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Safe and Effective Care Environment - CH1 1,4,0<\Number> C<\Answers> Question 1: Which of the following actions is NOT a part of standard precautions for infection control? A) Wearing gloves when in contact with blood or body fluids B) Using a mask and eye protection when splashes or sprays are anticipated C) Washing hands with soap and water after contact with a contaminated surface D) Using a gown when there is a risk of clothing becoming soiled <\Body> Correct Answer: C) Washing hands with soap and water after contact with a contaminated surface Rationale: Standard precautions emphasize hand hygiene using alcohol-based hand rubs or soap and water, not specifically after contact with contaminated surfaces. Hand hygiene should be performed before and after patient contact, as well as after glove removal. <\Explain> 2,4,0<\Number> A<\Answers> Question 2: Which of the following patients requires the use of a respirator mask when providing care under standard precautions? A) A patient with tuberculosis (TB) B) A patient with influenza C) A patient with a common cold D) A patient with a urinary tract infection (UTI) <\Body> Correct Answer: A) A patient with tuberculosis (TB)Rationale: A respirator mask, such as an N95 mask, is required when caring for patients with airborne infections like TB. <\Explain> 3,4,0<\Number> B<\Answers> Question 3: Which standard precaution is most important to prevent the transmission of healthcare-associated infections? A) Wearing gloves B) Using hand hygiene C) Using gowns D) Wearing masks <\Body> Correct Answer: B) Using hand hygiene Rationale: Hand hygiene is the single most important practice to prevent the transmission of healthcare-associated infections. <\Explain> 4,4,0<\Number> C<\Answers> Question 4: When should healthcare workers perform hand hygiene using soap and water instead of alcohol-based hand rubs? A) Before eating a meal B) After routine patient contact C) When hands are visibly soiled D) After using the restroom <\Body> Correct Answer: C) When hands are visibly soiled Rationale: Soap and water should be used when hands are visibly soiled or contaminated with blood, body fluids, or other potentially infectious materials. <\Explain> 5,4,0<\Number> A<\Answers> Question 5: Which of the following actions is NOT a part of standard precautions when caring for a patient with a contagious infection? A) Using a separate bathroom for the patient B) Proper disposal of contaminated sharps C) Wearing gloves when handling contaminated items D) Placing the patient in isolation <\Body> Correct Answer: A) Using a separate bathroom for the patient Rationale: Standard precautions do not require a separate bathroom for the patient. Isolation precautions may be necessary depending on the specific infectious agent. <\Explain> 6,4,0<\Number> C<\Answers> Question 6: In the event of a fire in a healthcare facility, which action should the nurse prioritize first? A) Evacuate all patients immediately B) Attempt to extinguish the fire C) Activate the fire alarm system D) Secure all patient medical records <\Body> Correct Answer: C) Activate the fire alarm system Rationale: Activating the fire alarm system is the first step in ensuring the safety of all individuals in the facility. It alerts others to the presence of a fire and initiates the appropriate emergency response. <\Explain> 7,4,0<\Number> B<\Answers> Question 7: During a hospital evacuation, which patients should be evacuated first? A) Patients on the second floor B) Patients in critical condition C) Pediatric patients D) Ambulatory patients <\Body> Correct Answer: B) Patients in critical condition Rationale: Patients with critical conditions who are unable to move independently should be evacuated first to ensure their safety and timely medical care. <\Explain> 8,4,0<\Number> C<\Answers> Question 8: What is the primary goal of the "RACE" protocol in fire emergency response? A) Remove all patients from the affected area B) Activate the fire alarm system C) Confine the fire to a limited area D) Extinguish the fire using fire extinguishers <\Body> Correct Answer: C) Confine the fire to a limited area Rationale: The "RACE" protocol stands for Rescue, Alarm, Confine, and Extinguish. Its primary goal is to confine the fire to a limited area to prevent its spread. <\Explain> 9,4,0<\Number> A<\Answers> Question 9: In the event of a hazardous chemical spill in the healthcare facility, what should the nurse do first? A) Evacuate the area B) Ventilate the room C) Contact the hazardous materials team D) Assess the patients in the area <\Body> Correct Answer: A) Evacuate the area Rationale: Safety should be the top priority, and evacuating the area ensures that individuals are removed from potential harm due to the hazardous chemical spill. <\Explain> 10,4,0<\Number> C<\Answers> Question 10: When caring for a patient during a disaster or emergency situation, what is the nurse's primary responsibility? A) Administering medications as scheduled B) Documenting the patient's vital signs C) Ensuring the patient's safety and well-being D) Contacting the patient's family <\Body> Correct Answer: C) Ensuring the patient's safety and well-being Rationale: During a disaster or emergency, the nurse's primary responsibility is to ensure the safety and well-being of the patient. <\Explain> 11,4,0<\Number> B<\Answers> Question 11: When assessing a client for allergies, which question should the nurse prioritize? A) "Do you have any food preferences?" B) "Have you ever had a reaction to medications or foods?" C) "What is your favorite season of the year?" D) "Have you traveled outside the country recently?" <\Body> Correct Answer: B) "Have you ever had a reaction to medications or foods?" Rationale: This question directly addresses the client's history of allergic reactions, which is crucial information for ensuring their safety during healthcare interventions. <\Explain> 12,4,0<\Number> B<\Answers> Question 12: A client reports a history of seasonal allergies. Which type of allergen is the client likely sensitive to? A) Latex B) Pollen C) Shellfish D) Dust mites <\Body> Correct Answer: B) Pollen Rationale: Seasonal allergies often result from sensitivity to pollen from trees, grasses, or weeds. <\Explain> 13,4,0<\Number> C<\Answers> Question 13: While assessing a pediatric patient for allergies, the nurse should inquire about a family history of: A) Employment history B) Travel experiences C) Allergic reactions D) Favorite foods <\Body> Correct Answer: C) Allergic reactions Rationale: Family history of allergic reactions can help identify potential genetic predispositions to allergies in the pediatric patient. <\Explain> 14,4,0<\Number> B<\Answers> Question 14: A client with a known penicillin allergy is prescribed a new medication. What should the nurse do first? A) Administer the new medication as prescribed B) Consult with the healthcare provider regarding an alternative medication C) Assess the client's vital signs D) Notify the pharmacy for a medication review <\Body> Correct Answer: B) Consult with the healthcare provider regarding an alternative medication Rationale: When a client has a known allergy, the nurse should consult with the healthcare provider to explore alternative medications that are safe for the client. <\Explain> 15,4,0<\Number> B<\Answers> Question 15: What is the primary purpose of using a skin-prick test when assessing for allergies? A) To determine the severity of an allergic reaction B) To identify the specific allergen triggering the response C) To administer allergy medications D) To assess the client's overall health <\Body> Correct Answer: B) To identify the specific allergen triggering the response Rationale: Skin-prick tests are used to identify the specific allergen causing an allergic reaction in a client. <\Explain> 16,4,0<\Number> B<\Answers> Question 16: Before performing a procedure on a client, what is the nurse's primary action to ensure correct client identification? A) Ask the client's roommate for confirmation B) Verify the client's identity using two unique identifiers C) Check the medical record after the procedure D) Rely on the client's verbal confirmation <\Body> Correct Answer: B) Verify the client's identity using two unique identifiers Rationale: Verifying the client's identity using two unique identifiers, such as name and date of birth, is a critical safety measure to prevent errors during procedures. <\Explain> 17,4,0<\Number> C<\Answers> Question 17: Which of the following is NOT considered a valid unique identifier when verifying a client's identity before a procedure? A) Full name B) Date of birth C) Room number D) Medical record number <\Body> Correct Answer: C) Room number Rationale: The room number is not a unique identifier for verifying a client's identity. It's important to use information specific to the individual client, such as their name, date of birth, or medical record number. <\Explain> 18,4,0<\Number> D<\Answers> Question 18: During the preoperative checklist, the nurse asks the client to state their name and date of birth. What is the purpose of this action? A) To engage the client in conversation B) To confirm the client's mental status C) To provide comfort and reassurance D) To verify the client's identity <\Body> Correct Answer: D) To verify the client's identity Rationale: Asking the client to state their name and date of birth helps verify their identity before a procedure, ensuring the correct client is receiving the intended care. <\Explain> 19,4,0<\Number> A<\Answers> Question 19: When confirming a pediatric client's identity, which additional step should the nurse take compared to adult clients? A) Ask the parent or guardian to confirm the child's identity B) Check the client's school ID card C) Rely solely on the child's verbal confirmation D) Verify the child's identity using two unique identifiers <\Body> Correct Answer: A) Ask the parent or guardian to confirm the child's identity Rationale: For pediatric clients, it is important to involve the parent or guardian in confirming the child's identity to prevent errors. <\Explain> 20,4,0<\Number> C<\Answers> Question 20: A client is receiving care in a long-term care facility. Which unique identifier is commonly used in this setting to confirm the client's identity? A) Social security number B) Insurance policy number C) Room number D) Medical record number <\Body> Correct Answer: C) Room number Rationale: In long-term care facilities, room numbers are often used as a unique identifier in addition to other identifiers like name and medical record number. <\Explain> 21,4,0<\Number> B<\Answers> Question 21: Before administering a medication, the nurse should double-check the client's medication order against the medication label at least how many times? A) Once B) Twice C) Three times D) Four times <\Body> Correct Answer: B) Twice Rationale: Double-checking a medication order against the medication label should occur at least twice: first when preparing the medication and again at the client's bedside before administration. <\Explain> 22,4,0<\Number> C<\Answers> Question 22: Which of the following is NOT a reason for double-checking a medication order before administration? A) Ensuring the client receives the correct medication B) Preventing medication errors C) Reducing the client's anxiety D) Enhancing patient safety <\Body> Correct Answer: C) Reducing the client's anxiety Rationale: Double-checking a medication order primarily focuses on ensuring medication safety and preventing errors rather than reducing the client's anxiety. <\Explain> 23,4,0<\Number> A<\Answers> Question 23: A nurse is preparing to administer a medication to a client. What is the most appropriate action before administration? A) Double-check the client's name and date of birth B) Ask the client for their preferred medication C) Administer the medication immediately to avoid delays D) Verify the medication order with another nurse <\Body> Correct Answer: A) Double-check the client's name and date of birth Rationale: Double-checking the client's name and date of birth ensures that the medication is intended for the correct patient. <\Explain> 24,4,0<\Number> D<\Answers> Question 24: What is the primary purpose of involving a second nurse to double-check a medication order before administration? A) To expedite the medication administration process B) To ensure that the client receives the medication on time C) To reduce the workload of the first nurse D) To prevent medication errors <\Body> Correct Answer: D) To prevent medication errors Rationale: Involving a second nurse in double-checking medication orders is a safety measure to reduce the risk of medication errors. <\Explain> 25,4,0<\Number> C<\Answers> Question 25: When double-checking a medication order with another nurse, what information should be verified? A) The client's room number B) The expiration date of the medication C) The client's name, medication, dose, and route D) The nurse's shift schedule <\Body> Correct Answer: C) The client's name, medication, dose, and route Rationale: The primary focus of double-checking a medication order is to ensure the client's name, the medication, its dose, and the route of administration are correct. <\Explain> 26,4,0<\Number> C<\Answers> Question 26: What is the nurse's priority when caring for a client at risk of falls? A) Administering pain medication as needed B) Encouraging the client to ambulate frequently C) Implementing fall prevention measures D) Restricting the client to bed rest <\Body> Correct Answer: C) Implementing fall prevention measures Rationale: Preventing falls is a priority in the care of clients at risk. Implementing fall prevention measures, such as bed alarms and providing assistance with ambulation, is essential for safety. <\Explain> 27,4,0<\Number> C<\Answers> Question 27: When assessing an older adult's home for safety hazards, which finding should the nurse prioritize addressing? A) Loose cabinet door handles B) A cluttered bookshelf C) Uneven flooring in the hallway D) Faded paint on the bedroom walls <\Body> Correct Answer: C) Uneven flooring in the hallway Rationale: Uneven flooring poses a significant fall risk for older adults. Addressing this hazard is a priority to prevent injuries. <\Explain> 28,4,0<\Number> A<\Answers> Question 28: Which safety precaution is essential when caring for a client with a seizure disorder? A) Providing soft bedding and pillows B) Restraining the client during a seizure C) Keeping the environment well-lit D) Placing a tongue depressor in the client's mouth <\Body> Correct Answer: A) Providing soft bedding and pillows Rationale: Providing soft bedding and pillows helps protect the client from injury during a seizure by preventing head or limb trauma. <\Explain> 29,4,0<\Number> A<\Answers> Question 29: To prevent pressure ulcers in an immobilized client, what should the nurse prioritize? A) Frequent repositioning and skin assessment B) Limiting the client's fluid intake C) Using a high-density foam mattress D) Applying a heating pad to the bony prominences <\Body> Correct Answer: A) Frequent repositioning and skin assessment Rationale: Frequent repositioning and skin assessment are essential for preventing pressure ulcers in immobilized clients. <\Explain> 30,4,0<\Number> C<\Answers> Question 30: Which intervention is crucial to prevent complications in a client with a central venous catheter (CVC)? A) Administering IV medications without delay B) Applying pressure to the insertion site after flushing C) Maintaining strict sterile technique during catheter care D) Reducing the client's oral fluid intake <\Body> Correct Answer: C) Maintaining strict sterile technique during catheter care Rationale: Maintaining strict sterile technique during CVC care is crucial to prevent infection and other complications associated with central lines. <\Explain> 31,4,0<\Number> B<\Answers> Question 31: When is it appropriate to apply physical restraints to a client in a healthcare setting? A) To discipline a combative client B) To prevent falls and ensure safety C) At the client's request for comfort D) To facilitate staff convenience during care <\Body> Correct Answer: B) To prevent falls and ensure safety Rationale: Restraints should only be used when necessary to prevent harm to the client or others, such as preventing falls, not for disciplinary purposes or staff convenience. <\Explain> 32,4,0<\Number> B<\Answers> Question 32: Which action should the nurse prioritize when applying wrist restraints to a client? A) Ensure the restraints are tied securely to the bed frame B) Check the client's circulation and skin integrity frequently C) Apply the restraints directly to the client's skin D) Administer sedative medications to keep the client calm <\Body> Correct Answer: B) Check the client's circulation and skin integrity frequently Rationale: Frequent circulation and skin integrity checks are essential to prevent complications when using wrist restraints. <\Explain> 33,4,0<\Number> C<\Answers> Question 33: A client's family member asks why restraints are being used on their loved one. What should the nurse explain as the primary reason for restraint use? A) To limit the client's movement for staff convenience B) To discipline the client for noncompliance C) To prevent the client from removing medical devices D) To keep the client sedated and calm <\Body> Correct Answer: C) To prevent the client from removing medical devices Rationale: Restraints may be used to prevent the client from removing necessary medical devices or tubes, ensuring their safety and treatment effectiveness. <\Explain> 34,4,0<\Number> A<\Answers> Question 34: Which statement best describes the documentation requirements for clients in restraints? A) Document every 4 hours or per facility policy B) Document only at the end of the shift C) Documentation is not necessary when using restraints D) Document once a day during routine rounds <\Body> Correct Answer: A) Document every 4 hours or per facility policy Rationale: Documentation of client assessment, restraints' necessity, and monitoring must be done regularly, as required by facility policies and regulatory standards. <\Explain> 35,4,0<\Number> B<\Answers> Question 35: Which type of restraint is considered the least restrictive and is typically used for clients at risk of falls? A) Vest restraint B) Belt restraint C) Wrist restraint D) Mitt restraint <\Body> Correct Answer: B) Belt restraint Rationale: Belt restraints are considered less restrictive than other types and are often used to prevent falls while allowing more freedom of movement. <\Explain> 36,4,0<\Number> B<\Answers> Question 36: A nurse is working in a healthcare facility and observes an unfamiliar person wandering in a restricted area. What is the nurse's initial action? A) Approach the person and ask if they need assistance B) Alert security or hospital authorities immediately C) Politely ask the person to leave the area D) Ignore the situation and continue working <\Body> Correct Answer: B) Alert security or hospital authorities immediately Rationale: When an unfamiliar person is found in a restricted area, the priority is to ensure the safety and security of the healthcare facility by immediately notifying security or hospital authorities. <\Explain> 37,4,0<\Number> C<\Answers> Question 37: During a fire drill in a healthcare facility, which action should the nurse prioritize when evacuating clients? A) Stop to gather personal belongings and valuables B) Ensure that all windows and doors are securely locked C) Follow established evacuation routes and assist clients as needed D) Evacuate clients only if the fire alarm is confirmed as real <\Body> Correct Answer: C) Follow established evacuation routes and assist clients as needed Rationale: During a fire drill or actual fire, the priority is to safely evacuate clients following established evacuation routes and providing assistance as necessary. <\Explain> 38,4,0<\Number> B<\Answers> Question 38: Which security measure should the nurse implement to prevent infant abduction in the maternity unit? A) Place a "Do Not Disturb" sign on the nursery door B) Require all visitors to wear hospital-issued badges C) Leave infants unattended during breastfeeding sessions D) Allow family members to hold the infant without supervision <\Body> Correct Answer: B) Require all visitors to wear hospital-issued badges Rationale: Requiring all visitors to wear hospital-issued badges helps identify authorized personnel and prevents unauthorized access to the maternity unit. <\Explain> 39,4,0<\Number> C<\Answers> Question 39: When providing care to a client in home healthcare, what safety precaution should the nurse take to prevent falls? A) Leave all doors and windows open for proper ventilation B) Encourage the client to perform unsupervised exercises C) Ensure that the client's home environment is free from hazards D) Administer sedatives to keep the client calm and immobile <\Body> Correct Answer: C) Ensure that the client's home environment is free from hazards Rationale: Ensuring a hazard-free home environment is essential to prevent falls when providing care in a client's home. <\Explain> 40,4,0<\Number> B<\Answers> Question 40: A client in a long-term care facility has a documented history of elopement attempts. What security measure should the nurse implement? A) Assign a roommate to keep the client company B) Use bed alarms and door alarms to monitor the client's movements C) Restrict the client to their room at all times D) Allow the client to roam freely for exercise <\Body> Correct Answer: B) Use bed alarms and door alarms to monitor the client's movements Rationale: Using bed alarms and door alarms helps monitor the client's movements and prevent elopement attempts. <\Explain> 41,4,0<\Number> C<\Answers> Question 41: When assisting a client with transferring from the bed to a chair, what is the nurse's priority to ensure proper ergonomic technique? A) Ensure that the client's feet are touching the ground B) Bend at the waist while lifting to minimize strain C) Keep the client's back straight and use leg muscles D) Have the client cross their arms over their chest <\Body> Correct Answer: C) Keep the client's back straight and use leg muscles Rationale: To maintain proper ergonomic technique and prevent back injuries, the nurse should keep their back straight and use their leg muscles when assisting with transfers. <\Explain> 42,4,0<\Number> D<\Answers> Question 42: Which client condition should prompt the nurse to consider the use of mechanical assistive devices for lifting and transferring? A) Mild muscle weakness B) Recent weight loss C) Confusion and disorientation D) Total dependence on staff for mobility <\Body> Correct Answer: D) Total dependence on staff for mobility Rationale: Clients who are totally dependent on staff for mobility are at high risk of injury and may require mechanical assistive devices for lifting and transferring to ensure safety. <\Explain> 43,4,0<\Number> B<\Answers> Question 43: When using a mechanical lift to transfer a client, what is the nurse's primary responsibility? A) Operating the lift as quickly as possible to save time B) Ensuring that the client is securely and comfortably positioned in the lift C) Using manual lifting techniques to supplement the mechanical lift D) Minimizing communication with the client during the transfer <\Body> Correct Answer: B) Ensuring that the client is securely and comfortably positioned in the lift Rationale: The primary responsibility when using a mechanical lift is to ensure the client's safety and comfort by securely positioning them in the lift. <\Explain> 44,4,0<\Number> B<\Answers> Question 44: Which healthcare team member is responsible for conducting an initial assessment of a client's mobility and recommending ergonomic techniques for moving and lifting? A) Nurse manager B) Physical therapist C) Respiratory therapist D) Dietitian <\Body> Correct Answer: B) Physical therapist Rationale: Physical therapists are responsible for assessing a client's mobility and recommending appropriate ergonomic techniques for moving and lifting based on the client's condition. <\Explain> 45,4,0<\Number> C<\Answers> Question 45: To prevent musculoskeletal injuries when moving a heavy client in bed, what should the nurse encourage the client to do? A) Hold their breath during the movement B) Clench their fists tightly C) Keep their body relaxed and assist as needed D) Lift their head and shoulders off the bed <\Body> Correct Answer: C) Keep their body relaxed and assist as needed Rationale: Clients should keep their bodies relaxed and assist as needed when being moved to prevent musculoskeletal injuries for both the client and the caregiver. <\Explain> 46,4,0<\Number> D<\Answers> Question 46: What should the nurse prioritize when using a patient-controlled analgesia (PCA) pump to administer pain medication? A) Set the pump to administer the maximum allowable dose B) Educate the client on how to bypass the pump if needed C) Avoid monitoring the client's vital signs to prevent interference D) Ensure that the PCA pump is programmed according to the healthcare provider's orders <\Body> Correct Answer: D) Ensure that the PCA pump is programmed according to the healthcare provider's orders Rationale: Programming the PCA pump according to the healthcare provider's orders is essential to prevent medication errors and ensure safe pain management. <\Explain> 47,4,0<\Number> A<\Answers> Question 47: When operating an infusion pump for a client receiving intravenous (IV) fluids, what action should the nurse take to enhance safety? A) Elevate the IV bag above the level of the client's heart B) Set the pump to deliver fluids at the fastest rate possible C) Avoid regular monitoring of the IV site and infusion rate D) Clamp the IV tubing to prevent air from entering the line <\Body> Correct Answer: A) Elevate the IV bag above the level of the client's heart Rationale: Elevating the IV bag above the level of the client's heart helps maintain proper fluid flow and prevents air from entering the IV line. <\Explain> 48,4,0<\Number> A<\Answers> Question 48: What is the primary purpose of using bed alarms for clients at risk of falls? A) To alert the nurse when the client needs assistance B) To restrain the client to the bed for safety C) To create noise in the room to prevent sleep disturbances D) To limit the client's mobility <\Body> Correct Answer: A) To alert the nurse when the client needs assistance Rationale: Bed alarms are used to alert the nurse or healthcare team when the client attempts to get out of bed, indicating a need for assistance and fall prevention. <\Explain> 49,4,0<\Number> B<\Answers> Question 49: When using a mechanical lift to transfer a client, what is the nurse's primary responsibility? A) Lift the client rapidly to avoid delays B) Ensure the client is securely positioned in the lift C) Delegate the task to a nursing assistant D) Operate the lift without assistance <\Body> Correct Answer: B) Ensure the client is securely positioned in the lift Rationale: The nurse's primary responsibility when using a mechanical lift is to ensure that the client is securely and comfortably positioned to prevent injury. <\Explain> 50,4,0<\Number> B<\Answers> Question 50: What is the appropriate action when handling a portable oxygen cylinder for a client? A) Store the cylinder near a heat source for easy access B) Ensure that the cylinder is always in an upright position C) Use oil-based lubricants on the cylinder's valve D) Place the cylinder in a closed cabinet for storage <\Body> Correct Answer: B) Ensure that the cylinder is always in an upright position Rationale: Oxygen cylinders should always be stored and used in an upright position to prevent accidents and ensure proper oxygen flow. <\Explain> 51,4,0<\Number> C<\Answers> Question 51: What is the primary purpose of an error incidence report in healthcare? A) To assign blame and hold individuals accountable B) To document minor incidents for future reference C) To identify system failures and improve patient safety D) To keep a record of routine daily occurrences <\Body> Correct Answer: C) To identify system failures and improve patient safety Rationale: Error incidence reports are used to identify system failures and implement improvements in patient safety, not to assign blame. <\Explain> 52,4,0<\Number> C<\Answers> Question 52: When should a nurse complete an error incidence report? A) Only for major, life-threatening errors B) After discussing the error with colleagues C) For any deviation from established protocols D) Within 24 hours of the error occurring <\Body> Correct Answer: C) For any deviation from established protocols Rationale: Error incidence reports should be completed for any deviation from established protocols or standards of care to capture information that may improve patient safety. <\Explain> 53,4,0<\Number> B<\Answers> Question 53: What should the nurse include when documenting an error in an incidence report? A) Names of colleagues involved in the error B) A detailed description of the error and contributing factors C) An explanation of why the error occurred D) Suggestions for disciplinary actions <\Body> Correct Answer: B) A detailed description of the error and contributing factors Rationale: Error incidence reports should include a detailed description of the error and any contributing factors to facilitate analysis and improvements. <\Explain> 54,4,0<\Number> C<\Answers> Question 54: Which action demonstrates a commitment to the culture of safety in healthcare? A) Avoiding error incidence reports to prevent negative consequences B) Blaming colleagues for errors in patient care C) Reporting near-misses and errors for learning and improvement D) Ignoring safety protocols to save time <\Body> Correct Answer: C) Reporting near-misses and errors for learning and improvement Rationale: A culture of safety encourages healthcare workers to report near-misses and errors to promote learning, improvement, and patient safety. <\Explain> 55,4,0<\Number> D<\Answers> Question 55: What should the nurse prioritize when reporting an error in an incidence report? A) Keeping the incident confidential to protect colleagues B) Assigning blame to the individual responsible for the error C) Using vague language to avoid liability D) Providing accurate and complete information <\Body> Correct Answer: D) Providing accurate and complete information Rationale: Accuracy and completeness in incident reporting are crucial for identifying root causes and implementing effective improvements. <\Explain> 56,4,0<\Number> C<\Answers> Question 56: What is the appropriate action for a nurse who suspects a colleague is abusing substances while on duty? A) Confront the colleague privately and offer assistance B) Ignore the suspicion to avoid causing conflict C) Report the concern to the appropriate supervisor or authority D) Discuss the suspicion with other coworkers to gather evidence <\Body> Correct Answer: C) Report the concern to the appropriate supervisor or authority Rationale: Suspected substance abuse by a colleague should be reported to the appropriate supervisor or authority to ensure patient safety and address the issue appropriately. <\Explain> 57,4,0<\Number> C<\Answers> Question 57: A nurse overhears a coworker discussing plans to work while impaired due to alcohol consumption. What should the nurse do first? A) Offer to cover the coworker's shift B) Confront the coworker about their plans C) Report the concern to the charge nurse or manager D) Ignore the situation as it is not the nurse's responsibility <\Body> Correct Answer: C) Report the concern to the charge nurse or manager Rationale: When a coworker plans to work while impaired, it is essential to report the concern to the charge nurse or manager to prevent potential harm to patients. <\Explain> 58,4,0<\Number> A<\Answers> Question 58: What is the primary purpose of a whistleblower protection policy in healthcare? A) To encourage employees to report unsafe practices B) To protect employees engaged in unsafe practices C) To allow employees to engage in unethical behavior D) To discourage employees from reporting concerns <\Body> Correct Answer: A) To encourage employees to report unsafe practices Rationale: Whistleblower protection policies are in place to encourage employees to report unsafe practices and protect them from retaliation. <\Explain> 59,4,0<\Number> B<\Answers> Question 59: When should a nurse report a coworker's unsafe practice or error? A) Only if the error resulted in harm to a patient B) Immediately, regardless of whether harm occurred C) After discussing the error with the coworker involved D) During the annual performance review <\Body> Correct Answer: B) Immediately, regardless of whether harm occurred Rationale: Unsafe practices or errors should be reported immediately, regardless of whether harm has occurred, to prevent potential harm in the future. <\Explain> 60,4,0<\Number> D<\Answers> Question 60: What should the nurse prioritize when reporting unsafe practices by personnel? A) Protecting the reputation of the coworker involved B) Gathering evidence before reporting C) Maintaining confidentiality of the report D) Ensuring patient safety and well-being <\Body> Correct Answer: D) Ensuring patient safety and well-being Rationale: The primary priority when reporting unsafe practices is to ensure patient safety and well-being. <\Explain> 61,4,0<\Number> B<\Answers> Question 61: A nurse is working on a busy medical-surgical unit and realizes that there are not enough staff members to safely care for the number of patients on the floor. What is the nurse's most appropriate action? A) Proceed with patient care, prioritizing tasks and skipping breaks B) Document the unsafe staffing levels and inform the charge nurse or manager C) Request additional patients to be assigned to the unit to meet staffing ratios D) Speak to coworkers about the issue but take no further action <\Body> Correct Answer: B) Document the unsafe staffing levels and inform the charge nurse or manager Rationale: When faced with unsafe staffing levels, the nurse's first responsibility is to document the situation and inform the charge nurse or manager to address the issue appropriately. <\Explain> 62,4,0<\Number> C<\Answers> Question 62: What is the potential consequence of unsafe staffing levels in a healthcare setting? A) Increased efficiency in patient care B) Improved nurse-to-patient communication c ) Compromised patient safety and quality of care D) Reduced workload for healthcare providers <\Body> Correct Answer: C) Compromised patient safety and quality of care Rationale: Unsafe staffing levels can lead to compromised patient safety and a decreased quality of care due to a lack of resources and adequate supervision. <\Explain> 63,4,0<\Number> B<\Answers> Question 63: In a long-term care facility, a nurse observes that there is only one certified nursing assistant (CNA) responsible for caring for 25 residents during the evening shift. What is the nurse's best action? A) Assist the CNA with resident care to ensure their needs are met B) Report the unsafe staffing situation to the charge nurse or supervisor C) Confront the CNA about their workload and suggest they work faster D) Leave the facility to avoid being associated with the unsafe staffing levels <\Body> Correct Answer: B) Report the unsafe staffing situation to the charge nurse or supervisor Rationale: When faced with unsafe staffing levels, the nurse should report the situation to the charge nurse or supervisor to address the issue at an administrative level. <\Explain> 64,4,0<\Number> D<\Answers> Question 64: A nurse is working in a pediatric intensive care unit and realizes that there are insufficient nurses to adequately monitor and care for critically ill patients. What ethical principle should guide the nurse's actions? A) Autonomy B) Beneficence C) Non-maleficence D) Justice <\Body> Correct Answer: D) Justice Rationale: The ethical principle of justice calls for fair and equitable distribution of resources, including staffing, to ensure that all patients receive the care they need. <\Explain> 65,4,0<\Number> C<\Answers> Question 65: What potential risk is associated with unsafe staffing levels in a healthcare facility? A) Increased job satisfaction among healthcare providers B) Improved patient outcomes and shorter hospital stays C) Medication errors, patient falls, and missed assessments D) Reduced workload for healthcare providers <\Body> Correct Answer: C) Medication errors, patient falls, and missed assessments Rationale: Unsafe staffing levels can lead to an increased risk of medication errors, patient falls, and missed assessments due to a lack of available staff to provide adequate care. <\Explain> 66,4,0<\Number> C<\Answers> Question 66: What is the primary reason for using personal protective equipment (PPE) when handling hazardous materials in a healthcare setting? A) To minimize exposure to infectious diseases only B) To enhance the appearance and professionalism of healthcare workers C) To protect healthcare workers and patients from potential harm D) To reduce the cost of purchasing hazardous materials <\Body> Correct Answer: C) To protect healthcare workers and patients from potential harm Rationale: The primary purpose of using PPE is to protect healthcare workers and patients from potential harm, including exposure to hazardous materials. <\Explain> 67,4,0<\Number> D<\Answers> Question 67: When disposing of hazardous waste in a healthcare facility, what is the nurse's responsibility? A) Place the waste in the regular trash bin for convenience B) Label the waste container with the word "Hazardous" C) Store the waste in an unmarked container to prevent accidents D) Follow facility protocols for proper disposal and labeling <\Body> Correct Answer: D) Follow facility protocols for proper disposal and labeling Rationale: Nurses should follow facility protocols for the proper disposal and labeling of hazardous waste to ensure safety and compliance with regulations. <\Explain> 68,4,0<\Number> C<\Answers> Question 68: What should the nurse do before administering a medication classified as hazardous? A) Dilute the medication with a non-hazardous solution B) Administer the medication quickly to minimize exposure C) Verify the correct medication, dosage, and route D) Store the medication in a clear, unlabeled container <\Body> Correct Answer: C) Verify the correct medication, dosage, and route Rationale: Before administering a hazardous medication, the nurse should verify the correct medication, dosage, and route to prevent errors and potential harm. <\Explain> 69,4,0<\Number> B<\Answers> Question 69: Which type of fire extinguisher is suitable for use in the event of a fire involving flammable liquids? A) Class A fire extinguisher B) Class B fire extinguisher C) Class C fire extinguisher D) Class D fire extinguisher <\Body> Correct Answer: B) Class B fire extinguisher Rationale: Class B fire extinguishers are suitable for use in fires involving flammable liquids, such as hazardous materials. <\Explain> 70,4,0<\Number> D<\Answers> Question 70: What is the primary purpose of a Material Safety Data Sheet (MSDS)? A) To provide instructions on how to use hazardous materials B) To list the cost of hazardous materials for billing purposes C) To document incidents of hazardous material exposure D) To provide detailed information on the properties and hazards of chemicals <\Body> Correct Answer: D) To provide detailed information on the properties and hazards of chemicals Rationale: MSDSs provide detailed information on the properties and hazards of chemicals, helping healthcare workers understand and handle hazardous materials safely. <\Explain> 71,4,0<\Number> B<\Answers> Question 71: A nurse is caring for a client with heart failure. Which action should the nurse prioritize in the client's plan of care? A) Administering pain medication as needed B) Monitoring daily weight and fluid intake C) Providing a high-sodium diet to increase blood pressure D) Limiting physical activity to prevent fatigue <\Body> Correct Answer: B) Monitoring daily weight and fluid intake Rationale: Monitoring daily weight and fluid intake is essential in managing heart failure. It helps assess for fluid retention and provides valuable information about the client's condition. Weight gain can indicate fluid accumulation, and monitoring fluid intake can help regulate sodium and fluid levels, which is crucial in heart failure management. Administering pain medication as needed, providing a high-sodium diet, and limiting physical activity are not the primary interventions for managing heart failure. <\Explain> 72,4,0<\Number> B<\Answers> Question 72: A nurse is caring for a client with diabetes who is scheduled for surgery in the morning. The client asks about taking their insulin before surgery. What is the nurse's best response? A) "You should skip your insulin dose tonight to avoid low blood sugar during surgery." B) "Continue to take your insulin as prescribed, but let the surgical team know about your medication." C) "Stop taking insulin for the next 48 hours to ensure it doesn't interfere with the anesthesia." D) "Take a double dose of insulin tonight to compensate for missing it before surgery." <\Body> Correct Answer: B) "Continue to take your insulin as prescribed, but let the surgical team know about your medication." Rationale: It is essential for clients with diabetes to maintain their insulin regimen as prescribed, even before surgery. Skipping insulin or taking double doses can lead to uncontrolled blood sugar levels, which can be harmful. The surgical team should be informed about the client's medication, as they may adjust the insulin dose or provide appropriate management to maintain blood sugar within the target range during surgery. <\Explain> 73,4,0<\Number> B<\Answers> Question 73: A nurse is caring for a client with a suspected urinary tract infection (UTI). Which intervention is a priority in the client's plan of care? A) Administering pain medication B) Obtaining a urine culture and sensitivity C) Offering cranberry juice to the client D) Assisting with ambulation <\Body> Correct Answer: B) Obtaining a urine culture and sensitivity Rationale: When a UTI is suspected, the priority is to obtain a urine culture and sensitivity to identify the causative organism and determine the most effective antibiotic treatment. Administering pain medication, offering cranberry juice, and assisting with ambulation are important aspects of care but are not the priority in this situation. <\Explain> 74,4,0<\Number> B<\Answers> Question 74: A nurse is caring for a client with a history of falls. Which intervention should be included in the client's fall prevention plan? A) Administering a sedative at bedtime B) Encouraging the use of a bedside commode C) Placing the client in a room with dim lighting D) Allowing the client to wear non-skid socks <\Body> Correct Answer: B) Encouraging the use of a bedside commode Rationale: Encouraging the use of a bedside commode is an important fall prevention measure for clients at risk for falls. It reduces the need for the client to walk to the bathroom, which can be a fall hazard. Administering sedatives, dim lighting, and non-skid socks do not directly address the risk of falls and may have adverse effects. <\Explain> 75,4,0<\Number> D<\Answers> Question 75: A nurse is caring for a postoperative client who has a nasogastric tube in place for gastric decompression. What action should the nurse prioritize in the client's care? A) Monitoring the surgical incision for infection B) Administering pain medication as needed C) Irrigating the nasogastric tube with saline every hour D) Maintaining the patency of the nasogastric tube <\Body> Correct Answer: D) Maintaining the patency of the nasogastric tube Rationale: Maintaining the patency of the nasogastric tube is essential to ensure effective gastric decompression and prevent complications. Monitoring the surgical incision, administering pain medication, and irrigating the tube with saline are important aspects of care but are not the top priority when the client has a nasogastric tube in place. <\Explain> 76,4,0<\Number> B<\Answers> Question 76: A nurse is discussing advanced directives with a group of clients. Which statement by a client indicates a clear understanding of a living will? A) "A living will allows someone to make decisions for me if I become incapacitated." B) "A living will outlines the medical treatments I want or do not want if I can't communicate my wishes." C) "A living will designates a family member to act as my healthcare proxy." D) "A living will specifies the distribution of my assets after I pass away." <\Body> Correct Answer: B) "A living will outlines the medical treatments I want or do not want if I can't communicate my wishes." Rationale: A living will is a legal document that specifies the medical treatments a person wants or does not want if they become unable to communicate their wishes, especially in situations of terminal illness or end-of-life care. <\Explain> 77,4,0<\Number> C<\Answers> Question 77: A client is admitted to the hospital and is unable to make medical decisions due to a temporary loss of consciousness. Which document allows the healthcare team to make decisions on behalf of the client during this period? A) Advance healthcare directive B) Living will C) Durable power of attorney for healthcare D) Trust document <\Body> Correct Answer: C) Durable power of attorney for healthcare Rationale: A durable power of attorney for healthcare, also known as a healthcare proxy, designates someone to make medical decisions on behalf of the client when they are unable to do so temporarily. An advance healthcare directive and a living will provide specific instructions but do not designate a proxy. A trust document pertains to financial matters, not healthcare decisions. <\Explain> 78,4,0<\Number> C<\Answers> Question 78: A nurse is caring for a terminally ill client with a living will specifying the desire to avoid mechanical ventilation. The client's condition deteriorates, and ventilation is required to maintain oxygenation. What should the nurse do? A) Honor the client's living will and refrain from using mechanical ventilation. B) Initiate mechanical ventilation immediately to preserve life. C) Consult the healthcare provider for guidance. D) Administer pain medication and wait for the client's decision. <\Body> Correct Answer: C) Consult the healthcare provider for guidance. Rationale: In this situation, the nurse should consult the healthcare provider to discuss the client's wishes as outlined in the living will and assess the appropriateness of mechanical ventilation based on the client's current condition. The living will serves as a guide, but it may be necessary to reevaluate the client's preferences in the context of their current medical status. <\Explain> 79,4,0<\Number> B<\Answers> Question 79: A client is admitted with a severe head injury and is unable to make decisions. There is no advance directive in place. Who should the healthcare team consult to make medical decisions for the client? A) The client's primary care physician B) The client's closest family member C) The hospital's ethics committee D) The court-appointed guardian <\Body> Correct Answer: B) The client's closest family member Rationale: In the absence of an advance directive or designated healthcare proxy, healthcare decisions are typically made by the client's closest family member, such as a spouse, parent, or adult child. Consulting the primary care physician, the ethics committee, or a court-appointed guardian may be necessary in specific cases but is not the initial step. <\Explain> 80,4,0<\Number> A<\Answers> Question 80: A client with a terminal illness has designated their best friend as their healthcare proxy in the durable power of attorney for healthcare. The client's biological family disagrees with this choice. What should the nurse do? A) Follow the wishes of the client and respect their choice of healthcare proxy. B) Notify the healthcare provider to make a decision regarding the proxy. C) Consult the hospital's legal department for resolution. D) Inform the biological family that their opinion takes precedence. <\Body> Correct Answer: A) Follow the wishes of the client and respect their choice of healthcare proxy. Rationale: The client's choice of a healthcare proxy in the durable power of attorney for healthcare should be honored, provided it is a legally valid designation. The nurse should respect the client's wishes and involve the designated proxy in decision-making, regardless of the biological family's opinion. <\Explain> 81,4,0<\Number> B<\Answers> Question 81: A nurse is caring for a client who is refusing a prescribed medication due to concerns about potential side effects. What is the nurse's primary role in this situation? A) Persuade the client to take the medication as prescribed. B) Document the client's refusal and the reason for it. C) Administer the medication covertly to ensure compliance. D) Consult with the healthcare provider to change the medication. <\Body> Correct Answer: B) Document the client's refusal and the reason for it. Rationale: The nurse's primary role in this situation is to respect the client's autonomy and ensure that the client's refusal and the reason for it are documented accurately. It is not appropriate to coerce or administer medication without consent. The nurse can consult with the healthcare provider if the client's concerns warrant a medication change. <\Explain> 82,4,0<\Number> B<\Answers> Question 82: A nurse is caring for a client with a language barrier who is unable to understand the treatment plan. What should the nurse do to advocate for the client's understanding? A) Proceed with the treatment as planned. B) Seek assistance from a medical interpreter. C) Use simple gestures to convey information. D) Ask the client to nod to indicate understanding. <\Body> Correct Answer: B) Seek assistance from a medical interpreter. Rationale: To advocate for the client's understanding, the nurse should seek assistance from a medical interpreter or use other language assistance services to facilitate effective communication and ensure the client comprehends the treatment plan. Proceeding with treatment without ensuring understanding can lead to misunderstandings and potential harm. <\Explain> 83,4,0<\Number> A<\Answers> Question 83: A nurse is caring for a pediatric client who is scheduled for a painful procedure. The child's parent asks to be