Fundamentals of Nursing 8th Edition By Taylor-Test Bank




Fundamentals of Nursing 8th Edition By Taylor-Test Bank

Chapter 2

1. After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation?
A) Scientific knowledge
B) Traditional knowledge
C) Authoritative knowledge
D) Philosophical knowledge
Ans: A
The clinical nurse specialist utilized scientific knowledge, which is gained through the research-based scientific method. Philosophical knowledge is not a source of nursing knowledge, but is a type of general knowledge. Authoritative knowledge comes from an expert and is accepted as truth based upon the person’s perceived expertise. Traditional knowledge is that part of nursing practice passed down from generation to generation and is not based upon scientific inquiry.



2. Which of the following theories emphasizes the relationships between the whole and the parts, and describes how parts function and behave?
A) General systems theory
B) Nursing theory
C) Adaptation theory
D) Developmental theory
Ans: A
General systems theory describes how to break whole things into parts and then learn how the parts work together in “systems.” Nursing theory attempts to describe, explain, predict, and control desired outcomes of nursing care practices. Adaptation theory defines adaptation as the adjustment of living matter to other living things and to environmental conditions. Developmental theory outlines the process of growth and development of humans as orderly and predictable.



3. A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal cord injury. What type of research method will be used to study the perceptions of this group of individuals?
A) Qualitative research
B) Quantitative research
C) Basic research
D) Applied research
Ans: A
The nurse researcher will use qualitative research methods to investigate perceptions, and the researcher will analyze words instead of numbers, which are analyzed in quantitative research. Basic and applied research are quantitative research methods.



4. A staff development nurse is asking a group of new staff nurses to read and be prepared to discuss a qualitative study that focuses on nursing events of the past. This is done in an attempt to increase understanding of the nursing profession today. What method of qualitative research is used in this article?
A) Historical
B) Phenomenology
C) Grounded theory
D) Ethnography
Ans: A
This article uses historical methodology, which examines events of the past to increase understanding of the nursing profession today. Phenomenology is used to describe experiences as they are lived by the subjects being studied. Grounded theory is the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene. Ethnography is used to examine issues of a culture that are of interest to nursing.



5. In understanding the historical influences on nursing knowledge, nursing as a profession struggled for years to establish its own identify and to receive recognition for its contributions to health care. Why?
A) The conceptual and theoretical basis for nursing practice came from outside the profession.
B) Nurses were too busy working in practice to increase the public awareness associated with the role of the nurse.
C) Nurses spent most of their time in laboratory settings conducting research.
D) Women were independent and refused to work collectively.
Ans: A
Despite Florence Nightingale’s belief in the uniqueness of nursing, the training of nurses was initially carried out under the direction and control of the medical profession. Because the conceptual and theoretical basis for nursing practice came from outside the profession, nursing struggled for years to establish its own identify and to receive recognition for its significant contributions to health care.



6. An obstetrical nurse wishes to identify whether clients’ perceptions of a high level of support from their partner is associated with a decreased length of the second stage of labor. Which type of quantitative research is most appropriate for this research question?
A) Correlational research
B) Descriptive research
C) Quasi-experimental research
D) Experimental research
Ans: A
Correlational quantitative research is used to examine relationships between two or more variables. In this case, the variables are perceptions of partner support and length of Stage 2 labor. There is no manipulation of the variables as there would be in an experimental or quasi-experimental study. The focus on the relationship between the two variables goes beyond simple description of events.



7. Nurse researchers have predicted that a newly created mentorship program will result in decreased absenteeism, increased retention, and decreased attrition among a hospital’s nursing staff. Which of the following does this predicted relationship represent?
A) Hypothesis
B) Dependent variable
C) Abstract
D) Methodology
Ans: A
A hypothesis is an expected statement of the relationship between variables in a study. In this study, the dependent variables are absenteeism, retention, and attrition while the independent variable is the mentorship program. The methodology of a study is the logistical framework that guides the planning and execution of the study. An abstract is a summary of a research study published in a journal.



8. The practice of changing patients’ bedclothes each day in acute care settings is an example of what type of knowledge?
A) Authoritative
B) Traditional
C) Scientific
D) Applied
Ans: B
Changing bedclothes daily in acute care settings is an example of traditional knowledge. The practice is not based on research findings, but is rather a part of nursing practice passed down from generation to generation.



9. A student nurse learns how to give injections from the nurse manager. This is an example of the acquisition of what type of knowledge?
A) Authoritative
B) Traditional
C) Scientific
D) Applied
Ans: A
Authoritative knowledge comes from an expert and is accepted as truth, based on the person’s perceived expertise. Authoritative knowledge generally remains unchallenged as long as the presumed authority maintains his or her perceived expertise.



10. A client undergoing chemotherapy for a brain tumor believes that having a good attitude will help in the healing process. This is an example of what type of knowledge?
A) Science
B) Philosophy
C) Process
D) Virtue
Ans: B
Philosophy is the study of wisdom, fundamental knowledge, and the processes used to develop and construct one’s perceptions of life. Philosophy provides a viewpoint and implies a system of values and beliefs. Each individual develops a personal philosophy to give meaning to experiences and to guide behavior and attitudes. Personal philosophies are developed by learning from interpersonal relationships, through formal and informal educational experiences, through religion and culture, and from the environment.



11. Which of the following accurately describes Florence Nightingale’s influence on nursing knowledge?
A) She defined nursing practice as the continuation of medical practice.
B) She differentiated between health nursing and illness nursing.
C) She established training for nurses under the direction of the medical profession.
D) She established a theoretical base for nursing that originated outside the profession.
Ans: B
Nightingale influenced nursing knowledge and practice by demonstrating efficient and knowledgeable nursing care, defining nursing practice as separate and distinct from medical practice, and differentiating between health nursing and illness nursing.



12. During the first half of the 20th century, a change in the structure of society resulted in changed roles for women and, in turn, for nursing. What was one of these changes?
A) More women retired from the workforce to raise families.
B) Women became more dependent and sought higher education.
C) The focus of nursing changed to “hands-on training.”
D) Nursing research was conducted and published.
Ans: D
As a result of World Wars I and II, women increasingly entered the workforce, became more independent, and sought higher education. At the same time, nursing began to focus more on education than hands-on training, and nursing research was conducted and published.



13. A staff nurse asks a student, “Why in the world are you studying nursing theory?” How would the student best respond?
A) “Our school requires we take it before we can graduate.”
B) “We do it so we know more than your generation did.”
C) “I think it explains how we should collaborate with others.”
D) “It helps explain how nursing is different from medicine.”
Ans: D
Nursing theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting, and controlling desired outcomes of nursing care practices.



14. Why are the developmental theories important to nursing practice?
A) They describe how parts work together as a system.
B) They outline the process of human growth and development.
C) They define human adaptation to others and to the environment.
D) They explain the importance of legal and ethical care.
Ans: B
Developmental theories outline the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. Nurses apply this knowledge to develop interventions for people across the life span. Systems theory, adaptation theories, and legal/ethical care are also important to nursing, but these do not explain the importance of human growth and development in nursing care.



15. There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing?
A) Person
B) Environment
C) Health
D) Nursing
Ans: A
The four concepts listed are all common in nursing theory, but the most important—and the focus of nursing—is the person (client).



16. What is the ultimate goal of expanding nursing knowledge through nursing research?
A) Learn improved ways to promote and maintain health.
B) Develop technology to provide hands-on nursing care.
C) Apply knowledge to become independent practitioners.
D) Become full-fledged partners with other care providers.
Ans: A
The ultimate goal of expanding nursing’s body of knowledge through nursing research is to learn improved ways to promote and maintain health. Ongoing practice-based research reflects the nursing profession’s commitment to meet the ever-changing demands of health care consumers. While doing research also facilitates the development of technology, helps produce independent practitioners, and provides partnerships with other providers of care, those are not the ultimate goals of nursing research.



17. What was significant about the promotion of the National Center for Nursing Research to the current National Institute of Nursing Research (NINR)?
A) Increased numbers of articles are published in research journals.
B) NINR gained equal status with all other National Institutes of Health.
C) NINR became the major research body of the International Council of Nurses.
D) It decreased emphasis on clinical research as an important area for nursing.
Ans: B
The National Center for Nursing Research was promoted to the National Institute of Nursing Research (NINR) in 1993, gaining equal status with all other National Institutes of Health.



