NR341 Complex Adult Health
Exam 1 Textbook Questions
with Rationales EXAM
QUESTIONS AND VERIFIED
CORRECT ANSWERS
(Grooming is included in an MSE which consists of appearance, behavior, speech, mood,
disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self
or others. Long-term memory is included in an MSE which consists of appearance, behavior,
speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and
ideas of harming self or others. Support systems are not included in an MSE which consists of
appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Affect is included in an MSE which consists of
appearance, behavior, speech, and mood, disorders of the form of thought, perceptual
disturbances, cognition, and ideas of harming self or others. The presence of pain is not
included in an MSE which consists of appearance, behavior, speech, mood, disorders of the
form of thought, perceptual disturbances, cognition, and ideas of harming self or others.)
A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for
treatment of pneumonia. During the night shift, the client is found climbing into the bed of
another client who becomes upset and frightened. Which of the following actions should the
nurse take?
A. assist the client to the correct room.
B. place the client in restraints.
C. re-orient the client to time and place.
D. move the client to a room at the end of the hall. - CORRECT ANSWER-A
,(assisting the client to the correct room protects both clients. It helps re-orient the client who is
unable to find her own room, and it prevents the other client from an invasion of her personal
space.)
A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities. - CORRECT ANSWER-C
(A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.)
A nurse is monitoring a client who is post operative and unable to respond to questions. Which
of the following nonverbal behaviors should the nurse identify as an indication that the client
has pain? (Select all that apply.)
A. Restlessness
B. Grimacing
C. Moaning
D. Clenching
E. Drowsiness - CORRECT ANSWER-A, B, D
(Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious
in response to the discomfort.
,Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting
the lower lip are behavioral indicators of pain.
Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal
behaviors, that indicate pain.
Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients
who have pain.
Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of
pain.)
A nurse is caring for a client who is one day post operative following gynecologic surgery and
reports incisional pain. Which of the following actions should the nurse take first?
A. determine the time the client last received pain medication.
B. Measure the clients vital signs, including temperature.
C. ask the client to rate her pain on a scale of from 0 to 10.
D. re-position the client and offer her a back rub. - CORRECT ANSWER-C
(Using evidence-based practice, the nurse should first determine the severity of the client's pain
by using a standard pain scale. Then the nurse can plan the appropriate interventions.)
A nurse is planning care for a client who is post operative. Which of the following statements
about pain management should the nurse consider when implementing client care? (Select all
that apply.)
A. use of analgesics will eventually lead to addiction.
B. each clients expression of pain may be different and individualized.
C. Patient controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
, D. Pain level and tolerance can be assessed using a scale from 0 to 10.
E. The client will express the feeling of pain both verbally and nonverbally. - CORRECT ANSWER-
B, C, D, E
(Use of analgesics will eventually lead to addiction is incorrect. The administration of analgesics
does not lead to addiction. This is a common misconception about pain management.)
A nurse is caring for a client your request prescription pain medication. Which of the following
actions should the nurse perform first?
A. re-position the client.
B. administer the medication.
C. determine the location of the pain.
D. review the effects of the pain medication. - CORRECT ANSWER-C
(The first action the nurse should take using the nursing process is to assess the client. By
determining the location of the pain, the nurse can take the necessary steps to alleviate the
client's pain, such as administering pain medication, repositioning the client, and teaching the
client about the effects of the medication.)
A nurse is applying a cold compress for a client who has pain and minor swelling in a suture
laceration on the forearm. Which of the following assessments should the nurse use to
determine whether the treatment is effective?
A. inspecting the site for reduced swelling
B. monitoring the clients pulse rate
C. asking the client to rate the pain
D. having the client perform range of motion of the affected arm - CORRECT ANSWER-C
Exam 1 Textbook Questions
with Rationales EXAM
QUESTIONS AND VERIFIED
CORRECT ANSWERS
(Grooming is included in an MSE which consists of appearance, behavior, speech, mood,
disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self
or others. Long-term memory is included in an MSE which consists of appearance, behavior,
speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and
ideas of harming self or others. Support systems are not included in an MSE which consists of
appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Affect is included in an MSE which consists of
appearance, behavior, speech, and mood, disorders of the form of thought, perceptual
disturbances, cognition, and ideas of harming self or others. The presence of pain is not
included in an MSE which consists of appearance, behavior, speech, mood, disorders of the
form of thought, perceptual disturbances, cognition, and ideas of harming self or others.)
A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for
treatment of pneumonia. During the night shift, the client is found climbing into the bed of
another client who becomes upset and frightened. Which of the following actions should the
nurse take?
A. assist the client to the correct room.
B. place the client in restraints.
C. re-orient the client to time and place.
D. move the client to a room at the end of the hall. - CORRECT ANSWER-A
,(assisting the client to the correct room protects both clients. It helps re-orient the client who is
unable to find her own room, and it prevents the other client from an invasion of her personal
space.)
A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities. - CORRECT ANSWER-C
(A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.)
A nurse is monitoring a client who is post operative and unable to respond to questions. Which
of the following nonverbal behaviors should the nurse identify as an indication that the client
has pain? (Select all that apply.)
A. Restlessness
B. Grimacing
C. Moaning
D. Clenching
E. Drowsiness - CORRECT ANSWER-A, B, D
(Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious
in response to the discomfort.
,Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting
the lower lip are behavioral indicators of pain.
Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal
behaviors, that indicate pain.
Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients
who have pain.
Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of
pain.)
A nurse is caring for a client who is one day post operative following gynecologic surgery and
reports incisional pain. Which of the following actions should the nurse take first?
A. determine the time the client last received pain medication.
B. Measure the clients vital signs, including temperature.
C. ask the client to rate her pain on a scale of from 0 to 10.
D. re-position the client and offer her a back rub. - CORRECT ANSWER-C
(Using evidence-based practice, the nurse should first determine the severity of the client's pain
by using a standard pain scale. Then the nurse can plan the appropriate interventions.)
A nurse is planning care for a client who is post operative. Which of the following statements
about pain management should the nurse consider when implementing client care? (Select all
that apply.)
A. use of analgesics will eventually lead to addiction.
B. each clients expression of pain may be different and individualized.
C. Patient controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
, D. Pain level and tolerance can be assessed using a scale from 0 to 10.
E. The client will express the feeling of pain both verbally and nonverbally. - CORRECT ANSWER-
B, C, D, E
(Use of analgesics will eventually lead to addiction is incorrect. The administration of analgesics
does not lead to addiction. This is a common misconception about pain management.)
A nurse is caring for a client your request prescription pain medication. Which of the following
actions should the nurse perform first?
A. re-position the client.
B. administer the medication.
C. determine the location of the pain.
D. review the effects of the pain medication. - CORRECT ANSWER-C
(The first action the nurse should take using the nursing process is to assess the client. By
determining the location of the pain, the nurse can take the necessary steps to alleviate the
client's pain, such as administering pain medication, repositioning the client, and teaching the
client about the effects of the medication.)
A nurse is applying a cold compress for a client who has pain and minor swelling in a suture
laceration on the forearm. Which of the following assessments should the nurse use to
determine whether the treatment is effective?
A. inspecting the site for reduced swelling
B. monitoring the clients pulse rate
C. asking the client to rate the pain
D. having the client perform range of motion of the affected arm - CORRECT ANSWER-C