present during the procedure. What action should the nurse take to advocate for the client? A) Allow the parent to be present during the procedure. B) Deny the parent's request to minimize distractions. C) Sedate the child to minimize distress. D) Perform the procedure quickly to reduce discomfort. <\Body> Correct Answer: A) Allow the parent to be present during the procedure. Rationale: Allowing the parent to be present during a painful procedure is a well-established practice that can provide emotional support to the child and enhance their comfort and sense of security. Denying the parent's request or sedating the child without consent may not align with the best interests of the child. Performing the procedure quickly is important but should not substitute for parental presence when requested. <\Explain> 84,4,0<\Number> D<\Answers> Question 84: A nurse is caring for a client with a history of self-harm behaviors. During a routine assessment, the nurse discovers that the client has a concealed sharp object. What should the nurse do to advocate for the client's safety? A) Ignore the discovery to respect the client's privacy. B) Remove the sharp object discreetly without notifying the client. C) Verbally confront the client about the object and request its removal. D) Inform the healthcare provider and request a psychiatric consult. <\Body> Correct Answer: D) Inform the healthcare provider and request a psychiatric consult. Rationale: Discovering a concealed sharp object with a client who has a history of self-harm is a safety concern that should be addressed promptly. The nurse's priority is to advocate for the client's safety by informing the healthcare provider, who can assess the situation and initiate appropriate interventions, including a psychiatric consult. Ignoring the discovery or removing the object without communication may not address the underlying issues. <\Explain> 85,4,0<\Number> B<\Answers> Question 85: A nurse is caring for an older adult client who is confused and disoriented in the hospital. The client's family is concerned about the client's safety and requests the use of physical restraints. What is the nurse's best response to advocate for the client? A) Use physical restraints as requested to prevent falls. B) Consult with the healthcare provider to discuss alternatives to restraints. C) Explain the benefits of restraints to the family and proceed with their request. D) Transfer the client to a long-term care facility to address safety concerns. <\Body> Correct Answer: B) Consult with the healthcare provider to discuss alternatives to restraints. Rationale: The nurse should advocate for the client's safety by consulting with the healthcare provider to discuss alternatives to physical restraints. Restraints should be a last resort and used only when all other options have been considered and ruled out. Educating the family about the risks and benefits of restraints is important, but the primary action should be to explore alternatives. <\Explain> 86,4,0<\Number> B<\Answers> Question 86: A nurse is caring for a client with multiple chronic health conditions. Which action demonstrates effective collaboration with the care team? A) Making independent decisions about the client's care plan. B) Updating the healthcare provider about the client's progress regularly. C) Requesting consultations without informing the client. D) Avoiding communication with other healthcare team members. <\Body> Correct Answer: B) Updating the healthcare provider about the client's progress regularly. Rationale: Effective collaboration with the care team involves ongoing communication and sharing of information. Updating the healthcare provider about the client's progress ensures that the entire team is informed and can make appropriate decisions regarding the client's care. Making independent decisions without involving the team, requesting consultations without informing the client, and avoiding communication hinder collaboration and may lead to suboptimal care. <\Explain> 87,4,0<\Number> B<\Answers> Question 87: A nurse is caring for a client who requires physical therapy, occupational therapy, and speech therapy. Which action should the nurse prioritize to facilitate effective collaboration among these therapy services? A) Scheduling therapy sessions at different times to minimize disruptions. B) Communicating the client's goals and progress with each therapy team. C) Limiting therapy services to one discipline at a time for simplicity. D) Encouraging the client to choose only one therapy service to pursue. <\Body> Correct Answer: B) Communicating the client's goals and progress with each therapy team. Rationale: Effective collaboration among therapy services involves open communication and sharing of information about the client's goals and progress. This ensures that each therapy team can work together to achieve the best outcomes for the client. Scheduling therapy sessions at different times, limiting services, or discouraging the pursuit of multiple therapies may not be in the client's best interest and can hinder collaboration. <\Explain> 88,4,0<\Number> D<\Answers> Question 88: A nurse is caring for a client who is undergoing surgery. Which action demonstrates collaboration with the surgical team? A) Administering pain medication without notifying the surgeon. B) Discussing postoperative care plans with the client's family. C) Contacting the radiology department for imaging requests. D) Collaborating with the anesthesiologist to manage pain during surgery. <\Body> Correct Answer: D) Collaborating with the anesthesiologist to manage pain during surgery. Rationale: Collaborating with the anesthesiologist to manage pain during surgery is an example of effective collaboration with the surgical team. The anesthesiologist plays a critical role in ensuring the client's comfort during the procedure. Administering pain medication without notifying the surgeon may not be appropriate or safe. Discussing postoperative care plans with the family and contacting radiology are important aspects of care but are not direct collaborations with the surgical team. <\Explain> 89,4,0<\Number> C<\Answers> Question 89: A nurse is caring for a client with a complex medical history. Which action promotes effective collaboration with the interprofessional team? A) Withholding information from the pharmacy team to avoid medication changes. B) Avoiding discussions about the client's condition with the social worker. C) Coordinating care conferences to involve all relevant team members. D) Exclusively relying on the healthcare provider for decision-making. <\Body> Correct Answer: C) Coordinating care conferences to involve all relevant team members. Rationale: Coordinating care conferences that involve all relevant team members promotes effective collaboration and ensures that everyone is informed and working together to provide comprehensive care. Withholding information from the pharmacy team, avoiding discussions with the social worker, and exclusively relying on the healthcare provider hinder collaboration and may result in fragmented care. <\Explain> 90,4,0<\Number> D<\Answers> Question 90: A nurse is caring for a client with a newly diagnosed chronic illness. Which action demonstrates collaboration with the client in the care planning process? A) Creating a care plan without discussing it with the client. B) Informing the client about the treatment plan without options. C) Encouraging the client to follow the prescribed regimen without input. D) Engaging the client in shared decision-making about their care. <\Body> Correct Answer: D) Engaging the client in shared decision-making about their care. Rationale: Collaboration with the client involves engaging them in shared decision-making about their care. Creating a care plan without the client's input, providing information without options, and expecting compliance without involving the client in the decision-making process do not promote effective collaboration or client-centered care. <\Explain> 91,4,0<\Number> A<\Answers> Question 91: A nurse is documenting the care provided to a client. Which action demonstrates appropriate documentation? A) Recording the client's vital signs even when they are normal. B) Documenting the client's complaints without an assessment. C) Charting care as soon as it is completed at the end of the shift. D) Using abbreviations and acronyms to save time. <\Body> Correct Answer: A) Recording the client's vital signs even when they are normal. Rationale: Appropriate documentation includes recording vital signs, assessments, and care provided, even when within the normal range. It is important to document all relevant information accurately and in a timely manner. Documenting complaints without an assessment, charting care only at the end of the shift, and using abbreviations that are not approved can lead to incomplete or inaccurate records. <\Explain> 92,4,0<\Number> B<\Answers> Question 92: A nurse is documenting care in a client's electronic health record (EHR). What is the primary reason for using EHRs for documentation? A) To save time and reduce documentation workload. B) To enhance communication among healthcare team members. C) To protect the confidentiality of client information. D) To eliminate the need for handwritten documentation. <\Body> Correct Answer: B) To enhance communication among healthcare team members. Rationale: One of the primary reasons for using electronic health records (EHRs) is to enhance communication among healthcare team members. EHRs allow for real-time access to client information, promote interprofessional collaboration, and provide a centralized location for comprehensive documentation. While EHRs can improve efficiency, protect confidentiality, and reduce handwritten documentation, their main purpose is to support communication and coordination of care. <\Explain> 93,4,0<\Number> B<\Answers> Question 93: A nurse is documenting care for a client with a pressure ulcer. Which documentation is the most appropriate for describing the wound's appearance? A) "Wound on sacral area looks bad." B) "Pressure ulcer is deep, 4 cm x 5 cm, with necrotic tissue and odor." C) "Patient's wound is getting worse." D) "Wound appears to be healing slowly." <\Body> Correct Answer: B) "Pressure ulcer is deep, 4 cm x 5 cm, with necrotic tissue and odor." Rationale: Appropriate wound documentation should include specific details about the wound's appearance, size, depth, presence of necrotic tissue, and any odor. Vague descriptions like "looks bad," "getting worse," or "healing slowly" do not provide clear and objective information about the wound, which is essential for proper care planning and evaluation. <\Explain> 94,4,0<\Number> D<\Answers> Question 94: A nurse is documenting medication administration for a client. What should be included in the medication documentation? A) The client's room number and bed assignment. B) The nurse's opinion about the client's response to the medication. C) The client's allergies and past adverse reactions. D) The medication name, dosage, route, time, and site of administration. <\Body> Correct Answer: D) The medication name, dosage, route, time, and site of administration. Rationale: Medication documentation should include essential details such as the medication name, dosage, route, time, and site of administration. Information like the client's room number, nurse's opinions, allergies, and past reactions are important but should be documented separately in the client's record. <\Explain> 95,4,0<\Number> B<\Answers> Question 95: A nurse is documenting the client's plan of care. Which statement is appropriate for the nurse to include in the care plan? A) "Client will be pain-free at all times." B) "Client will ambulate as tolerated." C) "Client will never experience complications." D) "Client will not require any further medical attention." <\Body> Correct Answer: B) "Client will ambulate as tolerated." Rationale: The goal in a care plan should be realistic and achievable. Stating that the client will be pain-free at all times or will never experience complications is unrealistic and not within the nurse's control. "Client will ambulate as tolerated" is a realistic and patient-centered goal that reflects the client's abilities and needs. <\Explain> 96,4,0<\Number> A<\Answers> Question 96: A nurse is caring for a client who requests information about their medical condition but wishes to keep it confidential from their family. What ethical principle should the nurse prioritize in this situation? A) Autonomy B) Beneficence C) Nonmaleficence D) Veracity <\Body> Correct Answer: A) Autonomy Rationale: In this situation, the nurse should prioritize the ethical principle of autonomy, which respects the client's right to make informed decisions about their own healthcare, including the decision to keep medical information confidential from family members. <\Explain> 97,4,0<\Number> B<\Answers> Question 97: A nurse is asked to administer a medication to a client, but the nurse suspects that the medication may be harmful to the client. What should the nurse do first based on ethical principles? A) Administer the medication as prescribed. B) Seek clarification from the healthcare provider. C) Consult with other nursing staff for advice. D) Withhold the medication without informing anyone. <\Body> Correct Answer: B) Seek clarification from the healthcare provider. Rationale: When faced with a situation where the nurse suspects that a prescribed medication may be harmful, the nurse should prioritize the ethical principle of advocacy for the client's well-being. Seeking clarification from the healthcare provider is the appropriate action to ensure the safety and best interests of the client. <\Explain> 98,4,0<\Number> D<\Answers> Question 98: A nurse is caring for a pediatric client whose parents have religious beliefs that prohibit certain medical interventions. The healthcare provider recommends a life-saving treatment that goes against the parents' beliefs. What ethical dilemma does the nurse face in this situation? A) Autonomy vs. beneficence B) Veracity vs. fidelity C) Justice vs. nonmaleficence D) Autonomy vs. paternalism <\Body> Correct Answer: D) Autonomy vs. paternalism Rationale: In this scenario, the ethical dilemma faced by the nurse involves balancing the autonomy of the parents (who hold certain religious beliefs) with the principle of paternalism (the healthcare provider's recommendation for a life-saving treatment). The nurse must navigate this conflict while advocating for the best interests of the child. <\Explain> 99,4,0<\Number> A<\Answers> Question 99: A nurse is assigned to care for a client with a known history of substance abuse who is requesting pain medication. The client appears to be in severe pain, but the nurse is concerned about potential drug-seeking behavior. What should the nurse do based on ethical principles? A) Administer pain medication as requested to relieve the client's pain. B) Discuss the client's history of substance abuse with the healthcare provider. C) Withhold pain medication to avoid enabling addictive behavior. D) Consult with the client's family for guidance. <\Body> Correct Answer: A) Administer pain medication as requested to relieve the client's pain. Rationale: The nurse should prioritize the ethical principle of beneficence and provide appropriate pain relief to the client based on their assessment of pain. While the client's history of substance abuse should be considered and communicated to the healthcare provider, it should not be a reason to withhold pain medication when the client is in genuine pain. <\Explain> 100,4,0<\Number> C<\Answers> Question 100: A nurse is caring for a terminally ill client who expresses a desire for physician-assisted suicide to end their suffering. What ethical principle is central to this situation? A) Fidelity B) Veracity C) Autonomy D) Nonmaleficence <\Body> Correct Answer: C) Autonomy Rationale: In this situation, the central ethical principle is autonomy. The client has the right to make decisions about their own end-of-life care, including the choice to pursue physician-assisted suicide in certain jurisdictions where it is legally permitted. <\Explain> 101,4,0<\Number> C<\Answers> Question 101: A charge nurse is overseeing the care of a group of clients on a busy medical-surgical unit. A newly graduated nurse is assigned to administer medications to one of the clients. What action should the charge nurse prioritize when supervising the new graduate? A) Administer the medications personally to ensure accuracy. B) Assign additional clients to the new graduate for efficiency. C) Provide clear instructions and monitor the new graduate's administration. D) Delegate medication administration to the nursing assistant. <\Body> Correct Answer: C) Provide clear instructions and monitor the new graduate's administration. Rationale: When supervising a newly graduated nurse, the charge nurse should prioritize providing clear instructions and closely monitoring the administration of medications. This promotes safe and accurate care. Administering medications personally may not be necessary if the new graduate is competent, but clear supervision is essential to ensure proper practice. Assigning additional clients or delegating to unlicensed personnel without proper oversight can compromise patient safety. <\Explain> 102,4,0<\Number> C<\Answers> Question 102: A charge nurse is responsible for supervising unlicensed assistive personnel (UAP) on a busy surgical unit. What is the primary role of the charge nurse in this supervisory role? A) Perform all client care tasks to ensure accuracy. B) Delegate all client care responsibilities to the UAP. C) Provide guidance, direction, and monitor the UAP's performance. D) Complete documentation for the UAP to save time. <\Body> Correct Answer: C) Provide guidance, direction, and monitor the UAP's performance. Rationale: The primary role of the charge nurse when supervising UAP is to provide guidance, direction, and ongoing monitoring of the UAP's performance. Delegating all responsibilities or performing all tasks personally are not effective approaches to supervision. While the charge nurse may assist with documentation, it should not be the primary focus of supervision. <\Explain> 103,4,0<\Number> C<\Answers> Question 103: A charge nurse is supervising a nursing student who is providing care to a client with diabetes. The nursing student is unsure about insulin administration. What should the charge nurse do in this situation? A) Take over the care of the client to prevent errors. B) Ask another nurse to supervise the nursing student. C) Provide guidance, education, and demonstrate insulin administration. D) Ignore the nursing student's uncertainty to avoid embarrassment. <\Body> Correct Answer: C) Provide guidance, education, and demonstrate insulin administration. Rationale: In this situation, the charge nurse should provide guidance, education, and demonstrate the correct technique for insulin administration to the nursing student. This approach promotes learning and ensures that the student can safely and competently provide care. Taking over care may not be necessary if proper supervision and education are provided. <\Explain> 104,4,0<\Number> B<\Answers> Question 104: A charge nurse is overseeing the care of clients in a long-term care facility. One of the nursing assistants reports that a client is complaining of severe pain. The charge nurse instructs the nursing assistant to administer pain medication as prescribed. What is the charge nurse's primary responsibility in this situation? A) Administer the pain medication personally to ensure effectiveness. B) Verify the prescription with the healthcare provider before administration. C) Communicate with the client about the pain and assess the response. D) Delegate the administration of pain medication to another nursing assistant. <\Body> Correct Answer: B) Verify the prescription with the healthcare provider before administration. Rationale: The charge nurse's primary responsibility in this situation is to verify the prescription for pain medication with the healthcare provider before administration. It is essential to ensure that the medication is appropriate, safe, and within the scope of the nursing assistant's practice. Administering pain medication personally or delegating without verification can pose risks to the client's safety. Assessing the client's response and communicating about the pain are important steps but should follow prescription verification. <\Explain> 105,4,0<\Number> C<\Answers> Question 105: A charge nurse is supervising a group of nurses caring for clients on a busy medical-surgical unit. One of the nurses is responsible for administering blood transfusions. What action should the charge nurse take to ensure safe supervision of this task? A) Assign additional clients to the nurse to improve efficiency. B) Trust the nurse's experience and delegate without direct oversight. C) Provide guidance and closely monitor the nurse during transfusions. D) Complete all necessary documentation for the nurse. <\Body> Correct Answer: C) Provide guidance and closely monitor the nurse during transfusions. Rationale: When supervising the administration of blood transfusions, the charge nurse should provide guidance and closely monitor the nurse performing the task. Blood transfusions are high-risk procedures, and direct oversight is essential to ensure the safety and accuracy of the process. Assigning additional clients, delegating without oversight, or completing documentation do not substitute for proper supervision during transfusions. <\Explain> 106,4,0<\Number> A<\Answers> Question 106: A nurse is working on a busy medical-surgical unit and has multiple tasks to complete during the shift. What is the primary principle of effective time management for the nurse? A) Prioritize tasks based on their complexity. B) Multitask to complete as many tasks as possible simultaneously. C) Complete tasks in the order they are assigned. D) Delegate all tasks to unlicensed assistive personnel (UAP). <\Body> Correct Answer: A) Prioritize tasks based on their complexity. Rationale: Effective time management in nursing involves prioritizing tasks based on their complexity and urgency. This approach ensures that critical and time-sensitive tasks are addressed first, enhancing patient safety and quality of care. Multitasking can lead to errors, and completing tasks in the order they are assigned may not optimize time management. Delegating tasks to UAP should be done judiciously and in accordance with the nurse's scope of practice. <\Explain> 107,4,0<\Number> B<\Answers> Question 107: A nurse is caring for multiple clients with diverse needs. What time management strategy can help the nurse stay organized and focused during the shift? A) Delay documentation until the end of the shift. B) Create a to-do list and set specific priorities. C) Delegate all tasks to other nurses. D) Avoid taking breaks to maximize productivity. <\Body> Correct Answer: B) Create a to-do list and set specific priorities. Rationale: Creating a to-do list and setting specific priorities is an effective time management strategy for staying organized and focused during a shift. It allows the nurse to identify critical tasks, manage time efficiently, and ensure that important responsibilities are addressed promptly. Delaying documentation until the end of the shift can lead to errors and omissions. Delegating all tasks to other nurses may not be feasible or appropriate for all responsibilities. Taking reasonable breaks is essential for nurse well-being and should not be avoided. <\Explain> 108,4,0<\Number> A<\Answers> Question 108: A nurse is caring for a client who requires frequent wound dressing changes and medication administration. What time management approach should the nurse use to optimize care delivery? A) Perform wound dressing changes and medication administration concurrently. B) Delegate wound dressing changes to unlicensed assistive personnel (UAP). C) Prioritize wound dressing changes over medication administration. D) Complete wound dressing changes only when the client requests them. <\Body> Correct Answer: A) Perform wound dressing changes and medication administration concurrently. Rationale: Performing wound dressing changes and medication administration concurrently, when appropriate and safe, can optimize time management and reduce disruptions for the client. This approach ensures that both critical tasks are completed efficiently. Delegating wound dressing changes to UAP may be suitable in some cases, but it should be done judiciously and in accordance with policies and procedures. Prioritizing tasks based on clinical need and avoiding unnecessary delays in wound care are essential for quality care. Waiting for the client's request may not align with the care plan and clinical guidelines. <\Explain> 109,4,0<\Number> B<\Answers> Question 109: A nurse is responsible for administering medications to multiple clients. What action should the nurse take to ensure accurate medication administration and effective time management? A) Administer all medications at the beginning of the shift to save time. B) Group medications by route and administer them sequentially. C) Delegate medication administration to unlicensed assistive personnel (UAP). D) Administer medications randomly throughout the shift. <\Body> Correct Answer: B) Group medications by route and administer them sequentially. Rationale: Grouping medications by route and administering them sequentially is an effective time management strategy that enhances accuracy and minimizes interruptions. This approach reduces the risk of medication errors and allows the nurse to work efficiently. Administering all medications at the beginning of the shift may not align with prescribed administration times and could lead to missed doses. Delegating medication administration to UAP is generally not within their scope of practice. Administering medications randomly can be disorganized and may result in errors. <\Explain> 110,4,0<\Number> C<\Answers> Question 110: A nurse is caring for a client who requires frequent monitoring of vital signs. How can the nurse optimize time management while providing appropriate care? A) Delay vital sign assessments until the end of the shift. B) Delegate vital sign assessments to unlicensed assistive personnel (UAP). C) Incorporate vital sign assessments into other care activities. D) Perform vital sign assessments more frequently than necessary. <\Body> Correct Answer: C) Incorporate vital sign assessments into other care activities. Rationale: Incorporating vital sign assessments into other care activities, such as during medication administration or when providing hygiene care, optimizes time management and ensures that the client's needs are met efficiently. Delaying vital sign assessments until the end of the shift can lead to missed changes in the client's condition. Delegating vital sign assessments to UAP may not be within their scope of practice, depending on the facility's policies. Performing vital sign assessments more frequently than necessary can be excessive and may disrupt the client unnecessarily. <\Explain> 111,4,0<\Number> C<\Answers> Question 111: A nurse is admitting a client to the medical-surgical unit. What is the nurse's primary responsibility during the admission process? A) Completing discharge paperwork for the client. B) Providing education on post-discharge care. C) Assessing the client's condition and needs. D) Arranging transportation for the client's discharge. <\Body> Correct Answer: C) Assessing the client's condition and needs. Rationale: During the admission process, the nurse's primary responsibility is to assess the client's condition and needs. This assessment forms the basis for the client's care plan and ensures that appropriate interventions are initiated. Completing discharge paperwork, providing post-discharge education, and arranging transportation are tasks related to the discharge process, not admission. <\Explain> 112,4,0<\Number> C<\Answers> Question 112: A client is being transferred from a medical-surgical unit to the intensive care unit (ICU). What action should the nurse prioritize during the transfer process? A) Complete the client's discharge paperwork. B) Notify the family about the transfer. C) Communicate relevant information to the ICU staff. D) Ensure that the client's room is cleaned immediately. <\Body> Correct Answer: C) Communicate relevant information to the ICU staff. Rationale: During the transfer process, the nurse's priority is to communicate relevant information to the ICU staff to ensure a safe transition of care. This includes providing a detailed handoff report on the client's condition, treatments, and any important considerations. Completing discharge paperwork, notifying the family, and cleaning the room are tasks that occur after the transfer is complete. <\Explain> 113,4,0<\Number> A<\Answers> Question 113: A nurse is discharging a client who had surgery. What should the nurse ensure before the client's discharge? A) Provide comprehensive discharge education. B) Begin the discharge process promptly upon admission. C) Transfer the client to another unit for further care. D) Delegate the discharge process to a nursing assistant. <\Body> Correct Answer: A) Provide comprehensive discharge education. Rationale: Before a client's discharge, the nurse should ensure that comprehensive discharge education is provided to the client and their family or caregivers. This education includes instructions on post-discharge care, medications, follow-up appointments, and any signs of complications to watch for. Beginning the discharge process promptly upon admission is not necessary. Transferring the client to another unit would be indicated only if further specialized care is needed. Delegating the discharge process to a nursing assistant is not appropriate for tasks that require nursing judgment and education. <\Explain> 114,4,0<\Number> B<\Answers> Question 114: A nurse is admitting a pediatric client to the pediatric unit. What is an essential component of the admission process for pediatric clients? A) Administering medications immediately upon admission. B) Ensuring that a legal guardian or parent is present. C) Transferring the child to the adult unit for better care. D) Delaying the admission process for a thorough assessment. <\Body> Correct Answer: B) Ensuring that a legal guardian or parent is present. Rationale: An essential component of the admission process for pediatric clients is ensuring that a legal guardian or parent is present. Consent and collaboration with the child's guardian are crucial for the child's care and decision-making. Administering medications immediately upon admission may not be necessary and should be based on clinical judgment. Transferring the child to the adult unit is not indicated unless medically necessary. Delaying the admission process excessively is not ideal but should not compromise obtaining informed consent. <\Explain> 115,4,0<\Number> C<\Answers> Question 115: A client is being discharged from the hospital. What is a critical aspect of the nurse's responsibility during the discharge process? A) Administering prescribed medications before discharge. B) Completing the client's admission assessment. C) Ensuring that the client understands post-discharge instructions. D) Securing transportation for the client to leave the hospital. <\Body> Correct Answer: C) Ensuring that the client understands post-discharge instructions. Rationale: A critical aspect of the nurse's responsibility during the discharge process is ensuring that the client understands post-discharge instructions. This includes information on medications, follow-up appointments, self-care, and any signs of complications. Administering medications before discharge is important but not the primary focus of the nurse's role during discharge. Completing the admission assessment is unrelated to the discharge process. Securing transportation for the client may be necessary but is not the primary responsibility of the nurse. <\Explain> 116,4,0<\Number> D<\Answers> Question 116: A nurse is discussing a client's medical condition with a coworker in the hospital cafeteria. What action by the nurse demonstrates a breach of client confidentiality? A) Using the client's initials instead of their full name. B) Speaking quietly to ensure others cannot overhear. C) Sharing the information with a trusted colleague. D) Discussing the client's condition in a public area. <\Body> Correct Answer: D) Discussing the client's condition in a public area. Rationale: Discussing a client's medical condition in a public area, such as the hospital cafeteria, constitutes a breach of client confidentiality. This action may unintentionally allow unauthorized individuals to overhear sensitive information. Using initials, speaking quietly, and sharing information with trusted colleagues are measures to protect client confidentiality. <\Explain> 117,4,0<\Number> D<\Answers> Question 117: A nurse is caring for a client with a highly contagious disease. What is the nurse's primary responsibility regarding client confidentiality in this situation? A) Informing all healthcare team members about the diagnosis. B) Disclosing the diagnosis to the client's family without consent. C) Ensuring that the client's room is clearly marked with the diagnosis. D) Limiting the disclosure of the diagnosis to those with a need to know. <\Body> Correct Answer: D) Limiting the disclosure of the diagnosis to those with a need to know. Rationale: The nurse's primary responsibility in caring for a client with a highly contagious disease is to limit the disclosure of the diagnosis to those with a legitimate need to know, such as healthcare team members directly involved in the client's care. Informing all healthcare team members, disclosing the diagnosis to the family without consent, or marking the room with the diagnosis can compromise the client's confidentiality and may not be necessary for safe care. <\Explain> 118,4,0<\Number> B<\Answers> Question 118: A nurse is providing care to a celebrity client. What should be the nurse's priority when it comes to maintaining client confidentiality? A) Sharing interesting details about the celebrity's condition with friends. B) Avoiding discussing the client's condition with anyone. C) Informing the media about the client's hospitalization. D) Documenting the client's condition in the medical record. <\Body> Correct Answer: B) Avoiding discussing the client's condition with anyone. Rationale: When caring for a celebrity client, the nurse's priority is to avoid discussing the client's condition with anyone who does not have a legitimate need to know, even if the client is a public figure. Sharing interesting details with friends, informing the media, or documenting the condition in the medical record is not in alignment with maintaining client confidentiality. <\Explain> 119,4,0<\Number> C<\Answers> Question 119: A nurse is caring for a minor client who requests that their medical information not be shared with their parents. What action should the nurse take regarding confidentiality in this situation? A) Share all medical information with the client's parents. B) Inform the client's parents about the request. C) Respect the client's request for confidentiality if legally allowed. D) Document the request but continue sharing information with the parents. <\Body> Correct Answer: C) Respect the client's request for confidentiality if legally allowed. Rationale: When a minor client requests confidentiality, the nurse should respect this request if legally allowed. Depending on the jurisdiction and the client's age, minors may have the legal right to request that their medical information not be shared with their parents. Sharing all information with parents, informing the parents about the request, or disregarding the request would not respect the client's autonomy and confidentiality. <\Explain> 120,4,0<\Number> B<\Answers> Question 120: A nurse is using a computer in the hospital's nursing station to access a client's electronic health record (EHR). What action should the nurse take to maintain client confidentiality when using the EHR? A) Share the EHR login credentials with trusted colleagues. B) Log out of the EHR when finished and safeguard login information. C) Print a copy of the EHR and leave it in a public area. D) Keep the EHR session open for quick access throughout the shift. <\Body> Correct Answer: B) Log out of the EHR when finished and safeguard login information. Rationale: To maintain client confidentiality when using the EHR, the nurse should log out of the EHR when finished and safeguard login information. Sharing login credentials with colleagues, leaving printed EHR copies in public areas, or keeping the EHR session open for quick access can compromise client confidentiality and data security. <\Explain> 121,4,0<\Number> C<\Answers> Question 121: A nurse is providing education to a client about their rights regarding medical treatment and decision-making. What is a fundamental aspect of client education on this topic? A) Advising the client to always follow the healthcare provider's recommendations. B) Encouraging the client to delegate decision-making to family members. C) Informing the client of their right to informed consent and refusal. D) Discouraging the client from asking questions about their treatment. <\Body> Correct Answer: C) Informing the client of their right to informed consent and refusal. Rationale: A fundamental aspect of client education regarding rights is informing the client of their right to informed consent and refusal. This includes the right to make informed decisions about their medical treatment and to refuse treatment if they choose to do so. Advising unquestioning compliance, encouraging delegation of decision-making, or discouraging questions goes against the principles of informed consent and patient autonomy. <\Explain> 122,4,0<\Number> C<\Answers> Question 122: A client is scheduled to undergo a surgical procedure. What should the nurse emphasize when educating the client about the informed consent process? A) The need for the client's signature on the consent form only. B) The importance of signing the consent form before any discussion. C) The right to ask questions and seek clarification. D) The necessity of relying solely on the healthcare provider's decision. <\Body> Correct Answer: C) The right to ask questions and seek clarification. Rationale: When educating a client about the informed consent process, the nurse should emphasize the client's right to ask questions, seek clarification, and fully understand the procedure before signing the consent form. Informed consent is a collaborative process that involves the client's active participation and understanding. Emphasizing the need for the client's signature only, signing the form before discussion, or relying solely on the healthcare provider's decision does not align with the principles of informed consent. <\Explain> 123,4,0<\Number> D<\Answers> Question 123: A nurse is educating a client about their right to privacy and confidentiality. What is a key component of this education? A) Discouraging the client from sharing personal information with healthcare providers. B) Informing the client that their information is shared freely among the healthcare team. C) Explaining that healthcare providers are exempt from privacy laws. D) Assuring the client that their information will be kept confidential within legal limits. <\Body> Correct Answer: D) Assuring the client that their information will be kept confidential within legal limits. Rationale: A key component of educating a client about their right to privacy and confidentiality is assuring the client that their information will be kept confidential within legal limits. Healthcare providers are obligated to protect a client's privacy and confidentiality, but there are exceptions for legal and medical reasons. Discouraging the client from sharing personal information, misinforming them about information sharing among the healthcare team, or suggesting that healthcare providers are exempt from privacy laws is not accurate or ethical. <\Explain> 124,4,0<\Number> C<\Answers> Question 124: A nurse is preparing a client for a surgical procedure and discussing the consent form. What is the primary purpose of obtaining informed consent from the client? A) To ensure that the client receives the most expensive treatment option. B) To protect the healthcare provider from liability. C) To respect the client's autonomy and right to make decisions about their care. D) To expedite the admission process for the client. <\Body> Correct Answer: C) To respect the client's autonomy and right to make decisions about their care. Rationale: The primary purpose of obtaining informed consent from the client is to respect the client's autonomy and their right to make informed decisions about their medical care. Informed consent is not about the cost of treatment, protecting the healthcare provider, or expediting the admission process. It is a legal and ethical requirement that ensures the client's participation in their healthcare decisions. <\Explain> 125,4,0<\Number> C<\Answers> Question 125: A nurse is providing education to a client regarding their right to refuse medical treatment. What should the nurse emphasize to the client about this right? A) The right to refuse treatment only if it is non-invasive. B) The need to explain their refusal to the healthcare provider. C) The right to refuse treatment for any reason, even if it is life-saving. D) The requirement to obtain family consent before refusing treatment. <\Body> Correct Answer: C) The right to refuse treatment for any reason, even if it is life-saving. Rationale: The nurse should emphasize to the client that they have the right to refuse treatment for any reason, even if the treatment is life-saving. This right is based on the principle of patient autonomy and respects the client's right to make decisions about their own body. While it is encouraged to discuss reasons for refusal with the healthcare provider, it is not a requirement. Obtaining family consent before refusing treatment is not a standard practice unless the client lacks decision-making capacity. <\Explain> 126,4,0<\Number> B<\Answers> Question 126: A nurse receives a verbal order from a healthcare provider for a medication. What is the nurse's priority action? A) Administer the medication immediately. B) Confirm the order in writing. C) Call the pharmacy for medication availability. D) Consult with the charge nurse for guidance. <\Body> Correct Answer: B) Confirm the order in writing. Rationale: The nurse's priority action when receiving a verbal order from a healthcare provider is to confirm the order in writing. This ensures accuracy and serves as documentation of the order. Administering the medication immediately without written confirmation can lead to errors. Calling the pharmacy or consulting the charge nurse may be necessary, but confirming the order in writing is the first step. <\Explain> 127,4,0<\Number> B<\Answers> Question 127: A nurse is reviewing a medication order in a client's electronic health record (EHR). The order appears unclear. What should the nurse do next? A) Proceed with administering the medication as written. B) Contact the healthcare provider to clarify the order. C) Ask a colleague for their interpretation of the order. D) Administer a different medication instead. <\Body> Correct Answer: B) Contact the healthcare provider to clarify the order. Rationale: If a medication order appears unclear, the nurse should contact the healthcare provider to seek clarification. Administering the medication without understanding the order can lead to medication errors. Consulting with colleagues or administering a different medication is not appropriate until the order is clarified. <\Explain> 128,4,0<\Number> B<\Answers> Question 128: A nurse receives a telephone order from a healthcare provider for a change in a client's treatment plan. What should the nurse do first? A) Document the order in the client's chart. B) Repeat the order back to the healthcare provider. C) Implement the change in the client's care immediately. D) Seek approval from the charge nurse. <\Body> Correct Answer: B) Repeat the order back to the healthcare provider. Rationale: When receiving a telephone order, the nurse's first action should be to repeat the order back to the healthcare provider to ensure accuracy and clarity. Documenting the order, implementing the change, and seeking approval from the charge nurse may follow, but repeating the order back is a crucial step in the process. <\Explain> 129,4,0<\Number> C<\Answers> Question 129: A nurse is reviewing a healthcare provider's written prescription for a client's medication. What information should the nurse prioritize when verifying the order? A) The client's preferred medication brand. B) The healthcare provider's contact information. C) The medication name, dosage, route, and frequency. D) The client's insurance information. <\Body> Correct Answer: C) The medication name, dosage, route, and frequency. Rationale: When verifying a healthcare provider's written prescription, the nurse should prioritize checking the medication name, dosage, route, and frequency to ensure accuracy and safety in medication administration. The client's preferred brand, the healthcare provider's contact information, and the client's insurance information are relevant but secondary considerations in this context. <\Explain> 130,4,0<\Number> C<\Answers> Question 130: A nurse is preparing to administer a medication to a client. The medication order in the client's electronic health record (EHR) is different from what the client verbalized. What should the nurse do first? A) Administer the medication as documented in the EHR. B) Ask another nurse for their opinion on the order. C) Verify the order with the healthcare provider. D) Document the client's verbalized request. <\Body> Correct Answer: C) Verify the order with the healthcare provider. Rationale: When there is a discrepancy between the medication order in the EHR and the client's verbalized request, the nurse should first verify the order with the healthcare provider to ensure the correct medication is administered. Administering the medication based solely on the EHR documentation can lead to errors. Consulting another nurse may be helpful but should not replace verification with the healthcare provider. Documenting the client's verbalized request is important but should not take precedence over order verification. <\Explain> 131,4,0<\Number> B<\Answers> Question 131: A nurse is caring for four clients. Which client should the nurse prioritize for immediate assessment? A) A client with a scheduled medication administration in 30 minutes. B) A client reporting chest pain and shortness of breath. C) A client requesting assistance with bathing. D) A client scheduled for a routine follow-up appointment tomorrow. <\Body> Correct Answer: B) A client reporting chest pain and shortness of breath. Rationale: When prioritizing care, the nurse should address potentially life-threatening situations first. Chest pain and shortness of breath are symptoms that could indicate a cardiac emergency. Administering scheduled medications, assisting with bathing, and routine follow-up appointments are important but not as high a priority as assessing a client with urgent symptoms. <\Explain> 132,4,0<\Number> C<\Answers> Question 132: A nurse is providing care to a group of clients. Which client should the nurse attend to first? A) A post-operative client who needs pain medication. B) A client who requests assistance with repositioning. C) A client receiving a blood transfusion with an allergic reaction. D) A client scheduled for a routine dressing change. <\Body> Correct Answer: C) A client receiving a blood transfusion with an allergic reaction. Rationale: The nurse should prioritize the client receiving a blood transfusion with an allergic reaction because this is a potentially life-threatening situation that requires immediate attention to prevent further complications. While pain management, client requests, and routine dressing changes are important, they are not as urgent as addressing an allergic reaction to a blood transfusion. <\Explain> 133,4,0<\Number> B<\Answers> Question 133: A nurse is triaging clients in the emergency department. Which client should the nurse see first? A) A client with a sprained ankle requesting ice and elevation. B) A client with a suspected stroke who has slurred speech. C) A client with a minor laceration requesting sutures. D) A client with a history of hypertension requesting blood pressure monitoring. <\Body> Correct Answer: B) A client with a suspected stroke who has slurred speech. Rationale: The nurse should prioritize the client with a suspected stroke who has slurred speech because stroke symptoms require immediate assessment and intervention to minimize potential brain damage. While the other clients' needs are important, they are not as urgent as evaluating and addressing stroke symptoms. <\Explain> 134,4,0<\Number> B<\Answers> Question 134: A nurse is caring for a group of clients. Which client should the nurse attend to first? A) A client with controlled diabetes requesting a snack. B) A client with a newly placed tracheostomy who is coughing vigorously. C) A client with a stage III pressure ulcer requiring a dressing change. D) A client with a history of asthma requesting a breathing treatment. <\Body> Correct Answer: B) A client with a newly placed tracheostomy who is coughing vigorously. Rationale: The nurse should prioritize the client with a newly placed tracheostomy who is coughing vigorously because this client is at risk of airway obstruction or displacement of the tracheostomy tube, which requires immediate intervention. While the other clients' needs are important, they are not as critical as ensuring the airway is clear for the tracheostomy client. <\Explain> 135,4,0<\Number> C<\Answers> Question 135: A nurse is working in a busy medical-surgical unit. Which client should the nurse attend to first? A) A client with diabetes requesting a dietary consultation. B) A client with a urinary tract infection (UTI) who needs a urine specimen collected. C) A client with a history of cardiac disease reporting chest discomfort. D) A client scheduled for a routine medication administration. <\Body> Correct Answer: C) A client