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answer. Red denotes the incorrect answer you provided.
Questions
1
Question 1
Mr. Harris is a 38-year-old single male who works full time for a community police
force. He has lived with bipolar affective disorder type II for 10 years and has a
history of two severe depressive episodes and three hypomanic episodes. He
continues to take antidepressant medication (a selective serotonin re-uptake
inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently
on sick leave from his work while he recovers from surgery to his right knee. He
has developed drainage from the surgical site and is referred to a home care
nurse.
The home care nurse is unfamiliar with details of care for a client with bipolar
disorder. What is the most appropriate first step in planning care for this client?
1)
2)
Rationale: The client is a good source of information about his own care, but a
knowledgeable professional will provide more accurate and general information
3)
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 60-61.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 99-100.
Question 2
Mr. Harris is a 38-year-old single male who works full time for a community police
force. He has lived with bipolar affective disorder type II for 10 years and has a
history of two severe depressive episodes and three hypomanic episodes. He
continues to take antidepressant medication (a selective serotonin re-uptake
inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently
on sick leave from his work while he recovers from surgery to his right knee. He
has developed drainage from the surgical site and is referred to a home care
nurse.
Although the physician has stated that Mr. Harris may bear full weight on his
knee, Mr. Harris tells the nurse that his knee gets very tired and sore if he walks
for too long. What is the best action for the nurse to take to address Mr. Harris
concern?
1)
Rationale: A referral to the appropriate service would facilitate his mobility and
address his concerns.
2)
Suggest that he decrease his activities and elevate his knee on a pillow.
3)
Rationale: This is false reassurance and does not address the clients concerns
with mobility.
4)
Rationale: Although this would help with the clients socialization, it does not
directly address his immediate concerns with mobility.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 28.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 2042.
Question 3
Mr. Harris is a 38-year-old single male who works full time for a community police
force. He has lived with bipolar affective disorder type II for 10 years and has a
history of two severe depressive episodes and three hypomanic episodes. He
continues to take antidepressant medication (a selective serotonin re-uptake
inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently
on sick leave from his work while he recovers from surgery to his right knee. He
has developed drainage from the surgical site and is referred to a home care
nurse.
Mr. Harris tells the nurse that he is thinking about stopping his antidepressant
because it is interfering with his sexual enjoyment. What is the nurses best
action in this situation?
1)
2)
3)
Rationale: This is unnecessary as the central cause of the problem is the drug.
4)
References:
Abrams, A. C., Pennington, S. S., & Lammon, B. (2007). Clinical drug therapy:
Rationales for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 176-178.
Brophy, K. M., Scarlett-Ferguson, H., & Webber, K. S. (2008). Clinical drug therapy
for Canadian practice (1st Canadian ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 177-183.
Question 4
Mr. Harris is a 38-year-old single male who works full time for a community police
force. He has lived with bipolar affective disorder type II for 10 years and has a
history of two severe depressive episodes and three hypomanic episodes. He
continues to take antidepressant medication (a selective serotonin re-uptake
inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently
on sick leave from his work while he recovers from surgery to his right knee. He
has developed drainage from the surgical site and is referred to a home care
nurse.
Mr. Harris reports that his antidepressant is causing dry mouth and occasional
episodes of diarrhea. What initial suggestion should the nurse make to the client?
1)
2)
3)
4)
References:
Abrams, A. C., Pennington, S. S., & Lammon, B. (2007). Clinical drug therapy:
Rationales for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 176-178.
Brophy, K. M., Scarlett-Ferguson, H., & Webber, K. S. (2008). Clinical drug therapy
for Canadian practice (1st Canadian ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, p. 183.
Question 5
Mr. Harris is a 38-year-old single male who works full time for a community police
force. He has lived with bipolar affective disorder type II for 10 years and has a
history of two severe depressive episodes and three hypomanic episodes. He
continues to take antidepressant medication (a selective serotonin re-uptake
inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently
on sick leave from his work while he recovers from surgery to his right knee. He
has developed drainage from the surgical site and is referred to a home care
nurse.
Mr. Harris father dies suddenly. Shortly after the funeral, the nurse visits Mr.
Harris. He states that he does not want to see anybody, feels no enjoyment in
anything, and feels hopeless and useless. What is the most pertinent question for
the nurse to ask during the visit?
1)
Rationale: It is important to show empathy, but this is not the most pertinent
question given his symptom cluster.
2)
Rationale: The question is too vague and non-specific. He may not ask for help
because he feels helpless and hopeless.
3)
4)
Rationale: This response shows empathy, but is not the most pertinent
question.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 281.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 391.
Question 6
Prior to teaching the session, the nurse wants to identify the learning needs of
participants. Which action would be most effective in identifying these learning
needs?
1)
Organize a group discussion with the students about the effects of
tobacco.
2)
Consult with a band elder about the learning needs of adolescents who
smoke.
Rationale: The learning needs identified for one group of learners are not
necessarily relevant to the current group. The data collection needs to be more
specific.
3)
Consult with the high school teacher about the students current
knowledge level.
Rationale: The high school teacher could be a good resource but learners are
the best source of information about their learning needs.
4)
Rationale: Reference to the literature is helpful, but will not necessarily identify
the needs of this specific group of learners.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 349-350.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 320-324.
Question 7
Which approach should the nurse use to interest these students in smoking
cessation?
1)
Ask one of the non-smoking students to explain her decision not to smoke.
2)
3)
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 683.
Question 8
The nurse wants to explore with the students the cultural significance of tobacco
use. Which approach would most effectively meet this goal?
1)
Quiz the participants about cultural practices associated with tobacco use.
2)
Have a respected elder speak about the cultural practices associated with
tobacco use.
3)
Research and provide an interpretation of cultural practices involving
tobacco use.
4)
Ask the teacher to explain usual cultural practices involving tobacco use.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 345-350.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 323, 328.
Question 9
Several students in the group are successful in their plans to stop smoking.
These students express an interest in promoting non-smoking among their
classmates. Which action should the nurse suggest as the most effective in
promoting non-smoking among the student population?
1)
Rationale: Although the school official can affect a policy about smoking in the
school setting, this policy will likely have little effect on student health
behaviours.
2)
Rationale: The nurse can provide information about non-smoking, but may not
be the most effective lobbyist with other students.
3)
4)
Rationale: Former smokers will carry little importance if they are not part of the
adolescent peer group.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 358.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 331-333.
10
Question 10
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion.
She is admitted to the hospital for observation. On admission, her husband tells
the nurse that his wife has been taking a number of different medications over
the past 3 months. It is suspected that Mrs. Marchand has been overmedicated.
Babinskis reflex
2)
Visual acuity
3)
Mental status
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 661.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 1928.
11
Question 11
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion.
She is admitted to the hospital for observation. On admission, her husband tells
the nurse that his wife has been taking a number of different medications over
the past 3 months. It is suspected that Mrs. Marchand has been overmedicated.
RR 10 breaths/min
2)
3)
4)
HR 100 beats/min
Rationale: This pulse rate is still within the acceptable range. Slight elevation
may be due to anxiety.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 433.
Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia,
PA: Wolters Kluwer Health, p. 451.
12
Question 12
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion.
She is admitted to the hospital for observation. On admission, her husband tells
the nurse that his wife has been taking a number of different medications over
the past 3 months. It is suspected that Mrs. Marchand has been overmedicated.
Rationale: It may be difficult for Mrs. Marchand to set her own schedule because
she is confused.
2)
Rationale: The nurse must allow Mrs. Marchand adequate time to perform care.
This will foster independence for Mrs. Marchand.
3)
Rationale: It may be difficult for Mrs. Marchand to select her own menus
because she is confused.