18. Which of the following is a responsibility of an institutional review board (IRB)?
A) Secure informed consent for researchers
B) Review written accuracy of research proposals
C) Determine risk status of all studies
D) Secure funding for institutional research
Ans: C
Federal regulations require that institutions receiving federal funding, or conducting studies of drugs or medical devices regulated by the Food and Drug Administration establish IRBs. The IRB reviews all studies conducted in the institution to determine risk status and to ensure that ethical principles are followed. The IRB does not secure informed consent, review the accuracy of proposals, or secure funding.



19. Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review?
A) Institutional practice
B) Authoritative nursing
C) Evidence-based nursing
D) Factual-based nursing
Ans: C
Evidence-based nursing practice (EBNP) is the conscientious, explicit, and judicious use of research-based information in making decisions about the delivery of care. EBNP does not include institutional practice, authoritative nursing, or factual-based nursing.



20. One step in implementing evidence-based practice is to ask a question about a clinical area of interest or an intervention. The most common method is the PICO format. Which of the following accurately defines the letters in the PICO acronym?
A) P = population
B) I = institution
C) C = compromise
D) O = output
Ans: A
P = patient, population, or problem of interest, I = intervention of interest, C = comparison of interest, and O = outcome of interest



21. The nurse understands that general systems theory has important implications in nursing. Which of the following is an assumption of the general systems theory?
A) Human systems are open and dynamic.
B) All humans are born with instinctive needs.
C) Human needs are motivational forces.
D) People grow and change throughout their lives.
Ans: A
General systems theory assumes that human systems are open and dynamic with implicit boundaries. Human needs theory assumes that all humans are born with instinctive needs and human needs are motivational forces. Change theory assumes that people grow and change throughout their lives.



22. A nursing student is conducting a literature review via the Internet to identify a problem area that may be applicable in scope for nursing. When conducting the search, which of the following would be most important for the student to keep in mind?
A) The Internet should be the last resort for scientific literature review.
B) Very few nursing sites are available through the Internet.
C) Most websites that provide nursing information are reliable.
D) MedLine is a reputable online database of nursing information.
Ans: D
MedLine is a highly reputable online database of nursing information. The Internet is continuously growing as a resource for nursing research and has developed into a sophisticated tool for information retrieval, as well as research for the general public and for nursing and health professionals. Hundreds of sites are available through the World Wide Web. However, not all websites that provide nursing information are reliable.



23. A group of students is reviewing information about evidence-based practice in preparation for an exam. The students demonstrate understanding of the information when they identify which of the following as associated with evidence-based practice?
A) It emphasizes personal experience over science.
B) Clinical expertise is integrated with external evidence.
C) It involves gaining solutions to problems.
D) The purpose is to learn about a specific problem.
Ans: B
Evidence-based practice (EBP) is an approach to health care that realizes that pathophysiologic reasoning and personal experience are necessary, but not sufficient for making decisions. Advocates argue that medical decisions should be based, as much as possible, on a firm foundation of high-grade scientific evidence, rather than on experience or opinion. Its practice involves integrating individual clinical expertise with the best available external evidence from systematic research. Nursing research aims to gain solutions to problems, learn about a specific problem, or to understand a situation.



24. A nurse researcher decides to conduct a qualitative research study. With which of the following would the researcher be involved?
A) Collection of numerical data
B) Determination of cause and effect
C) Controlling personal biases
D) Real world data collection
Ans: D
Qualitative research strives for an understanding of the whole and requires the researcher to become the instrument as data is collected in the real-world, naturalistic setting. Numerical data, cause and effect and control of personal bias are key aspects of quantitative research.



25. In what way can a nurse differentiate strong research from poor research?
A) By conducting the research
B) Through author dialogue
C) By critiquing the study
D) Through the nurse’s own informal investigation
Ans: C
Nurses must have a working knowledge of research methods, and a beginning ability to read for application and to critique research.



26. Nursing research is linked most closely to what?
A) Propositions
B) Outcome measures
C) Treatments
D) Nursing process
Ans: D
Many similarities are found between the formalized research process and the nursing process format that is an integral part of nursing education.



27. Which of the following research studies would be of most interest to a nurse manager?
A) Sister Callista Roy’s theory on adaptation
B) Patricia Benner’s From Novice to Expert
C) Kleinpell and Ferrans’ older intensive-care clients
D) Madeleine Leininger’s transcultural nursing theory
Ans: B
Research affects the clinical practice of nurses in all areas, particularly in relation to the goals of nursing. Benner’s research will assist a nurse manager to support all levels of his or her staff.



28. How are the first stages of the nursing process and nursing research linked?
A) They will answer a posed question.
B) Each begins with goal development.
C) The nurse assesses problems initially.
D) There is a period of evaluation.
Ans: C
The first step for the practicing nurse is to assess a problem; for the researcher, the first step is to recognize the general problem area.



29. A nursing instructor would like to study the effect peer tutoring has on student success. What is the independent variable?
A) Nursing student
B) Nursing education
C) Peer tutoring
D) Student success
Ans: C
The independent variable is the presumed cause or influence on the dependent variable.



30. A nursing student has been asked to correlate her clinical experiences with two different theories of nursing. The student will recognize that which of the following concepts are common to all theories of nursing? Select all that apply.
A) The client
B) The environment
C) Illness
D) Needs
E) Nursing
Ans: A, B, E
While nursing theories vary significantly in their conceptualizations, the elements that are common to all include the client (person), the environment, health, and nursing. The concepts of needs and illness are addressed by some theories but these are not explicitly defined by other theories.



31. Which of the following are examples of characteristics of evidence-based practice? Select all that apply.
A) It is a problem-solving approach.
B) It uses the best evidence available.
C) It is generally accepted in clinical practice.
D) It is based on current institutional protocols.
E) It blends the science and art of nursing.
Ans: A, B, E
Evidence-based nursing is a problem-solving approach to making clinical decisions, using the best evidence available. EBP may meet resistance in clinical practice as a result of the nursing shortage, the acuity level of clients, nurse’s skill in reading and evaluating published research, and an organizational culture that does not support change. EBP blends both the science and the art of nursing so that the best client outcomes are achieved. EBP takes into consideration client preferences and values as well as the clinical experiences of the nurse.



32. Which of the following are characteristics of nursing theories? Select all that apply.
A) They provide rational reasons for nursing interventions.
B) They are based on descriptions of what nursing should be.
C) They provide a knowledge base for appropriate nursing responses.
D) They provide a base for discussion of nursing issues.
E) They help resolve current nursing issues and establish trends.
Ans: A, C, D, E
Nursing theory provides rational and knowledgeable reasons for nursing interventions, based on descriptions of what nursing is and what nurses do. Additionally, nursing theory gives nurses the knowledge base necessary for acting and responding appropriately in various situations. It also provides a base for discussion, and, ideally, helps resolve current nursing issues. Nursing theories should be simple and general; simple terminology and broadly applicable concepts ensure their usefulness in a wide variety of nursing practice situations.



33. Which of the following examples represents the type of knowledge known as process? Select all that apply.
A) A nurse dispenses medications to clients.
B) A nurse changes the linens on a client’s bed.
C) A nurse studies a nursing journal article on infection control.
D) A nurse consults an ethics committee regarding an ethical dilemma.
E) A nurse believes in providing culturally competent nursing care.
Ans: A, B
A process is a series of actions, changes, or functions intended to bring about a desired result. During a process, one takes systematic and continuous steps to meet a goal and uses both assessments and feedback to direct actions that meet the goal. Reading a nursing journal is considered science. Consulting an ethics committee and providing culturally competent nursing care is considered philosophy.



34. Which qualitative research method is described as follows: to describe experiences as they are lived by the subjects being studied?
A) Historical
B) Ethnography
C) Grounded theory
D) Phenomenology
Ans: D
The purpose of phenomenology, which is both a philosophy and a research method, is to describe experiences as they are lived by the subjects being studied. Historical research examines events of the past to increase understanding of the nursing profession today. Ethnography is used to examine issues of a culture that are of interest to nursing. The basis of grounded theory methodology is the discovery of how people describe their own reality, and how their beliefs are related to their actions in a social scene.



