Test Bank for Concepts for Nursing Practice, 3rd Edition (Chapters 1-57)
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TEST BANK FOR Giddens:
Concepts for Nursing Practice,
3rd Edition 2024/2025
UPDATE WITH
RATIONALES
Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
3. The school nurse talking with a high school class about the difference between growth and
Concepts for Nursing Practice,
3rd Edition 2024/2025
UPDATE WITH
RATIONALES
Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
3. The school nurse talking with a high school class about the difference between growth and
TEST BANK FOR Giddens:
Concepts for Nursing Practice,
3rd Edition 2024/2025
UPDATE WITH
RATIONALES
Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
3. The school nurse talking with a high school class about the difference between growth and
Concepts for Nursing Practice,
3rd Edition 2024/2025
UPDATE WITH
RATIONALES
Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
3. The school nurse talking with a high school class about the difference between growth and
development would best describe growth as
a. processes by which early cells specialize.
b. psychosocial and cognitive changes.
c. qualitative changes associated with aging.
d. quantitative changes in size or weight.
ANS: D
a. processes by which early cells specialize.
b. psychosocial and cognitive changes.
c. qualitative changes associated with aging.
d. quantitative changes in size or weight.
ANS: D
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Growth is a quantitative change in which an increase in cell number and size results in an
increase in overall size or weight of the body or any of its parts. The processes by which
early cells specialize are referred to as differentiation. Psychosocial and cognitive changes
are referred to as development. Qualitative changes associated with aging are referred to as
maturation.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. The most appropriate response of the nurse when a mother asks what the Denver II does is
that it
a. can diagnose developmental disabilities.
b. identifies a need for physical therapy.
c. is a developmental screening tool.
d. provides a framework for health teaching.
ANS: C
The Denver II is the most commonly used measure of developmental status used by
healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.
Diagnosis requires a thorough neurodevelopment history and physical examination.
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The
need for any therapy would be identified with a comprehensive evaluation, not a screening
tool. Some providers use the Denver II as a framework for teaching about expected
development, but this is not the primary purpose of the tool.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
5. To plan early intervention anNd care for an infant with Down syndrome, the nurse considers
knowledge of other physical development exemplars such as
a. cerebral palsy.
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD).
d. failure to thrive.
ANS: D
Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of
motor/developmental delay. Autism is an exemplar of social/emotional developmental
delay. ADHD is an exemplar of a cognitive disorder.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. To plan early intervention and care for a child with a developmental delay, the nurse would
consider knowledge of the concepts most significantly impacted by development, including
a. culture.
b. environment.
c. functional status.
d. nutrition.
ANS: C
increase in overall size or weight of the body or any of its parts. The processes by which
early cells specialize are referred to as differentiation. Psychosocial and cognitive changes
are referred to as development. Qualitative changes associated with aging are referred to as
maturation.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. The most appropriate response of the nurse when a mother asks what the Denver II does is
that it
a. can diagnose developmental disabilities.
b. identifies a need for physical therapy.
c. is a developmental screening tool.
d. provides a framework for health teaching.
ANS: C
The Denver II is the most commonly used measure of developmental status used by
healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.
Diagnosis requires a thorough neurodevelopment history and physical examination.
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The
need for any therapy would be identified with a comprehensive evaluation, not a screening
tool. Some providers use the Denver II as a framework for teaching about expected
development, but this is not the primary purpose of the tool.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
5. To plan early intervention anNd care for an infant with Down syndrome, the nurse considers
knowledge of other physical development exemplars such as
a. cerebral palsy.
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD).
d. failure to thrive.
ANS: D
Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of
motor/developmental delay. Autism is an exemplar of social/emotional developmental
delay. ADHD is an exemplar of a cognitive disorder.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. To plan early intervention and care for a child with a developmental delay, the nurse would
consider knowledge of the concepts most significantly impacted by development, including
a. culture.
b. environment.
c. functional status.
d. nutrition.
ANS: C
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Function is one of the concepts most significantly impacted by development. Others include
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept
that is considered to significantly affect development; the difference is the concepts that
affect development are those that represent major influencing factors (causes); hence
determination of development would be the focus of preventive interventions. Environment
is considered to significantly affect development. Nutrition is considered to significantly
affect development.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks
to her toys and makes up stories. The mother wants her child to have a psychological
evaluation. The nurse’s best initial response is to
a. refer the child to a psychologist immediately.
b. explain that playing make believe is normal at this age.
c. complete a developmental screening using a validated tool.
d. separate the child from the mother to get more information.
ANS: B
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is
normal at this age. A referral to a psychologist would be premature based only on the
complaint of the mother. Completing a developmental screening would be very appropriate
but not the initial response. The nurse would certainly want to get more information, but
separating the child from the mother is not necessary at this time.
OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is
so needy and acting like a child. The best response of the nurse is that in the hospital,
adolescents
a. have separation anxiety.
b. rebel against rules.
c. regress because of stress.
d. want to know everything.
ANS: C
Regression to an earlier stage of development is a common response to stress. Separation
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually
not an issue if the adolescent understands the rules and would not create childlike behaviors.
An adolescent may want to “know everything” with their logical thinking and deductive
reasoning, but that would not explain why they would act like a child.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept
that is considered to significantly affect development; the difference is the concepts that
affect development are those that represent major influencing factors (causes); hence
determination of development would be the focus of preventive interventions. Environment
is considered to significantly affect development. Nutrition is considered to significantly
affect development.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks
to her toys and makes up stories. The mother wants her child to have a psychological
evaluation. The nurse’s best initial response is to
a. refer the child to a psychologist immediately.
b. explain that playing make believe is normal at this age.
c. complete a developmental screening using a validated tool.
d. separate the child from the mother to get more information.
ANS: B
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is
normal at this age. A referral to a psychologist would be premature based only on the
complaint of the mother. Completing a developmental screening would be very appropriate
but not the initial response. The nurse would certainly want to get more information, but
separating the child from the mother is not necessary at this time.
OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is
so needy and acting like a child. The best response of the nurse is that in the hospital,
adolescents
a. have separation anxiety.
b. rebel against rules.
c. regress because of stress.
d. want to know everything.