4)
Rationale: Having Mr. Marchand assist does not allow Mrs. Marchand
independence within her present limitations.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 710-711.
Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia,
PA: Wolters Kluwer Health, p. 108.
13
Question 13
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion.
She is admitted to the hospital for observation. On admission, her husband tells
the nurse that his wife has been taking a number of different medications over
the past 3 months. It is suspected that Mrs. Marchand has been overmedicated.
Mr. Marchand is distressed by the news of his wifes discharge and tells the nurse
that he is afraid to take her home. Mr. Marchand is concerned that his wife will
take too many pills again. Which response by the nurse best demonstrates
advocacy?
1)
I understand your concerns. However, in her home environment she will
function much better.
2)
If you are still feeling afraid, you can always call a community health
nurse to assist you with medications.
3)
If you are worried about her medications, would you consider placing
your wife in a long-term care facility?
4)
You seem worried. Would you like to meet with the home care nurse so
you may discuss your concerns?
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 373.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 100.
14
Question 14
2)
3)
4)
References:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders,
pp. 1359-1360.
15
Question 15
Mr. Jones systolic BP drops below 80 mmHg and his pulse increases. He appears
grey with diaphoresis. After administering oxygen, what should the nurse do
next?
1)
Rationale: This is important because the client will most likely receive IV fluids
and medications necessary to prevent circulatory collapse.
2)
Rationale: This will likely need to be done, but it is not the priority. The priority
is to prevent circulatory collapse.
3)
4)
References:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p.
1495.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, pp. 773-775.
16
Question 16
Two days later, Mr. Jones begins to verbalize feelings of despair about his illness.
He states, I will never be able to return to work. Which statement should the
nurse record in the care plan to reflect Mr. Jones present problem?
1)
Rationale: No mention is made that the client is anxious about being in hospital.
2)
Rationale: The client has decreased feelings of control over his present situation
and future outcomes.
3)
Rationale: This does not capture the sense of what the client expressed.
4)
Rationale: This does not capture the sense of what the client expressed.
References:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p.
1561.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 733.
17
Question 17
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son
is not breathing. She tells the ambulance attendant that when she went in to
feed him, he was blue and she could not wake him up. Her husband is out of
town on business. The baby is dead on arrival at the hospital.
In order to establish a rapport with Mrs. Spencer, which action by the emergency
nurse would be most appropriate?
1)
Rationale: Providing Mrs. Spencer with a calming environment where she is not
alone will assist in establishing a warm, caring relationship in a time of crisis.
2)
3)
Rationale: This focuses on the nurse and ignores the client. Establishing a
therapeutic relationship is more important.
4)
References:
James, S. R., & Ashwill, J. W. (2007). Nursing care of children: Principles and
practice (3rd ed.). St. Louis, MO: Elsevier Saunders, p. 636.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p.
683.
18
Question 18
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son
is not breathing. She tells the ambulance attendant that when she went in to
feed him, he was blue and she could not wake him up. Her husband is out of
town on business. The baby is dead on arrival at the hospital.
Mrs. Spencer screams and cries out loudly for her baby. Which action by the
nurse is most appropriate in dealing with this situation?
1)
Rationale: This suggests that crying is the appropriate behaviour and does not
show compassion or understanding.
2)
Rationale: This is not helpful and could cause further emotional outbursts. The
mother should not be left alone.
3)
Rationale: This is supportive, but does not acknowledge the clients feelings.
4)
Rationale: This shows acceptance and understanding of the situation and opens
communication in a supportive way.
References:
Betz, C., & Snowden, L. (2008). Mosbys pediatric nursing reference. St. Louis:
Mosby, p. 660.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p.
681.
19
Question 19
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son
is not breathing. She tells the ambulance attendant that when she went in to
feed him, he was blue and she could not wake him up. Her husband is out of
town on business. The baby is dead on arrival at the hospital.
The nurse recognizes the need for emotional support for Mrs. Spencer. What is
the most appropriate initial action by the nurse?
1)
Rationale: This will be done at a later time after confirmation of the cause of
death.
2)
Rationale: This assumes that Mrs. Spencer would want to have the clergy
involved.
3)
Rationale: It is important to have a support person with the mother because this
is a stressful time. The mother may also feel guilty about her sons death.
4)
References:
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 270.
James, S. R., & Ashwill, J. W. (2007). Nursing care of children: Principles and
practice (3rd ed.). St. Louis, MO: Elsevier Saunders, p. 636.
20
Question 20
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son
is not breathing. She tells the ambulance attendant that when she went in to
feed him, he was blue and she could not wake him up. Her husband is out of
town on business. The baby is dead on arrival at the hospital.
Before Mrs. Spencer leaves the Emergency Department, what is the most
effective strategy to help her appropriately deal with her grief?
1)
Rationale: Mrs. Spencer may not be ready to deal with new information because
she is still absorbing her loss.
2)
3)
4)
References:
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 270.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The
art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, p. 1008.
21
Question 21
Nicholas, 8 years old, has a history of asthma and has been brought to the
Emergency Department by his mother. Nicholas is experiencing shortness of
breath, chest tightness and wheezing.
2)
Fluticasone (Flovent)
3)
Budesonide (Pulmicort)
4)
Rationale: This is a short-acting drug that will provide relief for bronchospasm
by causing bronchodilation and vasodilation.
References:
Lilley, L. L., Harrington, S., Snyder, J. S., & Swart, B. (2007). Pharmacology and
the nursing process in Canada. St. Louis, MO: Elsevier Mosby, pp. 603, 610.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
1451-1456.
22
Question 22
Nicholas, 8 years old, has a history of asthma and has been brought to the
Emergency Department by his mother. Nicholas is experiencing shortness of
breath, chest tightness and wheezing.
The Emergency Department physician orders Nicholas oxygen by mask. How can
the nurse be sure that the appropriate rate of oxygen is being delivered?
1)
Use a Venturi mask to deliver oxygen at specific concentrations and then
wean as his condition improves.
Rationale: A Venturi mask may cause Nicholas to feel afraid that he will
suffocate. A Venturi mask is also used on clients who need 35-60% oxygen or a
flow rate of 6-10 mL/minute.
2)
Monitor arterial blood gases and adjust the rate of oxygen flow to maintain
PaO2 above 100 mmHg.
3)
Monitor oxygen saturation and adjust the rate of oxygen flow to maintain
results above 95%.
4)
Begin by delivering oxygen at 70% and then reduce the concentration as
dyspnea diminishes.
References:
Wilkinson, J. M., & Van Leuven, K. (2007). Fundamentals of nursing: Theory,
concepts and applications. Philadelphia, PA: F. A. Davis Company, p. 868.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p.
1408.
23
Question 23
Nicholas, 8 years old, has a history of asthma and has been brought to the
Emergency Department by his mother. Nicholas is experiencing shortness of
breath, chest tightness and wheezing.
24.2 mg
Rationale: The dose is too small. The formula is daily dose/3 = weight x 40
mg/day.
2)
72.8 mg
Rationale: The dose is too small. The formula is daily dose/3 = weight x 40
mg/day.
3)
242 mg
4)
728 mg
References:
Elkin, M. K., Perry, A. G., & Potter, P. A. (2007). Nursing interventions and clinical
skills (4th ed.). St. Louis, MO: Elsevier Health Sciences, p. 373.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The
art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, p. 373.
24
Question 24
Nicholas, 8 years old, has a history of asthma and has been brought to the
Emergency Department by his mother. Nicholas is experiencing shortness of
breath, chest tightness and wheezing.
Nicholas' condition has improved and the nurse is teaching him how to
administer his medications by metered dose inhaler (MDI). What should the
nurse consider when planning the teaching session?
