NSCC NSG 1 - FUNDAMENTALS FINAL EXAM (650 QUESTIONS WITH 100% CORRECT SOLUTIONS)2024 NEWES, Exams of Nursing

Download NSCC NSG 1 - FUNDAMENTALS FINAL EXAM (650 QUESTIONS WITH 100% CORRECT SOLUTIONS)2024 NEWES and more Exams Nursing in PDF only on Docsity! NSCC NSG 1 - FUNDAMENTALS FINAL EXAM (650 QUESTIONS WITH 100% CORRECT SOLUTIONS)2024 NEWEST REVISED AND GRADED A+) A patient had surgery 6 hrs ago. The nurse enters the room to find the patient restless and grimacing. Which action should the nurse take first? A. Ask the patient, "Are you having pain?" B. Leave the patient's room so they can rest quietly C. Ask the patient, "You seem to be moving around in the bed and grimacing. Can you tell me whats going on?" D. Administer pain medication - Solution C. Ask the patient, "You seem to be moving around in the bed and grimacing. Can you tell me whats going on?" Which statement(s) about communication is/are true? (Select all that apply) Communication is: A. Most basically described as talking and listening B. Used to meet physical and psychosocial needs C. The process of sending and receiving information D. A basis for forming relationships - Solution B. Used to meet physical and psychosocial needs C. The process of sending and receiving information D. A basis for forming relationships The Associate Degree Nurse is prepared to function as (Select all that apply). A. An effective member of the health care team. B. A clinical nurse specialist. C. A director of Nursing Staff activities. D. An assessor, planner, implementer, and evaluator of patient care. E. Patient health care educator - Solution A. An effective member of the health care team. D. An assessor, planner, implementer, and evaluator of patient care. E. Patient health care educator A patient tells the nurse information that will affect the outcome of his hospitalization; then he requests the nurse to keep it a secret. What would the nurse's best response would be? A. "I'm sorry everything you say must be reported." B. "Why would you want me to keep this information a secret?" C. "I want you to trust me, so I'll keep it a secret." D. "I'll only tell the doctor about this." - Solution B. "Why would you want me to keep this information a secret?" Sister Callista Roy developed which theory of nursing? A. Theory of Interpersonal relations B. Adaptation model C. Hierarchy of Needs D. Systems model - Solution B. What is a general definition of accountability? A. Doing what one is told. B. Carrying out all physician's orders as written. C. Being answerable for one's conduct. D. Lobbying for current health issues. - Solution C. Being answerable for one's conduct. How does chronic illness differ from acute illness? - Solution Chronic illness lasts longer 01.04.01When did Mildred Montag begin associate degree nursing? 1800's 1920's 1950's 1940's - Solution 1950's The NSCC Nurse Education Program prepares graduates to become entry level practice nurses who are licensed to do which? A. Utilize a holistic approach to nursing care. B. Demonstrate professional behaviors C. Recognize the role of the nurse as a leader D. All of the above - Solution D. All of the above What is expected of nursing students regarding class attendance in the Nurse Education Program? A. 50% of synchronous classes. B. 100% of all synchronous class sessions. C. 75% of synchronous classes. D. Any classes I want - Solution B. 100% of all synchronous class sessions. 02.05.05What are brown spots on the hands of elderly persons caused by? long-term sun exposure. fatty liver disease. excess melanin in the diet. old age. - Solution long-term sun exposure. Which patient should the nurse use touch most cautiously with? A. A baby admitted with a fever B. The spouse of a patient who is upset that her husband has suffered a complication. C. An older adult with a diagnosis of dementia D. A middle aged woman just diagnosed with lung cancer - Solution C. An older adult with a diagnosis of dementia 02.02.08In Orem's nursing model, what is the role of the nurse? Influence the patient's development in achieving an optimal level of self- care. Promote the patient's adaptive behaviors by manipulating stimuli. Identify and help the individual respond to stressors. Help patients develop patterns of living that accommodate environmental changes. - Solution Promote the patient's adaptive behaviors by manipulating stimuli What plays a part in the health-illness continuum? (Select all that apply) A. Socio-economics. B. Heredity. C. Stress. D. Age. E. Race. - Solution A. Socio-economics. B. Heredity. C. Stress. D. Age. E. Race. A negligent act committed during professional performance which results in injury, loss, or damage is known as: _______________________ - Solution Malpractice 02.05.06 What diseases are older adults are at risk for? Heart disease and osteoporosis Cardiovascular disease and liver disease Osteoporosis and HIV (human immunodeficiency virus) HIV and liver disease - Solution Heart disease and osteoporosis 02.04.05__________________Is a health program, administered by the state and funded by Federal and state governments to provide care for low- income people - Solution Medicaid What is the ANA code of ethics for nurses is enforced by? A. Each nurse's conscience and ethical behavior. B. The physician. C. A committee of nurses of the ANA. D. A panel of Registered Nurses. - Solution A. Each nurse's conscience and ethical behavior 02.05.04List at least six developmental tasks of older adulthood:__________________ - Solution Adjusting to decreasing health A. "Does it hurt only when you move? B. "When did you first notice this pain?" C. "How would you rate the pain on a scale of 1-10?" D. "Tell me about your pain." E. "Is your pain severe?" - Solution D. "Tell me about your pain." 02.04.07One legal provision states that the patient has the right to informed consent. What does this mean? (Select all that apply) The patient is entitled to an explanation of the treatment he is to have. The patient must sign a consent form for treatment. The patient has a right to refuse treatment. The patient can read their own chart. - Solution The patient is entitled to an explanation of the treatment he is to have. The patient must sign a consent form for treatment. The patient has a right to refuse treatment. What does the ANA Code of Ethics require within your nursing practice? An understanding of your own value system is not necessary to effectively care for patients. Discussion of the patient's care plan in the cafeteria is appropriate in order to elicit a variety of approaches. Reporting an incompetent colleague or one guilty of unethical behavior is not required because her loss would increase staff workload. Care is given with respect to the dignity of man, regardless of race, color, creed or socio-economic status. - Solution Care is given with respect to the dignity of man, regardless of race, color, creed or socio-economic status Which statement(s) by the nurse demonstrate that active listening has occurred? (Select all that apply) A. "I sat with my patient and his wife to talk about their fears about the surgery. B. "I had the same surgery before so I told the patient all about my experience, knowing that hers will be similar" C. "I taught my patient about his upcoming surgery while I was changing his IV site." D. "I took detailed notes when I listened to my patient describe his symptoms." E. "I made eye contact and listened carefully as my patient described his symptoms." - Solution A. "I sat with my patient and his wife to talk about their fears about the surgery. E. "I made eye contact and listened carefully as my patient described his symptoms." 