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Total Questions : 68

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Question 1:

A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

A. Assist the client to acknowledge that he has a distorted body image. B. Encourage the client to talk about his feelings regarding his body image C. Determine the client's perception of his body image. D. Discuss alternative coping strategies to relieve the stress he feels about his body image.

Answer and Explanation

Choice A:

Assist the client to acknowledge that he has a distorted body image: This may be important later, but first the nurse must assess the client’s current perception of his body image to guide interventions.

Choice B:

Encourage the client to talk about his feelings regarding his body image: While therapeutic communication is crucial, assessment comes before intervention. Understanding the client’s perception helps tailor the discussion.

Choice C:

Determine the client's perception of his body image:According to the nursing process, assessment is the first step. This helps guide individualized care for disturbed body image.

Choice D:

Discuss alternative coping strategies to relieve the stress he feels about his body image: Coping strategies are appropriate after assessing the client’s emotional and psychological needs.

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Question 2:

Answer and Explanation

Choice A:

Choice B:

Choice C:

Determine the client's perception of his body image:According to the nursing process, assessment is the first step. This helps guide individualized care for disturbed body image.

Choice D:

Discuss alternative coping strategies to relieve the stress he feels about his body image: Coping strategies are appropriate after assessing the client’s emotional and psychological needs.

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Question 3:

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

A. Place the head of the client's bed flat. B. Remove the client's dentures. C. Increase the lights in the client's room. D. Wash the client's body.

Answer and Explanation

Choice A:

Place the head of the client's bed flat: The head of the bed should be elevated to prevent discoloration from blood pooling in the face (livor mortis).

Choice B:

Remove the client's dentures: Dentures should be left in if possible to maintain the shape of the face, especially if family will view the body.

Choice C:

Increase the lights in the client's room: Soft lighting is more appropriate; bright lighting is not necessary and may be distressing to the family.

Choice D:

Wash the client's body:It is respectful and standard practice to cleanse the body, unless contraindicated by culture or religion.

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Question 4:

Which nursing intervention can cause an unsafe sleeping environment for the hospitalized patient?

A. Placing a call bell at the bedside for the patient to contact the nurse. B. The patient's bed is in a high position with side rails up C. A small night-light left on in the bedroom D. All clutter is removed between the bed and the bathroom

Answer and Explanation

Choice A:

Placing a call bell at the bedside for the patient to contact the nurse: This is a safe practice that allows the patient to call for help if needed.

Choice B:

The patient's bed is in a high position with side rails up:This can increase fall risk if the patient tries to get out of bed without assistance. The bed should be in the lowest position.

Choice C:

A small night-light left on in the bedroom: This is a safety measure to prevent disorientation or falls when patients get up during the night.

Choice D:

All clutter is removed between the bed and the bathroom: This is a safe practice that reduces fall risk.

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Question 5:

The physician orders magnesium sulfate 1g. The magnesium is dissolved in 150 ml. bag, to be infused over 60 minutes. What is the ml/hr that the drug should be infused? (LABEL CORRECTLY USE UPPER CASE LETTERS, ROUND TO WHOLE NUMBER TO RECEIVE CREDIT).

Answer and Explanation

Correct Answer: "150" ml/hr

Explanation

Volume(ml)=150ml

Time(hr)=1hr

Rate= 150ml ÷1hr

= 150ml/hr

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Question 6:

A nurse is in the process of admitting an ethnically diverse patient. To plan culturally competent care, what must the nurse do? (Select the 3 correct answers.)

A. Assume that cultural processes are the same within a social group. B. Ask the client if they have any religious dietary restrictions. C. Communicate effectively. D. Provide a medical interpreter if the client has a different cultural belief from the nurse. E. Conduct a systematic cultural assessment.

Answer and Explanation

Choice A:

Assume that cultural processes are the same within a social group:This is stereotyping and ignores individual differences within cultural groups.

Choice B:

Ask the client if they have any religious dietary restrictions:This shows respect for the client’s culture and promotes individualized care.

Choice C:

Communicate effectively:Effective communication is essential for understanding the client’s cultural beliefs and needs.

Choice D:

Provide a medical interpreter if the client has a different cultural belief from the nurse:A medical interpreter is needed if the language is different, not necessarily because of a difference in beliefs.

Choice E:

Conduct a systematic cultural assessment:This is necessary to understand the client's values, beliefs, and practices and to provide culturally appropriate care.

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Question 7:

A nurse is assessing a patient's self-concept. Which areas will the nurse include? (Select 4 correct answers.)

A. Support of significant others B. Identity C. Body image D. Availability of insurance E. Coping behaviors

Answer and Explanation

Choice A:

Support of significant others:The presence or absence of support systems affects self-worth and confidence, influencing self-concept.

Choice B:

Identity:Personal identity (including roles, values, and self-knowledge) is a core component of self-concept.

Choice C:

Body image:How a person perceives their physical appearance contributes directly to their self-concept.

Choice D:

Availability of insurance:While important for healthcare access, insurance is a social determinant, not a direct component of self-concept.

Choice E:

Coping behaviors:How one manages stress and adversity reflects and impacts their self-concept.

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Question 8:

The nurse is caring for a patient who is depressed because her children have gone away to college. Which type of loss is experienced by the patient?

A. maturational B. situational C. perceived D. conditional

Answer and Explanation

Choice A:

Maturational:This is a normal life transition, such as children growing up and leaving home, that can still feel like a loss.

Choice B:

Situational:Situational loss results from unexpected events, such as a job loss or illness, not normal developmental changes.

Choice C:

Perceived:A perceived loss is defined by the individual and is not obvious to others, like loss of independence. This example is better categorized as maturational.

Choice D:

Conditional:“Conditional loss” is not a recognized category in grief theory.

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Question 9:

A nurse is caring for a client in the emergency department who had a traumatic amputation of his left arm in an industrial accident 1 hr ago. The nurse should expect the client to be in which of the following stages of grief?

A. Denial B. Depression C. Acceptance D. Bargaining

Answer and Explanation

Choice A:

Denial:Denial is often the first stage of grief, especially shortly after a traumatic and unexpected event.

Choice B:

Depression:Depression typically appears in later stages, after the reality of the loss has set in.

Choice C:

Acceptance:Acceptance occurs at the end of the grief process after full emotional processing.

Choice D:

Bargaining:Bargaining usually comes after denial and involves trying to negotiate to reverse or lessen the loss.

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Question 10:

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse includer

A. Bronchial airway constriction B. Hypoglycemia C. Dilated pupils D. Decreased blood pressure

Answer and Explanation

Choice A:

Bronchial airway constriction:Airway dilation (not constriction) occurs to increase oxygen delivery during the fight-or-flight response.

Choice B:

Hypoglycemia:Hyperglycemia (not hypo) occurs due to glucose release for energy.

Choice C:

Dilated pupils:Pupil dilation enhances vision and is a classic sympathetic nervous system response.

Choice D:

Decreased blood pressure:Blood pressure typically increases during the fight-or-flight response to enhance circulation.

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Total Questions : 68

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Ati lpn fundamentals exam

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