1)
2)
3)
4)
References:
Leifer, G. (2007). Introduction to maternity and pediatric nursing (5th ed.). St.
Louis, MO: Elsevier, pp. 432-434.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p.
943.
25
Question 25
Nicholas, 8 years old, has a history of asthma and has been brought to the
Emergency Department by his mother. Nicholas is experiencing shortness of
breath, chest tightness and wheezing.
What is the best way to assess if Nicholas is administering his metered dose
inhaler (MDI) correctly?
1)
Monitor the number of doses that he administered before emptying the
canister.
Rationale: He may have been removing medication from the canister but not
using the MDI correctly.
2)
3)
Observe him using the MDI, looking for vapour after inhalation.
4)
References:
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 678.
deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St.
Louis, MO: Elsevier, p. 124.
26
Question 26
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has
been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and
morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain.
The nurse provides information to Mrs. Smith about pain. Which statement is
correct regarding pain?
1)
Rationale: Very few people lie about the severity of the pain.
2)
3)
People need pain medication when they are awake and asleep.
4)
References:
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The
art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 1390-1391.
27
Question 27
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has
been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and
morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain.
Today, Mrs. Smith rates her pain as 8 on a scale of 0 to 10. She states that she is
comfortable when her pain level is 3. During the past 48 hours, Mrs. Smith has
taken 10 mg p.o. morphine q.4h. What should the nurse do initially to assist Mrs.
Smith in managing her pain?
1)
2)
Recommend to Mrs. Smith that she take her breakthrough doses of
morphine.
3)
4)
Remind Mrs. Smith that the pain medication will never relieve all her pain.
References:
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The
art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, p. 1394.
28
Question 28
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has
been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and
morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain.
Mrs. Smith tells the nurse that she has heard from her friend that nonpharmacological methods of pain relief are better than pharmacological
methods. She wants to stop all her pain medication and use only guided imagery
to relieve her pain. What type of information should the nurse give Mrs. Smith?
1)
Non-pharmacological measures are best used in combination with
pharmacological measures.
2)
The effectiveness of non-pharmacological measures for pain management
has been well researched.
3)
Non-pharmacological measures should be used instead of ineffective
pharmacological measures.
4)
Non-pharmacological measures must be performed by professionals
trained in these areas.
References:
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The
art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 1388-1390.
29
Question 29
Jane, 18 years old, is brought to the hospital by her mother after she
intentionally slashed her left wrist. Janes mother tells the nurse that prior to this
incident her daughter had been distraught over a breakup with her boyfriend.
As the nurse is assessing Janes wounds, Jane expresses a desire to kill herself.
She is to be admitted to the psychiatric unit for observation. What is the
appropriate sequence of nursing actions?
1)
Dress the wounds, ensure that Jane cannot harm herself and prepare her
for admission.
Rationale: When in question, client safety should always be dealt with first.
2)
Ensure that Jane cannot harm herself, prepare her for admission and dress
the wounds.
3)
Ensure that Jane cannot harm herself, dress the wounds and prepare her
for admission.
4)
Dress the wounds, prepare Jane for admission and ensure that she cannot
harm herself.
Rationale: When in question, client safety should always be dealt with first.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 334-338.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 271-274.
30
Question 30
Jane, 18 years old, is brought to the hospital by her mother after she
intentionally slashed her left wrist. Janes mother tells the nurse that prior to this
incident her daughter had been distraught over a breakup with her boyfriend.
On admission to the psychiatric unit, what should the nurse do after completing
the initial assessment?
1)
2)
Rationale: This is the first step following the initial assessment and forms the
clients database.
3)
4)
Rationale: This is inappropriate since Jane recently broke up with her boyfriend.
Also, this would not be done after completing the initial assessment.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 24.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 234-235.
31
Question 31
Jane, 18 years old, is brought to the hospital by her mother after she
intentionally slashed her left wrist. Janes mother tells the nurse that prior to this
incident her daughter had been distraught over a breakup with her boyfriend.
Jane begins to cry while the nurse is dressing the wrist wound. What is the most
appropriate nursing response?
1)
I see you are crying. Would you like to talk about it?
2)
Rationale: Why questions may be legitimate, but often make the client feel
threatened. They may cause the client to become defensive or protective. A
better approach is to rephrase the why question to be less direct.
3)
Rationale: This assumes that the client is crying due to physical pain.
4)
Rationale: This does not demonstrate the nurses awareness of the clients
feelings.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 334-338.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 259-260.
32
Question 32
Jane, 18 years old, is brought to the hospital by her mother after she
intentionally slashed her left wrist. Janes mother tells the nurse that prior to this
incident her daughter had been distraught over a breakup with her boyfriend.
The nurse finds Jane with the dressing removed and the wound bleeding
profusely. What should the nurse do first?
1)
2)
3)
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, pp. 2164-2168.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 1323.
33
Question 33
Jane, 18 years old, is brought to the hospital by her mother after she
intentionally slashed her left wrist. Janes mother tells the nurse that prior to this
incident her daughter had been distraught over a breakup with her boyfriend.
Dilated pupils
2)
3)
4)
Rationale: The pulse often becomes rapid and thready with shock.
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, pp. 303-308.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1643.
34
Question 34
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He
and his wife immigrated to Canada 5 years ago from Hong Kong. They speak
very little English, and Mr. Wong avoids talking to the nursing staff.
When caring for Mr. Wong, what should the nurse consider?
1)
Rationale: This stereotypes people based on their country of origin. They may
have the same language but not all members of a culture will share the same
beliefs. The nurse needs to assess each individuals beliefs prior to adapting
care.
2)
3)
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 317-319.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 120-121.
35
Question 35
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He
and his wife immigrated to Canada 5 years ago from Hong Kong. They speak
very little English, and Mr. Wong avoids talking to the nursing staff.
When caring for Mr. Wong, the nurse recognizes that some of her common
gestures and expressions may be offensive or misunderstood. Which statement
best describes the nurses approach?
1)
The nurse should be sensitive to how her behaviours may be perceived by
Mr. Wong.
Rationale: Nurses who recognize key concepts of other cultures can be more
effective and demonstrate a greater understanding of clients from other cultures.
2)
The nurse should not be expected to change her way of giving care to suit
a clients beliefs.
3)
The nurse must ensure that her caregiving meets hospital protocol and
policy.
Rationale: This is inaccurate; care is done to meet client needs and not
protocols or policy, although those boundaries exist to delineate standards.
4)
The nurse should advise Mr. Wongs family to provide him with a
translator.
Rationale: This puts the responsibility on the family and takes it away from the
nurse.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 317-319.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 136-138.
36
Question 36
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He
and his wife immigrated to Canada 5 years ago from Hong Kong. They speak
very little English, and Mr. Wong avoids talking to the nursing staff.
The nurse is assisting Mr. Wong into a wheelchair and explaining that he is going
for an abdominal series X-ray. He is shaking his head and speaking quickly in a
language the nurse does not understand. His family has gone home. What should
the nurse do to ensure Mr. Wong understands the procedure?
1)
him.
Call his wife so she can talk to him, calm him down and explain the test to
Rationale: This assumes that his wife could explain the medical test so he could
give informed consent. Use of a family member as an interpreter can be
culturally inappropriate.
2)
Wait until he becomes calm and then assist him into the wheelchair.
Rationale: This does not address Mr. Wongs concern, nor does it ensure that he
understands what the procedure involves.
3)
Notify the Radiology Department that Mr. Wong is not well-informed about
the procedure.
Rationale: This is not the problem; the client needs to understand the test so he
can consent. He is indicating no by shaking his head, which cannot be ignored.
4)
Contact a person who is able to translate and then explain the procedure.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 320.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 144.