02.03.06What is the best way for the nurse to enhance ethical decision making? (Select all that apply) Awareness of own values and ethical aspects of nursing Familiarity with nursing code of ethics Respect values, opinions, responsibilities of other health care professionals that may differ Appreciate the patient's perspective Participate in or establish ethics rounds Serve on institutional ethics committees Strive for collaborative practice in which nurses function effectively in cooperation with other health care professionals Serve on quality improvement projects - Solution Awareness of own values and ethical aspects of nursing Familiarity with nursing code of ethics Respect values, opinions, responsibilities of other health care professionals that may differ Appreciate the patient's perspective Participate in or establish ethics rounds Serve on institutional ethics committees Strive for collaborative practice in which nurses function effectively in cooperation with other health care professionals Patients harmed by student acts may bring suit for damages against who? (Select all that apply) Nursing student. Nursing instructor. All nursing students on the unit. Hospital. Nursing school - Solution Nursing student. Nursing instructor. Hospital. 02.03.03List the 6 essential features of professional nursing practice per the ANA._______________________________________________________ __________________________ - Solution Protection, promotion and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering, diagnosis and treatment of human response, advocacy in the care of individuals, families, groups, communities and organizations 02.02.02What is the philosophy of the Nurse Education Faculty of North Shore Community College? The person as a holistic being with unique biophysical, emotional, intellectual, social, cultural, and spiritual dimensions who throughout the life span interacts with a changing environment. The environment as including all factors, internal and external that impacts upon and contributes to the uniqueness of the person. Health as a dynamic state of wellness. Wellness is a fluctuating state of being, encompassing physical, psychological and spiritual health. The patient as the individual, family and /or the community. All of the above - Solution All of the above A patient comes into the emergency room with severe chest pain. Which statement by the nurse is most appropriate? A. "I'll give you some medication to relieve the pain" B. "Don't worry. We'll take good care of you." C. "You might be having a heart attack so try not to think about the pain." D. "If you lie still and relax, you'll be fine in a little while ." - Solution A. "I'll give you some medication to relieve the pain" C. Maslow's need, outcomes, and assessment D. Assessment, implementation, and evaluation - Solution D. Assessment, implementation, and evaluation What stage of the nursing process involves problem identification? A. Planning interventions B. Evaluation C. Diagnosis D. Planning outcomes - Solution C. Diagnosis The nurse is ordered to administer a medication to a non-verbal confused patient. Allergy information is not on file in the patient's chart. The nurse realizes it is unsafe to administer the medication until allergy information is verified and they notify the doctor of the situation. The nurse then calls the patient's nursing home to verify their allergy list. What important professional skill is the nurse practicing in this patient care scenario? A. Critical thinking B. Therapeutic communication C. Reflection D. Intellectual empathy - Solution A. Critical thinking How does a " risk for" nursing diagnosis differ from a possible nursing diagnosis? A. A risk diagnosis is based on data about the patient. B. A possible diagnosis is based on partial (or incomplete) data. C. Nurses collect the data to support risk diagnoses. D. A possible diagnosis becomes an actual diagnosis when symptoms develop - Solution B. A possible diagnosis is based on partial (or incomplete) data. A patient comes to the urgent care clinic because he stepped on a rusty nail. Which type of assessment should the nurse perform when collecting data from this patient? A. Comprehensive B. Ongoing C. Initial focused D. Special needs - Solution C. Initial focused Which is an example of an ongoing assessment? A. Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol). B. Examining the patient's mouth at the time she complains of a sore throat. C. Requesting the patient to rate intensity on a pain scale with the first perception of pain. D. Asking the patient in detail how he will return to his normal exercise activities. - Solution A. Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol). Which explains why it is important to have the correct etiology for a nursing diagnosis? A. It is the cause of the problem. B. It cannot always be observe. C. It directs nursing care. D. It is an inference. - Solution C. It directs nursing care. Which example includes both objective and subjective data? A. The patient's blood pressure is 132/68 and her heart rate is 88. B. The patient's cholesterol is elevated, and he states he likes fried food. C. The patient states she has trouble sleeping and that she drinks coffee in the evening D. The patient states he gets frequent headaches and that he takes aspirin for the pain. - Solution B. The patient's cholesterol is elevated, and he states he likes fried food. A nurse is prioritizing care for four patients. Which patient should the nurse see first? A. A patient needing teaching about medications B. A patient with a healing abdominal incision C. A patient with difficulty breathing D. A patient who is complaining of a headache - Solution C. A patient with difficulty breathing Who is the source of control within the patient-centered care model? A. the doctor B. the nurse C. the family D. the patient - Solution D. Discharge against medical advice. D. Refusal of care discharge. - Solution C. Discharge against medical advice. What referral agency focuses on care of patients whose condition is terminal, and whose goal is to promote comfort, quality of life, and management of symptoms? A. Meals on wheels B. Adult day care center C. Ambulatory care center D. Hospice - Solution D. Hospice Why is clarification of data necessary? (Select all that apply) A. To properly assess the patient's health status. B. To promote quality care. C. To support nursing judgment. D. To minimize errors. E. To improve teamwork and collaboration. - Solution A. To properly assess the patient's health status. B. To promote quality care. C. To support nursing judgment. D. To minimize errors. Which of these patient scenarios is most indicative of critical thinking? A. Administering nausea medication according to what was given last shift. B. Asking a patient what nausea relief methods have worked best in the past. C. Doing deep breathing exercises with the patient to control nausea. D. Explaining to the patient that it is best to wait it out to see if their nausea subsides naturally - Solution B. Asking a patient what nausea relief methods have worked best in the past. Which nursing diagnosis is written in the correct format? A. Readiness for enhanced nutrition B. Pain related to stating: "on a scale of 1-10, it's a 10" C. Risk for infection related to compromised immunity AEB fever D. Impaired mobility related to hip fracture AEB limited ROM, pain, gait changes - Solution D. Impaired mobility related to hip fracture AEB limited