1.

Which women made significant contributions to the nursing care

of soldiers during the Civil War? Select all that apply.
1. Harriet Tubman
2. Florence Nightingale
3. Fabiola
4. Dorothea Dix
5. Sojourner Truth
2. Curricula for nursing education are strongly influenced by which
of the following? Select all that apply.
1. Physician groups
2. Professional nursing organizations
3. Individual state boards of nursing
4. Hospital administrators
5. The National Council of State Boards of Nursing
3. Which is an example of continuing education for nurses?
1. Attending the hospital’s orientation program
2. Completing a workshop on ethical aspects of nursing
3. Obtaining information about the facility’s new computer
charting system
4. Talking with a company representative about a new piece
of equipment
4. Health promotion is best represented by which activity?
1. Administering immunizations
2. Giving a bath
3. Preventing accidents in the home
4. Performing diagnostic procedures
5. Who were America’s first two trained nurses?
1. Barton and Wald
2. Dock and Sanger
3. Richards and Mahoney
4. Henderson and Breckinridge
6. A nurse with 2 to 3 years of experience who has the ability to
coordinate multiple complex nursing care demands is at which
stage of Benner’s stages of nursing expertise?
1. Advanced beginner
2. Competent
3. Proficient
4. Expert
7. Which professional organization developed a code for nursing
students?
1. ANA
2. NLN
3. AACN
4. NSNA
8. Which social force is most likely to significantly impact the future
supply and demand for nurses?
1. Aging
2. Economics
3. Science/technology
4. Telecommunications
9. A registered nurse is interested in functioning as a health care
advocate for individuals whose lives are affected by violence.
This nurse will be investigating which expanded career role?
1. Clinical nurse specialist
2. Forensic nurse
3. Nurse practitioner
4. Nurse educator
10. Fill in the blank:
Instead of debating academic requirements for RN preparation,
nursing is now focusing on academic __________ for nursing
students and graduates. PROGRESSION

1. Which of the following is the lowest level of “best evidence” for

evidence-based practice?
1. Clinical experiences
2. Opinions of experts
3. Client values and preferences
4. Trial and error
2. A quantitative research approach is most appropriate for which
study?
1. A study measuring the effects of sleep deprivation on wound
healing
2. A study examining the bereavement process in spouses of
clients with terminal cancer
3. A study exploring factors influencing weight control behavior
4. A study examining a client’s feelings before and after a bone
marrow aspiration
3. A qualitative research approach is most appropriate for which
study?
1. A study measuring nutrition and weight loss or gain in clients
with cancer
2. A study examining oxygen levels after endotracheal suctioning
3. A study examining client reactions to stress after open heart
surgery
4. A study measuring differences in blood pressure before,
during, and after a procedure
4. A key function of a study’s methodology is to
1. Determine the hypotheses that will be tested in the study.
2. Exercise control over contaminating factors in the study
environment.
3. Identify grants and other funding sources for conducting the
study.
4. Protect the rights of the study’s participants.
5. In the PICO format for phrasing research questions and
identifying key terms for a literature search, what does
the “P” stand for?
1. Patterns
2. Population
3. Probability
4. Purpose
6. Which of the following is a nursing responsibility when reading
published nursing research?
1. Assume that the research was properly conducted since it
has been published.
2. Evaluate whether the findings are applicable to the nurse’s
specific clients.
3. Implement the research findings if at least two studies have
shown the same results.
4. Request the raw data from the researchers so that the nurse
can analyze the statistics again.
7. A research critique can best be defined as a/an
1. Appraisal of a study’s strengths and weaknesses.
2. Conclusion about the utilization potential of a study’s findings.
3. Criticism of a study’s flaws.
4. Summary of a study’s key points.
8. An 85-year-old client in a nursing home tells a nurse, “Because
the doctor was so insistent, I signed the papers for that research
study. Also, I was afraid he would not continue taking care of
me.” Which client right is being violated?
1. Right not to be harmed
2. Right to full disclosure
3. Right to privacy and confidentiality
4. Right to self-determination
9. Place each of the following steps of evidence-based practice
change in their usual sequence. 3,2,1,5,4,6
1. _____ Locate the best evidence. 3
2. _____ Ask the clinical question. 2
3. _____ Assess the need for change. 1
4. _____ Integrate the change with client preferences. 5
5. _____ Analyze the evidence. 4
6. _____ Implement and evaluate the change. 6
10. A nurse proposes that the hospital apply the findings from a re
cent research study that shows that clients appreciate classical
orchestra music and playing it frequently lowers clients’ blood
pressure. Which aspect of research suggests that it may not be
appropriate to implement this as evidence-based practice?
1. All research is flawed.
2. The research would not have taken into consideration the
cost of acquiring and playing the music in a hospital.
3. One study would not be sufficient to show that all clients
would find orchestral music pleasing.
4. Research cannot demonstrate clients’ appreciation of music
since research is only appropriate for physiological problems

1. “A supposition or system of ideas that is proposed to explain a

given phenomenon” best defines which of the following?
1. A concept
2. A conceptual framework
3. A theory
4. A paradigm
2. “A group of related ideas or statements” best defines which of
the following?
1. A philosophy
2. A conceptual framework
3. A theory
4. A paradigm
3. “A set of shared understandings and assumptions about reality
and the world” is a definition for which of the following?
1. A concept
2. A conceptual framework
3. A practice discipline
4. A paradigm
4. Which provides the best explanation for describing nursing as a
practice discipline?
1. Nursing focuses on performing the professional role.
2. It takes time and experience to become a competent nurse.
3. Research and theory development is a central focus.
4. Nurses function as members of a team who form a practice
group.
5. Person, environment, health, and nursing constitute the
metaparadigm for nursing because they do which of the
following?
1. Provide a framework for implementing the nursing process.
2. Can be utilized in any setting when caring for a client.
3. Can be utilized to determine applicability of a research study.
4. Focus on the needs of a group of clients.
6. Which is an accurate statement about the role of nursing theory?
1. Practice theories assist nurses to reflect on the effectiveness
of what they do.
2. Midlevel theories, describing the interrelationships among
a broad range of concepts within nursing, have been well
tested through nursing research.
3. All schools of nursing in the United States are organized
around one of the conceptual models described in this
chapter.
4. Nursing theory guides the direction of research but not that
of education or practice.
7. The purpose of theory in science is to
1. Build a rationale for programs of research.
2. Explain why scientists do what they do.
3. Help scientists interpret phenomena.
4. Distinguish science from art.

1. A primary care provider’s orders indicate that a surgical consent

form needs to be signed. Because the nurse was not present
when the primary care provider discussed the surgical proce
dure, which statement best illustrates the nurse fulfilling the
client advocate role?
1. “The doctor has asked that you sign this consent form.”
2. “Do you have any questions about the procedure?”
3. “What were you told about the procedure you are going to
have?”
4. “Remember that you can change your mind and cancel the
procedure.”
2. Although the client refused the procedure, the nurse insisted and
inserted a nasogastric tube in the right nostril. The administrator
of the hospital decides to settle the lawsuit because the nurse is
most likely to be found guilty of which of the following?
1. An unintentional tort
2. Assault
3. Invasion of privacy
4. Battery
3. A nurse discovers that a primary care provider has prescribed
an unusually large dosage of a medication. Which is the most
appropriate action?
1. Administer the medication.
2. Notify the prescriber.
3. Call the pharmacist.
4. Refuse to administer the medication.
4. A primary care provider prescribes one tablet, but the nurse
accidently administers two. After notifying the primary care pro
vider, the nurse monitors the client carefully for untoward effects
of which there are none. Is the client likely to be successful in
suing the nurse for professional negligence?
1. No, the client was not harmed.
2. No, the nurse notified the primary care provider.
3. Yes, a breach of duty exists.
4. Yes, foreseeability is present.
5. A nursing student is employed and working as an unlicensed as
sistive personnel (UAP) on a busy surgical unit. The nurses know
that the UAP is enrolled in a nursing program and will be gradu
ating soon. A nurse asks the UAP if he has performed a urinary
catheterization on clients while in the nursing program. When the
UAP says “Yes,” the nurse asks him to help her out by doing a
urinary catheterization on a postsurgical client. What is the best
response by the UAP?
1. “Let me get permission from the client first.”
2. “Sure. Which client is it?”
3. “I can’t do it unless you supervise me.”
4. “I can’t do it. Is there something else I can help you with?”
6. The primary care provider wrote a do-not-resuscitate (DNR)
order. The nurse recognizes that which applies in the planning of
nursing care for this client?
1. The client may no longer make decisions regarding his or her
own health care.
2. The client and family know that the client will most likely die
within the next 48 hours.
3. The nurses will continue to implement all treatments focused
on comfort and symptom management.
4. A DNR order from a previous admission is valid for the
current admission.
7. The nurse’s partner/spouse undergoes exploratory surgery at
the hospital where the nurse is employed. Which practice is
most appropriate?
1. Because the nurse is an employee, access to the chart is
allowed.
2. The relationship with the client provides the nurse special
access to the chart.
3. Access to the chart requires a signed release form.
4. The nurse can ask the surgeon to discuss the outcome of
the surgery.
8. Following a motor vehicle crash, a nurse stops and offers
assistance. Which of the following actions is/are most
appropriate? Select all that apply.
1. The nurse needs to know the Good Samaritan Act for the state.
2. The nurse is not held liable unless there is gross negligence.
3. After assessing the situation, the nurse can leave to obtain help.
4. The nurse can expect compensation for helping.
5. The nurse offers to help but cannot insist on helping.
9. The nurse notices that a colleague’s behaviors have changed
during the past month. Which behaviors could indicate signs of
impairment? Select all that apply.
1. Is increasingly absent from the nursing unit during the shift.
2. Interacts well with others.
3. “Forgets” to sign out for administration of controlled
substances.
4. Offers to administer prn opioids for other nurses’ clients.
5. Is able to say “no” to requests to work more shifts.
10. Which nursing actions could result in professional negligence?
Select all that apply.
1. Learns about a new piece of equipment.
2. Forgets to complete the assessment of a client.
3. Does not follow up on client’s complaints.
4. Charts client’s drug allergies.
5. Questions primary care provider about an illegible order

