lit environment helps the patient focus and absorb information. **5.** True\ **Rationale:** Both processes follow similar steps to identify needs, plan, implement, and evaluate interventions. **6.** A, C\ **Rationale:** Tailoring information and encouraging questions make the teaching more effective and patient-centered. **7.** C\ **Rationale:** A comfortable environment with minimal distractions promotes better concentration and learning. **8.** B\ **Rationale:** The affective domain is focused on feelings, beliefs, and attitudes. **9.** B\ **Rationale:** Using culturally appropriate materials and interpreters respects the patient's beliefs and improves understanding. **10.** True\ **Rationale:** Patients learn best with information presented in manageable portions. **11.** B\ **Rationale:** Teaching a physical skill, such as injections, addresses the psychomotor domain. **12.** A, B, D\ **Rationale:** These interventions make the instructions easier to follow, thus improving adherence. **13.** C\ **Rationale:** The teaching-learning process focuses on educating patients to promote understanding and behavior changes. **14.** B\ **Rationale:** Demonstrating the skill correctly indicates understanding. **15.** B\ **Rationale:** Observing a physical task, such as an injection, evaluates the psychomotor domain. **16.** D\ **Rationale:** A variety of resources, including visual aids and interpreters, can help meet diverse learning needs. **17.** True\ **Rationale:** A trusting nurse-patient relationship facilitates open communication and enhances learning. **18.** A\ **Rationale:** Asking the patient to teach-back or demonstrate confirms their understanding. **19.** C\ **Rationale:** A professional interpreter ensures accurate communication and respects privacy and understanding. **20.** A\ **Rationale:** Verbalizing understanding demonstrates cognitive processing of information. **Pain Management and Sleep Practice Test** **1. Pain that lasts longer than 6 months and may have less identifiable causes than acute pain is typically classified as:** - A\) Acute pain - B\) Chronic pain - C\) Breakthrough pain - D\) Neuropathic pain **2. True or False: Pain tolerance is the maximum amount of pain a person is willing to endure, while pain threshold is the point at which a stimulus is perceived as painful.\*\*** **3. Psychosocial influences on pain perception may include which of the following? *(Select all that apply)*** - A\) Cultural beliefs - B\) Age - C\) Ethnic background - D\) Weather conditions **4. Which of the following would be considered subjective data when assessing a patient\'s pain?** - A\) Blood pressure - B\) Heart rate - C\) Patient\'s self-reported pain level - D\) Grimacing during movement **5. True or False: Acute pain is generally protective in nature, alerting the body to potential or actual tissue damage.\*\*** **6. A patient reports a sharp, shooting pain down the leg that is constant and has been present for several months. This description is consistent with which type of pain?** - A\) Acute pain - B\) Chronic pain - C\) Breakthrough pain - D\) Radiating pain **7. Which of the following interventions would be appropriate for managing chronic pain in a patient? *(Select all that apply)*** - A\) Cognitive-behavioral therapy - B\) Short-term use of opioid analgesics - C\) Regular physical exercise tailored to the patient\'s abilities - D\) Ice packs applied continuously **8. When administering a patient-controlled analgesia (PCA), which of the following should the nurse monitor closely?** - A\) Blood pressure and temperature - B\) Respiratory rate and sedation level - C\) Weight - D\) Skin integrity **9. Non-pharmacologic measures that can help reduce pain include: *(Select all that apply)*** - A\) Deep breathing exercises - B\) Massage - C\) Music therapy - D\) Corticosteroid injections **10. A nurse needs to assess a patient\'s pain. Which of the following components should be included in the assessment? *(Select all that apply)*** - A\) Intensity of pain - B\) Quality of pain - C\) Duration of pain - D\) Last meal the patient ate **11. True or False: Non-Rapid Eye Movement (NREM) sleep has three stages, progressing from light to deep sleep.\*\*** **12. Which stage of sleep is associated with restorative sleep, deep muscle relaxation, and growth hormone release?** - A\) Stage 1 NREM - B\) REM sleep - C\) Stage 3 NREM - D\) Stage 2 NREM **13. Which of the following factors are known to negatively impact sleep?** - A\) High caffeine intake close to bedtime - B\) Regular exercise in the evening - C\) Quiet, dim environment - D\) Reduced fluid intake before bedtime **14. A patient reports difficulty falling asleep and feeling tired throughout the day. Which of the following interventions would promote better sleep? *(Select all that apply)*** - A\) Establishing a regular sleep schedule - B\) Drinking caffeinated beverages in the evening - C\) Using a sleep mask to reduce light exposure - D\) Engaging in strenuous exercise before bed **15. True or False: Infants and young children generally require less sleep than adults.