Evolve: Fundamentals Basics of Nursing Practice Questions
With Complete Solutions
A 2-g sodium diet is prescribed for a client with stage 2
hypertension, and the nurse teaches the client the rationale for
this diet. The client reports distaste for the food. The primary
nurse hears the client request that the family "bring in a ham and
cheese sandwich and fries." What is the most effective nursing
intervention?
1
Discuss the diet with the client and family.
2
Tell the client why salty foods should not be eaten.
3
Explain the dietary restriction to the client's visitors.
4
Ask the dietitian to teach the client and family about sodium
restrictions Correct Answers 1
Discuss the diet with the client and family.
A 2-year-old child admitted with a diagnosis of pneumonia was
administered antibiotics, fluids, and oxygen. The child's
temperature increased until it reached 103° F. When notified, the
health care provider determined that there was no need to
change treatment, even though the child had a history of febrile
seizures. Although concerned, the nurse took no further action.
Later, the child had a seizure that resulted in neurological
impairment. Legally, who is responsible for the child's injury?
1
Health care provider, because this decision took precedence over
the nurse's concern
,2
Health care provider, because of total responsibility for the
child's health and treatment regimen
3
Nurse, because failure to further question the health care
provider about the child's status placed the child at risk
4
Neither, because high fevers are common in children and the
health care provider had little cause for concern Correct
Answers Nurse, because failure to further question the health
care provider about the child's status placed the child at risk
It is the nurse's responsibility to foresee potential harm and
prevent risks by acting as a client advocate. This is not
acceptable as a rationale for inaction. The nurse and health care
provider share interdependent roles in the assessment and care
of clients. High temperatures are common in children but are
nonetheless a valid cause for concern.
A 3-year-old child with eczema of the face and arms has
disregarded the nurse's warnings to "stop scratching, or else!"
The nurse finds the toddler scratching so intensely that the arms
are bleeding. The nurse then ties the toddler's arms to the crib
sides, saying, "I'm going to teach you one way or another." How
should the nurse's behavior be interpreted?
1.These actions can be construed as assault and battery.
2.The problem was resolved with forethought and
accountability.
3.Skin must be protected, and the actions taken were by a
reasonably prudent nurse.
,4.The nurse had tried to reason with the toddler and expected
understanding and cooperation Correct Answers These actions
can be construed as assault and battery
Assault is a threat or an attempt to do violence to another, and
battery means touching an individual in an offensive manner or
actually injuring another person.
A 90-year-old female resident of a nursing home falls and
fractures the proximal end of her right femur. The surgeon plans
to reduce the fracture with an internal fixation device. The
general fact about the older adult that the nurse should consider
when caring for this client is that:
1
Aging causes a lower pain threshold
2
Physiological coping defenses are reduced
3
Most confused states result from dementia
4
Older adults psychologically tolerate changes well Correct
Answers Physiological coping defenses are reduced
A client becomes hostile when learning that amputation of a
gangrenous toe is being considered. After the client's outburst,
what is the best indication that the nurse-client interaction has
been therapeutic?
1
Increased physical activity
2
Absence of further outbursts
, 3
Relaxation of tensed muscles
4
Denial of the need for further discussion Correct Answers 3
Relaxation of tensed muscles
Relaxation of muscles and facial expression are examples of
nonverbal behavior; nonverbal behavior is an excellent index of
feelings because it is less likely to be consciously controlled.
Increased activity may be an expression of anger or hostility.
Clients may suppress verbal outbursts despite feelings and
become withdrawn. Refusing to talk may be a sign that the client
is just not ready to discuss feelings.
A client comes to the clinic complaining of a productive cough
with copious yellow sputum, fever, and chills for the past two
days. The first thing the nurse should do when caring for this
client is to:
1
Encourage fluids
2
Administer oxygen
3
Take the temperature
4
Collect a sputum specimen Correct Answers 3
Take the temperature
Baseline vital signs are extremely important; physical
assessment precedes diagnostic measures and intervention. This
is done after the health care provider makes a medical diagnosis;
With Complete Solutions
A 2-g sodium diet is prescribed for a client with stage 2
hypertension, and the nurse teaches the client the rationale for
this diet. The client reports distaste for the food. The primary
nurse hears the client request that the family "bring in a ham and
cheese sandwich and fries." What is the most effective nursing
intervention?