1. When an ethical issue arises, one of the most important nursing

responsibilities in managing client care situations is which of the
following?
1. Be able to defend the morality of one’s own actions.
2. Remain neutral and detached when making ethical
decisions.
3. Ensure that a team is responsible for deciding ethical
questions.
4. Follow the client and family’s wishes exactly.
2. Which of the following situations is most clearly a violation of
the underlying principles associated with professional nursing
ethics?
1. A hospital’s policy permits use of internal fetal monitoring
during labor. However, there is literature to both support and
refute the value of this practice.
2. When asked about the purpose of a medication, a nurse
colleague responds, “Oh, I never look them up. I just give
what is prescribed.”
3. The nurses on the unit agree to sponsor a fund-raising
event to support a labor strike proposed by fellow nurses at
another facility.
4. A client reports that he didn’t quite tell the doctor the truth
when asked if he was following his therapeutic diet at home.
3. Following a motor vehicle crash, the parents of a child with
no apparent brain function refuse to permit withdrawal of life
support from the child. Although the nurse believes the child
should be allowed to die and organ donation considered, the
nurse supports their decision. Which moral principle provides
the basis for the nurse’s actions?
1. Respect for autonomy
2. Nonmaleficence
3. Beneficence
4. Justice
4. Which of the following statements would be most helpful when a
nurse is assisting clients in clarifying their values?
1. “That was not a good decision. Why did you think it
would work?”
2. “The most important thing is to follow the plan of care. Did
you follow all your doctor’s orders?”
3. “Some people might have made a different decision. What
led you to make your decision?”
4. “If you had asked me, I would have given you my opinion
about what to do. Now, how do you feel about your
choice?”
5. After recovering from her hip replacement, an older adult client
wants to go home. The family wants the client to go to a nursing
home. If the nurse were acting as a client advocate, the nurse
would perform which of the following actions?
1. Inform the family that the client has a right to decide on
her own.
2. Ask the primary care provider to discharge the client
to home.
3. Suggest the client hire a lawyer to protect her rights.
4. Help the client and family communicate their views to
each other.
6. Values, moral frameworks, and codes of ethics influence
the professional nurse’s moral decisions in which of the
following ways?
1. The nurse will provide direct client care that is consistent
with the nurse’s personal values.
2. The nurse will seek to ensure that the client’s values and the
nurse’s are the same.
3. The choice of moral framework determines what the client
outcome will be.
4. The nurse is bound to act according to the nurses’ code of
ethics even if the nurse’s values are different.

1. Which of the following is an example of a primary prevention

activity?
1. Antibiotic treatment of a suspected urinary tract infection
2. Occupational therapy to assist a client in adapting his or her
home environment following a stroke
3. Nutrition counseling for young adults with a strong family
history of high cholesterol
4. Removal of tonsils for a client with recurrent tonsillitis
2. Which of the following statements is true regarding types of
health care agencies?
1. Hospitals provide only acute, inpatient services.
2. Public health agencies are funded by governments to
investigate and provide health programs.
3. Surgery can only be performed inside a hospital setting.
4. Skilled nursing, extended care, and long-term care facilities
provide care for older adults whose insurance no longer
covers hospital stays.
3. In most cases, clients must have a primary care provider in
order to receive health insurance benefits. If a client is in need
of a primary care provider, it is most appropriate for the nurse to
recommend which of the following?
1. Family practice physician
2. Physical therapist
3. Case manager/discharge planner
4. Pharmacist
4. The most significant method for reducing the ongoing increase
in the cost of health care in the United States includes controlling
which of the following?
1. Number of children according to the family’s income
2. Numbers of uninsured and underinsured persons
3. Number of physicians and nurses nationwide
4. Competition among drug and medical equipment
manufacturers
5. A client is seeking to control health care costs for both
preventive and illness care. Although no system guarantees
exact out-of-pocket expenditures, the most prepaid and
predictable client contribution would be seen with
1. Medicare.
2. An individual fee-for-service insurance.
3. A preferred provider organization (PPO).
4. A health maintenance organization (HMO).

1. The ANA’s Health System Reform Agenda (2008) included which

of the following?
1. Primary health care should be based in acute care hospitals.
2. A minimum standard of health care for all persons should be
paid for completely with public funds.
3. Case management should be focused on clients with
enduring health care needs.
4. Essential services should be initiated simultaneously to avoid
gaps.
2. The Pew Commission competencies for future practitioners included
the need for providers to become skilled in which of the following?
1. Use of technology
2. Emphasizing practice in tertiary settings
3. Traditional clinical approaches
4. Making decisions for incompetent clients
3. Which of the following is characteristic of nursing care provided
in community-based health?
1. Clients are primarily those with identified illnesses.
2. Clients are individuals in groups according to their
geographic commonalities.
3. Care is paid for by the community as a whole rather than by
individuals.
4. All clients are case managed.
4. When performing collaborative health care, the nurse must
implement which of the following?
1. Assume a leadership role in directing the health care team.
2. Rely on the expertise of other health care team members.
3. Be physically present for the implementation of all aspects of
the care plan.
4. Delegate decision-making authority to each health care provider.
5. The nurse concludes that effective discharge planning (hospital
to home) has been conducted when the client states which of
the following?
1. “As soon as I get home, the nurse will come out, look at
where I live, and see what kind of care I will need.”
2. “All I need are my medications and a ride home. Then I’m all
ready for discharge.”
3. “When I visit my doctor in 10 days, they will show me how to
change my bandages.”
4. “I have the phone numbers of the home care nurse and the
therapist who will visit me at home tomorrow.”
6. A large disaster in a community resulted in the destruction of
many family homes and many individuals were injured. The as
sistance of community health nurses and home health nurses is
needed. The home health nurse is most likely to perform which
of the following?
1. Provide for a safe water supply.
2. Monitor for communicable diseases.
3. Establish communication and support systems.
4. Assess and treat individual clients.

1. Care in the home is an alternative to hospital placement.

Which of the following is one major difference associated with
in-home care?
1. Does not focus on curative and lifesaving approaches.
2. Is less able to manage complex symptoms.
3. Facilitates extensive involvement of significant others/family.
4. Permits use of pain medication regimens not allowed in the
hospital.
2. If a primary care provider prescribed the following, which could
be delegated to the home health aide?
1. Feeding and bathing the client
2. Teaching the client about medications
3. Assessing wound healing progress
4. Adjusting oxygen flow
3. After the nurse instructed a client about the rationale for sitting
with feet elevated to enhance venous return, the client refuses
to perform the activity. Which statement by the nurse would be
most useful?
1. “If you won’t cooperate, I can’t help you.”
2. “Tell me the reasons you won’t put your feet up.”
3. “It is essential that you do this.”
4. “I’ll notify your doctor that you are unable to keep your
feet up.”
4. A home health nurse is providing care for a client who has paral
ysis on one side and whose spouse provides most of the care.
Which of the following may be a sign of caregiver role strain?
1. The caregiver loses weight and has insomnia.
2. The caregiver asks other family and friends for help.
3. The caregiver asks the nurse what other ways he or she can
help the client.
4. The caregiver seems sad whenever the client’s prognosis is
discussed.
5. A client is scheduled to be discharged from the hospital. Which
should the discharge planner at the hospital acquire first before
home nursing care can be initiated?
1. Insurance coverage
2. An in-home caregiver
3. A curable health problem
4. A physician’s authorization
6. The nurse doing home health care recognizes that the practice
includes which of the following? Select all that apply.
1. Hospice care
2. Visiting clients who live in skilled nursing facilities
3. Care of both the client and the family
4. Absence of high-tech equipment and procedures
5. Care of clients who cannot afford to go to the doctor’s office
or clinic
6. Performing physical, psychosocial, and emotional
interventions
7. Which of the following indicates the client and family require
some added safety teaching or teaching?
1. Client wears a medical alert bracelet at all times.
2. A list of medications is posted on the refrigerator.
3. Area rugs have been removed.
4. Client puts on an emergency response necklace whenever
leaving home.

Chapter 9
1. In nursing administration, technology facilitates which activities?
Select all that apply.
1. Institutional compliance with accreditation health and safety
requirements
2. Tracking the most expensive client conditions
3. Determining which employees are doing the best job
4. Current budget expenditures
5. Client satisfaction with care
2. What is the challenge most associated with the utilization of an
electronic client record system?
1. Cost
2. Accuracy
3. Privacy
4. Durability
3. What is one disadvantage associated with electronic
(e.g., Internet-based) courses?
1. They take longer.
2. Interpersonal communication is not possible.
3. Everyone has to “log on” at the same time.
4. It is harder to establish a sense of community.
4. What is the primary advantage of using computers while
conducting nursing research?
1. Locating potential participants
2. Designing the steps of the research plan
3. Analyzing the quantitative data
4. Disseminating the research findings
5. A client insists that the practitioner use a treatment method
discovered on an Internet website. Which is the most
appropriate nursing response?
1. “The treatment must be examined to see if it is appropriate.”
2. “Most website treatments have not been studied or
researched.”
3. “The person establishing the website is the only one who
can use it on clients.”
4. “Websites are like advertising; they are biased and may not
be legitimate.”

1. A client with diarrhea also has a primary care provider’s order for
a bulk laxative daily. The nurse, not realizing that bulk laxatives
can help solidify certain types of diarrhea, concludes, “The pri
mary care provider does not know the client has diarrhea.” What
type of statement is this?
1. A fact
2. An inference
3. A judgment
4. An opinion
2. A client reports feeling hungry, but does not eat when food is
served. Using clinical reasoning skills, the nurse should perform
which of the following?
1. Assess why the client is not ingesting the food provided.
2. Continue to leave the food at the bedside until the client is
hungry enough to eat.
3. Notify the primary care provider that tube feeding may be
indicated soon.
4. Believe the client is not really hungry.
3. A client complains of shortness of breath. During assessment
the nurse observes that the client has edema of the left leg only.
The nurse reviews evidence-based practice literature and re
flects on a previous client with the same clinical manifestations.
What do these actions represent?
1. Clinical judgment
2. Clinical reasoning
3. Reflection
4. Intuition
4. The client who is short of breath benefits from the head of the
bed being elevated. Because this position can result in skin
breakdown in the sacral area, the nurse decides to study the
amount of sacral pressure occurring in other positions. What
decision making is the nurse engaging in?
1. The research method
2. The trial-and-error method
3. Intuition
4. The nursing process
5. In the clinical reasoning process, the nurse sets and weighs the
criteria, examines alternatives, and performs which of the follow
ing before implementing a plan?
1. Reexamines the purpose for making the decision.
2. Consults the client and family members to determine their
view of the criteria.
3. Identifies and considers various means for reaching the
outcomes.
4. Determines the logical course of action should intervening
problems arise.
6. The nurse is concerned about a client who begins to breathe
very rapidly. Which action by the nurse reflects clinical
reasoning?
1. Notify the primary care provider.
2. Obtain vital signs and oxygen saturation.
3. Request a chest x-ray.
4. Call the rapid response team.
7. The nurse is teaching a client about wound care during a follow
up visit in the client’s home. Which critical thinking attitude
causes the nurse to reconsider the plan and supports evidence
based practice when the client states, “I just don’t know how I
can afford these dressings”?
1. Integrity
2. Intellectual humility
3. Confidence
4. Independence
8. When the nurse considers that a client is from a developing
country and may have a positive tuberculosis test due to a prior
vaccination, which critical thinking attitude and skill is the nurse
practicing?
1. Creating environments that support critical thinking
2. Tolerating dissonance and ambiguity
3. Self-assessment
4. Seeking situations where good thinking is practiced
9. A client in a cardiac rehabilitation program says to the nurse,
“I have to eat a low-sodium diet for the rest of my life, and I
hate it!” Which is the most appropriate response by the nurse?
1. “I will get a dietary consult to talk to you before next week.”
2. “What do you think is so difficult about following a
low-sodium diet?”
3. “At least you survived a heart attack and are able to return
to work.”
4. “You may not need to follow a low-sodium diet for as long
as you think.”
10. Which reasoning process describes the nurse’s actions when
the nurse evaluates possible solutions for care of an infected
wound for optimal client outcomes?
1. Intuition
2. Research process
3. Trial and error
4. Problem solving