35. The nurse working in research correctly identifies which of the following to be mandatory for the ethical conduction of research in a hospital setting?
A) Clients must grant informed consent if they are to participate.
B) All interventions must benefit all clients.
C) The client must directly and personally benefit from the research.
D) Descriptive studies are more ethical than experimental studies.
Ans: A
Informed consent is an absolute prerequisite for clients who are asked to participate as subjects in a research study. Not all interventions will benefit all (or even any) clients. The risks and benefits of research are considered carefully in light of ethical principles, but this does not necessarily mean that every participant in a study stands to benefit from it. Ethical standards are applicable and achievable in every type of research, and descriptive studies are not necessarily more ethical than experiments.



Chapter 12

1. Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?
A) Place defining characteristics after the etiology and link them by the phrase “as  evidenced by.”
B) Phrase the nursing diagnosis as a client need.
C) Place the etiology prior to the client problem and linked by the phrase “related to.”
D) Incorporate subjective and judgmental terminology.
Ans: A
Defining characteristics should follow the etiology and be linked by the phrase “as evidenced by” when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase “related to.” Avoid using judgmental language and write in legally advisable terms.



2. In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?
A) Ineffective airway clearance as evidenced by inability to clear secretions
B) Ineffective health maintenance as evidenced by unhealthy habits
C) Ineffective breathing pattern related to pneumonia
D) Ineffective therapeutic regimen management due to smoking
Ans: A
The appropriately written nursing diagnosis is “ineffective airway clearance related to inability to clear secretions.” “Ineffective health maintenance related to unhealthy habits” is incorrect because it shows value judgments by the nurse. “Ineffective breathing pattern related to pneumonia” is incorrectly written because it includes a medical diagnosis. “Ineffective therapeutic regimen management due to smoking” is incorrect because the clause “due to” implies a direct cause-and-effect relationship.



3. The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?
A) The client is more vulnerable to certain problems than other individuals would be.
B) The diagnoses present significant risks for the development of medical diagnoses.
C) The data necessary to make a definitive nursing diagnosis is absent.
D) The diagnosis has yet to be confirmed by another practitioner.
Ans: A
Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. They do not denote a particular link to medical diagnoses nor do they require independent confirmation. Missing data is associated with possible nursing diagnoses.



4. A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented “Noncompliance related hostility” on the client’s chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?
A) Presuming to know the factors contributing to the problem
B) Identifying a problem that cannot be changed
C) Identifying a problem without corroborating evidence in the statement
D) Neglecting to identify potential complications related to the problem
Ans: A
Multiple factors may underlie the client’s response to education in a complex and emotionally charged situation, such as receiving a new ostomy. As a result, it is likely presumptuous to ascribe the client’s response to hostility. The problem is likely modifiable with a correct approach; the evidence underlying a nursing diagnosis is not normally explicit in the statement itself. The existence of potential complications is not central to the psychosocial nature of this client’s situation.



5. The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?
A) Validate the nursing diagnosis
B) Identify potential complications
C) Cross-reference the nursing diagnosis with medical diagnoses
D) Modify interventions based on the diagnosis
Ans: A
After writing a nursing diagnosis, it is important to verify and validate the diagnosis. This action should precede the modification of the client’s care. Nursing diagnoses do not always correlate with medical diagnoses and not every nursing diagnosis is accompanied by potential complications.



6. Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?
A) A cluster of several significant cues of data that suggest a particular health problem
B) A single, definitive cue that is closely associated with a common diagnosis
C) A cue that can be verified by objective, medical data
D) A group of related nursing diagnoses that exist within the same NANDA-approved domain
Ans: A
A data cluster is a grouping of client data or cues that points to the existence of a client health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. Medical corroboration is not always possible or necessary. The presence of multiple nursing diagnoses within one domain does not necessarily validate further diagnoses in that same domain.



7. In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
A) To collect information about subjective and objective data
B) To correlate nursing and medical diagnostic criteria
C) To identify etiologies of health problems
D) To evaluate mutually developed expected outcomes
Ans: C
The purpose of diagnosing, the second step in the nursing process, is to identify how an individual, a group, or a community responds to actual or potential health and life processes; to identify etiologies (factors that contribute to or cause health problems); and to identify resources or strengths that the individual, group, or community can draw on to prevent or resolve problems.



8. Which of the following client care concerns is clearly a nursing responsibility?
A) Prescribing medications
B) Monitoring health status changes
C) Ordering diagnostic examinations
D) Performing surgical procedures
Ans: B
Monitoring for health status changes is clearly a nursing responsibility. The other options are medical responsibilities, although in some instances an advanced practice nurse practitioner may be responsible for A and C.



9. After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?
A) Selecting nursing interventions to meet expected outcomes
B) Establishing a database of information for future comparison
C) Mutually establishing desired outcomes of the plan of care
D) Evaluating the effectiveness of the established plan of care
Ans: A
The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued client outcomes for which the nurse is responsible.



10. Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client?
A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client.
B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client.
C) The nurse must decide if he or she is qualified to make a nursing diagnosis and  will accept responsibility for treating it.
D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.
Ans: C
The term diagnosis means there is a problem requiring qualified treatment. The nurse must decide if he or she is qualified to make the diagnosis and will be able to treat it. If not, the nurse must refer the client to a qualified person for treatment.



11. A student is reviewing a client’s chart before giving care. She notes the following diagnoses in the contents of the chart: “appendicitis” and “acute pain.” Which of the diagnoses is a medical diagnosis?
A) Neither appendicitis nor acute pain
B) Both appendicitis and acute pain
C) Appendicitis
D) Acute pain
Ans: C
Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses describe problems treated by the nurse within the scope of independent nursing practice.



12. A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client’s physiologic response. This action is known as a:
A) medical diagnosis.
B) nursing diagnosis.
C) collaborative problem.
D) goal for care.
Ans: C
Collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize the complications of the event.



13. A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?
A) “I often have diarrhea after I eat spicy foods.”
B) “My skin is so dry I just can’t keep from scratching.”
C) “I get out of breath when I walk a few steps.”
D) “I just feel so bad about myself these days.”
Ans: C
Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting it. The term cue is often used to denote significant data, which “raises a red flag” to look for patterns or clusters of data that signal a nursing diagnosis. In this instance, the client’s statement of getting out of breath when walking would be a cue to assess other subjective and objective data related to the respiratory system.



14. What is the focus of a diagnostic statement for a collaborative problem?
A) The client problem
B) The potential complication
C) The nursing diagnosis
D) The medical diagnosis
Ans: B
To write a diagnostic statement for a collaborative problem, the nurse should focus on the potential complications of the problem and use “PC” (for potential complication), followed by a colon, and list the complications that might occur. For clarity, the nurse should link the potential complications and the collaborative problem by using “related to.”



15. Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?
A) Trust clinical judgment and experience over asking for help.
B) Respect clinical intuition, but never allow it to determine a diagnosis.
C) Recognize personal biases as a strength in formulating diagnoses.
D) Keep an open mind and trust your intuition when formulating diagnoses.
Ans: D
To correctly diagnose health problems, the nurse must be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy; trust clinical experience and judgment but be willing to ask for help when the situation demands more than his or her qualifications and experience can provide; respect clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of observations and continue to search for clues to verify intuition. The nurse must also recognize personal biases and keep an open mind.



16. A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby’s strengths?
A) Nothing; this observation is not important.
B) The mother is just behaving as all mothers do.
C) A baby is not capable of having strengths.
D) Nurturing is a strength for developing infants.
Ans: D
A strength, as assessed by the nurse during data interpretation and analysis, contributes to a client’s level of wellness. In this case, the obvious love of the mother for her baby indicates a significant strength in the normal growth and development of the baby.



17. A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data?
A) No problem
B) Possible problem
C) Actual problem
D) Clinical problem
Ans: A
The nurse reaches one of four basic conclusions after interpreting and analyzing the client data. Different nursing responses are possible for each conclusion. In this case, the nurse would most likely conclude there was no problem and reinforce the client’s health habits.