1
Discuss the diet with the client and family.
2
Tell the client why salty foods should not be eaten.
3
Explain the dietary restriction to the client's visitors.
4
Ask the dietitian to teach the client and family about sodium
restrictions Correct Answers 1
Discuss the diet with the client and family.
A 2-year-old child admitted with a diagnosis of pneumonia was
administered antibiotics, fluids, and oxygen. The child's
temperature increased until it reached 103° F. When notified, the
health care provider determined that there was no need to
change treatment, even though the child had a history of febrile
seizures. Although concerned, the nurse took no further action.
Later, the child had a seizure that resulted in neurological
impairment. Legally, who is responsible for the child's injury?
1
Health care provider, because this decision took precedence over
the nurse's concern
,2
Health care provider, because of total responsibility for the
child's health and treatment regimen
3
Nurse, because failure to further question the health care
provider about the child's status placed the child at risk
4
Neither, because high fevers are common in children and the
health care provider had little cause for concern Correct
Answers Nurse, because failure to further question the health
care provider about the child's status placed the child at risk
It is the nurse's responsibility to foresee potential harm and
prevent risks by acting as a client advocate. This is not
acceptable as a rationale for inaction. The nurse and health care
provider share interdependent roles in the assessment and care
of clients. High temperatures are common in children but are
nonetheless a valid cause for concern.
A 3-year-old child with eczema of the face and arms has
disregarded the nurse's warnings to "stop scratching, or else!"
The nurse finds the toddler scratching so intensely that the arms
are bleeding. The nurse then ties the toddler's arms to the crib
sides, saying, "I'm going to teach you one way or another." How
should the nurse's behavior be interpreted?
1.These actions can be construed as assault and battery.
2.The problem was resolved with forethought and
accountability.
3.Skin must be protected, and the actions taken were by a
reasonably prudent nurse.
,4.The nurse had tried to reason with the toddler and expected
understanding and cooperation Correct Answers These actions
can be construed as assault and battery
Assault is a threat or an attempt to do violence to another, and
battery means touching an individual in an offensive manner or
actually injuring another person.
A 90-year-old female resident of a nursing home falls and
fractures the proximal end of her right femur. The surgeon plans
to reduce the fracture with an internal fixation device. The
general fact about the older adult that the nurse should consider
when caring for this client is that:
1
Aging causes a lower pain threshold
2
Physiological coping defenses are reduced
3
Most confused states result from dementia
4
Older adults psychologically tolerate changes well Correct
Answers Physiological coping defenses are reduced
A client becomes hostile when learning that amputation of a
gangrenous toe is being considered. After the client's outburst,
what is the best indication that the nurse-client interaction has
been therapeutic?
1
Increased physical activity
2
Absence of further outbursts
, 3
Relaxation of tensed muscles
4
Denial of the need for further discussion Correct Answers 3
Relaxation of tensed muscles
Relaxation of muscles and facial expression are examples of
nonverbal behavior; nonverbal behavior is an excellent index of
feelings because it is less likely to be consciously controlled.
Increased activity may be an expression of anger or hostility.
Clients may suppress verbal outbursts despite feelings and
become withdrawn. Refusing to talk may be a sign that the client
is just not ready to discuss feelings.
A client comes to the clinic complaining of a productive cough
with copious yellow sputum, fever, and chills for the past two
days. The first thing the nurse should do when caring for this
client is to:
1
Encourage fluids
2
Administer oxygen
3
Take the temperature
4
Collect a sputum specimen Correct Answers 3
Take the temperature
Baseline vital signs are extremely important; physical
assessment precedes diagnostic measures and intervention. This
is done after the health care provider makes a medical diagnosis;