1. Which of the following behaviors is most representative of the

nursing diagnosis phase of the nursing process?
1. Identifying major problems or needs
2. Organizing data in the client’s family history
3. Establishing short-term and long-term goals
4. Administering an antibiotic
2. Which of the following behaviors would indicate that the nurse
was utilizing the assessment phase of the nursing process to
provide nursing care?
1. Proposes hypotheses.
2. Generates desired outcomes.
3. Reviews results of laboratory tests.
4. Documents care.
3. Which of the following elements is best categorized as secondary
subjective data?
1. The nurse measures a weight loss of 10 pounds since the
last clinic visit.
2. Spouse states the client has lost all appetite.
3. The nurse palpates edema in lower extremities.
4. Client states severe pain when walking up stairs.
4. The nurse wishes to determine the client’s feelings about a
recent diagnosis. Which interview question is most likely to elicit
this information?
1. “What did the doctor tell you about your diagnosis?”
2. “Are you worried about how the diagnosis will affect you in
the future?”
3. “Tell me about your reactions to the diagnosis.”
4. “How is your family responding to the diagnosis?”
5. The use of a conceptual or theoretical framework for collecting
and organizing assessment data ensures which of the following?
1. Correlation of the data with other members of the health
care team
2. Demonstration of cost-effective care
3. Utilization of creativity and intuition in creating a plan of care
4. Collection of all necessary information for a thorough
appraisal
6. Which of the following is the purpose of assessing?
1. Establish a database of client responses to his or her health
status.
2. Identify client strengths and problems.
3. Develop an individualized plan of care.
4. Implement care, prevent illness, and promote wellness.
7. In the validating activity of the assessing phase of the nursing
process, the nurse performs which of the following?
1. Collects subjective data.
2. Applies a framework to the collected data.
3. Confirms data are complete and accurate.
4. Records data in the client record.
8. A major characteristic of the nursing process is which of the
following?
1. A focus on client needs
2. Its static nature
3. An emphasis on physiology and illness
4. Its exclusive use by and with nurses
9. Which of the following would be true regarding use of the
observing method of data collection?
1. When observing, the nurse uses only the visual sense.
2. Observing is done only when no other nursing interventions
are being performed at the same time.
3. Data should be gathered as it occurs, rather than in any
particular order.
4. Observed data should be interpreted in relation to other
sources of collected data.
10. Which of the following represent effective planning of the
interview setting? Select all that apply.
1. Keep the lighting dimmed so as not to stress the
client’s eyes.
2. Ensure that no one can overhear the interview
conversation.
3. Stand near the client’s head while he or she is in the bed
or chair.
4. Keep approximately 3 feet from the client during the
interview.
5. Use a standard form to be sure all relevant data are
covered in the interview.

1. The nurse is conducting the diagnosing phase (nursing

diagnosis) of the nursing process for a client with a seizure
disorder. Which step exists between data analysis and
formulating the diagnostic statement?
1. Assess the client’s needs.
2. Delineate the client’s problems and strengths.
3. Determine which interventions are most likely to succeed.
4. Estimate the cost of several different approaches.
2. In the diagnostic statement “Excess Fluid Volume related to
decreased venous return as manifested by lower extremity
edema (swelling),” the etiology of the problem is which of the
following?
1. Excess fluid volume
2. Decreased venous return
3. Edema
4. Unknown
3. Which of the following nursing diagnoses contains the proper
components?
1. Risk for Caregiver Role Strain related to unpredictable illness
course
2. Risk for Falls related to tendency to collapse when having
difficulty breathing
3. Impaired Communication related to stroke
4. Sleep Deprivation secondary to fatigue and a noisy
environment
4. One of the primary advantages of using a three-part diagnostic
statement such as the problem–etiology–signs/symptoms (PES)
format includes which of the following?
1. Decreases the cost of health care.
2. Improves communication between nurse and client.
3. Helps the nurse focus on health and wellness elements.
4. Standardizes organization of client data.
5. A collaborative (multidisciplinary) problem is indicated instead of
a nursing or medical diagnosis
1. If both medical and nursing interventions are required to treat
the problem.
2. When independent nursing actions can be utilized to treat
the problem.
3. In cases where nursing interventions are the primary actions
required to treat the problem.
4. When no medical diagnosis (disease) can be determined.
6. In the case in which a client is vulnerable to developing a health
problem, the nurse chooses which type of nursing diagnosis
status?
1. A risk nursing diagnosis
2. A syndrome nursing diagnosis
3. A health promotion nursing diagnosis
4. An actual nursing diagnosis
7. Which of the following is true regarding the state of the science
in regards to nursing diagnosis?
1. The original taxonomy has proven to be adequate in scope.
2. The organizing framework of the taxonomy is based on the
work of Florence Nightingale.
3. More research is needed to validate and refine the diagnostic
labels.
4. New diagnostic labels are approved by means of a vote of
registered nurses.
8. Which of the following would indicate a significant cue when
comparing data to standards? Select all that apply.
1. The client has moved partway toward a set goal (e.g., weight
loss).
2. The client’s vision is within normal range only when wearing
glasses.
3. A child is able to control bladder and bowels at age 18
months.
4. A recently widowed woman states she is “unable to cry.”
5. A 16-year-old high school student reports spending 6 hours
doing homework five nights per week.

1. After being admitted directly to the surgery unit, a 75-year-old

client who had elective surgery to replace an arthritic hip was
discharged from the postanesthesia recovery unit. The
client has been on the orthopedic floor for several hours. Which
type of planning will be least useful during the first shift on the
orthopedic unit?
1. Initial
2. Ongoing
3. Discharge
4. Strategic
2. The client with a fractured pelvis requests that family members
be allowed to stay overnight in the hospital room. Before
determining whether or not this request can be honored, the
nurse should consult which of the following?
1. Hospital policies
2. Standardized care plans
3. Orthopedic protocols
4. Standards of care
3. The nurse assesses a postoperative client with an abdominal
wound and finds the client drowsy when not aroused. The cli
ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within
preoperative range, extremities are warm with good pulses but
skin is very dry. The client declines oral fluids due to nausea, and
reports no bowel movement in the past 2 days. Hip dressing
is dry with drains intact. Which element is most likely to be
considered of high priority for a change in the current care plan?
1. Pain
2. Nausea
3. Constipation
4. Potential for wound infection
4. The nurse selects the nursing diagnosis of Risk for Impaired
Skin Integrity related to immobility, dry skin, and surgical inci
sion. Which of the following represents a properly stated goal/
outcome? The client will
1. Turn in bed q2h.
2. Report the importance of applying lotion to skin daily.
3. Have intact skin during hospitalization.
4. Use a pressure-reducing mattress.
5. The care plan includes a nursing intervention “4/2/15 Measure
client’s fluid intake and output. F. Jenkins, RN.” What element of
a proper nursing intervention has been omitted?
1. Action verb
2. Content
3. Time
4. None
6. Place the following activities of planning in the correct order of
their use. 3,1,4,2
1. Establish goals/outcomes.
2. Write the care plan.
3. Set priorities.
4. Choose interventions.
7. The nurse recognizes which of the following as a benefit of using
a standardized care plan?
1. No individualization is needed.
2. The nurse chooses from a list of interventions.
3. They are much shorter than nurse-authored care plans.
4. They have been approved by accrediting agencies.
8. Which of the following is likely to occur if a goal statement is
poorly written?
1. There is no standard against which to compare outcomes.
2. The nursing diagnoses cannot be prioritized.
3. Only dependent nursing interventions can be used.
4. It is difficult to determine which nursing interventions can be
delegated.
9. When written properly, NOC outcomes and indicators
1. Do not require customization.
2. Address several nursing diagnoses.
3. Are broad statements of desired end points.
4. Reflect both the nurse’s and the client’s values.
10. Which of the following principles does the nurse use in selecting
interventions for the care plan?
1. Actions should address the etiology of the nursing diagnosis.
2. Always select independent interventions when possible.
3. There is one best intervention for each goal/outcome.
4. Interventions should be “doing,” not just “monitoring.”