18. A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
A) No problem
B) Possible problem
C) Actual problem
D) Clinical problem
Ans: B
The nurse reaches one of four basic conclusions after interpreting and analyzing the client data: no problem, possible problem, actual or potential problem, or clinical problem. When dealing with a possible problem, the nurse must collect more data to confirm or disprove a suspected problem.



19. A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?
A) “needs nasal oxygen to improve breathing”
B) “cough related to ineffective airway clearance”
C) “ineffective airway clearance related to thick mucus”
D) “refuses to cough and expectorate thick mucus”
Ans: C
It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough.



20. A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?
A) disturbed thought processes
B) related to
C) Alzheimer’s disease
D) incoherent language
Ans: A
The purpose of the problem statement is to describe the health state or health problem of the client as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the client and what the client would like to change in his or her health status, it suggests client outcomes. NANDA recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. Disturbed thought processes is a NANDA-approved descriptor for this client problem. The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor, and in this case is Alzheimer’s disease. Incoherent language is considered a defining characteristic or subjective/objective data signaling the existence of an actual or potential health problem.



21. A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he “can’t live with this fear.” Which of the following diagnoses for this client is correctly written?
A) Post-trauma syndrome related to being attacked
B) Psychological overreaction related to being attacked
C) Needs assistance coping with attack
D) Mental distress related to being attacked
Ans: A
Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology. Overreaction and mental distress implies a value judgment by the nurse. Needs assistance addresses the need of the client.



22. Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Possible nursing diagnosis
D) Wellness diagnosis
Ans: B
Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. An actual nursing diagnosis has four components: label, definition, defining characteristics, and related factors.



23. A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase “Disturbed Self-Esteem” identify?
A) The expected outcome of the plan of care
B) A cue to determining a health problem
C) The major defining characteristic of a health problem
D) The health state or problem of the client
Ans: D
The problem, a part of a nursing diagnosis, describes the health state or health problem of the client as clearly and concisely as possible. It identifies what is unhealthy about the client and what the client would like to change. It also suggests client outcomes but is not an outcomes statement.



24. In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is “presence of large scar over left side of face”?
A) Etiology
B) Problem
C) Defining characteristics
D) Client need
Ans: A
The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The etiology directs nursing interventions.



25. A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem?
A) “I have assessed you and find you are fatigued.”
B) “I analyzed and interpreted your information as fatigue.”
C) “Why are you so tired all the time?”
D) “I think fatigue is a problem for you. Do you agree?”
Ans: D
After a tentative nursing diagnosis is made, it should be validated. Clients who are able to participate in decision making should be encouraged to validate the diagnosis.



26. Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?
A) Defining the domain of nursing practice
B) Informing patients of their care
C) Improving communication among nurses
D) Structuring curricular content
Ans: C
Although all the choices are correct, improved communication among nurses and other health care professionals is probably the most important benefit that accurate, up-to-date nursing diagnoses offer nurses.



27. According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
A) Ineffective airway clearance
B) Ineffective coping
C) Impaired urinary elimination
D) Risk for body image disturbance
Ans: D
Risk for disturbed body image is the least priority among all the nursing diagnoses mentioned, according to the Maslow’s hierarchy. Body image disturbance is not vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other options could be an actual diagnosis present in the client. Ineffective airway clearance is the most important diagnosis because it is vital to life. Impaired urinary elimination is the next most important diagnosis because it is a physiological need. Ineffective coping is a social need, followed by the least important diagnosis of disturbed body image.



28. A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
A) Impaired physical mobility
B) Disturbed body image
C) Risk for infection
D) Risk for social isolation
Ans: B
The diagnosis of disturbed body image is appropriate for the client because he is worried about the appearance of his legs due to swelling and the external fixation device. There is no mention about impaired physical mobility or risk for social isolation in the client’s concern. There may be a risk of infection, but the client does not mention it.



29. A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
A) Risk for impaired physical mobility due to surgery
B) Ineffective denial related to poor coping mechanisms
C) Disturbed body image related to the incision scar
D) Risk of injury related to surgical outcomes
Ans: C
The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms, and injury related to surgical outcomes are also not related to the client’s concern.



30. A nurse who is caring for an unresponsive client formulates the nursing diagnosis, “Risk for Aspiration related to reduced level of consciousness.” The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
A) Is written as a two-part statement
B) Describes human response to a health problem
C) Describes potential for enhancement to a higher state
D) Made when not enough evidence supports the problem
Ans: A
The risk diagnoses are written as two-part statements because they do not include defining characteristics. An actual nursing diagnosis describes human response to a health problem. Wellness diagnoses describe potential for enhancement to a higher state. A possible nursing diagnosis is made when not enough evidence supports the problem.



31. After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?
A) Impaired urinary elimination
B) Readiness for enhanced sleep
C) Risk for infection
D) Possible impaired adjustment
Ans: A
Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.



32. What is the nurse accountable for, according to the state nurse practice act?
A) Continuing education
B) Nursing diagnoses
C) Prescribing medications
D) Mentoring other nurses
Ans: B
State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable.



33. A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or …
A) Categorizing
B) Diagnosing
C) Grouping
D) Clustering
Ans: D
Cue clustering brings together cues that if viewed separately would not convey the same meaning.



34. The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.
A) Dysphagia
B) Bowel Incontinence
C) Impaired Swallowing
D) Impaired Physical Mobility
E) Risk for Hemiparesis
Ans: B, C, D
Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all health problems that can be independently prevented or resolved by nursing practice. Dysphagia and hemiparesis are medical diagnoses.



35. Which of the following reflects the diagnosis phase?
A) The nurse identifies that the client does not tolerate activity.
B) The nurse performs wound care using sterile technique.
C) The nurse sets a tolerable pain rating with the client.
D) The nurse documents the client’s response to pain medication.
Ans: A
Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client’s response to pain medication is an example of evaluation.



Chapter 24

1. Upon auscultation of a client’s heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following?
A) A dysrhythmia
B) Tachycardia
C) Bradycardia
D) Hypertension
Ans: A
An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.



2. The nurse notes a difference in systolic blood pressure readings between the client’s arms. How will the nurse approach subsequent readings based upon this difference in blood pressures?
A) The nurse will use the arm with the highest reading.
B) The nurse will use the arm with the lowest reading.
C) The nurse will average the two blood pressures and document this average.
D) The nurse will obtain a blood pressure on the client’s leg.
Ans: A
An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10-mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.



3. An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?
A) Assess the client’s temperature by axilla.
B) Assess the client’s skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client’s temperature.
D) Take the client’s temperature rectally.
Ans: A
The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.



4. When assessing a client’s vital signs, a nursing student has explained each of her next actions prior to assessing the client’s temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client’s respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse’s decision?
A) Respirations have both autonomic and voluntary control.
B) The nurse likely assessed the client’s respiratory rate simultaneous to heart rate.
C) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D) Tachypnea is an expected finding among hospitalized individuals.
Ans: A
Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.



5. Which of the following clients should the nurse monitor vital signs every four hours?
A) A client in a critical care unit
B) A client hospitalized for high blood pressure
C) a resident in a long-term care facility
D) a long-term care resident on Medicare A
Ans: B
Vital signs are assessed at least every four hours in hospitalized clients with elevated temperatures, with high or low blood pressures, with changes in pulse rate or rhythm, or with respiratory difficulty. In critical care settings, technologically advanced devices are used to continually monitor clients’ vital signs. Regulations require monthly vital sign measurements in long-term care residents, but if the resident is classified as Medicare A (meaning discharged from the hospital and Medicare is paying for the stay to receive skilled nursing care) vital signs are taken daily.



6. Which is the primary source of heat in the body?
A) Hormones
B) Metabolism
C) Blood circulation
D) Muscles
Ans: B
The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise.



7. A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer?
A) Evaporation
B) Radiation
C) Conduction
D) Convection
Ans: D
Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.



8. Which of the following is an average normal temperature in Centigrade for a healthy adult?
A) oral: 37.0°C
B) rectal: 36.5°C
C) axillary: 37.5°C
D) tympanic: 34.4°C
Ans: A
The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.



