Detailed Answers
An 85-year-old man has been hospitalized after a fall at home, and his 86 year old wife is at
his bedside. She told the nurse that she is his primary care giver. The nurse should assess the
caregiver for signs of possible caregiver burnout, such as:
A. Depression
B. Weight gain
C. Hypertension
D. Social phobias - answers-A. Depression
During a morning assessment, the nurse notices that an older patient is less attentive and is
unable to recall yesterday's events. Which test is appropriate for assessing the patient's
mental status?
A. Geriatric Depression Scale, short form
B. Rapid Disability Rating Scale-2
C. Mini-Cog
D. Get Up and Go Test - answers-C. Mini-Cog
An older patient has been admitted to the intensive care unit after falling at home. Within 8
hours, his condition has stabilized, and he is transferred to a medical unit. The family is
wondering whether he will be able to go back home. Which assessment instrument is most
appropriate for the nurse to choose at this time?
A. Lawton IADL instrument
B. Hospital Admission Risk Profile (HARP)
,C. Mini-Cog
D. NEECHAM Confusion Scale - answers-B. Hospital Admission Risk Profile (HARP)
During a functional assessment of an older person's home environment, which statement or
question by the nurse is most appropriate regarding Common environmental hazards?
A. Please slow toilet seats are safe because they are nearer to the ground in case of falls.
B. Do you have a relative or friend who can help install grab bars in your shower?
C. These small rugs are ideal for preventing you from sleeping on the hard floor
D. it would be safer to keep the writing low in this room to avoid glare in your eyes - answers-
B. Do you have a relative or friend who can help install grab bars in your shower?
When beginning to assess a person spirituality, Which question by the nurse would be most
appropriate?
A. Do you believe in God?
B. How does your spirituality relate to your health care decisions?
C. What religious faith do you follow
D. Do you believe in the power of prayer? - answers-B. How does your spirituality relate to
your health care decisions?
After completing an initial assessment of a patient, the nurse has charted that his respirations
are eupneic and his pulse is 58 beats per minute. These types of data would be.
A. Objective
B. Reflective
C. Subjective
D. Introspective - answers-A. Objective
,A patient tells the nurse that he is very nervous, is nauseated and feels hot. These types of data
would be
A. Objective
B. Reflective
C. Subjective
D. Introspective - answers-C. Subjective
The patients record, laboratory studies, objective data, and subjective data combine to form the
A. Data base
B. Admitting data
C. Financial Statement
D. Discharge Summary - answers-A. Data base
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to
A. Immediately notify the patients physician
B. Document the sound exactly as it was heard.
C. Validate the data by asking a coworker to listen to breath sounds
D. Assess it again in 20 minutes to note whether the sound is still present - answers-C. Validate
the data by asking a coworker to listen to breath sounds
The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse
should keep in mind that novice nurses, without a background of skills and experience from
which to draw, are more likely to make their decisions using:
, A. Intuition
B. A set of rules
C. Articles in journals
D. Advice from supervisors - answers-b. A set of rules.
Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
A. Intuition
B. The nursing process
C. Clinical knowledge
D. Diagnostic reasoning - answers-A. Intuition
The nurse is reviewing information about EBP. Which statement best reflects EBP?
A. EBP relies on tradition for support of best practices
B. EBP is simply the use of best practice techniques for the treatment of patients
C. EBP emphasizes the use of best evidence with the clinicians experience
D. The patients own preferences are not important with EBP. - answers-C. EBP emphasizes the
use of best evidence with the clinicians experience
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is
an example of a first-level priority problem
A. Patient with postoperative pain
B. Newly diagnosed patient with diabetes who needs diabetic teaching
C. Individual with a small laceration on the sole of the foot
D. Individual with shortness of breath and respiratory distress - answers-D. Individual with
shortness of breath and respiratory distress