37
Question 37
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He
and his wife immigrated to Canada 5 years ago from Hong Kong. They speak
very little English, and Mr. Wong avoids talking to the nursing staff.
What is the benefit of providing Mr. Wong with a back rub during evening care?
1)
2)
3)
To relax muscles
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 718-719.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1033.
38
Question 38
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He
and his wife immigrated to Canada 5 years ago from Hong Kong. They speak
very little English, and Mr. Wong avoids talking to the nursing staff.
What best describes appropriate skin care to prevent anal excoriation due to the
diarrhea Mr. Wong is experiencing?
1)
Rationale: The dry tissue is abrasive and would add to the irritation.
2)
3)
Rationale: This would cleanse the irritated area and provide protection.
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1009.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1430.
39
Question 39
Chantelle, 16 years old, comes to the womens health centre 2 weeks following
the completion of screening for sexually transmitted infections (STIs). The
screening results were positive for gonorrhea and Chlamydia.
The nurse wants to provide information that will assist Chantelle to reduce her
future risk for pregnancy and sexually transmitted infections. What is the most
realistic and effective option to reduce these risks?
1)
2)
Rationale: This is the most realistic option because it does not eliminate the
choice for sexual intercourse. It is also the most effective means of preventing
STIs and pregnancy.
3)
Rationale: The withdrawal method will not eliminate the risk of STIs. A small
amount of seminal fluid is released during the excitement phase and prior to
ejaculation. This method will not provide protection against human
papillomavirus (HPV) or infections transmitted via open lesions on the genitals
(e.g., herpes, syphilis).
4)
Rationale: Pregnancy can occur with outer genital contact if seminal fluid is
introduced into the vaginal opening. STIs, such as HPV and those transmitted via
open lesions on the genitals, are still a risk.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 671, 1377.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 466-470.
40
Question 40
Chantelle, 16 years old, comes to the womens health centre 2 weeks following
the completion of screening for sexually transmitted infections (STIs). The
screening results were positive for gonorrhea and Chlamydia.
Chantelle reveals that she has been sexually active for the past year and that
she has had several different sexual partners. What is the best approach to help
Chantelle reduce her vulnerability for future sexual health problems?
1)
Inform Chantelle of the risks she is taking by having unprotected sex with
multiple partners.
2)
Explore Chantelles beliefs about the benefits and risks associated with
high-risk sexual behaviours.
Rationale: This non-judgmental approach does not imply that Chantelle has
been engaging in high-risk behaviours, and explores her perceptions of possible
benefits of having multiple partners. Chantelles rationale for her behaviour
might provide clues about the possible existence of unresolved developmental
tasks.
3)
Encourage Chantelle to discuss her sexual activities with a supportive
friend.
Rationale: Most females of this age will talk to a friend who may not have
accurate information. The nurse needs to provide accurate information.
4)
Give Chantelle some pamphlets on how to protect herself from STIs and
unwanted pregnancy.
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 468-469.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
120-121, 68-69.
41
Question 41
Chantelle, 16 years old, comes to the womens health centre 2 weeks following
the completion of screening for sexually transmitted infections (STIs). The
screening results were positive for gonorrhea and Chlamydia.
Chantelle tells the nurse that her current partner does not like to use condoms.
She wants him to use a condom but is afraid that he will leave her if she insists.
What is the most useful intervention?
1)
Assist Chantelle to develop strategies for negotiating with her partner
about condom use.
Rationale: With the history of multiple sexual partners and positive STI
screening results, Chantelle is at high risk for future STIs. The most effective
means of prevention is the consistent and proper use of condoms. Assisting her
to develop strategies will give her the tools to negotiate condom use with
potential future partners.
2)
Explore Chantelles reasons for having sex and her fear of abandonment.
3)
Rationale: This would be helpful information, but it does not address the
immediate problem.
4)
Encourage Chantelle to look for a partner who would be more respectful of
her wishes.
Rationale: This is directive and insensitive and does not consider Chantelles
desire to continue in this relationship.
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 468.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
68-69, 121.
42
Question 42
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he
passed out and was rushed to hospital by a neighbour. Extensive gastric surgery
is required.
During the preoperative interview, the nurse notes that Mr. Nobis uses the
bedpan frequently to pass loose black stools. He appears to be confused, restless
and dehydrated. His pulse rate is increasing, his respirations are rapid and
shallow, and he is hypotensive. What nursing intervention is necessary at this
time?
1)
2)
3)
Rationale: The client is demonstrating early signs of shock. The physician needs
to be advised of his condition, and orders from the physician are needed for
further treatment.
4)
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1643.
Smeltzer, S. C., Bare, B., Hinkle, J. L., & Cheever, K. H. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins, pp. 303-308, 1023-1025.
43
Question 43
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he
passed out and was rushed to hospital by a neighbour. Extensive gastric surgery
is required.
The physician has ordered the insertion of an indwelling urinary catheter. After a
difficult insertion of the catheter, the nurse notes that no urine appears to be
draining. What should the nurse do initially?
1)
2)
Rationale: Removal comes after the placement of the catheter has been
checked.
3)
Rationale: The bladder is not likely to be distended with an n.p.o. for surgery.
4)
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 1366-1370.
Smeltzer, S. C., Bare, B., Hinkle, J. L., & Cheever, K. H. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins, pp. 1286-1287.
44
Question 44
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he
passed out and was rushed to hospital by a neighbour. Extensive gastric surgery
is required.
Mr. Nobis condition deteriorates and his vital signs are worsening. His skin is
cold and pale, and he is disoriented and agitated. His pulse oximetry is 76% and
his BP 85/50 mmHg. What should the nurse do first?
1)
Rationale: At this time, increasing the IV is not the priority and would require
the physicians order.
2)
Administer oxygen.
Rationale: This would be the nurses first action because the client is
demonstrating hypoxia.
3)
Rationale: The physician would be called but it is not the first action.
4)
Continue monitoring.
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 825-826,
925.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1090.
45
Question 45
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he
passed out and was rushed to hospital by a neighbour. Extensive gastric surgery
is required.
The physician has ordered an IV of Ringers lactate at 150 mL/h. Which findings
would indicate a restoration of fluid balance?
1)
Urine output of 500 mL per 24 hours, elevated blood urea nitrogen (BUN),
elevated serum sodium
Rationale: Output remains decreased from normal and the blood work is
elevated, indicating hemoconcentration and fluid volume deficit.
2)
3)
Urine output of 300 mL per 24 hours, BUN normal, increased serum
sodium
4)
References:
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 925, 941.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 1151-1154.
46
Question 46
Rationale: Mouth care should be performed every 4 hours to reduce the risk of
infection.
2)
Allow John to eat his meals in the cafeteria with his family and friends.
3)
Rationale: This needs a physicians order. This is not necessary and increases
risk of bleeding and infection.
4)
Encourage John to eat raw fruits and vegetables that he finds appealing.
References:
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 916.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
1621-1624.
47
Question 47
Which statement by the nurse will help John understand the chemotherapy?
1)
These medications will help to destroy the cancer cells in your body.
2)
These medications stimulate the normal cells to grow faster than the
cancer cells.
3)
There are side-effects from these medications but they can be easily
controlled.
4)
References:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p.
277.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
1620-1630.
48
Question 48
While assisting John with his morning care, the nurse observes that he has
become extremely fatigued. What should the nurse do?
1)
2)
3)
Rationale: This would not relieve the fatigue and may even increase his fatigue
if two nurses are caring for him.
4)
References:
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 962.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 529.
49
Question 49
2)
Move the client who has a fracture from a single room to the two-bed
room, and assign John to the single room.
Rationale: This would be the best solution. This client is not at risk of spreading
or developing an infection.
3)
Move the client who has chickenpox from a single room to the two-bed
room, and assign John to the single room.