with a history of cardiac disease reporting chest discomfort. Rationale: The nurse should prioritize the client with a history of cardiac disease reporting chest discomfort because this symptom may indicate a cardiac event, such as a myocardial infarction (heart attack), and requires immediate assessment and intervention. While the other clients' needs are important, they are not as critical as addressing potential cardiac issues. <\Explain> 136,4,0<\Number> C<\Answers> Question 136: A nurse working in a long-term care facility suspects that a client is experiencing abuse by a family member. What is the nurse's immediate action? A) Confront the family member about the suspicion. B) Document the suspicion in the client's chart. C) Report the suspicion to the appropriate authorities. D) Discuss the suspicion with a colleague for advice. <\Body> Correct Answer: C) Report the suspicion to the appropriate authorities. Rationale: When a nurse suspects abuse or neglect, the immediate action is to report the suspicion to the appropriate authorities. Confronting the family member may escalate the situation and compromise the safety of the client. Documentation is essential but should follow the reporting process. Discussing the suspicion with a colleague is appropriate, but reporting to the authorities takes precedence to protect the client's well-being. <\Explain> 137,4,0<\Number> C<\Answers> Question 137: A school nurse is informed by a teacher that several students in a class have been diagnosed with a communicable disease. What should the nurse do first? A) Notify the school principal about the outbreak. B) Isolate the affected students in a designated area. C) Report the outbreak to the local health department. D) Inform the parents of the affected students. <\Body> Correct Answer: C) Report the outbreak to the local health department. Rationale: When a school nurse becomes aware of a communicable disease outbreak, the first action should be to report the outbreak to the local health department. This helps initiate appropriate public health measures to control the spread of the disease. While notifying the school principal, isolating affected students, and informing parents are important actions, reporting to the health department is the priority in managing communicable disease outbreaks. <\Explain> 138,4,0<\Number> D<\Answers> Question 138: A nurse is caring for an elderly client in a home healthcare setting and suspects that the client is being financially exploited by a family member. What should the nurse do? A) Confront the family member about the suspicion. B) Document the suspicion in the client's medical record. C) Discuss the suspicion with the client's primary healthcare provider. D) Report the suspicion to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion to the appropriate authorities. Rationale: When a nurse suspects financial exploitation of an elderly client, the appropriate action is to report the suspicion to the appropriate authorities, such as Adult Protective Services (APS) or local law enforcement. Confronting the family member directly may put the client at risk. Documentation is important but should follow the reporting process. Discussing the suspicion with the primary healthcare provider may be appropriate, but reporting to authorities is the priority to protect the client. <\Explain> 139,4,0<\Number> D<\Answers> Question 139: A nurse is working in a healthcare facility and suspects that a colleague is diverting medications for personal use. What is the nurse's immediate action? A) Confront the colleague about the suspicion. B) Document the suspicion in the colleague's personnel file. C) Discuss the suspicion with the charge nurse. D) Report the suspicion to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion to the appropriate authorities. Rationale: When a nurse suspects a colleague of diverting medications, the immediate action is to report the suspicion to the appropriate authorities, such as the facility's administration, pharmacy, or a state regulatory agency. Confronting the colleague directly may interfere with an investigation and could be unsafe. Documentation may be necessary but should follow the reporting process. Discussing the suspicion with the charge nurse may be appropriate, but reporting to the authorities is essential to address potential medication diversion. <\Explain> 140,4,0<\Number> D<\Answers> Question 140: A home healthcare nurse is caring for a client and notices multiple unexplained bruises and injuries. What should the nurse do? A) Confront the client about the injuries. B) Document the injuries in the client's medical record. C) Discuss the injuries with the client's family. D) Report the injuries to Adult Protective Services (APS). <\Body> Correct Answer: D) Report the injuries to Adult Protective Services (APS). Rationale: When a nurse observes unexplained injuries or signs of possible abuse or neglect in a client, the immediate action is to report the injuries to the appropriate authorities, such as Adult Protective Services (APS). Confronting the client may not be safe or effective. Documentation is essential but should follow the reporting process. Discussing the injuries with the client's family may not be appropriate if there are concerns about family involvement in the abuse or neglect. <\Explain> 141,4,0<\Number> C<\Answers> Question 141: A nurse is participating in a performance improvement (PI) project in a healthcare facility. What is the primary goal of PI initiatives? A) Reducing healthcare costs. B) Increasing staff workload. C) Improving patient outcomes. D) Enhancing administrative tasks. <\Body> Correct Answer: C) Improving patient outcomes. Rationale: The primary goal of performance improvement (PI) initiatives in healthcare is to improve patient outcomes by enhancing the quality and safety of care provided. While cost reduction and administrative efficiency are important considerations, the ultimate focus of PI is on improving the care and experiences of patients. <\Explain> 142,4,0<\Number> C<\Answers> Question 142: A nurse is involved in a performance improvement (PI) project aimed at reducing medication errors. Which step is essential in the PI process? A) Identifying a scapegoat for errors. B) Assigning blame to individual staff members. C) Analyzing the root causes of errors. D) Implementing punitive measures immediately. <\Body> Correct Answer: C) Analyzing the root causes of errors. Rationale: In the performance improvement (PI) process, it is essential to analyze the root causes of errors rather than assigning blame to individual staff members or seeking scapegoats. Identifying the underlying causes helps in implementing effective preventive measures and improving the system to reduce future errors. <\Explain> 143,4,0<\Number> C<\Answers> Question 143: A nurse is participating in a performance improvement (PI) project focused on reducing hospital-acquired infections (HAIs). What should be the nurse's initial step in this project? A) Conducting staff training on infection control. B) Identifying specific types of HAIs to target. C) Collecting and analyzing data on current infection rates. D) Implementing new infection control policies immediately. <\Body> Correct Answer: C) Collecting and analyzing data on current infection rates. Rationale: The initial step in a performance improvement (PI) project focused on reducing hospital-acquired infections (HAIs) is to collect and analyze data on current infection rates. This data provides the baseline for understanding the scope of the problem and allows for targeted interventions. Staff training, identification of specific HAIs, and policy implementation are subsequent steps in the PI process. <\Explain> 144,4,0<\Number> C<\Answers> Question 144: A nurse is involved in a performance improvement (PI) project to enhance the accuracy of medication administration. What action should the nurse take to facilitate this process? A) Assign blame to nurses involved in medication errors. B) Withhold information from the PI team to avoid criticism. C) Report all medication errors to the PI team for analysis. D) Implement punitive measures without investigation. <\Body> Correct Answer: C) Report all medication errors to the PI team for analysis. Rationale: To facilitate the performance improvement (PI) process and enhance the accuracy of medication administration, it is essential to report all medication errors to the PI team for analysis. Blaming individuals, withholding information, or implementing punitive measures without investigation can hinder the reporting of errors and the improvement process. <\Explain> 145,4,0<\Number> C<\Answers> Question 145: A nurse is participating in a performance improvement (PI) project aimed at reducing patient falls. What is the nurse's role in this project? A) Assigning blame to healthcare providers after each fall. B) Implementing punitive measures for patients who fall. C) Analyzing the root causes of patient falls. D) Withholding information about falls from the PI team. <\Body> Correct Answer: C) Analyzing the root causes of patient falls. Rationale: In a performance improvement (PI) project focused on reducing patient falls, the nurse's role includes analyzing the root causes of patient falls. This analysis helps identify contributing factors and allows for the development of effective preventive strategies. Blaming healthcare providers or patients and implementing punitive measures are not the primary roles of nurses in the PI process. <\Explain> <\Questions> <\Section>
Health Promotion & Maintenance - CH2 1,4,0<\Number> A<\Answers> Question 1: During which stage of development does a child typically begin to develop basic trust or mistrust, according to Erik Erikson's psychosocial theory? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Preschool age (3-6 years) D) School-age (6-12 years) <\Body> Correct Answer: A) Infancy (0-1 year) Rationale: Erik Erikson's first psychosocial stage is Trust vs. Mistrust, which occurs during infancy. During this stage, infants develop a sense of trust when their basic needs are consistently met, leading to a positive outcome. <\Explain> 2,4,0<\Number> C<\Answers> Question 2: Which immunization is typically administered to infants at birth to provide protection against hepatitis B? A) MMR (Measles, Mumps, Rubella) B) DTaP (Diphtheria, Tetanus, Pertussis) C) Hepatitis B D) Polio (IPV) <\Body> Correct Answer: C) Hepatitis B Rationale: Hepatitis B vaccination is typically administered to newborns at birth to provide early protection against hepatitis B infection. MMR, DTaP, and Polio vaccines are given at different stages of childhood. <\Explain> 3,4,0<\Number> B<\Answers> Question 3: At what age should children be transitioned from rear-facing car seats to forward-facing car seats? A) 1 year B) 2 years C) 3 years D) 4 years <\Body> Correct Answer: B) 2 years Rationale: The American Academy of Pediatrics recommends transitioning children from rear-facing car seats to forward-facing car seats at around 2 years of age or when they outgrow the rear-facing seat's weight and height limits. <\Explain> 4,4,0<\Number> C<\Answers> Question 4: Which developmental stage is characterized by children developing a sense of initiative or guilt, according to Erik Erikson's psychosocial theory? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Preschool age (3-6 years) D) School-age (6-12 years) <\Body> Correct Answer: C) Preschool age (3-6 years) Rationale: Erik Erikson's third psychosocial stage is Initiative vs. Guilt, which occurs during preschool age. Children in this stage begin to explore their environment and develop a sense of purpose and initiative. <\Explain> 5,4,0<\Number> C<\Answers> Question 5: Which nutrient is essential for the formation and maintenance of strong bones and teeth in children? A) Vitamin C B) Iron C) Calcium D) Vitamin D <\Body> Correct Answer: C) Calcium Rationale: Calcium is essential for bone and teeth formation and maintenance. It is crucial for children's growth and development. <\Explain> 6,4,0<\Number> A<\Answers> Question 6: What is the primary goal of health promotion during the adolescent stage? A) Promoting independence B) Preventing childhood illnesses C) Ensuring proper nutrition in infants D) Monitoring vital signs in the elderly <\Body> Correct Answer: A) Promoting independence Rationale: Adolescents are striving for independence and autonomy. Health promotion during this stage should focus on supporting their development of independence and decision-making skills. <\Explain> 7,4,0<\Number> A<\Answers> Question 7: At what age should children typically begin receiving the influenza (flu) vaccine annually? A) 2 years B) 5 years C) 12 years D) 18 years <\Body> Correct Answer: A) 2 years Rationale: Children should start receiving the annual influenza vaccine at 2 years of age and continue to receive it annually to protect against seasonal flu. <\Explain> 8,4,0<\Number> C<\Answers> Question 8: Which cognitive development stage, according to Jean Piaget, is characterized by children being able to think logically about concrete events and understand conservation? A) Sensorimotor stage B) Preoperational stage C) Concrete operational stage D) Formal operational stage <\Body> Correct Answer: C) Concrete operational stage Rationale: According to Piaget, the concrete operational stage (7-11 years) is when children develop the ability to think logically about concrete events and understand principles like conservation of mass and volume. <\Explain> 9,4,0<\Number> C<\Answers> Question 9: Which is a common psychosocial challenge faced by middle-aged adults, according to Erik Erikson's psychosocial theory? A) Identity vs. Role Confusion B) Intimacy vs. Isolation C) Generativity vs. Stagnation D) Ego Integrity vs. Despair <\Body> Correct Answer: C) Generativity vs. Stagnation Rationale: Erikson's psychosocial challenge for middle-aged adults is Generativity vs. Stagnation, where individuals seek to contribute to the next generation and society or may feel stagnation. <\Explain> 10,4,0<\Number> B<\Answers> Question 10: Which type of play is characterized by a child playing alongside others without direct interaction or sharing of toys? A) Solitary play B) Parallel play C) Cooperative play D) Associative play <\Body> Correct Answer: B) Parallel play Rationale: Parallel play is when children play alongside others but do not directly interact or share toys. It is common among toddlers. <\Explain> 11,4,0<\Number> B<\Answers> Question 11: Which age-related change in the musculoskeletal system increases the risk of falls in older adults? A) Increased bone density B) Decreased muscle strength C) Enhanced joint flexibility D) Improved proprioception <\Body> Correct Answer: B) Decreased muscle strength Rationale: Decreased muscle strength is a common age-related change in the musculoskeletal system that can lead to impaired balance and an increased risk of falls in older adults. <\Explain> 12,4,0<\Number> B<\Answers> Question 12: What is the primary physiological change that occurs in the cardiovascular system as a part of the aging process? A) Increased cardiac output B) Reduced elasticity of blood vessels C) Blunted response to stress D) Improved circulation <\Body> Correct Answer: B) Reduced elasticity of blood vessels Rationale: One of the primary age-related changes in the cardiovascular system is reduced elasticity of blood vessels, which can contribute to hypertension and other cardiovascular issues. <\Explain> 13,4,0<\Number> B<\Answers> Question 13: Which age-related change in the respiratory system may lead to decreased lung function in older adults? A) Increased lung capacity B) Decreased lung elasticity C) Improved oxygen exchange D) Enhanced respiratory muscle strength <\Body> Correct Answer: B) Decreased lung elasticity Rationale: Decreased lung elasticity is a common age-related change in the respiratory system that can lead to decreased lung function and increased vulnerability to respiratory diseases. <\Explain> 14,4,0<\Number> C<\Answers> Question 14: Which of the following sensory changes is commonly associated with the aging process? A) Improved hearing acuity B) Enhanced taste perception C) Reduced visual acuity D) Increased olfactory sensitivity <\Body> Correct Answer: C) Reduced visual acuity Rationale: Reduced visual acuity, or declining vision, is a common age-related sensory change in older adults. <\Explain> 15,4,0<\Number> C<\Answers> Question 15: What is a common age-related change in the gastrointestinal system that may lead to constipation in older adults? A) Increased gastric acid production B) Poor absorption of nutrients C) Slower peristalsis D) Decreased appetite <\Body> Correct Answer: C) Slower peristalsis Rationale: Slower peristalsis, or the movement of food through the digestive tract, is a common age-related change in the gastrointestinal system that can contribute to constipation. <\Explain> 16,4,0<\Number> C<\Answers> Question 16: Which cognitive change is often observed in normal aging and is characterized by a slower processing speed for information? A) Improved long term memory B) Enhanced problem-solving skills C) Slower reaction time D) Increased attention span <\Body> Correct Answer: C) Slower reaction time Rationale: Slower reaction time is a cognitive change commonly observed in normal aging and is associated with a reduced processing speed for information. <\Explain> 17,4,0<\Number> C<\Answers> Question 17: What is a potential risk factor for osteoporosis in older adults? A) Regular weight-bearing exercise B) High calcium intake C) Low vitamin D levels D) Adequate estrogen production <\Body> Correct Answer: C) Low vitamin D levels Rationale: Low vitamin D levels are a potential risk factor for osteoporosis in older adults, as vitamin D is essential for calcium absorption and bone health. <\Explain> 18,4,0<\Number> D<\Answers> Question 18: Which psychological adjustment is often associated with the later stages of the aging process, as described by Erik Erikson? A) Identity vs. Role Confusion B) Intimacy vs. Isolation C) Generativity vs. Stagnation D) Ego Integrity vs. Despair <\Body> Correct Answer: D) Ego Integrity vs. Despair Rationale: According to Erik Erikson, the later stages of the aging process are characterized by the psychosocial challenge of Ego Integrity vs. Despair, where individuals reflect on their life and seek to find meaning and satisfaction. <\Explain> 19,4,0<\Number> C<\Answers> Question 19: What is a common age-related change in the endocrine system that may lead to insulin resistance in older adults? A) Increased production of insulin B) Enhanced thyroid hormone production C) Reduced growth hormone secretion D) Decreased cortisol levels <\Body> Correct Answer: C) Reduced growth hormone secretion Rationale: Reduced growth hormone secretion is a common age-related change in the endocrine system that can contribute to insulin resistance in older adults. <\Explain> 20,4,0<\Number> B<\Answers> Question 20: Which type of memory, often affected by normal aging, is responsible for retaining and recalling recent experiences and information? A) Semantic memory B) Short-term memory C) Episodic memory D) Procedural memory <\Body> Correct Answer: B) Short-term memory Rationale: Short-term memory, responsible for retaining and recalling recent experiences and information, is often affected by normal aging. <\Explain> 21,4,0<\Number> B<\Answers> Question 21: Which risk factor is most commonly associated with the infancy stage (0-1 year) in terms of sudden infant death syndrome (SIDS)? A) Obesity B) Smoking exposure C) Lack of immunizations D) Excessive screen time <\Body> Correct Answer: B) Smoking exposure Rationale: Smoking exposure, particularly maternal smoking during pregnancy or exposure to secondhand smoke, is a significant risk factor for Sudden Infant Death Syndrome (SIDS) during the infancy stage. <\Explain> 22,4,0<\Number> B<\Answers> Question 22: In which developmental stage (1-3 years) is lead exposure a significant risk factor for developmental delays? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Preschool age (3-6 years) D) School-age (6-12 years) <\Body> Correct Answer: B) Toddlerhood (1-3 years) Rationale: Lead exposure is a significant risk factor for developmental delays, particularly during the toddlerhood stage when children may be more likely to ingest lead-containing substances. <\Explain> 23,4,0<\Number> C<\Answers> Question 23: Which developmental stage is most critical for the identification and early intervention of speech and language disorders? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Preschool age (3-6 years) D) School-age (6-12 years) <\Body> Correct Answer: C) Preschool age (3-6 years) Rationale: Preschool age is a critical period for identifying and intervening in speech and language disorders, as early intervention can have a significant impact on a child's communication development. <\Explain> 24,4,0<\Number> C<\Answers> Question 24: Which risk factor is often associated with the school-age stage (6-12 years) in terms of childhood obesity? A) Breastfeeding B) Regular physical activity C) Sedentary lifestyle and poor diet D) Adequate sleep <\Body> Correct Answer: C) Sedentary lifestyle and poor diet Rationale: A sedentary lifestyle and poor diet, including excessive consumption of sugary and high-calorie foods, are common risk factors for childhood obesity during the school-age stage. <\Explain> 25,4,0<\Number> D<\Answers> Question 25: During which developmental stage is substance abuse and experimentation with alcohol and drugs a significant risk factor for adolescents? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Preschool age (3-6 years) D) Adolescence (12-18 years) <\Body> Correct Answer: D) Adolescence (12-18 years) Rationale: Adolescence is a stage where individuals may experiment with alcohol and drugs, and substance abuse becomes a significant risk factor during this developmental period. <\Explain> 26,4,0<\Number> B<\Answers> Question 26: Which risk factor is commonly associated with middle adulthood in terms of heart disease prevention? A) Physical fitness B) Tobacco use C) Healthy diet D) Childhood immunizations <\Body> Correct Answer: B) Tobacco use Rationale: Tobacco use is a significant risk factor for heart disease, and middle adulthood is a critical stage for addressing and preventing smoking habits to reduce this risk. <\Explain> 27,4,0<\Number> D<\Answers> Question 27: In the older adult stage, which risk factor is closely linked to the development of osteoporosis? A) Regular weight-bearing exercise B) Adequate calcium intake C) Hormone replacement therapy D) Frequent alcohol consumption <\Body> Correct Answer: D) Frequent alcohol consumption Rationale: Frequent alcohol consumption is a risk factor for osteoporosis in older adults as it can interfere with calcium absorption and bone health. <\Explain> 28,4,0<\Number> C<\Answers> Question 28: During which developmental stage is the risk of sexually transmitted infections (STIs) often a concern? A) Infancy (0-1 year) B) Toddlerhood (1-3 years) C) Adolescence (12-18 years) D) Middle adulthood (40-65 years) <\Body> Correct Answer: C) Adolescence (12-18 years) Rationale: Adolescence is a stage when individuals may engage in sexual activity, and the risk of sexually transmitted infections (STIs) becomes a concern during this developmental period. <\Explain> 29,4,0<\Number> B<\Answers> Question 29: Which risk factor is commonly associated with middle adulthood in terms of cancer prevention? A) Physical fitness B) Family history of cancer C) Regular health screenings D) Adequate sleep <\Body> Correct Answer: B) Family history of cancer Rationale: A family history of cancer is a risk factor for cancer, and middle adulthood is a stage when individuals should be aware of their family's medical history and undergo regular health screenings. <\Explain> 30,4,0<\Number> C<\Answers> Question 30: During the infancy stage (0-1 year), what risk factor should be assessed to prevent accidental suffocation and Sudden Infant Death Syndrome (SIDS)? A) Parental education level B) Breastfeeding initiation C) Safe sleep practices D) Introduction of solid foods <\Body> Correct Answer: C) Safe sleep practices Rationale: Safe sleep practices, including placing infants on their backs in a crib with no soft bedding or toys, are crucial in preventing accidental suffocation and Sudden Infant Death Syndrome (SIDS) during infancy. <\Explain> 31,4,0<\Number> C<\Answers> Question 31: When assessing individual risk factors for cardiovascular disease, which factor is considered non-modifiable? A) High blood pressure B) Smoking C) Family history of heart disease D) Physical inactivity <\Body> Correct Answer: C) Family history of heart disease Rationale: Family history of heart disease is a non-modifiable risk factor, as individuals cannot change their genetic predisposition to heart disease. It is important to assess this factor to determine the level of risk for an individual. <\Explain> 32,4,0<\Number> B<\Answers> Question 32: In a community health assessment, which factor is an example of a social determinant of health? A) High cholesterol levels B) Access to healthcare services C) Smoking status D) Sedentary lifestyle <\Body> Correct Answer: B) Access to healthcare services Rationale: Access to healthcare services is a social determinant of health that can significantly impact a community's overall health outcomes. It includes factors like healthcare availability, affordability, and accessibility. <\Explain> 33,4,0<\Number> C<\Answers> Question 33: When evaluating individual risk factors for diabetes, which one is considered a modifiable risk factor? A) Age B) Family history of diabetes C) Body mass index (BMI) D) Gender <\Body> Correct Answer: C) Body mass index (BMI) Rationale: Body mass index (BMI) is a modifiable risk factor for diabetes, as it can be influenced through lifestyle changes such as diet and exercise. Age, family history, and gender are non-modifiable risk factors. <\Explain> 34,4,0<\Number> B<\Answers> Question 34: In a community health assessment, which factor can contribute to health disparities among different population groups? A) Access to parks and recreational facilities B) Education level C) Smoking prevalence D) Availability of healthcare providers <\Body> Correct Answer: B) Education level Rationale: Education level is a social determinant of health that can contribute to health disparities among different population groups. Lower educational attainment is often associated with poorer health outcomes. <\Explain> 35,4,0<\Number> C<\Answers> Question 35: When assessing individual risk factors for lung cancer, which factor is considered a modifiable risk factor? A) Age B) Family history of lung cancer C) Smoking status D) Gender <\Body> Correct Answer: C) Smoking status Rationale: Smoking status is a modifiable risk factor for lung cancer, as individuals can quit smoking to reduce their risk. Age, family history, and gender are non-modifiable risk factors. <\Explain> 36,4,0<\Number> B<\Answers> Question 36: In a community health assessment, which factor is an example of an environmental determinant of health? A) Blood pressure levels B) Availability of healthy food options C) Physical activity level D) Genetic predisposition to diseases <\Body> Correct Answer: B) Availability of healthy food options Rationale: The availability of healthy food options in the environment is an environmental determinant of health. It can influence the dietary choices of individuals within a community. <\Explain> 37,4,0<\Number> C<\Answers> Question 37: When assessing individual risk factors for obesity, which factor is considered a non-modifiable risk factor? A) Diet B) Physical activity level C) Family history of obesity D) Body mass index (BMI) <\Body> Correct Answer: C) Family history of obesity Rationale: Family history of obesity is a non-modifiable risk factor, as individuals cannot change their genetic predisposition to obesity. It is important to assess this factor to understand an individual's risk. <\Explain> 38,4,0<\Number> C<\Answers> Question 38: In a community health assessment, which factor is an example of a behavioral determinant of health? A) Air quality B) Availability of public transportation C) Tobacco use prevalence D) Access to healthcare facilities <\Body> Correct Answer: C) Tobacco use prevalence Rationale: Tobacco use prevalence is a behavioral determinant of health that reflects the behaviors and habits of individuals within a community. It can influence the community's overall health outcomes. <\Explain> 39,4,0<\Number> C<\Answers> Question 39: When evaluating individual risk factors for hypertension (high blood pressure), which factor is considered modifiable through lifestyle changes? A) Age B) Family history of hypertension C) Salt intake D) Gender <\Body> Correct Answer: C) Salt intake Rationale: Salt intake is a modifiable risk factor for hypertension. Individuals can reduce their salt intake through dietary changes. Age, family history, and gender are non-modifiable risk factors. <\Explain> 40,4,0<\Number> C<\Answers> Question 40: In a community health assessment, which factor is an example of an economic determinant of health? A) Physical activity levels B) Access to clean drinking water C) Income level D) Smoking prevalence <\Body> Correct Answer: C) Income level Rationale: Income level is an economic determinant of health that can influence access to resources and healthcare services, affecting overall health and well-being in a community. <\Explain> 41,4,0<\Number> B<\Answers> Question 41: Which behavior is considered a high-risk behavior for the development of lung cancer? A) Irregular exercise B) Smoking tobacco products C) 4 hours of sleep daily D) Being overweight <\Body> Correct Answer: B) Smoking tobacco products Rationale: Smoking tobacco products is a high-risk behavior that is strongly associated with an increased risk of developing lung cancer. <\Explain> 42,4,0<\Number> D<\Answers> Question 42: Which behavior is a high-risk behavior for the transmission of sexually transmitted infections (STIs)? A) Infrequent sexual activity B) Using an IUD C) Having a monogamous sexual relationship D) Engaging in unprotected sex with multiple partners <\Body> Correct Answer: D) Engaging in unprotected sex with multiple partners Rationale: Engaging in unprotected sex with multiple partners is a high-risk behavior that increases the likelihood of transmitting sexually transmitted infections (STIs). <\Explain> 43,4,0<\Number> D<\Answers> Question 43: Which behavior is considered a high-risk behavior for the development of type 2 diabetes? A) Regular physical activity B) Maintaining a balanced diet C) Monitoring blood glucose levels D) Consuming excessive sugary foods and beverages <\Body> Correct Answer: D) Consuming excessive sugary foods and beverages Rationale: Consuming excessive sugary foods and beverages is a high-risk behavior that can contribute to the development of type 2 diabetes. <\Explain> 44,4,0<\Number> D<\Answers> Question 44: Which behavior is a high-risk behavior for the development of hypertension (high blood pressure)? A) Consuming a low-sodium diet B) Engaging in regular stress-reduction techniques C) Maintaining a healthy weight D) Consuming a diet high in sodium and processed foods <\Body> Correct Answer: D) Consuming a diet high in sodium and processed foods Rationale: Consuming a diet high in sodium and processed foods is a high-risk behavior that can contribute to the development of hypertension. <\Explain> 45,4,0<\Number> D<\Answers> Question 45: Which behavior is considered a high-risk behavior for the development of alcohol use disorder? A) Drinking alcohol in moderation B) Abstaining from alcohol completely C) Seeking support for mental health issues D) Engaging in heavy and frequent alcohol consumption <\Body> Correct Answer: D) Engaging in heavy and frequent alcohol consumption Rationale: Engaging in heavy and frequent alcohol consumption is a high-risk behavior that increases the risk of developing alcohol use disorder. <\Explain> 46,4,0<\Number> D<\Answers> Question 46: Which behavior is a high-risk behavior for the development of skin cancer? A) Regular use of sunscreen B) Wearing protective clothing and hats in the sun C) Avoiding indoor tanning beds D) Excessive sun exposure without protection <\Body> Correct Answer: D) Excessive sun exposure without protection Rationale: Excessive sun exposure without protection, such as sunscreen and protective clothing, is a high-risk behavior for the development of skin cancer. <\Explain> 47,4,0<\Number> D<\Answers> Question 47: Which behavior is considered a high-risk behavior for the development of obesity? A) Engaging in regular physical activity B) Consuming a balanced diet C) Monitoring calorie intake D) Overeating and consuming high-calorie foods <\Body> Correct Answer: D) Overeating and consuming high-calorie foods Rationale: Overeating and consuming high-calorie foods are high-risk behaviors that can contribute to the development of obesity. <\Explain> 48,4,0<\Number> D<\Answers> Question 48: Which behavior is a high-risk behavior for the development of substance use disorder? A) Seeking professional help for addiction B) Using prescription medications as prescribed C) Avoiding exposure to addictive substances D) Experimenting with illicit drugs <\Body> Correct Answer: D) Experimenting with illicit drugs Rationale: Experimenting with illicit drugs is a high-risk behavior that increases the risk of developing substance use disorder. <\Explain> 49,4,0<\Number> D<\Answers> Question 49: Which behavior is considered a high-risk behavior for the development of dental caries (cavities)? A) Irregular dental check-ups B) Not flossing daily C) Limiting meat consumption D) Frequent consumption of sugary snacks and beverages <\Body> Correct Answer: D) Frequent consumption of sugary snacks and beverages Rationale: Frequent consumption of sugary snacks and beverages is a high-risk behavior that can contribute to the development of dental caries. <\Explain> 50,4,0<\Number> D<\Answers> Question 50: Which behavior is a high-risk behavior for the transmission of HIV (Human Immunodeficiency Virus)? A) Infrequent sexual activity B) Consistent use of only one brand of condoms C) Mutual monogamy with an uninfected partner D) Engaging in unprotected sex with multiple partners, some of whom may be infected <\Body> Correct Answer: D) Engaging in unprotected sex with multiple partners, some of whom may be infected Rationale: Engaging in unprotected sex with multiple partners, some of whom may be infected, is a high-risk behavior for the transmission of HIV. <\Explain> 51,4,0<\Number> C<\Answers> Question 51: Which lifestyle choice is associated with a reduced risk of cardiovascular disease? A) Consuming a diet high in saturated fats B) Smoking tobacco products regularly C) Engaging in regular physical activity D) Avoiding fruits and vegetables <\Body> Correct Answer: C) Engaging in regular physical activity Rationale: Engaging in regular physical activity is a positive lifestyle choice that is associated with a reduced risk of cardiovascular disease by improving heart health and reducing the risk of risk factors such as obesity and hypertension. <\Explain> 52,4,0<\Number> D<\Answers> Question 52: Which lifestyle choice can contribute to the development of type 2 diabetes? A) Maintaining a healthy weight B) Consuming a diet rich in fiber and whole grains C) Engaging in regular physical activity D) Consuming excessive sugary foods and beverages <\Body> Correct Answer: D) Consuming excessive sugary foods and beverages Rationale: Consuming excessive sugary foods and beverages is a negative lifestyle choice that can contribute to the development of type 2 diabetes by affecting blood sugar levels and insulin resistance. <\Explain> 53,4,0<\Number> A<\Answers> Question 53: Which lifestyle choice is essential for maintaining proper bone health and reducing the risk of osteoporosis? A) Adequate calcium and vitamin D intake B) Infrequent smoking of tobacco products C) Regular exposure to indoor tanning beds D) Consuming a diet high in processed foods <\Body> Correct Answer: A) Adequate calcium and vitamin D intake Rationale: Adequate calcium and vitamin D intake are positive lifestyle choices essential for maintaining proper bone health and reducing the risk of osteoporosis. <\Explain> 54,4,0<\Number> C<\Answers> Question 54: Which lifestyle choice can contribute to the development of obesity? A) Engaging in regular physical activity B) Consuming a balanced diet with appropriate portion sizes C) Overeating and consuming high-calorie foods D) Getting adequate sleep <\Body> Correct Answer: C) Overeating and consuming high-calorie foods Rationale: Overeating and consuming high-calorie foods are negative lifestyle choices that can contribute to the development of obesity by leading to excessive calorie intake. <\Explain> 55,4,0<\Number> A<\Answers> Question 55: Which lifestyle choice is associated with a reduced risk of skin cancer? A) Using sunscreen and protective clothing in the sun B) Engaging in indoor tanning bed sessions C) Frequent sun exposure without protection D) Avoiding outdoor activities <\Body> Correct Answer: A) Using sunscreen and protective clothing in the sun Rationale: Using sunscreen and protective clothing in the sun is a positive lifestyle choice that is associated with a reduced risk of skin cancer by protecting the skin from harmful UV radiation. <\Explain> 56,4,0<\Number> D<\Answers> Question 56: Which lifestyle choice can contribute to the development of hypertension (high blood pressure)? A) Reducing sodium intake B) Engaging in regular physical activity C) Maintaining a healthy weight D) Consuming a diet high in sodium and processed foods <\Body> Correct Answer: D) Consuming a diet high in sodium and processed foods Rationale: Consuming a diet high in sodium and processed foods is a negative lifestyle choice that can contribute to the development of hypertension. <\Explain> 57,4,0<\Number> D<\Answers> Question 57: Which lifestyle choice can lead to the development of substance use disorder? A) Seeking support for mental health issues B) Using prescription medications as prescribed C) Avoiding exposure to addictive substances D) Experimenting with illicit drugs <\Body> Correct Answer: D) Experimenting with illicit drugs Rationale: Experimenting with illicit drugs is a negative lifestyle choice that can lead to the development of substance use disorder by introducing individuals to addictive substances. <\Explain> 58,4,0<\Number> B<\Answers> Question 58: Which lifestyle choice is essential for maintaining proper dental health and preventing dental caries (cavities)? A) Annual dental check-ups B) Practicing good oral hygiene C) Avoiding dental X-rays D) Flossing once weekly <\Body> Correct Answer: B) Practicing good oral hygiene Rationale: Practicing good oral hygiene, including tooth brushing and flossing, is a positive lifestyle choice essential for maintaining proper dental health and preventing dental caries. <\Explain> 59,4,0<\Number> A<\Answers> Question 59: Which lifestyle choice is associated with a reduced risk of colorectal cancer? A) Engaging in regular colorectal cancer screenings B) Ignoring symptoms and avoiding medical check-ups C) Consuming a diet high in processed meats D) Engaging in heavy alcohol consumption <\Body> Correct Answer: A) Engaging in regular colorectal cancer screenings Rationale: Engaging in regular colorectal cancer screenings is a positive lifestyle choice that is associated with a reduced risk of colorectal cancer by detecting the disease at an early, more treatable stage. <\Explain> 60,4,0<\Number> C<\Answers> Question 60: Which lifestyle choice can contribute to the development of mental health issues, such as depression and anxiety? A) Seeking support from friends and family B) Engaging in stress-reduction techniques C) Engaging in unhealthy coping mechanisms, such as substance abuse D) Practicing mindfulness and relaxation exercises <\Body> Correct Answer: C) Engaging in unhealthy coping mechanisms, such as substance abuse Rationale: Engaging in unhealthy coping mechanisms, such as substance abuse, is a negative lifestyle choice that can contribute to the development of mental health issues. <\Explain> 61,4,0<\Number> C<\Answers> Question 61: When educating a client with diabetes about monitoring blood glucose levels, which statement is correct? A) "You should only check your blood sugar when you feel unwell." B) "It's best to test your blood sugar once a week." C) "Regularly monitor your blood sugar as recommended by your healthcare provider." D) "Fasting blood sugar monitoring is not necessary for diabetes management." <\Body> Correct Answer: C) "Regularly monitor your blood sugar as recommended by your healthcare provider." Rationale: Regular blood sugar monitoring is essential for managing diabetes effectively. The frequency and timing of monitoring should be determined by the healthcare provider's recommendations. <\Explain> 62,4,0<\Number> C<\Answers> Question 62: When providing education to a pregnant client, which advice is important regarding prenatal vitamins? A) "Prenatal vitamins are optional during pregnancy." B) "Take prenatal vitamins only in the first trimester." C) "Prenatal vitamins should be taken throughout pregnancy as prescribed." D) "Prenatal vitamins should be taken after the baby is born." <\Body> Correct Answer: C) "Prenatal vitamins should be taken throughout pregnancy as prescribed." Rationale: Prenatal vitamins provide essential nutrients for both the mother and developing baby throughout pregnancy. They should be taken as prescribed by the healthcare provider. <\Explain> 63,4,0<\Number> C<\Answers> Question 63: When teaching a client about the importance of hand hygiene, which statement is accurate? A) "Hand hygiene is necessary only before eating." B) "Washing hands with water alone for 15 seconds is sufficient." C) "Hand hygiene should be performed before and after meals, after using the restroom, and as needed." D) "Hand hygiene is essential only if you have visible dirt on your hands." <\Body> Correct Answer: C) "Hand hygiene should be performed before and after meals, after using the restroom, and as needed." Rationale: Hand hygiene is a critical practice for preventing the spread of infections. It should be performed at key times, including before and after meals, after using the restroom, and as needed throughout the day. <\Explain> 64,4,0<\Number> C<\Answers> Question 64: When educating a client about medication adherence, what is a crucial point to emphasize? A) "It's okay to skip doses occasionally if you're feeling better." B) "Always take medications with grapefruit juice for better absorption." C) "Follow the prescribed medication regimen exactly as directed by your healthcare provider." D) "Stopping medications abruptly is safe if you experience side effects." <\Body> Correct Answer: C) "Follow the prescribed medication regimen exactly as directed by your healthcare provider." Rationale: Medication adherence is essential for achieving optimal treatment outcomes. Clients should be educated to follow their healthcare provider's instructions precisely. <\Explain> 65,4,0<\Number> C<\Answers> Question 65: When teaching a client about smoking cessation, what advice should be provided? A) "It's okay to smoke fewer cigarettes each day to gradually quit." B) "Nicotine replacement therapy is ineffective for quitting smoking." C) "Set a quit date and stop smoking completely on that day." D) "Smoking is safe as long as you do it away from others." <\Body> Correct Answer: C) "Set a quit date and stop smoking completely on that day." Rationale: Setting a quit date and stopping smoking completely is a recommended approach for successful smoking cessation. Gradual reduction is less effective. <\Explain> 66,4,0<\Number> C<\Answers> Question 66: When educating a client with hypertension (high blood pressure) about sodium intake, what should be emphasized? A) "Increase your sodium intake for better blood pressure control." B) "Limit sodium intake to less than 1,000 mg per day." C) "Reduce sodium intake to recommended levels by reading food labels and avoiding high-sodium foods." D) "Sodium intake doesn't affect blood pressure." <\Body> Correct Answer: C) "Reduce sodium intake to recommended levels by reading food labels and avoiding high-sodium foods." Rationale: Educating clients to reduce sodium intake through dietary changes and food label awareness is crucial for managing hypertension. <\Explain> 67,4,0<\Number> C<\Answers> Question 67: When providing education on safe food handling, what should be stressed regarding food borne illnesses? A) "Food borne illnesses are rare, so no special precautions are needed." B) "Hand washing is optional before handling food." C) "Proper food handling and cooking techniques can prevent food borne illnesses." D) "Food borne illnesses are solely caused by under cooked meats." <\Body> Correct Answer: C) "Proper food handling and cooking techniques can prevent food borne illnesses." Rationale: Food borne illnesses can be prevented by following safe food handling practices, including proper cooking and hand hygiene. <\Explain> 68,4,0<\Number> C<\Answers> Question 68: When educating a client with a chronic respiratory condition like asthma, what should be emphasized regarding inhaler use? A) "Use your inhaler only when you have a severe asthma attack." B) "Inhalers are safe for children of any age." C) "Follow the prescribed inhaler regimen, including both controller and rescue inhalers." D) "Inhalers are not effective in managing asthma symptoms." <\Body> Correct Answer: C) "Follow the prescribed inhaler regimen, including both controller and rescue inhalers." Rationale: Clients with asthma should be educated on using both controller and rescue inhalers as prescribed by their healthcare provider to manage their condition effectively. <\Explain> 69,4,0<\Number> C<\Answers> Question 69: When teaching a client about the importance of seat belt use while driving, what should be stressed? A) "Seat belts are optional for adults." B) "Seat belts are only necessary for long-distance trips." C) "Always wear a seat belt while in a moving vehicle to reduce the risk of injury during accidents." D) "Seat belts should be worn only by the driver, not passengers." <\Body> Correct Answer: C) "Always wear a seat belt while in a moving vehicle to reduce the risk of injury during accidents." Rationale: Seat belt use is essential for all occupants of a vehicle at all times to reduce the risk of injury in the event of an accident. <\Explain> 70,4,0<\Number> B<\Answers> Question 70: When educating a client about the benefits of breastfeeding for an infant, what should be emphasized? A) "Formula feeding is a better option for infant health." B) "Breastfeeding provides essential nutrients and antibodies for optimal infant growth and immune protection." C) "Breastfeeding is only recommended for the first month after birth." D) "Infants do not benefit from breastfeeding." <\Body> Correct Answer: B) "Breastfeeding provides essential nutrients and antibodies for optimal infant growth and immune protection." Rationale: Breastfeeding offers numerous benefits to infants, including essential nutrients and antibodies for their growth and immune protection. <\Explain> 71,4,0<\Number> C<\Answers> Question 71: During a prenatal visit, a pregnant client asks about the purpose of the alpha-fetoprotein (AFP) screening. What information should the nurse provide? A) "AFP screening is primarily used to assess fetal heart rate." B) "AFP screening is performed to check for gestational diabetes." C) "AFP screening helps identify potential neural tube defects and Down syndrome." D) "AFP screening determines the baby's gender." <\Body> Correct Answer: C) "AFP screening helps identify potential neural tube defects and Down syndrome." Rationale: AFP screening is a prenatal test that assesses the levels of alpha-fetoprotein in the mother's blood to detect potential neural tube defects and chromosomal abnormalities such as Down syndrome in the developing fetus. <\Explain> 72,4,0<\Number> B<\Answers> Question 72: A pregnant client is at 36 weeks of gestation and asks the nurse about signs of labor. Which response by the nurse is accurate? A) "You should expect your water to break before any contractions." B) "Labor typically begins with strong, regular contractions and may be preceded by a 'bloody show.'" C) "Labor always starts with mild back pain and discomfort." D) "You'll experience labor only if you have Braxton Hicks contractions." <\Body> Correct Answer: B) "Labor typically begins with strong, regular contractions and may be preceded by a 'bloody show.'" Rationale: Labor often begins with strong, regular contractions, and some clients may notice a "bloody show" as a sign that labor is approaching. <\Explain> 73,4,0<\Number> B<\Answers> Question 73: A postpartum client is experiencing perineal discomfort after a vaginal delivery. What comfort measure should the nurse suggest? A) "Apply direct pressure to the perineum to relieve pain." B) "Use a sitz bath to soothe the perineal area." C) "Avoid all forms of perineal hygiene to prevent infection." D) "Apply heat to the perineum for at least 30 minutes daily." <\Body> Correct Answer: B) "Use a sitz bath to soothe the perineal area." Rationale: A sitz bath can help soothe perineal discomfort and promote healing after a vaginal delivery by providing warm water immersion. <\Explain> 74,4,0<\Number> A<\Answers> Question 74: A client in the early stages of labor is receiving oxytocin (Pitocin) to augment contractions. What should the nurse monitor closely during this time? A) Fetal heart rate B) Maternal blood pressure C) Maternal temperature D) Maternal respiratory rate <\Body> Correct Answer: A) Fetal heart rate Rationale: When oxytocin is used to augment contractions, the nurse should closely monitor the fetal heart rate to ensure the baby's well-being and detect any signs of fetal distress. <\Explain> 75,4,0<\Number> B<\Answers> Question 75: A prenatal client reports experiencing "quickening." What does this term refer to? A) The first prenatal visit to the healthcare provider B) The sensation of the baby's first movements in the uterus C) The process of labor beginning D) The onset of Braxton Hicks contractions <\Body> Correct Answer: B) The sensation of the baby's first movements in the uterus Rationale: "Quickening" is the term used to describe the sensation of a pregnant woman feeling her baby's first movements in