ANS: C
Regression to an earlier stage of development is a common response to stress. Separation
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually
not an issue if the adolescent understands the rules and would not create childlike behaviors.
An adolescent may want to “know everything” with their logical thinking and deductive
reasoning, but that would not explain why they would act like a child.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
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Concept 02: Functional Ability
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is assessing a patient’s functional ability. Which patient best demonstrates the
definition of functional ability?
a. Considers self as a healthy individual; uses cane for stability
b. College educated; travels frequently; can balance a checkbook
c. Works out daily, reads well, cooks, and cleans house on the weekends
d. Healthy individual, volunteers at church, works part time, takes care of family and
house
ANS: D
Functional ability refers to the individual’s ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
and maintain health and well-being. The other options are good; however, healthy
individual, church volunteer, part time worker, and the patient who takes care of the family
and house fully meets the criteria for functional ability.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. The nurse is assessing a patient’s functional performance. What assessment parameters will
be most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration
assessment
d. Health and well-being, amount of community volunteer time, working outside the
home, and ability to care for family and house
ANS: A
Functional impairment, disability, or handicap refers to varying degrees of an individual’s
inability to perform the tasks required to complete normal life activities without assistance.
Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy,
memory, and concentration are part of a depression screening. Healthy, volunteering,
working, and caring for family and house are functional abilities, not performance.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into
the patient’s functional ability. What question would be the most appropriate?
a. “Are you able to shop for yourself?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
c. “Do you know what today’s date is?”
d. “Were you sad or depressed more than once in the last 3 days?”
ANS: B
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is assessing a patient’s functional ability. Which patient best demonstrates the
definition of functional ability?
a. Considers self as a healthy individual; uses cane for stability
b. College educated; travels frequently; can balance a checkbook
c. Works out daily, reads well, cooks, and cleans house on the weekends
d. Healthy individual, volunteers at church, works part time, takes care of family and
house
ANS: D
Functional ability refers to the individual’s ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
and maintain health and well-being. The other options are good; however, healthy
individual, church volunteer, part time worker, and the patient who takes care of the family
and house fully meets the criteria for functional ability.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. The nurse is assessing a patient’s functional performance. What assessment parameters will
be most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration
assessment
d. Health and well-being, amount of community volunteer time, working outside the
home, and ability to care for family and house
ANS: A
Functional impairment, disability, or handicap refers to varying degrees of an individual’s
inability to perform the tasks required to complete normal life activities without assistance.
Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy,
memory, and concentration are part of a depression screening. Healthy, volunteering,
working, and caring for family and house are functional abilities, not performance.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into
the patient’s functional ability. What question would be the most appropriate?
a. “Are you able to shop for yourself?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
c. “Do you know what today’s date is?”
d. “Were you sad or depressed more than once in the last 3 days?”
ANS: B
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“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining
the patient’s ability to perform self-care activities. A nutritional health risk assessment is not
the functional assessment. Knowing the date is part of a mental status exam. Assessing
sadness is a question to ask in the depression screening.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney
Model of Nursing for a patient who is currently unconscious. Which interventions would be
most critical to developing a plan of care for this patient?
a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature
ANS: D
The most critical aspects of care for an unconscious patient are safe environment, breathing,
and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting,
transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and
socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however,
these are not the most critical for developing the plan of care in an unconscious patient.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The home care nurse is trying to determine the necessary services for a 65-year-old patient
who was admitted to the home care service after left knee replacement. Which tool is the
best for the nurse to utilize?
a. Minimum Data Set (MDS)
b. Functional Status Scale (FSS)
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
d. The Edmonton Functional Assessment Tool
ANS: C
The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing
home patients. The FSS is for children. The Edmonton is for cancer patients.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you
rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a
checkbook?” “How would you rate your ability to keep track of your appointments?” Which
tool would be indicated for the best results of this patient’s perception of their abilities?
a. Functional Activities Questionnaire (FAQ)
b. Mini Mental Status Exam (MMSE)
c. 24hFAQ
d. Performance-based functional measurement
ANS: A
the patient’s ability to perform self-care activities. A nutritional health risk assessment is not
the functional assessment. Knowing the date is part of a mental status exam. Assessing
sadness is a question to ask in the depression screening.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney
Model of Nursing for a patient who is currently unconscious. Which interventions would be
most critical to developing a plan of care for this patient?
a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature
ANS: D
The most critical aspects of care for an unconscious patient are safe environment, breathing,
and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting,
transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and
socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however,
these are not the most critical for developing the plan of care in an unconscious patient.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The home care nurse is trying to determine the necessary services for a 65-year-old patient
who was admitted to the home care service after left knee replacement. Which tool is the
best for the nurse to utilize?
a. Minimum Data Set (MDS)
b. Functional Status Scale (FSS)
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
d. The Edmonton Functional Assessment Tool
ANS: C
The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing
home patients. The FSS is for children. The Edmonton is for cancer patients.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you
rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a
checkbook?” “How would you rate your ability to keep track of your appointments?” Which
tool would be indicated for the best results of this patient’s perception of their abilities?
a. Functional Activities Questionnaire (FAQ)
b. Mini Mental Status Exam (MMSE)
c. 24hFAQ
d. Performance-based functional measurement
ANS: A
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The FAQ is an example of a self-report tool which provides information about the patient’s
perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is
used to assess functional ability in postoperative patients. Performance-based tools involve
actual observation of a standardized task, completion of which is judged by objective
criteria.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is
assessing the patient’s risk for falls so that falls prevention can be implemented if necessary.
Select all the risk factors that apply from this patient's history and physical. (Select all that
apply.)
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
ANS: B, D, E, F
Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a
risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or
stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not
contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension
and dizziness is a fall risk. Dizziness does contribute to falls.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is
used to assess functional ability in postoperative patients. Performance-based tools involve
actual observation of a standardized task, completion of which is judged by objective
criteria.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is
assessing the patient’s risk for falls so that falls prevention can be implemented if necessary.
Select all the risk factors that apply from this patient's history and physical. (Select all that
apply.)