ROM, pain, gait changes What are methods of data collection? (Select all that apply) A. Interview. B. Observation and examination. C. Consultation with other team members. D. Review of records and reports. E. Evaluation - Solution A. Interview. B. Observation and examination. C. Consultation with other team members. D. Review of records and reports. What are the steps of the nursing process? A. Assessment, diagnosis, planning, implementation and evaluation. B. Assessment, planning, inventing, and establishing outcomes. C. Planning, diagnosing and critical thinking. D. Evaluation, diagnosis, assessment, implementation, and critical thinking. - Solution A. Assessment, diagnosis, planning, implementation and evaluation. Before a patient can achieve love and belonging needs, what most basic needs must be met first? A. Self-actualization needs B. Self-esteem needs C. Physiological needs D. Individualized needs - Solution C. Physiological needs According to the PES format, why are the problem (need), etiology and signs/symptoms combined? A. To result in a treatment outcome. B. To include qualifiers as appropriate. C. To form a neutral diagnostic statement. D. To form the outcome of ambiguous statements. - Solution C. To form a neutral diagnostic statement. Which event would necessitate writing an incident report? A. Expedited discharge B. Discharge against medical advice (AMA) C. Unethical behavior D. Discharge with services - Solution B. Discharge against medical advice (AMA) In validating data, what might be necessary for the nurse to do? ( Select all that apply) A. Chart vital signs on the graphic sheet. B. Check the results of lab tests. C. Report changes to the physician. D. Confirm with the patient that the laboratory tests are correct - Solution A. Chart vital signs on the graphic sheet. B. Check the results of lab tests. C. Report changes to the physician. D. Confirm with the patient that the laboratory tests are correct What criteria for evaluation of nursing care is included? (select all that apply). A. How the patient states he feels. B. How the patient thinks he is doing. C. The behavior the patient demonstrates. D. How previous patients have reacted. - Solution A. How the patient states he feels. B. How the patient thinks he is doing. C. The behavior the patient demonstrates Which is the best example of an outcome statement? The patient will: A. Use an incentive spirometer when awake. B. Walk two times during day and evening shift. C. Maintain oxygen saturation above 92% while performing ADLs daily. D. Tolerate 10 sets of range of motion activities with Physical Therapy before discharge - Solution D. Tolerate 10 sets of range of motion activities with Physical Therapy before discharge. Which criteria does not apply to goal statements? A. Short-range. B. Long-range. C. Specific. D. Environmental - Solution D. Environmental. What is a nursing diagnosis? A. It is based on the medical diagnosis. B. It is the process of evaluating data and determining a specific patient problem. C. It is based on intuition. D. It is determined on admission and should not change if properly diagnosed - Solution B. It is the process of evaluating data and determining a specific patient problem. In which nursing care delivery model are clinicians held accountable for some standard of cost-effectiveness and quality of care? A. Total patient care B. Primary nursing C. Team nursing D. Case management - Solution D. Case management Which should be included in a patient's discharge summary? (select all that apply) A. The condition of the patient at discharge. B. The teaching conducted. C. Medications taken in the past 2 years. D. Resolved health problems E. Referrals given - Solution A. The condition of the patient at discharge. B. The teaching conducted. E. Referrals given How are subjective symptoms best described? A. Patient perceives and can describe. B. Patient feels, but is unable to communicate. C. Nurse believes to be present at any given time. D. Nurse can detect through special examination. - Solution A. What is the definition of reflection in relation to critical thinking? A. The formulation of problems in clinical reasoning. B. The utilization of approach in clinical judgement. C. The purposeful thinking back or recalling of a situation to discover its purpose or meaning. D. The evaluation of credibility in sources of information. - Solution C. The purposeful thinking back or recalling of a situation to discover its purpose or meaning. You have made an error in writing a nurses note in your patient's paper chart. Which is the correct nursing action? A. Draw a single line through the error so that your writing is still legible, write the word error and sign your name. B. Cross out the error so that no one can read what you wrote. C. Throw out the paper and start all over again on a fresh page. D. Write over your error, using a darker pen or thicker ink, if necessary - Solution A. Draw a single line through the error so that your writing is still legible, write the word error and sign your name. What are some critical thinking skills nurses should possess? (select all that apply) A. Staying well informed. B. Avoiding personal bias. C. Evaluating credibility of sources of information. D. Utilizing the nursing process. E. Recognizing personal knowledge gaps. F. Careful listening. - Solution A. Staying well informed. B. Avoiding personal bias. C. Evaluating credibility of sources of information. D. Utilizing the nursing process. E. Recognizing personal knowledge gaps. F. Careful listening. What is the primary goal of the home health care nurse? A. Tell the case manager important information about the patient. B. To promote patient self-care. C. Tell the patient's family what the patient needs. D. Order whatever durable medical equipment the patient needs - Solution B. To promote patient self-care What best describes the goal statement in the nursing care plan? (Select all that apply) A. The goal statement can be broken down into both short and long term goals. B. The goal statement should reflect the patient's problems. C. The goal statement should be achievable. D. The goal statement should be measurable - Solution A. The goal statement can be broken down into both short and long term goals. B. The goal statement should reflect the patient's problems. C. The goal statement should be achievable. D. The goal statement should be measurable. Which of the following documentation formats tells the patient's story in chronological order? A. SOAP B. Problem-Intervention-Evaluation C. Narrative D. Focus - Solution C. Narrative You are caring for a patient who has had a partial hip replacement. Following are a list of actions you carry out while caring for the patient. Based on the information you have in the question state whether or not the action listed below is independent, dependent, or interdependent. A. Administer Percocet, two tablets at 10 AM. B. Assist the physical therapist ambulate the patient in the hallway. C. Take the patient's vital signs even though they are not due. - Solution Dependent Interdependent Independent What does the objective data in a SOAP note include? (Select all that apply) A. Physical signs and observations of the patient. B. Statements made by the patient. C. Physician orders. D. Information gathered during the history taking. - Solution A. Physical signs and observations of the patient E. Documenting patient discharge teaching. - Solution A. Managing hospital discharge plans. B. Maintaining quality of care. C. Coordinating health care services across