1. When initiating the implementation phase of the nursing process,

the nurse performs which of the following phases first?
1. Carrying out nursing interventions
2. Determining the need for assistance
3. Reassessing the client
4. Documenting interventions
2. Under what circumstances is it considered acceptable practice
for the nurse to document a nursing activity before it is carried
out?
1. When the activity is routine (e.g., raising the bed rails)
2. When the activity occurs at regular intervals (e.g., turning the
client in bed)
3. When the activity is to be carried out immediately (e.g., a
stat medication)
4. It is never acceptable.
3. The primary purpose of the evaluation phase of the care
planning process is to determine whether
1. Desired outcomes have been met.
2. Nursing activities were carried out.
3. Nursing activities were effective.
4. Client’s condition has changed.
4. The client has a high-priority nursing diagnosis of Risk for
Impaired Skin Integrity related to the need for several weeks of
imposed bed rest. The nurse evaluates the client after 1 week
and finds the skin integrity is not impaired. When the care plan is
reviewed, the nurse should perform which of the following?
1. Delete the diagnosis since the problem has not occurred.
2. Keep the diagnosis since the risk factors are still present.
3. Modify the nursing diagnosis to Impaired Mobility.
4. Demote the nursing diagnosis to a lower priority.
5. If the nurse planned to evaluate the length of time clients must
wait for a nurse to respond to a client need reported over the
intercom system on each shift, which process does this reflect?
1. Structure evaluation
2. Process evaluation
3. Outcome evaluation
4. Audit
6. Which of the following is true regarding the relationship of
implementing to the other phases of the nursing process?
1. The findings from the assessing phase are reconfirmed in the
implementing phase.
2. After implementing, the nurse moves to the diagnosing
phase.
3. The nurse’s need for involvement of other health care team
members in implementing occurs during the planning phase.
4. Once all interventions have been completed, evaluating can
begin.
7. The care plan calls for administration of a medication plus
client education on diet and exercise for high blood pressure.
The nurse finds the blood pressure extremely elevated. The
client is very distressed with this finding. Which nursing skill of
implementing would be needed most?
1. Cognitive
2. Intellectual
3. Interpersonal
4. Psychomotor
8. Which of the following demonstrates appropriate use of
guidelines in implementing nursing interventions? Select
all that apply.
1. No interventions should be carried out without the nurse
having clear rationales.
2. Always follow the primary care provider’s orders exactly,
without variation.
3. Encourage all clients to be as dependent as desired and
allow the nurse to perform care for them.
4. When possible, give the client options in how interventions
will be implemented.
5. Each intervention should be accompanied by client
teaching.
9. Which of the following represents application of the
components of evaluating?
1. Goal achievement must be written as either completely met
or unmet.
2. Data related to expected outcomes must be collected.
3. If the outcome was achieved, conclude that the plan was
effective.
4. After determining that the outcome was not met, start over
with a new nursing care plan.
10. An element of quality improvement, rather than quality
assurance, is which of the following?
1. Focus is on individual outcomes.
2. Evaluates organizational structures.
3. Aims to confirm that quality exists.
4. Plans corrective actions for problems.

1. Which action by a nurse ensures confidentiality of a client’s com

puter record?
1. The nurse logs on to the client’s file and leaves the computer
to answer the client’s call light.
2. The nurse shares her computer password.
3. The nurse closes a client’s computer file and logs off.
4. The nurse leaves client computer worksheets at the com
puter workstation.
2. The case management model using critical pathways would be
appropriate for a client with which diagnosis?
1. Myocardial infarction (heart attack)
2. Diabetes, hypertension
3. Myocardial infarction, diabetes, hypertension
4. Diabetes, hypertension, an infected foot ulcer, senile
dementia
3. After making a documentation error, which action should the
nurse take?
1. Use correcting liquid to cover the mistake and make a new
entry.
2. Draw a line through it and write error above the entry.
3. Draw a line through it and write mistaken entry above it.
4. Draw a line through the mistake and write mistaken entry
with initials above it.
4. Which charting entry would be the most defensible in court?
1. Client fell out of bed
2. Client drunk on admission
3. Large bruise on left thigh
4. Notified Dr. Jones of BP of 90/40
5. The client’s VS are WNL. He has BRP and he receives his pain
pill PRN. His nutrition is DAT. Interpret the commonly used
abbreviations.
1. NKA: No known allergies
2. BRP: bathroom priviliges
3. PRN: as needed
4. DAT: diet as tolerated
6. During the first day a nurse is caring for a client who has been
in the hospital for 2 days, the nurse thinks that the client’s blood
pressure (BP) seems high. What is the next step?
1. Ask the client about past blood pressure ranges.
2. Review the graphic record on the client’s record.
3. Examine the medication record for antihypertensive
medications.
4. Review the progress notes included in the client’s record.
7. A student nurse observes the change-of-shift report. Which
behavior(s) by the reporting nurse represents effective nursing
practice? Select all that apply.
1. Provides the medical diagnosis or reason for admission.
2. States the time the client last received pain medication.
3. Speaks loudly when giving report.
4. States priorities of care that are due shortly after the report.
5. Reports on number of visitors for each client.
8. Which charting entries are written correctly? Select all that apply.
1. MS 5 gr given IV for c/o abdominal pain
2. Lanoxin 0.25 mg given orally per Dr. Smith’s stat order
3. KCl 15 mL given orally for K+ level of 2.9
4. Regular insulin 10.0 u given SQ for capillary blood glucose
of 180
5. Ambien 5 mg given orally at bedtime per request
9. A 74-year-old female is brought to the emergency department
c/o right hip pain. The right leg is shorter than the left and is
externally rotated. During inspection, the nurse observes what
appears to be cigarette burns on the client’s inner thighs. Which
of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs
bilaterally
2. Several burned areas on both of the client’s inner thighs
3. Multiple lesions on inner thighs possibly related to elder
abuse
4. Several lesions on inner thighs similar to cigarette burns
10. Which charting rule(s) will keep the nurse legally safe? Select all
that apply.
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
4. Record only information that pertains to the client’s health
problems.

Chapter 16
1. A nurse and a primary care provider inform a client that
chemotherapy is recommended for a diagnosis of cancer. Which
nursing action is most representative of the concept of holism?
1. Offer to come to the client’s home to provide needed
physical care.
2. Contact the client’s spiritual adviser.
3. Inquire how this will affect other aspects of the client’s life.
4. Provide the client with information about how to join a
support group.
2. A nurse is planning a workshop on health promotion for older
adults. Which topic will be included?
1. Prevention of falls
2. Cardiovascular risk factors
3. Adequate sleep
4. How to stop smoking
3. While hospitalized, a client is very worried about business
activities. The client spends a great deal of time on the phone
and with colleagues instead of resting. Which principle of need
therapy applies to this client?
1. His higher level need cannot be met unless the lower level
physiological need is met.
2. His lower level physiological needs are being deferred while
higher needs are addressed.
3. The higher need takes precedence and the lower need no
longer must be met.
4. It is necessary for someone else to meet his higher level
needs so he can focus on the lower level needs.
4. Which statement by the client best represents the contemplation
stage of the stages of behavior change?
1. “I currently do not need to exercise and do not intend to
start in the next six months.”
2. “I have tried several times to exercise 30 minutes three times
a week but am seriously thinking of trying again in the next
month.”
3. “I currently do not exercise 30 minutes three times a week,
but I am thinking about starting to do so within the next
six months.”
4. “I have exercised 30 minutes three times a week regularly for
more than six months.”
5. A client who is 46 pounds overweight tells you, “I was just
born to be fat. I don’t have the willpower.” Although weight
loss occurred while attending two previous programs that
“guaranteed” weight loss, the weight returned along with extra
pounds after each program. According to the Health Promotion
Model, the nurse is most likely to focus on which behavior
specific cognition and affect variable for this client?
1. Perceived barriers to action
2. Perceived self-efficacy
3. Interpersonal influences
4. Situational influences
6. Which of the following are overarching goals of Healthy People
2020? Select all that apply.
1. Raise the education and literacy level.
2. Increase quality and years of healthy life.
3. Eliminate health disparities.
4. Distribute health-related information.
5. Promote healthy behaviors.
7. The nurse who is assisting a client in the action stage of change
would use which strategy?
1. Reinforce the importance of providing rewards for positive
behavior.
2. Ask the client if he or she would like information.
3. Guide the client to create a plan of action.
4. Remind the client of previous successes.
8. Which is the best response by the nurse if a client fails to follow
the information or teaching provided?
1. Give up, because the client doesn’t want to change.
2. Develop a tough approach.
3. Reteach the information, because the nurse is the expert.
4. Reassess the client’s importance given to the behavior and
readiness to change it.
9. A client is admitted for heart failure. The nurse assesses that
the client’s blood pressure is below normal range and the api
cal pulse is 110 beats/min. The nurse knows that the increase
in the client’s pulse illustrates which aspect of the client’s ho
meostatic mechanism?
1. Compensation
2. Decompensation
3. Self-regulation
4. Equilibrium
10. Using Maslow’s framework, which statement characterizes the
highest level of need?
1. “Nurse, my pain is severe . . . is it time for my shot?”
2. “I felt welcomed when I first joined the group and I look
forward to the monthly meetings.”
3. “I’m very proud of receiving the Employee of the Month
award.”
4. “There have been home break-ins with burglary in our
neighborhood. We are thinking of moving.”

1. Which one of the following is an example of the emotional

component of wellness?
1. The client chooses healthy foods.
2. A new father decides to take parenting classes.
3. A client expresses frustration with her partner’s substance
abuse.
4. A widow with no family decides to join a bowling league.
2. Which individual appears to have “taken on” the sick role?
1. A client who is obese states, “I deserve to have a heart
attack.”
2. A mother is ill and says, “I won’t be able to make your lunch
today.”
3. A man with low back pain misses several physical therapy
appointments.
4. An older adult states, “My horoscope says I will be well
again.”
3. Because a client recently diagnosed with diabetes mellitus is
confident that blood sugar control can be improved with diet
and exercise alone, and recently checked out a video on the
management of diabetes at the HMO education center, the
client’s actions are most representative of which model?
1. Health belief model
2. Clinical model
3. Role performance model
4. Agent–host–environment model
4. Because a client with human immunodeficiency virus (HIV)
is scheduled to begin several medications to manage the
infection, the nurse will need to provide client education. Which
client characteristics are most likely to predict adherence with
the treatment program? Select all that apply.
1. Educational level
2. A trusting relationship with the health care provider
3. An expectation that the medications will be helpful
4. Being able to take the medications twice daily instead of
four times daily
5. Sex
5. Which one of the following might be the BEST way to measure
adherence to a prescribed medication regime?
1. Direct observation of medication administration
2. Evidence of illness complications or exacerbations
3. Monitoring laboratory values of elements influenced by the
medication
4. Questioning the client about his or her medication routine
6. Which of the following is least likely to influence a client’s
personal definition of health/wellness?
1. The client’s ability to perform his or her usual activities
2. The cultural traditions the client uses in everyday life
3. The availability and accessibility of health care services
appropriate for the client’s health condition
4. The medical diagnostic terminology used to describe the
client’s signs and symptoms
7. Which of the following is an internal variable affecting health
status, beliefs, or practices?
1. Living situation
2. Socioeconomic status
3. Family structure
4. Genetics
8. A client recently diagnosed with a chronic illness asks for help
in understanding the term chronic. It would be correct for the
nurse to say which of the following?
1. Symptoms are always less severe than with an acute illness.
2. Chronic illnesses are considered incurable.
3. Signs and symptoms of chronic illnesses tend to be stable
for many years.
4. Chronic illnesses have no effective treatments.
9. Although not every client progresses in order through each stage,
what is the usual sequence in Suchman’s stages of illness? 3, 5, 1, 4, 2
1. The client makes contact with medical care.
2. The client goes into rehabilitation/recovery.
3. Signs and symptoms appear.
4. The client takes on the dependent role.
5. The client takes on the sick role.
10. A married mother of three small children has frequent immobi
lizing headaches of unknown cause. The nurse anticipates that
the woman may have which of the following possible
reactions? Select all that apply.
1. She feels guilty when unable to perform her usual activities.
2. She is angry and acting out.
3. She shifts some responsibilities to the spouse.
4. She takes on a job to help pay for the medical expenses.
5. She has fewer social interactions with her friends.