Rationale: The client who has chickenpox is still contagious and could infect
others on the unit.
4)
Assign John to the two-bed room with another teenage client with
leukemia.
References:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p.
2121.
Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.).
St. Louis, MO: Elsevier, p. 935.
50
Question 50
Mr. Potter, 62 years old, states that after discussion with his family, he has
decided not to continue with chemotherapy for his terminal cancer. What
response should the nurse make?
1)
Rationale: The nurse is accepting the clients decision without introducing any
value judgment.
2)
3)
Are you very sure that you have considered all the consequences of this
decision?
Rationale: The client indicated that he has made his decision after careful
consideration and the nurse is not accepting this.
4)
Rationale: This option does not accept the clients decision and puts the
physicians wishes before those of the client.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 11.
51
Question 51
When asking a 78-year-old client who wears a hearing aid a question about her
diet, the nurse receives an unrelated answer. What should the nurse do initially?
1)
Rationale: The nurse has assumed that the client heard clearly what was said
without validating that fact by repeating the statement at a slower pace and
lower pitch.
2)
Rationale: The ability to hear high frequency sounds decreases with age. The
older adult hears a slower, lower-pitched voice best.
3)
4)
Rationale: This would be done if the client still did not hear the question after
repeating it in a slower and deeper voice.
References:
Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, A. (2008). Toward healthy
aging (7th Ed.). St. Louis, MO: Elsevier, p. 560.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 270.
52
Question 52
Meet with each team member separately to try to break the tension.
Rationale: All members of a group need to understand the cause of tension and
work together to resolve it.
2)
Rationale: This will take the focus away from the case. There should be a
separate meeting to address the issue of increasing tension at meetings.
3)
Rationale: The nurse should attempt to resolve the tension before seeking
outside help.
4)
Rationale: The team members should meet to discuss the tension and allow
members to express their feelings. This will help to strengthen the team.
References:
Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships:
Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier
Saunders, pp. 480-482.
Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st
Canadian ed.). Toronto, ON: Elsevier, p. 34.
53
Question 53
Rationale: Rehabilitation efforts should begin with the initial contact with the
client. The client may not be comfortable with the nurse during the initial
contact.
2)
Rationale: Rehabilitation begins with the initial contact with the nurse and is
based on the initial assessment. Rehabilitative therapy may be ordered at any
time.
3)
Rationale: This is when the initial contact with the nurse occurs and when
rehabilitation should be initiated.
4)
References:
deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St.
Louis, MO: Elsevier, p. 399.
Potter, P. A., & Griffin Perry, A. (2007). Basic nursing: Essentials for practice (6th
ed.). St. Louis, MO: Mosby, pp. 28-29.
54
Question 54
Rationale: This may not allow for variation in cultural and religious values.
2)
Rationale: This is not the most appropriate option, since the current groups
needs must be assessed. However, the previous groups needs may be
informative.
3)
Rationale: This allows for the learners to participate and allows the nurse to
develop a learning plan to meet their needs.
4)
Rationale: The nurse is not assessing the learning needs, but simply assuming
the needs of the group.
References:
Bastable, S. (2008). Nurse as educator: Principles of teaching and learning for
nursing practice (3rd ed.). Boston, MA: Jones & Bartlett, p. 97.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 301-302.
55
Question 55
1)
Mrs. Dufour will be taken care of here. This will allow you to spend more
time with her.
2)
I understand that you will miss your wife. Tell me what you mean by not
knowing what to do at home?
Rationale: This response acknowledges the statement made by Mr. Dufour and
correctly asks for clarification.
3)
Mr. Dufour, have you thought about developing a hobby? Tell me about
your interests.
Rationale: This response offers a solution to the stated concern before exploring
the concern with the client.
4)
Mr. Dufour, it sounds as though you feel guilty about not caring for Mrs.
Dufour at home.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 13.
Riley, J. B. (2008). Communication in nursing (6th ed.). St. Louis, MO: Mosby, p.
100.
56
Question 56
Mr. Toth, 64 years old, has advanced multiple sclerosis. He is having difficulty
chewing and swallowing, and frequently chokes and aspirates. The nurse offers
him a soft diet meal and he refuses, stating, I won't eat this. Feed me some real
food. He is fully aware of the implications and consequences of this decision to
continue with a regular diet. What should the nurse do?
1)
2)
Rationale: Continuing to provide the soft diet ignores the clients wishes.
3)
Rationale: Collaborating with family members to convince Mr. Toth to change his
mind is coercive.
4)
Rationale: Collaborating with the physician to write the soft diet as a prescribed
order is ignoring Mr. Toths wishes.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 11.
57
Question 57
Mrs. Andrews, 80 years old, is admitted to a long-term care facility. Mrs. Andrews
is very quiet during the admission procedure and responds to the nurse only
when she is spoken to. While the nurse is helping Mrs. Andrews to unpack her
belongings, Mrs. Andrews begins to cry. How should the nurse respond?
1)
Rationale: Asking the client for an explanation of her feelings does not promote
open communication. Why questions may place the client on the defensive
and are usually a barrier to communication.
2)
3)
Mrs. Andrews, the other residents are happy here. Don't you think you
will be too?
Rationale: This statement diminishes Mrs. Andrews feelings at this time and
focuses on the other clients. This is a barrier to communication.
4)
Rationale: In this statement the nurse is showing empathy for Mrs. Andrews and
is giving her an opportunity to talk about her feelings.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 11.
58
Question 58
What response would be most helpful when a nursing colleague asks for
feedback on her communication skills after having difficulty in dealing with an
aggressive client?
1)
You really preserved his self-esteem. I liked how you handled the
situation, but you were just not firm enough.
2)
I do not feel comfortable giving you feedback. I think feedback about
your performance should come from the supervisor.
3)
You are such a kind person, but in nursing, you need to be able to take
control in situations like this. You need to be more assertive.
4)
I saw that when you called him by his first name, he really relaxed.
Perhaps if you had a firmer tone of voice, he might have listened to you.
References:
deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St.
Louis, MO: Elsevier, p. 131.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby.
59
Question 59
While helping at a career day in a high school, a nurse is approached by a 40year-old teacher who requests a blood pressure assessment. The teacher has
been receiving medical treatment for stress-related hypertension since the
beginning of the school year. What are the priority nursing actions for health
promotion?
1)
Assess blood pressure and refer the teacher to a stress-management
clinic.
2)
Recommend exploring a decreased workload and counselling to manage
stress.
3)
Assess blood pressure and explore current stress management strategies
that the teacher is using.
4)
Recommend exploring a decrease in workload and provide information on
current prescribed medications.
References:
deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St.
Louis, MO: Elsevier, p. 119.
60
Question 60
Rationale: The insulin vial should be rolled between the palms. Shaking may
result in an inaccurate dose.
2)
3)
4)
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
p. 866.
61
Question 61
Geoff is a nurse caring for Mrs. Khan. Mrs. Khans husband states that their
religious beliefs prevent a man from looking after a woman. What should be
Geoffs response to Mr. Khan?
1)
I will speak to the nurse-in-charge to rearrange the assignment so that
your wife has a female nurse.
2)
I appreciate your religious beliefs. However, I assure you that I will
provide respectful care to your wife.
Rationale: This is not an issue of whether Geoff can provide respectful care.
3)
I respect your chosen religion, but it does not comply with my beliefs
about gender equality.
4)
I cannot change the assignment at this time. Perhaps tomorrow we can
find a female nurse.
Rationale: This does not demonstrate sensitivity to the clients stated beliefs. It
implies that the problem is not important and can be deferred to another day.
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
pp. 314-315.
62
Question 62
Health records indicate that there has been a significant decline in the number of
immunizations administered over the past 15 years in a community of 10,000
people. What is the most efficient first step to identify the reason for this decline
in immunizations?