all levels of care. What do critical thinking and the nursing process have in common? A. They are both linear processes used to guide one's thinking. B. They are both thinking methods used to solve a problem. C. They both use specific steps to solve a problem. D. They both use similar steps to solve a problem. - Solution B. They are both thinking methods used to solve a problem. The nurse documents symptoms, she observes as objective data. Which might these include? A. Headache B. Pain C. Red, swollen leg D. Nausea - Solution C. Red, swollen leg Why do nurses write care plans? (select all that apply) A. To implement plans to solve patient problems. B. To evaluate patient progress. C. To specify plans to solve patient problems. D. To identify patient problems. - Solution A. To implement plans to solve patient problems. B. To evaluate patient progress. C. To specify plans to solve patient problems. D. To identify patient problems. Which questions may appear on a nursing history? (Select all that apply) A. Have you ever been in the hospital before? B. Are you on any medications at home? C. Are you following any special diet? D. Do you have any allergies? E. What is your living situation? - Solution A. Have you ever been in the hospital before? B. Are you on any medications at home? C. Are you following any special diet? D. Do you have any allergies? E. What is your living situation? The nurse works with the respiratory therapist to administer a patient's breathing treatment. The patient's breathing status and tolerance of the treatment is reported to the primary care provider by the nurse. The nurse then discusses the options for further treatment with the patient. What is this an example of? A. Delegation B. Collaboration C. Coordination of care D. Supervision of care - Solution B. Collaboration What are some examples of services that can be provided for home care? (Select all that apply) A. Meals on wheels B. Skilled nursing C. Physical therapy D. Home health aid - Solution A. Meals on wheels B. Skilled nursing C. Physical therapy D. Home health aid The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? A. "I would have the patient rate her pain on a scale of 0 to 10." B. "I would ask the patient when she had her last bowel movement." C. "I would take the patient's pulse oximetry reading." D. "I would interview the patient about history of tobacco use." - Solution A. "I would have the patient rate her pain on a scale of 0 to 10." Which assessment data best supports a report of severe pain in an adult patient whose baseline vital signs are within an average normal range? A. Oral temperature 100°F (37.8°C) B. Respiratory rate 26 breaths/min and shallow Counting the rate for 1 full minute B. Exposing only the left side of the chest C. Determining why assessment of apical pulse is indicated D. Using your ring finger to palpate the intercostal spaces - Solution A. Counting the rate for 1 full minute What are techniques of body mechanics? (select all that apply) A. Reaching B. Pivoting C. Lifting D. Stooping - Solution A. Reaching B. Pivoting C. Lifting Which is an objective of bedrest? A. To increase cardiac demand B. To reduce workload of nurses due to short staffing C. To allow for rest and regaining of strength D. To restrain the patient from harming themself - Solution C. To allow for rest and regaining of strength What is a contracture? A. shortening and hardening of muscles, tendons and tissues which leads to rigid and deformed joints B. prolonged muscle spasms cause from under usage of muscles with prolonged bed rest C. stretching of the muscles, tendons, and tissues caused from a prolonged amount of time in extension. D. tearing of the muscles, tendons, and tissues that leads to loose and painful joints - Solution A. shortening and hardening of muscles, tendons and tissues which leads to rigid and deformed joints When moving a patient's arm towards their trunk, the nurse is performing which range of motion (ROM) position? A. Eversion B. Adduction C. Abduction D. Pronation - Solution B. Adduction What are principles of good body mechanics? (select all that apply) A. Maintain proper body alignment. B. Maintain the line of gravity. C. Maintain a stable center of gravity. D. Maintain a wide base of support. - Solution A. Maintain proper body alignment. B. Maintain the line of gravity. C. Maintain a stable center of gravity. D. Maintain a wide base of support. Use of proper body mechanics is important to avoid which? A. Muscle injuries B. Skeletal injuries C. Injury to the patient D. Excessive fatigue - Solution A. Muscle injuries B. Skeletal injuries C. Injury to the patient D. Excessive fatigue How should the nurse wash the perineum of a female patient? Back to front Using a circular motion Side to side Front to back - Solution Front to back How warm should the water in the basin be to provide foot care? 105°F to 110°F 110°F to 115°F 115°F to 120°F Under 100°F - Solution 105°F to 110°F How does the nurse hold the toothbrush when brushing the teeth? Straight up and down Holding the brush at a 90-degree angle Holding the brush at a 45-degree angle Hold the brush in the nondominant hand so as not to hurt the patient - Solution Holding the brush at a 45-degree angle When changing an occupied bed, how does the nurse prevent the patient from becoming chilled? Have the patient sit in a chair with a blanket. Provide the patient with a heating pad. C. Acute Why is a bath important? (Select all that apply) A. physical movement promotes circulation. B. It stimulates the patient. C. bacteria multiply on the skin and must be removed. D. blood collects in small veins and needs to be removed. - Solution A. physical movement promotes circulation. C. bacteria multiply on the skin and must be removed. How can the incidence of pressure ulcers be reduced?(Select all that apply) A. Keeping pressure off bony prominences. B. Repositioning immobile patients at least every 2 hours. C. Keeping the skin dry. D. Keeping pressure off the skin. - Solution A. Keeping pressure off bony prominences. B. Repositioning immobile patients at least every 2 hours. C. Keeping the skin dry. D. Keeping pressure off the skin. Which nursing intervention should the nurse prioritize for a patient who is bedridden and has a nursing diagnosis of: Impaired Skin Integrity related to prolonged bed rest? A. Use hot water to cleanse the patient's skin B. Change the patient's position every 3 hours C. Turn the patient every 2 hours D. Limit the patient's fluids to 1000 mL/day - Solution C. Turn the patient every 2 hours How is posture defined? A. Muscles which are always in tight contraction. B. Undue strain placed upon the muscles, ligaments and joints in maintaining balance. C. Positioning of the tendons, ligaments, joints and muscles while standing, sitting or lying. D. The complete relaxation of all the muscles of the body. - Solution C. Positioning of the tendons, ligaments, joints and muscles while standing, sitting or lying. Which reading would require reporting and follow up? A. Axillary temperature of 97 degrees F B. Rectal temperature of 102 degrees F C. Oral temperature of 99 degrees F D. Rectal temperature of 100 degrees F - Solution B. Rectal temperature of 102 degrees F Your patient presents with a BP of 80/60 and is complaining of being dizzy and feeling faint. Your patient is likely to be: A. systolic B. hypokalemic C. hypotensive D. hypertensive - Solution C. hypotensive Where on the body might pressure ulcers be found? (Select all that apply) A. Bicep. B. Coccyx. C. Heels. D. Stomach. - Solution