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
ANS: B, D, E, F
Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a
risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or
stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not
contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension
and dizziness is a fall risk. Dizziness does contribute to falls.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Concept 03: Family Dynamics
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The most appropriate initial nursing intervention when the nurse notes dysfunctional
interactions and lack of family support for a patient would be to
a. enforce hospital visiting policies.
b. monitor the dysfunctional interactions.
c. notify the primary care provider.
d. role model appropriate support.
ANS: D
Nurses can, at times, role model more appropriate interactions or provide suggestions for
improving communication and interactions among family members. If the nurse determines
that the number of visitors has a negative impact on the patient, hospital policy may be to
limit visitors, but that would not be the initial action. Monitoring the dysfunctional
interactions would not be an adequate response. The primary care provider should certainly
be notified, but that would not be the initial response.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
2. The nurse caring for a patient would identify a need for additional interventions related to
family dynamics when
a. extended family offers to help.
b. family members express concern.
c. the ill member demands attention.
d. memories are shared.
ANS: C
It is not uncommon for the ill family member to become demanding and indicate that they
deserve special treatment and care, and the supportive family may need assistance in
understanding the dynamics of the illness in order to continue to be supportive. Offers from
extended family to help can be indicative of positive dynamics. Concern expressed by
family members can be indicative of positive dynamics. Sharing of family memories can be
indicative of positive dynamics.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
3. Two women have an established long-term relationship and are attending parenting classes
in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of
family?
a. Cohabiting
b. Nuclear
c. Same-sex
d. Single parent
ANS: C
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The most appropriate initial nursing intervention when the nurse notes dysfunctional
interactions and lack of family support for a patient would be to
a. enforce hospital visiting policies.
b. monitor the dysfunctional interactions.
c. notify the primary care provider.
d. role model appropriate support.
ANS: D
Nurses can, at times, role model more appropriate interactions or provide suggestions for
improving communication and interactions among family members. If the nurse determines
that the number of visitors has a negative impact on the patient, hospital policy may be to
limit visitors, but that would not be the initial action. Monitoring the dysfunctional
interactions would not be an adequate response. The primary care provider should certainly
be notified, but that would not be the initial response.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
2. The nurse caring for a patient would identify a need for additional interventions related to
family dynamics when
a. extended family offers to help.
b. family members express concern.
c. the ill member demands attention.
d. memories are shared.
ANS: C
It is not uncommon for the ill family member to become demanding and indicate that they
deserve special treatment and care, and the supportive family may need assistance in
understanding the dynamics of the illness in order to continue to be supportive. Offers from
extended family to help can be indicative of positive dynamics. Concern expressed by
family members can be indicative of positive dynamics. Sharing of family memories can be
indicative of positive dynamics.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
3. Two women have an established long-term relationship and are attending parenting classes
in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of
family?
a. Cohabiting
b. Nuclear
c. Same-sex
d. Single parent
ANS: C
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This family would be considered a same-sex family. Cohabiting refers to a couple who live
together with no legal bond. Nuclear refers to the traditional male and female core family
with one or more children. Single parent refers to a family with one adult and one or more
children.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
4. The nurse identifies the family with a child graduating from college as having which effect
on the family life cycle?
a. Minimal impact
b. Considered to be a negative impact on the family unit
c. Leads to role confusion
d. Expectation of role change
ANS: D
The family life cycle developmental theory focuses on the growth and development of
changes in role relationships during transitional periods. A child graduating from college is
an example of a transition which requires a role change. As this is a transition, one would
expect to see a change so minimal impact would not be expected. Graduation does not imply
that it will be a negative change on the family life cycle or lead to role confusion.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
5. When reviewing the purposes of a family assessment, the nurse educator would identify a
need for further teaching if the student responded that family assessment is used to gain an
understanding of which aspect of the family?
a. Development
b. Function
c. Political views
d. Structure
ANS: C
An understanding of the political views of family members is not a primary purpose of a
family assessment. A family assessment provides the nurse with information and an
understanding of family dynamics. This is important to nurses for the provision of quality
health care. A family assessment provides an understanding of family development,
function, and structure.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. A nurse is planning to assess the structure of a family. Which question should the nurse ask?
a. “Who lives with you in this home?”
b. “Who does the grocery shopping?”
c. “Who provides support in your family?”
d. “How old are the members of your family?”
ANS: A
together with no legal bond. Nuclear refers to the traditional male and female core family
with one or more children. Single parent refers to a family with one adult and one or more
children.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
4. The nurse identifies the family with a child graduating from college as having which effect
on the family life cycle?
a. Minimal impact
b. Considered to be a negative impact on the family unit
c. Leads to role confusion
d. Expectation of role change
ANS: D
The family life cycle developmental theory focuses on the growth and development of
changes in role relationships during transitional periods. A child graduating from college is
an example of a transition which requires a role change. As this is a transition, one would
expect to see a change so minimal impact would not be expected. Graduation does not imply
that it will be a negative change on the family life cycle or lead to role confusion.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
5. When reviewing the purposes of a family assessment, the nurse educator would identify a
need for further teaching if the student responded that family assessment is used to gain an
understanding of which aspect of the family?
a. Development
b. Function
c. Political views
d. Structure
ANS: C
An understanding of the political views of family members is not a primary purpose of a
family assessment. A family assessment provides the nurse with information and an
understanding of family dynamics. This is important to nurses for the provision of quality
health care. A family assessment provides an understanding of family development,
function, and structure.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. A nurse is planning to assess the structure of a family. Which question should the nurse ask?
a. “Who lives with you in this home?”
b. “Who does the grocery shopping?”
c. “Who provides support in your family?”
d. “How old are the members of your family?”
ANS: A
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The structure of the family includes who is in the family and what their relationship is.
