Custom: NUR 109 Final Assessment

Question 2

Custom: NUR 109 Final Assessment. A nurse is reviewing the medical records of several clients to determine which are at risk for developing a pressure injury. Which of the following clients should the nurse identify as being at the highest risk?

• A client who is alert and oriented but has limited mobility due to a leg cast.
• A client who is receiving physical therapy and is able to ambulate with a walker.
• A client who is older, has a history of diabetes, and is currently experiencing urinary incontinence.
• A client who is overweight but is able to change positions in bed independently.

Question 3

A nurse is teaching a group of newly licensed nurses about the importance of evidence-based practice (EBP). Which of the following statements should the nurse include in the teaching?

• “EBP is primarily used to reduce healthcare costs and increase efficiency.”
• “EBP is based solely on the nurse’s clinical experience and intuition.”
• “EBP involves integrating the best available research evidence with clinical expertise and client values.”
• “EBP is a static process that does not change over time.”

Question 4

A nurse is caring for a client who is scheduled for surgery. The client expresses concern about the risks of the procedure. Which of the following actions should the nurse take?

• Tell the client that there is no need to worry and that the surgery is routine.
• Listen to the client’s concerns and provide them with information about the procedure and its risks.
• Inform the client that they can cancel the surgery at any time.
• Refer the client to the surgeon for further explanation.

Question 5

A nurse is providing care for a client who has a living will. Which of the following statements best describes the purpose of a living will?

• It is a legal document that designates a person to make healthcare decisions for the client if they are unable to do so.
• It is a document that provides directives for medical treatment per the client’s wishes if they are unable to communicate.
• It is a document that outlines the client’s funeral arrangements.
• It is a legal document that specifies how the client’s assets should be distributed after death.

Question 6

A nurse is preparing a discharge plan for a client who has limited English proficiency. Which of the following strategies should the nurse include to ensure the client understands the instructions? (Select all that apply.)

• Use pictures and diagrams to supplement written and verbal instructions.
• Provide written materials in the client’s primary spoken language.
• Incorporate culturally relevant information and examples into the teaching.
• Use a variety of teaching materials, such as videos and brochures.
• Speak slowly and loudly to the client.

Question 7

A nurse is conducting a health screening for a group of older adults. Which of the following findings should the nurse identify as a potential sign of elder neglect?

• The client has a clean and well-maintained appearance.
• The client is able to manage their own medications.
• The client has poor hygiene and is wearing dirty clothing.
• The client is active and participates in social activities.

Question 8

A nurse is assessing a client who is experiencing pain. Which of the following actions should the nurse take first?

• Administer a dose of pain medication.
• Determine the location of the pain.
• Ask the client to rate the pain on a scale of 0 to 10.
• Assess the client’s vital signs.

Question 9

A nurse is teaching a class about the different types of pain. Which of the following statements should the nurse include when describing acute pain?

• “Acute pain is long-lasting and often does not have a clear cause.”
• “Acute pain occurs suddenly and is typically related to a specific injury or trauma.”
• “Acute pain is often difficult to treat and may require long-term management.”
• “Acute pain is not as severe as chronic pain.” Custom: NUR 109 Final Assessment

Question 10

A nurse is caring for a client who is taking celecoxib for the treatment of osteoarthritis. Which of the following findings should the nurse report to the provider?

• Black, tarry stools
• Constipation
• Increased appetite
• Dry mouth

Question 11

A nurse is providing information to a client about palliative care services. Which of the following statements by the client indicates an understanding of the teaching?

• “Palliative care is only for people who are dying.”
• “Palliative care will help me get better faster.”
• “This service assists with making me comfortable during my illness.”
• “Palliative care is only for people who have cancer.”

Question 12

A nurse is communicating with a client who has aphasia. Which of the following actions should the nurse take?

• Speak loudly and slowly to the client.
• Use complex sentences and provide a lot of information at once.
• Use simple, short sentences and allow extra time for the client to respond.
• Finish the client’s sentences for them if they are struggling to find the right words. Custom: NUR 109 Final Assessment

Question 13

A nurse is teaching a group of students about the wellness continuum. Which of the following statements should the nurse include in the teaching?

• “The wellness continuum is a fixed point that does not change over time.”
• “Health and illness are two separate and distinct states.”
• “The wellness continuum recognizes that health is multidimensional and includes physical, mental, and social well-being.”
• “The wellness continuum is only applicable to people who are healthy.”

Question 14

A nurse is providing teaching to a client who is taking ibuprofen for the treatment of pain. Which of the following instructions should the nurse include?