B. Coccyx. C. Heels. For what reasons are passive range of motion exercises beneficial for a patient with an immobile limb? (Select all that apply) A. They increase muscle strength. B. They aid in circulation. C. They maintain joint function. D. They treat decubitus ulcers - Solution B. They aid in circulation. C. They maintain joint function. A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? A. Intractable B. Acute C. Chronic Cover the patient as much as possible B. Sing to the patient while performing care C. Expect the patient to protest to finish quickly D. Be organized E. Complete the bath, taking as much time as possible - Solution A. Cover the patient as much as possible D. Be organized The nurse is assessing a patient who returned from surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? A. Heart rate 80 beats/min B. Temperature 100.6°F C. Oxygen saturation 95% D. Blood pressure 160/92 mm Hg - Solution D. Blood pressure 160/92 mm Hg What is maximum pressure exerted against the arterial wall when the ventricles contract called? A. Pulse. B. Cardiac output. C. Systolic pressure. D. Diastolic pressure - Solution C. Systolic pressure. When should the nurse assess for pain? A. During the admission interview only B. Only when the patient complains of pain C. Every 4 hours for the first 2 days after surgery D. Whenever a full set of vital signs is taken - Solution D. Whenever a full set of vital signs is taken Signs and symptoms of extremely high fever include which? (Select all that apply) A. Increased pulse B. Malaise C. Decreased appetite D. Shock - Solution A. Increased pulse B. Malaise C. Decreased appetite How many cc in one ounce? - Solution 30 Contributing causes of pressure ulcers include which? (Select all that apply) A. paralysis. B. frequent position changes. C. poor nutrition. D. continence. - Solution A. paralysis C. poor nutrition. Which method would be best to take the temperature of a sixty year old man with severe dyspnea and severe diarrhea? A. rectal B. axillary C. oral D. inguinal - Solution B. axillary The nurse administers acetaminophen 650 mg orally to a patient complaining of a severe headache. When should the nurse reassess the patient's pain? A. 15 minutes after administration B. Immediately before the next dose is due C. 30-60 minutes after administration D. 90 minutes after administration - Solution C. 30-60 minutes after administration A 16 year old girl is hospitalized because of a fractured leg. Her affected leg is in traction. You note that her unaffected leg is becoming smaller in size (atrophied). Given a physician's activity order for bed rest is in place, what would be the nurse's best action? A. Carry out passive range of motion of the unaffected leg several times a day. B. Exercise both legs actively three times a day. C. Carry out active range of motion of the unaffected leg several times a day. D. Exercise both legs passively three times a day. - Solution C. Carry out active range of motion of the unaffected leg several times a day. Offer him a magazine to read - Solution C. Help the patient to use slow rhythmic breathing and contact the provider and tell them the patient's pain regimen is ineffective Define reactive hyperemia____________________. - Solution blanchable erythema When providing foot care to a diabetic patient, what does the nurse do? A. soak feet and let air dry B. inspect feet while wet C. wash with soap, warm water, and dry completely D. encourage patient to go barefoot when home - Solution C. wash with soap, warm water, and dry completely Which nursing interventions help to prevent contractures in patients on prolonged bed rest? A. Keeping the patient in supine body alignment and limiting any range of motion. B. Bathing the patient daily and changing the patient's position every 4 hours. C. Changing the patient's position every 2 hours and performing range of motion exercises. D. Encouraging the patient to increase their intake of calcium and performing range of motion exercises every 12 hours. - Solution C. Changing the patient's position every 2 hours and performing range of motion exercises. How can pain be best described? A. What the nurse assesses it to be B. What the family says it is C. What the MD says it is D. What the patient says it is - Solution D. What the patient says it is When taking care of a patient's dentures, what may the nurse do? (Select all that apply) A. keep the dentures in the patient's mouth. B. insert a denture cleaning tablet in the water. C. cover with water in a labeled container. D. brush the dentures with a regular toothbrush. E. use toothpaste to clean the dentures. - Solution B. insert a denture cleaning tablet in the water. C. cover with water in a labeled container. D. brush the dentures with a regular toothbrush. E. use toothpaste to clean the dentures. When cleansing the eyes, how should each eye should be wiped? A. from the outer canthus to the inner canthus. B. from the inner canthus to the outer canthus. C. in any direction which the nurse chooses. D. in the direction the patient chooses - Solution B. from the inner canthus to the outer canthus. What may extended periods of immobility due to disability, injury or prolonged bed rest create? (Select all that apply) A. Psychological effects. B. Economic concerns. C. Physiological effects. D. Social concerns - Solution A. Psychological effects. B. Economic concerns. C. Physiological effects. D. Social concerns. Where does deep somatic pain occur? A. Abdominal cavity B. Bones and muscles C. Cranium and thorax D. Skin and subcutaneous tissue - Solution B. Bones and muscles What do factors that affect blood pressure include? (Select all that apply) A. Viscosity of vascular blood. B. Position C. Strength of heart contractions. D. Peripheral resistance. E. Volume of vascular blood - Solution A. Viscosity of vascular blood. B. Position C. What should the nurse do when obtaining a respiratory rate? A. Note skin color. B. Keep fingertips in place on apical pulse. C. Count respirations for 30-60 seconds. D. Count pulse at the same time. - Solution C. Count respirations for 30-60 seconds. Your patient is receiving an IV anticoagulant. He is requesting to be shaved. What does the nurse answer? A. "I will get you a straight razor" B. "Patients on anticoagulants cannot shave secondary to bleeding" C. "Do you have an electric razor?" D. "Your beard looks really good" - Solution C. "Do you have an electric razor?" When taking a blood pressure, the nurse utilizes which assessment techniques? (Select all that apply) A. Diagnosis B. Percussion C. Auscultation D. Palpation E. Inspection - Solution C. Auscultation D. Palpation Which nursing behavior indicates the highest potential for spreading infections among patients? A. Disinfects dirty hands with antibacterial soap B. Allows alcohol-based rub to dry for 10 seconds C. Washes hands only when leaving each room D. Uses warm water for medical asepsis - Solution C. Washes hands only when leaving each room The nurse is removing personal protective equipment (PPE). Which item should be removed first? A. Gown B. Gloves C. Face shield D. Hair covering - Solution B. Gloves A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? A. Contact B. Protective C. Droplet D. Airborne - Solution B. Protective A patient is admitted to the hospital with tuberculosis. Which precaution must the nurse institute when caring for this patient? A. Droplet B. Airborne C. Direct contact D. Indirect contact - Solution B. Airborne While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? A. Continue using