“Who does the shopping?” would provide information about family functioning. “Who
provides support?” would provide information about family functioning. “How old are the
members?” would provide information about family development.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
7. Which factors which would alert the nurse to negative/dysfunctional family dynamics?
a. Aging of family members
b. Chronic illness of a family member
c. Disability of a family member
d. Intimate partner violence
ANS: D
Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging
of family members is an exemplar of changes to family dynamics. Chronic illness of a
family member is an exemplar of changes to family dynamics. Disability of a family
member is an exemplar of changes to family dynamics.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
“Who does the shopping?” would provide information about family functioning. “Who
provides support?” would provide information about family functioning. “How old are the
members?” would provide information about family development.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
7. Which factors which would alert the nurse to negative/dysfunctional family dynamics?
a. Aging of family members
b. Chronic illness of a family member
c. Disability of a family member
d. Intimate partner violence
ANS: D
Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging
of family members is an exemplar of changes to family dynamics. Chronic illness of a
family member is an exemplar of changes to family dynamics. Disability of a family
member is an exemplar of changes to family dynamics.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
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Concept 04: Culture
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is caring for an older Chinese adult male who is grimacing and appears restless
after abdominal surgery. What is the nurse’s best action?
a. Ask the patient if he is anxious about his hospital stay.
b. Ask a translator to conduct a FACES pain scale assessment.
c. Ask the patient about pain and assess vital signs.
d. Ask the patient about any history of depression or anxiety.
ANS: C
In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and
there is a stigma about talking about any mental health problems. The nurse should ask the
patient about pain and also assess vital signs for physiological signs of pain, since the
patient may not admit to any pain. Assuming the patient is depressed or anxious is not the
best action when considering individual cultural differences and the risk of pain after major
surgery. The registered nurse should never delegate assessment to any unlicensed member
of the healthcare team such as a translator. The translator may assist with communication,
but the nurse is responsible for the pain assessment.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs
Category: Physiological Integrity: Basic Care and Comfort
2. Understanding cultural differ nces in health care is important because it will help the nurse
to understand the manner in which
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is caring for an older Chinese adult male who is grimacing and appears restless
after abdominal surgery. What is the nurse’s best action?
a. Ask the patient if he is anxious about his hospital stay.
b. Ask a translator to conduct a FACES pain scale assessment.
c. Ask the patient about pain and assess vital signs.
d. Ask the patient about any history of depression or anxiety.
ANS: C
In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and
there is a stigma about talking about any mental health problems. The nurse should ask the
patient about pain and also assess vital signs for physiological signs of pain, since the
patient may not admit to any pain. Assuming the patient is depressed or anxious is not the
best action when considering individual cultural differences and the risk of pain after major
surgery. The registered nurse should never delegate assessment to any unlicensed member
of the healthcare team such as a translator. The translator may assist with communication,
but the nurse is responsible for the pain assessment.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs
Category: Physiological Integrity: Basic Care and Comfort
2. Understanding cultural differ nces in health care is important because it will help the nurse
to understand the manner in which
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ANS: B
When a nurse provides nutritional education to a patient who is from a culture that values
greater power distance, it might appear that the patient is willing to accept all that the nurse
suggests, when further prompting would elicit additional questions or concerns. The patient
from a collectivist culture will usually consult family members for a best course of action. It
is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest
male relative for help with decision making. While writing everything down may be OK for
some cultures, with Asian patients it may be best to prompt further to elicit additional
questions or concerns.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain
due to
a. feminine attributes.
b. unequal gender.
c. fixed gender roles.
d. female inequality.
ANS: C
In cultures with more fixed gender roles, women are usually given the role of caretaker for
aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to
harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles
of males and females being unevenly distributed. Female inequality refers to female gender
and roles being less than or unequal to male roles.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
5. A 60-year-old Italian immigrant presents for an annual physical. He is counseled about
diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and
pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When
developing a plan of care, the nurse should consider which cultural orientation for this
patient?
a. Short term
b. Long term
c. Leisurely term
d. Noncommittal
ANS: A
Short-term cultural orientation focuses on the present or past and emphasizes quick results.
Long-term cultural orientation focuses the future and long-term rewards.
Long-term-oriented cultures favor thrift, perseverance, and adopting to changing
circumstances. Leisurely term and noncommittal are undefined in cultural orientation.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
6. The emphasis on understanding cultural influence on health care is important because of
a. disability entitlements.
b. HIPAA requirements.
When a nurse provides nutritional education to a patient who is from a culture that values
greater power distance, it might appear that the patient is willing to accept all that the nurse
suggests, when further prompting would elicit additional questions or concerns. The patient
from a collectivist culture will usually consult family members for a best course of action. It
is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest
male relative for help with decision making. While writing everything down may be OK for
some cultures, with Asian patients it may be best to prompt further to elicit additional
questions or concerns.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain
due to
a. feminine attributes.
b. unequal gender.
c. fixed gender roles.
d. female inequality.
ANS: C
In cultures with more fixed gender roles, women are usually given the role of caretaker for
aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to
harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles
of males and females being unevenly distributed. Female inequality refers to female gender
and roles being less than or unequal to male roles.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
5. A 60-year-old Italian immigrant presents for an annual physical. He is counseled about
diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and
pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When
developing a plan of care, the nurse should consider which cultural orientation for this
patient?
a. Short term
b. Long term
c. Leisurely term
d. Noncommittal
ANS: A
Short-term cultural orientation focuses on the present or past and emphasizes quick results.
Long-term cultural orientation focuses the future and long-term rewards.
Long-term-oriented cultures favor thrift, perseverance, and adopting to changing
circumstances. Leisurely term and noncommittal are undefined in cultural orientation.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
6. The emphasis on understanding cultural influence on health care is important because of
a. disability entitlements.
b. HIPAA requirements.
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c. increasing global diversity.
d. litigious society.
ANS: C
Culture is an essential aspect of health care because of increasing diversity. Disability
entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries
in relation to housing, employment, and health care. HIPAA requirements refers to the
HIPAA Privacy Rule, which protects the privacy of individually identifiable health
information; the HIPAA Security Rule, which sets national standards for the security of
electronic protected health information; and the confidentiality provisions of the Patient
Safety Rule, which protect identifiable information being used to analyze patient safety
events and improve patient safety. Litigious society refers to excessively ready to go to law
or initiate a lawsuit.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
7. What interrelated constructs facilitate a nurse to become culturally competent?
a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge
b. Cultural desire, self-awareness, cultural knowledge, and cultural identity
c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity
d. Cultural desire, self-awareness, cultural knowledge, and cultural skill
ANS: D
The process of cultural competence consists of four interrelated constructs: cultural desire,
self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of
health care refers to achieving the highest level of health care for all people by addressing
societal inequalities and historical and contemporary injustices. Cultural identity is the
norms, values, beliefs, of a culture learned through families and group
members.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
and behaviors
d. litigious society.
