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    Exam Review

    1. A nurse is caring for a client receiving hospice care who is in the final stages of dying. The client's son appears alarmed and reports that his father is making unusual sounds when breathing. What is the best response from the nurse?
      A)
      "I will increase the oxygen flow to help ease his breathing."
      B)
      "Let me call the respiratory therapist to look at your father."
      C)
      "I will ask the healthcare provider to prescribe suctioning for the noisy breathing."
      D)
      "These sounds are common and usually not painful at the end of life.
    2. A nurse is giving change-of-shift report using the situation, background, assessment, and recommendation (SBAR) communication model to the oncoming nurse regarding a client who has a traumatic brain injury. Which of the following information should the nurse include in the background "B" segment of SBAR?
      A)
      The client's change in status
      B)
      The severity of the problem
      C)
      The past medical history of a concussion
      D)
      The analysis of the situation
    3. A nurse is caring for a client who has terminal cancer and is receiving hospice care.
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for a client who has terminal cancer and is receiving hospice care.

      Click to highlight the information from the nurses' notes that indicate the client is actively dying.

      Heart rate 42/min, irregular

      Blood pressure 62/48 mm Hg

      2000:

      Called by family requesting to visit the client. Client does not respond to verbal, tactile, or painful stimulation. Cheyne-Stokes breathing, noisy respirations. Bowel sounds are present in all 4 quadrants. Family reports no urine output in the last 4 hrs. Skin intact, no breakdown noted.

      Family gathered around client. Update on client's condition provided.

    4. A nurse is assessing a client who reports gradual blurriness of vision over the past 6 months. The nurse inspects the client's eye and notes a cloudy area in part of the lens. Which vision condition does the nurse anticipate that the client is experiencing?
      A)
      Presbyopia
      B)
      Cataracts
      C)
      Macular degeneration
      D)
      Glaucoma
    Page 1 of 12

    Exam Review

    1. A nurse teaches a client how to check their radial pulse as part of discharge education. To evaluate the effectiveness of teaching in the psychomotor domain. which of the following actions should the nurse take?
      A)
      Have the client locate the radial pulse on an anatomically accurate illustration.
      B)
      Observe the client demonstrate how to check their radial pulse.
      C)
      Ask the client to verbalize the steps for checking their radial pulse.
      D)
      Verify the client's understanding of the normal range for a radial pulse.
    2. The nurse working on an inpatient hospice unit has received a change-of-shift report. Which client should the nurse assess first?
      A)
      A 70-year-old client with lung cancer who has a respiratory rate of 16 breaths/minute with a non-productive cough
      B)
      A 46-year-old client with metastatic breast cancer who has a pain level of 8 on a scale of 0-10 and anxious about home pain management.
      C)
      A 30-year-old client with chronic kidney disease who has a urine output of 240 mL/hr for the past 8 hours
      D)
      A 62-year-old client with colon cancer with clammy, pale skin, blood pressure 118/80 mmHg, and heart rate of 88 bpm.
    3. A nurse is caring for an older adult client in a long-term care facility who recently lost her spouse and spends most of her time alone in her room with minimal interaction with others. Which of the following is the most supportive intervention by the nurse to address the client's sensory deprivation?
      A)
      Ask the client what activities she enjoys and facilitate access to the activities.
      B)
      Encourage the client to attend all activities offered by the facility.
      C)
      Ask the client to attend the weekly women's exercise group.
      D)
      Encourage the client to attend group therapy sessions.
    4. A nurse is caring for an older adult client who reports recent difficulty hearing in his right ear. In addition, he has a large amount of cerumen in the same ear that is difficult to remove. Which type of hearing loss does the nurse expect when assessing this client?
      A)
      Presbyopia
      B)
      Presbycusis
      C)
      Conductive
      D)
      Otitis
    Page 2 of 12

    Exam Review

    1. A nurse is instructing a student nurse about the importance of rest in the hospital. Which of the following clinical environments should the nurse include in discussing as the most likely to contribute to severe sensory overload when a client is receiving care?
      A)
      Critical care unit (CCU)
      B)
      Medical-surgical unit
      C)
      Long-term care agencies
      D)
      Urgent care clinic
    2. A client with chronic obstructive pulmonary disease (COPD) recently lost a spouse and frequently voices frustration, saying, "If I can just get better, I promise I'll be a better person." Which behavior indicates the bargaining stage of the Kubler-Ross model of grief?
      A)
      Experiencing numbness and denying the reality of the loss
      B)
      Expressing they are sad and not wanting to move on with life without their deceased partner.
      C)
      Displaying anger and blaming others for current difficulties
      D)
      Expressing regret and attempting to negotiate a different outcome
    3. A nurse is assessing a client who reports frequent episodes of vertigo. Which sensory deficit will the nurse assess further?
      A)
      Tactile
      B)
      Gustatory
      C)
      Olfactory
      D)
      Kinesthetic
    4. A nurse is caring for a client with hearing loss in a long-term care facility. The nurse has provided teaching to the client to improve her ability to understand others. Identify the following statements the client makes to the nurse after receiving education as effective or ineffective in supporting her ability to hear individuals who communicate with her.
      A)
      "Let me face the light in the room when you are speaking."
      B)
      "Avoid using hand gestures and speak directly into my left ear."
      C)
      "Verify that I have understood the information you have shared with me."
      D)
      "Talk to me at a distance so I can read your lips."
      E)
      "Face me when speaking and use gestures for what you are trying to convey."
    Page 3 of 12