the gloves inside the package because the package is intact. B. Remove the gloves gloves and use a new pair of sterile gloves. C. Throw all supplies away that were to be used and begin again. D. Use the gloves and make sure the yellow edges of the package do not touch the client. - Solution B. Remove the gloves gloves and use a new pair of sterile gloves. What is part of the procedure for removal of an IV? A. apply pressure to the site for 10 seconds B. wear sterile gloves C. pull the catheter out perpendicular to the skin D. turn off the IV fluid infusion - Solution D. turn off the IV fluid infusion Assessment of lung sounds is part of the nurse's assessment for which complication of IV therapy? A. sepsis B. The nurse has educated a patient being discharged from the emergency room with instructions for heat therapy applications for 15 minutes every 3 hours. Which statement(s) by the patient indicate(s) a need for more teaching? (Select all that apply) A. "If it feels like it is not warm enough, I can increase the temperature setting" B. "If it feels like it is too hot, I should remove it even though it hasn't been on for 15 minutes." C. "If I find that it is helping, I can leave it in place for 45 minutes." D. "Putting the heat source directly on my skin improves the effectiveness." - Solution A. "If it feels like it is not warm enough, I can increase the temperature setting" C. "If I find that it is helping, I can leave it in place for 45 minutes." D. "Putting the heat source directly on my skin improves the effectiveness." Hyperthermia is the same thing as being febrile. true false - Solution false What type of is energy transfer does application of a chemical cold pack to an injury represent? A. Conduction B. Radiation C. Evaporation D. Convection - Solution A. Conduction What is a typical cause of fire in healthcare facilities? Anesthesia or electrical causes Patients smoking in bed Carelessly discarded smoking materials Use of scented candles - Solution Anesthesia or electrical causes Which action by a nursing assistant would require further teaching to help prevent a back injury? Moving patients alone Use of assistive devices Proper body mechanics Asking a colleague for help - Solution Moving patients alone What is the leading cause of unintentional deaths in America? Poisoning Motor vehicle accidents Firearms Falls - Solution What does the acronym CUS stand for? - Solution What are common workplace accidents among health care workers? (Select all that apply) Violence Back injuries Radiation injury Needle stick injuries Falls - Solution A patient repeats instruction for applying a cold pack to a sprained ankle to the nurse. Which statement indicates an understanding of the teaching? A. "The ice will help increase circulation." B. "I should apply the ice pack directly to my skin." C. "The ice pack should only be left on for 20 minutes." D. "It is normal for my skin to be discolored in irregular patterns." - Solution C. "The ice pack should only be left on for 20 minutes." What complication should the nurse be especially watchful for in a patient with heart failure? A. Air Embolism B. Phlebitis C. Circulatory Overload D. Infiltration - Solution C. Circulatory Overload According to the guidelines for the use of Standard Precautions, how does the nurse determine when to wear gloves? A. Check the patient's diagnosis for possible communicable disease. B. Use gloves for every patient when contact with any body fluid is possible. C. Identify whether the patient falls into any of the risk categories for AIDS or other blood-borne pathogens. D. Review the policy and procedure manual for which patients need isolation precautions. - Solution B. Use gloves for every patient when contact with any body fluid is possible. Which is the nurse's independent decision when providing heat/cold therapy? A. The frequency of application. B. The duration of the application. C. The frequency of skin assessment. D. The location of the application - Solution C. The frequency of skin assessment. The nurse will be starting an IV on a patient at the beginning of a hospitalization that will require a week of IV antibiotics. What site is the nurse most likely to choose unless there is an extenuating circumstance? A. The forearm The patient is a 97-year-old female suffering from dementia who ambulates well with her walker. What does the nurse do to keep her as safe as possible? A. Have the walker nearby at all times. B. Place the patient at the end of the hall away from the noise and nurses station. C. Restrain her at all times. D. Leave the lights on 24hrs a day - Solution A. Have the walker nearby at all times. A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? A. "When it is cold outside, I will use a non-vented furnace." B. "I will schedule an appointment with the chimney inspector next week." C. "Every December is the time to change batteries in the carbon monoxide detector." D. "If I feel dizzy when using the heater, I need to have it inspected." - Solution A. "When it is cold outside, I will use a non-vented furnace." What is the most common cause of accidental death among adults aged 65 and older? A. Falls B. Burns C. Motor vehicle accidents D. Poisoning - Solution A. Falls Just before hanging a dose of IV antibiotics, the nurse assesses a patient with a capped intermittent IV access device used only for administration of antibiotics every 6 hours. The IV site is not reddened, painful, warm or swollen. What conclusion can the nurse draw from this assessment? A. The IV is patent. B. Phlebitis is not present. C. The IV has not infiltrated. D. There is no evidence of sepsis. - Solution B. Phlebitis is not present. The patient complains of pain at the IV site. What should the nurse do next? A. Take vital signs B. Assess the site C. Remove the IV D. Apply a warm compress - Solution B. Assess the site What principle is a basis for the practice of medical and surgical asepsis? A. There is no real direct method for transmitting microorganisms. B. Antibiotics, like penicillin, are the only methods available to interrupt an infectious process. C. All microorganisms can cause illness. D. An interruption of the micro-organisms life cycle can prevent an illness from developing. - Solution D. An interruption of the micro-organisms life cycle can prevent an illness from developing. What is an example of medical asepsis? A. Gowning B. Autoclaving C. Handwashing D. Scrubbing - Solution C. Handwashing Clean gloves should be worn in which situation? A. When direct or indirect contact with an individual's body fluids is anticipated. B. Before touching your own hair and face. C. When prolonged contact with a patient is anticipated. D. When it is necessary to touch the floor for any reason. - Solution A. When direct or indirect contact with an individual's body fluids is anticipated. What are organisms that are capable of causing disease called? A. Morphens B. Contaminants C. Pathogens D. Septics - Solution C. Pathogens Which factor is necessary to identify and consider when teaching a family about safety in the home? A. The town where the home is located. B. For a patient receiving anticoagulants, which nursing intervention is the priority when discontinuing an IV? A. Inspect the catheter tip after removal B. Apply heat after removal C. Apply pressure to the site for 5-10 minutes D. Wear sterile gloves for the procedure - Solution C. Apply pressure to the site for 5-10 minutes What is the effect of cold when applied to a local area? A. Increases capillary permeability. B. Maintains metabolism. C. Reduces