ANS: C
Culture is an essential aspect of health care because of increasing diversity. Disability
entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries
in relation to housing, employment, and health care. HIPAA requirements refers to the
HIPAA Privacy Rule, which protects the privacy of individually identifiable health
information; the HIPAA Security Rule, which sets national standards for the security of
electronic protected health information; and the confidentiality provisions of the Patient
Safety Rule, which protect identifiable information being used to analyze patient safety
events and improve patient safety. Litigious society refers to excessively ready to go to law
or initiate a lawsuit.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
7. What interrelated constructs facilitate a nurse to become culturally competent?
a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge
b. Cultural desire, self-awareness, cultural knowledge, and cultural identity
c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity
d. Cultural desire, self-awareness, cultural knowledge, and cultural skill
ANS: D
The process of cultural competence consists of four interrelated constructs: cultural desire,
self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of
health care refers to achieving the highest level of health care for all people by addressing
societal inequalities and historical and contemporary injustices. Cultural identity is the
norms, values, beliefs, of a culture learned through families and group
members.
OBJ: NCLEX Client Needs Category: Psychosocial Integrity
and behaviors
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Concept 05: Spirituality
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is assessing a patient's spirituality and observes the patient meditating before any
treatments. What is the nurse’s best action?
a. Document that the patient is not religious.
b. Offer the patient a copy of the Bible to read.
c. Arrange for quiet time for the patient as needed.
d. Limit the time patient can meditate before procedures.
ANS: C
The nurse can best promote the patient’s spirituality practices by arranging for the patient to
be left alone when possible to meditate. Meditation is an exemplar of spirituality, not
necessarily of the Christian faith. The Bible is most often read by believers in the Christian
faith. Meditation does not imply that the patient is not religious. Time for meditation should
not be limited, whenever possible.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health
Promotion and Maintenance
2. When conducting a spiritual assessment of a hospitalized patient, the nurse should remain
aware of which potential barrier to effective communication?
a. Clarifying the
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is assessing a patient's spirituality and observes the patient meditating before any
treatments. What is the nurse’s best action?
a. Document that the patient is not religious.
b. Offer the patient a copy of the Bible to read.
c. Arrange for quiet time for the patient as needed.
d. Limit the time patient can meditate before procedures.
ANS: C
The nurse can best promote the patient’s spirituality practices by arranging for the patient to
be left alone when possible to meditate. Meditation is an exemplar of spirituality, not
necessarily of the Christian faith. The Bible is most often read by believers in the Christian
faith. Meditation does not imply that the patient is not religious. Time for meditation should
not be limited, whenever possible.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health
Promotion and Maintenance
2. When conducting a spiritual assessment of a hospitalized patient, the nurse should remain
aware of which potential barrier to effective communication?
a. Clarifying the
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ANS: A
There are a few similar and related terms to spirituality worth mentioning to provide
distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of
believing, that grounds and guides authentic living and gives meaning in the present
moment of inter-relating.” Religiosity, another similar term, is an external expression
(public or private), in the form of practicing a belief or faith, whereas spirituality is an
internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the
adherence to religious dogma or creed, the expression of moral beliefs, and/or the
participation in organized or individual worship, or sacred practices.”
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
4. When developing a plan of care, the nurse should consider which attribute of the concept of
spirituality?
a. Spirituality is not a well-known universal concept.
b. Chronic versus acute illnesses affect spirituality.
c. Convincing patients to pray is a priority intervention.
d. Referrals may be needed to spiritual counselors.
ANS: D
The attributes of the concept of spirituality in the context of nursing care are described
below.
• Spirituality is universal. All individuals, even those who profess no religious belief,
are driven to derive meaning and purpose from life.
• Illness impacts spiritu lity in a variety of ways. Some patients and families will draw
closer to God or however they conceive that higher Power to be in an effort to seek
support, healing, and comfort. Others may blame and feel anger toward that Higher
Power for any illness and misfortune that may have befallen a loved one or their
entire family. Still others will be neutral in their spiritual reactions.
• There has to be willingness on the part of patient and/or family to share and/or act on
spiritual beliefs and practices.
• The nurse needs to be aware that specific spiritual beliefs and practices are impacted
by family and culture.
• The nurse needs to be willing to assess the concept of spirituality in patients and
families and based on this ongoing assessment to integrate the spiritual beliefs of
patients and families into care.
• The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., a
Minister, Priest, Rabbi, an Imam.
• Community-based religious organizations can provide supportive care to families
and patients and nurses need to be aware of these resources.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
MULTIPLE RESPONSE
a
There are a few similar and related terms to spirituality worth mentioning to provide
distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of
believing, that grounds and guides authentic living and gives meaning in the present
moment of inter-relating.” Religiosity, another similar term, is an external expression
(public or private), in the form of practicing a belief or faith, whereas spirituality is an
internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the
adherence to religious dogma or creed, the expression of moral beliefs, and/or the
participation in organized or individual worship, or sacred practices.”
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
4. When developing a plan of care, the nurse should consider which attribute of the concept of
spirituality?
a. Spirituality is not a well-known universal concept.
b. Chronic versus acute illnesses affect spirituality.
c. Convincing patients to pray is a priority intervention.
d. Referrals may be needed to spiritual counselors.
ANS: D
The attributes of the concept of spirituality in the context of nursing care are described
below.
• Spirituality is universal. All individuals, even those who profess no religious belief,
are driven to derive meaning and purpose from life.
• Illness impacts spiritu lity in a variety of ways. Some patients and families will draw
closer to God or however they conceive that higher Power to be in an effort to seek
support, healing, and comfort. Others may blame and feel anger toward that Higher
Power for any illness and misfortune that may have befallen a loved one or their
entire family. Still others will be neutral in their spiritual reactions.