1. The major factor contributing to the increased emphasis on the

need for proficiency in cultural nursing practice in the United
States is which of the following?
1. An increasing birth rate
2. Increased access to health care services
3. Demographic changes
4. A decreasing rate of immigration
2. Which behavior is an initial step in culturally responsive nursing
practice?
1. Help the client recognize the need to adapt health practices
to fit commonly accepted practices.
2. Discuss the meaning of the medical regimen with the client.
3. Inform the client that lack of adherence to the medical
regimen may be detrimental.
4. Ask a cultural broker to explain the relevance of the
intervention.
3. In initiating care for a client from a different culture than the nurse,
which of the following would be an appropriate statement?
1. “Since, in your culture, people don’t drink ice water, I will
bring you hot tea.”
2. “Do you have any books I could read about people of your
culture?”
3. “Please let me know if I do anything that is not acceptable in
your culture.”
4. “You will need to set aside your usual customs and practices
while you are in the hospital.”
4. Which behavior is most representative of a culturally competent
nurse?
1. Helps clients of Native American heritage identify ways to
relate more to their culture.
2. Helps parents of Latino heritage recognize that their children
need to speak English.
3. Interprets and validates beliefs of a client with African
American heritage.
4. Asks a nurse of Japanese heritage to teach others dosage
calculations since Asians are good at math.
5. An outcome of achieving national cultural health goals would be
which of the following?
1. All cultures receive the same health care.
2. All people have the same life expectancy.
3. All U.S. residents have access to the same quality of health
care.
4. All cultures are fully assimilated into the dominant society.
6. Which nursing action primarily supports restoring HEALTH using
traditional methods?
1. Herbal teas
2. Prayer
3. Wearing symbolic objects
4. Exercise
7. A client with strong preferences for folk healing methods would
prefer which of the following to treat a sinus infection?
1. Hospitalization
2. Steam humidifier
3. Antibiotic therapy
4. “Watch and wait”
8. Which of the following factors are most likely to be influenced
by culture as opposed to personal characteristics? Select all
that apply.
1. Value of older people in society
2. Gender roles
3. Nonverbal gestures
4. Skill with technology
5. Intelligence
6. Diet
9. What is the most productive method of gathering assessment
data regarding heritage?
1. Physical exam
2. Medical history
3. Blood analysis
4. Traditional beliefs and practices checklist
10. A client who speaks limited English requires instructions for
a test. No one at your agency speaks the person’s language.
What is the nurse’s best approach?
1. Provide the instructions in writing.
2. Locate a professional interpreter.
3. Ask a family member to translate on the phone.
4. Document that the required instruction is not possible.

1. A client asks the nurse the differences between traditional thera

pies and alternative therapies. What is the best response?
1. Alternative therapies cost less than traditional therapies.
2. Alternative therapies are used if traditional therapies are
ineffective.
3. Alternative therapies can be as effective as traditional
therapies for some conditions.
4. Alternative therapies utilize products from nature but
traditional therapies do not.
2. Before meeting with a client with a terminal illness, a new
graduate nurse reviews information on spirituality. Which is the
best explanation of spirituality?
1. That which gives people purpose and meaning in their lives
2. A formalized religious dogma
3. A nondenominational community service
4. People being responsible for their life patterns
3. Which nursing action is most likely to create a healing
environment?
1. Use technology to prevent health care–associated infections.
2. Empower clients to make healthy decisions for themselves.
3. Assist clients to obtain a safe and comfortable place to live.
4. Ensure that primary care providers’ orders are carried out.
4. A client asks the nurse to state one of the primary principles
associated with naturopathy. Which of the following is the best
response?
1. A higher being guides the learning needed to treat disease.
2. It focuses on environmental causes when treating illnesses.
3. It focuses on early detection and treatment of disease.
4. It is a way of life to maintain health and prevent disease.
5. From the perspective of traditional Chinese medicine, which is
the best definition of disease?
1. Imbalance or disruption in food digestion
2. Imbalance or interruption in the flow of qi
3. Imbalance or disruption in key social relationships
4. Imbalance or disruption in thoughts or emotions
6. A client asks how herbs are similar to prescribed medications.
What is the nurse’s best answer?
1. “They are nothing alike. You should ask your doctor these
types of questions.”
2. “Thirty percent of current prescription drugs are derived from
plants.”
3. “Medications are much more effective than herbs.”
4. “Herbs are more dangerous than prescribed medications.”
7. What is a rationale for assessment of clients’ use of herbs?
1. There are potential adverse interactions between some
herbs and some medications.
2. Clients should not take anything that is not prescribed by
the primary care provider.
3. These data will contribute to the body of knowledge on the
use of herbs.
4. It is important to establish a pattern that clients tell nurses
everything.
8. Which oils may be placed directly on the skin?
1. Rose and orange
2. Green apple and jasmine
3. Clary sage and rosemary
4. Lavender and tea tree
9. What are the effects of massage as a manual healing method?
Select all that apply.
1. Communication and caring
2. Mental and physical relaxation
3. Increased muscle strength
4. Speeds the removal of waste products
5. Lowers blood pressure and heart rate
10. Your friend is considering in vitro fertilization in hopes of be
coming pregnant. Which one of the following is an accurate
statement?
1. “There is some evidence that acupuncture improves the
chance of pregnancy in this situation.”
2. “Massage therapy may increase your sense of relaxation,
which may help in getting pregnant.”
3. “Ask your doctor about which herbs will increase the
likelihood of pregnancy.”
4. “Research suggests that yoga improves the chance of
pregnancy in this situation.”

1. The parents of a 5-month-old infant and a 3-year-old child ask

the nurse about the sequence and timing of developmental
milestones for the infant. Which is the most appropriate
response?
1. “This infant should reach the milestones at the same time as
your older child.”
2. “The infant may reach the milestones in a different order than
your older child.”
3. “The sequence of reaching each milestone should follow the
same pattern but may be at a different rate.”
4. “There are no predictable patterns. Try to enjoy the
uniqueness of each child.”
2. The nurse knows that the study of growth and development is
an exploration of which of the following?
1. Physical changes of the growing child
2. Increasing complexity of function and skill progression of the
growing child
3. Environmental factors such as family, religion, and culture of
the growing child
4. Physical developments and the increasing level and
progression of function and skill of the growing child
3. The nurse examines a 2-year-old child recently hospitalized
with pneumonia. Which pattern of behavior is most likely to be
exhibited by the child?
1. Lies quietly while the nurse listens to the lungs
2. Asks many questions about what the nurse is doing and
hearing
3. Fusses, cries, and pushes the nurse away during
assessment of the breath sounds
4. Enjoys playing “nurse” with the stethoscope, and listens
to self and others’ breath sounds
4. A 14-year-old is scheduled to have surgical repair of a spinal
curvature (scoliosis). The adolescent will be hospitalized for
about 2 weeks. Which nursing intervention will be most helpful
during the hospital stay?
1. Have peers visit frequently during the day.
2. Instruct parents to room-in with her.
3. Encourage her to go to the recreation room.
4. Encourage her to arrange for her teachers to provide her
with homework.
5. A 65-year-old man who recently retired from 40 years of work
as an independent contractor is scheduled for a physical
examination. The nurse should be concerned about which
comment?
1. “My wife and I are planning to drive to Nebraska in June
to visit our grandkids.”
2. “Every day, when I wake up, it’s hard to find a reason to get
out of bed.”
3. “I often take ibuprofen for the pain in my knees.”
4. “People still call me for advice on building projects. I may
never get to retire!”
6. An 11-year-old child is scheduled for a yearly physical
examination. The accompanying parent expresses concern
because the child “seems all wrapped up in the soccer
teammates and other peers, leaving very little time for the
family.” Using Havighurst’s developmental tasks, what would be
the nurse’s best response?
1. “This is somewhat unusual. Are there problems that we
need to discuss?”
2. “Although this is normal for 11-year-olds, this transition can
be difficult for families.”
3. “Become involved in her life and insist that she set aside
time for the family.”
4. “This is normal development. You need to let her grow up.”
7. A nurse decides that a review of which theorist would be help
ful before teaching 4- and 5-year olds in a preschool class how
to brush their teeth?
1. Fowler
2. Erikson
3. Gould
4. Peck
8. A 5-year-old boy arrives for the preadmission work-up for a
surgical procedure. When the nurse brings in the intravenous
(IV) control pump the child states: “It’s going to bite me
because I have been bad.” Using knowledge of Piaget,
Erikson, and Fowler, which is the best nursing action?
1. Reassure him by providing opportunities to touch and
explore the machine, as well as explaining how it works.
2. Understand that his imagination is out of control. Tell him
that his fears are unfounded and that he needs to be a
“big boy.”
3. Recognize that he is too young to understand and that he
needs to be quickly distracted.
4. Acknowledge his need for fantasy by reassuring him that if
he is a “good boy” the bad machine will not bite him.
9. A 15-month-old is admitted to the hospital for hernia surgery.
When his mother leaves him, he cries inconsolably. Using
knowledge of attachment theory and cognitive theory, which is
the best nursing action?
1. Encourage his mother to stay with him as much as possible.
2. Put a picture of his mother in his crib to remind him that
she will return soon.
3. Hold and cuddle him as much as possible.
4. Distract him with toys and music.
10. Which behavior is of most concern to the nurse caring for a
25-year-old client after surgery for an appendectomy?
1. The client states: “It will be good to get back on my bike.
I miss the exercise.”
2. The client states: “I have no problem living at my parents’
house. They have lots of room and money and it’s a very
comfortable and easy lifestyle for me.”
3. The client gets out of bed and walks to the bathroom with
assistance.
4. Several age-mate friends visit while the client is
hospitalized.