9. What anatomic site regulates the pulse rate and force?
A) Thermoregulatory center
B) Cardiac sinoatrial node
C) Cardiac atria and valves
D) Peripheral chemoreceptors
Ans: B
The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial node. The other anatomic sites may affect, but do not regulate, the pulse rate and force.



10. A client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?
A) Left ventricle pumps more forcefully; pulse is stronger
B) Stimulates the vagus nerve to increase the rate
C) Stimulates the vagus nerve to decrease the rate
D) Right ventricle is less efficient; pulse is thready
Ans: C
Parasympathetic stimulation via the vagus nerve decreases the heart rate. The Valsalva maneuver stimulates the vagus nerve, resulting in a slower pulse rate.



11. The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?
A) Absent and infrequent
B) Shallow and slow
C) Rapid and deep
D) Noisy and difficult
Ans: C
Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood tends to increase the rate and depth of respirations. An increase in carbon dioxide is the most powerful respiratory stimulant.



12. A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term “afebrile” indicate?
A) Normal body temperature
B) Decreased body temperature
C) Increased body temperature
D) Fluctuating body temperature
Ans: A
A person with normal body temperature is referred to as afebrile.



13. A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?
A) Bradycardia
B) Tachycardia
C) Dysrhythmia
D) Bigeminal
Ans: B
The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.



14. A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?
A) “Do you have problems breathing when you walk up stairs?”
B) “Does your medication help you breathe better?”
C) “How many pillows do you sleep on at night to breathe better?”
D) “Tell me about your breathing difficulties since you stopped smoking.”
Ans: C
People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.



15. What population is at greatest risk for hypertension?
A) Hispanic
B) White
C) Asian
D) African American
Ans: D
Race is a factor in hypertension, a disorder characterized by high blood pressure. It is more prevalent and more severe in African American men and women.



16. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?
A) Stroke
B) Anemia
C) Cancer
D) Infection
Ans: A
Hypertension is the most important risk factor associated with stroke.



17. A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?
A) “Eat a diet high in fruits and vegetables.”
B) “Remember to drink eight to 10 glasses of water a day.”
C) “It is important to have increased fats in your diet.”
D) “Put away the salt shaker and eat low-salt foods.”
Ans: D
High salt intake is a high risk factor for the development of hypertension.



18. A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client’s blood pressure is 90/50. What is the name for this condition?
A) Orthostatic hypotension
B) Orthostatic hypertension
C) Ambulatory bradycardia
D) Ambulatory tachycardia
Ans: A
Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.



19. What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?
A) Rectal
B) Tympanic
C) Oral
D) Axillary
Ans: C
Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults, as well as in infants and young children. This is due to the danger of breaking the thermometer in the mouth.



20. A nurse is taking a client’s temperature and wants the most accurate measurement, based on core body temperature. What site should be used?
A) Rectal
B) Oral
C) Axillary
D) Forehead
Ans: A
Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites.



21. A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy?
A) It is an embarrassing and painful assessment.
B) Thermometer insertion stimulates the vagus nerve.
C) It is less expensive to take oral temperatures.
D) It is to avoid perforating the wall of the rectum.
Ans: B
Because inserting the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature may not be allowed for clients after cardiac surgery.



22. As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
A) The blood pressure does not change.
B) The blood pressure is erratic.
C) The blood pressure decreases.
D) The blood pressure increases.
Ans: D
The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system. This is reflected in an increased blood pressure.



23. Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate?
A) The radial pulse is more rapid than the apical pulse.
B) This is a normal finding and should be ignored.
C) The client’s arteries are very compliant.
D) Not all of the heartbeats are reaching the periphery.
Ans: D
A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.



24. A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?
A) Reading is erroneously high
B) Reading is erroneously low
C) Pressure on the cuff with be painful
D) It will be difficult to pump up the bladder
Ans: A
The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.



25. Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?
A) Systolic pressure
B) Diastolic pressure
C) Auscultatory gap
D) Pulse pressure
Ans: A
The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.



26. An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?
A) Bradycardia
B) Tachycardia
C) Dysrhythmia
D) Normal pulse
Ans: B
Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse rate.



27. A client in a physician’s office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension?
A) It depends on the time of day the BP was taken.
B) It depends on whether the client is male or female.
C) No, a single BP reading should not be used.
D) Yes, this reading is high enough to be significant.
Ans: C
The American Heart Association recommends that blood pressure readings be averaged on two or more subsequent occasions before diagnosing hypertension.



28. All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned?
A) An older adult
B) A pregnant adolescent
C) A junior high football player
D) An infant 2 months of age
Ans: D
A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms.



29. A home health care nurse notices that his assigned client uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?
A) “Just flush the glass and mercury down the toilet.”
B) “Do not vacuum the area where it breaks.”
C) “Open the windows and close off the room for an hour.”
D) “Throw away any clothing exposed to the mercury.”
Ans: A
Mercury should never be flushed down the toilet. Mercury is not only hazardous to people but it also pollutes the environment, especially if it gets into water. The other responses are correct.



30. A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client’s condition?
A) Hyperventilation
B) Hypoventilation
C) Dyspnea
D) Apnea
Ans: C
Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client’s condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than four to six minutes.



31. A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?
A) Femoral
B) Temporal
C) Pedal
D) Radial
Ans: D
The radial artery is the site most commonly assessed in a clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior medial aspect of the thigh, just below the inguinal ligament, about halfway between the anterior superior iliac spine and the symphysis pubis. The pulsation of the temporal artery is palpated in front of the upper part of the ear; however, it is not the site most commonly assessed in the clinical setting. The pedal pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the dorsalis pedis pulse may be congenitally absent in some clients.



32. A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent?
A) Pulse rate
B) Pulse quality (amplitude)
C) Pulse rhythm
D) Pulse deficit
Ans: B
Pulse quality/amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (4+). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.



33. A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured?
A) Rectal
B) Oral
C) Skin surface
D) Axillary
Ans: A
Core temperatures are measured by nurses rectally. Surface body temperatures are measured at oral (sublingual), axillary, and skin surface sites.



34. The nurse at the beginning of the shift plans to see which client first, based on the following vital signs?
A) The client age 2 years whose respiratory rate is 16 breaths/minute
B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC)
C) The client age 7 years whose pulse is 120 beats/minute
D) The client age 10 years whose blood pressure is 102/62 mmHg
Ans: A
Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients’ vital signs are within normal limits.



35. A nurse walks into a client’s room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next?
A) Take vital signs again in 15 to 30 minutes.
B) Document the data and report it later.
C) Ask the client if he is anxious or afraid.
D) Report findings to the physician immediately.
Ans: D
The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.



Chapter 36

1. During a visit to the pediatrician’s office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when …
A) the child can recognize bladder fullness.
B) the child can hold the urine for four to five hours.
C) The child cannot control urination until seated on the toilet.
D) The child ignores the desire to void.
Ans: A
Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet.



2. A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?
A) Suprapubic catheter
B) Indwelling urethral catheter
C) Intermittent urethral catheter
D) Straight catheter
Ans: A
A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.



3. A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?
A) Increased output of dilute urine
B) Increased urine concentration
C) A risk of urinary tract infections
D) Transient incontinence and increased urine production
Ans: A
Diuretics result in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding.



4. A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra?
A) Has different innervation
B) No connection with bladder
C) Shorter in length
D) Longer in length
Ans: C
The anatomy of the urethra differs in males and females. The male urethra is about 51/2 to 61/4 inches (13.7 to 16.2 cm) long. The female urethra is about 11/2 to 21/2 inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization and risk for infection.



5. Which of the following describes the term micturition?
A) Emptying the bladder
B) Catheterizing the bladder
C) Collecting a urine specimen
D) Experiencing total incontinence
Ans: A
The process of emptying the bladder is known as urination, micturition, or voiding.



6. A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training?
A) The child should be able to hold urine for four hours.
B) The child should be between 18 and 24 months old.
C) The child should be able to communicate the need to void.
D) The child does not need the desire to gain control of voiding.
Ans: C
Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function, and toilet training usually begins at about 2 to 3 years of age. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. The child’s desire to gain control is also important.



7. A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?
A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection.
B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency.
C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.
D) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence.
Ans: C
Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result.



