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