Chapter 21
1. The parent of an 8-month-old girl who has been admitted to
the hospital with pneumonia is worried about the infant having
sudden infant death syndrome (SIDS). The parent stated that
“My sister’s baby died at the age of 2 months and all he had was
a little cold.” Which is the nurse’s best response?
1. “You don’t need to worry. Your daughter is too old for SIDS.”
2. “Girls are less likely to have SIDS than boys are.”
3. “We don’t know what causes SIDS, so I would try not to
worry about it.”
4. “You must be very anxious; let’s talk about SIDS and what
you are thinking.”
2. Four-year-old Angie, whose grandmother recently died, tells
the nurse, “My grandma has wings just like angels. She flew to
heaven yesterday and tomorrow she’ll be back.” Which is the
nurse’s best response?
1. “She’s not coming back, honey.”
2. “It is normal for a little one to make believe.”
3. “You must miss your grandma a lot.”
4. “When people get old they die.”
3. Because near-drowning is one of the leading causes of vegeta
tive state in young children, which is the best instruction for the
nurse to teach parents?
1. Supervise children at all times when near any source of
water.
2. Enroll children in swimming classes at an early age to ensure
water safety.
3. Make bathroom doors and toilets easily accessible and
appropriate for a toddler’s size.
4. Allow unsupervised play only in “kiddy pools” designated for
young children.
4. Which statement most accurately describes physical
development during the school-age years?
1. Child’s weight almost triples.
2. Child acquires stereognosis.
3. Few physical changes occur during middle childhood.
4. Fat gradually increases, which contributes to the child’s
heavier appearance.
5. Females experience an increase in weight and fat deposition
during puberty. Which nursing action is most appropriate to this
age group?
1. Give reassurance that these changes are normal.
2. Suggest dietary measures to control weight gain.
3. Recommend increased exercise to control weight gain.
4. Encourage low-fat diet to prevent fat deposition.
6. A night shift nurse notices that a postpartum (after delivery of a
baby) client is crying and rubbing her baby’s head. The mother
states, “Look how lopsided my little Sam’s head is. It is all
my fault. My mom told me that I should have laid down more
instead of sitting. Now, Sam’s head is all smashed and funny
looking.” Which is the best response by the nurse?
1. “Do you mean to tell me that your mother told you that?
Are you serious?”
2. “The head is soft and changed shape as it moved through
the birth canal.”
3. “I will provide you with materials to read that will clear that up
for you.”
4. “There is no need to cry. His head will return to normal in a
few days.”
7. During a physical examination a 24-month-old child clings to
the parent and cries every time the nurse attempts to touch her.
From knowledge of psychosocial development, the nurse makes
which conclusion about the child?
1. The child is displaying normal toddler development.
2. The child needs further psychological evaluation.
3. The child is manipulative and should be taken from the
parent to be examined.
4. The child is showing signs of regression
8. After falling off playground equipment, a 5-year-old is brought
to the emergency department with a broken arm. The parents
ask for ways to keep her occupied while wearing the cast.
Which is the best response by the nurse?
1. “You will need to talk to the primary care provider about
this.”
2. “Let her watch television or do puzzles and other quiet
games.”
3. “Activities that do not involve the use of the arm or risk
damage to the cast are okay.”
4. “She can ride a bike, jump rope, or play with friends if you
watch her closely.”
9. According to Piaget’s theory of cognitive development, the
movement from intuitive reasoning to logical reasoning in
school-age children is called the concrete operations phase.
Which is an example of this phase?
1. A science-fair project comparing how fast different objects
fall from a set height
2. Feeling responsible for wishing that a sibling would go
away, and now that sibling is ill and hospitalized
3. Understanding how geometric figures might fit into a
futuristic and idealistic world
4. Learning to ride a bike
10. Parents ask the nurse how they will know that their daughter
has reached puberty. Which is the best response by the nurse?
1. “The first noticeable sign of puberty in females is
appearance of the breast bud.”
2. “The growth spurt usually begins between ages 10 and 14.”
3. “The apocrine glands, found over most of the body, begin
to produce sweat.”
4. “The adolescent will display significant mood swings.”

1. Because a 45-year-old woman is worried that she still has

regular menstrual periods, she asks about menopause. Which
answer by the nurse is most appropriate?
1. “Regular menses in a 45-year-old woman should be
promptly evaluated by a gynecologist.”
2. “Although you continue to have menstrual periods, you are
unlikely to become pregnant.”
3. “It is common for women to experience menopause in their
late 40s.”
4. “Many women dread menopause because it is an
unpleasant experience.”
2. A nurse is planning a teaching session on a wellness topic.
Which adult generation group would be most likely to be
skeptical about health teaching by the nurse?
1. Baby boomer
2. Generation X
3. Generation Y
4. Millennial
3. A woman is seen at her primary care provider’s office. She has
been losing weight and not feeling well. She is 44 years old.
What is the leading cancer death in female clients between the
ages of 25 and 64?
1. Breast cancer
2. Lymphoma
3. Lung cancer
4. Colon cancer
4. The nurse is planning an educational program on sexually
transmitted infections (STIs) for young adults. Which topic
should be given priority?
1. Syphilis
2. HIV
3. Gonorrhea
4. Chlamydia
5. Which statement about moral development in adults is the most
correct?
1. Moral development is completed during adolescence.
2. Moral development continues throughout adulthood.
3. Moral development is highly individualized.
4. Moral development correlates to spiritual development.
6. If the nurse were assessing the status of a middle-aged client’s
psychosocial development, which activity should be the focus?
1. Selecting a life partner
2. Balancing the needs of others
3. Reviewing one’s life course
4. Establishing a sense of self
7. The nurse is developing a health promotion teaching plan for
a community group of middle-aged adults. Information about
which immunizations should be included?
1. Pneumococcal, meningococcal
2. Pertussis, influenza, meningococcal
3. Influenza, pneumococcal
4. Meningococcal, pertussis
8. When planning a screening program for cardiovascular
disease in the middle-aged adult, the nurse has limited funds
and decides to address which significant elements? Select all
that apply.
1. Blood pressure measurement
2. Electrocardiogram
3. Cholesterol measurement
4. Sexual performance
5. Activity level
9. A woman comes into the emergency department with multiple
bruises about the face and head. The nurse suspects that IPV
may be related to the injuries. What is the most appropriate
action for the nurse to take at this time?
1. Ask the person if she is afraid of someone at home who is
hurting her.
2. Refer the person to a shelter for battered women.
3. Call a social worker to assess the person for IPV.
4. Document the concern in the chart, but do nothing else.
10. The nurse is completing a health history on a 24-year-old male.
Which activity is the best indicator of appropriate psychosocial
development?
1. Creating a scrapbook of his life experiences
2. Joining the board of directors for three chari

1. The nurse provides care for an older adult whose husband died
8 months ago. Which of the following behaviors indicates that
the client is experiencing effective coping? Select all that apply.
1. Shows the nurse photographs of her family.
2. Refuses to keep her beauty appointments.
3. Visits her husband’s grave every 2 weeks.
4. Attends church on a regular basis.
5. Increases her consumption of alcohol.
2. A nurse in a long-term care facility is caring for several older
adults with noticeable hearing losses. Which is the best way for
the nurse to communicate with these clients?
1. Speak slowly using the proper volume and as few words as
possible.
2. Write the information using large lettering.
3. Speak in a low and distinct voice tone.
4. Have the client increase the volume in the hearing aid.
3. The nurse observes that an 85-year-old man at an adult day
care center fondly shares stories about traveling on the “orphan
trains” and his subsequent adoption. Following a behavioral
assessment, the nurse should perform which interventions?
1. Refer him for a geriatric psychiatric evaluation.
2. Listen and ask him questions about his life.
3. Distract him and change the conversation.
4. Involve him in more social activities.
4. The home health nurse evaluates an older adult for depression.
The client’s daughter is present and comments, “I don’t see
the need for this evaluation. Aren’t all older people depressed?”
Which is the nurse’s best initial response?
1. “How many losses has your mother had?”
2. “Your mother looks so depressed.”
3. “How long has she been depressed?”
4. “Depression is not a normal part of aging.”
5. While being admitted to a rehabilitation unit, an 82-year-old
woman mentions to the nurse that she “has trouble holding her
water,” adding “if I could have that tube back in me like I had in
the hospital, I wouldn’t have so many accidents.” What is the
nurse’s best response?
1. “Don’t worry, the staff will bring plenty of pads to keep
you dry.”
2. “I’ll put the tube back in you so you will stay dry.”
3. “Tell me more about your problem.”
4. “Just call the staff and we’ll help you to the bathroom
in time.”
6. The nurse notices that when an 80-year-old man rises from a
seated position, the client uses both arms to push himself up,
and also “rocks” back and forth before finally standing. What is
the most appropriate nursing intervention for this client?
1. Suggest a referral to physical therapy for strengthening
exercises.
2. Request a waist restraint to remind the client not to stand by
himself.
3. Praise the client for his attempts to remain independent.
4. Assist the client to rise by grasping both his shoulders and
pulling forward.
7. A healthy 78-year-old woman who is considering marriage to a
healthy 79-year-old neighbor tells the nurse that she wonders if
they will be able to have sexual intercourse. Which is the nurse’s
most appropriate response?
1. “Sexual activity may be too demanding for your heart.”
2. “Older women maintain sexual function, but most older men
are impotent.”
3. “Most older people are not interested in sexual activity.”
4. “Both of you may have slower responses to sexual
stimulation.”
8. The client complains of having difficulty clearly seeing the words
in the newspaper unless he holds the newspaper an arm’s
length away. The nurse uses which terminology to document
this assessment?
1. Presbycusis
2. Xerostomia
3. Presbyopia
4. Presbyesophagus
9. The nursing student is planning care for an older adult who had
a total knee replacement yesterday evening. Which nursing
intervention would be most appropriate?
1. Ask the client how much of his bath he can independently
perform.
2. Ask the client if he has any questions regarding discharge
from the hospital.
3. Tell the client that he needs to decide when he wants his
medications.
4. Tell the client that he needs to rest and will be given a
complete bed bath.
10. A 76-year-old woman with dementia lives in an assisted living
facility and often asks, “When will my sister come to visit me
this afternoon?” The sister passed away last year. Which is the
best response from the nurse?
1. “This is so sad. I’m sorry to tell you but your sister died last
year.”
2. “She won’t be coming to visit today.”
3. “I understand you want her to visit you. Where did you and
your sister grow up?”
4. “Wait and see if she comes to visit today.”