• There has to be willingness on the part of patient and/or family to share and/or act on
spiritual beliefs and practices.
• The nurse needs to be aware that specific spiritual beliefs and practices are impacted
by family and culture.
• The nurse needs to be willing to assess the concept of spirituality in patients and
families and based on this ongoing assessment to integrate the spiritual beliefs of
patients and families into care.
• The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., a
Minister, Priest, Rabbi, an Imam.
• Community-based religious organizations can provide supportive care to families
and patients and nurses need to be aware of these resources.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
MULTIPLE RESPONSE
a
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1. When completing the FICA tool for spiritual assessment, which questions should the nurse
ask the patient? (Select all that apply.)
a. What things do you believe in that give meaning to life?
b. Are you connected with a faith center in your community?
c. How has your illness affected your personal beliefs?
d. When was the last time you have been to church?
e. What can I do for you?
ANS: A, B, C, E
The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence,
Community, and Address. “When was the last time you have been to church?” is not a
question included in the FICA assessment. The patient may attend community activities,
besides church, that foster his/her spiritual well-being.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. Which are true statements about the definition of spirituality in nursing? (Select all that
apply.)
a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality.
b. An exact definition was developed and
ask the patient? (Select all that apply.)
a. What things do you believe in that give meaning to life?
b. Are you connected with a faith center in your community?
c. How has your illness affected your personal beliefs?
d. When was the last time you have been to church?
e. What can I do for you?
ANS: A, B, C, E
The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence,
Community, and Address. “When was the last time you have been to church?” is not a
question included in the FICA assessment. The patient may attend community activities,
besides church, that foster his/her spiritual well-being.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. Which are true statements about the definition of spirituality in nursing? (Select all that
apply.)
a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality.
b. An exact definition was developed and
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The meaning and significance of the event might only be experienced by one individual;
others who might be participants in the event might be left virtually untouched and
unchanged. These life changing spiritual events include just about any occurrence that has
intense and personal relevance to those involved in the event. Examples of spiritually life
changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of
abilities, loss of independence, death and so many more. These events, having the power to
change individuals and families, also have the power to draw people toward the
transcendent—for many people that transcendent is known as God but this is not universal.
Day-to-day activities are not the best examples of spiritually life changing events.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
others who might be participants in the event might be left virtually untouched and
unchanged. These life changing spiritual events include just about any occurrence that has
intense and personal relevance to those involved in the event. Examples of spiritually life
changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of
abilities, loss of independence, death and so many more. These events, having the power to
change individuals and families, also have the power to draw people toward the
transcendent—for many people that transcendent is known as God but this is not universal.
Day-to-day activities are not the best examples of spiritually life changing events.
OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial
Integrity
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Concept 06: Adherence
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to
develop a collaborative plan of care that includes a goal of adhering to the prescribed
regimen. When the nurse is planning teaching for the patient, which is the most important
initial learning goal?
a. The patient will select the type of learning materials they prefer.
b. The patient will verbalize an understanding of the importance of following the
regimen.
c. The patient will demonstrate coping skills needed to manage hypertension.
d. The patient will verbalize the side effects of treatment.
ANS: A
Adults learn best when given information they can understand that is tailored to their
learning styles and needs. Verbalizing an understanding is important; however, the nurse
will first need to teach the patient.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension,
the patient can explain the information but fails to take the medications as prescribed. What
is the nurse’s next action?
a. Reeducate the patient, bec use learning did not occur because the patient’s
behavior did not change.
b. Assess the patient’s perception and attitude toward the
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to
develop a collaborative plan of care that includes a goal of adhering to the prescribed
regimen. When the nurse is planning teaching for the patient, which is the most important
initial learning goal?
a. The patient will select the type of learning materials they prefer.
b. The patient will verbalize an understanding of the importance of following the
regimen.
c. The patient will demonstrate coping skills needed to manage hypertension.
d. The patient will verbalize the side effects of treatment.
ANS: A
Adults learn best when given information they can understand that is tailored to their
learning styles and needs. Verbalizing an understanding is important; however, the nurse
will first need to teach the patient.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension,
the patient can explain the information but fails to take the medications as prescribed. What
is the nurse’s next action?
a. Reeducate the patient, bec use learning did not occur because the patient’s
behavior did not change.
b. Assess the patient’s perception and attitude toward the
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b. Establish a rapport with the patient by complimenting them on what they did
correctly, and ask what strategies they have tried thus far.
c. Refer the patient to a certified diabetic educator, because the educator is an expert
on management of diabetes complications.
d. Have the patient explain what medications they are on and what diet they should
be following.
ANS: B
Principles of a TPB indicate that the patient will need to establish a good rapport with the
nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their
diabetes self-management and adherence with the nurse, the patient may not open up to the
nurse. Although a referral to an educator is a good idea, it would be better to use this
resource as a follow-up for this visit. Having the patient verbalize medications and diet is
not part of the TPB method.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn about
glucose monitoring. Before planning teaching activities, which approach would be most
effective?
a. Assist the patient with long-term goals and plan teaching according to these goals.
b. Provide the patient with all the latest research from the Internet on glucose
monitoring.
c. Refer the patient to the diabetic specialist who can assist the patient with the
glucometer.
d. Assist the patient in developing realistic short-term goals.
ANS: D
Concordance reflects development of an alliance with patients based on realistic
expectations. Providing the patient with the research will not help with the practical skill of
using the glucometer. Long-term goals are useful; however, the goals need to be immediate
with a newly diagnosed patient learning a new skill. Referring the patient would be useful if
the patient has not been able to grasp the concept after several attempts.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
5. The nurse is developing a care plan for a patient who has low motivation and nonadherence
with blood glucose monitoring. Which statement by the patient would indicate to the nurse
that the patient is
correctly, and ask what strategies they have tried thus far.
c. Refer the patient to a certified diabetic educator, because the educator is an expert
on management of diabetes complications.
d. Have the patient explain what medications they are on and what diet they should
be following.