the uterus, usually occurring around the 18th to 20th week of gestation. <\Explain> 76,4,0<\Number> B<\Answers> Question 76: A postpartum client is breastfeeding her newborn and asks about the benefits of breastfeeding. What should the nurse include in the response? A) "Breastfeeding has no health benefits for the baby." B) "Breast milk provides essential nutrients and antibodies, promoting the baby's health and immunity." C) "Breastfeeding may lead to obesity in the baby." D) "Formula feeding is superior to breastfeeding." <\Body> Correct Answer: B) "Breast milk provides essential nutrients and antibodies, promoting the baby's health and immunity." Rationale: Breast milk is rich in essential nutrients and antibodies that provide numerous health benefits to the baby, including enhanced immunity and protection against infections. <\Explain> 77,4,0<\Number> B<\Answers> Question 77: A pregnant client with gestational diabetes asks about managing her condition. What dietary advice should the nurse provide? A) "Avoid carbohydrates completely to control blood sugar levels." B) "Consume a balanced diet with consistent carbohydrate intake and monitor blood sugar as advised by your healthcare provider." C) "Eat only high-protein foods to prevent blood sugar spikes." D) "Increase sugar intake to maintain energy levels." <\Body> Correct Answer: B) "Consume a balanced diet with consistent carbohydrate intake and monitor blood sugar as advised by your healthcare provider." Rationale: Clients with gestational diabetes should consume a balanced diet with consistent carbohydrate intake while monitoring blood sugar levels as recommended by their healthcare provider to manage their condition effectively. <\Explain> 78,4,0<\Number> C<\Answers> Question 78: A postpartum client who is breastfeeding is concerned about milk supply. What should the nurse suggest to help increase milk production? A) "Limit your fluid intake to prevent excessive milk production." B) "Breastfeed on a strict schedule to regulate milk supply." C) "Frequent breastfeeding and adequate hydration can help boost milk production." D) "Supplement breastfeeding with formula to ensure the baby's nutrition." <\Body> Correct Answer: C) "Frequent breastfeeding and adequate hydration can help boost milk production." Rationale: Frequent breastfeeding and staying adequately hydrated are key factors in maintaining and increasing milk production in breastfeeding mothers. <\Explain> 79,4,0<\Number> B<\Answers> Question 79: A pregnant client reports feeling a sudden gush of fluid from her vagina. What action should the nurse recommend? A) "Lie down and rest; it's likely normal vaginal discharge." B) "Go to the hospital immediately; this may be a sign that your water has broken." C) "Increase your fluid intake to prevent dehydration." D) "Continue your daily activities as usual; there's no cause for concern." <\Body> Correct Answer: B) "Go to the hospital immediately; this may be a sign that your water has broken." Rationale: A sudden gush of fluid from the vagina may indicate the rupture of the amniotic sac (water breaking), and the client should seek immediate medical evaluation. <\Explain> 80,4,0<\Number> C<\Answers> Question 80: A pregnant client in her second trimester asks about the importance of prenatal vitamins. What should the nurse explain? A) "Prenatal vitamins are not necessary during pregnancy." B) "Prenatal vitamins can replace a healthy diet, so you don't need to worry about your nutrition." C) "Prenatal vitamins provide essential nutrients that support the baby's growth and development." D) "Prenatal vitamins are prescribed to induce labor." <\Body> Correct Answer: C) "Prenatal vitamins provide essential nutrients that support the baby's growth and development." Rationale: Prenatal vitamins are recommended during pregnancy to provide essential nutrients that support the baby's growth and development, in addition to maintaining the mother's health. <\Explain> 81,4,0<\Number> B<\Answers> Question 81: In a diverse maternity care setting, the nurse recognizes that cultural differences may impact a client's birth preferences. Which principle should guide the nurse's care? A) Promoting adherence to Western birth practices regardless of cultural beliefs. B) Respecting and accommodating the client's cultural preferences and beliefs whenever possible. C) Discouraging any cultural practices that are not evidence-based. D) Assuming that all clients from the same cultural background have identical preferences. <\Body> Correct Answer: B) Respecting and accommodating the client's cultural preferences and beliefs whenever possible. Rationale: Providing culturally competent care involves respecting and accommodating the client's cultural preferences and beliefs to the extent possible while ensuring safe and evidence-based care. <\Explain> 82,4,0<\Number> B<\Answers> Question 82: A client from a culture that traditionally practices water births expresses a desire to have a water birth. What is the nurse's best response? A) "Water births are unsafe and not allowed in this facility." B) "Let's discuss your preferences and explore whether a water birth can be accommodated safely." C) "Water births are only allowed for certain cultural groups." D) "Water births are the only acceptable method of delivery." <\Body> Correct Answer: B) "Let's discuss your preferences and explore whether a water birth can be accommodated safely." Rationale: The nurse should engage in a discussion with the client to explore preferences and assess the feasibility and safety of a water birth in the specific clinical setting. <\Explain> 83,4,0<\Number> C<\Answers> Question 83: A pregnant client from a culture with traditional herbal remedies expresses a desire to use herbal teas during pregnancy. What action should the nurse take? A) Discourage the use of herbal teas, as they may be harmful. B) Encourage the client to rely solely on Western medicine during pregnancy. C) Assess the specific herbal remedies the client intends to use and their safety during pregnancy. D) Provide a list of approved herbal teas for pregnancy. <\Body> Correct Answer: C) Assess the specific herbal remedies the client intends to use and their safety during pregnancy. Rationale: The nurse should assess the safety of the specific herbal remedies the client intends to use during pregnancy and provide information based on evidence and safety considerations. <\Explain> 84,4,0<\Number> C<\Answers> Question 84: A laboring client from a cultural background that values modesty expresses discomfort with male healthcare providers present in the room. What is the nurse's best action? A) Ignore the client's discomfort to maintain the care team as is. B) Inform the client that all healthcare providers must be present. C) Respect the client's wishes and make necessary adjustments to ensure a female-only care team, if possible. D) Explain to the client that cultural preferences cannot be accommodated in the healthcare setting. <\Body> Correct Answer: C) Respect the client's wishes and make necessary adjustments to ensure a female-only care team, if possible. Rationale: It is essential to respect the client's cultural preferences and make reasonable adjustments, such as providing a female-only care team if feasible, to ensure the client's comfort and dignity. <\Explain> 85,4,0<\Number> C<\Answers> Question 85: A client from a culture that practices delayed cord clamping after birth asks about the benefits. What should the nurse explain? A) Delayed cord clamping has no known benefits. B) Delayed cord clamping can increase the risk of postpartum hemorrhage. C) Delayed cord clamping may improve the baby's iron stores and overall health. D) Delayed cord clamping is only practiced in certain cultures. <\Body> Correct Answer: C) Delayed cord clamping may improve the baby's iron stores and overall health. Rationale: Delayed cord clamping has been associated with potential benefits for the newborn, including improved iron stores and overall health. It is not limited to specific cultures and can be considered based on clinical circumstances. <\Explain> 86,4,0<\Number> D<\Answers> Question 86: A laboring client follows cultural practices that involve family members present in the birthing room. The client's preferences conflict with the hospital's policy. What should the nurse do? A) Follow the hospital policy and limit family members in the room. B) Respect the client's cultural practices and allow all requested family members in the room. C) Encourage the client to abandon cultural practices for the sake of hospital policy. D) Consult with the healthcare provider to determine the best course of action. <\Body> Correct Answer: D) Consult with the healthcare provider to determine the best course of action. Rationale: When cultural practices conflict with hospital policies, it is appropriate for the nurse to consult with the healthcare provider to find a solution that respects the client's preferences while ensuring safety and compliance with clinical guidelines. <\Explain> 87,4,0<\Number> B<\Answers> Question 87: A pregnant client from a culture with specific dietary restrictions asks about dietary modifications during pregnancy. What should the nurse advise? A) "You should adhere to your cultural dietary restrictions without any changes." B) "Follow your cultural dietary restrictions, but ensure you're getting all the necessary nutrients for a healthy pregnancy." C) "Ignore your cultural dietary restrictions during pregnancy for the baby's health." D) "Pregnancy does not require any dietary changes." <\Body> Correct Answer: B) "Follow your cultural dietary restrictions, but ensure you're getting all the necessary nutrients for a healthy pregnancy." Rationale: The nurse should encourage the client to follow cultural dietary restrictions while ensuring that the diet is well-balanced and provides all the necessary nutrients for a healthy pregnancy. <\Explain> 88,4,0<\Number> B<\Answers> Question 88: A laboring client from a culture that values quiet during childbirth requests a calm and silent birthing environment. How should the nurse respond? A) Maintain a noisy environment to ensure communication among the care team. B) Respect the client's request for a quiet and calm birthing environment whenever possible. C) Inform the client that silence during childbirth is not possible in a healthcare setting. D) Encourage the client to use earplugs to block out noise. <\Body> Correct Answer: B) Respect the client's request for a quiet and calm birthing environment whenever possible. Rationale: It is important to respect the client's cultural preferences, such as a quiet and calm birthing environment, whenever feasible while ensuring safe and effective care. <\Explain> 89,4,0<\Number> C<\Answers> Question 89: A postpartum client from a culture that values postpartum rest and confinement asks about resuming daily activities. What should the nurse explain? A) "You should resume all daily activities immediately after childbirth." B) "Rest and confinement are not necessary; you can return to normal activities right away." C) "Postpartum rest and confinement have cultural significance and can be beneficial for recovery." D) "Ignore cultural practices and return to normal activities to avoid complications." <\Body> Correct Answer: C) "Postpartum rest and confinement have cultural significance and can be beneficial for recovery." Rationale: Postpartum rest and confinement practices have cultural significance and can be beneficial for the client's recovery, so they should be respected and understood. <\Explain> 90,4,0<\Number> B<\Answers> Question 90: A pregnant client from a culture that practices home births expresses a desire to give birth at home. What should the nurse do? A) Inform the client that home births are illegal and unsafe. B) Discuss the safety concerns of home births and explore alternatives within the healthcare facility. C) Encourage the client to proceed with a home birth without medical supervision. D) Insist that the client give birth in the hospital regardless of her preferences. <\Body> Correct Answer: B) Discuss the safety concerns of home births and explore alternatives within the healthcare facility. Rationale: The nurse should discuss the safety concerns associated with home births and explore alternatives within the healthcare facility that align with the client's preferences while ensuring safety. <\Explain> 91,4,0<\Number> B<\Answers> Question 91: Which of the following is an essential preventive practice for early detection of breast cancer in women? A) Annual mammograms starting at age 60 B) Monthly breast self-examinations C) Yearly clinical breast examinations by a healthcare provider D) Triennial Pap smears <\Body> Correct Answer: B) Monthly breast self-examinations Rationale: Monthly breast self-examinations are recommended for early detection of breast abnormalities. Clinical breast examinations and mammograms are also important screening methods, but self-examinations empower women to monitor their breast health regularly. <\Explain> 92,4,0<\Number> C<\Answers> Question 92: At what age should individuals begin regular colorectal cancer screening, such as colonoscopy or sigmoidoscopy? A) 30 years old B) 40 years old C) 50 years old D) 60 years old <\Body> Correct Answer: C) 50 years old Rationale: Colorectal cancer screening, such as colonoscopy or sigmoidoscopy, is generally recommended to start at age 50 for average-risk individuals. Screening may start earlier for individuals with certain risk factors or family history. <\Explain> 93,4,0<\Number> D<\Answers> Question 93: Which immunization is typically administered to infants shortly after birth to provide protection against hepatitis B? A) MMR (Measles, Mumps, Rubella) B) DTaP (Diphtheria, Tetanus, Pertussis) C) Hib (Haemophilus influenzae type b) D) Hepatitis B <\Body> Correct Answer: D) Hepatitis B Rationale: Infants are typically administered the hepatitis B vaccine shortly after birth to provide early protection against hepatitis B infection. <\Explain> 94,4,0<\Number> A<\Answers> Question 94: A 45-year-old woman with a family history of breast cancer asks about screening recommendations. What should the nurse recommend? A) Annual mammograms starting at age 45 B) Monthly breast self-examinations C) Mammograms every 10 years starting at age 50 D) No need for breast cancer screening due to family history <\Body> Correct Answer: A) Annual mammograms starting at age 45 Rationale: Women with a family history of breast cancer are often recommended to start annual mammograms earlier, typically at age 45, as they have an increased risk. <\Explain> 95,4,0<\Number> A<\Answers> Question 95: Which preventive health measure is recommended to reduce the risk of cardiovascular disease? A) Regular exercise B) Avoiding all dietary fats C) Daily consumption of red meat D) Frequent consumption of sugary beverages <\Body> Correct Answer: A) Regular exercise Rationale: Regular exercise is a key preventive measure to reduce the risk of cardiovascular disease. It helps improve cardiovascular health, lower blood pressure, and maintain a healthy weight. <\Explain> 96,4,0<\Number> C<\Answers> Question 96: Which routine screening test is used to detect potential vision problems in school-age children? A) Pap smear B) Mammogram C) Snellen hart D) Colonoscopy <\Body> Correct Answer: C) Snellen chart Rationale: The Snellen eye chart is used for visual acuity testing and is a routine screening method to detect potential vision problems in school-age children. <\Explain> 97,4,0<\Number> C<\Answers> Question 97: What is the primary goal of cervical cancer screening, such as the Pap smear? A) Detecting ovarian cancer B) Detecting breast cancer C) Detecting cervical cancer in its early, treatable stages D) Detecting lung cancer <\Body> Correct Answer: C) Detecting cervical cancer in its early, treatable stages Rationale: The primary goal of cervical cancer screening, including the Pap smear, is to detect cervical cancer in its early, treatable stages, allowing for timely intervention and prevention. <\Explain> 98,4,0<\Number> C<\Answers> Question 98: Which preventive practice is recommended for individuals at risk of developing type 2 diabetes? A) Reducing physical activity B) Increasing sugar intake C) Maintaining a healthy weight and engaging in regular physical activity D) Skipping dinner regularly <\Body> Correct Answer: C) Maintaining a healthy weight and engaging in regular physical activity Rationale: Individuals at risk of developing type 2 diabetes are advised to maintain a healthy weight and engage in regular physical activity as part of preventive measures to reduce their risk. <\Explain> 99,4,0<\Number> B<\Answers> Question 99: What is the recommended interval for routine dental check-ups and cleanings for adults with good oral health? A) Every 3 months B) Every 6 months C) Annually D) Every 2 years <\Body> Correct Answer: B) Every 6 months Rationale: For adults with good oral health, routine dental check-ups and cleanings are typically recommended every 6 months to maintain oral hygiene and detect any dental issues early. <\Explain> 100,4,0<\Number> C<\Answers> Question 100: Which preventive measure is recommended for individuals at risk of skin cancer due to sun exposure? A) Avoiding sunscreen products B) Using tanning beds regularly C) Wearing protective clothing and applying sunscreen with SPF D) Spending extended periods in direct sunlight without protection <\Body> Correct Answer: C) Wearing protective clothing and applying sunscreen with SPF Rationale: Individuals at risk of skin cancer due to sun exposure should wear protective clothing and apply sunscreen with SPF to reduce their risk. <\Explain> 101,4,0<\Number> B<\Answers> Question 101: Which action by a community member demonstrates active participation in community health education? A) Ignoring health-related information and advice B) Attending a local health fair and engaging in health discussions C) Isolating oneself from community health initiatives D) Criticizing community health programs without offering solutions <\Body> Correct Answer: B) Attending a local health fair and engaging in health discussions Rationale: Actively participating in community health education involves attending events such as health fairs, engaging in discussions, and seeking information to improve one's health knowledge. <\Explain> 102,4,0<\Number> B<\Answers> Question 102: A community health nurse is planning an educational workshop on diabetes prevention. What should the nurse prioritize when developing the workshop? A) Providing complex medical terminology to impress participants B) Tailoring the content to the specific needs and cultural preferences of the target audience C) Offering a one-size-fits-all approach to reach a broader audience D) Focusing solely on advanced diabetes management techniques <\Body> Correct Answer: B) Tailoring the content to the specific needs and cultural preferences of the target audience Rationale: Effective community health education involves tailoring the content to the specific needs, literacy levels, and cultural preferences of the target audience to ensure engagement and understanding. <\Explain> 103,4,0<\Number> C<\Answers> Question 103: A community health educator is conducting a workshop on smoking cessation. What teaching strategy should the educator employ to enhance participant engagement? A) Presenting statistics on smoking-related illnesses B) Using fear tactics to emphasize the dangers of smoking C) Providing practical tips and strategies for quitting D) Excluding personal stories and testimonials <\Body> Correct Answer: C) Providing practical tips and strategies for quitting Rationale: Providing practical tips and strategies for quitting smoking is an effective teaching strategy to engage participants in a smoking cessation workshop. It offers actionable steps for behavior change. <\Explain> 104,4,0<\Number> A<\Answers> Question 104: A community member is interested in learning about healthy eating habits and weight management. What type of community health education program should the individual seek out? A) A cooking class B) A self-help book on dieting C) A high-intensity exercise program D) An advanced medical seminar <\Body> Correct Answer: A) A cooking class Rationale: Joining a cooking class focused on healthy eating can provide practical skills and knowledge related to nutrition and weight management. <\Explain> 105,4,0<\Number> B<\Answers> Question 105: What is a potential benefit of community health education programs that promote physical activity? A) Increased social isolation B) Reduced risk of chronic diseases C) Greater reliance on medication D) Decreased interest in fitness <\Body> Correct Answer: B) Reduced risk of chronic diseases Rationale: Community health education programs promoting physical activity can help reduce the risk of chronic diseases, such as heart disease and diabetes, by encouraging regular exercise. <\Explain> 106,4,0<\Number> B<\Answers> Question 106: A community health educator is planning a workshop on safe sex practices for adolescents. Which approach should the educator prioritize to enhance the effectiveness of the program? A) Providing limited information to avoid promoting sexual activity B) Offering comprehensive and age-appropriate information on safe sex C) Avoiding discussion of contraception methods D) Focusing solely on abstinence as the only option <\Body> Correct Answer: B) Offering comprehensive and age-appropriate information on safe sex Rationale: To enhance the effectiveness of a safe sex education program for adolescents, it is important to provide comprehensive and age-appropriate information on safe sex practices, including contraception and abstinence. <\Explain> 107,4,0<\Number> D<\Answers> Question 107: A community health organization is conducting a health fair focused on promoting healthy eating habits. What can attendees expect to find at this event? A) Demonstrations on how to smoke meats B) Samples of high-sugar and high-fat foods C) Information on the benefits of regular exercise D) Displays of fresh fruits and vegetables and nutrition education <\Body> Correct Answer: D) Displays of fresh fruits and vegetables and nutrition education Rationale: A health fair promoting healthy eating habits is likely to feature displays of fresh fruits and vegetables and provide nutrition education to attendees. <\Explain> 108,4,0<\Number> C<\Answers> Question 108: Which factor is critical for the success of community health education programs? A) Exclusive focus on healthcare professionals as educators B) High cost of participation to ensure program quality C) Collaboration with community members and stakeholders D) Restricting access to health information <\Body> Correct Answer: C) Collaboration with community members and stakeholders Rationale: Collaboration with community members and stakeholders is critical for the success of community health education programs, as it helps ensure that programs are tailored to community needs and preferences. <\Explain> 109,4,0<\Number> C<\Answers> Question 109: A community health educator is planning a smoking cessation program. What should be a primary focus when assessing program participants? A) Their past smoking habits B) Their preferred brand of cigarettes C) Their willingness and readiness to quit smoking D) Their income level <\Body> Correct Answer: C) Their willingness and readiness to quit smoking Rationale: Assessing program participants' willingness and readiness to quit smoking is crucial in tailoring the smoking cessation program to their specific needs and motivation levels. <\Explain> 110,4,0<\Number> C<\Answers> Question 110: What is the primary goal of community health education programs aimed at promoting vaccinations? A) Promoting vaccine misinformation B) Reducing access to vaccines C) Increasing vaccine coverage and reducing vaccine-preventable diseases D) Encouraging vaccine hesitancy <\Body> Correct Answer: C) Increasing vaccine coverage and reducing vaccine-preventable diseases Rationale: The primary goal of community health education programs promoting vaccinations is to increase vaccine coverage and reduce the incidence of vaccine-preventable diseases. <\Explain> 111,4,0<\Number> B<\Answers> Question 111: A nurse is assessing a client's self-care abilities during a home visit. Which of the following actions by the client demonstrates effective self-care? A) The client regularly misses medication doses. B) The client seeks assistance for activities of daily living (ADLs). C) The client avoids any physical activity or exercise. D) The client frequently self-diagnoses and self-prescribes medications. <\Body> Correct Answer: B) The client seeks assistance for activities of daily living (ADLs). Rationale: Seeking assistance for activities of daily living (ADLs) indicates that the client recognizes their limitations and is taking steps to address them, demonstrating effective self-care. <\Explain> 112,4,0<\Number> A<\Answers> Question 112: During an assessment, a nurse observes that a client with diabetes regularly monitors blood glucose levels, administers insulin as prescribed, and maintains a balanced diet. What is the nurse's assessment of the client's self-care abilities? A) Effective self-care B) Ineffective self-care C) Self-neglect D) Self-harm <\Body> Correct Answer: A) Effective self-care Rationale: The client's regular monitoring, adherence to medication, and dietary choices demonstrate effective self-care in managing diabetes. <\Explain> 113,4,0<\Number> C<\Answers> Question 113: A nurse is assessing a client's self-care abilities in a home setting. Which of the following findings should raise concern regarding the client's ability to manage their health? A) The client has a well-organized medication schedule and routinely takes prescribed medications. B) The client has grab bars and a raised toilet seat installed in the bathroom for safety. C) The client reports feeling isolated and having limited social support. D) The client engages in regular physical activity and follows a healthy diet. <\Body> Correct Answer: C) The client reports feeling isolated and having limited social support. Rationale: Social isolation and limited social support can hinder a client's ability to effectively manage their health, as they may lack assistance and motivation for self-care. <\Explain> 114,4,0<\Number> B<\Answers> Question 114: A nurse is evaluating a client's self-care abilities related to managing chronic pain. What self-care behaviors should the nurse assess for in this client? A) Avoiding all physical activity to prevent exacerbation of pain. B) Engaging in relaxation techniques and adhering to a prescribed pain management plan. C) Overusing prescribed pain medications to eliminate discomfort. D) Ignoring pain symptoms and not seeking medical attention. <\Body> Correct Answer: B) Engaging in relaxation techniques and adhering to a prescribed pain management plan. Rationale: Engaging in relaxation techniques and adhering to a prescribed pain management plan are positive self-care behaviors for managing chronic pain. <\Explain> 115,4,0<\Number> B<\Answers> Question 115: A nurse is assessing a client's self-care abilities related to wound care at home. What is an essential aspect of evaluating the client's self-care in this context? A) The client's ability to self-diagnose and treat infections without medical advice. B) The client's understanding and adherence to wound care instructions provided by healthcare professionals. C) The client's avoidance of seeking medical attention for wounds. D) The client's use of expired or inadequate wound care supplies. <\Body> Correct Answer: B) The client's understanding and adherence to wound care instructions provided by healthcare professionals. Rationale: Evaluating the client's understanding and adherence to wound care instructions from healthcare professionals is essential for assessing their self-care abilities. <\Explain> 116,4,0<\Number> B<\Answers> Question 116: A nurse is assessing a client's self-care abilities in managing hypertension. Which client behavior indicates effective self-care? A) The client frequently skips doses of antihypertensive medications. B) The client engages in regular physical activity and maintains a low-sodium diet. C) The client avoids all healthcare appointments related to hypertension. D) The client self-prescribes over-the-counter herbal supplements for blood pressure control. <\Body> Correct Answer: B) The client engages in regular physical activity and maintains a low-sodium diet. Rationale: Engaging in regular physical activity and maintaining a low-sodium diet are positive self-care behaviors for managing hypertension. <\Explain> 117,4,0<\Number> C<\Answers> Question 117: A nurse is evaluating a client's self-care abilities related to managing asthma. What action by the client raises concern about their self-care abilities? A) The client carries a rescue inhaler at all times. B) The client avoids known asthma triggers. C) The client does not refill prescriptions for maintenance inhalers. D) The client tracks asthma symptoms and peak flow readings. <\Body> Correct Answer: C) The client does not refill prescriptions for maintenance inhalers. Rationale: Not refilling prescriptions for maintenance inhalers indicates ineffective self-care, as these medications are essential for managing asthma. <\Explain> 118,4,0<\Number> C<\Answers> Question 118: A nurse is assessing a client's self-care abilities related to wound care. What client behavior indicates the need for further education on wound care? A) The client cleans the wound gently with soap and water and applies an appropriate dressing. B) The client avoids touching the wound with clean hands. C) The client applies antibiotic ointment liberally to the wound. D) The client monitors the wound for signs of infection. <\Body> Correct Answer: C) The client applies antibiotic ointment liberally to the wound. Rationale: Applying antibiotic ointment liberally to the wound may indicate a need for further education, as it is not typically recommended and can impede wound healing. <\Explain> 119,4,0<\Number> C<\Answers> Question 119: A nurse is assessing a client's self-care abilities related to diabetes management. What behavior by the client indicates effective self-care? A) The client consumes a high-sugar diet regularly. B) The client administers insulin without monitoring blood glucose levels. C) The client attends regular diabetes education sessions and follows the prescribed meal plan. D) The client discontinues all diabetes medications without consulting a healthcare provider. <\Body> Correct Answer: C) The client attends regular diabetes education sessions and follows the prescribed meal plan. Rationale: Attending regular diabetes education sessions and following the prescribed meal plan are positive self-care behaviors for diabetes management. <\Explain> 120,4,0<\Number> C<\Answers> Question 120: A nurse is evaluating a client's self-care abilities related to fall prevention in the home. What client action demonstrates effective self-care in this context? A) The client ignores environmental hazards that increase fall risk. B) The client avoids using assistive devices such as grab bars. C) The client engages in regular exercise to improve strength and balance. D) The client rarely leaves home to reduce the risk of falls. <\Body> Correct Answer: C) The client engages in regular exercise to improve strength and balance. Rationale: Engaging in regular exercise to improve strength and balance is a positive self-care behavior for fall prevention. <\Explain> 121,4,0<\Number> C<\Answers> Question 121: A nurse is using a stethoscope to auscultate a client's lung sounds. Where should the nurse place the stethoscope to assess the client's breath sounds accurately? A) Over the clothes on the chest B) Over the ribs on the back C) Directly on the skin surface D) In the client's hand <\Body> Correct Answer: C) Directly on the skin surface Rationale: To assess lung sounds accurately, the nurse should place the stethoscope directly on the client's skin surface. <\Explain> 122,4,0<\Number> A<\Answers> Question 122: During a physical examination, a nurse uses a sphygmomanometer to measure a client's blood pressure. What is the correct placement of the stethoscope for auscultatory blood pressure measurement? A) Over the brachial artery B) Over the radial artery C) Over the carotid artery D) Over the femoral artery <\Body> Correct Answer: A) Over the brachial artery Rationale: For auscultatory blood pressure measurement, the stethoscope should be placed over the brachial artery. <\Explain> 123,4,0<\Number> D<\Answers> Question 123: A nurse is assessing a client's body temperature using an electronic oral thermometer. What is the appropriate location for accurate temperature measurement? A) Under the client's armpit B) In the client's ear canal C) On the client's forehead D) Under the client's tongue <\Body> Correct Answer: D) Under the client's tongue Rationale: To obtain an accurate body temperature measurement using an electronic oral thermometer, it should be placed under the client's tongue. <\Explain> 124,4,0<\Number> C<\Answers> Question 124: During a physical assessment, a nurse uses a pulse oximeter to measure a client's oxygen saturation. What body part should the nurse apply the pulse oximeter probe to for accurate readings? A) Forehead B) Chest C) Finger D) Foot <\Body> Correct Answer: C) Finger Rationale: The pulse oximeter probe should be applied to the client's finger to measure oxygen saturation accurately. <\Explain> 125,4,0<\Number> C<\Answers> Question 125: A nurse is performing a neurological assessment and uses a reflex hammer to elicit deep tendon reflexes. What area should the nurse tap with the reflex hammer to assess the patellar reflex? A) The client's forearm B) The client's ankle C) The client's knee D) The client's abdomen <\Body> Correct Answer: C) The client's knee Rationale: To assess the patellar reflex, the nurse should tap the client's knee with the reflex hammer. <\Explain> 126,4,0<\Number> A<\Answers> Question 126: During a physical examination, a nurse uses an ophthalmoscope to assess a client's eyes. Which part of the eye should the nurse focus on during this assessment? A) The retina B) The eyelashes C) The cornea D) The eyelids <\Body> Correct Answer: A) The retina Rationale: When using an ophthalmoscope to assess the eyes, the nurse should focus on the retina for a detailed examination. <\Explain> 127,4,0<\Number> A<\Answers> Question 127: A nurse is conducting a cardiac assessment and uses a stethoscope to auscultate heart sounds. Which area should the nurse listen to for the aortic valve sound? A) The upper left sternal border B) The lower left sternal border C) The lower right sternal border D) The upper right sternal border <\Body> Correct Answer: A) The upper left sternal border Rationale: To auscultate the aortic valve sound, the nurse should listen at the upper left sternal border. <\Explain> 128,4,0<\Number> D<\Answers> Question 128: A nurse is using a Doppler ultrasound device to assess peripheral vascular circulation. Where should the nurse apply the Doppler probe to locate the dorsalis pedis pulse? A) Over the brachial artery B) Over the radial artery C) Over the femoral artery D) Over the dorsum of the foot <\Body> Correct Answer: D) Over the dorsum of the foot Rationale: To locate the dorsalis pedis pulse using a Doppler ultrasound device, the nurse should apply the probe over the dorsum of the foot. <\Explain> 129,4,0<\Number> D<\Answers> Question 129: During a physical examination, a nurse uses a stethoscope to auscultate bowel sounds in a client's abdomen. What area of the abdomen should the nurse listen to for bowel sounds? A) The upper right quadrant B) The lower left quadrant C) The lower right quadrant D) All quadrants <\Body> Correct Answer: D) All quadrants Rationale: When auscultating bowel sounds, the nurse should listen to all quadrants of the abdomen to assess the presence and characteristics of bowel sounds. <\Explain> 130,4,0<\Number> C<\Answers> Question 130: A nurse is using a reflex hammer to elicit the biceps reflex. Where should the nurse tap to elicit this reflex accurately? A) The client's knee B) The client's forehead C) The client's biceps tendon D) The client's ankle <\Body> Correct Answer: C) The client's biceps tendon Rationale: To elicit the biceps reflex accurately, the nurse should tap the client's biceps tendon with a reflex hammer. <\Explain> <\Questions> <\Section>
Psychosocial Integrity - CH3 1,4,0<\Number> B<\Answers> Question 1: A nurse is providing crisis intervention to a client who recently experienced a traumatic event. The client is exhibiting signs of acute stress and anxiety. Which intervention should the nurse prioritize during the crisis intervention process? A) Encourage the client to immediately discuss the traumatic event in detail. B) Teach the client relaxation techniques, such as deep breathing exercises. C) Provide the client with information about long-term therapy options. D) Advise the client to avoid discussing the event to prevent retraumatization. <\Body> Correct Answer: B) Teach the client relaxation techniques, such as deep breathing exercises. Rationale: In crisis intervention for acute stress and anxiety, the priority is to help the client manage their immediate distress. Teaching relaxation techniques, such as deep breathing exercises, is crucial because it can help the client regain control over their emotions and reduce anxiety symptoms. Encouraging the client to discuss the traumatic event in detail (option A) may not be appropriate during the acute phase, as it can potentially worsen their distress. Providing information about long-term therapy options (option C) can be discussed later, after the client's acute symptoms are under control. Advising the client to avoid discussing the event (option D) is not recommended as it may lead to emotional suppression and delayed recovery. <\Explain> 2,4,0<\Number> B<\Answers> Question 2: A nurse is caring for a client who has just been informed of a life-threatening medical diagnosis. The client appears shocked and unable to process the information. Which nursing intervention is most appropriate in this situation? A) Encourage the client to make immediate decisions about their treatment plan. B) Offer information and support in a calm and empathetic manner. C) Provide the client with detailed information about end-of-life options. D) Advise the client to keep the diagnosis a secret from their family. <\Body> Correct Answer: B) Offer information and support in a calm and empathetic manner. Rationale: When a client is initially informed of a life-threatening diagnosis, they may be in a state of shock and emotional distress. The most appropriate nursing intervention is to offer information and support in a calm and empathetic manner (option B). This helps the client begin to process the information and provides emotional support during this crisis. Encouraging immediate decisions about treatment (option A) may overwhelm the client and is not advisable during the initial shock phase. Providing detailed information about end-of-life options (option C) is premature and should be discussed at a later time when the client is more emotionally stable. Advising the client to keep the diagnosis a secret from their family (option D) is not ethical and goes against principles of open communication and support. <\Explain> 3,4,0<\Number> B<\Answers> Question 3: A nurse is providing crisis intervention to a client who has experienced the sudden loss of a loved one. Which nursing action is a priority during the initial phase of crisis intervention? A) Encouraging the client to attend a support group immediately. B) Allowing the client to express their feelings and thoughts. C) Administering a sedative medication to help the client sleep. D) Advising the client to make significant life changes right away. <\Body> Correct Answer: B) Allowing the client to express their feelings and thoughts. Rationale: During the initial phase of crisis intervention, it is essential to provide a safe and supportive environment for the client to express their feelings and thoughts (option B). This allows the client to begin processing their grief and emotions. Encouraging immediate attendance at a support group (option A) may be premature. Administering sedative medication (option C) should only be considered if the client is experiencing severe distress and is unable to cope. Advising significant life changes (option D) is not appropriate during the initial phase of crisis intervention. <\Explain> 4,4,0<\Number> D<\Answers> Question 4: A nurse is assessing a client who has experienced a traumatic event and is at risk for developing post-traumatic stress disorder (PTSD). Which assessment finding is most concerning and requires immediate intervention? A) The client reports occasional nightmares related to the trauma. B) The client avoids places and activities associated with the trauma. C) The client expresses guilt and self-blame for the traumatic event. D) The client experiences flashbacks and intrusive thoughts of the trauma. <\Body> Correct Answer: D) The client experiences flashbacks and intrusive thoughts of the trauma. Rationale: Flashbacks and intrusive thoughts (option D) are concerning symptoms of PTSD and may significantly impact the client's daily life. Immediate intervention and support are required to address these symptoms. While the other options (A, B, and C) are also associated with PTSD, they may not be as severe or immediate in nature. <\Explain> 5,4,0<\Number> B<\Answers> Question 5: A nurse is providing crisis intervention to a client who has lost their job unexpectedly. The client is expressing feelings of hopelessness and helplessness. Which therapeutic technique should the nurse use to assist the client in crisis? A) Offering solutions and suggestions for finding a new job. B) Allowing the client to vent their feelings without interruption. C) Encouraging the client to immediately apply for unemployment benefits. D) Reminding the client that others have faced job loss and coped. <\Body> Correct Answer: B) Allowing the client to vent their feelings without interruption. Rationale: Allowing the client to vent their feelings without interruption (option B) is a crucial therapeutic technique in crisis intervention. It provides the client with a supportive and non-judgmental space to express their emotions. Offering solutions and suggestions (option A) may be premature and can make the client feel invalidated. Encouraging immediate actions like applying for unemployment benefits (option C) may not address the client's emotional needs. Reminding the client about others who have faced job loss (option D) may come across as minimizing their feelings. <\Explain> 6,4,0<\Number> C<\Answers> Question 6: A nurse is providing crisis intervention to a client who has experienced a sexual assault. The client is feeling overwhelmed and fearful. Which nursing action is a priority during the crisis intervention process? A) Immediately reporting the assault to the authorities. B) Providing the client with information about self-defense techniques. C) Ensuring the client's physical safety and offering emotional support. D) Advising the client to avoid discussing the assault with anyone. <\Body> Correct Answer: C) Ensuring the client's physical safety and offering emotional support. Rationale: Ensuring the client's physical safety and offering emotional support (option C) is the immediate priority when providing crisis intervention to a sexual assault survivor. Reporting the assault to the authorities (option A) should be done with the client's consent and at their own pace. Providing self-defense information (option B) is not appropriate during the immediate crisis period. Advising the client to avoid discussing the assault (option D) is not recommended, as open communication and support are essential for recovery. <\Explain> 7,4,0<\Number> A<\Answers> Question 7: A nurse is providing crisis intervention to a client who has lost their home in a natural disaster. The client is experiencing feelings of shock and disbelief. Which phase of crisis intervention is the client likely in? A) The impact phase B) The exploration phase C) The equilibrium phase D) The resolution phase <\Body> Correct Answer: A) The impact phase Rationale: The impact phase is the initial reaction to a crisis, characterized by shock, disbelief, and a sense of being overwhelmed. During this phase, the client may have difficulty processing what has occurred. The exploration phase (option B) involves a search for coping strategies and assistance, the equilibrium phase (option C) is when the client begins to adapt and regain stability, and the resolution phase (option D) is marked by problem resolution and recovery. <\Explain> 8,4,0<\Number> B<\Answers> Question 8: A nurse is providing crisis intervention to a client who has just experienced the sudden death of a loved one. The client is exhibiting anger and irritability. Which therapeutic technique should the nurse use to address these emotions? A) Encourage the client to suppress their anger to avoid conflict. B) Advise the client to engage in physical exercise to release tension. C) Tell the client that anger is not an appropriate response to grief. D) Instruct the client to distract themselves from their emotions. <\Body> Correct Answer: B) Advise the client to engage in physical exercise to release tension. Rationale: Physical exercise can be a healthy outlet for releasing tension and anger during the grieving process. It is important to encourage constructive ways of dealing with emotions. Encouraging the client to suppress their anger (option A) is not therapeutic and can lead to further emotional distress. Telling the client that anger is not an appropriate response (option C) invalidates their feelings. Instructing the client to distract themselves (option D) may not address the underlying emotions and can be counterproductive in the grieving process. <\Explain> 9,4,0<\Number> C<\Answers> Question 9: A nurse is providing crisis intervention to a client who has lost their job due to company downsizing. The client is experiencing anxiety and insomnia. Which nursing intervention is appropriate to address these symptoms? A) Administer a sedative medication to help the client sleep. B) Encourage the client to avoid discussing their job loss with friends. C) Teach the client relaxation techniques, such as deep breathing exercises. D) Advise the client to immediately start a new job search. <\Body> Correct Answer: C) Teach the client relaxation techniques, such as deep breathing exercises. Rationale: Teaching relaxation techniques, such as deep breathing exercises (option C), can help the client manage anxiety and insomnia associated with job loss. Administering sedative medication (option A) should be considered only after non-pharmacological interventions have been attempted. Encouraging the client to avoid discussing their job loss (option B) may lead to isolation and emotional suppression. Advising immediate job searching (option D) may not be feasible or appropriate given the client's current emotional state. <\Explain> 10,4,0<\Number> D<\Answers> Question 10: A nurse is providing crisis intervention to a client who has been involved in a serious car accident. The client is experiencing flashbacks and severe anxiety. Which intervention should the nurse prioritize? A) Encourage the client to avoid thinking about the accident. B) Provide the client with information about legal actions. C) Offer the client cognitive-behavioral therapy (CBT) immediately. D) Ensure the client's physical safety and provide emotional support. <\Body> Correct Answer: D) Ensure the client's physical safety and provide emotional support. Rationale: The priority during crisis intervention for a client experiencing flashbacks and severe anxiety after a traumatic event is to ensure the client's physical safety and provide emotional support (option D). This helps stabilize the client and addresses their immediate distress. Encouraging avoidance of thinking about the accident (option A) is not therapeutic. Providing information about legal actions (option B) can be addressed later. Cognitive-behavioral therapy (CBT) (option C) may be appropriate in the future but is not the immediate priority. <\Explain> 11,4,0<\Number> B<\Answers> Question 11: A nurse is providing crisis intervention to a client who is agitated and threatening self-harm. Which safety precaution should the nurse prioritize in this situation? A) Offer the client a comforting hug to provide emotional support. B) Maintain a safe physical distance while engaging in therapeutic communication. C) Administer a sedative medication without the client's consent. D) Encourage the client to discuss their self-harming thoughts in detail. <\Body> Correct Answer: B) Maintain a safe physical distance while engaging in therapeutic communication. Rationale: When a client is agitated and threatening self-harm, the nurse's priority is to maintain a safe physical distance (option B) to prevent harm to both the client and the nurse. Offering a comforting hug (option A) may escalate the situation or be perceived as invasive. Administering sedative medication without consent (option C) should only be done under appropriate circumstances and orders. Encouraging detailed discussion of self-harming thoughts (option D) is not advisable during a crisis. <\Explain> 12,4,0<\Number> C<\Answers> Question 12: A nurse is caring for a client who is experiencing severe alcohol withdrawal during crisis intervention. Which safety precaution is essential for this client? A) Administering a sedative medication immediately. B) Allowing unrestricted access to alcohol to prevent withdrawal symptoms. C) Frequent monitoring of vital signs and assessment for signs of delirium tremens. D) Encouraging the client to consume caffeine to stay awake. <\Body> Correct Answer: C) Frequent monitoring of vital signs and assessment for signs of delirium tremens. Rationale: In the context of severe alcohol withdrawal, the safety precaution that is essential is frequent monitoring of vital signs and assessment for signs of delirium tremens (option C). Delirium tremens can be life-threatening, and close monitoring is critical. Administering sedative medication (option A) may be necessary, but it should be done based on the client's symptoms and medical orders. Allowing unrestricted access to alcohol (option B) is not safe and can