1. Because a severely injured middle-aged client informed the

nurse that he did not have any immediate family members, the
nurse contacted extended family members. Which of the follow
ing is most representative of extended family members?
1. Grandparents, aunts, and uncles
2. Parents and spouse
3. Children who no longer live at home
4. Roommates and close family friends
2. Examine Figures 24–3 and 24–4 on pages 390–391. Based on
the information in these two diagrams, which family member is
at greatest risk for developing a health problem?
1. Alice
2. Bill
3. Kim
4. Mary
3. What should a nurse instruct a client who identifies “the family”
as two college roommates, a dog, and a cat when completing a
family health history form?
1. Include all information about blood relatives and the animals
and roommates that might influence his health.
2. Include only information about genetic/hereditary and
environmental illnesses of blood relatives.
3. Leave the area blank since the client does not live with blood
relatives.
4. Use the client’s own judgment in completing the area since
the physical exam is more important than the history.
4. A visual representation of family members by sex, age, health
status, and lines of relationships through the generations is
referred to as a _________. genogram
5. To assess the impact of illness on the family as a unit, it is
essential for the nurse to assess which factors? Select all that
apply.
1. The duration of the illness
2. The meaning of the illness to the family and its significance
to family systems
3. The coping mechanisms used by other families with similar
illnesses
4. The financial impact of the illness (including factors such as
insurance and ability of the ill member to work)
5. The incidence of the illness in the community at large
6. An adult child brings a parent to an agency with signs and
symptoms of potential fluid retention (e.g., high blood pressure,
swollen feet) possibly related to excessive sodium intake. Further
nursing assessment indicates inadequate food storage and
preparation techniques in the home. Which would be the most
appropriate nursing diagnosis?
1. Readiness for Enhanced Family Coping
2. Disabled Family Coping
3. Impaired Parenting
4. Caregiver Role Strain
7. Prior to finalizing a family-oriented nursing care plan and imple
menting interventions, it is essential for the nurse to perform
which of the following?
1. Meet with all family members simultaneously.
2. Confirm that the family health insurance covers all family
members.
3. Establish a trusting relationship with the family as a group.
4. Complete a thorough history and physical examination of
each family member.
8. Nurses often utilize systems theory to assess family units. Which
example illustrates a family unit that does NOT meet the criteria
of a well-functioning system?
1. The family members allow input from outside the family unit.
2. The family members are interdependent.
3. Each member’s personal boundaries are well defined.
4. The primary activities of each member focus on personal
purposes.
9. What is a primary function of a family?
1. Provide everything each member wants.
2. Provide an environment that supports growth of individuals.
3. Ensure that the members are accepted into society.
4. Ensure that family resources are not shared with the broader
community
10. Which family risk factor for developing a health problem is of
highest priority for the nurse to address?
1. Family members’ ages of 4, 13, 38, 42, and 75 place them
in many different developmental stages.
2. There is a history of adult-onset diabetes on the 42-year
old father’s side.
3. The primary wage earner for a family of five has recently
been let go from the job and lost health insurance.
4. The family members are primarily sedentary and no one en
gages in physical exercise for more than 1 hour each week.

1. Which example best illustrates the principle of knowing the client?

1. The nurse provides a back rub to help the client relax, and
then makes the bed with clean linen.
2. The nurse listens as the client describes how he has been
caring for his diabetes at home.
3. The nurse administers a piggyback antibiotic for a client with
pneumonia.
4. The nurse collects a urine specimen to send to the lab, and
explains to the client the reason for the test.
2. The nurse teaches a client with diabetes how to make decisions
about insulin management after discharge. This teaching most
clearly reflects which caring activity?
1. Empowering the client
2. Compassion
3. Knowing the client
4. Nursing presence
3. Mayeroff described allowing the other to grow in his own way
and time. This behavior most clearly reflects which major ingredi
ent of caring?
1. Humility
2. Knowing
3. Patience
4. Courage
4. Leininger’s theory, culture care diversity and universality, would
provide the best framework for assessing which nursing
situation?
1. The Indonesian parents of an infant prefer to use hot/cold
therapies to prevent seizures so they withhold the prescribed
seizure medication (phenobarbital).
2. Staff nurses on a hospital unit discuss how to reorganize cli
ent care to provide more continuity of staff with clients.
3. Nurses in a community agency search for learning resources
about intravenous therapy in the home setting.
4. A nurse manager explores ways to assist new nursing grad
uates to develop clinical skills on the hospital unit.
5. In a reflective journal, a nursing student writes this statement
about a comatose client on the hospice unit: “The Do-Not
Resuscitate order was not on the chart, and none of the nurses
knew what measures should be taken if the client stopped
breathing.” This statement most clearly reflects which of the four
ways of knowing?
1. Empirical
2. Personal
3. Ethical
4. Aesthetic
6. The nurse sits with the client and holds the client’s hand as his
pain decreases. This situation is an example of which caring
practice?
1. Nursing presence
2. Assessment
3. Knowing the client
4. Empowering
7. Which nursing theory is depicted by a model with spiritual
ethical caring in the center, surrounded by technologic,
physical, legal, political, economic, social-cultural, and
educational systems?
1. Nursing as caring
2. Theory of bureaucratic caring
3. Caring, the human mode of being
4. Theory of human care
8. The nursing student reviews the pathophysiology of myocardial
infarction in preparation for the next day’s clinical experience.
This activity is an example of which type of knowledge
development?
1. Empirical knowing
2. Aesthetic knowing
3. Personal knowing
4. Ethical knowing
9. A nurse, sitting quietly in a chair, breathing deeply, and focusing
on the mental image of a crystal is using which mind–body
therapy?
1. Storytelling
2. Yoga
3. Music therapy
4. Meditation
10. A 40-year-old client who comes to the clinic for a routine
physical exam asks the nurse how much exercise is
recommended for a healthy lifestyle. Which answer is most
appropriate?
1. Moderate activity for 10 minutes daily
2. Moderate activity for 20 minutes two to three times a week
3. Vigorous activity for 25 minutes three days a week
4. Vigorous activity for 30 minutes daily

1. A student nurse is caring for a 72-year-old client with Alzheimer’s

disease who is very confused. Which is the most appropriate
communication strategy to be used by the student nurse?
1. Written directions for bathing
2. Speaking very loudly
3. Gentle touch while providing ADLs
4. Flat facial expression
2. Place the following descriptions of the helping relationship
phases in the correct sequence. 3, 1, 2, 4
1. After introductions, the nurse asks, “What plans do you have
for the upcoming holiday weekend?”
2. The nurse states, “It sounds like you are concerned about
the possible complications of having diabetes. What would
be the most helpful for you at this time?”
3. The nurse reads in the medical history that the client was
diagnosed with diabetes 1 week ago.
4. The nurse states, “When we met, you knew very little about
diabetes and now you are able to use your new information
and apply it to your own personal situations.”
3. The nurse who uses appropriate therapeutic listening skills will
display which behaviors? Select all that apply.
1. Absorb both the content and the feeling the client is
conveying.
2. Presume an understanding of the client needs.
3. Adopt an open professional posture.
4. React quickly to the message.
5. Reassure the client that everything will be fine.
4. A nurse tells a client who is struggling with cancer pain, “It is
normal to feel frustrated about the discomfort.” Which is most
representative of the skills associated with the working phase of
the helping relationship?
1. Respect
2. Genuineness
3. Concreteness
4. Confrontation
5. A depressed client who has not bathed or dressed in clean
clothes today is reading the lunch menu but is unable to make
a decision. Which would be the most appropriate nursing
diagnosis for this client?
1. Anxiety
2. Powerlessness
3. Chronic Low Self-Esteem
4. Social Isolation
6. After being admitted for emergency surgery, an 80-year-old
client has just returned to the room from the PAR (postanesthe
sia room). Which nursing interventions are most likely to facilitate
effective communication with this client? Select all that apply.
1. Ask the client, “Do you know where you are?”
2. Ask the client or support person about visual or learning
problems.
3. Inform the client and support person(s) about events likely to
occur during the next 2 hours.
4. Provide the client with instructions about discharge.
5. Tell the client, “You will feel better soon.”
7. The nurse is communicating with a well-oriented older adult
client in a long-term care setting. Which statement best reflects
respectful and caring communication?
1. “Are we ready for our shower?”
2. “It’s time to go to the dining room, honey.”
3. “Are you comfortable, Mrs. Smith?”
4. “You would rather wear the slacks, wouldn’t you?”
8. The client made the following statement to the nurse, “My
doctor just told me that he cannot save my leg and that I need
to have an above-the-knee amputation.” Which response by the
nurse is most appropriate?
1. “Dr. Jones is an excellent surgeon.”
2. “Are you in pain?”
3. “If I were you, I’d get a second opinion.”
4. “Tell me more. . . .”
9. The nurse is communicating with a primary care provider about
medical interventions prescribed for a client. Which statement
is most representative of a collaborative relationship?
1. “That new medication you prescribed for Mr. Black
is ineffective.”
2. “I am worried about Mr. Black’s blood pressure. It is not
decreasing even with the new antihypertensive medication.”
3. “Can we talk about Mr. Black?”
4. “Excuse me doctor. I think we need to talk about
Mr. Black’s blood pressure.”
10. The nurse asks the client, “What do you fear most about your
surgery tomorrow?” This is an example of which communica
tion technique?
1. Providing general leads
2. Seeking clarification
3. Presenting reality
4. Summarizing

