NUR 155 Exam 1 (Units 1 & 2) Questions With Complete
Solutions
A 74-year-old female is brought to the emergency department
c/o right hip pain. The right leg is shorter than the left and is
externally rotated. During inspection, the nurse observes what
appears to be cigarette burns on the client's inner thighs. Which
of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs
bilaterally
2. Several burned areas on both of the client's inner thighs
3. Multiple lesions on inner thighs possibly related to elder
abuse
4. Several lesions on inner thighs similar to cigarette burns
Correct Answer Answer: 1
Rationale: Option 1 is the most specific, non-assuming, and
nonjudgmental charting. Option 2 could be more specific by
describing the lesions and not calling them "burns." Option 3 is
making
a judgment of elder abuse, and option 4 is also making an
assumption that the lesions are from cigarette burns
A client is admitted for heart failure. The nurse assesses that the
client's blood pressure is below normal range and the apical
pulse is 110 beats/min. The nurse knows that the increase in the
client's pulse illustrates which aspect of the client's homeostatic
mechanism?
1. Compensation
2. Decompensation
3. Self-regulation
4. Equilibrium Correct Answer Answer: 1
, Rationale: The compensatory mechanism of increasing the heart
rate is the body's way of trying to balance an ineffective cardiac
output since the BP has decreased. Decompensation (option 2)
occurs when the compensatory mechanism is ineffective. Self-
regulation
(option 3) refers to the homeostatic mechanisms that come into
play automatically in the healthy person. Equilibrium (option 4)
is balance through adaptation to the environment.
A client recently diagnosed with a chronic illness asks for help
in understanding the term chronic. It would be correct for the
nurse to say which of the following?
1. Symptoms are always less severe than with an acute illness.
2. Chronic illnesses are considered incurable.
3. Signs and symptoms of chronic illnesses tend to be stable for
many years.
4. Chronic illnesses have no effective treatments. Correct
Answer
A client who is 46 pounds overweight tells you, "I was just
born to be fat. I don't have the willpower." Although weight loss
occurred while attending two previous programs that
"guaranteed" weight loss, the weight returned along with extra
pounds after each program. According to the Health Promotion
Model, the nurse is most likely to focus on which behavior
specific
cognition and affect variable for this client?
1. Perceived barriers to action
2. Perceived self-efficacy
3. Interpersonal influences
4. Situational influences Correct Answer Answer: 2
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