ANS: B
Principles of a TPB indicate that the patient will need to establish a good rapport with the
nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their
diabetes self-management and adherence with the nurse, the patient may not open up to the
nurse. Although a referral to an educator is a good idea, it would be better to use this
resource as a follow-up for this visit. Having the patient verbalize medications and diet is
not part of the TPB method.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn about
glucose monitoring. Before planning teaching activities, which approach would be most
effective?
a. Assist the patient with long-term goals and plan teaching according to these goals.
b. Provide the patient with all the latest research from the Internet on glucose
monitoring.
c. Refer the patient to the diabetic specialist who can assist the patient with the
glucometer.
d. Assist the patient in developing realistic short-term goals.
ANS: D
Concordance reflects development of an alliance with patients based on realistic
expectations. Providing the patient with the research will not help with the practical skill of
using the glucometer. Long-term goals are useful; however, the goals need to be immediate
with a newly diagnosed patient learning a new skill. Referring the patient would be useful if
the patient has not been able to grasp the concept after several attempts.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
5. The nurse is developing a care plan for a patient who has low motivation and nonadherence
with blood glucose monitoring. Which statement by the patient would indicate to the nurse
that the patient is
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
6. The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular
disease and has poor circulation to the feet. Which learning goal should the nurse include in
the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will understand the rationale for proper foot care after instruction.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will post reminder stickers on the calendar to check feet every day and
record scheduled appointments with podiatrist.
ANS: D
6. The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular
disease and has poor circulation to the feet. Which learning goal should the nurse include in
the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will understand the rationale for proper foot care after instruction.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will post reminder stickers on the calendar to check feet every day and
record scheduled appointments with podiatrist.
ANS: D
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To begin the assessment of adherence, it is first important to clarify with the patient (a) their
beliefs and perceptions about their health risk status, (b) their existing knowledge about
cardiovascular disease risk reduction, (c) any prior experience with healthcare professionals,
and (d) their degree of confidence with controlling the disease. The other actions allow
evaluation of the patient’s short-term response to teaching.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
9. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse
notes which behavior as the most reassuring sign that the patient has been following the
treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia?
a. The patient has a list of glucose readings for the past 10 days.
b. The patient has a list of medications along with newly refilled meds.
c. The patient has a list of all foods and beverages for a 3-day period.
d. The patient verbalizes the side effects of all his medications.
ANS: B
Confirming how often a patient renews or refills his/her prescriptions is a measurement of
the patient’s persistence with continuation of the treatment. Having a list of glucose readings
or verbalizing side effects does not necessarily mean that the patient is compliant unless the
readings were
beliefs and perceptions about their health risk status, (b) their existing knowledge about
cardiovascular disease risk reduction, (c) any prior experience with healthcare professionals,
and (d) their degree of confidence with controlling the disease. The other actions allow
evaluation of the patient’s short-term response to teaching.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
9. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse
notes which behavior as the most reassuring sign that the patient has been following the
treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia?
a. The patient has a list of glucose readings for the past 10 days.
b. The patient has a list of medications along with newly refilled meds.
c. The patient has a list of all foods and beverages for a 3-day period.
d. The patient verbalizes the side effects of all his medications.
ANS: B
Confirming how often a patient renews or refills his/her prescriptions is a measurement of
the patient’s persistence with continuation of the treatment. Having a list of glucose readings
or verbalizing side effects does not necessarily mean that the patient is compliant unless the
readings were
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Concept 07: Self-Management
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is
being discharged on medications and given the Dietary Approaches to Stop Hypertension
(DASH) diet to follow. What statement by the patient signals to the nurse that the patient is
motivated to learn?
a. “I am sure the medications will help to bring down my blood pressure.”
b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.”
c. “Do I really need
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is
being discharged on medications and given the Dietary Approaches to Stop Hypertension
(DASH) diet to follow. What statement by the patient signals to the nurse that the patient is
motivated to learn?
a. “I am sure the medications will help to bring down my blood pressure.”
b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.”
c. “Do I really need
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A femur fracture is considered an acute medical event. Pregnancy is an expected and normal
life event/condition. Depression and diabetes are considered disease states.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best
promotes self-efficacy for the parents to help the child follow the prescribed treatments?
a. Ask parents to list all
life event/condition. Depression and diabetes are considered disease states.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best
promotes self-efficacy for the parents to help the child follow the prescribed treatments?
a. Ask parents to list all
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An insulin pen will be the most effective method for injection for an older adult secondary
to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very
small calibration marks and numbers, making it more difficult for older adults to see the
appropriate doses. Daily home visits are not usually paid for by insurance. Most patients
must learn to administer medications themselves. The upper arm subcutaneous site is too
difficult for self-administration and may not be feasible for an older adult.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is developing a teaching plan for a patient diagnosed with congestive heart
failure. Which are the most appropriate teaching points to include that will assist in
self-management of the disease? (Select all that apply.)
a. Side effects of medications
b. Activity restrictions
c. Daily weights
d. Increased sodium intake
e. Blood pressure monitoring
ANS: A, B, C, E
Congestive heart failure (CHF) is one of the most common complications of coronary artery
disease in which the heart fails to pump efficiently enough to meet the metabolic demands
of the body. Fluid overload is a common complication. As with most chronic conditions,
patients with CHF benefit from education about their disease and self-managing diet,
physical activity, weight, and medication adherence. Fluid retention occurs with increased
sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very
small calibration marks and numbers, making it more difficult for older adults to see the
appropriate doses. Daily home visits are not usually paid for by insurance. Most patients
must learn to administer medications themselves. The upper arm subcutaneous site is too
difficult for self-administration and may not be feasible for an older adult.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is developing a teaching plan for a patient diagnosed with congestive heart
failure. Which are the most appropriate teaching points to include that will assist in
self-management of the disease? (Select all that apply.)
a. Side effects of medications
b. Activity restrictions
c. Daily weights
d. Increased sodium intake
e. Blood pressure monitoring
ANS: A, B, C, E
Congestive heart failure (CHF) is one of the most common complications of coronary artery
disease in which the heart fails to pump efficiently enough to meet the metabolic demands
of the body. Fluid overload is a common complication. As with most chronic conditions,
patients with CHF benefit from education about their disease and self-managing diet,
physical activity, weight, and medication adherence. Fluid retention occurs with increased
sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
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Concept 08: Fluid and Electrolytes
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is admitting an older adult with decompensated congestive heart failure. The
nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which
physician order should the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day
ANS: A
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.