8. A nurse is assessing the urine output of a client with Parkinson’s disease who is on levodopa. Which of the following is a common finding for a client on this medication?
A) The urine may be brown or black.
B) The urine may be blood-tinged.
C) The urine may be green or blue-green.
D) The urine may be orange or orange-red.
Ans: A
Levodopa (l-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine.



9. A client tells the nurse, “Every time I sneeze, I wet my pants.” What is this type of involuntary escape of urine called?
A) Urinary incontinence
B) Urinary incompetence
C) Normal micturition
D) Uncontrolled voiding
Ans: A
The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence.



10. During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom?
A) Urinary incontinence
B) Urinary retention
C) Involuntary voiding
D) Urinary frequency
Ans: B
Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often than usual.



11. A nurse is assessing the urine on a newborn’s diaper. What would be a normal assessment finding?
A) Scanty to no urine
B) Highly concentrated urine
C) Light in color and odorless
D) Dark in color and odorous
Ans: C
Infants are born with little ability to concentrate urine. An infant’s urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine.



12. An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?
A) Diminished kidney ability to concentrate urine
B) Increased bladder muscle tone causing urinary frequency
C) Increased bladder contractility causing urinary stasis
D) Decreased intake of fluids during daytime hours
Ans: A
Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability to concentrate urine that may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia.



13. After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention?
A) Between the symphysis pubis and the umbilicus
B) Over the costovertebral region of the flank
C) In the left lower quadrant of the abdomen
D) Between ribs 11 and 12 and the umbilicus
Ans: A
When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder.



14. A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine?
A) Compare the amount of output with intake.
B) Use a clean measuring cup for each voiding.
C) Tell the client to wash the urethra before voiding.
D) Wear gloves when handling a client’s urine.
Ans: D
Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing.



15. A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching?
A) “I need to tell you that I am having my menstrual period.”
B) “I will void into the specimen bottle you gave me.”
C) “I will keep the toilet paper in the specimen.”
D) “I will be sure that no stool is included in my urine.”
Ans: C
Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a clean receptacle and avoid contamination with stool. Note on the request form if a woman is having her menstrual period. Instruct clients not to put toilet paper into the urine because this makes analysis more difficult.



16. A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen?
A) Pour urine from the collecting bag.
B) Remove the catheter and ask the client to void.
C) Aspirate urine from the collecting bag.
D) Aspirate urine from the collection port.
Ans: D
When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port.



17. A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?
A) Void and discard the urine.
B) Begin the collection at a specific time.
C) Add the first voiding to the specimen.
D) Keep the urine warm during collection.
Ans: A
The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, or the collected urine is kept cold through refrigeration or putting it on ice.



18. An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses?
A) Social Isolation
B) Impaired Adjustment
C) Defensive Coping
D) Impaired Memory
Ans: A
Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person’s self-concept, causing him or her to feel like a social outcast.



19. A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding?
A) Assist him to a standing position.
B) Tell him he has to void to be discharged.
C) Pour cold water over his genitalia.
D) Ask his wife to assist with the urinal.
Ans: A
Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, encourage them to void while standing at the bedside unless this is contraindicated.



20. A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults?
A) 1 to 2 (4-oz) glasses per day
B) 5 to 6 (6-oz) glasses per day
C) 8 to 10 (8-oz) glasses per day
D) 16 to 20 (12-oz) glasses per day
Ans: C
Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine, sodium, and sugar.



21. A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill?
A) Deflate the balloon by aspirating the fluid.
B) Ask the client to take several deep breaths.
C) Tell the client burning may initially occur.
D) Wash hands and put on gloves.
Ans: D
Although all the steps listed are correct, the first step of any skill involving body fluids is to wash hands and don gloves.



22. A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next?
A) Report this abnormal finding to the physician.
B) Perform another catheterization to verify the amount.
C) Document this normal finding for postvoid residual.
D) Palpate the abdomen for a distended bladder.
Ans: C
A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR.



23. A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure?
A) A clean catheter and rubber gloves
B) A sterile catheterization kit or tray
C) Solutions to sterilize the urethra
D) Solutions to sterilize the vagina
Ans: B
The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray.



24. A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information?
A) “I understand these will help me control stress incontinence.”
B) “I know this is also called pelvic floor muscle training.”
C) “I will do these 30 to 80 times a day for two months.”
D) “I will contract the muscles in my abdomen and thighs.”
Ans: D
Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contract are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises.



25. A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client?
A) Public embarrassment
B) Skin breakdown and UTI
C) Inability to control urine
D) Odor and leakage
Ans: B
Clients frequently turn to absorbent products for protection when they are incontinent of urine and if they have not had this condition properly diagnosed and treated. When used improperly, such products may cause skin breakdown and place the client at risk for a UTI.



26. A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information?
A) “I will take showers rather than baths.”
B) “I will wear underpants with cotton crotches.”
C) “I will tell my parents if I have burning or pain.”
D) “I will wipe back to front after going to the toilet.”
Ans: D
Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum).



27. A client is taking diuretics. What should the nurse teach the client about his urine?
A) Urinary output will be decreased.
B) Urinary output will be increased.
C) Urine will be a pale yellow color.
D) Urine may be brown or black.
Ans: C
Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication.



28. A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client’s anxiety?
A) “We do these procedures every day, so you don’t need to worry.”
B) “I have had this done to me, and it only hurt for a little while.”
C) “Why are you so worried? Do you think you have a tumor?”
D) “Let me explain to you what they do during this procedure.”
Ans: D
Various diagnostic procedures, typically performed in a hospital operating room or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client’s anxiety.



29. A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client’s condition?
A) Anuria
B) Oliguria
C) Polyuria
D) Dysuria
Ans: D
The nurse could document the client’s condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations.



30. A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?
A) Condom catheter
B) Urinary bag
C) Straight catheter
D) Retention catheter
Ans: C
The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.



31. A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following?
A) “I should take frequent bubble baths.”
B) “I need to void after sexual intercourse.”
C) “I should wipe from back to front after going to the bathroom.”
D) “I need to wear pants that are snug fitting.”
Ans: B
The client’s statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination.



32. A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following?
A) Polyuria
B) Dysuria
C) Nocturia
D) Hematuria
Ans: B
Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.



33. What is the micturition reflex?
A) The process of filtration beginning with the glomerulus
B) The act of bladder contraction and perceived need to void
C) The reabsorption of the substances the body wants to retain
D) The secretion of electrolytes that are harmful to the body
Ans: B
Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.



34. A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client?
A) Supine
B) Sims’
C) High Fowler’s
D) Dorsal recumbent
Ans: A
Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning.



35. The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client?
A) Risk for activity intolerance
B) Risk for impaired skin integrity
C) Risk for infection
D) Risk for falls
Ans: B
A client who is incontinent, utilizes adult diapers, and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area.



Chapter 44

1. A woman tells a nurse, “My husband wants to have sex when I have my period. Is that safe?” What is an appropriate answer?
A) “No, the flow of blood could be slowed down.”
B) “No, it will tend to make your cramps worse.”
C) “Yes, but be sure to douche after sex.”
D) “Yes, there is no reason not to have sex then.”
Ans: D
There is no scientific rationale to support abstinence from sexual activity during menses. Sexual activity during menses may be more pleasurable and may reduce or relieve cramping.



2. A male client age 15 years is experiencing nocturnal emissions. What nursing intervention would be appropriate for this client?
A) Ask the parents to consult with a specialist.
B) Tell the client to limit physical activity in the evening.
C) Ask the primary care provider to perform a physical examination.
D) No intervention is necessary as this is a normal phenomenon.
Ans: D
Many males, particularly adolescent boys, may experience a phenomenon known as a nocturnal emission, or “wet dream.” These ejaculatory episodes occur during sleep without physical stimulation. They are perfectly normal and do not represent any sort of deviation.



3. In which of the phases of the sexual response cycle may secretions from Cowper’s glands appear at the glans of the penis?
A) Excitement
B) Plateau
C) Orgasm
D) Resolution
Ans: B
In the male, secretions from Cowper’s glands may appear at the glans of the penis during the plateau phase.