• Take the medication on an empty stomach.
• Take the medication with food.
• Do not take the medication with any other medications.
• Only take the medication when the pain is severe.

Question 15

A nurse is assessing a client who is experiencing chronic pain. Which of the following information should the nurse obtain from the client?

• Location, quality, and duration of the pain.
• The client’s family history of pain.
• The client’s diet and exercise habits.
• The client’s insurance coverage for pain management.

Question 16

A correctional nurse is caring for a client who was recently injured in the facility. The client is complaining of pain but is not due to receive any more pain medication for a while. Which of the following interventions could the nurse include to achieve the goal of pain relief?

• Using distractions like watching TV to keep the client’s mind off the pain
• Apply heat therapy to the pain area
• Give the medication even though it is not due yet
• Use of acupuncture

Question 17

A community health nurse is researching social determinants of health in the differing populations they serve. The nurse should identify that which of the following factors place populations at the highest risk for negative health outcomes?

• Poverty
• Transportation access
• Language barriers
• Genetics

Question 18

A nurse is conducting a pain assessment for a client who reports discomfort. Which of the following actions is the most appropriate for the nurse to take to obtain a comprehensive understanding of the client’s pain?

• Review the patient’s medical history for past pain management interventions and their outcomes.
• Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity.
• Measure the patient’s vital signs and note any changes.
• Observe the patient’s facial expressions and body language for signs of discomfort.

Question 19

A nurse is caring for a terminally ill client on hospice who passed away during the shift. Select the first 3 postmortem care actions the nurse should take:

• Verify the provider has certified and documented death of the client.
• Consider any cultural, religious, or social practices of the client that would impact postmortem care.
• Dim the lights and minimize noise to provide a calm environment.
• Tell the family to leave the room while you prepare the body.
• Lay the client’s head flat.

Question 20

An 82-year-old woman with a history of chronic illnesses, including severe dementia and heart disease, is admitted to a long-term care facility. The client is on multiple medications including aspirin. During a routine assessment, the nurse observes several bruises in various stages of healing, as well as signs of malnutrition and poor hygiene. The client appears fearful and hesitant to make eye contact. The client’s daughter, who is her primary caregiver, is frequently present and seems agitated when questioned about the client’s condition. Custom: NUR 109 Final Assessment

The most likely cause of the client’s condition based on the nurse’s observations is potential physical abuse and neglect by the caregiver. The nurse should document the client’s physical findings and report the concerns to the facility’s social worker or elder abuse specialist for further evaluation to address the situation effectively.

Question 21

A nurse is preparing to communicate with a hearing-impaired client during a routine assessment. Which of the following strategies is most appropriate for ensuring effective communication with this client?

• Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively.
• Use written communication to supplement verbal instructions and ensure the client understands the information.
• Speak loudly and slowly to the client to ensure they can hear you clearly.
• Avoid standing in front of the client while speaking.

Question 22

The nurse is caring for a child who has a diagnosis of metastatic brain cancer. The father states “I can’t believe this is happening to us. I feel numb.” Which of the following nursing interventions by the nurse is the first priority?

• Explore effective ways of family coping
• Encourage the family’s expression of their feelings
• Discuss the disease and its manifestations with family members
• Instruct the family about anticipatory grieving

Question 23

A nursing student is preparing a presentation on cultural competence for a group of fellow nursing students. Which of the following statements could the student include in their explanation to best describe cultural competence in nursing?

• “Cultural competence involves understanding and respecting diverse cultural backgrounds and incorporating this understanding into client care to improve outcomes and client satisfaction.”
• “Cultural competence is only necessary when caring for clients from cultures that are significantly different from one’s own.”
• “Cultural competence means that healthcare providers must follow a standardized approach to care that applies to all clients, regardless of their cultural background.”
• “Cultural competence requires that nurses adopt the cultural practices of their clients to provide the best care.” Custom: NUR 109 Final Assessment

Question 24

A nurse is teaching a class about the physical manifestations of grief. Which of the following manifestations should the nurse include?

• Bradycardia
• Blurred vision
• Insomnia
• Increased ability to concentrate

Question 25

The nurse is reviewing the medical history and nursing notes for a client. Based on the findings, select the cues that indicate the client is nearing the end of life:

• Neurological Status: Semi-conscious, intermittent periods of drowsiness, limited response to verbal stimuli.
• Respiratory Pattern: Cheyne-Stokes respiration (rapid, shallow breathing alternating with periods of apnea).
• Integumentary: Skin is cool and mottled, particularly on the extremities.
• Intake: Has not consumed solid food for 48 hours.
• Vital Signs: Low blood pressure, irregular heart rate, and fluctuating/variable respiratory rates.