Nurs 225 Midterm Questions and
Answers A+ Graded (2025)
The .nurse .is .assessing .a .confused .patient. .In .trying .to .determine .the .client's
.level .of .pain, .the .nurse .should
a) .Be .aware .that .confused .patients .do .not .feel .as .much .pain .due .to .their
.confusion
b) .Observe .the .client .carefully .for .changes .in .behavior .or .vital .signs
c) .Ask .the .client's .family .how .much .pain .the .client .normally .has
d) .Use .only .pain .scales .that .feature .numbers .or .faces .the .client .can .point .to .-
.CORRECT .ANSWER-b) .Observe .the .client .carefully .for .changes .in .behavior .or
.vital .signs
Rationale: .Nurse .should .observe .the .confused .client .for .non .verbal .cues .to .pain
.when .they .cannot .express .it .verbally.
Vital .signs, .level .of .consciousness, .and .skin .color .that .you .observe .are
.considered .which .type .of .data?
a) .Focused .data
b) .Objective .data
c) .Secondary .data
d) .Subjective .data .- .CORRECT .ANSWER-b) .Objective .data
What .assessment .techniques .do .you .use .when .assessing .the .skin, .hair, .and
.nails? .- .CORRECT .ANSWER-Inspection .and .palpation
Which .of .the .following .would .be .considered .an .abnormal .assessment .finding?
a) .A .patient's .skin .is .warm .to .the .touch
b) .A .patient's .tongue .is .covered .in .a .white-yellowish .coating
c) .A .patient's .hair .is .thick .in .texture .and .light .brown .in .color
d) .A .patient's .nails .display .a .160 .degree .shape/curvature .- .CORRECT .ANSWER-
b) .A .patient's .tongue .is .covered .in .a .white-yellowish .coating
Rationale: .this .can .indicate .a .fungal .infection, .e.g. .thrush
Which .of .the .following .is .a .normal .assessment .finding .for .the .shape .of .the
.nails?
a) .About .160 .degrees
b) .Concave
c) .Greater .than .180 .degrees
d) .Spoon .shaped .- .CORRECT .ANSWER-a) .About .160 .degrees
, Identify .contributing .factors .to .pressure .ulcer .formation. .Select .all .that .apply.
a) .Malnutrition
b) .Middle .age
c) .Decreased .sensory .perception/mobility
d) .Stress
e) .Excessive .sweating
f) .Ethnic .background .- .CORRECT .ANSWER-a) .Malnutrition
c) .Decreased .sensory .perception/mobility
d) .Stress
e) .Excessive .sweating
Identify .prevention .strategies .for .pressure .ulcers. .Select .all .that .apply.
a) .Use .a .moisture .barrier .ointment; .apply .after .incontinent .episodes
b) .Reposition .at .least .every .4 .hours; .use .a .written .schedule
c) .When .the .patient .is .in .the .side-lying .position .in .bed .use .the .30-degree .lateral
.position
d) .Place .the .patient .on .a .pressure-reducing .support .surface
e) .Maintain .the .head .of .the .bed .at .45 .degrees
f) .Massage .the .reddened .bony .prominences
g) .Oral .supplements .should .be .instituted .if .the .patient .is .found .to .be
.undernourished .- .CORRECT .ANSWER-a) . Use .a .moisture .barrier .ointment; .apply
.after .incontinent .episodes
c) .When .the .patient .is .in .the .side-lying .position .in .bed .use .the .30-degree .lateral
.position
d) .Place .the .patient .on .a .pressure-reducing .support .surface
g) .Oral .supplements .should .be .instituted .if .the .patient .is .found .to .be
.undernourished
Rationale:
- .Increased .moisture .contributes .to .formation .of .pressure .ulcers, .to .moisture-
barrier .ointment .is .an .effective .preventative .strategy
- .Patients .should .be .reposition .at .least .every .2 .hours, .not .4
- .The .30 .degree .tilt .is .the .standard .hospital .bed .position .for .comfort .& .safety
- .Bony .prominences .should .not .be .massaged .to .prevent .irritation .or .damage .to
.skin. .Bony .prominences .are .at .higher .risk .of .developing .pressure .ulcers .than
.other .areas .of .the .body
- .Malnutrition .impairs .wound .healing, .so .proper .nutrition .will .aid .in .the
.prevention .of .ulcer .formation
Which .of .the .following .may .indicate .internal .hemorrhage? .Select .all .that .apply.