4. A male client tells the nurse that he does not understand why he feels the way he does when he is sexually excited. What would the nurse teach the client?
A) “I don’t know, but I will ask my boyfriend if he can describe his feelings to me.”
B) “The sexual response cycle includes excitement, plateau, orgasm, and resolution.”
C) “That is something that just happens and nobody knows why.”
D) “Isn’t sex wonderful? I think it has different parts to the experience.”
Ans: B
The sexual response cycle is a total body response with many physiologic changes throughout the body. The cycle has four phases: excitement, plateau, orgasm, and resolution.



5. A woman age 70 years tells the nurse that she is still sexually active. How would the nurse respond?
A) “You are too old for that kind of behavior.”
B) “Tell me what you enjoy the most.”
C) “You can be sexually active as long as you want to be.”
D) “There comes a time in life when this is no longer important.”
Ans: C
Sexual activity does not need to be hindered by age. Couples (or individuals) may continue intimate relationships for as long as they desire.



6. A young woman has been diagnosed with human papilloma virus (HPV). As a result, she will be at increased risk for which of the following?
A) Infertility
B) Genital warts
C) Vaginal bleeding
D) Cervical cancer
Ans: D
Infection with human papillomavirus (HPV), a sexually transmitted infection, increases a woman’s risk for cervical cancer.



7. A nurse is educating a student nurse on how STIs affect the health of their clients. Which of the following statements accurately describes an effect of an STI?
A) STIs are most common in young to middle adulthood populations.
B) The incidence of STIs is decreasing due to health promotion efforts.
C) Most of the time STIs cause no symptoms, especially in women.
D) Health problems caused by STIs are more severe and frequent in men.
Ans: C
Most of the time, STIs cause no symptoms, particularly in women. STIs affect men and women of all backgrounds and economic levels; they are most prevalent among teenagers and young adults. The incidence of STIs is rising, in part because in the last few decades, young people have become sexually active earlier yet are marrying later. Health problems caused by STIs tend to be more severe and more frequent for women than for men, in part because the frequency of asymptomatic infection means that many women do not seek care until serious problems have developed.



8. What term is used to describe painful intercourse?
A) Dyspareunia
B) Dysmenorrhea
C) Impotence
D) Vulvodynia
Ans: A
Dyspareunia is painful intercourse. Dysmenorrhea is pain with menstruation. Impotence is erectile failure. Vulvodynia is vulvar pain.



9. An adolescent male tells the nurse that he is afraid his penis will be damaged because he masturbates every day. The nurse’s response is based on what knowledge?
A) Masturbation is not a normal activity.
B) Only adult men masturbate.
C) Masturbation may delay puberty.
D) Self-stimulation is a normal activity.
Ans: D
Masturbation is a technique of sexual expression in which an individual practices self-stimulation. People masturbate regardless of age, sex, or marital status. It is a normal activity.



10. A heterosexual couple enjoys both anal and vaginal intercourse. What may result from these sexual activities?
A) Feelings of guilt and shame
B) Vaginal infections
C) Damage to the vagina
D) Penile infections
Ans: B
Once the penis is placed in the rectum, it should not be introduced into the vagina without thorough cleansing because microorganisms present in the rectum may cause vaginal infections.



11. While answering questions posed by a nurse during a health history, a young woman says, “Before my period I get headaches, am moody, and my breasts hurt.” What is the client experiencing?
A) Perimenopause
B) Menarche
D) Menses
Ans: C
Menstrual cycle–related distress, commonly called premenstrual (tension) syndrome (PMS), occurs in 50% to 90% of the female population. It is characterized by irritability, emotional tension, anxiety, mood changes, headache, breast tenderness, and water retention.



12. What are the primary nursing considerations when assisting with, or conducting, a physical assessment of the genitalia?
A) Ensuring sterility of all equipment and supplies
B) Respecting the client’s privacy and modesty
C) Providing a means for cleansing the area
D) Leaving the room during the assessment
Ans: B
When assisting with, or conducting, a physical assessment of the genitalia, keep the client comfortable and respect his or her privacy and modesty.



13. What is the most significant difficulty regarding sexuality faced by people taking medications for hypertension?
A) Medications result in increased desire for sex.
B) Medications change sexual functioning.
C) Clients experience a growth of body hair.
D) Clients experience increased body odors.
Ans: B
The most significant difficulty a person with hypertension faces regarding sexuality is that the medication used to control the disease frequently causes a change in sexual functioning. Impotence is a common response in men.



14. What do most nursing interventions pertaining to sexuality involve?
A) Teaching to promote sexual health
B) Examinations to identify sexually transmitted infections
C) Advocacy for those with sexual dysfunctions
D) Maintaining confidentiality and privacy
Ans: A
Most nursing interventions pertaining to a client’s sexuality involve education to promote sexual health. Major goals of education are a change in knowledge, a change in client attitude, or a change in behavior.



15. A woman is using Depo-Provera as a method of birth control. What common side effect should the nurse explain to the client?
A) Constipation
B) Nausea
C) Irregular bleeding
D) Pregnancy
Ans: C
Depo-Provera is a progestin-only hormonal birth control system. One injection can prevent pregnancy for 12 weeks and is 99.7% effective. Irregular bleeding is the most common side effect.



16. A nurse is explaining the use of an IUD to a female client interested in obtaining contraception. Which of the following statements regarding the IUD is correct?
A) The intrauterine device (IUD) is an object that is placed by the client within the uterus to prevent implantation of a fertilized ovum.
B) IUDs are small devices made of flexible plastic that provide irreversible birth control.
C) IUDs do not prevent fertilization of the egg.
D) IUDs seem to affect the way the sperm or egg moves.
Ans: D
IUDs seem to affect the way the sperm or egg moves. IUDs are small devices made of flexible plastic that provide reversible birth control. The intrauterine device (IUD) is an object that is placed by a physician or nurse practitioner within the uterus to prevent implantation of a fertilized ovum. IUDs usually prevent fertilization of the egg, but the precise mechanism by which it works is unknown.



17. A nurse is counseling a female victim of sexual assault. Which of the following statements accurately describes the increased risks for this client?
A) The client is three times more likely to suffer from depression.
B) The client is 10 times more likely to suffer from post-traumatic stress disorder.
C) The client is 20 times more likely to abuse alcohol and 26 times more likely to abuse drugs.
D) The client is 20 times more likely to contemplate suicide.
Ans: A
Victims of sexual assault are 3 times more likely to suffer from depression, 6 times more likely to suffer from post-traumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide.



18. A nurse is responding to sexual harassment from a client at work. Which of the following is a recommended guideline for dealing with this behavior?
A) If confronted by management, deny any feelings about being harassed.
B) Do not confront the person harassing you in person.
C) Set and enforce limits to the behavior and maintain boundaries.
D) Document the incident but do not report it to the supervisor unless harassment continues.
Ans: C
The following assertive response is recommended and supports the nurse in maintaining his or her self-respect; it encourages the client to accept responsibility for his or her behavior. Be self-aware: Do not deny feelings about being harassed. Confront: Provide feedback to the client in a nonthreatening way and clearly state what behavior is or is not acceptable. Set limits: Define clear and reasonable consequences that will be enforced if the behavior continues. Enforce the stated limits: Maintain boundaries. Report: Document the incident and submit to the supervisor.



19. A woman complains of pain with intercourse. What client medications should the nurse check for that contribute to dyspareunia?
A) Antihistamines
B) Calcium supplements
C) Antibiotics
D) Antihypertensives
Ans: A
Common causes of dyspareunia are organic problems, including inadequate lubrication at the vaginal opening or within the vaginal walls. Medications that cause dyspareunia include antihistamines, certain tranquilizers, marijuana, and alcohol.



20. After instructing the male client on the performance of a testicular examination, the nurse instructs the client to perform the examination how often?
A) Monthly
B) Weekly
C) Bi-monthly
D) Bi-yearly
Ans: A
The client should perform a testicular examination monthly.



21. The client suffered a myocardial infarction (MI) and has shared with the nurse that he is reluctant to resume sexual activity. He is worried about having another MI. The nurse discusses various methods of sexual expression and points out that the most important body area for sexual arousal and stimulation is which of the following?
A) Breasts
B) Skin
C) Brain
D) Genitalia
Ans: C
The human body contains many erogenous zones, areas that when stimulated cause sexual arousal and desire. These include the genitalia, the skin, and the breasts, but the most important body area for sexual arousal and stimulation is the brain.