1)
Analyze the age characteristics of the community using the most recent
census data.
Rationale: Census data would provide an efficient means of reviewing the age
profile of the community.
2)
Rationale: Hospital admission data would reflect only occurrences of illness that
necessitated hospitalization, which is a small percentage of the preventable
diseases in question.
3)
Conduct a series of home visits in the community asking about
immunization practices.
4)
Review disease-specific mortality and morbidity data from Statistics
Canada.
References:
Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community:
Community-oriented practice (2nd ed.). Toronto, ON: Mosby, p. 171.
Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st
Canadian ed.). Toronto, ON: Elsevier, p. 38.
63
Question 63
Mr. Clark, 19 years old, is admitted to hospital for pneumonia and has just been
told that he is HIV positive. He asks the nurse not to reveal the diagnosis to his
wife, even if she asks a lot of questions. What should the nurse do initially?
1)
2)
Rationale: This maintains Mr. Clarks privacy and confidentiality as per the Code
of Ethics for Registered Nurses. It is Mr. Clarks responsibility to inform his wife.
The nurses role is to explore with Mr. Clark the process of disclosure.
3)
Inform Mrs. Clark only if she asks about the cause of the pneumonia.
4)
Tell Mr. Clark that he is required to immediately inform his wife of the
diagnosis.
Rationale: It is a breach of the Code of Ethics for Registered Nurses to force Mr.
Clark to tell his wife at this time. The nurses role is to respect his decision and to
create a safe environment for him and not to exert undue influence on him.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, pp. 15-16.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 91.
64
Question 64
The nurse is visiting a family living in city housing adjacent to a landfill site.
During the discussion, the mother states that there are often bad odours that
seep into their apartment building. What is the most important information for
the nurse to collect to complete the assessment?
1)
2)
3)
4)
References:
Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community:
Community-oriented practice (2nd ed.). Toronto, ON: Mosby, pp. 217, 222.
Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st
Canadian ed.). Toronto, ON: Elsevier, pp. 263-264.
65
Question 65
Mrs. Mackay is the caregiver for her 85-year-old father. Mrs. Mackay would like to
take a 2-week vacation with her husband. She approaches the community health
nurse for assistance in accessing community resources. What is the most
appropriate resource for the nurse to suggest to Mrs. Mackay?
1)
Rationale: This is expensive and not the best support for the family.
2)
3)
4)
Rationale: This is a source of support, but not appropriate for the needs of this
family at this time.
References:
Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M.
A. (2006). Medical-surgical nursing in Canada: Assessment and management of
clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 77.
Rice, R. (2006). Home care nursing practice: Concepts and application (4th ed.).
St. Louis, MO: Mosby, p. 447.
66
Question 66
Rationale: This is not an effective strategy and is not the nurses role. Children
and staff have already been exposed.
2)
3)
4)
Test all the children and staff in the daycare centre for pertussis.
References:
Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and
children (8th ed.). St. Louis, MO: Elsevier Mosby, pp. 672-673.
67
Question 67
Mrs. Hatch, 64 years old, has been living with chronic arthritic pain for 3 years.
She reports the pain as 7 out of 10 on a pain scale. Her blood pressure and pulse
are within normal ranges for her age. What does the nurse need to be aware of
in order to accurately understand Mrs. Hatchs pain experience?
1)
Elevated blood pressure and increased pulse rate should accompany her
level of pain.
2)
Her pain tolerance has increased because mental adaptation has occurred.
Rationale: A person with chronic non-cancer pain often does not show overt
symptoms and does not adapt to the pain. Rather the person suffers more
because of mental exhaustion and depression.
3)
4)
Her pain scale rating of 7 is the most reliable indicator of her pain.
Rationale: The clients report of pain is the most reliable indicator of pain
because pain is a subjective experience (American Pain Society).
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarth's textbook of medicalsurgical nursing. (1st Canadian ed.).
Philadelphia, PA: Lippincott Williams & Wilkins, p. 1020.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 234.
68
Question 68
Mr. Lord was discharged from the hospital to home care this morning. The nurse
realizes that she forgot to include important information in the discharge
summary. What is the best action by the nurse to ensure continuity of care with
the home care agency?
1)
Phone Mr. Lord and ask him to give the home care nurse the information.
2)
Document the omission in Mr. Lords hospital record and phone the home
care agency.
3)
4)
Fax an updated discharge summary to the home care agency and follow
up with a phone call.
Rationale: Written communication between agencies is more reliable. A followup phone call would help to ensure that the message was received.
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
pp. 126-128.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 17.
69
Question 69
2)
3)
4)
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
p. 473.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 271.
70
Question 70
During the change of shift report, the nurse notices that a co-worker is using
sarcastic and disrespectful terms to describe the clients. How should the nurse
respond?
1)
Rationale: This creates distrust among team members and administration and
is disrespectful to the co-worker.
2)
3)
4)
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 13.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1661.
71
Question 71
A client with terminal lung cancer informs the nurse of his decision to commit
suicide. He tells the nurse that this is a secret between them. What is the nurses
responsibility?
1)
Rationale: The nurse has a duty to convey information that may result in an
injury to a client or third party.
2)
Respect the confidentiality of information obtained while caring for the
client.
3)
Rationale: The family may be a valuable resource, but the health-care team
must be told.
4)
Rationale: A referral to a support group does not ensure that the client will go,
and the client may commit suicide while waiting to see someone else.
References:
Stuart, G. W., & Laraia, M. T. (2009). Principles and practice of psychiatric nursing
(9th ed.). St. Louis, MO: Elsevier Mosby, pp. 122-123, 137, 326-327.
72
Question 72
Michael, 2 years old, has been admitted with respiratory distress. When the
nurse approaches him to conduct a respiratory assessment, Michael becomes
very upset and starts crying and clinging to his mother, who is also crying. What
is the best action for the nurse to take?
1)
Rationale: This will increase anxiety for the mother and child. It is also not
compatible with principles of traumatic care.
2)
3)
4)
References:
Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships:
Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier
Saunders, pp. 399-401.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 277.
73
Question 73
2)
Rationale: An attempt should be made to resolve the conflict among the group
members.
3)
4)
References:
Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships:
Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier
Saunders, pp. 481-483.
Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice.
Philadelphia, PA: Lippincott Williams & Wilkins, p. 107.
74
Question 74
A 69-year-old man with chronic bronchitis tells the home care nurse that his
dyspnea gets worse only when he attends the pulmonary rehabilitation classes.
He does not want to return to the classes. What is the nurses best approach in
this situation?
1)
Encourage the client to see his physician to assess the change in medical
condition.
2)
Explore with the client other aspects such as medication compliance and
finances.
3)
4)
Rationale: A better approach is to assess the reasons for the clients feelings.
References:
Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships:
Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier
Saunders, p. 201.
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 581.
75
Question 75
Mr. Porter is unconscious following a traumatic brain injury 3 days ago. What is
the most important intervention to optimize his rehabilitation outcome?
1)
2)
3)
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, pp. 1941-1942.
Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., &
Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and
management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p.
1513.
76
Question 76
Julie, 16 years old, is admitted to the pediatric unit after fainting at school. She
recently lost a great deal of weight and will not eat her hospital meals. She
tearfully admits that she has to start eating more but is afraid to do so because
she is too fat. What is the nurses best response?
1)
You are not fat. You are within the normal weight range for your height.
Rationale: This response is very condescending and does not validate Julies
concerns.
2)
You think you are fat? Lets go to the scale and weigh you.
Rationale: This response does not validate Julies concerns, and a scale is the
worst thing a client with anorexia can use.