inflammation. D. Increases circulation. - Solution C. Reduces inflammation When a nurse is considering the use of a physical restraint on a patient, what is important for the nurse to understand? A. An MD order is necessary whenever a restraint is used. B. Physical restraints do not cause any harm to the patient. C. It is an independent nursing decision to use a restraint. D. The nurse may put up all four side rails on a patient's bed to ensure safety. - Solution A. An MD order is necessary whenever a restraint is used. What are the factors affecting patient's safety related risk (Select all that apply) A. Environment B. Mobility C. Cognition D. Sensory impairment E. Lifestyle F. Developmental - Solution A. Environment B. Mobility C. Cognition D. Sensory impairment E. Lifestyle F. Developmental What should the nurse wear when discontinuing a patient's IV? A. Gloves and goggles B. Clean gloves C. No gloves D. Sterile gloves - Solution B. Clean gloves What is medical/surgical restraint? A. Used to encourage the patient to stay in their chair. B. A device to prevent the patient from getting out of bed. C. Used to prevent the patient from interfering with treatment. D. A device to prevent the patient from leaving the facility - Solution C. Used to prevent the patient from interfering with treatment. What is the primary effect of local heat therapy? A. Vasoconstriction. B. Inflammation. C. Vasodilation. D. Evaporation - Solution C. Vasodilation. The nurse is assessing the bleeding on a patient who has had a vaginal delivery. What type of precautions should the patient be placed on? A. Standard B. Contact C. Protective D. Droplet - Solution A. Standard The nurse is teaching a group of older adults at an assisted living facility about age-related physiological changes. Which question is the most important to ask this group? A. Are you able to hear the fire alarm in the building? B. Are you able to remember the name of the person you just met? C. Are you able to read your favorite book? D. Are you able to open a jar of pickles? - Solution A. Are you able to hear the fire alarm in the building? Apply warm soaks. B. Restart the IV in another location. C. Turn IV flow off. D. Assess vital signs and lung sounds - Solution C. Turn IV flow off. A patient is receiving IV fluids at 150mL/hr. She begins to complain of shortness of breath (SOB) and has crackles throughout her lung fields. What complication does the nurse suspect? A. Circulatory overload B. Sepsis C. Phlebitis D. Extravasation - Solution A. Circulatory overload Which patient is at highest risk for injury from application of heat or cold? A. A 50-year-old patient with asthma. B. A 60-year-old patient who is unconscious. C. A 9-year-old child with a fractured tibia. D. A 32-year-old patient who is 2 days post-op - Solution B. A 60-year-old patient who is unconscious. When heat is needed deep within tissue, which type of heat application is the most effective? A. Hot water bottle. B. Heating pad. C. Warm moist compress. D. Heat lamp. - Solution C. Warm moist compress. Which category is a type of Healthcare Acquired infection (HAI) that results from a diagnostic test or procedure? A. Iatrogenic B. Exogenous C. Nosocomial D. Endogenous - Solution A. Iatrogenic What is an example of a portal of entry for germs? A. Skin B. Food C. Water D. Sneezing - Solution A. Skin A patient has a fractured ankle. The nurse knows that application of heat is most effective at what point of the injury? A. Heat will not be effective in treating the injury. B. Only after treating the injury with ice first. C. Only within the first few hours. D. After 24-48 hours. - Solution D. After 24-48 hours. Which action by the elderly patient indicates effective teaching in preventing accidents at home? A. Patient waits for help before moving. B. Patient uses a walker her neighbor gave her. C. Patient removes all scatter rugs. D. Patient stays in bed - Solution C. Patient removes all scatter rugs. What does the term "sterile" mean? A. Completely free from all micro-organisms. B. Surgically scrubbed for 15 minutes. C. Free of transient bacteria. D. Clean - Solution A. Completely free from all micro-organisms. What can the nurse assess using Erik Erikson's theory? A. Developmental tasks B. Social identity C. Moral development D. Self-esteem - Solution A. Developmental tasks What best describes someone's overall view of themself? A. Self concept B. Role performamce A. Moderate B. Mild C. Panic D. Severe - Solution D. Severe Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? A. Self-Care Deficit: Dressing B. Ineffective Coping C. Risk for Injury D. Activity Intolerance - Solution C. Risk for Injury Which instruction should the nurse include when providing discharge teaching for a patient with a serious visual deficit? A. Install blinking lights to alert an incoming phone call. B. Have gas appliances inspected regularly to detect gas leaks. C. Wear properly fitting shoes and socks. D. Avoid using throw rugs on the floors. - Solution D. Avoid using throw rugs on the floors. A patient with a hearing impairment comes into the clinic for treatment. What action should the nurse take to enhance communicating with this patient? A. Shout. B. Talk into the most affected ear. C. Use touch to get the client's attention. D. Drop the voice at the end of a sentence. - Solution C. Use touch to get the client's attention. Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? A. Limit oral hygiene to one time a day. B. Teach the patient to combine foods in each bite. C. Assess for sores or open areas in the mouth. D. Instruct the patient to avoid salt substitutes. - Solution C. Assess for sores or open areas in the mouth. Which intervention is helpful when caring for a patient with impaired vision? A. Suggest the patient use bright overhead lighting. B. Advise the patient to avoid wearing sunglasses when outdoors. C. Do not offer large-print books, as this may embarrass the patient. D. Place the patient's eyeglasses within easy reach. - Solution D. Place the patient's eyeglasses within easy reach. A nurse provides care to a patient with a visual impairment. Which intervention should the nurse include in this patient's plan of care? A. Call the patient by name. B. Speak loudly to the patient. C. Touch the patient before speaking to the patient. D. Position herself to the side of the patient. - Solution A. Call the patient by name. A nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? A. Encouraging family members to visit only during the day. B. Applying wrist restraints during periods of agitation. C. Playing soft, calming music during the evening. D. Administering lorazepam (a tranquilizer). - Solution C. Playing soft, calming music during the evening You walk into your patient's room, you wake them up by tapping them on the shoulder. They awake easily, what sleep cycle stage can you assume they were in prior to waking? :A. NREM Stage I B. NREM Stage II C. NREM Stage III D. REM - Solution B. NREM Stage II What can you recommend to your patient to improve their "sleep hygiene"? :A. To take a cold shower prior to bed. B. If they cannot fall alseep after 30 minutes, to go for a run. C. Utilize a nightlight if they feel nervous in the dark. D. Avoid napping during the day. - Solution D. Avoid napping during the day. You are home health nurse visiting a patient. He states that he sleepwalks. What are you most concerned about? A client from a non-American culture says that to maintain health there needs to be a balance between the body and nature. Which health