1. Which learning activity reflects Bloom’s affective domain?

1. Administering an injection
2. Accepting the loss of a limb
3. Inserting a catheter
4. Learning how to read
2. Which is the best method of helping a client newly diagnosed
with diabetes to learn the dietary requirements associated with
the disease?
1. Provide a videotape that addresses the dietary requirements
associated with the disease.
2. Ask a nutritionist to visit the client to present information and
handouts about the diabetic diet.
3. Ask the client to make a list of her favorite foods and how to
work them into her diet.
4. Have the client attend a group meeting for clients with
diabetes to discuss their adaptation to this chronic health
condition.
3. A nurse is scheduling a teaching situation. Which client is most
ready to learn?
1. A 45-year-old man whose health care provider has just
informed him that he has cancer
2. A 3-year-old child whose parents are reading a storybook
about going to the hospital
3. A 60-year-old female who received medication 5 minutes
ago for relief of abdominal pain
4. A 70-year-old man, recovering from a stroke who has
returned from physical therapy
4. How can the nurse best assess a client’s style of learning?
1. Ask the client how he or she learns best.
2. Use a variety of teaching strategies.
3. Observe the client’s interactions with others.
4. Ask family members.
5. A 74-year-old client who takes multiple medications tells the
nurse, “I have no idea what that little yellow pill is for.” What is
the best nursing diagnosis for this client?
1. Deficient Knowledge
2. Health-Seeking Behavior
3. Deficient Knowledge (Medication Information)
4. Noncompliance
6. A client is scheduled to have a diagnostic procedure. Which
questions by the nurse will most likely produce a “teachable
moment”? Select all that apply.
1. “Have you ever had this procedure before?”
2. “What are your concerns about this procedure?”
3. “What would you like to know about the procedure?”
4. “Are you prepared for this procedure?”
5. “What have you heard or read about the procedure?”
7. A client needs to learn to self-administer insulin injections.
Which statements reflect possible low literacy skills? Select all
that apply.
1. “I will read the information later—I’m too tired right now.”
2. “I’ve watched my brother give his own shots. I know how
to do it.”
3. “Just show my wife.”
4. “Do you have a video showing how I should give myself the
shot?”
5. “I don’t understand this one section in the handout.”
8. A primary care provider admitted a client experiencing
hypertensive crisis because of the failure to take his prescribed
medications. To determine learning needs, which client
assessment by the nurse would have the highest priority?
1. Age
2. Perception of the effects of hypertension
3. Ability to purchase needed medications
4. Support system
9. A client has a learning outcome of “Select foods that are low in
fat content.” Which statement reflects that the client has met
this learning outcome?
1. “I understand the importance of maintaining a low-fat diet.”
2. “I feel better about myself now.”
3. “See how I revised my favorite recipe to be lower in fat.”
4. “Since changing my diet, my husband is also losing
weight.”
10. A client’s learning outcome is “Client will verbalize medication
name, purpose, and appropriate precautions.” Which
documented statement reflects evidence of learning?
1. Taught name, purpose, and precautions for the new
cardiac medication; seemed to understand.
2. Written information about the medication provided and
reviewed; correct responses were given to follow-up
questions.
3. Written information read to client; stated he would read it
when he got home.
4. Asked questions about the new cardiac medication;
satisfied with the information.

Chapter 28
1. The nurse leader informs the staff of a local emergency and
instructs them to stay at the hospital to prepare for major
casualties. The staff displays high levels of anxiety and
disorganization. Which is the most appropriate leadership
style at this time?
1. Autocratic
2. Democratic
3. Laissez-faire
4. Bureaucratic
2. During client rounds, a client tells the nurse manager that he has
not received his medications all shift. In using the skills and
competencies of a manager, what will be the nurse’s first action?
1. Communicate: Discuss the client’s statement with the
assigned nurse.
2. Manage resources: Assign another nurse to administer the
client’s medications.
3. Enhance employee performance: Provide the client’s nurse
with a mentor to review proper medication procedures.
4. Manage conflict: Call the nurse into the client’s room and
mediate a discussion between them.
3. Which example reflects a nurse manager with accountability but
not authority?
1. To reduce costs, administrators instruct the manager to
inform the staff to reduce overtime.
2. The manager evaluates the unit staff but cannot promote or
terminate staff.
3. The manager is to recommend a new staffing procedure to
the institution’s nurse manager group.
4. The manager prepares a monthly budget variance report
that includes plans to correct overspending.
4. An unlicensed assistant (UAP) has previously performed client
transfers safely (bed to chair) on many occasions. It would be
inappropriate to delegate this unsupervised task to the UAP
under which condition?
1. The unit had a new wheelchair.
2. This was an older client.
3. It was the client’s first time out of bed after surgery.
4. The UAP has just returned from an extended leave of
absence.
5. The nurse manager plans to implement a new method for
scheduling staff vacations. Senior staff members oppose the
change, whereas newer staff members are more accepting.
Which is the most effective strategy for resolving this difference?
1. Provide an extensive and detailed rationale for the proposed
change, then implement.
2. Explain that the change will occur as designed, regardless of
the staff’s preference.
3. Withdraw the proposal to prevent a decrease in staff morale.
4. Encourage interaction between the opposing sides to
attempt resolution.
6. Which is more commonly a characteristic of a manager rather
than a leader?
1. Is visionary.
2. Has been given legitimate power by the organization.
3. Primary effectiveness is through influencing others.
4. Often takes risks and explores new solutions to problems.
7. A leader is most likely to be effective when acting which way?
Select all that apply.
1. Adopts the leadership style of the leader who had the
position before him or her.
2. Gives equal consideration to group members who are in
favor of and opposed to a desired change.
3. Plans and organizes group activities.
4. Modifies his or her own behaviors based on the needs of
individual members of the group.
5. Asks members for opinion of the leader’s effectiveness.
8. When economic conditions are tight, a hospital may reduce the
number of middle-level nurse managers. This can potentially
disrupt nursing care because middle-level managers are
responsible for which of the following?
1. Supervision of nonmanagerial staff
2. Reporting institutional changes to direct-care staff
3. Productivity and effectiveness of a group of managers
4. Creating institutional goals and strategic plans
9. A management function of bedside direct-care nurses includes
determining whether the client has reached the intended out
comes designated in the care plan. This is an example of which
of the four management functions?
1. Planning
2. Organizing
3. Directing
4. Coordinating
10. The nurse asks an unlicensed assistant (UAP) to weigh a cli
ent. The UAP carefully assists the client out of bed to stand
on the scale, weighs the client, and safely returns the client to
bed. Later, when the UAP reports the weight to the nurse, it
is discovered that the client had been placed on bed rest and
should not have been allowed out of bed. This situation violates
which of the following five rights of delegation?
1. Right task
2. Right person
3. Right direction and communication
4. Right supervision and evaluation

Chapter 29
1. The client’s temperature at 8:00 am using an oral electronic
thermometer is 36.1°C (97.2°F). If the respiration, pulse, and
blood pressure were within normal range, what would the nurse
do next?
1. Wait 15 minutes and retake it.
2. Check what the client’s temperature was the last time it was
taken.
3. Retake it using a different thermometer.
4. Chart the temperature; it is normal.
2. Which client meets the criteria for selection of the apical site for
assessment of the pulse rather than a radial pulse?
1. A client who is in shock
2. A client whose pulse changes with body position changes
3. A client with an arrhythmia
4. A client who had surgery less than 24 hours ago
3. When the nurse enters a client’s room to measure routine vital
signs, the client is on the phone. What technique should the
nurse use to determine the respiratory rate?
1. Count the respirations during conversational pauses.
2. Ask the client to end the phone call now and resume it at a
later time.
3. Wait at the client’s bedside until the phone call is completed
and then count respirations.
4. Since there is no evidence of distress or urgency, postpone
the measurement until later.
4. For a client with a previous blood pressure of 138/74 mmHg
and pulse of 64 beats/min, approximately how long should the
nurse take to release the blood pressure cuff in order to obtain
an accurate reading?
1. 10–20 seconds
2. 30–45 seconds
3. 1–1.5 minutes
4. 3–3.5 minutes
5. It would be appropriate to delegate the taking of vital signs of
which client to unlicensed assistive personnel?
1. A client being prepared for elective facial surgery with a
history of stable hypertension
2. A client receiving a blood transfusion with a history of
transfusion reactions
3. A client recently started on a new antiarrhythmic agent
4. A client who is admitted frequently with asthma attacks
6. An 85-year-old client has had a stroke resulting in right-sided
facial drooping, difficulty swallowing, and the inability to move
self or maintain position unaided. The nurse determines that
which sites are most appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery
7. A nursing diagnosis of Ineffective Peripheral Tissue Perfusion
would be validated by which one of the following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
4. Absent posterior tibial and pedal pulses
8. The nurse reports that the client has dyspnea when ambulating.
The nurse is most likely to have assessed which of the
following?
1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood
9. When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then:
a thumping sound continuing down to 150 mmHg:
muffled sounds continuing down to 130 mmHg;
soft thumping sounds continuing down to 105 mmHg;
muffled sounds continuing down to 95 mmHg;
then silence.
The nurse records the blood pressure as _____________.
10. In Figure 29–28 •, which number indicates the client’s oxygen
saturation as measured by pulse oximetry? _____________

1. Which is a normal finding on auscultation of the lungs?

1. Tympany over the right upper lobe
2. Resonance over the left upper lobe
3. Hyperresonance over the left lower lobe
4. Dullness above the left 10th intercostal space
2. The nurse positions the client sitting upright during palpation of
which area?
1. Abdomen
2. Genitals
3. Breast
4. Head and neck
3. After auscultating the abdomen, the nurse should report which
finding to the primary care provider?
1. Bruit over the aorta
2. Absence of bowel sounds for 60 seconds
3. Continuous bowel sounds over the ileocecal valve
4. A completely irregular pattern of bowel sounds
4. If unable to locate the client’s popliteal pulse during a routine
examination, what should the nurse do next?
1. Check for a pedal pulse.
2. Check for a femoral pulse.
3. Take the client’s blood pressure on that thigh.
4. Ask another nurse to try to locate the pulse.
5. Which of the following is an expected finding during assessment
of the older adult?
1. Facial hair that becomes finer and softer
2. Decreased peripheral, color, and night vision
3. Increased sensitivity to odors
4. An irregular respiratory rate and rhythm at rest
6. List five aspects of the skin that the nurse assesses during a
routine examination.
1.
2.
3.
4.
5.
7. If the client reports loss of short-term memory, the nurse would
assess this using which one of the following?
1. Have the client repeat a series of three numbers, increasing
to eight if possible.
2. Have the client describe his or her childhood illnesses.
3. Ask the client to describe how he or she arrived at this location.
4. Ask the client to count backward from 100 subtracting
seven each time.
8. Refer back to Figure 30–14. If the client can accurately read
only the top three lines, what would be an appropriate nursing
diagnosis?
1. Deficient Knowledge
2. Impaired Memory
3. Ineffective Tissue Perfusion
4. Risk for Injury
9. To palpate lymph nodes, the nurse uses which technique?
1. Use the flat of all four fingers in a vertical and then side-to
side motion.
2. Use the back of the hand and feel for temperature variation
between the right and left sides.
3. Use the pads of two fingers in a circular motion.
4. Compress the nodes between the index fingers of both
hands.
10. For a client whose assessment of the musculoskeletal system
is normal, which does the nurse check on the medical record?
(Select all that apply.)
1. ____ Atrophied
2. ____ Contractured
3. ____ Crepitation
4. ____ Equal
5. ____ Firm
6. ____ Flaccid
7. ____ Hypertrophied
8. ____ Spastic
9. ____ Symmetrical
10. ____ Tremor