    Exam Review

    1. A nurse is teaching a client who wishes to stop smoking cigarettes. Which of the following teaching methods uses the affective domain of learning?
      A)
      Encourage the client to share feelings and concerns related to smoking cessation.
      B)
      Discuss the benefits of smoking cessation with the client by utilizing handouts for recalling information.
      C)
      Review active strategies for smoking cessation with the client, such as chewing gum.
      D)
      Create short-term goals to assist the client in becoming successful in smoking cessation
    2. The nurse is caring for a client who requires occupational therapy. Which question asked by the nurse would be most appropriate when assessing a client for the sensory perception of stereognosis?
      A)
      "Have you smelled odors lately that others cannot smell?"
      B)
      "Have you found it difficult to communicate verbally?"
      C)
      "Have you been experiencing any strange tastes lately?"
      D)
      "Can you close your eyes and tell me what I am placing in your hand right now?"
    3. A 55-year-old client presents to a primary care clinic for an annual checkup and states "I am really struggling to read the fine print in the newspaper and my eyes feel very strained when I use my smartphone". Which of the following sensory deficits is the client describing?
      A)
      Peripheral neuropathy
      B)
      Presbyopia
      C)
      Presbycusis
      D)
      Xerostomia
    4. A nurse is reviewing the purpose and criteria for hospice care with a group of nursing students. Which statement best reflects the understanding of a commonly used eligibility criterion for hospice care?
      A)
      "A client is eligible for hospice care when they have a life expectancy of 6 months or less if the disease follows its natural course."
      B)
      "Hospice care is available to clients who request emotional support regardless of their Illness status."
      C)
      "Hospice care is appropriate when a client has difficulty performing activities of daily living independently."
      D)
      "Clients must first complete all curative treatments before qualifying for hospice care."
    Page 4 of 12

    Exam Review

    1. A terminally ill client who has a life expectancy of 5 months expresses anxiety about hospice care and states "I am afraid I will die sooner if I receive hospice care". Which statement should the nurse include in the client's teaching about hospice care?
      A)
      "You seem to be experiencing some difficulty with this stage of the grieving process."
      B)
      "Hospice care assists in understanding treatment options, making treatment decisions, and coordinating care."
      C)
      "Hospice care is focused on improving the overall wellness of people with chronic illnesses."
      D)
      "Hospice care focuses on a holistic approach to healthcare and is designed to relieve symptoms, not to hasten death."
    2. The nurse is caring for multiple clients on the unit. Which client would be most appropriate for a referral for palliative care support?
      A)
      An 80-year-old client diagnosed with unmanageable chronic obstructive pulmonary disease (COPD)
      B)
      A 70-year-old client undergoing rehabilitation after a mild stroke with good recovery prognosis
      C)
      A 50-year-old client experiencing an acute exacerbation of a manageable chronic condition
      D)
      A 25-year-old client recovering from a minor surgical procedure with an expected full recovery
    3. The nurse is assessing a client with malnutrition. Which sensory deficit would be most likely to cause this condition?
      A)
      Xerostomia
      B)
      Peripheral neuropathy
      C)
      Diabetic retinopathy
      D)
      Disequilibrium
    4. A nurse is caring for a client who is postoperative. Which of the following factors could present a barrier to the nurse effectively communicating with the client? Select all that apply.
      A)
      Client's hearing condition
      B)
      Volume of the client's television
      C)
      Quantity of visitors at 1300
      D)
      Reported pain level at 0745
      E)
      Adverse effects of medication administered at 1045
      F)
      Modality client is using to listen to music at 1045
      G)
      Volume of food consumed at 1300
    Page 5 of 12

    Exam Review

    1. A nurse is completing a hand-off report to the nurse taking over the next shift. Which of the following is the best reason for ensuring effective communication during this process?
      A)
      To ensure continuity of care and promote client safety.
      B)
      To reduce the risk of medication errors during the transition of care.
      C)
      To promote teamwork and enhance staff efficiency on the unit.
      D)
      To comply with the hospital's legal documentation requirements.
    2. The nurse is caring for a 76-year-old client who would benefit from therapy services. When assessing the client, which clinical manifestations would indicate impaired proprioception in an older adult client?
      A)
      Decreased hearing in one ear
      B)
      Inability to understand language or communicate verbally
      C)
      Difficulty maintaining balance when standing
      D)
      Inability to detect what an object is in their hand
    3. A terminally ill client tells the nurse. "I cannot sleep at night. I keep thinking about what is going to happen to me." How should the nurse respond?
      A)
      "Just close your eyes and practice the relaxation techniques I taught you."
      B)
      "You are so lucky you have so many people who care about you."
      C)
      "You are having difficulty resting because of your current situation?"
      D)
      "Everything will be ok: I will bring you a warm beverage"
    4. The nurse is planning care for a client with hearing loss. The client recently received a new hearing aid device. Which of the following would be a priority for the nurse to address?
      A)
      The client states, "I don't need that thing. I can hear just fine!"
      B)
      The client thinks that the hearing aid is "ugly".
      C)
      The client's family members are concerned the client will reject the hearing aid.
      D)
      The client changes the battery every week.
    Page 6 of 12