belief system does this client follow? A. Scientific B. Biomedical C. Magico-religious D. Holistic - Solution D. Holistic What is acculturation? A. Belief held by an individual or group that all/most members of a particular culture, subculture, ethnic group, or race behave in the same way. B. The degree to which a particular ethnic group adopts the values, attitudes, beliefs, and practices of the dominant culture. C. Classification of people according to shared biological characteristics. D. A culture's sense of affiliation by it's common practices and heritage. - Solution B. The degree to which a particular ethnic group adopts the values, attitudes, beliefs, and practices of the dominant culture. Which of the following statements made by an older adult whose husband recently died most indicates the need for follow-up by the nurse? A. "I planted a tree at church in my husband's honor." B. "I have been unable to talk with my children lately." C. "My friends think that I need to go to a grief support group." D. "I believe that someday I'll meet my husband in heaven." - Solution B. "I have been unable to talk with my children lately." A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patient's religious affiliation, which action should the nurse take? A. Administer the medication as prescribed. B. Hold the medication until after Yom Kippur. C. Explain the importance of taking the medication despite the holiday. D. Ask the physician to change the route of administration. - Solution D. Ask the physician to change the route of administration. When performing a spiritual assessment, who is the preferred source of information? A. Durable power of attorney B. Next of kin C. Patient D. Patient's clergyman - Solution C. Patient The nurse, a Roman Catholic, notes that a patient with a terminal illness identifies as being an atheist. What should the nurse do to support this patient's spiritual needs? A. Suggest the chaplain visit with the patient. B. Offer to read Bible passages with the patient . C. Assess the patient's value system and beliefs. D. Explain the importance of religion at end of life. - Solution C. Assess the patient's value system and beliefs. A patient tells the nurse , "I feel that God has abandoned me. I am so angry that I can't even pray." The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? A. Spiritual Distress B. Risk for Spiritual Distress C. Impaired Religiosity D. Moral Distress - Solution A. Spiritual Distress A patient gynecological problem believes she is being punished for having had an abortion as a teenager. What should the nurse do to assist with this patient's spiritual needs? A. Refer her to the hospital chaplain. B. Provide teaching material about the health problem. C. Explain that it is unlikely that the abortion caused the health problem. D. Suggest that the patient forgive herself for an action that occurred when she was a teenager. - Solution A. Refer her to the hospital chaplain. The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which action by the nurse is appropriate? A. Offer a prayer for healing using the nurse's usual words and format. B. Begin the prayer with "Jehovah God" as she always does while avoiding the name of Jesus. C. Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer. D. An 85-year-old Chinese patient is admitted to the hospital for treatment of acute congestive heart failure. The family states that they practice traditional Chinese medicine and had difficulty getting the patient to come to the emergency department. When planning care, what does the nurse needs to do? A. Obtain a list of the herbal medicines the patient takes, so that drug interactions can be prevented. B. Realize that treatment for this patient is likely to be unsuccessful because the patient does not believe in Western medicine. C. Allow the patient to continue taking all herbal remedies without notifying the doctor. D. Educate the patient on the harmful effects of folk-medicine. - Solution A. Obtain a list of the herbal medicines the patient takes, so that drug interactions can be prevented. A patient who is a quadriplegic has been placed on a Clinitron flotation bed for treatment of a decubitus ulcer. The noise of the motorized bed has been keeping him awake, and he is becoming fatigued, agitated, and restless. What would be the nurse's best intervention? A. Inform the physician of the patient's adverse reaction to the bed. B. Tell the patient he must remain on the bed until his decubitus ulcer is healed, and encourage him to try to rest. C. Administer a tranquilizer during the day and sleeping medication at night to help him cope with the noxious sensory stimulus. D. Provide diversional activities during the day, and try to help the patient reinterpret the motor hum as soothing and relaxing at night. - Solution D. Provide diversional activities during the day, and try to help the patient reinterpret the motor hum as soothing and relaxing at night. Mrs. Ray complains of extreme fatigue. She has three children at home ages 8,10 and 12 years. A review of systems reveals no physical problems. Mrs. Ray takes no prescription or over the counter medication except for an occasional acetaminophen for a headache. She recently quit smoking, is trying to "eat healthier", and has started an exercise program. The sleep history reveals no changes in bedtime routine, stress level, or environment, but Mrs. Ray is having trouble falling and staying asleep. The nursing intervention most specific to Mrs. Ray's nursing diagnosis would be to: A. Promote a quiet environment conducive to sleep when Mrs. Ray goes to bed. B. Instruct Mrs. Ray not to exercise during the evening near bedtime. C. Teach Mrs. Ray about symptoms associated with nicotine withdrawal. D. Instruct Mrs. Ray to limit caffeine intake and avoid all caffeine after 4pm. - Solution C. Teach Mrs. Ray about symptoms associated with nicotine withdrawal. Which foods would be contraindicated in the diet of the Orthodox Jewish client? A. Fish with fins B. Vegetables C. Milk separated from meat D. Pork - Solution D. Pork Mrs. Ray complains of extreme fatigue. She has three children at home ages 8,10 and 12 years. A review of systems reveals no physical problems. Mrs. Ray takes no prescription or over the counter medication except for an occasional acetaminophen for a headache. She recently quit smoking, is trying to "eat healthier", and has started an exercise program. The sleep history reveals no changes in bedtime routine, stress level, or environment, but Mrs. Ray is having trouble falling and staying asleep. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: A. Increased exercise B. Nicotine withdrawal C. Caffeine intake D. Environmental changes - Solution B. Nicotine withdrawal The nurse is discussing lack of sleep in a middle-aged adult. What should the nurse assess to determine a possible cause to the lack of sleep? A. Anxiety B. Loud teenagers C. Caring for pets D. Late night television - Solution A. Anxiety Which factor is held in common by many of the world's religions? A. Strict health code, including dietary laws. B. Belief that one must submit to a god or gods. C. Rules prohibiting alcohol consumption. D. Sacred writings that reveal the nature of the Supreme Being. - Solution D. Sacred writings that reveal the nature of the Supreme Being. What is the most effective action by the nurse when delivering spiritual care to a patient? A. Assume that a patient who shares the nurse's religious affiliates has the same beliefs. B. Try to meet the patient's spiritual needs independently. C.