3)
Rationale: This response validates Julies concern of being fat and encourages
her to continue to speak. The nurse is also demonstrating empathy, which will
help gain the clients trust.
4)
You look fine to me. Look at that pretty young girl in the mirror.
Rationale: This response does not validate Julies concerns and is patronizing. A
mirror is a most stressful place for a client with anorexia.
References:
Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice.
Philadelphia, PA: Lippincott Williams & Wilkins, pp. 104-105.
77
Question 77
As a result of reading research related to the practice setting, the nurse identifies
the need to change some of the existing unit protocols. How should the nurse
initiate the change?
1)
2)
Rationale: This occurs once a decision has been made to institute change.
3)
4)
Rationale: This could occur after a review and critique have been conducted
and administrative approval has been gained.
References:
LoBiondo-Wood, G., Haber, J., Cameron, C., & Singh, M. (2005). Nursing research
in Canada: Methods, critical appraisal, and utilization (1st Canadian ed.). St.
Louis, MO: Mosby, pp. 11-12.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 90.
78
Question 78
Ms. Parker presents to the Emergency Department with her partner, Ms.
Broderick. Ms. Parker has a discoloured and painful contusion to her left
periorbital area. Her partner states that Ms. Parker fell down the stairs the night
before. How should the nurse proceed?
1)
Rationale: An ice pack would be more appropriate. In addition, the client needs
to be screened for abuse if it is suspected.
2)
Ask Ms. Broderick to leave for a few minutes so that the nurse can speak
to Ms. Parker alone.
Rationale: The client should be interviewed alone when there is the slightest
suspicion that the injury does not match the history. All women should be
screened; abuse also occurs in lesbian relationships.
3)
Question Ms. Parker and Ms. Broderick more closely as to the exact nature
of the fall.
Rationale: If Ms. Broderick is the perpetrator, the nurse may not be able to
identify the real cause of the abuse when interviewing both women together.
4)
Rationale: The head injury needs to be assessed fully prior to the administration
of analgesia.
References:
Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice.
Philadelphia, PA: Lippincott Williams & Wilkins, p. 886.
79
Question 79
Rationale: Inborn tolerance may result in excessive alcohol or other drug intake.
2)
Nurses are less at risk for alcoholism than the general population.
Rationale: Nurses are equally at risk for developing substance abuse problems.
3)
4)
References:
Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice.
Philadelphia, PA: Lippincott Williams & Wilkins, pp. 506-507.
80
Question 80
Mrs. Davis, 72 years old, has left-sided hemiparesis and attends daily therapy
sessions to assist with ambulation. She will live with her daughter temporarily.
Family members express concern about how they will meet her needs. Which
action by the nurse will be most effective in preparing them for this role?
1)
Rationale: This information will not prepare the family to meet these goals.
2)
Rationale: Active participation will prepare the family to continue Mrs. Davis
exercises at home.
3)
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 163.
81
Question 81
There has been an outbreak of diarrhea at the daycare centre. What action
should the public health nurse implement to prevent the spread of
gastroenteritis?
1)
Rationale: This is the most important and most basic technique in preventing
and controlling transmission of a communicable disease.
2)
Recommend that all the daycare children be given dextrose-electrolytes
(Pedialyte).
Rationale: This may not be advisable and does not address the present
problem.
3)
Rationale: Disinfecting the play area would not solve the problem.
4)
Recommend that the daycare centre be isolated until the problem is
resolved.
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 799.
82
Question 82
Mrs. Lombardo, 92 years old, is admitted to hospital with abdominal pain. She is
anxious and constantly ringing her call bell. A nurse on the unit overhears a
colleague tell Mrs. Lombardo to use the call bell only if she requires pain
medication. What should the nurse do?
1)
Rationale: The nurse has a responsibility to discuss the incident with the
colleague.
2)
Rationale: This would not be done initially. The nurse should first approach the
colleague and discuss the issue.
3)
4)
Ask Mrs. Lombardo why she is constantly ringing the call bell.
Rationale: This does not address the issue of intervening when there are
questionable actions of colleagues.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, p. 9.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 92, 99.
83
Question 83
A client asks for information on herbal medicine. What information should the
nurse give the client?
1)
2)
Herbal medicines contain natural ingredients that are often more effective.
3)
Rationale: This may not be accurate in all cases and is misleading information
for the client.
4)
Herbal medicine should be used only as a supplement to traditional
medicine.
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2006). Fundamentals of nursing:
Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Prentice-Hall,
pp. 334-335.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 936-937.
84
Question 84
Mr. OConell, a 19-year-old skateboarder, has been treated for a Colles fracture.
He is now ready to go home. What is the most appropriate action to prevent
further injury?
1)
Rationale: There is a risk of re-injury during this time. He should refrain from
skateboarding until healing is complete.
2)
Rationale: The nurse has an opportunity to encourage the client to use safety
measures at a time when the client is more likely to understand their
importance.
3)
Tell him that he should be more careful about the sports he chooses.
Rationale: This does not address the issue of encouraging safety and is not
therapeutic communication.
4)
Tell him that he should have worn wrist guards to prevent this injury.
Rationale: The client is already aware of this. This does not encourage him to
use protective gear in the future.
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
pp. 516-517.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 982.
85
Question 85
Susan, a newly graduated registered nurse, has difficulty completing her work on
time. She feels overwhelmed and is worried that she will miss deadlines for client
care. Which action would be most effective in managing her time?
1)
2)
Rationale: This will increase fatigue. The nurse needs adequate rest periods for
relaxation.
3)
Rationale: This will not help with the issue of time management.
4)
Rationale: Planning is the most important because the nurse needs to learn to
prioritize.
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
pp. 516-517.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 154-155.
86
Question 86
Mr. Bell, 60 years old, is terminally ill. He wishes to say goodbye to his dog but
the nurse in charge tells him that no pets are allowed on the medical unit. What
action is appropriate for Mr. Bells nurse to take?
1)
Apologize to Mr. Bell and explain that nurses must follow hospital policy.
Rationale: Nurses should not passively accept policies that are not in line with
client needs.
2)
Allow the family to bring the dog for a visit late in the evening.
Rationale: This avoids the problem and does not change policy for future clients
who may have similar wishes.
3)
Rationale: Nurses should advocate for their clients and should challenge
policies that are obsolete or inconsistent with client needs.
4)
Suggest that his family meet with the hospital administrator to obtain
permission.
Rationale: Mr. Bells family is dealing with his dying and should not be expected
to fill the role of change agent.
References:
Canadian Nurses Association. (2008). Code of ethics for registered nurses.
Ottawa, ON: Author, pp. 8-9.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 100.
87
Question 87
Coffee club
2)
Baking club
Rationale: Baking may increase the weight of these women, thereby increasing
their risk of injury from osteoporosis.
3)
Walking club
Rationale: Walking will promote strong bones, and walking together will
promote socialization.
4)
Book club
Rationale: Reading and discussion will promote socialization but will not help
with the osteoporosis.
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 2072.
Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., &
Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and
management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p.
1718.
88
Question 88
Marie, 18 years old, is 3 months pregnant. She had a small amount of vaginal
bleeding and her physician has ordered a pelvic ultrasound. What should the
nurse do prior to this test?
1)
Rationale: For the sound waves to reflect best, the client needs to have a full
bladder.
2)
Rationale: This is incorrect information and may increase Maries anxiety. X-rays
are not used in ultrasounds.
3)
Rationale: A full bladder holds the uterus stable and reflects the sound waves
the best.
4)
Rationale: The discomfort is due to the full bladder and the client does not
require an analgesic for this procedure.
References:
Leifer, G. (2007). Introduction to maternity and pediatric nursing (5th ed.). St.
Louis, MO: Elsevier, p. 66.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p.
217.