worsen withdrawal symptoms. Encouraging caffeine consumption (option D) may not be appropriate and can exacerbate agitation. <\Explain> 13,4,0<\Number> C<\Answers> Question 13: A nurse is providing crisis intervention to a client who is expressing homicidal thoughts and is a danger to others. Which safety precaution should the nurse implement immediately? A) Offer the client a quiet and private room for reflection. B) Ensure the client has access to any requested weapons. C) Initiate appropriate security measures and involve authorities. D) Encourage the client to express their thoughts openly. <\Body> Correct Answer: C) Initiate appropriate security measures and involve authorities. Rationale: When a client is expressing homicidal thoughts and poses a danger to others, the immediate safety precaution is to initiate appropriate security measures and involve authorities (option C) to protect the client and others. Offering a quiet room (option A) is not appropriate in this situation. Ensuring access to weapons (option B) is dangerous and should be prevented. Encouraging open expression of homicidal thoughts (option D) is not safe and can potentially lead to harm. <\Explain> 14,4,0<\Number> A<\Answers> Question 14: A nurse is providing crisis intervention to a client who has a history of self-harm and is currently in a state of distress. Which safety precaution should the nurse implement first? A) Remove any sharp objects or potential means of self-harm from the client's environment. B) Offer the client a list of self-help books for coping with self-harm urges. C) Ask the client to sign a contract promising not to engage in self-harm. D) Administer a sedative medication to calm the client immediately. <\Body> Correct Answer: A) Remove any sharp objects or potential means of self-harm from the client's environment. Rationale: The first safety precaution to implement when caring for a client with a history of self-harm who is currently in distress is to remove any sharp objects or potential means of self-harm from the client's environment (option A). This helps reduce the immediate risk of self-harm. Offering self-help books (option B) may be beneficial but should not take precedence over safety. Self-harm contracts (option C) are not considered a reliable safety measure. Administering a sedative medication (option D) may be necessary but should be done based on the client's condition and medical orders. <\Explain> 15,4,0<\Number> C<\Answers> Question 15: A nurse is caring for a client who has been sexually assaulted and is receiving crisis intervention. Which safety precaution should the nurse prioritize for this client? A) Provide the client with unrestricted access to their personal belongings. B) Allow the client to be alone in a private room to process the trauma. C) Ensure the client's physical safety and offer emotional support. D) Encourage the client to immediately confront the perpetrator. <\Body> Correct Answer: C) Ensure the client's physical safety and offer emotional support. Rationale: When caring for a client who has been sexually assaulted and is receiving crisis intervention, the priority is to ensure the client's physical safety and offer emotional support (option C). This includes preventing further harm and addressing immediate distress. Providing unrestricted access to personal belongings (option A) may not be safe. Allowing the client to be alone in a private room (option B) should be based on the client's preference and safety considerations. Encouraging immediate confrontation (option D) may not be appropriate and can be harmful. <\Explain> 16,4,0<\Number> A<\Answers> Question 16: A nurse is providing crisis intervention to a client who is experiencing an acute panic attack. Which safety precaution should the nurse prioritize? A) Encourage the client to engage in deep breathing exercises. B) Offer the client a cup of caffeinated coffee to increase alertness. C) Administer a sedative medication to calm the client immediately. D) Allow the client to leave the healthcare facility to go home. <\Body> Correct Answer: A) Encourage the client to engage in deep breathing exercises. Rationale: When a client is experiencing an acute panic attack, the priority is to encourage the client to engage in deep breathing exercises (option A). This can help alleviate the symptoms of panic and promote relaxation. Offering caffeinated coffee (option B) is not recommended, as caffeine can exacerbate anxiety. Administering a sedative medication (option C) may be necessary in some cases but should be done based on the client's condition and medical orders. Allowing the client to leave the healthcare facility (option D) may not be safe if the client is in a state of distress. <\Explain> 17,4,0<\Number> B<\Answers> Question 17: A nurse is caring for a client who is experiencing severe depression and has expressed suicidal thoughts. Which safety precaution is essential when providing crisis intervention for this client? A) Offer the client unrestricted access to medications for self-administration. B) Maintain a therapeutic relationship while closely monitoring the client. C) Encourage the client to isolate themselves to avoid triggering events. D) Advise the client to keep their suicidal thoughts private. <\Body> Correct Answer: B) Maintain a therapeutic relationship while closely monitoring the client. Rationale: When caring for a client with severe depression and suicidal thoughts, the essential safety precaution is to maintain a therapeutic relationship while closely monitoring the client (option B). This allows for emotional support and helps ensure the client's safety. Offering unrestricted access to medications (option A) is not safe and can be harmful. Encouraging isolation (option C) is not recommended, as social support is important. Advising the client to keep suicidal thoughts private (option D) is not appropriate, as open communication is crucial for intervention. <\Explain> 18,4,0<\Number> C<\Answers> Question 18: A nurse is providing crisis intervention to a client who is experiencing a severe anxiety attack. The client's breathing is rapid, and they report chest pain. Which safety precaution should the nurse implement first? A) Administer a sedative medication to calm the client. B) Encourage the client to sit in a quiet, dark room. C) Assess the client's vital signs and oxygen saturation. D) Advise the client to take deep breaths and relax. <\Body> Correct Answer: C) Assess the client's vital signs and oxygen saturation. Rationale: When a client is experiencing a severe anxiety attack with rapid breathing and chest pain, the first safety precaution is to assess the client's vital signs and oxygen saturation (option C) to rule out any physical health concerns. Administering a sedative medication (option A) may be necessary, but it should be done based on the client's condition and medical orders. Encouraging the client to sit in a quiet, dark room (option B) may not address potential physical health issues. Advising deep breathing and relaxation (option D) can be helpful but should be based on the client's overall condition. <\Explain> 19,4,0<\Number> B<\Answers> Question 19: A nurse is providing crisis intervention to a client who is experiencing severe agitation and aggression. Which safety precaution should the nurse prioritize? A) Offer the client a calming herbal tea to reduce anxiety. B) Maintain a safe physical distance and call for assistance. C) Advise the client to engage in strenuous physical exercise. D) Encourage the client to express their anger openly. <\Body> Correct Answer: B) Maintain a safe physical distance and call for assistance. Rationale: When a client is experiencing severe agitation and aggression, the priority is to maintain a safe physical distance (option B) to protect the safety of both the client and the nurse. Offering calming herbal tea (option A) may not be effective in such cases. Advising strenuous physical exercise (option C) may not be safe and can escalate the situation. Encouraging open expression of anger (option D) is not appropriate when the client is in an agitated state. <\Explain> 20,4,0<\Number> B<\Answers> Question 20: A nurse is providing crisis intervention to a client who is experiencing acute delirium. Which safety precaution should the nurse prioritize? A) Administer a sedative medication to calm the client. B) Ensure the client's environment is well-lit and free from hazards. C) Encourage the client to engage in complex cognitive tasks. D) Advise the client to consume alcoholic beverages for relaxation. <\Body> Correct Answer: B) Ensure the client's environment is well-lit and free from hazards. Rationale: When caring for a client experiencing acute delirium, the priority is to ensure the client's environment is well-lit and free from hazards (option B) to prevent accidents and injuries. Administering a sedative medication (option A) may be considered in some cases but should be done based on the client's condition and medical orders. Encouraging complex cognitive tasks (option C) is not appropriate during delirium. Advising alcohol consumption (option D) can exacerbate delirium and is not recommended. <\Explain> 21,4,0<\Number> D<\Answers> Question 21: A nurse is caring for a client who is recovering from substance abuse and is transitioning back into the community. Which resource is essential for the client's ongoing recovery? A) A private therapist for individual counseling. B) Supportive friends who are also substance users. C) Access to local bars and nightclubs. D) Participation in a 12-step recovery group. <\Body> Correct Answer: D) Participation in a 12-step recovery group. Rationale: Participation in a 12-step recovery group (option D) is essential for clients recovering from substance abuse, as it provides peer support, accountability, and a structured program for maintaining sobriety. A private therapist (option A) may be beneficial, but peer support is also crucial. Supportive friends (option B) who are also substance users can be detrimental to recovery. Access to bars and nightclubs (option C) is not conducive to maintaining sobriety. <\Explain> 22,4,0<\Number> B<\Answers> Question 22: A nurse is caring for a client diagnosed with major depressive disorder. The client has limited social supports and often feels isolated. What resource should the nurse explore to help address the client's isolation? A) Encourage the client to avoid social interactions for self-preservation. B) Connect the client with local community organizations and clubs. C) Suggest the client rely solely on the healthcare team for support. D) Advise the client to limit contact with family members. <\Body> Correct Answer: B) Connect the client with local community organizations and clubs. Rationale: To address the client's isolation, the nurse should explore resources that promote social engagement, such as connecting the client with local community organizations and clubs (option B). Encouraging avoidance of social interactions (option A) can worsen isolation. Relying solely on the healthcare team (option C) may not provide adequate social support. Limiting contact with family members (option D) is not recommended, as family support can be valuable. <\Explain> 23,4,0<\Number> B<\Answers> Question 23: A nurse is working with a client who is recovering from a traumatic experience and experiencing post-traumatic stress disorder (PTSD). Which resource should the nurse recommend to assist the client in coping with their symptoms? A) Avoidance of any reminders of the traumatic event. B) Participation in a trauma-focused therapy program. C) Isolation from family and friends to minimize triggers. D) Relying solely on self-help books for support. <\Body> Correct Answer: B) Participation in a trauma-focused therapy program. Rationale: Clients with PTSD benefit from trauma-focused therapy programs (option B) that help them process and manage their symptoms. Avoidance of reminders (option A) can reinforce avoidance behaviors and worsen symptoms. Isolation (option C) is not recommended, as social support can be crucial. Relying solely on self-help books (option D) may not provide the level of support and guidance needed for recovery from PTSD. <\Explain> 24,4,0<\Number> B<\Answers> Question 24: A nurse is providing care to a client who has been diagnosed with schizophrenia. The client's family is seeking resources to better understand and support their loved one. What resource should the nurse recommend to the family? A) Encourage the family to limit communication with the client. B) Suggest the family join a local support group for caregivers of individuals with mental illness. C) Advise the family to avoid discussing the client's diagnosis. D) Provide the family with self-help books on mental illness. <\Body> Correct Answer: B) Suggest the family join a local support group for caregivers of individuals with mental illness. Rationale: Joining a local support group for caregivers of individuals with mental illness (option B) can provide the family with valuable information, coping strategies, and emotional support. Limiting communication (option A) and avoiding discussion of the diagnosis (option C) can hinder understanding and support. While self-help books (option D) can be helpful, the interaction and shared experiences in a support group are often more beneficial for families. <\Explain> 25,4,0<\Number> D<\Answers> Question 25: A nurse is caring for a client diagnosed with bipolar disorder. The client is interested in finding resources for managing their condition and mood swings. What resource should the nurse recommend? A) Encourage the client to avoid medication and therapy. B) Suggest the client rely solely on family support. C) Advise the client to explore online bipolar disorder forums. D) Recommend the client attend a bipolar disorder support group. <\Body> Correct Answer: D) Recommend the client attend a bipolar disorder support group. Rationale: Attending a bipolar disorder support group (option D) can provide the client with peer support, shared coping strategies, and a sense of community. Encouraging avoidance of medication and therapy (option A) is not in the client's best interest. Relying solely on family support (option B) may not provide the specialized knowledge and understanding that a support group can offer. While online forums (option C) can be helpful, in-person support groups often provide a more comprehensive experience. <\Explain> 26,4,0<\Number> C<\Answers> Question 26: A nurse is caring for a client who has a history of self-harm and is seeking resources to manage their impulses. What resource should the nurse recommend to the client? A) Suggest the client avoid discussing self-harm urges with anyone. B) Encourage the client to rely solely on self-help books. C) Recommend the client attend a support group for individuals with self-harm tendencies. D) Advise the client to continue self-harming as a coping mechanism. <\Body> Correct Answer: C) Recommend the client attend a support group for individuals with self-harm tendencies. Rationale: Attending a support group for individuals with self-harm tendencies (option C) can provide the client with a safe space to share experiences, learn healthier coping strategies, and receive peer support. Avoiding discussion of self-harm urges (option A) is not recommended, as open communication is important for recovery. Relying solely on self-help books (option B) may not provide the level of support needed. Continuing self-harming (option D) is not a healthy coping mechanism and should be discouraged. <\Explain> 27,4,0<\Number> C<\Answers> Question 27: A nurse is providing care to a client with an eating disorder who is seeking resources for recovery. What resource should the nurse recommend to the client? A) Suggest the client limit their meals to reduce calorie intake. B) Encourage the client to avoid discussions about body image. C) Recommend the client attend an eating disorder support group. D) Advise the client to rely solely on nutritional supplements. <\Body> Correct Answer: C) Recommend the client attend an eating disorder support group. Rationale: Attending an eating disorder support group (option C) can provide the client with peer support, shared coping strategies, and a safe environment for discussing their challenges. Limiting meals (option A) is not recommended and can exacerbate the eating disorder. Avoiding discussions about body image (option B) can hinder progress in therapy. Relying solely on nutritional supplements (option D) is not a comprehensive approach to recovery. <\Explain> 28,4,0<\Number> C<\Answers> Question 28: A nurse is caring for a client who is recovering from a recent loss of a loved one. The client is experiencing grief and seeks resources for coping. What resource should the nurse recommend to the client? A) Encourage the client to isolate themselves from friends and family. B) Suggest the client focus solely on work to distract from grief. C) Recommend the client join a grief support group. D) Advise the client to avoid discussing their feelings of loss. <\Body> Correct Answer: C) Recommend the client join a grief support group. Rationale: Joining a grief support group (option C) can provide the client with emotional support, shared experiences, and coping strategies specific to grief. Isolating from friends and family (option A) is not recommended, as social support is crucial during grieving. Focusing solely on work (option B) can be a form of avoidance and may not facilitate healthy grieving. Avoiding discussion of feelings of loss (option D) can hinder the grieving process. <\Explain> 29,4,0<\Number> C<\Answers> Question 29: A nurse is caring for a client who is recovering from a severe anxiety disorder and is looking for resources to manage anxiety symptoms. What resource should the nurse recommend? A) Encourage the client to avoid situations that trigger anxiety. B) Suggest the client rely solely on medication for anxiety management. C) Recommend the client participate in cognitive-behavioral therapy (CBT). D) Advise the client to limit contact with friends and family. <\Body> Correct Answer: C) Recommend the client participate in cognitive-behavioral therapy (CBT). Rationale: Cognitive-behavioral therapy (CBT) (option C) is an evidence-based treatment for anxiety disorders that helps clients manage symptoms and develop coping strategies. Avoiding triggering situations (option A) can reinforce avoidance behaviors and worsen anxiety. Relying solely on medication (option B) may not address the underlying causes of anxiety. Limiting contact with friends and family (option D) is not recommended, as social support can be beneficial in anxiety management. <\Explain> 30,4,0<\Number> C<\Answers> Question 30: A nurse is providing care to a client with a history of domestic violence. The client is seeking resources to escape the abusive relationship. What resource should the nurse recommend to the client? A) Encourage the client to remain in the abusive relationship for the sake of stability. B) Suggest the client rely solely on self-help books for guidance. C) Recommend the client contact a local domestic violence shelter or hotline. D) Advise the client to keep the abuse a secret to avoid further harm. <\Body> Correct Answer: C) Recommend the client contact a local domestic violence shelter or hotline. Rationale: Recommending the client contact a local domestic violence shelter or hotline (option C) is crucial for providing immediate safety and assistance in escaping an abusive relationship. Encouraging the client to remain in the abusive relationship (option A) is not safe. Relying solely on self-help books (option B) may not provide the necessary support and protection. Advising secrecy (option D) can perpetuate the cycle of abuse and is not in the client's best interest. <\Explain> 31,4,0<\Number> C<\Answers> Question 31: A nurse is assessing an elderly client in a long-term care facility. The nurse notices unexplained bruising on the client's arms. What should the nurse do first? A) Document the findings and continue monitoring the client. B) Confront the client about the bruising to determine the cause. C) Notify the charge nurse and the facility's abuse hotline. D) Administer pain medication to relieve any discomfort. <\Body> Correct Answer: C) Notify the charge nurse and the facility's abuse hotline. Rationale: When unexplained bruising is observed in a vulnerable adult, it is essential to follow facility protocols and report the findings to the charge nurse and the facility's abuse hotline (option C) to ensure the client's safety. Documenting the findings (option A) is important but should be done after reporting the suspicion of abuse. Confronting the client (option B) may not be appropriate initially. Administering pain medication (option D) without further assessment and investigation is premature. <\Explain> 32,4,0<\Number> D<\Answers> Question 32: A school nurse is evaluating a 10-year-old student who frequently comes to school with untreated injuries. The nurse suspects child abuse. What is the nurse's priority action? A) Inform the child's teacher about the suspicions. B) Document the findings in the student's medical record. C) Interview the child privately to gather more information. D) Report the suspicion of child abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of child abuse to the appropriate authorities. Rationale: When child abuse is suspected, the nurse's priority is to report the suspicion to the appropriate authorities (option D) following legal and ethical obligations to protect the child. Informing the child's teacher (option A) and documenting findings (option B) are important but should occur after reporting. Interviewing the child privately (option C) is not the nurse's role; it is best left to trained child protective services professionals. <\Explain> 33,4,0<\Number> A<\Answers> Question 33: A nurse is assessing a client in the emergency department who presents with injuries consistent with physical abuse. The client is accompanied by the suspected abuser, who is a family member. What should the nurse do first? A) Ask the suspected abuser to leave the room. B) Complete a thorough assessment of the client's injuries. C) Confront the suspected abuser about the injuries. D) Offer resources for anger management to the suspected abuser. <\Body> Correct Answer: A) Ask the suspected abuser to leave the room. Rationale: In cases of suspected abuse, the safety of the victim is a priority. The nurse should ask the suspected abuser to leave the room (option A) to ensure the client's safety and prevent further harm. Afterward, a thorough assessment of the client's injuries (option B) should be conducted. Confronting the suspected abuser (option C) may escalate the situation and is not the nurse's primary role. Offering resources for anger management (option D) can be addressed later, if appropriate. <\Explain> 34,4,0<\Number> C<\Answers> Question 34: A home health nurse is caring for an elderly client who has unexplained weight loss, dehydration, and pressure ulcers. The client's family member is the primary caregiver. What action should the nurse take? A) Document the client's condition and continue with the care plan. B) Discuss the client's condition with the family member and offer assistance. C) Report the findings to the home health agency supervisor. D) Administer fluids and wound care to address the client's immediate needs. <\Body> Correct Answer: C) Report the findings to the home health agency supervisor. Rationale: When signs of neglect are identified in a client's home, it is crucial to report the findings to the appropriate authority, in this case, the home health agency supervisor (option C). Documentation (option A) is important but should follow the reporting process. Discussing the client's condition with the family member (option B) can be done after reporting to ensure the client's safety. Administering fluids and wound care (option D) may be necessary but should be based on a comprehensive assessment and care plan. <\Explain> 35,4,0<\Number> C<\Answers> Question 35: A nurse is assessing a toddler who is brought to the pediatric clinic with multiple bruises and a fractured arm. The parents provide inconsistent explanations for the injuries. What should the nurse do first? A) Confront the parents about the inconsistent explanations. B) Document the findings in the child's medical record. C) Notify child protective services to report suspected abuse. D) Administer pain medication to the child to alleviate discomfort. <\Body> Correct Answer: C) Notify child protective services to report suspected abuse. Rationale: When child abuse is suspected, the nurse's priority is to report the suspicion to child protective services (option C) to ensure the child's safety. Confronting the parents (option A) may not be safe and can escalate the situation. Documenting findings (option B) is important but should follow the reporting process. Administering pain medication (option D) can be addressed after ensuring the child's safety. <\Explain> 36,4,0<\Number> D<\Answers> Question 36: A nurse is caring for an older adult client in a long-term care facility who appears fearful and withdrawn. The nurse notices unexplained weight loss and untreated medical conditions. What should the nurse do first? A) Document the client's condition and discuss it with the charge nurse. B) Confront the client about the unexplained weight loss and medical conditions. C) Notify the family members about the client's deteriorating health. D) Report the suspicion of neglect to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of neglect to the appropriate authorities. Rationale: In cases of suspected neglect, the nurse's priority is to report the suspicion to the appropriate authorities (option D) to ensure the client's safety. Documenting the client's condition (option A) is important but should follow the reporting process. Confronting the client (option B) may not be safe and is not the primary role of the nurse. Notifying family members (option C) can be done after reporting. <\Explain> 37,4,0<\Number> D<\Answers> Question 37: A nurse is assessing a child who has been brought to the emergency department with a head injury. The child's caregiver provides inconsistent accounts of how the injury occurred. What should the nurse do first? A) Document the caregiver's explanations and continue with the assessment. B) Confront the caregiver about the inconsistencies in their accounts. C) Notify the charge nurse and the facility's abuse hotline. D) Report the suspicion of child abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of child abuse to the appropriate authorities. Rationale: When inconsistent explanations for injuries are provided, and child abuse is suspected, the nurse's priority is to report the suspicion to the appropriate authorities (option D) following legal and ethical obligations to protect the child. Documenting the caregiver's explanations (option A) should follow the reporting process. Confronting the caregiver (option B) may not be safe and can hinder the investigation. Notifying the charge nurse and the facility's abuse hotline (option C) may be appropriate in other settings but is not the primary action in this case. <\Explain> 38,4,0<\Number> D<\Answers> Question 38: A school nurse is assessing a 12-year-old student who frequently arrives at school with bruises and injuries. The student is evasive when questioned about the injuries. What action should the nurse take? A) Document the findings in the student's medical record and inform the teacher. B) Discuss the injuries with the student privately to gather more information. C) Notify the school counselor and share the concerns. D) Report the suspicion of child abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of child abuse to the appropriate authorities. Rationale: When child abuse is suspected, especially when the child is evasive about injuries, the nurse's priority is to report the suspicion to the appropriate authorities (option D) to ensure the child's safety. Documenting findings (option A) and discussing injuries privately (option B) should follow the reporting process. Notifying the school counselor (option C) is important but should not delay reporting. <\Explain> 39,4,0<\Number> D<\Answers> Question 39: A nurse is caring for a client in a long-term care facility who exhibits signs of verbal abuse from another resident. The client appears fearful and anxious. What should the nurse do first? A) Document the client's signs of distress and continue with routine care. B) Confront the resident responsible for the verbal abuse. C) Notify the charge nurse and the facility's abuse hotline. D) Offer the client emotional support and reassurance. <\Body> Correct Answer: D) Offer the client emotional support and reassurance. Rationale: When a client in a long-term care facility is experiencing distress due to verbal abuse, the nurse's first action should be to offer emotional support and reassurance to the affected client (option D). This helps address the immediate emotional needs. Documenting the client's signs of distress (option A) is important but should follow offering support. Confronting the resident responsible (option B) may not be safe and should involve facility protocols. Notifying the charge nurse and the facility's abuse hotline (option C) should occur after addressing the client's immediate needs. <\Explain> 40,4,0<\Number> D<\Answers> Question 40: A nurse is assessing an elderly client who has multiple pressure ulcers in various stages of healing. The client is unable to provide a clear explanation for the ulcers. What should the nurse do first? A) Document the appearance and stages of the pressure ulcers. B) Confront the client about the ulcers and their cause. C) Notify the healthcare provider about the client's condition. D) Report the suspicion of neglect to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of neglect to the appropriate authorities. Rationale: In cases where elderly clients have multiple pressure ulcers and are unable to provide a clear explanation, the nurse's priority is to report the suspicion of neglect to the appropriate authorities (option D) to ensure the client's safety. Documenting the ulcers (option A) should follow the reporting process. Confronting the client (option B) may not be safe and can hinder the investigation. Notifying the healthcare provider (option C) can be done after reporting. <\Explain> 41,4,0<\Number> B<\Answers> Question 41: A nurse is caring for a client who has been physically abused by their partner. What is the nurse's priority intervention? A) Encourage the client to leave their partner immediately. B) Assess the client's physical injuries and provide treatment. C) Suggest couples therapy for the client and their partner. D) Offer resources for anger management to the client. <\Body> Correct Answer: B) Assess the client's physical injuries and provide treatment. Rationale: The nurse's priority intervention is to assess and address the client's physical injuries (option B) to ensure their safety and well-being. While leaving an abusive relationship (option A) is a goal, it may not be immediately feasible, and the client's safety is paramount. Couples therapy (option C) is not appropriate in cases of abuse, as it can escalate the situation. Offering resources for anger management (option D) may be considered later but is not the initial priority. <\Explain> 42,4,0<\Number> C<\Answers> Question 42: A school nurse is providing education to students about preventing bullying. What intervention should the nurse emphasize? A) Encourage bystanders to join in and support the bully. B) Teach students to ignore bullying behavior. C) Instruct students to report bullying to a trusted adult. D) Advise students to confront bullies on their own. <\Body> Correct Answer: C) Instruct students to report bullying to a trusted adult. Rationale: The most effective intervention to prevent bullying is to instruct students to report bullying to a trusted adult (option C). Encouraging bystanders to support the bully (option A) is not appropriate and can perpetuate the behavior. Ignoring bullying behavior (option B) is not a recommended strategy, as it may not lead to resolution. Directly confronting bullies on their own (option D) may not be safe for the victim and can escalate the situation. <\Explain> 43,4,0<\Number> D<\Answers> Question 43: A nurse is caring for an elderly client in a long-term care facility who reports financial exploitation by a family member. What is the nurse's priority intervention? A) Document the client's report and continue with routine care. B) Confront the family member about the financial exploitation. C) Notify the facility's administrator about the client's concerns. D) Report the suspicion of financial abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of financial abuse to the appropriate authorities. Rationale: The nurse's priority intervention is to report the suspicion of financial abuse to the appropriate authorities (option D) to ensure the client's protection. Documenting the client's report (option A) is important but should follow the reporting process. Confronting the family member (option B) may not be safe and can hinder the investigation. Notifying the facility's administrator (option C) can be done after reporting to ensure facility protocols are followed. <\Explain> 44,4,0<\Number> D<\Answers> Question 44: A nurse is providing care to a child who has disclosed sexual abuse. What should the nurse do first? A) Advise the child to keep the abuse a secret. B) Document the child's disclosure and injuries. C) Confront the alleged abuser to get their side of the story. D) Report the disclosure of sexual abuse to child protective services. <\Body> Correct Answer: D) Report the disclosure of sexual abuse to child protective services. Rationale: When a child discloses sexual abuse, the nurse's first action is to report the disclosure to child protective services (option D) to ensure the child's safety. Advising the child to keep the abuse a secret (option A) is not appropriate and can perpetuate harm. Documenting the child's disclosure and injuries (option B) is important but should follow the reporting process. Confronting the alleged abuser (option C) should involve legal authorities, not the nurse. <\Explain> 45,4,0<\Number> C<\Answers> Question 45: A nurse is caring for an adult client who is a victim of domestic violence and wants to leave the abusive relationship. What should the nurse include in the safety plan for the client? A) Encourage the client to confront the abuser and demand change. B) Provide the client with the abuser's contact information. C) Offer resources for safe housing and a local domestic violence hotline. D) Suggest reconciliation counseling for the client and the abuser. <\Body> Correct Answer: C) Offer resources for safe housing and a local domestic violence hotline. Rationale: The nurse should include resources for safe housing and a local domestic violence hotline (option C) in the safety plan for the client to ensure their immediate safety. Encouraging the client to confront the abuser (option A) may not be safe and can escalate the situation. Providing the client with the abuser's contact information (option B) is not appropriate and can jeopardize the client's safety. Suggesting reconciliation counseling (option D) is not recommended in cases of domestic violence, as safety is the priority. <\Explain> 46,4,0<\Number> B<\Answers> Question 46: A nurse is providing care to a child who is at risk of abuse in the home. What intervention should the nurse prioritize? A) Teach the child self-defense techniques. B) Develop a safety plan for the child. C) Confront the child's parents about the risk. D) Offer resources for family counseling. <\Body> Correct Answer: B) Develop a safety plan for the child. Rationale: The nurse's priority intervention is to develop a safety plan for the child (option B) to ensure their protection. Teaching the child self-defense techniques (option A) may not be effective or safe. Confronting the child's parents (option C) may not be appropriate and can escalate the situation. Offering resources for family counseling (option D) can be considered later but is not the initial priority. <\Explain> 47,4,0<\Number> D<\Answers> Question 47: A nurse is caring for an elderly client who has been emotionally abused by a family member. What intervention should the nurse prioritize? A) Document the client's emotional state and continue with routine care. B) Confront the family member about the emotional abuse. C) Notify the facility's administrator about the client's concerns. D) Report the suspicion of emotional abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of emotional abuse to the appropriate authorities. Rationale: The nurse's priority intervention is to report the suspicion of emotional abuse to the appropriate authorities (option D) to ensure the client's protection. Documenting the client's emotional state (option A) is important but should follow the reporting process. Confronting the family member (option B) may not be safe and can hinder the investigation. Notifying the facility's administrator (option C) can be done after reporting to ensure facility protocols are followed. <\Explain> 48,4,0<\Number> D<\Answers> Question 48: A nurse is assessing a child who has disclosed physical abuse by a parent. What should the nurse do first? A) Advise the child to avoid the parent responsible for the abuse. B) Document the child's disclosure and physical injuries. C) Confront the parent about the allegations. D) Report the disclosure of physical abuse to child protective services. <\Body> Correct Answer: D) Report the disclosure of physical abuse to child protective services. Rationale: When a child discloses physical abuse, the nurse's first action is to report the disclosure to child protective services (option D) to ensure the child's safety. Advising the child to avoid the parent responsible for the abuse (option A) may not be effective and can put the child at risk. Documenting the child's disclosure and physical injuries (option B) is important but should follow the reporting process. Confronting the parent (option C) should involve legal authorities, not the nurse. <\Explain> 49,4,0<\Number> B<\Answers> Question 49: A nurse is caring for a client who is a victim of elder abuse by a family member. What should the nurse prioritize in the client's care plan? A) Encourage the client to confront the abuser and demand change. B) Assess the client's physical and emotional injuries. C) Provide the client with the abuser's contact information. D) Offer resources for family counseling. <\Body> Correct Answer: B) Assess the client's physical and emotional injuries. Rationale: The nurse should prioritize assessing the client's physical and emotional injuries (option B) to address their immediate needs and ensure their safety. Encouraging the client to confront the abuser (option A) may not be safe and can escalate the situation. Providing the client with the abuser's contact information (option C) is not appropriate and can jeopardize the client's safety. Offering resources for family counseling (option D) can be considered later but is not the initial priority. <\Explain> 50,4,0<\Number> D<\Answers> Question 50: A school nurse is assessing a child who frequently arrives at school with untreated injuries and appears anxious. The child avoids eye contact and provides inconsistent explanations for the injuries. What should the nurse do first? A) Document the child's condition and continue with the school day. B) Confront the child about the injuries and their cause. C) Notify the school counselor and share the concerns. D) Report the suspicion of child abuse to the appropriate authorities. <\Body> Correct Answer: D) Report the suspicion of child abuse to the appropriate authorities. Rationale: When child abuse is suspected, especially when the child avoids eye contact and provides inconsistent explanations for injuries, the nurse's priority is to report the suspicion to the appropriate authorities (option D) to ensure the child's safety. Documenting the child's condition (option A) is important but should follow the reporting process. Confronting the child (option B) may not be safe and can hinder the investigation. Notifying the school counselor (option C) can be done after reporting. <\Explain> 51,4,0<\Number> B<\Answers> Question 51: A nurse is counseling an adult client who is a survivor of childhood physical abuse. The client expresses feelings of guilt and self-blame for the abuse. What therapeutic approach should the nurse use? A) Encourage the client to confront their abusive family members. B) Validate the client's feelings and provide support for healing. C) Advise the client to forgive and forget the past. D) Recommend confronting the abusers for closure. <\Body> Correct Answer: B) Validate the client's feelings and provide support for healing. Rationale: In counseling survivors of abuse, validating the client's feelings and providing support for healing (option B) is essential. Encouraging confrontation with abusive family members (option A) may not be safe and can be retraumatizing. Advising the client to forgive and forget (option C) oversimplifies the healing process. Recommending confrontation for closure (option D) may not be appropriate and can be emotionally distressing. <\Explain> 52,4,0<\Number> B<\Answers> Question 52: A nurse is counseling a client who has been sexually assaulted. The client experiences flashbacks and nightmares related to the assault. What therapeutic technique should the nurse use to address these symptoms? A) Encourage the client to avoid discussing the assault. B) Teach the client relaxation techniques to manage anxiety. C) Advise the client to suppress their memories to prevent distress. D) Recommend immediate confrontation of the assailant. <\Body> Correct Answer: B) Teach the client relaxation techniques to manage anxiety. Rationale: Teaching relaxation techniques to manage anxiety (option B) is a helpful therapeutic approach to address symptoms such as flashbacks and nightmares in survivors of sexual assault. Encouraging avoidance (option A) can worsen symptoms. Advising the client to suppress memories (option C) is not recommended and can lead to further distress. Recommending immediate confrontation (option D) may not be safe and can retraumatize the client. <\Explain> 53,4,0<\Number> A<\Answers> Question 53: A nurse is counseling an elderly client who is a survivor of financial exploitation by a family member. The client expresses feelings of shame and embarrassment. What therapeutic response should the nurse provide? A) "You shouldn't feel ashamed; it's not your fault." B) "It's best to forget about what happened and move on." C) "You need to confront your family member about the exploitation." D) "Tell me more about your experience and how it made you feel." <\Body> Correct Answer: A) "You shouldn't feel ashamed; it's not your fault." Rationale: Providing reassurance and validating the client's feelings by saying, "You shouldn't feel ashamed; it's not your fault" (option A) is a therapeutic response that helps reduce feelings of shame and self-blame. Encouraging the client to forget and move on (option B) dismisses their emotions and experiences. Advising confrontation (option C) may not be safe or appropriate in this context. Asking the client to share their feelings and experiences (option D) encourages open communication and understanding. <\Explain> 54,4,0<\Number> B<\Answers> Question 54: A nurse is counseling a child who has witnessed domestic violence in the home. The child displays signs of anxiety and fear. What therapeutic intervention should the nurse prioritize? A) Encourage the child to confront the abusive parent. B) Provide age-appropriate education on domestic violence. C) Suggest that the child avoid discussing the violence. D) Recommend family therapy to address the issue. <\Body> Correct Answer: B) Provide age-appropriate education on domestic violence. Rationale: Providing age-appropriate education on domestic violence (option B) is a therapeutic intervention that can help the child understand and cope with the situation. Encouraging confrontation (option A) may not be safe for the child and can escalate the violence. Advising avoidance of discussing the violence (option C) can lead to increased anxiety. Recommending family therapy (option D) may not be appropriate until safety concerns are addressed. <\Explain> 55,4,0<\Number> B<\Answers> Question 55: A nurse is counseling an adolescent who has been emotionally abused by a peer. The adolescent expresses feelings of low self-esteem. What therapeutic approach should the nurse use? A) Encourage the adolescent to confront the abusive peer. B) Teach the adolescent self-esteem-building techniques. C) Advise the adolescent to avoid discussing their feelings. D) Recommend group therapy for the adolescent and the peer. <\Body> Correct Answer: B) Teach the adolescent self-esteem-building techniques. Rationale: Teaching self-esteem-building techniques (option B) is a therapeutic approach to address low self-esteem in adolescents who have experienced emotional abuse. Encouraging confrontation (option A) may not be safe and can escalate the situation. Advising avoidance of discussing feelings (option C) can hinder emotional healing. Recommending group therapy (option D) may be considered, but addressing the adolescent's self-esteem is a priority. <\Explain> 56,4,0<\Number> B<\Answers> Question 56: A nurse is counseling an adult client who is a survivor of childhood sexual abuse. The client experiences flashbacks and nightmares related to the abuse. What therapeutic technique should the nurse use to address these symptoms? A) Encourage the client to avoid discussing the abuse. B) Teach the client grounding techniques to manage dissociation. C) Advise the client to confront the abuser for closure. D) Recommend immediate forgiveness of the abuser. <\Body> Correct Answer: B) Teach the client grounding techniques to manage dissociation. Rationale: Teaching grounding techniques to manage dissociation (option B) is a therapeutic approach to help clients cope with symptoms like flashbacks and nightmares related to sexual abuse. Encouraging avoidance of discussing the abuse (option A) can hinder healing. Advising confrontation with the abuser (option C) may not be safe and can be retraumatizing. Recommending immediate forgiveness (option D) is not appropriate and can invalidate the client's experiences. <\Explain> 57,4,0<\Number> C<\Answers> Question 57: A nurse is counseling a client who is a survivor of intimate partner violence (IPV). The client expresses feelings of fear and uncertainty about leaving the abusive relationship. What therapeutic response should the nurse provide? A) "You should confront your partner and demand change." B) "Leaving the relationship is your only option for safety." C) "It's normal to have mixed feelings about leaving." D) "Avoid discussing your feelings with anyone." <\Body> Correct Answer: C) "It's normal to have mixed feelings about leaving." Rationale: Acknowledging the client's mixed feelings and providing validation by saying, "It's normal to have mixed feelings about leaving" (option C), is a therapeutic response that supports the client's emotional experience. Encouraging confrontation (option A) may not be safe and can escalate the situation. Telling the client that leaving is the only option (option B) oversimplifies their circumstances. Advising avoidance of discussing feelings (option D) hinders open communication. <\Explain> 58,4,0<\Number> B<\Answers> Question 58: A nurse is counseling a child who has been physically abused by a caregiver. The child expresses feelings of anger and sadness. What therapeutic approach should the nurse use? A) Encourage the child to confront the caregiver. B) Teach the child relaxation techniques to manage emotions. C) Advise the child to suppress their feelings to avoid conflict. D) Recommend immediate forgiveness of the caregiver. <\Body> Correct Answer: B) Teach the child relaxation techniques to manage emotions. Rationale: Teaching the child relaxation techniques to manage emotions (option B) is a therapeutic approach to help the child cope with feelings of anger and sadness. Encouraging confrontation (option A) may not be safe and can escalate the situation. Advising suppression of feelings (option C) can be detrimental to the child's emotional well-being. Recommending immediate forgiveness (option D) is not appropriate and can invalidate the child's experiences. <\Explain> 59,4,0<\Number> B<\Answers> Question 59: A nurse is counseling an elderly client who is a survivor of emotional abuse by a family member. The client expresses feelings of loneliness and isolation. What therapeutic response should the nurse provide? A) "You should confront your family member about their behavior." B) "Is there a specific support system you'd like to have?" C) "Avoid discussing your feelings to maintain family harmony." D) "Forgive and forget, and everything will get better." <\Body> Correct Answer: B) "Is there a specific support system you'd like to have?" Rationale: Asking the client about their preferred support system by saying, "Is there a specific support system you'd like to have?" (option B), is a therapeutic response that acknowledges the client's feelings and offers assistance in addressing their loneliness and isolation. Encouraging confrontation (option A) may not be safe and can escalate the situation. Advising avoidance of discussing feelings (option C) is not beneficial for emotional healing. Suggesting immediate forgiveness (option D) oversimplifies the client's experiences. <\Explain> 60,4,0<\Number> B<\Answers> Question 60: A nurse is counseling a child who has been neglected by their parents. The child expresses feelings of sadness and abandonment. What therapeutic approach should the nurse use? A) Encourage the child to confront their parents about the neglect. B) Teach the child coping strategies to manage their emotions. C) Advise the child to suppress their feelings to avoid conflict. D) Recommend immediate reconciliation with the parents. <\Body> Correct Answer: B) Teach the child coping strategies to manage their emotions. Rationale: Teaching the child coping strategies to manage emotions (option B) is a therapeutic approach to help the child cope with feelings of sadness and abandonment resulting from neglect. Encouraging confrontation (option A) may not be safe and can escalate the situation. Advising suppression of feelings (option C) can be detrimental to the child's emotional well-being. Recommending immediate reconciliation (option D) is not appropriate and can invalidate the child's experiences. <\Explain> 61,4,0<\Number> C<\Answers> Question 61: A nurse is caring for a client with Alzheimer's disease who exhibits aggressive behavior, including hitting and shouting at staff and other residents. What is the priority intervention for the nurse? A) Administer a sedative medication to calm the client. B) Restrict the client to their room to prevent aggressive outbursts. C) Assess the client for underlying causes of the aggression. D) Ignore the aggressive behavior to avoid reinforcing it. <\Body> Correct Answer: C) Assess the client for underlying causes of the aggression. Rationale: When managing aggressive behavior in clients with Alzheimer's disease, the priority is to assess for underlying causes such as pain, discomfort, or unmet needs. Sedative medications (option A) should not be the first approach, and restricting the client to their room (option B) can exacerbate the behavior. Ignoring the behavior (option D) is not appropriate as it may put the client and others at risk. <\Explain> 62,4,0<\Number> A<\Answers> Question 62: A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and agitation. What intervention should the nurse implement to address the hallucinations? A) Encourage the client to engage in reality-based activities. B) Administer a benzodiazepine to calm the client. C) Ignore the hallucinations to avoid reinforcing them. D) Place the client in seclusion to minimize stimulation. <\Body> Correct Answer: A) Encourage the client to engage in reality-based activities. Rationale: Encouraging the client to engage in reality-based activities (option A) can help distract them from the hallucinations and improve their connection with the real world. Administering a benzodiazepine (option B) is not the first-line intervention for hallucinations. Ignoring the hallucinations (option C) may not be safe or effective. Placing the client in seclusion (option D) should only be considered when the client's safety or the safety of others is at risk. <\Explain> 63,4,0<\Number> C<\Answers> Question 63: A nurse is caring for a client with bipolar disorder who is in the manic phase. The client is exhibiting rapid speech, decreased need for sleep, and engaging in risky behaviors. What intervention should the nurse prioritize? A) Provide the client with additional stimulants to maintain their energy. B) Set strict limits and restrictions on the client's behavior. C) Administer a sedative medication to calm the client. D) Encourage the client to engage in creative activities. <\Body> Correct Answer: C) Administer a sedative medication to calm the client. Rationale: In the manic phase of bipolar disorder, the priority is to administer sedative medications (option C) to help reduce the client's symptoms and prevent harm associated with risky behaviors. Providing additional stimulants (option A) is contraindicated. Setting limits and restrictions (option B) may be necessary but is not the initial priority. Encouraging creative activities (option D) may be helpful once the client's agitation is controlled. <\Explain> 64,4,0<\Number> C<\Answers> Question 64: A nurse is caring for a client with borderline personality disorder who has a history of self-harm. The client is expressing suicidal ideation. What is the nurse's priority intervention? A) Provide the client with a list of suicide crisis hotlines. B) Ask the client to sign a no-suicide contract. C) Conduct a thorough suicide risk assessment. D) Encourage the client to express their feelings through art. <\Body> Correct Answer: C) Conduct a thorough suicide risk assessment. Rationale: When a client with a history of self-harm expresses suicidal ideation, the priority is to conduct a thorough suicide risk assessment (option C) to determine the level of risk and develop an appropriate safety plan. Providing a list of crisis hotlines (option A) can be helpful but is not the initial priority. A no-suicide contract (option B) may not be effective in managing the client's safety. Encouraging expression through art (option D) may be considered but should follow the assessment. <\Explain> 65,4,0<\Number> C<\Answers> Question 65: A nurse is caring for a client with severe depression who is refusing to eat or drink. What should the nurse do first? A) Administer a high-calorie nutritional supplement. B) Encourage the client to eat their favorite foods. C) Assess the client's nutritional status and risk for dehydration. D) Document the client's refusal and inform the healthcare provider. <\Body> Correct Answer: C) Assess the client's nutritional status and risk for dehydration. Rationale: The first step when a client is refusing to eat or drink is to assess their nutritional status and risk for dehydration (option C). This assessment will help determine the severity of the situation and guide further interventions. Administering a nutritional supplement (option A) may be considered after assessment. Encouraging the client to eat favorite foods (option B) may not be effective if the client is severely depressed. Documenting the refusal and informing the healthcare provider (option D) should also be done but should not delay the assessment. <\Explain> 66,4,0<\Number> C<\Answers> Question 66: A nurse is caring for a client with severe anxiety who is experiencing panic attacks. What intervention should the nurse implement during a panic attack? A) Administer an antipsychotic medication to reduce anxiety. B) Encourage the client to breathe into a paper bag. C) Provide a quiet, safe environment and stay with the client. D) Ignore the client's behavior to avoid reinforcing it. <\Body> Correct Answer: C) Provide a quiet, safe environment and stay with the client. Rationale: During a panic attack, the priority is to provide a quiet, safe environment and stay with the client (option C) to offer reassurance and support. Administering an antipsychotic medication (option A) is not the first-line intervention for panic attacks. Encouraging the client to breathe into a paper bag (option B) can be dangerous and is not recommended. Ignoring the client's behavior (option D) is not appropriate during a panic attack. <\Explain> 67,4,0<\Number> C<\Answers> Question 67: A nurse is caring for a client with post-traumatic stress disorder (PTSD) who is experiencing flashbacks and severe anxiety. What intervention should the nurse implement to help the client cope with flashbacks? A) Administer a sedative medication to calm the client. B) Encourage the client to avoid triggers that may lead to flashbacks. C) Use grounding techniques to help the client stay connected to the present. D) Ignore the client's distress to avoid reinforcing the flashbacks. <\Body> Correct Answer: C) Use grounding techniques to help the client stay connected to the present. Rationale: Using grounding techniques (option C) is an effective intervention to help clients with PTSD cope with flashbacks and stay connected to the present moment. Administering a sedative medication (option A) may not address the underlying issue. Encouraging avoidance of triggers (option B) can limit the client's life and is not a long-term solution. Ignoring the client's distress (option D) is not appropriate and can exacerbate their symptoms. <\Explain> 68,4,0<\Number> A<\Answers> Question 68: A nurse is caring for a client with anorexia nervosa who is refusing to eat. The client's family is concerned about their deteriorating health. What intervention should the nurse implement to promote nutritional intake? A) Administer a nutritional supplement through a feeding tube. B) Encourage the client to eat small, frequent meals. C) Ignore the client's refusal to eat to avoid reinforcing it. D) Document the client's refusal and inform the healthcare provider. <\Body> Correct Answer: A) Administer a nutritional supplement through a feeding tube. Rationale: When a client with anorexia nervosa is refusing to eat and their health is deteriorating, the priority is to provide nutrition through a feeding tube (option A) to prevent further complications. Encouraging small, frequent meals (option B) may not be effective in severe cases. Ignoring the client's refusal (option C) can be dangerous and is not recommended. Documenting the refusal and informing the healthcare provider (option D) should also be done, but feeding is the immediate priority. <\Explain> 69,4,0<\Number> C<\Answers> Question 69: A nurse is caring for a client with borderline personality disorder who is engaging in self-harming behaviors. What intervention should the nurse implement to address self-harm? A) Apply restraints to prevent the client from self-harming. B) Encourage the client to express their feelings through art. C) Conduct a thorough assessment of the client's emotional state. D) Ignore the self-harming behaviors to avoid reinforcing them. <\Body> Correct Answer: C) Conduct a thorough assessment of the client's emotional state. Rationale: When a client with borderline personality disorder is engaging in self-harming behaviors, the first step is to conduct a thorough assessment of the client's emotional state (option C) to identify triggers and develop appropriate interventions. Applying restraints (option A) is not the initial approach and can be traumatic for the client. Encouraging creative expression (option B) may be beneficial but should follow the assessment. Ignoring self-harming behaviors (option D) is not appropriate as they may indicate distress. <\Explain> 70,4,0<\Number> B<\Answers> Question 70: A nurse is caring for a client with severe depression who is experiencing social withdrawal and refusing to engage in activities. What intervention should the nurse implement to promote socialization? A) Administer an antidepressant medication to improve mood. B) Encourage the client to participate in group therapy sessions. C) Allow the client to isolate themselves until they feel ready to socialize. D) Document the client's social withdrawal and inform the healthcare provider. <\Body> Correct Answer: B) Encourage the client to participate in group therapy sessions. Rationale: Encouraging the client to participate in group therapy sessions (option B) can provide a supportive and structured environment for socialization. While antidepressant medication (option A) may be part of the treatment plan, it does not directly address social withdrawal. Allowing the client to isolate themselves (option C) can exacerbate symptoms. Documenting the withdrawal and informing the healthcare provider (option D) is important but should not replace active interventions. <\Explain> 71,4,0<\Number> C<\Answers> Question 71: A nurse is evaluating the support system of a client with a history of substance abuse. Which of the following findings indicates a positive aspect of the client's support system? A) The client's family is overprotective and controls all aspects of the client's life. B) The client's friends frequently encourage drug use and provide substances. C) The client's spouse expresses concern and encourages participation in a support group. D) The client's co-workers are unaware of the client's substance abuse history. <\Body> Correct Answer: C) The client's spouse expresses concern and encourages participation in a support group. Rationale: A positive aspect of the client's support system is when a family member, in this case, the spouse, expresses concern and encourages participation in a support group, indicating a desire for the client's recovery and well-being. <\Explain> 72,4,0<\Number> D<\Answers> Question 72: A nurse is assessing the support system of an elderly client who lives alone and has limited social interactions. Which finding should the nurse consider a potential concern? A) The client has a close-knit group of friends who visit regularly. B) The client's adult children live in the same town and visit weekly. C) The client relies on a home healthcare aide for daily care and companionship. D) The client prefers solitude and does not engage in any social activities. <\Body> Correct Answer: D) The client prefers solitude and does not engage in any social activities. Rationale: A potential concern in this scenario is the client's preference for solitude and avoidance of social activities, which may lead to social isolation and negatively impact their psychosocial well-being. <\Explain> 73,4,0<\Number> C<\Answers> Question 73: A nurse is evaluating the support system of a client who has been diagnosed with a terminal illness. Which statement by the client's family member indicates a need for further education regarding support systems? A) "We've arranged for a hospice nurse to provide care at home." B) "We take turns visiting the client in the hospital to provide companionship." C) "The client's insurance covers all the medical expenses." D) "We encourage the client to attend support group meetings." <\Body> Correct Answer: C) "The client's insurance covers all the medical expenses." Rationale: This statement indicates a misunderstanding of the support system, as it focuses solely on financial aspects and may not address the emotional and psychosocial needs of the client during a terminal illness. <\Explain> 74,4,0<\Number> C<\Answers> Question 74: A nurse is assessing the support system of a pregnant teenager. What finding should the nurse identify as a potential source of support for the client? A) The client's partner is unsupportive and avoids the client. B) The client's parents are unaware of the pregnancy. C) The client has a close friend who offers emotional support. D) The client's siblings live in a different state. <\Body> Correct Answer: C) The client has a close friend who offers emotional support. Rationale: The presence of a close friend who offers emotional support is a potential source of support for the pregnant teenager. This friend can provide the client with needed encouragement and understanding during a challenging time. <\Explain> 75,4,0<\Number> C<\Answers> Question 75: A nurse is evaluating the support system of a client diagnosed with major depressive disorder. Which finding suggests a positive aspect of the client's support system? A) The client's spouse is often critical and belittling. B) The client's adult children live in a different country. C) The client attends weekly therapy sessions with a mental health professional. D) The client's friends are unaware of the client's diagnosis. <\Body> Correct Answer: C) The client attends weekly therapy sessions with a mental health professional. Rationale: Attending weekly therapy sessions with a mental health professional indicates that the client is actively seeking and receiving professional support for their major depressive disorder, which is a positive aspect of their support system. <\Explain> 76,4,0<\Number> C<\Answers> Question 76: A nurse is assessing the support system of a client who has recently lost a spouse. What finding should the nurse consider a potential concern? A) The client has a strong network of friends who offer emotional support. B) The client's adult children live nearby and visit frequently. C) The client avoids discussing the loss and prefers solitude. D) The client receives grief counseling from a therapist. <\Body> Correct Answer: C) The client avoids discussing the loss and prefers solitude. Rationale: The client's avoidance of discussing the loss and preference for solitude may indicate difficulty in processing grief and a potential need for further emotional support. <\Explain> 77,4,0<\Number> C<\Answers> Question 77: A nurse is evaluating the support system of a client diagnosed with schizophrenia. What finding suggests a positive aspect of the client's support system? A) The client's family is distant and rarely visits. B) The client's friends encourage the use of alcohol and drugs. C) The client attends a weekly support group for individuals with schizophrenia. D) The client's co-workers are unaware of the diagnosis. <\Body> Correct Answer: C) The client attends a weekly support group for individuals with schizophrenia. Rationale: Attending a weekly support group for individuals with schizophrenia indicates that the client is actively engaging in a supportive network that can provide understanding and coping strategies for managing the condition. <\Explain> 78,4,0<\Number> B<\Answers> Question 78: A nurse is assessing the support system of a client diagnosed with bipolar disorder. What finding should the nurse consider a potential concern? A) The client's spouse is understanding and encourages medication compliance. B) The client's adult children live in a different state and rarely visit. C) The client's close friend is unaware of the diagnosis. D) The client attends regular therapy sessions with a mental health professional. <\Body> Correct Answer: B) The client's adult children live in a different state and rarely visit. Rationale: The limited physical presence and infrequent visits of the client's adult children may be a potential concern, as proximity and regular interaction can play a significant role in providing emotional support for someone with bipolar disorder. <\Explain> 79,4,0<\Number> B<\Answers> Question 79: A nurse is evaluating the support system of a client diagnosed with cancer. What finding suggests a positive aspect of the client's support system? A) The client's spouse is overwhelmed and avoids discussing the diagnosis. B) The client's adult children live in the same town and assist with daily tasks. C) The client's friends are unaware of the diagnosis. D) The client has not sought any form of professional counseling. <\Body> Correct Answer: B) The client's adult children live in the same town and assist with daily tasks. Rationale: The presence of adult children who live nearby and assist with daily tasks is a positive aspect of the client's support system. They can provide practical assistance and emotional support during the client's illness. <\Explain> 80,4,0<\Number> C<\Answers> Question 80: A nurse is assessing the support system of a client with a history of substance abuse who is in recovery. What finding should the nurse identify as a potential source of support for the client? A) The client's spouse continues to use substances. B) The client's adult children live in a different country. C) The client attends regular Alcoholics Anonymous (AA) meetings. D) The client's friends encourage recreational drug use. <\Body> Correct Answer: C) The client attends regular Alcoholics Anonymous (AA) meetings. Rationale: Attending regular Alcoholics Anonymous (AA) meetings is a potential source of support for the client in recovery from substance abuse. AA meetings provide a supportive environment for individuals working toward sobriety. <\Explain> 81,4,0<\Number> B<\Answers> Question 81: A nurse is providing support to a client diagnosed with diabetes who needs to learn how to self-administer insulin injections. What teaching approach should the nurse use to best support the client's learning? A) Provide written instructions and diagrams for the client to review. B) Demonstrate the injection technique and have the client practice. C) Give the client a pamphlet with information on diabetes management. D) Verbally explain the steps of insulin administration to the client. <\Body> Correct Answer: B) Demonstrate the injection technique and have the client practice. Rationale: The most effective teaching approach for learning a hands-on skill like insulin injection is to demonstrate the technique and allow the client to practice under supervision, providing hands-on experience and reinforcement of the skill. <\Explain> 82,4,0<\Number> A<\Answers> Question 82: A nurse is caring for a client with anxiety disorder who is experiencing panic attacks. What coping strategy should the nurse teach the client to use during a panic attack? A) Encourage deep breathing exercises. B) Advise the client to isolate themselves. C) Suggest drinking caffeinated beverages. D) Recommend taking over-the-counter sedatives. <\Body> Correct Answer: A) Encourage deep breathing exercises. Rationale: Deep breathing exercises can help reduce anxiety during a panic attack by promoting relaxation and regulating the client's breathing. It is a useful coping strategy in this situation. <\Explain> 83,4,0<\Number> C<\Answers> Question 83: A nurse is caring for a client who has recently lost a loved one. What should the nurse include when providing grief support to the client? A) Encourage the client to avoid discussing their feelings. B) Suggest replacing grieving with distractions like work. C) Allow the client to express their emotions and offer a listening ear. D) Recommend that the client immediately resume their normal routine. <\Body> Correct Answer: C) Allow the client to express their emotions and offer a listening ear. Rationale: Supporting a grieving client involves allowing them to express their emotions and offering a listening ear, providing an opportunity for the client to share their feelings and thoughts. <\Explain> 84,4,0<\Number> C<\Answers> Question 84: A nurse is caring for a client with bipolar disorder who is learning to recognize early signs of mood changes. What should the nurse emphasize when teaching the client about this skill? A) Avoid discussing mood changes with family or friends. B) Rely solely on medication to manage mood swings. C) Keep a mood journal to track emotions and triggers. D) Isolate themselves during mood fluctuations. <\Body> Correct Answer: C) Keep a mood journal to track emotions and triggers. Rationale: Keeping a mood journal to track emotions and triggers is an effective coping strategy for clients with bipolar disorder. It helps them recognize early signs of mood changes and allows for better self-management. <\Explain> 85,4,0<\Number> D<\Answers> Question 85: A nurse is providing support to a client with schizophrenia who is experiencing auditory hallucinations. What coping strategy should the nurse teach the client to manage these hallucinations? A) Encourage the client to engage in distracting activities. B) Instruct the client to confront the voices and argue with them. C) Recommend the use of over-the-counter sedative medications. D) Teach the client to use positive self-talk and grounding techniques. <\Body> Correct Answer: D) Teach the client to use positive self-talk and grounding techniques. Rationale: Positive self-talk and grounding techniques are helpful coping strategies for clients experiencing hallucinations. These techniques can help the client stay connected to reality and reduce distress. <\Explain> 86,4,0<\Number> C<\Answers> Question 86: A nurse is caring for a client with post-traumatic stress disorder (PTSD) who is learning coping strategies to manage flashbacks. What should the nurse teach the client to do when experiencing a flashback? A) Encourage the client to engage in self-harming behaviors. B) Instruct the client to avoid any reminders of the traumatic event. C) Teach the client to use grounding techniques and focus on their surroundings. D) Advise the client to confront the flashback and relive the traumatic event. <\Body> Correct Answer: C) Teach the client to use grounding techniques and focus on their surroundings. Rationale: Using grounding techniques and focusing on the present surroundings can help clients with PTSD cope with flashbacks and stay connected to reality. Encouraging self-harming behaviors (option A) or avoidance (option B) is not recommended, and confronting the flashback (option D) can be retraumatizing. <\Explain> 87,4,0<\Number> C<\Answers> Question 87: A nurse is providing support to a client who is struggling with substance addiction. What coping strategy should the nurse emphasize to help the client manage cravings? A) Suggest replacing the addictive substance with a different but less harmful one. B) Encourage the client to isolate themselves during cravings. C) Teach the client relaxation techniques, such as deep breathing. D) Recommend engaging in risky behaviors to distract from cravings. <\Body> Correct Answer: C) Teach the client relaxation techniques, such as deep breathing. Rationale: Teaching relaxation techniques, such as deep breathing, can help clients manage cravings in a healthy way by reducing anxiety and stress, which are often triggers for substance use. <\Explain> 88,4,0<\Number> C<\Answers> Question 88: A nurse is caring for a client with obsessive-compulsive disorder (OCD) who is learning to resist the urge to engage in compulsive behaviors. What should the nurse teach the client to do when experiencing obsessive thoughts? A) Encourage the client to give in to the compulsions briefly. B) Instruct the client to avoid situations that trigger obsessions. C) Teach the client to delay the compulsive response and use exposure therapy. D) Recommend that the client suppress the obsessive thoughts. <\Body> Correct Answer: C) Teach the client to delay the compulsive response and use exposure therapy. Rationale: Delaying the compulsive response and using exposure therapy are evidence-based strategies to help clients with OCD resist the urge to engage in compulsions and gradually reduce the intensity of obsessive thoughts. <\Explain> 89,4,0<\Number> C<\Answers> Question 89: A nurse is providing support to a client with major depressive disorder who is learning coping strategies. What should the nurse teach the client to do when experiencing feelings of hopelessness? A) Advise the client to avoid seeking professional help. B) Suggest setting unrealistic goals to boost self-esteem. C) Teach the client to challenge negative thoughts and seek social support. D) Recommend isolating themselves to avoid burdening others. <\Body> Correct Answer: C) Teach the client to challenge negative thoughts and seek social support. Rationale: Challenging negative thoughts and seeking social support are effective coping strategies for clients with major depressive disorder. Isolation (option D) and avoiding professional help (option A) are not recommended. <\Explain> 90,4,0<\Number> C<\Answers> Question 90: A nurse is caring for a client with an eating disorder who is working on developing healthier eating habits. What should the nurse emphasize when teaching the client about meal planning? A) Encourage the client to skip one meal a day to reduce calorie intake. B) Advise the client to avoid any foods they consider "unhealthy." C) Teach the client to include a variety of balanced foods in their meals. D) Recommend excessive exercise to compensate for food intake. <\Body> Correct Answer: C) Teach the client to include a variety of balanced foods in their meals. Rationale: Teaching the client to include a variety of balanced foods in their meals is essential for developing healthier eating habits and addressing an eating disorder. Skipping meals (option A) and avoiding "unhealthy" foods (option B) can perpetuate unhealthy behaviors. <\Explain> 91,4,0<\Number> B<\Answers> Question 91: A nurse is assessing a family with a newly diagnosed diabetic child. The parents appear anxious and overwhelmed. Which family dynamic should the nurse consider when planning care? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Authoritative parenting style D) Absence of family dynamics <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: The parents' anxiety and feeling overwhelmed may indicate dysfunctional family dynamics, which can affect the child's care and well-being. <\Explain> 92,4,0<\Number> B<\Answers> Question 92: A nurse is caring for a hospitalized child with a fractured limb. The child's parents constantly argue and disagree about the child's treatment plan. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Authoritarian parenting style D) Uninvolved parenting style <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: The constant arguing and disagreement between the parents suggest dysfunctional family dynamics, which can impact decision-making and care coordination. <\Explain> 93,4,0<\Number> A<\Answers> Question 93: A nurse is conducting a family assessment for a pediatric patient. The parents have a collaborative approach to decision-making and involve the child in discussions about their care. What type of family dynamic is this indicative of? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Permissive parenting style D) Uninvolved parenting style <\Body> Correct Answer: A) Cohesive family dynamics Rationale: The collaborative approach to decision-making and involving the child in discussions about care reflects cohesive family dynamics, where family members work together and communicate effectively. <\Explain> 94,4,0<\Number> B<\Answers> Question 94: A nurse is assessing a family with an elderly member who has recently been diagnosed with dementia. The family members express feelings of guilt and frustration. What family dynamic is likely at play in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Uninvolved parenting style D) Authoritative parenting style <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: The expressions of guilt and frustration by family members may indicate dysfunctional family dynamics in response to the diagnosis of dementia. <\Explain> 95,4,0<\Number> A<\Answers> Question 95: A nurse is assessing a family with a child who has been diagnosed with a developmental disability. The parents are actively seeking information and resources to support their child's needs. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Authoritative parenting style D) Uninvolved parenting style <\Body> Correct Answer: A) Cohesive family dynamics Rationale: The parents' active efforts to seek information and resources to support their child's needs reflect cohesive family dynamics, where family members work together to address challenges. <\Explain> 96,4,0<\Number> B<\Answers> Question 96: A nurse is assessing a family with a history of substance abuse. The parents prioritize obtaining substances over meeting their children's basic needs. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Permissive parenting style D) Authoritarian parenting style <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: The prioritization of obtaining substances over meeting children's basic needs suggests dysfunctional family dynamics associated with substance abuse. <\Explain> 97,4,0<\Number> B<\Answers> Question 97: A nurse is caring for a hospitalized child with a chronic illness. The family members have different opinions about the child's treatment, and there is a lack of communication and cooperation. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Authoritarian parenting style D) Uninvolved parenting style <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: The lack of communication and cooperation among family members with differing opinions suggests dysfunctional family dynamics, which can impact decision-making and care. <\Explain> 98,4,0<\Number> D<\Answers> Question 98: A nurse is assessing a family with an adolescent child who is displaying rebellious behavior. The parents have strict rules and do not allow the child to express their opinions. What type of family dynamic is likely at play in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Permissive parenting style D) Authoritarian parenting style <\Body> Correct Answer: D) Authoritarian parenting style Rationale: The strict rules and lack of expression of the child's opinions suggest an authoritarian parenting style within the family dynamic. <\Explain> 99,4,0<\Number> A<\Answers> Question 99: A nurse is conducting a family assessment for a patient who is transgender. The family members are supportive and affirming of the patient's gender identity. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Permissive parenting style D) Authoritative parenting style <\Body> Correct Answer: A) Cohesive family dynamics Rationale: The family members' support and affirmation of the patient's gender identity indicate cohesive family dynamics, where the family is accepting and supportive of individual differences. <\Explain> 100,4,0<\Number> B<\Answers> Question 100: A nurse is assessing a family with a history of domestic violence. The parent attempts to justify the abusive behavior of their partner. What type of family dynamic is evident in this situation? A) Cohesive family dynamics B) Dysfunctional family dynamics C) Permissive parenting style D) Uninvolved parenting style <\Body> Correct Answer: B) Dysfunctional family dynamics Rationale: Attempting to justify abusive behavior within the family indicates dysfunctional family dynamics related to domestic violence. <\Explain> 101,4,0<\Number> B<\Answers> Question 101: A nurse is caring for a patient from a different cultural background who practices traditional healing methods. What should the nurse prioritize when providing culturally competent care? A) Encourage the patient to abandon traditional healing practices. B) Respect and incorporate the patient's cultural beliefs into the care plan. C) Disregard cultural factors and provide standardized care. D) Explain the superiority of Western medicine to the patient. <\Body> Correct Answer: B) Respect and incorporate the patient's cultural beliefs into the care plan. Rationale: Cultural competence in nursing involves respecting and incorporating the patient's cultural beliefs and practices into the care plan to provide patient-centered care. <\Explain> 102,4,0<\Number> B<\Answers> Question 102: A nurse is caring for a Muslim patient who is fasting during Ramadan. What should the nurse consider when administering medications to the patient during daylight hours? A) Administer medications without informing the patient. B) Respect the patient's fasting and adjust the medication schedule accordingly. C) Encourage the patient to break the fast for medication administration. D) Refuse to administer medications during daylight hours. <\Body> Correct Answer: B) Respect the patient's fasting and adjust the medication schedule accordingly. Rationale: It is important to respect the patient's religious practices and adjust the medication schedule to accommodate their fasting during Ramadan. <\Explain> 103,4,0<\Number> B<\Answers> Question 103: A nurse is caring for a Native American patient who prefers to have a tribal elder present during medical discussions. What should the nurse do to provide culturally sensitive care? A) Refuse the request as it may impede medical care. B) Allow the presence of the tribal elder during discussions if the patient wishes. C) Disregard the request and proceed with medical discussions. D) Insist that family members be present instead of a tribal elder. <\Body> Correct Answer: B) Allow the presence of the tribal elder during discussions if the patient wishes. Rationale: Respecting the patient's request to have a tribal elder present during discussions is important for providing culturally sensitive care. <\Explain> 104,4,0<\Number> C<\Answers> Question 104: A nurse is caring for a Chinese patient who believes in the concept of yin and yang balance. What should the nurse consider when planning the patient's care? A) Disregard the patient's cultural beliefs as they are not relevant to healthcare. B) Discuss the ineffectiveness of yin and yang balance in modern medicine. C) Incorporate the patient's beliefs into the care plan and treatments. D) Encourage the patient to abandon traditional Chinese beliefs. <\Body> Correct Answer: C) Incorporate the patient's beliefs into the care plan and treatments. Rationale: Cultural competence in nursing involves incorporating the patient's cultural beliefs into the care plan and treatments, promoting holistic care. <\Explain> 105,4,0<\Number> C<\Answers> Question 105: A nurse is caring for a Hispanic patient who values the role of the extended family in decision-making. What should the nurse do to provide culturally competent care? A) Limit family involvement to immediate family members only. B) Encourage the patient to make decisions independently. C) Respect the patient's preference for extended family involvement. D) Disregard the patient's cultural values and make decisions independently. <\Body> Correct Answer: C) Respect the patient's preference for extended family involvement. Rationale: Cultural competence involves respecting the patient's cultural values and preferences, including the role of extended family in decision-making. <\Explain> 106,4,0<\Number> B<\Answers> Question 106: A nurse is caring for a Hindu patient who is a vegetarian. What dietary considerations should the nurse make to respect the patient's cultural beliefs? A) Encourage the patient to eat meat for better nutrition. B) Provide vegetarian meal options and avoid offering meat-based foods. C) Disregard the patient's dietary preferences and serve meat. D) Offer meat-based foods and explain the health benefits. <\Body> Correct Answer: B) Provide vegetarian meal options and avoid offering meat-based foods. Rationale: Respecting the patient's dietary preferences and providing vegetarian meal options aligns with cultural competence and patient-centered care. <\Explain> 107,4,0<\Number> C<\Answers> Question 107: A nurse is caring for a transgender patient who prefers gender-neutral pronouns. What should the nurse do to provide culturally sensitive care? A) Ignore the patient's gender-neutral pronoun preference. B) Use traditional gender pronouns to avoid confusion. C) Respect the patient's preference and use gender-neutral pronouns. D) Explain the importance of using traditional gender pronouns. <\Body> Correct Answer: C) Respect the patient's preference and use gender-neutral pronouns. Rationale: Cultural competence includes respecting the patient's gender identity and using their preferred pronouns to provide respectful and sensitive care. <\Explain> 108,4,0<\Number> B<\Answers> Question 108: A nurse is caring for a Jewish patient who observes the Sabbath from Friday evening to Saturday evening. What should the nurse consider when planning care for this patient? A) Schedule all medical procedures during the Sabbath. B) Avoid scheduling invasive procedures during the Sabbath hours. C) Disregard the patient's religious practices and follow the usual schedule. D) Encourage the patient to skip observing the Sabbath for medical reasons. <\Body> Correct Answer: B) Avoid scheduling invasive procedures during the Sabbath hours. Rationale: Respecting the patient's religious practices, such as avoiding invasive procedures during the Sabbath, is important in providing culturally sensitive care. <\Explain> 109,4,0<\Number> C<\Answers> Question 109: A nurse is caring for a patient from a culture that values modesty and privacy. What should the nurse do to provide culturally competent care? A) Disregard the patient's cultural values and proceed with care. B) Explain the benefits of not adhering to cultural modesty. C) Respect the patient's values and provide privacy and modesty during care. D) Encourage the patient to adopt more liberal views on modesty. <\Body> Correct Answer: C) Respect the patient's values and provide privacy and modesty during care. Rationale: Cultural competence involves respecting the patient's cultural values, such as modesty and privacy, during care. <\Explain> 110,4,0<\Number> B<\Answers> Question 110: A nurse is caring for a patient from a culture that values stoicism and restraint in expressing emotions. What should the nurse do to provide culturally sensitive care? A) Encourage the patient to express emotions openly. B) Respect the patient's cultural preference for emotional restraint. C) Disregard the patient's cultural values and express emotions openly. D) Educate the patient about the importance of emotional expression. <\Body> Correct Answer: B) Respect the patient's cultural preference for emotional restraint. Rationale: Cultural competence involves respecting the patient's cultural values, such as emotional restraint, while providing care. <\Explain> 111,4,0<\Number> B<\Answers> Question 111: A nurse is caring for a patient who practices Islam and is observing fasting during Ramadan. What should the nurse prioritize when providing care to this patient during daylight hours? A) Encourage the patient to break the fast for better nutrition. B) Respect the patient's fasting and adjust the care plan accordingly. C) Disregard the patient's religious practices and offer meals as usual. D) Explain the benefits of not fasting during illness. <\Body> Correct Answer: B) Respect the patient's fasting and adjust the care plan accordingly. Rationale: Respecting the patient's religious practices, such as fasting during Ramadan, and adjusting the care plan accordingly is essential for providing culturally sensitive care. <\Explain> 112,4,0<\Number> B<\Answers> Question 112: A nurse is caring for a Christian patient who requests to have a priest present for a surgical procedure. What should the nurse do to accommodate the patient's request? A) Decline the request as it may delay the procedure. B) Respect the patient's request and arrange for a priest to be present. C) Disregard the request and proceed with the procedure as scheduled. D) Explain that having a priest present is unnecessary for medical procedures. <\Body> Correct Answer: B) Respect the patient's request and arrange for a priest to be present. Rationale: Respecting the patient's religious request for a priest's presence during a surgical procedure is important for providing culturally sensitive care. <\Explain> 113,4,0<\Number> B<\Answers> Question 113: A nurse is caring for a patient who practices Judaism and observes the Sabbath from Friday evening to Saturday evening. What should the nurse consider when scheduling medical procedures for this patient? A) Schedule all procedures during the Sabbath. B) Avoid scheduling invasive procedures during the Sabbath hours. C) Disregard the patient's religious practices and follow the usual schedule. D) Encourage the patient to skip observing the Sabbath for medical reasons. <\Body> Correct Answer: B) Avoid scheduling invasive procedures during the Sabbath hours. Rationale: Respecting the patient's religious observance of the Sabbath and avoiding invasive procedures during those hours is essential for culturally sensitive care. <\Explain> 114,4,0<\Number> B<\Answers> Question 114: A nurse is caring for a patient who practices Buddhism and requests a quiet environment with minimal disturbances for meditation. How should the nurse respond to this request? A) Ignore the request and maintain the usual noise levels. B) Respect the patient's request and provide a quiet environment. C) Disregard the patient's request and encourage participation in group activities. D) Explain the benefits of not meditating during hospitalization. <\Body> Correct Answer: B) Respect the patient's request and provide a quiet environment. Rationale: Respecting the patient's request for a quiet environment for meditation aligns with cultural competence and patient-centered care. <\Explain> 115,4,0<\Number> B<\Answers> Question 115: A nurse is caring for a Jehovah's Witness patient who refuses blood transfusions based on religious beliefs. What should the nurse do to provide culturally sensitive care? A) Persuade the patient to accept a blood transfusion for their health. B) Respect the patient's religious beliefs and explore alternative treatments. C) Disregard the patient's refusal and administer a blood transfusion. D) Educate the patient about the potential risks of refusing a transfusion. <\Body> Correct Answer: B) Respect the patient's religious beliefs and explore alternative treatments. Rationale: Respecting the patient's religious beliefs, such as refusing blood transfusions, and exploring alternative treatments aligns with cultural competence and patient-centered care. <\Explain> 116,4,0<\Number> B<\Answers> Question 116: A nurse is caring for a patient who practices Hinduism and requests to have family members perform a traditional ritual at the bedside. What should the nurse do to accommodate the patient's request? A) Deny the request to maintain a sterile environment. B) Respect the patient's request and facilitate the ritual in a safe manner. C) Disregard the request and encourage the patient to focus on medical care. D) Explain that traditional rituals have no place in modern healthcare. <\Body> Correct Answer: B) Respect the patient's request and facilitate the ritual in a safe manner. Rationale: Respecting the patient's request for a traditional ritual at the bedside and facilitating it safely is important for providing culturally sensitive care. <\Explain> 117,4,0<\Number> C<\Answers> Question 117: A nurse is caring for a patient who practices Sikhism and wears a turban as part of their religious attire. What should the nurse consider when providing care to this patient? A) Encourage the patient to remove the turban for ease of care. B) Remove the turban gently and respectfully and proceed with care as usual. C) Respect the patient's religious attire and provide care accordingly. D) Explain the benefits of not wearing a turban in a healthcare setting. <\Body> Correct Answer: C) Respect the patient's religious attire and provide care accordingly. Rationale: Respecting the patient's religious attire, such as a turban, and providing care accordingly is important for cultural competence and patient-centered care. <\Explain> 118,4,0<\Number> B<\Answers> Question 118: A nurse is caring for a patient who practices Rastafarianism and requests to have reggae music played during their hospital stay. How should the nurse respond to this request? A) Deny the request to maintain a quiet environment. B) Respect the patient's request and play reggae music as requested. C) Disregard the request and provide care without music. D) Explain that music is not allowed in the hospital. <\Body> Correct Answer: B) Respect the patient's request and play reggae music as requested. Rationale: Respecting the patient's request for reggae music aligns with cultural competence and patient-centered care. <\Explain> 119,4,0<\Number> B<\Answers> Question 119: A nurse is caring for a patient who practices Scientology and is interested in alternative therapies. What should the nurse do to provide culturally sensitive care? A) Discourage the patient from exploring alternative therapies. B) Respect the patient's interest in alternative therapies and inquire about preferences. C) Disregard the patient's beliefs and provide standard medical care. D) Educate the patient about the limitations of alternative therapies. <\Body> Correct Answer: B) Respect the patient's interest in alternative therapies and inquire about preferences. Rationale: Respecting the patient's interest in alternative therapies and inquiring about their preferences aligns with cultural competence and patient-centered care. <\Explain> 120,4,0<\Number> C<\Answers> Question 120: A nurse is caring for a patient who practices Scientology and expresses a desire for auditing sessions during hospitalization. What should the nurse do to accommodate the patient's request? A) Deny the request as auditing is not a recognized medical practice. B) Encourage the patient to focus on medical treatment and not auditing. C) Respect the patient's request and facilitate auditing sessions if possible. D) Explain the ineffectiveness of auditing in healthcare settings. <\Body> Correct Answer: C) Respect the patient's request and facilitate auditing sessions if possible. Rationale: Respecting the patient's request for auditing sessions and facilitating them if possible aligns with cultural competence and patient-centered care. <\Explain> 121,4,0<\Number> C<\Answers> Question 121: A nurse is providing care to a patient who has recently lost a loved one. The patient asks about grief support groups in the community. What should the nurse do? A) Disregard the request, as support groups are not effective in managing grief. B) Encourage the patient to avoid support groups and focus on individual coping. C) Provide information about local grief support groups and their meeting times. D) Suggest that the patient seek counseling instead of attending support groups. <\Body> Correct Answer: C) Provide information about local grief support groups and their meeting times. Rationale: Connecting the patient with local grief support groups can provide valuable resources and emotional support during the grieving process. <\Explain> 122,4,0<\Number> B<\Answers> Question 122: A nurse is caring for a patient who has experienced a miscarriage. The patient asks for reading materials to help cope with the loss. What action should the nurse take? A) Disregard the request, as reading materials are not helpful in this situation. B) Provide the patient with a list of books and articles related to miscarriage and grief. C) Encourage the patient to avoid reading about the loss and focus on other activities. D) Recommend that the patient seek professional counseling instead of reading. <\Body> Correct Answer: B) Provide the patient with a list of books and articles related to miscarriage and grief. Rationale: Providing reading materials on miscarriage and grief can offer the patient information and support in understanding their experience. <\Explain> 123,4,0<\Number> A<\Answers> Question 123: A nurse is caring for a patient who has lost a spouse and is struggling to cope with the grief. What resource should the nurse recommend to the patient to help with bereavement? A) A grief support group for couples. B) A grief support group for parents. C) A grief support group for children. D) A grief support group for healthcare professionals. <\Body> Correct Answer: A) A grief support group for couples. Rationale: Recommending a grief support group for couples can provide the patient with the opportunity to connect with others who have experienced similar losses and share their grief. <\Explain> 124,4,0<\Number> C<\Answers> Question 124: A nurse is providing care to a patient who has lost a child and is experiencing profound grief. The patient is interested in individual counseling. What should the nurse do? A) Disregard the patient's request for individual counseling. B) Encourage the patient to rely solely on support from friends and family. C) Assist the patient in finding a therapist or counselor specializing in grief. D) Suggest that the patient join a group therapy session instead. <\Body> Correct Answer: C) Assist the patient in finding a therapist or counselor specializing in grief. Rationale: Individual counseling with a therapist or counselor who specializes in grief can provide personalized support and coping strategies