The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand
ECV and place an additional load on the failing heart. Diuretics such as furosemide are
appropriate to decrease the ECV during heart failure. Increasing the potassium intake with
KCl is appropriate, because furosemide increases potassium excretion. Oxygen
administration is appropriate in this situation of near pulmonary edema from ECV excess.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and
Parenteral Therapies
2. The nurse assessed four patients at the beginning of the shift. Which finding should the
nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
ANS: B
Positive Chvostek sign indicates increased neuromuscular excitability, which can progress
to dangerous laryngospasm or seizures and thus needs to be reported first. The other
assessment findings are less urgent and need further assessment. Bilateral ankle edema is a
sign of ECV excess, and follow-up is needed, but the situation is not immediately
life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated
with ECV deficit; however, additional assessments of ECV deficit are required before
reporting to the physician. Constipation has many causes, including hypercalcemia and
opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse is admitting an older adult with decompensated congestive heart failure. The
nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which
physician order should the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day
ANS: A
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.
The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand
ECV and place an additional load on the failing heart. Diuretics such as furosemide are
appropriate to decrease the ECV during heart failure. Increasing the potassium intake with
KCl is appropriate, because furosemide increases potassium excretion. Oxygen
administration is appropriate in this situation of near pulmonary edema from ECV excess.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and
Parenteral Therapies
2. The nurse assessed four patients at the beginning of the shift. Which finding should the
nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
ANS: B
Positive Chvostek sign indicates increased neuromuscular excitability, which can progress
to dangerous laryngospasm or seizures and thus needs to be reported first. The other
assessment findings are less urgent and need further assessment. Bilateral ankle edema is a
sign of ECV excess, and follow-up is needed, but the situation is not immediately
life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated
with ECV deficit; however, additional assessments of ECV deficit are required before
reporting to the physician. Constipation has many causes, including hypercalcemia and
opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk
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d. Blood pressure 98/58
ANS: C
Administering IV potassium to a patient who has oliguria is not safe, because potassium
intake faster than potassium output can cause hyperkalemia with dangerous cardiac
dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are
consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not
necessarily indicate fluid overload, because it can be from increased nutritional intake. An
overnight weight gain indicates a fluid gain.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and
Parenteral Therapies
4. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which
patient should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland
ANS: B
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus
causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.
The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting
without fluid replacement causes ECV deficit and hypernatremia.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment
findings should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness
ANS: D
Tube feedings pose a risk for hypernatremia unless adequate water is administered between
tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum
sodium concentration is a laboratory measure for osmolality imbalances, not ECV
imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth,
postural hypotension, and tachycardia all can be signs of ECV deficit.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
6. The patient with which diagnosis should have the highest priority for teaching regarding
foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal
ANS: C
Administering IV potassium to a patient who has oliguria is not safe, because potassium
intake faster than potassium output can cause hyperkalemia with dangerous cardiac
dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are
consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not
necessarily indicate fluid overload, because it can be from increased nutritional intake. An
overnight weight gain indicates a fluid gain.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and
Parenteral Therapies
4. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which
patient should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland
ANS: B
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus
causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.
The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting
without fluid replacement causes ECV deficit and hypernatremia.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment
findings should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness
ANS: D
Tube feedings pose a risk for hypernatremia unless adequate water is administered between
tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum
sodium concentration is a laboratory measure for osmolality imbalances, not ECV
imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth,
postural hypotension, and tachycardia all can be signs of ECV deficit.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
6. The patient with which diagnosis should have the highest priority for teaching regarding
foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal
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ANS: C
When renal excretion is decreased, magnesium intake must be decreased also, to prevent
hypermagnesemia. The other conditions are not likely to require adjustment of magnesium
intake.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has
notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the
priority nursing intervention?
a. Raise bed side rails due to potential decreased level of consciousness and
confusion.
b. Examine sacral area and patient’s heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and
seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg
muscles.
ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in
the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause
edema, decreased level of consciousness, or seizures.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency
syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to
detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all
that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes
ANS: B, C, D
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and
hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium,
calcium, and magnesium. Appropriate assessments include postural blood pressure and heart
rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive
Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of
ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a
normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is
not likely with chronic diarrhea.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
When renal excretion is decreased, magnesium intake must be decreased also, to prevent
hypermagnesemia. The other conditions are not likely to require adjustment of magnesium
intake.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has
notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the
priority nursing intervention?
a. Raise bed side rails due to potential decreased level of consciousness and
confusion.
b. Examine sacral area and patient’s heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and
seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg
muscles.
ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in
the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause
edema, decreased level of consciousness, or seizures.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency
syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to
detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all
that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes
ANS: B, C, D
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and
hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium,
calcium, and magnesium. Appropriate assessments include postural blood pressure and heart
rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive
Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of
ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a
normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is
not likely with chronic diarrhea.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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2. The patient has recent bilateral, above-the-knee amputations and has developed C. difficile
diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?
(Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine.
ANS: A, B, F
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when
supine, which can be assessed in this patient. Although ECV deficit also causes postural
blood pressure drop with tachycardia, this assessment is not appropriate for a patient with
recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased
neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when
upright is a normal finding.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?
(Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine.
ANS: A, B, F
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when
supine, which can be assessed in this patient. Although ECV deficit also causes postural
blood pressure drop with tachycardia, this assessment is not appropriate for a patient with
recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased
neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when
upright is a normal finding.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
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Concept 09: Acid–Base Balance
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement
would indicate that the nurse’s teaching about the acid-base imbalance has been effective?
a. “To prevent another problem, I should eat less sodium during diarrhea.”
b.
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement
would indicate that the nurse’s teaching about the acid-base imbalance has been effective?
a. “To prevent another problem, I should eat less sodium during diarrhea.”
b.
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Subject
Nursing