89
Question 89
Which client would be at the greatest risk for developing testicular cancer?
1)
2)
Rationale: Testicular cancer is the most prevalent form of cancer in men 15-35
years of age. The risk of testicular cancer is greater in men who have had an
undescended testicle.
3)
A 30-year-old man who was hit by a hockey puck in the groin last year
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., &
Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and
management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p.
1462.
90
Question 90
What topic would be most important for a community health nurse to discuss
with a group of parents of toddlers?
1)
Bicycle safety
2)
3)
4)
Water safety
References:
Berman, A. J., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall,
p. 376.
Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and
children (8th ed.). St. Louis, MO: Elsevier Mosby, p. 631.
91
Question 91
When assessing Billy, a 2-year-old Asian Canadian, the nurse notes that his
height and weight fall within the fourth percentile on a growth chart. What is the
appropriate nursing action?
1)
Identify the findings as reflecting failure to thrive and notify the physician.
2)
Discuss the childs diet with the mother and refer the family to a dietitian.
Rationale: It may be appropriate to discuss the diet with the mother. There is no
need to refer to a dietitian at this time.
3)
Recognize that growth charts may not be applicable to all children and
discuss his growth pattern with his parents.
Rationale: Growth charts are based on norms for Caucasian children. A chart
designed for Asian children should be used.
4)
Suspect that the child may have a gastrointestinal problem and notify the
physician so the necessary diagnostic tests can be initiated.
Rationale: In the absence of other data, it is unlikely that the child has a
physiological problem and invasive diagnostic testing of children should be
avoided.
References:
Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and
children (8th ed.). St. Louis, MO: Elsevier Mosby, pp. 166-168.
Leonard Lowdermilk, D., & Perry, E. S. (2006). Maternity nursing (7th ed.). St.
Louis, MO: Elsevier Mosby, pp. 985-990, 1892.
92
Question 92
Ms. Laverty, 69 years old, has an advanced pressure ulcer. She is 160 cm tall and
weighs 72 kg. What food selection would be most effective to help her heal?
1)
Rationale: This provides the high-calorie, high-protein diet needed for healing.
Weight loss is a lower priority until the ulcer is healed.
2)
Rationale: This provides high fibre to manage bowel elimination problems from
immobility, but is not high in protein.
3)
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 181.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1510.
93
Question 93
The nurse has recently taken a position on a Urology Unit. After completing the
unit orientation, the nurse identifies several specific learning needs. What should
be the priority action?
1)
Rationale: This is appropriate, but not the first priority because results are more
long term.
2)
Rationale: This could be appropriate in the future, but the nurse needs a more
concrete learning opportunity.
3)
Rationale: Mentorship facilitates the nurses entry into this field, will help meet
the nurses learning needs and is a long-term strategy.
4)
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 35.
Ross-Kerr, J. C., & Wood, M. J. (2003). Canadian nursing: Issues and perspectives
(4th ed.). Toronto, ON: Elsevier, p. 416.
94
Question 94
Rationale: Clients who have a psychotic illness often have impaired judgment
and may not be able to understand or control sexual impulses, resulting in sexual
activity that may be detrimental to their health. While health teaching is an
important component of the nursing care plan, it does not go far enough.
2)
Ask the client to provide a urine sample for a pregnancy test and suggest
that she refrain from further sexual activity until she speaks to her physician.
Rationale: The client should have a pregnancy test. However, a client who is
suffering from a chronic psychotic illness is unlikely to stop the dangerous sexual
behaviour because of suggestions from the nurse.
3)
Explore the clients knowledge about risky sexual practices and supply her
with birth control pills.
Rationale: Birth control pills will protect the client from pregnancies, if she is
compliant. However, the use of condoms is necessary to protect her from
sexually transmitted infections.
4)
Provide health teaching about safer sex practices, supply the client with
condoms and advise the physician of the clients behaviour.
Rationale: Providing the client with condoms along with health teaching about
safer sex practices is an important nursing intervention. While the client may not
always use a condom, even frequent use will decrease her risk for sexually
transmitted infections. Advising the physician of the clients behaviour will
initiate a plan for administering the appropriate medication.
References:
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 466-469.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.
(2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp.
120-121.
95
Question 95
Mrs. Atkins, 66 years old, had a right total hip replacement yesterday. How
should the nurse position the clients right leg?
1)
Rationale: Leg should not be adducted because this may dislocate the joint.
2)
3)
4)
Rationale: The leg should not be adducted because this may dislocate the joint.
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarth's textbook of medical-surgical nursing (1st Canadian ed). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 2042.
Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., &
Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and
management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p.
1694.
96
Question 96
Ask the police officers to immobilize the client while he is receiving care.
Rationale: The client is verbally aggressive. Asking the police to restrain him
may escalate his aggression.
2)
3)
Rationale: This allows the nurse to assess the client and minimize personal
injury by having the colleague present.
4)
Rationale: The client needs to be assessed to determine the extent of his injury.
References:
Stuart, G. W., & Laraia, M. T. (2009). Principles and practice of psychiatric nursing
(9th ed.). St. Louis, MO: Elsevier Mosby, pp. 575, 578-580.
97
Question 97
Mr. Stinson, 64 years old, has a peripherally inserted central catheter (PICC) for
chemotherapy. What should the nurse do?
1)
2)
3)
Rationale: This would impede the mobility of the clients arm. PICCs are usually
inserted above the antecubital space.
4)
References:
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and
Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia,
PA: Lippincott Williams & Wilkins, p. 1010.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian
fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1317.
98
Question 98
Rationale: This is within the scope of nursing, not the physicians responsibility.
The nurse needs to educate the client.
2)
Rationale: This is not providing any teaching regarding the safe use of
medication and polypharmacy.
3)
Develop a contract with the client that he will not take any of the
medications.
Rationale: The nurse is asking the client to make a decision without adequate
information. Some of the medications may be essential to his health.
4)
Rationale: Ethically, the nurse must provide adequate information on which the
client can base his decision. Counselling can bring about a change in his attitude.
References:
deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St.
Louis, MO: Elsevier, pp. 643, 841-842.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 697-701.
99
Question 99
Insist that one of the nurses on the outgoing shift verify the count with
Rationale: At the end of each shift, controlled drugs are counted by the nurse
on the outgoing shift and the nurse on the incoming shift. Any errors must be
identified and corrected before the outgoing nurses are dismissed.
2)
Perform the count by himself and sign the narcotics record sheet if correct.
3)
Ask a colleague on his shift to co-sign the narcotics record sheet with him.
Rationale: A nurse from the outgoing shift and a nurse from the incoming shift
must do the count together.
4)
Sign the count and clarify the agency policy on narcotics with Sue.
Rationale: To sign that the count was correct without verifying that it is
demonstrates a lack of responsibility.
References:
Craven, R. F., Hirnle, C. J. (2009). Fundamentals of nursing: Human health and
function (6th ed.). Philadelphia, PA: Lippincott Williams Wilkins, p. 504.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., Wood, M. J. (2009). Canadian
fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 678.
100
Question 100
What dietary supplement should the nurse recommend a woman begin taking
prior to conception in order to decrease the incidence of neural tube defects?
1)
Vitamin A
2)
Calcium
3)
Ascorbic acid
4)
Folic acid
Rationale: Studies have shown a link between folic acid deficiency and neural
tube defects. Taking folic acid supplements prior to conception reduces the
occurrence of neural tube defects.
References:
Hockenberry, M. J., & Wilson, D. (2007). Wong's nursing care of infants and
children (8th ed.). St. Louis, MO: Elsevier Mosby, p. 571.
Leonard Lowdermilk, D., & Perry, E. S. (2006). Maternity nursing (7th ed.). St.
Louis, MO: Elsevier Mosby, p. 184.
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