for the patient. <\Explain> 125,4,0<\Number> C<\Answers> Question 125: A nurse is caring for a patient who has lost a sibling and is struggling to process the grief. The patient expresses a desire to memorialize their sibling's life. What should the nurse suggest? A) Disregard the request, as memorializing a sibling is not helpful. B ) Encourage the patient to forget about the loss and move on. C) Recommend creating a memorial or tribute in honor of the sibling. D) Suggest the patient join a grief support group for siblings. <\Body> Correct Answer: C) Recommend creating a memorial or tribute in honor of the sibling. Rationale: Creating a memorial or tribute can be a meaningful way for the patient to honor and remember their sibling, providing a sense of closure and healing. <\Explain> 126,4,0<\Number> C<\Answers> Question 126: A nurse is caring for a patient who has lost a spouse and is struggling with overwhelming grief. The patient has mentioned feeling isolated. What should the nurse recommend to address the patient's isolation? A) Encourage the patient to avoid social interactions to focus on grieving. B) Disregard the patient's feelings of isolation as a natural part of grief. C) Suggest the patient join a grief support group to connect with others who understand. D) Recommend that the patient rely solely on immediate family for support. <\Body> Correct Answer: C) Suggest the patient join a grief support group to connect with others who understand. Rationale: Joining a grief support group can help the patient connect with individuals who have experienced similar losses and provide a supportive network during the grieving process. <\Explain> 127,4,0<\Number> C<\Answers> Question 127: A nurse is caring for a patient who has lost a child to a chronic illness and is experiencing intense grief. The patient expresses a desire to participate in a memorial event. What should the nurse do? A) Discourage the patient from attending a memorial event. B) Suggest the patient create a private memorial at home instead. C) Provide information about upcoming memorial events and ceremonies. D) Recommend the patient focus on their own healing and avoid memorials. <\Body> Correct Answer: C) Provide information about upcoming memorial events and ceremonies. Rationale: Providing information about memorial events and ceremonies can allow the patient the opportunity to participate in a supportive and healing community event. <\Explain> 128,4,0<\Number> C<\Answers> Question 128: A nurse is providing care to a patient who has lost a sibling and is experiencing intense grief. The patient mentions feeling guilty about not spending enough time with their sibling before the loss. What should the nurse do? A) Encourage the patient to push aside feelings of guilt. B) Disregard the patient's feelings of guilt as irrelevant. C) Validate the patient's feelings and offer support in processing guilt. D) Recommend the patient avoid discussing their feelings of guilt. <\Body> Correct Answer: C) Validate the patient's feelings and offer support in processing guilt. Rationale: Validating the patient's feelings of guilt and offering support can help the patient process these emotions as part of the grieving process. <\Explain> 129,4,0<\Number> D<\Answers> Question 129: A nurse is caring for a patient who has lost a parent and is struggling to cope with the grief. The patient expresses a desire to create a memory book to celebrate their parent's life. What should the nurse suggest? A) Disregard the patient's request for a memory book. B) Encourage the patient to avoid dwelling on the loss. C) Recommend the patient join a grief support group instead. D) Assist the patient in creating a memory book in honor of their parent. <\Body> Correct Answer: D) Assist the patient in creating a memory book in honor of their parent. Rationale: Assisting the patient in creating a memory book can provide a therapeutic and meaningful way to celebrate their parent's life and cope with grief. <\Explain> 130,4,0<\Number> D<\Answers> Question 130: A nurse is caring for a patient who has lost a spouse and is experiencing grief-related insomnia. What resource should the nurse recommend to the patient to address sleep difficulties? A) Encourage the patient to avoid seeking help for sleep problems. B) Disregard the patient's insomnia as a normal part of grief. C) Recommend the patient seek guidance from a healthcare provider for sleep aids. D) Suggest the patient explore relaxation techniques and mindfulness practices. <\Body> Correct Answer: D) Suggest the patient explore relaxation techniques and mindfulness practices. Rationale: Recommending relaxation techniques and mindfulness practices can help the patient manage sleep difficulties associated with grief in a non-pharmacological way. <\Explain> 131,4,0<\Number> B<\Answers> Question 131: A nurse is caring for a non-English-speaking patient who is struggling to communicate. What should the nurse do first to assess and address the patient's language needs? A) Disregard the language barrier and continue with care. B) Request an interpreter to facilitate communication. C) Encourage the patient to learn English quickly. D) Use non-verbal gestures to communicate. <\Body> Correct Answer: B) Request an interpreter to facilitate communication. Rationale: When a language barrier is present, the nurse should request an interpreter to ensure effective communication and provide safe, patient-centered care. <\Explain> 132,4,0<\Number> C<\Answers> Question 132: A nurse is caring for a patient with limited English proficiency who requires education on medication management. What is the most appropriate action by the nurse? A) Provide written instructions in English. B) Use complex medical terminology to challenge the patient's language skills. C) Use simple language and diagrams, and consider using an interpreter. D) Disregard the need for education due to language barriers. <\Body> Correct Answer: C) Use simple language and diagrams, and consider using an interpreter. Rationale: Using simple language, diagrams, and potentially an interpreter ensures that the patient with limited English proficiency can understand and manage their medications effectively. <\Explain> 133,4,0<\Number> C<\Answers> Question 133: A nurse is caring for a patient with hearing impairment. The patient uses sign language as their primary mode of communication. What should the nurse do to support the patient's language needs? A) Disregard the need for sign language and communicate in writing. B) Encourage the patient to learn to speak verbally. C) Provide a sign language interpreter for effective communication. D) Speak loudly to ensure the patient can hear. <\Body> Correct Answer: C) Provide a sign language interpreter for effective communication. Rationale: To support effective communication with a patient who uses sign language, it is essential to provide a sign language interpreter to facilitate understanding and promote patient-centered care. <\Explain> 134,4,0<\Number> D<\Answers> Question 134: A nurse is caring for a patient with aphasia who has difficulty speaking and understanding spoken language. What is the best approach for the nurse to communicate with this patient? A) Speak rapidly to help the patient improve their language skills. B) Disregard the patient's communication difficulties. C) Use simple, non-verbal gestures to convey information. D) Speak slowly and use visual aids to enhance communication. <\Body> Correct Answer: D) Speak slowly and use visual aids to enhance communication. Rationale: Patients with aphasia benefit from slow, clear speech and the use of visual aids to aid in understanding and communication. <\Explain> 135,4,0<\Number> C<\Answers> Question 135: A nurse is caring for a patient who speaks a language other than English, and there is no interpreter available. What should the nurse do to ensure effective communication? A) Speak louder and use hand gestures to convey information. B) Disregard the language barrier and proceed with care. C) Use a translation app on a smartphone to communicate. D) Assign another patient as a translator. <\Body> Correct Answer: C) Use a translation app on a smartphone to communicate. Rationale: When an interpreter is unavailable, using a translation app on a smartphone can help bridge the language gap and ensure effective communication. <\Explain> 136,4,0<\Number> D<\Answers> Question 136: A nurse is providing discharge instructions to a patient with limited English proficiency. The patient appears confused and does not seem to understand the instructions. What should the nurse do next? A) Discharge the patient without further explanation. B) Provide written instructions in English. C) Reiterate the instructions using the same language. D) Request an interpreter to clarify and reinforce the instructions. <\Body> Correct Answer: D) Request an interpreter to clarify and reinforce the instructions. Rationale: When a patient with limited English proficiency does not understand instructions, it is essential to request an interpreter to ensure clear communication and patient safety. <\Explain> 137,4,0<\Number> C<\Answers> Question 137: A nurse is caring for a patient who is deaf and primarily communicates using American Sign Language (ASL). What should the nurse do to ensure effective communication? A) Speak loudly and use simplified language. B ) Use written notes to convey information. C) Request a qualified ASL interpreter. D) Disregard the patient's communication needs. <\Body> Correct Answer: C) Request a qualified ASL interpreter. Rationale: To ensure effective communication with a patient who primarily uses ASL, the nurse should request a qualified ASL interpreter to facilitate understanding and provide patient-centered care. <\Explain> 138,4,0<\Number> B<\Answers> Question 138: A nurse is caring for a patient with limited English proficiency. The patient's family member offers to interpret for the patient. What should the nurse do? A) Accept the family member as the interpreter to save time. B) Politely decline and request a qualified medical interpreter. C) Encourage the family member to improve their English skills. D) Disregard the need for an interpreter and continue with care. <\Body> Correct Answer: B) Politely decline and request a qualified medical interpreter. Rationale: It is essential to use qualified medical interpreters to ensure accurate and confidential communication. Family members may not provide unbiased or professional interpretation. <\Explain> 139,4,0<\Number> D<\Answers> Question 139: A nurse is caring for a patient who is mute and uses a communication board to convey messages. How should the nurse support the patient's communication needs? A) Disregard the patient's need for the communication board. B) Speak loudly and use gestures to communicate. C) Encourage the patient to communicate verbally. D) Provide and use the communication board as needed. <\Body> Correct Answer: D) Provide and use the communication board as needed. Rationale: Providing and using the communication board as needed is essential to support effective communication with a mute patient. <\Explain> 140,4,0<\Number> D<\Answers> Question 140: A nurse is caring for a patient with a speech disorder that makes speech difficult to understand. What should the nurse do to facilitate communication with the patient? A) Encourage the patient to speak more slowly. B) Disregard the patient's speech difficulties. C) Use written notes to communicate. D) Listen attentively, ask clarifying questions, and be patient. <\Body> Correct Answer: D) Listen attentively, ask clarifying questions, and be patient. Rationale: Active listening, asking clarifying questions, and being patient are crucial for effective communication with a patient with speech difficulties. <\Explain> 141,4,0<\Number> C<\Answers> Question 141: A nurse is assessing a patient who presents with symptoms of depression, including persistent sadness, loss of interest in activities, and changes in appetite and sleep. What action should the nurse take first? A) Disregard the symptoms as normal fluctuations in mood. B) Document the symptoms and continue with the assessment. C) Ask the patient about any suicidal thoughts or plans. D) Suggest the patient engage in physical exercise to improve mood. <\Body> Correct Answer: C) Ask the patient about any suicidal thoughts or plans. Rationale: Assessing for suicidal thoughts or plans is a priority when a patient presents with symptoms of depression. Safety is paramount, and identifying suicide risk is crucial. <\Explain> 142,4,0<\Number> B<\Answers> Question 142: A nurse is caring for a patient who is experiencing auditory hallucinations and believes that someone is plotting to harm them. What mental health condition is the patient likely experiencing? A) Bipolar disorder B) Schizophrenia C) Generalized anxiety disorder D) Obsessive-compulsive disorder <\Body> Correct Answer: B) Schizophrenia Rationale: Auditory hallucinations and delusions of harm are common symptoms of schizophrenia, a severe mental health condition characterized by disordered thinking and perception. <\Explain> 143,4,0<\Number> C<\Answers> Question 143: A nurse is assessing a patient who has a history of excessive alcohol consumption and exhibits withdrawal symptoms, including tremors, sweating, and agitation. What condition should the nurse suspect? A) Major depressive disorder B) Generalized anxiety disorder C) Alcohol withdrawal syndrome D) Bipolar disorder <\Body> Correct Answer: C) Alcohol withdrawal syndrome Rationale: The patient's history of excessive alcohol consumption and the presence of withdrawal symptoms suggest alcohol withdrawal syndrome, which can be life-threatening and requires immediate intervention. <\Explain> 144,4,0<\Number> B<\Answers> Question 144: A nurse is caring for a patient who reports feeling extremely elevated and euphoric, sleeping only a few hours a night, and engaging in risky behaviors such as excessive spending. What mental health condition is the patient likely experiencing during this manic episode? A) Major depressive disorder B) Bipolar disorder C) Schizophrenia D) Social anxiety disorder <\Body> Correct Answer: B) Bipolar disorder Rationale: The patient's symptoms of extreme elevation, reduced need for sleep, and risky behaviors are indicative of a manic episode, which is a hallmark of bipolar disorder. <\Explain> 145,4,0<\Number> C<\Answers> Question 145: A nurse is assessing a patient who experiences frequent, intrusive, and distressing thoughts about contamination and engages in repetitive handwashing rituals to reduce anxiety. What mental health condition is the patient likely experiencing? A) Post-traumatic stress disorder (PTSD) B ) Panic disorder C) Obsessive-compulsive disorder (OCD) D) Generalized anxiety disorder <\Body> Correct Answer: C) Obsessive-compulsive disorder (OCD) Rationale: The patient's intrusive thoughts and compulsive handwashing rituals are characteristic of obsessive-compulsive disorder (OCD), a condition characterized by obsessions and compulsions. <\Explain> 146,4,0<\Number> C<\Answers> Question 146: A nurse is caring for a patient who is experiencing extreme fear and avoidance of social situations, leading to significant distress and impairment in daily life. What mental health condition is the patient likely experiencing? A) Post-traumatic stress disorder (PTSD) B) Panic disorder C) Social anxiety disorder D) Borderline personality disorder <\Body> Correct Answer: C) Social anxiety disorder Rationale: The patient's extreme fear and avoidance of social situations, along with significant distress and impairment, are indicative of social anxiety disorder, a condition characterized by intense anxiety in social settings. <\Explain> 147,4,0<\Number> C<\Answers> Question 147: A nurse is assessing a patient who reports recurring and distressing nightmares related to a traumatic event experienced in the past. What mental health condition should the nurse suspect? A) Major depressive disorder B) Bipolar disorder C) Post-traumatic stress disorder (PTSD) D ) Schizoaffective disorder <\Body> Correct Answer: C) Post-traumatic stress disorder (PTSD) Rationale: The patient's recurring nightmares related to a traumatic event are characteristic of post-traumatic stress disorder (PTSD), which can occur after exposure to a traumatic event. <\Explain> 148,4,0<\Number> B<\Answers> Question 148: A nurse is caring for a patient who exhibits disorganized speech, bizarre behavior, and impaired social functioning. What mental health condition is the patient likely experiencing? A) Major depressive disorder B) Schizophrenia C) Bipolar disorder D) Generalized anxiety disorder <\Body> Correct Answer: B) Schizophrenia Rationale: The patient's symptoms of disorganized speech, bizarre behavior, and impaired social functioning are characteristic of schizophrenia, a severe mental health condition. <\Explain> 149,4,0<\Number> B<\Answers> Question 149: A nurse is assessing a patient who presents with rapid speech, decreased need for sleep, and impulsive behaviors such as reckless driving. What mental health condition should the nurse suspect during this manic episode? A) Major depressive disorder B) Bipolar disorder C) Panic disorder D) Generalized anxiety disorder <\Body> Correct Answer: B) Bipolar disorder Rationale: The patient's symptoms of rapid speech, decreased need for sleep, and impulsive behaviors are indicative of a manic episode, which is a hallmark of bipolar disorder. <\Explain> 150,4,0<\Number> C<\Answers> Question 150: A nurse is caring for a patient who frequently experiences sudden, intense episodes of fear and physical symptoms such as palpitations, sweating, and trembling. What mental health condition is the patient likely experiencing? A) Major depressive disorder B) Bipolar disorder C) Panic disorder D) Generalized anxiety disorder <\Body> Correct Answer: C) Panic disorder Rationale: The patient's sudden, intense episodes of fear accompanied by physical symptoms are characteristic of panic disorder, a condition characterized by recurrent panic attacks. <\Explain> 151,4,0<\Number> B<\Answers> Question 151: A nurse is teaching a group of clients about stress management techniques. Which technique involves consciously focusing on the present moment and reducing worries about the future or past? A) Progressive muscle relaxation B) Mindfulness meditation C) Deep breathing exercises D) Visualization techniques <\Body> Correct Answer: B) Mindfulness meditation Rationale: Mindfulness meditation involves focusing on the present moment, which can help reduce stress and anxiety by promoting awareness and relaxation. <\Explain> 152,4,0<\Number> C<\Answers> Question 152: A nurse is teaching a client with high levels of stress about a stress management technique that involves tensing and then relaxing specific muscle groups. What technique is the nurse describing? A) Mindfulness meditation B) Visualization exercises C) Progressive muscle relaxation D) Biofeedback therapy <\Body> Correct Answer: C) Progressive muscle relaxation Rationale: Progressive muscle relaxation is a stress management technique that involves tensing and then relaxing specific muscle groups to reduce physical tension and promote relaxation. <\Explain> 153,4,0<\Number> D<\Answers> Question 153: A nurse is instructing a group of clients on stress reduction techniques. Which technique involves deliberately taking slow, deep breaths to calm the body's stress response? A) Visualization exercises B) Biofeedback therapy C) Progressive muscle relaxation D) Deep breathing exercises <\Body> Correct Answer: D) Deep breathing exercises Rationale: Deep breathing exercises involve taking slow, deep breaths to activate the body's relaxation response, reducing stress and anxiety. <\Explain> 154,4,0<\Number> B<\Answers> Question 154: A nurse is teaching a client about stress management techniques that involve creating mental images of calm and peaceful scenes to reduce anxiety. What technique is the nurse describing? A) Biofeedback therapy B) Visualization exercises C) Progressive muscle relaxation D ) Mindfulness meditation <\Body> Correct Answer: B) Visualization exercises Rationale: Visualization exercises involve creating mental images of calm and peaceful scenes to reduce stress and promote relaxation. <\Explain> 155,4,0<\Number> B<\Answers> Question 155: A nurse is educating a client on a stress management technique that uses electronic monitoring to help individuals become aware of their physiological responses to stress. What technique is the nurse describing? A) Visualization exercises B) Biofeedback therapy C) Progressive muscle relaxation D) Mindfulness meditation <\Body> Correct Answer: B) Biofeedback therapy Rationale: Biofeedback therapy uses electronic monitoring to help individuals become aware of and control their physiological responses to stress, such as heart rate and muscle tension. <\Explain> 156,4,0<\Number> D<\Answers> Question 156: A nurse is teaching a group of clients about stress management techniques. Which technique involves engaging in physical activity to reduce stress and improve mood? A) Biofeedback therapy B) Visualization exercises C) Progressive muscle relaxation D) Exercise and physical activity <\Body> Correct Answer: D) Exercise and physical activity Rationale: Engaging in exercise and physical activity is a stress management technique that can help reduce stress, improve mood, and promote overall well-being. <\Explain> 157,4,0<\Number> C<\Answers> Question 157: A nurse is instructing a client on stress reduction techniques that involve keeping a journal to express thoughts and feelings. What technique is the nurse describing? A) Meditation B) Biofeedback therapy C) Journaling or expressive writing D) Visualization exercises <\Body> Correct Answer: C) Journaling or expressive writing Rationale: Journaling or expressive writing involves keeping a journal to express thoughts and feelings, which can be a therapeutic way to manage stress and emotions. <\Explain> 158,4,0<\Number> B<\Answers> Question 158: A nurse is teaching a client about stress management techniques. Which technique involves setting aside specific times for relaxation and leisure activities to reduce stress and promote work-life balance? A) Progressive muscle relaxation B) Time management C) Deep breathing exercises D) Mindfulness meditation <\Body> Correct Answer: B) Time management Rationale: Effective time management, including setting aside time for relaxation and leisure activities, can help reduce stress and promote work-life balance. <\Explain> 159,4,0<\Number> D<\Answers> Question 159: A nurse is educating a client on stress reduction techniques that involve seeking support from friends, family, or professionals. What technique is the nurse describing? A) Social isolation B) Emotional expression C) Coping strategies D) Social support <\Body> Correct Answer: D) Social support Rationale: Seeking support from friends, family, or professionals is a stress management technique that can provide emotional and practical assistance during stressful times. <\Explain> 160,4,0<\Number> A<\Answers> Question 160: A nurse is teaching a client about stress management techniques. Which technique involves identifying and challenging irrational thoughts and beliefs that contribute to stress and anxiety? A) Cognitive-behavioral therapy (CBT) B) Visualization exercises C) Progressive muscle relaxation D) Biofeedback therapy <\Body> Correct Answer: A) Cognitive-behavioral therapy (CBT) Rationale: Cognitive-behavioral therapy (CBT) is a structured approach that helps individuals identify and challenge irrational thoughts and beliefs, leading to reduced stress and improved coping skills. <\Explain> 161,4,0<\Number> C<\Answers> Question 161: A nurse is evaluating the care environment in a psychiatric unit. Which action is the nurse assessing that ensures patients' privacy and confidentiality? A) Providing group therapy sessions in an open common area B) Discussing patients' treatment plans in a public cafeteria C) Using curtains around each patient's bed for visual privacy D) Sharing patient information with visitors in the hallway <\Body> Correct Answer: C) Using curtains around each patient's bed for visual privacy Rationale: Using curtains around each patient's bed in a psychiatric unit provides visual privacy and helps maintain patient confidentiality. <\Explain> 162,4,0<\Number> C<\Answers> Question 162: A nurse is evaluating the care environment on a medical-surgical unit. Which practice ensures patients' safety during medication administration? A) Administering medications without checking the patient's identification B) Leaving medications at the patient's bedside for self-administration C) Checking the patient's identification before medication administration D) Administering medications quickly without explaining them to the patient <\Body> Correct Answer: C) Checking the patient's identification before medication administration Rationale: Checking the patient's identification before medication administration is a critical safety practice to ensure the right medication is given to the right patient. <\Explain> 163,4,0<\Number> B<\Answers> Question 163: A nurse is evaluating the care environment in a pediatric unit. What action ensures the safety of pediatric patients when they are not in their cribs or beds? A) Keeping all pediatric patients confined to their cribs or beds at all times B) Providing age-appropriate toys and activities in a safe play area C) Allowing pediatric patients to roam freely in the unit for exercise D) Restraining pediatric patients to prevent falls <\Body> Correct Answer: B) Providing age-appropriate toys and activities in a safe play area Rationale: Providing age-appropriate toys and activities in a safe play area allows pediatric patients to engage in developmentally appropriate activities while ensuring their safety. <\Explain> 164,4,0<\Number> B<\Answers> Question 164: A nurse is evaluating the care environment in a long-term care facility. What practice promotes residents' autonomy and independence? A) Making all decisions for residents without their input B) Encouraging residents to perform self-care activities when possible C) Restraining residents to prevent wandering D) Restricting residents' access to visitors <\Body> Correct Answer: B) Encouraging residents to perform self-care activities when possible Rationale: Encouraging residents to perform self-care activities when possible promotes their autonomy and independence in a long-term care setting. <\Explain> 165,4,0<\Number> C<\Answers> Question 165: A nurse is assessing the care environment in a rehabilitation unit. What feature ensures accessibility for patients with mobility challenges? A) Narrow doorways that may require assistance to pass through B) Elevators that are frequently out of service C) Wheelchair ramps and widened doorways D) Limited access to bathrooms <\Body> Correct Answer: C) Wheelchair ramps and widened doorways Rationale: Wheelchair ramps and widened doorways in the care environment ensure accessibility for patients with mobility challenges, promoting their independence. <\Explain> 166,4,0<\Number> B<\Answers> Question 166: A nurse is evaluating the care environment in a neonatal intensive care unit (NICU). What practice helps minimize the risk of infection in the NICU? A) Allowing visitors to handle multiple newborns without hand hygiene B) Frequent handwashing and strict hand hygiene protocols C) Encouraging healthcare providers to wear jewelry and accessories D) Using cloth linens for bedding <\Body> Correct Answer: B) Frequent handwashing and strict hand hygiene protocols Rationale: Frequent handwashing and strict hand hygiene protocols are essential in the NICU to minimize the risk of infection and protect vulnerable newborns. <\Explain> 167,4,0<\Number> B<\Answers> Question 167: A nurse is assessing the care environment in a mental health facility. What feature ensures the safety of patients in seclusion or restraint? A) Frequent use of seclusion and restraint as behavior management tools B) Regular monitoring of patients in seclusion or restraint C) Leaving patients unattended in seclusion or restraint for extended periods D) Using seclusion and restraint as punishment for patients <\Body> Correct Answer: B) Regular monitoring of patients in seclusion or restraint Rationale: Regular monitoring of patients in seclusion or restraint is crucial for their safety and well-being, ensuring that their physical and emotional needs are met. <\Explain> 168,4,0<\Number> C<\Answers> Question 168: A nurse is evaluating the care environment in a home healthcare setting. What practice helps prevent medication errors in this setting? A) Keeping all medications in a single, unlabeled container B) Administering medications without proper documentation C) Using a medication organizer with labeled compartments D) Storing medications in various locations around the home <\Body> Correct Answer: C) Using a medication organizer with labeled compartments Rationale: Using a medication organizer with labeled compartments helps prevent medication errors in a home healthcare setting by promoting accurate medication administration. <\Explain> 169,4,0<\Number> B<\Answers> Question 169: A nurse is assessing the care environment in a pediatric clinic. What practice ensures the safety of pediatric patients during medical procedures? A) Administering procedures without explaining them to the child B) Providing comfort measures and age-appropriate explanations C) Restraining children during procedures to prevent movement D) Avoiding child-friendly distractions <\Body> Correct Answer: B) Providing comfort measures and age-appropriate explanations Rationale: Providing comfort measures and age-appropriate explanations during medical procedures helps ensure the safety and cooperation of pediatric patients. <\Explain> 170,4,0<\Number> A<\Answers> Question 170: A nurse is evaluating the care environment in a post-operative unit. What practice promotes infection control in this setting? A) Frequent handwashing among healthcare providers B) Reusing single-use disposable equipment C) Crowded patient beds close together D) Allowing visitors to bring outside food <\Body> Correct Answer: A) Frequent handwashing among healthcare providers Rationale: Frequent handwashing among healthcare providers is a key practice for infection control in a post-operative unit, reducing the risk of healthcare-associated infections. <\Explain> 171,4,0<\Number> A<\Answers> Question 171: A nurse is caring for a terminally ill patient who is experiencing severe pain. What is the nurse's priority action to address the patient's pain? A) Administering pain medication as ordered B) Encouraging the patient to focus on positive thoughts C) Providing emotional support to the patient's family D) Discussing advanced care planning <\Body> Correct Answer: A) Administering pain medication as ordered Rationale: Pain management is a priority in end-of-life care. The nurse should administer pain medication as ordered to alleviate the patient's suffering and improve their comfort. <\Explain> 172,4,0<\Number> C<\Answers> Question 172: A patient with a terminal illness expresses a desire to discuss their end-of-life wishes. What is the nurse's best response? A) "We don't need to talk about that right now." B) "Let's wait until you're feeling better to discuss this." C) "I'm here to listen and support you. What would you like to talk about?" D) "I'll inform the healthcare provider about your concerns." <\Body> Correct Answer: C) "I'm here to listen and support you. What would you like to talk about?" Rationale: The nurse should provide an open and empathetic response, allowing the patient to express their end-of-life wishes and concerns when they are ready. <\Explain> 173,4,0<\Number> C<\Answers> Question 173: A patient at the end of life expresses fear and anxiety about dying. What is the nurse's most appropriate intervention? A) Avoid discussing the topic to prevent distress B) Encourage the patient to focus on happy memories C) Provide emotional support and active listening D) Suggest a distraction technique to divert the patient's attention <\Body> Correct Answer: C) Provide emotional support and active listening Rationale: Providing emotional support and active listening allows the patient to express their feelings and fears about dying. It promotes a therapeutic nurse-patient relationship and helps address the patient's emotional needs. <\Explain> 174,4,0<\Number> A<\Answers> Question 174: A patient at the end of life is experiencing shortness of breath and anxiety. What intervention should the nurse prioritize? A) Administering oxygen therapy B) Encouraging the patient to stay silent C) Suggesting meditation techniques D) Revisiting advanced care planning <\Body> Correct Answer: A) Administering oxygen therapy Rationale: Administering oxygen therapy is the priority to address the patient's shortness of breath and improve their comfort. This intervention can help alleviate respiratory distress. <\Explain> 175,4,0<\Number> A<\Answers> Question 175: A terminally ill patient has expressed a desire to spend time with their family in a home-like environment during their final days. What type of care setting should the nurse recommend? A) Hospice care B) Palliative care C) Intensive care unit (ICU) D) Acute care hospital <\Body> Correct Answer: A) Hospice care Rationale: Hospice care is designed to provide comfort and support to patients at the end of life in a home-like environment, often in the patient's own home. It focuses on quality of life and meeting the patient's physical, emotional, and spiritual needs. <\Explain> 176,4,0<\Number> C<\Answers> Question 176: A patient at the end of life has stopped eating and drinking. What nursing action is appropriate in this situation? A) Encourage the patient to eat and drink regardless of their wishes B) Offer small sips of water to prevent dehydration C) Respect the patient's decision to decline food and fluids D) Administer parenteral nutrition to maintain nutrition <\Body> Correct Answer: C) Respect the patient's decision to decline food and fluids Rationale: Respect for the patient's autonomy and wishes is crucial in end-of-life care. If the patient has made an informed decision to stop eating and drinking, the nurse should respect this choice while providing comfort measures and support. <\Explain> 177,4,0<\Number> C<\Answers> Question 177: A family member of a terminally ill patient asks the nurse about the purpose of a "do not resuscitate" (DNR) order. What is the nurse's best response? A) "A DNR order means that we will not provide any medical care to your loved one." B) "A DNR order is a legal document that allows us to withhold all treatments." C) "A DNR order specifies that we will not attempt cardiopulmonary resuscitation (CPR) if your loved one's heart stops or they stop breathing." D) "A DNR order is only used when the patient is actively dying." <\Body> Correct Answer: C) "A DNR order specifies that we will not attempt cardiopulmonary resuscitation (CPR) if your loved one's heart stops or they stop breathing." Rationale: A DNR order is a medical directive that specifies that CPR will not be initiated if the patient's heart stops or they stop breathing. It does not mean withholding all medical care. <\Explain> 178,4,0<\Number> A<\Answers> Question 178: A patient in end-of-life care has expressed a wish to spend time with a beloved pet. What action should the nurse take to fulfill this request? A) Allow the pet to visit the patient's room regularly B) Inform the patient that pets are not allowed in healthcare facilities C) Offer to find a pet therapy program for the patient D) Disregard the request as it may pose infection risks <\Body> Correct Answer: A) Allow the pet to visit the patient's room regularly Rationale: Allowing the patient's pet to visit their room regularly can provide emotional support and comfort to the patient in end-of-life care. The nurse should assess the pet's health and ensure infection control measures are in place. <\Explain> 179,4,0<\Number> A<\Answers> Question 179: A terminally ill patient is experiencing severe pain that is not adequately controlled with current medications. What is the nurse's priority action? A) Administering additional pain medication as ordered B) Encouraging the patient to endure the pain without complaint C) Initiating aggressive medical interventions D) Notifying the healthcare provider about the pain <\Body> Correct Answer: A) Administering additional pain medication as ordered Rationale: The nurse's priority is to alleviate the patient's suffering and improve their comfort. Administering additional pain medication as ordered is the appropriate action when pain is not adequately controlled. <\Explain> 180,4,0<\Number> A<\Answers> Question 180: A family member expresses guilt and sadness about not being able to fulfill the patient's wish to die at home. What is the nurse's best response? A) "It's important to focus on your own feelings right now." B) "You should have done everything possible to make that happen." C) "It's understandable that you're feeling this way. Let's talk about it." D) "Your loved one's wishes were unrealistic." <\Body> Correct Answer: C) "It's understandable that you're feeling this way. Let's talk about it." Rationale: The nurse should offer support and provide an opportunity for the family member to express their feelings and concerns. Open communication is essential in addressing their emotional needs. <\Explain> <\Questions> <\Section>
Physiological Integrity - CH4 1,4,0<\Number> B<\Answers> Question 1: A nurse is caring for a client with a prosthetic limb. Which action should the nurse prioritize when assisting the client with donning the prosthetic limb? A) Applying lotion to the residual limb B) Ensuring the prosthetic socket fits snugly C) Leaving the prosthetic limb off during sleep D) Allowing the client to self-administer pain medication <\Body> Correct Answer: B) Ensuring the prosthetic socket fits snugly Rationale: Proper fitting of the prosthetic socket is crucial to prevent complications and ensure the client's comfort and mobility. <\Explain> 2,4,0<\Number> C<\Answers> Question 2: When caring for a client with a hearing aid, which nursing intervention is most important to prevent infection and maintain device functionality? A) Cleaning the hearing aid with alcohol daily B) Removing the hearing aid during meals C) Storing the hearing aid in a dry, protective case D) Changing the hearing aid batteries weekly <\Body> Correct Answer: C) Storing the hearing aid in a dry, protective case Rationale: Storing the hearing aid properly in a dry, protective case prevents moisture damage and infection risk. <\Explain> 3,4,0<\Number> B<\Answers> Question 3: A nurse is caring for a client with constipation. Which intervention should the nurse prioritize to promote regular bowel movements? A) Administering a laxative immediately B) Encouraging increased fluid intake and fiber-rich foods C) Restricting all dietary intake until the bowel movement occurs D) Administering an enema without further assessment <\Body> Correct Answer: B) Encouraging increased fluid intake and fiber-rich foods Rationale: Promoting a diet rich in fiber and adequate hydration is the first step in managing constipation. <\Explain> 4,4,0<\Number> D<\Answers> Question 4: A client with urinary incontinence is using absorbent pads. What is the nurse's primary responsibility when assisting with this client's elimination needs? A) Ensuring the pads are changed every 8 hours B) Encouraging the client to limit fluid intake C) Teaching the client Kegel exercises D) Maintaining the client's dignity and privacy <\Body> Correct Answer: D) Maintaining the client's dignity and privacy Rationale: Maintaining the client's dignity and privacy is a fundamental aspect of care for clients with incontinence. <\Explain> 5,4,0<\Number> A<\Answers> Question 5: A nurse is caring for an immobilized client. Which action should the nurse prioritize to prevent pressure ulcers in this client? A) Frequent repositioning B) Application of tight dressings C) Use of an air mattress D) Limiting fluid intake <\Body> Correct Answer: A) Frequent repositioning Rationale: Frequent repositioning helps relieve pressure on vulnerable areas and is a key strategy in preventing pressure ulcers. <\Explain> 6,4,0<\Number> B<\Answers> Question 6: A client has been immobilized due to a fractured hip. What is the most appropriate nursing intervention to promote respiratory function in this client? A) Administering oxygen continuously B) Encouraging deep breathing exercises C) Restricting fluid intake D) Administering sedatives to promote rest <\Body> Correct Answer: B) Encouraging deep breathing exercises Rationale: Deep breathing exercises help prevent respiratory complications associated with immobility. <\Explain> 7,4,0<\Number> C<\Answers> Question 7: A nurse is caring for an immobilized client. Which assessment finding indicates a potential complication related to immobility? A) Increased muscle strength B) Decreased respiratory rate C) Skin breakdown over bony prominences D) Improved joint flexibility <\Body> Correct Answer: C) Skin breakdown over bony prominences Rationale: Skin breakdown over bony prominences is a common complication in immobilized clients due to pressure and should be assessed and managed promptly. <\Explain> 8,4,0<\Number> B<\Answers> Question 8: A nurse is assessing a client who has been immobile for an extended period. Which finding suggests a potential complication of immobility in the musculoskeletal system? A) Increased range of motion in joints B) Weakness and atrophy of muscles C) Improved muscle tone and strength D) Decreased joint pain and stiffness <\Body> Correct Answer: B) Weakness and atrophy of muscles Rationale: Immobility can lead to muscle weakness and atrophy due to disuse, which is a potential complication. <\Explain> 9,4,0<\Number> B<\Answers> Question 9: A nurse is caring for a client with impaired circulation. Which intervention is most effective in promoting circulation in the lower extremities? A) Applying cold compresses to the legs B) Elevating the legs above heart level C) Encouraging prolonged sitting D) Massaging the legs vigorously <\Body> Correct Answer: B) Elevating the legs above heart level Rationale: Elevating the legs above heart level helps improve venous return and promotes circulation in the lower extremities. <\Explain> 10,4,0<\Number> C<\Answers> Question 10: A client is at risk for venous thromboembolism (VTE). Which nursing intervention is essential to prevent VTE in this client? A) Encouraging bed rest B) Applying warm compresses to the legs C) Administering anticoagulant medications D) Limiting fluid intake <\Body> Correct Answer: C) Administering anticoagulant medications Rationale: Administering anticoagulant medications can help prevent venous thromboembolism (VTE) in high-risk clients. <\Explain> 11,4,0<\Number> B<\Answers> Question 11: A nurse is caring for a client in skeletal traction. What is the primary purpose of skeletal traction? A) To immobilize the client completely B) To maintain alignment of fractured bones C) To promote joint flexibility D) To alleviate pain associated with the fracture <\Body> Correct Answer: B) To maintain alignment of fractured bones Rationale: Skeletal traction is used to ensure proper alignment of fractured bones and facilitate healing. <\Explain> 12,4,0<\Number> D<\Answers> Question 12: A client in skin traction for a fractured femur has developed pressure ulcers on the skin beneath the traction. What should the nurse do first? A) Remove the traction to relieve pressure B) Apply antibiotic ointment to the ulcers C) Reapply the traction with additional padding D) Document the findings and notify the healthcare provider <\Body> Correct Answer: D) Document the findings and notify the healthcare provider Rationale: Pressure ulcers beneath the traction should be documented, and the healthcare provider should be informed for further evaluation and treatment. <\Explain> 13,4,0<\Number> C<\Answers> Question 13: A nurse is caring for a postoperative client who is experiencing pain. What is the nurse's priority when evaluating the need for non-pharmacological comfort interventions? A) Administering pain medication as prescribed B) Encouraging relaxation techniques C) Assessing the client's pain intensity and response D) Restricting the client's fluid intake <\Body> Correct Answer: C) Assessing the client's pain intensity and response Rationale: Before implementing non-pharmacological interventions, it is essential to assess the client's pain level and response to determine their effectiveness. <\Explain> 14,4,0<\Number> B<\Answers> Question 14: A client with a chronic illness experiences frequent discomfort. What non-pharmacological intervention should the nurse consider when assessing the need for comfort? A) Administering opioids as needed B) Teaching the client deep breathing exercises C) Encouraging the client to avoid all physical activity D) Limiting communication with the client <\Body> Correct Answer: B) Teaching the client deep breathing exercises Rationale: Deep breathing exercises can help alleviate discomfort and improve overall comfort, especially in clients with chronic illnesses. <\Explain> 15,4,0<\Number> A<\Answers> Question 15: A nurse has implemented relaxation techniques to manage a client's anxiety. What is the most appropriate method to evaluate the effectiveness of these non-pharmacological interventions? A) Monitoring the client's heart rate and blood pressure B) Administering an anxiolytic medication C) Encouraging the client to stay awake throughout the night D) Limiting the client's access to visitors <\Body> Correct Answer: A) Monitoring the client's heart rate and blood pressure Rationale: Monitoring vital signs, such as heart rate and blood pressure, can provide objective data to assess the effectiveness of relaxation techniques in reducing anxiety. <\Explain> 16,4,0<\Number> C<\Answers> Question 16: A client with chronic pain has been using guided imagery as a non-pharmacological intervention. What should the nurse assess to evaluate the outcomes of this intervention? A) The client's willingness to take opioids B) The client's ability to sleep continuously for 12 hours C) The client's pain intensity and frequency D) The client's preference for cold packs <\Body> Correct Answer: C) The client's pain intensity and frequency Rationale: Assessing the client's pain intensity and frequency provides measurable data to evaluate the effectiveness of guided imagery in managing chronic pain. <\Explain> 17,4,0<\Number> D<\Answers> Question 17: A nurse is assessing a client's nutritional status. Which physical assessment finding indicates a potential nutritional deficit? A) Moist, pink mucous membranes B) Shiny, healthy-looking hair C) Prominent, firm muscle mass D) Dry, cracked lips and poor skin turgor <\Body> Correct Answer: D) Dry, cracked lips and poor skin turgor Rationale: Dry, cracked lips and poor skin turgor can be signs of dehydration and suggest a potential nutritional deficit. <\Explain> 18,4,0<\Number> B<\Answers> Question 18: A client is admitted with a body mass index (BMI) of 16. What should the nurse assess for regarding the client's nutritional status? A) Obesity-related complications B) Potential malnutrition or undernutrition C) Adequate protein intake D) Overhydration and fluid retention <\Body> Correct Answer: B) Potential malnutrition or undernutrition Rationale: A BMI of 16 suggests a lower-than-normal body weight, which may indicate malnutrition or undernutrition. <\Explain> 19,4,0<\Number> D<\Answers> Question 19: A nurse is assessing a client's hydration status. What assessment finding is most indicative of adequate hydration? A) Dry mucous membranes B) Sunken fontanelles C) Dark yellow urine D) Elastic skin turgor <\Body> Correct Answer: D) Elastic skin turgor Rationale: Elastic skin turgor is a reliable indicator of hydration status. Hydrated skin will snap back into place promptly when gently pinched. <\Explain> 20,4,0<\Number> D<\Answers> Question 20: A nurse is caring for an elderly client. What age-related change should the nurse consider when assessing the client's hydration needs? A) Increased thirst sensation B) Improved kidney function C) Enhanced ability to concentrate urine D) Decreased sense of thirst <\Body> Correct Answer: D) Decreased sense of thirst Rationale: Aging is associated with a decreased sense of thirst, which may lead to inadequate fluid intake in elderly clients. <\Explain> 21,4,0<\Number> C<\Answers> Question 21: A nurse is assessing a client's nutritional status. What finding should prompt the nurse to consider the need for nutritional supplements? A) A balanced diet with all food groups B) BMI within the normal range C) Difficulty swallowing and inadequate oral intake D) Regular exercise routine <\Body> Correct Answer: C) Difficulty swallowing and inadequate oral intake Rationale: Difficulty swallowing and inadequate oral intake may necessitate nutritional supplements to ensure the client's nutritional needs are met. <\Explain> 22,4,0<\Number> C<\Answers> Question 22: A client with chronic diarrhea is at risk for nutrient deficiencies. What should the nurse assess to determine the need for nutritional supplements in this client? A) High dietary fiber intake B) Frequent consumption of fruits and vegetables C) Frequent bowel movements and fluid loss D) Weight gain <\Body> Correct Answer: C) Frequent bowel movements and fluid loss Rationale: Chronic diarrhea can lead to nutrient losses, and frequent bowel movements and fluid loss indicate a potential need for nutritional supplements. <\Explain> 23,4,0<\Number> B<\Answers> Question 23: A nurse is assessing a client receiving enteral tube feeding. What assessment finding suggests a potential side effect of tube feeding? A) Increased urine output B) Abdominal distention and discomfort C) Improved appetite and oral intake D) Elevated blood pressure <\Body> Correct Answer: B) Abdominal distention and discomfort Rationale: Abdominal distention and discomfort can be side effects of tube feeding, indicating the need for assessment and intervention. <\Explain> 24,4,0<\Number> C<\Answers> Question 24: A client receiving tube feeding reports a sour taste in the mouth and increased belching. What action should the nurse take to address these side effects? A) Increase the rate of the tube feeding B) Administer an antacid medication C ) Evaluate the position of the feeding tube D) Encourage the client to eat solid foods <\Body> Correct Answer: C) Evaluate the position of the feeding tube Rationale: A sour taste and increased belching may suggest tube misplacement, and the nurse should assess the tube's position. <\Explain> 25,4,0<\Number> D<\Answers> Question 25: A nurse is assessing a client's hygiene. What finding suggests a potential hygiene-related concern? A) Clean and well-groomed hair B) Nails trimmed and free from dirt C) Strong, pleasant body odor D) Foul-smelling breath and disheveled appearance <\Body> Correct Answer: D) Foul-smelling breath and disheveled appearance Rationale: Foul-smelling breath and a disheveled appearance may indicate poor oral hygiene and overall hygiene neglect. <\Explain> 26,4,0<\Number> D<\Answers> Question 26: A client with limited mobility is at risk for pressure ulcers. What assessment finding should prompt the nurse to evaluate the client's hygiene practices? A) Pink, intact skin on bony prominences B) Dry and well-moisturized skin C) Skin redness and warmth in pressure areas D) Presence of foul-smelling wound drainage <\Body> Correct Answer: D) Presence of foul-smelling wound drainage Rationale: Foul-smelling wound drainage can indicate poor wound hygiene practices and potential pressure ulcer development. <\Explain> 27,4,0<\Number> D<\Answers> Question 27: A nurse is assessing a client's sleep patterns. What finding suggests a potential sleep-related concern? A) Regular bedtime routine B) Falling asleep within 15 minutes of lying down C) Waking up feeling refreshed and rested D ) Frequent awakening during the night <\Body> Correct Answer: D) Frequent awakening during the night Rationale: Frequent awakening during the night can indicate disrupted sleep patterns and may be indicative of a sleep-related concern. <\Explain> 28,4,0<\Number> B<\Answers> Question 28: A client reports experiencing persistent difficulty falling asleep and staying asleep. What term should the nurse use to describe this sleep disorder? A) Narcolepsy B) Insomnia C) Sleep apnea D) Sleepwalking <\Body> Correct Answer: B) Insomnia Rationale: Difficulty falling asleep and staying asleep is characteristic of insomnia, a common sleep disorder. <\Explain> 29,4,0<\Number> A<\Answers> Question 29: Which of the following is an essential right of medication administration? A) Right time B) Right diagnosis C) Right dose D) Right frequency <\Body> Correct Answer: A) Right time Rationale: Administering medication at the correct time ensures its effectiveness and safety for the patient. <\Explain> 30,4,0<\Number> B<\Answers> Question 30: What should the nurse do if a patient questions the medication about to be administered? A) Explain the benefits of the medication and administer it. B) Delay administration and consult the healthcare provider. C) Reassure the patient and administer the medication. D) Administer the medication quickly to avoid resistance. <\Body> Correct Answer: B) Delay administration and consult the healthcare provider. Rationale: If a patient questions a medication, the nurse should pause and seek clarification to ensure patient safety. <\Explain> 31,4,0<\Number> C<\Answers> Question 31: When educating a client about a newly prescribed medication, the nurse should include information about: A) The cost of the medication. B) The medication's generic name. C) Potential side effects and adverse reactions. D) The nurse's personal experiences with the medication. <\Body> Correct Answer: C) Potential side effects and adverse reactions. Rationale: Educating the client about potential side effects and adverse reactions is essential for informed consent and monitoring for medication-related issues. <\Explain> 32,4,0<\Number> B<\Answers> Question 32: Which of the following statements by the client indicates a need for further education about medication administration? A) "I can cut this tablet in half if it's too big for me to swallow." B) "I should always take my medication with grapefruit juice." C) "I will take this medication at the same time every day." D) "I'll be sure to finish the entire prescription, even if I start feeling better." <\Body> Correct Answer: B) "I should always take my medication with grapefruit juice." Rationale: Grapefruit juice can interact with many drugs, so this statement indicates a need for correction. <\Explain> 33,4,0<\Number> D<\Answers> Question 33: When documenting medication administration, the nurse should record which of the following details? A) The patient's room number B) The nurse's personal opinions about the medication C) The patient's allergies and dietary preferences D) The time, date, and route of administration <\Body> Correct Answer: D) The time, date, and route of administration Rationale: Documentation should include essential information like the time, date, and route of medication administration for accurate record keeping. <\Explain> 34,4,0<\Number> B<\Answers> Question 34: Which action should the nurse take if a patient refuses to take a prescribed medication? A) Administer the medication secretly without the patient's knowledge. B) Document the refusal and the reason for it. C) Persuade the patient to take the medication by any means necessary. D) Withhold all other treatments until the medication is accepted. <\Body> Correct Answer: B) Document the refusal and the reason for it. Rationale: Documenting a medication refusal is crucial for legal and ethical reasons and ensures that healthcare providers are informed of the patient's decision. <\Explain> 35,4,0<\Number> C<\Answers> Question 35: Before administering a medication, the nurse should prioritize assessing the patient for: A) The medication's cost and insurance coverage. B) The patient's preference for medication administration. C) Contraindications, allergies, and potential side effects. D) The nurse's personal experience with the medication. <\Body> Correct Answer: C) Contraindications, allergies, and potential side effects. Rationale: Assessing for contraindications, allergies, and potential side effects is crucial to prevent harm and ensure safe medication administration. <\Explain> 36,4,0<\Number> C<\Answers> Question 36: Which of the following is considered a contraindication to a specific medication? A) The patient's dislike of the medication's taste. B) The patient's preference for a different brand of the medication. C) A medical condition that makes the medication unsafe. D) The patient's financial inability to afford the medication. <\Body> Correct Answer: C) A medical condition that makes the medication unsafe. Rationale: Contraindications are specific medical conditions or circumstances that make the use of a medication unsafe. <\Explain> 37,4,0<\Number> C<\Answers> Question 37: A patient is receiving an intravenous (IV) antibiotic known to cause nephrotoxicity. What should the nurse prioritize when monitoring for side effects? A) Blood pressure measurements B) Respiratory rate assessment C) Urine output and renal function D) Temperature charting <\Body> Correct Answer: C) Urine output and renal function Rationale: Nephrotoxic medications can affect renal function, so monitoring urine output and renal function is crucial to detect and prevent potential adverse effects. <\Explain> 38,4,0<\Number> B<\Answers> Question 38: A patient receiving a beta-blocker for hypertension reports feeling dizzy when standing up. What is the nurse's initial action? A) Administer another dose of the beta-blocker. B) Assess the patient's blood pressure and heart rate. C) Offer the patient a glass of water. D) Document the patient's complaint and continue the medication. <\Body> Correct Answer: B) Assess the patient's blood pressure and heart rate. Rationale: Dizziness can be a side effect of beta-blockers, and assessing the patient's blood pressure and heart rate helps determine the cause and appropriate action. <\Explain> 39,4,0<\Number> D<\Answers> Question 39: A nurse is disposing of expired medications. What should be the nurse's first action when following agency policy for medication disposal? A) Flush the medications down the toilet. B) Dispose of them in the regular trash. C) Crush the medications to prevent misuse. D) Check the agency's specific guidelines for disposal. <\Body> Correct Answer: D) Check the agency's specific guidelines for disposal. Rationale: Medication disposal procedures may vary by agency, so it is essential to follow the specific guidelines provided to ensure safe and appropriate disposal. <\Explain> 40,4,0<\Number> D<\Answers> Question 40: When disposing of controlled substances, which action should the nurse take to comply with agency policy? A) Return them to the pharmacy for reuse. B) Document their disposal in the patient's medical record. C) Witness the disposal by another healthcare provider. D) Follow the agency's specific controlled substance disposal procedures. <\Body> Correct Answer: D) Follow the agency's specific controlled substance disposal procedures. Rationale: Controlled substances have specific disposal requirements outlined by regulatory agencies, and the nurse should follow the agency's procedures to ensure compliance. <\Explain> 41,4,0<\Number> B<\Answers> Question 41: When administering medication through an intravenous (IV) line, what is the nurse's primary responsibility for monitoring and evaluation? A) Assess the patient's pain level. B) Monitor the IV infusion rate and site. C) Observe the patient's respiratory rate. D) Measure the patient's blood pressure. <\Body> Correct Answer: B) Monitor the IV infusion rate and site. Rationale: When administering medication via IV, it is crucial to monitor the infusion rate to prevent complications like infiltration or extravasation. <\Explain> 42,4,0<\Number> A<\Answers> Question 42: A patient is receiving parenteral nutrition (PN). What should the nurse regularly assess to monitor the effectiveness of the PN therapy? A) Blood glucose levels B) Urinary output C) Oral intake D) Respiratory rate <\Body> Correct Answer: A) Blood glucose levels Rationale: Regular monitoring of blood glucose levels is essential when a patient is receiving PN to ensure adequate nutrition and prevent hyperglycemia or hypoglycemia. <\Explain> 43,4,0<\Number> C<\Answers> Question 43: A patient is prescribed a medication for hypertension. What should the nurse prioritize when monitoring the client's response to this medication? A) Assessing the patient's pain level. B) Measuring the patient's temperature. C) Monitoring blood pressure and heart rate. D) Checking the patient's respiratory rate. <\Body> Correct Answer: C) Monitoring blood pressure and heart rate. Rationale: When administering medication for hypertension, it is essential to monitor the client's blood pressure and heart rate to assess the effectiveness of the treatment and any potential side effects. <\Explain> 44,4,0<\Number> B<\Answers> Question 44: A client is receiving IV antibiotics for an infection. What should the nurse assess to monitor the client's response to the medication? A) Skin color and texture. B) Urinary output and frequency. C) Appetite and food preferences. D) IV site condition and signs of infection. <\Body> Correct Answer: B) Urinary output and frequency. Rationale: Monitoring urinary output and frequency can help assess the client's response to IV antibiotics, as changes may indicate improved or worsening infection. <\Explain> 45,4,0<\Number> A<\Answers> Question 45: Before administering a blood transfusion, what is the nurse's priority action to ensure patient safety and compliance with agency policy? A) Verify the patient's blood type and crossmatch. B) Warm the blood bag to body temperature. C) Document the planned transfusion in the patient's chart. D) Start the transfusion immediately to save time. <\Body> Correct Answer: A) Verify the patient's blood type and crossmatch. Rationale: Ensuring the correct blood type and crossmatch is essential before a blood transfusion to prevent adverse reactions and ensure patient safety. <\Explain> 46,4,0<\Number> C<\Answers> Question 46: A nurse is preparing to administer a blood transfusion. What information should be verified before initiating the transfusion? A) The patient's room number and bed assignment. B) The patient's dietary preferences and allergies. C) The blood bag label, patient's identification, and blood compatibility. D) The nurse's personal experience with blood transfusions. <\Body> Correct Answer: C) The blood bag label, patient's identification, and blood compatibility. Rationale: Verifying the blood bag label, patient's identification, and blood compatibility are critical steps in ensuring the safety and accuracy of a blood transfusion. <\Explain> 47,4,0<\Number> C<\Answers> Question 47: A nurse is assessing a patient's central venous catheter (CVC) site for signs of infection. Which finding should be reported immediately as a potential complication? A) Mild tenderness at the CVC insertion site. B) Slight redness around the CVC site. C) Purulent drainage or discharge from the site. D) Skin cool to the touch near the CVC. <\Body> Correct Answer: C) Purulent drainage or discharge from the site. Rationale: Purulent drainage or discharge from a CVC site is a sign of infection and should be reported immediately to prevent the spread of infection. <\Explain> 48,4,0<\Number> C<\Answers> Question 48: A patient has a peripherally inserted central catheter (PICC) in place. What action should the nurse take to evaluate the PICC's patency? A) Assess the patient's pain level. B) Check the dressing for any bloodstains. C) Flush the PICC with sterile saline. D) Document the PICC's external appearance. <\Body> Correct Answer: C) Flush the PICC with sterile saline. Rationale: Flushing the PICC with sterile saline helps evaluate its patency and ensures that it is functional for medication administration. <\Explain> 49,4,0<\Number> A<\Answers> Question 49: A child weighing 22 pounds is prescribed a medication at a dose of 0.15 mg/kg. The medication is available in a concentration of 1 mg/mL. How many milliliters should the nurse administer? A) 1.5 mL B) 0.15 mL C) 2.2 mL D) 3 mL <\Body> Correct Answer: A) 1.5 mL Rationale: To calculate the dose, multiply the child's weight in kg (22 lbs / 2.2 = 10 kg) by the prescribed dose (0.15 mg/kg) to get 1.5 mg. Then, use the medication's concentration (1 mg/mL) to determine that 1.5 mg is equivalent to 1.5 mL. <\Explain> 50,4,0<\Number> B<\Answers> Question 50: A patient is prescribed 750 mg of an antibiotic to be administered orally. The available tablets are 250 mg each. How many tablets should the nurse administer? A) 2 tablets B) 3 tablets C) 4 tablets D) 5 tablets <\Body> Correct Answer: B) 3 tablets Rationale: To calculate the number of tablets needed, divide the prescribed dose (750 mg) by the tablet's strength (250 mg/tablet), which results in 3 tablets. <\Explain> 51,4,0<\Number> C<\Answers> Question 51 A patient has received a dose of intravenous (IV) pain medication. What should the nurse prioritize when monitoring the patient's response to the medication? A) Assessing the patient's blood pressure. B) Documenting the medication administration. C) Evaluating the patient's level of consciousness. D) Measuring the patient's urinary output. <\Body> Correct Answer: C) Evaluating the patient's level of consciousness. Rationale: Monitoring the patient's level of consciousness is essential after administering IV pain medication, as changes may indicate adverse effects such as sedation or respiratory depression. <\Explain> 52,4,0<\Number> B<\Answers> Question 52: A patient with heart failure is prescribed a diuretic medication. What should the nurse assess to monitor the patient's response to the diuretic therapy? A) Blood pressure and heart rate. B) Urinary output and fluid balance. C) Skin color and texture. D) Respiratory rate and effort. <\Body> Correct Answer: B) Urinary output and fluid balance. Rationale: Monitoring urinary output and fluid balance is crucial when a patient is on diuretic therapy to assess its effectiveness in reducing fluid volume. <\Explain> 53,4,0<\Number> B<\Answers> Question 53: A nurse is caring for a postoperative patient who underwent abdominal surgery. Which vital sign change should the nurse prioritize in monitoring during the immediate postoperative period? A) Blood pressure B) Respiratory rate C) Temperature D) Heart rate <\Body> Correct Answer: B) Respiratory rate Rationale: Respiratory rate is a critical vital sign to monitor after abdominal surgery because it can help detect complications like atelectasis or pneumonia, which are common in postoperative patients. <\Explain> 54,4,0<\Number> D<\Answers> Question 54: A patient with a history of hypertension presents to the emergency department with a blood pressure of 180/100 mm Hg. Which intervention should the nurse prioritize? A) Administering pain medication B) Initiating a fluid bolus C) Administering an antipyretic D) Monitoring cardiac rhythm <\Body> Correct Answer: D) Monitoring cardiac rhythm Rationale: High blood pressure can increase the risk of cardiac complications. The nurse should prioritize monitoring the cardiac rhythm to assess for any dysrhythmias or changes that may require immediate intervention. <\Explain> 55,4,0<\Number> D<\Answers> Question 55: A patient with suspected deep vein thrombosis (DVT) is scheduled for a venous Doppler ultrasound. What should the nurse instruct the patient to do before the procedure? A) Eat a full meal for energy B) Refrain from drinking water for 6 hours C) Continue taking prescribed anticoagulants D) Remove all jewelry from the affected leg <\Body> Correct Answer: D) Remove all jewelry from the affected leg Rationale: Jewelry can interfere with the ultrasound image quality. Instructing the patient to remove jewelry from the affected leg ensures accurate test results. <\Explain> 56,4,0<\Number> D<\Answers> Question 56: A patient is scheduled for a fasting blood glucose test in the morning. When should the nurse instruct the patient to stop eating and drinking before the test? A) 2 hours before the test B) 4 hours before the test C) At midnight the night before the test D) At least 8 hours before the test <\Body> Correct Answer: D) At least 8 hours before the test Rationale: Fasting blood glucose tests require the patient to abstain from eating and drinking for at least 8 hours to obtain accurate results. <\Explain> 57,4,0<\Number> C<\Answers> Question 57: A patient with a confirmed diagnosis of pulmonary embolism (PE) is receiving heparin therapy. What diagnostic test result is most critical for the nurse to monitor during treatment? A) Serum creatinine levels B) Prothrombin time (PT) C) Activated partial thromboplastin time (aPTT) D) Serum potassium levels <\Body> Correct Answer: C) Activated partial thromboplastin time (aPTT) Rationale: Heparin therapy is monitored by aPTT to ensure therapeutic anticoagulation while minimizing the risk of bleeding complications. <\Explain> 58,4,0<\Number> B<\Answers> Question 58: A patient with a suspected myocardial infarction (MI) is scheduled for a cardiac catheterization. What action should the nurse prioritize before the procedure? A) Administer an anticoagulant medication B) Ensure the patient is NPO (nothing by mouth) C) Provide an opioid analgesic for pain relief D) Administer a bronchodilator to improve oxygenation <\Body> Correct Answer: B) Ensure the patient is NPO (nothing by mouth) Rationale: Cardiac catheterization is typically performed on an empty stomach to reduce the risk of aspiration during the procedure. <\Explain> 59,4,0<\Number> D<\Answers> Question 59: When preparing to draw blood from a patient, the nurse should: A) Choose the largest needle available for a quicker draw. B) Use the tourniquet on the patient's upper arm to make veins more visible. C) Position the patient's arm at a 90-degree angle to the body. D) Cleanse the site with alcohol and allow it to air dry before inserting the needle. <\Body> Correct Answer: D) Cleanse the site with alcohol and allow it to air dry before inserting the needle. Rationale: Alcohol should be used to cleanse the site, and it should be allowed to air dry to prevent contamination of the blood sample. <\Explain> 60,4,0<\Number> A<\Answers> Question 60: The nurse is preparing to draw blood from an elderly patient with fragile veins. What should the nurse do to improve the chances of a successful blood draw? A) Apply a warm compress to the patient's arm before the procedure. B) Use a smaller gauge needle for a slower and gentler draw. C) Draw blood from the same vein as the previous blood draw to reduce trauma. D) Insert the needle at a 45-degree angle to the skin. <\Body> Correct Answer: A) Apply a warm compress to the patient's arm before the procedure. Rationale: Applying a warm compress can dilate the veins and make them more visible and accessible for the blood draw, especially in patients with fragile veins. <\Explain> 61,4,0<\Number> A<\Answers> Question 61: The nurse is reviewing the laboratory results for a patient with suspected dehydration. Which serum electrolyte value should the nurse expect to be elevated in this patient? A) Sodium (Na+) B) Potassium (K+) C) Calcium (Ca2+) D) Phosphorus (PO4-) <\Body> Correct Answer: A) Sodium (Na+) Rationale: Dehydration typically leads to an elevated serum sodium (hypernatremia) due to an imbalance of fluid and electrolytes. <\Explain> 62,4,0<\Number> A<\Answers> Question 62: A patient's complete blood count (CBC) reveals a hemoglobin level of 8 g/dL. What condition is most likely indicated by this result? A) Anemia B) Polycythemia C) Leukocytosis D) Thrombocytosis <\Body> Correct Answer: A) Anemia Rationale: A hemoglobin level below the normal range (usually 12-16 g/dL) indicates anemia, a condition characterized by a decrease in the oxygen-carrying capacity of the blood. <\Explain> 63,4,0<\Number> A<\Answers> Question 63: The nurse is assessing a patient's arterial blood gas (ABG) results. Which ABG value indicates respiratory alkalosis? A) pH 7.32 B) PaCO2 48 mm Hg C) HCO3- 26 mEq/L D) PaO2 85 mm Hg <\Body> Correct Answer: A) pH 7.32 Rationale: In respiratory alkalosis, the pH is elevated (gtr 7.45) with a low PaCO2 (lt 35 mm Hg). <\Explain> 64,4,0<\Number> B<\Answers> Question 64: A patient's white blood cell (WBC) count is 14,000/mm³. What does this result suggest? A) Normal WBC count B) Mild leukocytosis C) Severe leukopenia D) Elevated risk of bleeding <\Body> Correct Answer: B) Mild leukocytosis Rationale: A WBC count above the normal range (4,000-11,000/mm³) indicates leukocytosis, which can be a response to infection or inflammation. <\Explain> 65,4,0<\Number> B<\Answers> Question 65: A nurse is caring for a patient who is at risk for aspiration. What intervention should the nurse prioritize to monitor for aspiration? A) Administering an antacid after meals B) Keeping the head of the bed elevated at least 30 degrees C) Encouraging the patient to lie flat after meals D) Providing thickened liquids for all fluids <\Body> Correct Answer: B) Keeping the head of the bed elevated at least 30 degrees Rationale: Elevating the head of the bed helps prevent the risk of aspiration by reducing the chance of gastric contents flowing into the airway. <\Explain> 66,4,0<\Number> D<\Answers> Question 66: A patient with limited mobility is at risk for skin breakdown. What should the nurse do to effectively monitor the patient's skin? A) Change the patient's bedding every other day B) Apply moisturizing lotion to the skin daily C) Conduct a thorough skin assessment at least once a week D) Perform a daily skin assessment with a focus on pressure areas <\Body> Correct Answer: D) Perform a daily skin assessment with a focus on pressure areas Rationale: Regular, daily skin assessments with a focus on pressure areas are essential for early detection and prevention of skin breakdown in immobile patients. <\Explain> 67,4,0<\Number> C<\Answers> Question 67: A patient with diabetes mellitus has developed neuropathy. What complication risk should the nurse prioritize when caring for this patient? A) Hypertension B) Respiratory distress C) Foot ulcers and infections D) Renal failure <\Body> Correct Answer: C) Foot ulcers and infections Rationale: Neuropathy in diabetes can lead to decreased sensation in the feet, increasing the risk of foot ulcers and infections. Regular foot assessments and care are essential. <\Explain> 68,4,0<\Number> D<\Answers> Question 68: A postoperative patient has a nasogastric tube in place. What complication risk should the nurse monitor for in this patient? A) Skin breakdown B) Urinary retention C) Wound infection D) Aspiration pneumonia <\Body> Correct Answer: D) Aspiration pneumonia Rationale: Patients with nasogastric tubes are at risk for aspiration pneumonia if gastric contents reflux into the respiratory tract. Close monitoring for signs of aspiration is crucial. <\Explain> 69,4,0<\Number> B<\Answers> Question 69: A nurse is educating a postoperative patient about deep vein thrombosis (DVT) prevention. What instruction should the nurse provide to the patient? A) "Avoid moving your legs to prevent blood clot formation." B) "Perform ankle pumps and leg exercises regularly." C) "Skip your anticoagulant medications to reduce the risk of bleeding." D) "Apply a heating pad to your legs for increased circulation." <\Body> Correct Answer: B) "Perform ankle pumps and leg exercises regularly." Rationale: Ankle pumps and leg exercises help promote blood circulation and prevent DVT in postoperative patients. <\Explain> 70,4,0<\Number> C<\Answers> Question 70: A diabetic patient is being discharged from the hospital. What education should the nurse provide regarding foot care? A) "Avoid checking your feet daily to prevent skin breakdown." B) "Keep your feet elevated at all times to improve circulation." C) "Wash your feet with mild soap and lukewarm water, and dry them carefully." D) "Use heating pads to keep your feet warm during cold weather." <\Body> Correct Answer: C) "Wash your feet with mild soap and lukewarm water, and dry them carefully." Rationale: Proper foot hygiene, including washing with mild soap and thorough drying, is essential for preventing foot complications in diabetic patients. <\Explain> 71,4,0<\Number> A<\Answers> Question 71: A nurse is inserting a urinary catheter for a patient. What action should the nurse take to reduce the risk of catheter-associated urinary tract infection (CAUTI)? A) Use sterile technique during insertion and maintenance. B) Replace the catheter every 24 hours to prevent blockage. C) Secure the catheter to the patient's bedrail to prevent movement. D) Use soap and water to clean the catheter insertion site daily. <\Body> Correct Answer: A) Use sterile technique during insertion and maintenance. Rationale: Using sterile technique during catheter insertion and maintenance is essential to reduce the risk of CAUTI. <\Explain> 72,4,0<\Number> D<\Answers> Question 72: A patient has a nasogastric (NG) tube in place for enteral feeding. To minimize complications, what action should the nurse take? A) Irrigate the NG tube with tap water daily. B) Ensure that the NG tube is secured to the patient's bed. C) Keep the patient in a supine position at all times. D) Verify tube placement by measuring gastric pH before feeding. <\Body> Correct Answer: D) Verify tube placement by measuring gastric pH before feeding. Rationale: Verifying tube placement by measuring gastric pH helps ensure that the NG tube is correctly positioned in the stomach, reducing the risk of aspiration. <\Explain> 73,4,0<\Number> B<\Answers> Question 73: A nurse is monitoring a patient with a continuous cardiac monitor. The monitor displays ventricular fibrillation (VF). What is the nurse's immediate action? A) Administer epinephrine IV. B) Begin CPR and call for a defibrillator. C) Notify the healthcare provider. D) Increase the monitor sensitivity. <\Body> Correct Answer: B) Begin CPR and call for a defibrillator. Rationale: Ventricular fibrillation (VF) is a life-threatening cardiac arrhythmia. Immediate initiation of CPR and defibrillation is essential to restore normal rhythm. <\Explain> 74,4,0<\Number> A<\Answers> Question 74: A patient is on continuous oxygen therapy with a nasal cannula. What is the nurse's priority action to prevent complications associated with oxygen therapy? A) Monitor the patient's oxygen saturation continuously. B) Administer oxygen at the highest prescribed flow rate. C) Replace the nasal cannula with a face mask. D) Use cotton balls to secure the nasal cannula in place. <\Body> Correct Answer: A) Monitor the patient's oxygen saturation continuously. Rationale: Continuous monitoring of oxygen saturation helps ensure the patient receives the appropriate oxygen concentration while preventing complications like oxygen toxicity. <\Explain> 75,4,0<\Number> B<\Answers> Question 75: A nurse is caring for a postoperative patient. What is the nurse's priority intervention to prevent postoperative complications such as atelectasis and pneumonia? A) Administering opioids for pain relief as needed. B) Encouraging deep breathing and coughing exercises. C) Keeping the patient in a supine position at all times. D) Limiting fluid intake to avoid urinary retention. <\Body> Correct Answer: B) Encouraging deep breathing and coughing exercises. Rationale: Encouraging deep breathing and coughing exercises helps prevent atelectasis and pneumonia by maintaining lung function and clearing secretions. <\Explain> 76,4,0<\Number> A<\Answers> Question 76 A patient is at risk for pressure ulcers due to immobility. What intervention should the nurse prioritize to prevent skin breakdown? A) Frequent repositioning and pressure redistribution. B) Applying petroleum jelly to the skin daily. C) Limiting hydration to reduce urinary incontinence. D) Using donut-shaped cushions under pressure points. <\Body> Correct Answer: A) Frequent repositioning and pressure redistribution. Rationale: Frequent repositioning and pressure redistribution are essential strategies to prevent pressure ulcers in immobile patients. <\Explain> 77,4,0<\Number> C<\Answers> Question 77: A patient has just undergone abdominal surgery. What is the nurse's priority intervention to prevent postoperative complications? A) Administering pain medication as ordered. B) Allowing the patient to ambulate independently. C) Encouraging deep breathing and coughing exercises. D) Providing a high-fat diet to aid in wound healing. <\Body> Correct Answer: C) Encouraging deep breathing and coughing exercises. Rationale: Encouraging deep breathing and coughing exercises helps prevent atelectasis and pneumonia, common postoperative complications. <\Explain> 78,4,0<\Number> C<\Answers> Question 78: A patient has undergone orthopedic surgery and has a drain in place. What should the nurse do to prevent infection and promote wound healing around the drain site? A) Cleanse the site daily with hydrogen peroxide. B) Apply antibiotic ointment to the site routinely. C) Keep the area around the drain site dry and clean. D) Remove the drain as soon as possible. <\Body> Correct Answer: C) Keep the area around the drain site dry and clean. Rationale: Keeping the drain site clean and dry helps prevent infection and promotes wound healing. <\Explain> 79,4,0<\Number> B<\Answers> Question 79: A nurse is providing discharge education to a post-operative patient. Which statement by the patient indicates a need for further instruction? A) "I should continue taking my prescribed pain medication as needed." B) "I can remove the surgical dressing when I get home." C) "I will call my healthcare provider if I develop a fever." D) "I'll avoid heavy lifting for the next six weeks." <\Body> Correct Answer: B) "I can remove the surgical dressing when I get home." Rationale: The surgical dressing should not be removed by the patient unless instructed by the healthcare provider to do so. It is important for the nurse to clarify this to prevent infection. <\Explain> 80,4,0<\Number> C<\Answers> Question 80: A patient is recovering from abdominal surgery. What instruction should the nurse provide regarding wound care? A) "Change the dressing daily to keep the wound dry." B) "Keep the incision site exposed to air for better healing." C) "Wash the incision gently with soap and water during showers." D) "Apply hydrogen peroxide to the incision for cleaning." <\Body> Correct Answer: C) "Wash the incision gently with soap and water during showers." Rationale: Gently washing the incision with soap and water during showers helps keep the wound clean and reduces the risk of infection. <\Explain> 81,4,0<\Number> B<\Answers> Question 81: Which nursing intervention is essential when caring for a patient with a chest tube drainage system? A) Clamping the chest tube during ambulation B) Checking the drainage system for kinks or obstructions C) Keeping the drainage system above the level of the patient's chest D) Changing the drainage system collection container daily <\Body> Correct Answer: B. Checking the drainage system for kinks or obstructions. Rationale: Checking the drainage system for kinks or obstructions helps maintain proper drainage and prevents complications such as tension pneumothorax. Clamping the chest tube should never be done without a physician's order, and keeping the drainage system below the patient's chest level promotes proper drainage. Changing the collection container daily is not necessary unless it is full or contaminated. <\Explain> 82,4,0<\Number> C<\Answers> Question 82: When caring for a patient with a tracheostomy tube, the nurse should prioritize which action? A) Changing the tracheostomy tube cuff pressure daily B) Administering humidified oxygen via the tracheostomy tube C) Suctioning the tracheostomy tube as needed to maintain clear airways D) Cleaning the inner cannula with hydrogen peroxide twice a day <\Body> Correct Answer: C. Suctioning the tracheostomy tube as needed to maintain clear airways Rationale: Suctioning the tracheostomy tube as needed to maintain clear airways is a critical nursing intervention to prevent respiratory complications. Changing the tracheostomy tube cuff pressure daily is not necessary unless indicated by the physician. Administering humidified oxygen is important, but the primary focus should be on airway maintenance. Cleaning the inner cannula should be done with normal saline, not hydrogen peroxide, and frequency may vary depending on the patient's condition. <\Explain> 83,4,0<\Number> B<\Answers> Question 83: A patient with severe vomiting and diarrhea is at risk for which electrolyte imbalance? A) Hypercalcemia B) Hypokalemia C) Hyponatremia D) Hypernatremia <\Body> Correct Answer: B. Hypokalemia Rationale: Severe vomiting and diarrhea can lead to the loss of potassium, causing hypokalemia. Hypercalcemia, hyponatremia, and hypernatremia are not typically associated with excessive gastrointestinal fluid loss. <\Explain> 84,4,0<\Number> C<\Answers> Question 84: A patient with heart failure is prescribed a loop diuretic medication (e.g., furosemide). The nurse should closely monitor the patient for signs of which electrolyte imbalance? A) Hypernatremia B) Hyperkalemia C) Hypokalemia D) Hypocalcemia <\Body> Correct Answer: C. Hypokalemia Rationale: Loop diuretics can lead to potassium loss, increasing the risk of hypokalemia. Hypernatremia, hyperkalemia, and hypocalcemia are not the primary concerns when using loop diuretics. <\Explain> 85,4,0<\Number> A<\Answers> Question 85: A postoperative patient who had abdominal surgery is receiving patient-controlled analgesia (PCA) for pain management. The nurse should assess the patient for which potential complication related to PCA? A) Respiratory depression B) Hypertension C) Bradycardia D) Hyperglycemia <\Body> Correct Answer: A. Respiratory depression Rationale: The nurse should monitor the patient receiving PCA for respiratory depression, which can be a side effect of opioid pain medications. Hypertension, bradycardia, and hyperglycemia are not typically associated with PCA. <\Explain> 86,4,0<\Number> D<\Answers> Question 86: A patient with heart failure is prescribed a diuretic medication (e.g., furosemide) to manage fluid overload. What parameter should the nurse closely monitor when evaluating the effectiveness of the diuretic therapy? A) Blood pressure B) Hemoglobin level C) Serum electrolyte levels D) Urinary output <\Body> Correct Answer: D. Urinary output Rationale: The nurse should closely monitor urinary output when evaluating the effectiveness of diuretic therapy, as it reflects the reduction of fluid volume. While blood pressure, hemoglobin level, and serum electrolyte levels are important assessments, they may not directly indicate the diuretic's effectiveness in reducing fluid overload. <\Explain> 87,4,0<\Number> A<\Answers> Question 87: A nurse is caring for a patient with heart failure. Which assessment finding should the nurse prioritize when evaluating the patient's cardiovascular status? A) Blood pressure B) Body temperature C) Respiratory rate D) Skin color <\Body> Correct Answer: A. Blood pressure Rationale: When evaluating a patient with heart failure, monitoring blood pressure is essential as it helps assess the patient's cardiovascular status and the effectiveness of heart failure management. Changes in blood pressure can indicate worsening heart failure or the need for adjustments in medications or treatments. Body temperature, respiratory rate, and skin color are important assessments but are not as directly related to cardiovascular status. <\Explain> 88,4,0<\Number> B<\Answers> Question 88: A patient presents to the emergency department with chest pain. Which diagnostic test should the nurse anticipate being ordered to evaluate the patient's cardiovascular status? A) Complete blood count (CBC) B) Electrocardiogram (ECG) C) Urinalysis D) Lumbar puncture <\Body> Correct Answer: B. Electrocardiogram (ECG) Rationale: An electrocardiogram (ECG) is commonly ordered to assess a patient's cardiovascular status when chest pain is a concern. It helps identify cardiac abnormalities and diagnose conditions such as myocardial infarction. A complete blood count (CBC), urinalysis, and lumbar puncture are not primary tests for evaluating cardiovascular status in a patient with chest pain. <\Explain> 89,4,0<\Number> B<\Answers> Question 89: A nurse is caring for a patient with heart failure who is prescribed digoxin (Lanoxin). What is the nurse's priority assessment when managing the care of this patient? A) Blood pressure monitoring B) Serum potassium level C) Respiratory rate and oxygen saturation D) Neurological assessment <\Body> Correct Answer: B. Serum potassium level Rationale: When managing the care of a patient taking digoxin, it is essential to monitor the serum potassium level. Digoxin can cause toxicity, which is more likely in the presence of hypokalemia. While blood pressure, respiratory rate, oxygen saturation, and neurological assessment are important, assessing potassium levels is a critical priority. <\Explain> 90,4,0<\Number> A<\Answers> Question 90: A patient with atrial fibrillation is taking warfarin (Coumadin) to prevent blood clots. What instruction should the nurse provide to the patient when managing their care? A) Avoid foods high in vitamin K. B) Limit fluid intake to prevent bleeding. C) Discontinue warfarin if any signs of bleeding occur. D) Take an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) for pain relief. <\Body> Correct Answer: A. Avoid foods high in vitamin K. Rationale: When managing a patient taking warfarin, the nurse should instruct the patient to avoid foods high in vitamin K, as vitamin K can interfere with the anticoagulant effects of warfarin. Limiting fluid intake, discontinuing warfarin without medical guidance, and taking NSAIDs can have adverse effects and should be avoided. <\Explain> 91,4,0<\Number> B<\Answers> Question 91: A patient receiving intravenous (IV) antibiotics for a severe infection develops a sudden fever, chills, and difficulty breathing. What is the nurse's priority action? A) Administering an antipyretic medication B) Discontinuing the antibiotic infusion C) Increasing the IV fluid rate D) Administering a bronchodilator medication <\Body> Correct Answer: B. Discontinuing the antibiotic infusion Rationale: The patient's symptoms, including fever, chills, and difficulty breathing, may indicate an allergic or hypersensitivity reaction to the antibiotic. The priority action is to discontinue the antibiotic infusion to prevent further adverse reactions. Administering an antipyretic or bronchodilator is not the primary intervention in this situation. Increasing the IV fluid rate may be considered later but is not the immediate priority. <\Explain> 92,4,0<\Number> B<\Answers> Question 92: A patient with a history of heart disease is prescribed a new medication to lower cholesterol levels. After a few days of taking the medication, the patient reports muscle pain and weakness. What action should the nurse take? A) Encourage the patient to continue taking the medication as prescribed. B) Assess for signs of rhabdomyolysis and notify the healthcare provider. C) Advise the patient to take an over-the-counter pain reliever for muscle pain. D) Administer a higher dose of the cholesterol-lowering medication. <\Body> Correct Answer: B. Assess for signs of rhabdomyolysis and notify the healthcare provider. Rationale: Muscle pain and weakness can be signs of rhabdomyolysis, a serious adverse effect associated with some cholesterol-lowering medications. The nurse should assess for these signs and immediately notify the healthcare provider to determine whether the medication should be discontinued or adjusted. Encouraging continued medication use, advising over-the-counter pain relievers, or administering a higher dose without assessment could worsen the condition. <\Explain> 93,4,0<\Number> B<\Answers> Question 93: While caring for a patient experiencing an anaphylactic reaction to a medication, what is the nurse's immediate priority action? A) Administering an antipyretic medication B) Administering epinephrine (EpiPen) C) Documenting the patient's symptoms D) Offering emotional support to the patient <\Body> Correct Answer: B. Administering epinephrine (EpiPen) Rationale: Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms, including airway constriction and hypotension. The immediate priority in an anaphylactic reaction is to administer epinephrine (EpiPen) to reverse these effects and improve the patient's breathing and blood pressure. Administering an antipyretic, documenting symptoms, and offering emotional support are important but should follow the administration of epinephrine. <\Explain> 94,4,0<\Number> C<\Answers> Question 94: A nurse is caring for a patient who has just experienced a seizure. What should be the nurse's priority action immediately after the seizure activity stops? A) Administering antiseizure medication B) Restraining the patient to prevent further injury C) Assessing the patient's airway, breathing, and circulation (ABCs) D) Documenting the details of the seizure activity <\Body> Correct Answer: C. Assessing the patient's airway, breathing, and circulation (ABCs) Rationale: After a seizure, the nurse's immediate priority is to assess the patient's airway, breathing, and circulation (ABCs) to ensure the patient's safety and address any potential respiratory or cardiac issues. Administering antiseizure medication, restraining the patient, and documenting the seizure details are important but should follow the initial assessment of the patient's ABCs. <\Explain> 95,4,0<\Number> A<\Answers> Question 95: A patient with diabetes mellitus presents with polyuria, polydipsia, and unexplained weight loss. The nurse suspects which type of diabetes? A) Type 1 diabetes B) Type 2 diabetes C) Gestational diabetes D) Prediabetes <\Body> Correct Answer: A. Type 1 diabetes Rationale: The classic symptoms of polyuria, polydipsia, and unexplained weight loss are indicative of Type 1 diabetes, which results from autoimmune destruction of insulin-producing beta cells in the pancreas. <\Explain> 96,4,0<\Number> B<\Answers> Question 96: A patient with chronic obstructive pulmonary disease (COPD) experiences chronic bronchitis and emphysema. Which pathophysiological changes are most likely present in this patient? A) Inflammation of the bronchial tubes and airway constriction B) Destruction of alveolar walls and decreased lung elasticity C) Excessive mucus production and airway blockage D) Overproduction of surfactant and alveolar collapse <\Body> Correct Answer: B. Destruction of alveolar walls and decreased lung elasticity Rationale: Chronic bronchitis and emphysema are the two main forms of COPD. Emphysema is characterized by the destruction of alveolar walls and decreased lung elasticity, leading to impaired gas exchange and airflow limitation. <\Explain> 97,4,0<\Number> C<\Answers> Question 97: A patient with hypertension has been prescribed a beta-blocker medication. When evaluating the effectiveness of this treatment, what should the nurse prioritize assessing? A) Serum electrolyte levels B) Urine output C) Blood pressure and heart rate D) Liver function tests <\Body> Correct Answer: C. Blood pressure and heart rate Rationale: When evaluating the effectiveness of a beta-blocker medication for hypertension, the nurse should prioritize assessing blood pressure and heart rate. Beta-blockers are prescribed to lower blood pressure and heart rate, so monitoring these parameters helps determine if the treatment is achieving the desired goals. Serum electrolyte levels, urine output, and liver function tests are important but are not the primary indicators of beta-blocker effectiveness. <\Explain> 98,4,0<\Number> A<\Answers> Question 98: A patient with diabetes mellitus type 2 is prescribed metformin. What laboratory parameter should the nurse monitor to evaluate the patient's response to metformin therapy? A) Hemoglobin A1c (HbA1c) B) Serum potassium level C) Blood urea nitrogen (BUN) D) Serum albumin level <\Body> Correct Answer: A. Hemoglobin A1c (HbA1c) Rationale: To evaluate the response to metformin therapy in a patient with diabetes mellitus type 2, the nurse should monitor the hemoglobin A1c (HbA1c) level. HbA1c reflects long-term glucose control and provides information on the effectiveness of diabetes management. Monitoring serum potassium, BUN, and serum albumin levels is important for assessing other aspects of the patient's health but is not specific to metformin therapy. <\Explain> 99,4,0<\Number> B<\Answers> Question 99: A patient recovering from abdominal surgery is at risk for postoperative atelectasis. What nursing intervention should the nurse prioritize to prevent this complication? A) Administering IV antibiotics B) Encouraging deep breathing and coughing exercises C) Administering high-dose opioids for pain management D) Restricting fluid intake to minimize urine output <\Body> Correct Answer: B. Encouraging deep breathing and coughing exercises Rationale: To prevent postoperative atelectasis, the nurse should prioritize encouraging deep breathing and coughing exercises. These exercises help maintain lung expansion and prevent the collapse of alveoli, reducing the risk of atelectasis. Administering antibiotics may be necessary for surgical site infection prevention but does not directly address atelectasis. High-dose opioids can suppress respiratory function and increase the risk of atelectasis. Restricting fluid intake is not typically recommended, as hydration is important for postoperative recovery. <\Explain> 100,4,0<\Number> B<\Answers> Question 100: A patient who had a stroke is experiencing hemiparesis on the left side of the body. What intervention should the nurse include in the plan of care to promote recovery of the affected side? A) Encourage the patient to use the left hand exclusively B) Provide passive range-of-motion exercises for the left limbs C) Avoid any use of the left side to prevent injury D) Place the patient's food and belongings on the right side <\Body> Correct Answer: B. Provide passive range-of-motion exercises for the left limbs Rationale: To promote recovery of the affected side in a patient with hemiparesis after a stroke, the nurse should provide passive range-of-motion exercises for the left limbs. This helps prevent muscle contractures and maintain joint mobility. Encouraging the use of the left hand and placing items on the right side can be helpful, but passive range-of-motion exercises are essential for preventing complications associated with immobility. Avoiding any use of the left side is not recommended, as it can lead to further weakness and complications. <\Explain> 101,4,0<\Number> B<\Answers> Question 101: A nurse is educating a client with newly diagnosed type 2 diabetes about dietary management. Which dietary guideline should the nurse emphasize as a priority for glycemic control? A) Limiting carbohydrate intake to less than 10 grams per day B) Consuming a consistent amount of carbohydrates at each meal C) Avoiding all fruits and vegetables to prevent blood sugar spikes D) Increasing saturated fat intake for stable blood sugar levels <\Body> Correct Answer: B. Consuming a consistent amount of carbohydrates at each meal Rationale: The nurse should emphasize the importance of consuming a consistent amount of carbohydrates at each meal for glycemic control. Consistency in carbohydrate intake helps regulate blood sugar levels and prevents spikes or crashes. Severely limiting carbohydrates or avoiding fruits and vegetables is not recommended, as they provide essential nutrients. Increasing saturated fat intake is not advisable, as it may contribute to cardiovascular complications in clients with diabetes. <\Explain> 102,4,0<\Number> C<\Answers> Question 102: A nurse is educating a client with hypertension about lifestyle modifications. Which dietary recommendation should the nurse prioritize to help lower blood pressure? A) Increasing sodium intake to improve blood pressure regulation B) Consuming a high-caffeine diet to stimulate blood vessel dilation C) Reducing dietary sodium and increasing potassium-rich foods D) Limiting fluid intake to decrease blood volume <\Body> Correct Answer: C. Reducing dietary sodium and increasing potassium-rich foods Rationale: The nurse should prioritize recommending a dietary plan that includes reducing dietary sodium and increasing potassium-rich foods. This approach can help lower blood pressure by reducing fluid retention and promoting vasodilation. Increasing sodium intake, consuming a high-caffeine diet, and limiting fluid intake are not recommended for blood pressure management and can have adverse effects. <\Explain> <\Questions> <\Section> <\Tests> <\Source>