NUR 155 Exam 1 (Units 1 & 2)
A 74-year-old female is brought to the emergency department c/o right hip pain.
The right leg is shorter than the left and is externally rotated. During inspection,
the nurse observes what appears to be cigarette burns on the client's inner
thighs. Which of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client's inner thighs
3. Multiple lesions on inner thighs possibly related to elder
✅✅
abuse
4. Several lesions on inner thighs similar to cigarette burns - -Answer: 1
Rationale: Option 1 is the most specific, non-assuming, and nonjudgmental
charting. Option 2 could be more specific by describing the lesions and not
calling them "burns." Option 3 is making
a judgment of elder abuse, and option 4 is also making an assumption that the
lesions are from cigarette burns
A client is admitted for heart failure. The nurse assesses that the client's blood
pressure is below normal range and the apical pulse is 110 beats/min. The nurse
knows that the increase in the client's pulse illustrates which aspect of the client's
homeostatic mechanism?
1. Compensation
2. Decompensation
✅✅
3. Self-regulation
4. Equilibrium - -Answer: 1
Rationale: The compensatory mechanism of increasing the heart rate is the
body's way of trying to balance an ineffective cardiac output since the BP has
decreased. Decompensation (option 2) occurs when the compensatory
mechanism is ineffective. Self-regulation
(option 3) refers to the homeostatic mechanisms that come into play
automatically in the healthy person. Equilibrium (option 4) is balance through
adaptation to the environment.
A client recently diagnosed with a chronic illness asks for help in understanding
the term chronic. It would be correct for the nurse to say which of the following?
1. Symptoms are always less severe than with an acute illness.
2. Chronic illnesses are considered incurable.
, ✅✅
3. Signs and symptoms of chronic illnesses tend to be stable for many years.
4. Chronic illnesses have no effective treatments. - -
A client who is 46 pounds overweight tells you, "I was just
born to be fat. I don't have the willpower." Although weight loss occurred while
attending two previous programs that "guaranteed" weight loss, the weight
returned along with extra pounds after each program. According to the Health
Promotion Model, the nurse is most likely to focus on which behavior specific
cognition and affect variable for this client?
1. Perceived barriers to action
2. Perceived self-efficacy
✅✅
3. Interpersonal influences
4. Situational influences - -Answer: 2
Rationale: Perceived self-efficacy is the confidence the person has for achieving
the desired outcome. Option 1 is a person's
perceptions about available time, inconvenience, expense, and difficulty
performing the activity. Option 3 is the person's perceptions concerning the
behaviors, beliefs, or attitudes of others. Option 4 refers to the person's
perception of the environment and how it assists or detracts from the healthy
behavior
A married mother of three small children has frequent immobilizing headaches of
unknown cause. The nurse anticipates that the woman may have which of the
following possible reactions? Select all that apply.
1. She feels guilty when unable to perform her usual activities.
2. She is angry and acting out.
3. She shifts some responsibilities to the spouse.
✅✅
4. She takes on a job to help pay for the medical expenses.
5. She has fewer social interactions with her friends. - -
A nurse and a primary care provider inform a client that
chemotherapy is recommended for a diagnosis of cancer. Which nursing action is
most representative of the concept of holism?
1. Offer to come to the client's home to provide needed
physical care.
2. Contact the client's spiritual adviser.
3. Inquire how this will affect other aspects of the client's life.
A 74-year-old female is brought to the emergency department c/o right hip pain.
The right leg is shorter than the left and is externally rotated. During inspection,
the nurse observes what appears to be cigarette burns on the client's inner
thighs. Which of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client's inner thighs
3. Multiple lesions on inner thighs possibly related to elder
✅✅
abuse
4. Several lesions on inner thighs similar to cigarette burns - -Answer: 1
Rationale: Option 1 is the most specific, non-assuming, and nonjudgmental
charting. Option 2 could be more specific by describing the lesions and not
calling them "burns." Option 3 is making
a judgment of elder abuse, and option 4 is also making an assumption that the
lesions are from cigarette burns
A client is admitted for heart failure. The nurse assesses that the client's blood
pressure is below normal range and the apical pulse is 110 beats/min. The nurse
knows that the increase in the client's pulse illustrates which aspect of the client's
homeostatic mechanism?
1. Compensation
2. Decompensation
✅✅
3. Self-regulation
4. Equilibrium - -Answer: 1
Rationale: The compensatory mechanism of increasing the heart rate is the
body's way of trying to balance an ineffective cardiac output since the BP has
decreased. Decompensation (option 2) occurs when the compensatory
mechanism is ineffective. Self-regulation
(option 3) refers to the homeostatic mechanisms that come into play
automatically in the healthy person. Equilibrium (option 4) is balance through
adaptation to the environment.
A client recently diagnosed with a chronic illness asks for help in understanding
the term chronic. It would be correct for the nurse to say which of the following?
1. Symptoms are always less severe than with an acute illness.
2. Chronic illnesses are considered incurable.
, ✅✅
3. Signs and symptoms of chronic illnesses tend to be stable for many years.
4. Chronic illnesses have no effective treatments. - -
A client who is 46 pounds overweight tells you, "I was just
born to be fat. I don't have the willpower." Although weight loss occurred while
attending two previous programs that "guaranteed" weight loss, the weight
returned along with extra pounds after each program. According to the Health
Promotion Model, the nurse is most likely to focus on which behavior specific
cognition and affect variable for this client?
1. Perceived barriers to action
2. Perceived self-efficacy
✅✅
3. Interpersonal influences
4. Situational influences - -Answer: 2
Rationale: Perceived self-efficacy is the confidence the person has for achieving
the desired outcome. Option 1 is a person's
perceptions about available time, inconvenience, expense, and difficulty
performing the activity. Option 3 is the person's perceptions concerning the
behaviors, beliefs, or attitudes of others. Option 4 refers to the person's
perception of the environment and how it assists or detracts from the healthy
behavior
A married mother of three small children has frequent immobilizing headaches of
unknown cause. The nurse anticipates that the woman may have which of the
following possible reactions? Select all that apply.
1. She feels guilty when unable to perform her usual activities.
2. She is angry and acting out.
3. She shifts some responsibilities to the spouse.
✅✅
4. She takes on a job to help pay for the medical expenses.
5. She has fewer social interactions with her friends. - -
A nurse and a primary care provider inform a client that
chemotherapy is recommended for a diagnosis of cancer. Which nursing action is
most representative of the concept of holism?
1. Offer to come to the client's home to provide needed
physical care.
2. Contact the client's spiritual adviser.
3. Inquire how this will affect other aspects of the client's life.