22. The nurse is providing sexual education to a group of teenagers. One of the class members reports feeling sexually aroused when her boyfriend strokes her arms. The nurse points out that the human body has many erogenous zones, the largest being which of the following?
A) Skin
B) Brain
C) Genitalia
D) Breasts
Ans: A
The human body contains many erogenous zones, areas that when stimulated cause sexual arousal and desire. These include the genitalia, the brain, and the breasts, but the largest erogenous zone is the skin.



23. The clinic nurse sees the client today and asks about his chief complaint. The client describes to the nurse his inability to attain an erection. Which of the following would be a priority for the nurse to assess? Choose all that apply.
A) Medication history
B) Specifics about sexual problem
C) Sleep history
D) Physical activity history
E) History of diabetes
Ans: A, B, E
Assessment priorities for erectile dysfunction should include history of hypertension, current medications, diabetes, and specifics about the erectile problem. Physical activity should not adversely affect ability to attain an erection. Unless the client is severely sleep deprived, this also should not affect erectile ability.



24. During a class for 5th- and 6th-grade girls about menstruation, one student comments that she has heard that girls smell bad during their menses. Other students chime in saying they have heard the same thing and ask how to prevent odors. The nurse correctly answers with which of the following solutions?
A) Stay at home during heaviest flow
B) Use deodorizing pads and tampons
C) Utilize good hygiene and regular bathing
D) Change pads or tampons at least daily
Ans: C
Deodorized pads and tampons do little to minimize odor and can cause chemical irritation to the vulva and vagina. Good hygiene and regular bathing are much more effective during menses to prevent odor. Pads and tampons should be changed frequently to prevent odor and irritation from wetness, usually every few hours.



25. The nurse is caring for a female 29 years of age who is admitted with chronic pain secondary to rheumatoid arthritis. She confides in the nurse that she would like to be able to have sex with her husband but it just hurts too much. The nurse’s best response is which of the following?
A) After a time that sort of thing doesn’t matter.
B) Is your husband willing to forgo sex?
C) It may be time to put that behind you.
D) Modified positions may be possible.
Ans: D
The desire for human warmth and contact does not cease because of pain. Altered or modified positions for coitus are sometimes necessary, and discussing these with clients can be an important part of implementing the nursing process. The nurse should not discourage the client from wanting to enjoy sex, but should explore ways to help her.



26. A boy age 13 years visits the school nurse’s office and asks to speak privately with her. He looks very upset and embarrassed and struggles to make eye contact with the nurse. After some stuttered stops and starts, he finally asks about masturbating and if the things he has heard about it are true. The nurse provides correct education and information for the young man about masturbation by telling him which of the following? Choose all that apply.
A) It is a technique of self-stimulation
B) People do it regardless of age or gender
C) Masturbation can lead to blindness
D) Masturbation is not dirty or wrong
E) Masturbation can decrease intelligence
Ans: A, B, D
Masturbation is a technique of sexual expression in which an individual practices self-stimulation. It is a way for a person to learn what he or she prefers during stimulation and what feels good. People masturbate regardless of sex, age, or marital status. Masturbation is not dirty and will not lead to blindness or insanity.



27. The nurse is caring for a female age 45 years who discloses during the admission nursing history that she is no longer able to enjoy sex with her husband because it causes too much pain in her vagina. The nurse includes which of the following nursing diagnoses in the client’s care plan related to this information?
A) Sexual Dysfunction: Dyspareunia
B) Altered Sexuality Patterns: Change in sexual expression
C) Altered Sexuality Patterns: Loss of desire
D) Altered Sexuality Patterns: Change in positioning
Ans: A
“Sexual Dysfunction: Dyspareunia” is the correct choice because “dyspareunia” means painful intercourse. “Altered Sexuality Patterns: Change in sexual expression” is more about not being able to do what is usual for a particular person or client. The client has no loss of desire, but cannot enjoy sex because of pain. The problem is not about positioning, but about vaginal pain with intercourse.



28. A new client has come to the clinic wanting a method of birth control. The client asks about a diaphragm. What would the nurse teach this client about a diaphragm?
A) One size fits all females.
B) The diaphragm must be used during each episode of sexual activity.
C) A diaphragm’s effectiveness does not require spermicidal jelly.
D) The diaphragm may be removed an hour following intercourse.
Ans: B
The diaphragm must be used during each episode of sexual activity. It must be left in six hours after intercourse and should be used with spermicidal jelly. There are different sizes of diaphragms, and the client needs to be fitted by the health care practitioner.



29. The nursing instructor is talking with the junior nursing class about male reproductive issues. The instructor tells the students that the causes of erectile dysfunction include which of the following? Select all that apply.
A) Alcoholism
B) Spinal cord trauma
C) Tadalafil
D) Phosphodiesterase-5 inhibitors
E) Diabetes
Ans: A, B, E
Causes include cardiovascular disease, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hyperthyroidism, and hypothyroidism), alcoholism, chronic renal failure, genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin lymphoma, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury, multiple sclerosis), trauma to the pelvic or genital area, alcohol, smoking, medications, and drug abuse. Phosphodiesterase-5 inhibitors, which include Tadalafil, are used to treat erectile dysfunction; they don’t cause it.



30. The nurse is conducting a class on human sexual response. The participants have understood the education when they identify that, during the excitement phase of the sexual response, the man may experience what?
A) Nipple erection
B) Hypotension
C) Bradycardia
D) Decreased blood flow to genitals
Ans: A
Some of the physiologic changes include an increase in heart rate and blood pressure, and the appearance of a pink to red flush to the skin. The first obvious sign of arousal in the man is an erection of the penis caused by increased pelvic congestion of blood. The scrotum noticeably elevates, thickens, and enlarges. The skin of the penis and scrotum turns a deep reddish-purple in response to congestion and arousal. Male nipples may also harden and become erect.



31. Which of the following questions or statements would be most useful for the nurse to make when eliciting information about a client’s sexual history?
A) “We need to talk about this.”
B) Why did you have unprotected sex?
C) “How would you describe the problem?
D) I need to know sex partners’ numbers.”
Ans: C
A helpful way to elicit information about a client’s sexual history is to ask, How would you describe the problem?



32. The nurse conducting a class on human sexuality includes which of the following about gender identity?
A) It is opposite of biologic gender.
B) It may be the same as or different from biologic gender.
C) It is determined by male (XY) or female (XX) chromosomes.
D) It is determined by physical characteristics.
Ans: B
Gender sex denotes chromosomal sexual development. Gender identity is the inner sense one has of being male or female, which may be the same or different from biologic gender.



33. When conducting a class on sexuality with teenagers, the nurse includes that sexuality is which of the following?
A) External appearance of one’s genitalia as male or female
B) Male or female internal organ structure and function
C) How one experiences maleness or femaleness physically, emotionally, and mentally
D) The pleasure experienced during sexual activity
Ans: C
A critical component of human identity and well-being, sexuality involves how a person exhibits and experiences maleness or femaleness physically, emotionally, and mentally. Sexuality is defined not only by a person’s genitalia and hormones, but also by attitudes and feelings.



34. Parents of an infant express concern because the infant is touching his genitals. What should the nurse teach the parents?
A) Self-manipulation of genitals is normal behavior in an infant.
B) Have the child wear clothes that prohibit touching.
C) If this bad behavior continues, seek counseling.
D) Make him have time out every time it happens.
Ans: A
Infants touch their genitals. This is normal behavior for a toddler. Punishment of genital fondling may lead to guilt and shame regarding sexual behavior later in life.



35. Which of the following occurs in the male during the resolution phase of the sexual response cycle?
A) The penis becomes erect due to increased pelvic congestion of blood.
B) Involuntary spasmodic contractions occur in the penis.
C) The male orgasm occurs usually with ejaculation of semen from the penis.
D) The male experiences a period during which he is incapable of sexual response.
Ans: D
The resolution phase is characterized by a return to normal body functioning present before the excitement phase. The man experiences a period during which he is incapable of sexual response, called the refractory period. The length of the refractory period is individual; it might be a few minutes or even days before the man’s body responds readily to continued sexual stimulation.




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