\*\*** **16. A nurse is assessing a patient\'s sleep patterns and identifies that the patient rarely experiences dreams. The patient is likely getting insufficient time in which sleep stage?** - A\) Stage 3 NREM - B\) REM sleep - C\) Stage 2 NREM - D\) Stage 1 NREM **17. When teaching a patient about managing chronic pain at home, the nurse should include:** - A\) The importance of rotating pain medications frequently - B\) Only relying on pharmacologic methods for pain control - C\) Using a combination of pharmacologic and non-pharmacologic methods - D\) Avoiding all physical activity to prevent pain exacerbation **18. Which of the following assessments would indicate acute pain in a patient?** - A\) Report of dull, throbbing pain that has been present for years - B\) Elevated heart rate and blood pressure in response to pain - C\) Report of generalized body aches without specific cause - D\) Frequent sighing during rest periods **19. Which of the following are considered common sleep disorders? *(Select all that apply)*** - A\) Insomnia - B\) Sleep apnea - C\) Narcolepsy - D\) Myocarditis **20. When evaluating the effectiveness of a pain intervention, the nurse should:** - A\) Ask the patient to rate their pain on a scale from 0 to 10 - B\) Determine the patient\'s heart rate - C\) Assess for any changes in respiratory rate - D\) Discontinue all analgesics **Answer Key and Rationales** **1.** B\ **Rationale:** Chronic pain persists beyond the expected healing period, often lasting for more than 6 months. **2.** True\ **Rationale:** Pain tolerance is how much pain one can bear, while the pain threshold is the point at which pain is first perceived. **3.** A, B, C\ **Rationale:** Cultural beliefs, age, and ethnic background influence how individuals perceive and respond to pain. **4.** C\ **Rationale:** Subjective data is information provided by the patient, such as their pain level. **5.** True\ **Rationale:** Acute pain alerts the body to injury and protects against further damage. **6.** B\ **Rationale:** The description of a constant, shooting pain down the leg is consistent with chronic pain. **7.** A, C\ **Rationale:** Cognitive-behavioral therapy and appropriate exercise are effective for managing chronic pain. **8.** B\ **Rationale:** Close monitoring of respiratory rate and sedation levels is essential for patient safety with PCA. **9.** A, B, C\ **Rationale:** Non-pharmacologic methods like deep breathing, massage, and music therapy can help reduce pain. **10.** A, B, C\ **Rationale:** Pain assessment includes intensity, quality, and duration, but the patient's last meal is unrelated. **11.** True\ **Rationale:** NREM sleep has three stages, with each stage serving different physiological purposes. **12.** C\ **Rationale:** Stage 3 NREM is associated with restorative sleep and is crucial for physical recovery. **13.** A\ **Rationale:** High caffeine intake and irregular routines negatively impact sleep quality. **14.** A, C\ **Rationale:** Regular sleep schedules and reducing light exposure promote better sleep. **15.** False\ **Rationale:** Infants and children typically require more sleep than adults. **16.** B\ **Rationale:** REM sleep is associated with dreaming, so insufficient REM sleep often leads to fewer dreams. **17.** C\ **Rationale:** Effective chronic pain management often includes both pharmacologic and non-pharmacologic methods. **18.** B\ **Rationale:** Elevated heart rate and blood pressure indicate a physical response to acute pain. **19.** A, B, C\ **Rationale:** Insomnia, sleep apnea, and narcolepsy are common sleep disorders; myocarditis is not. **20.** A\ **Rationale:** Asking the patient to rate their pain is a direct way to evaluate the effectiveness of pain relief interventions. UNIT 4 **Pharmacological Concepts and Medication Administration Practice Test** **1. The nurse's legal responsibilities regarding medication administration include which of the following? *(Select all that apply)*** - A\) Following the "six rights" of medication administration - B\) Documenting medication administration in the patient's chart - C\) Administering medications based solely on patient request - D\) Assessing the patient's understanding of their medications **2. Which of the following is NOT one of the "six rights" of medication administration?** - A\) Right dose - B\) Right medication - C\) Right patient - D\) Right time of day **3. True or False: Pharmacokinetics is the study of

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