a) .Distension .or .swelling .of .affected .body .part
b) .An .elevated .white .blood .cell .count
c) .A .decreased .blood .pressure .and .increased .pulse
d) .A .change .in .the .type .and .amount .of .drainage .from .a .surgical .drain .-
.CORRECT .ANSWER-a) .Distension .or .swelling .of .affected .body .part
c) .A .decreased .blood .pressure .and .increased .pulse
d) .A .change .in .the .type .and .amount .of .drainage .from .a .surgical .drain
Answers A+ Graded (2025)
The .nurse .is .assessing .a .confused .patient. .In .trying .to .determine .the .client's
.level .of .pain, .the .nurse .should
a) .Be .aware .that .confused .patients .do .not .feel .as .much .pain .due .to .their
.confusion
b) .Observe .the .client .carefully .for .changes .in .behavior .or .vital .signs
c) .Ask .the .client's .family .how .much .pain .the .client .normally .has
d) .Use .only .pain .scales .that .feature .numbers .or .faces .the .client .can .point .to .-
.CORRECT .ANSWER-b) .Observe .the .client .carefully .for .changes .in .behavior .or
.vital .signs
Rationale: .Nurse .should .observe .the .confused .client .for .non .verbal .cues .to .pain
.when .they .cannot .express .it .verbally.
Vital .signs, .level .of .consciousness, .and .skin .color .that .you .observe .are
.considered .which .type .of .data?
a) .Focused .data
b) .Objective .data
c) .Secondary .data
d) .Subjective .data .- .CORRECT .ANSWER-b) .Objective .data
What .assessment .techniques .do .you .use .when .assessing .the .skin, .hair, .and
.nails? .- .CORRECT .ANSWER-Inspection .and .palpation
Which .of .the .following .would .be .considered .an .abnormal .assessment .finding?
a) .A .patient's .skin .is .warm .to .the .touch
b) .A .patient's .tongue .is .covered .in .a .white-yellowish .coating
c) .A .patient's .hair .is .thick .in .texture .and .light .brown .in .color
d) .A .patient's .nails .display .a .160 .degree .shape/curvature .- .CORRECT .ANSWER-
b) .A .patient's .tongue .is .covered .in .a .white-yellowish .coating
Rationale: .this .can .indicate .a .fungal .infection, .e.g. .thrush
Which .of .the .following .is .a .normal .assessment .finding .for .the .shape .of .the
.nails?
a) .About .160 .degrees
b) .Concave
c) .Greater .than .180 .degrees
d) .Spoon .shaped .- .CORRECT .ANSWER-a) .About .160 .degrees
, Identify .contributing .factors .to .pressure .ulcer .formation. .Select .all .that .apply.
a) .Malnutrition
b) .Middle .age
c) .Decreased .sensory .perception/mobility
d) .Stress
e) .Excessive .sweating
f) .Ethnic .background .- .CORRECT .ANSWER-a) .Malnutrition
c) .Decreased .sensory .perception/mobility
d) .Stress
e) .Excessive .sweating
Identify .prevention .strategies .for .pressure .ulcers. .Select .all .that .apply.
a) .Use .a .moisture .barrier .ointment; .apply .after .incontinent .episodes
b) .Reposition .at .least .every .4 .hours; .use .a .written .schedule
c) .When .the .patient .is .in .the .side-lying .position .in .bed .use .the .30-degree .lateral
.position
d) .Place .the .patient .on .a .pressure-reducing .support .surface
e) .Maintain .the .head .of .the .bed .at .45 .degrees
f) .Massage .the .reddened .bony .prominences
g) .Oral .supplements .should .be .instituted .if .the .patient .is .found .to .be
.undernourished .- .CORRECT .ANSWER-a) . Use .a .moisture .barrier .ointment; .apply
.after .incontinent .episodes
c) .When .the .patient .is .in .the .side-lying .position .in .bed .use .the .30-degree .lateral
.position
d) .Place .the .patient .on .a .pressure-reducing .support .surface
g) .Oral .supplements .should .be .instituted .if .the .patient .is .found .to .be
.undernourished
Rationale:
- .Increased .moisture .contributes .to .formation .of .pressure .ulcers, .to .moisture-
barrier .ointment .is .an .effective .preventative .strategy
- .Patients .should .be .reposition .at .least .every .2 .hours, .not .4
- .The .30 .degree .tilt .is .the .standard .hospital .bed .position .for .comfort .& .safety
- .Bony .prominences .should .not .be .massaged .to .prevent .irritation .or .damage .to
.skin. .Bony .prominences .are .at .higher .risk .of .developing .pressure .ulcers .than
.other .areas .of .the .body
- .Malnutrition .impairs .wound .healing, .so .proper .nutrition .will .aid .in .the
.prevention .of .ulcer .formation
Which .of .the .following .may .indicate .internal .hemorrhage? .Select .all .that .apply.
a) .Distension .or .swelling .of .affected .body .part
b) .An .elevated .white .blood .cell .count
c) .A .decreased .blood .pressure .and .increased .pulse
d) .A .change .in .the .type .and .amount .of .drainage .from .a .surgical .drain .-
.CORRECT .ANSWER-a) .Distension .or .swelling .of .affected .body .part
c) .A .decreased .blood .pressure .and .increased .pulse
d) .A .change .in .the .type .and .amount .of .drainage .from .a .surgical .drain
