FUNDAMENTALS OF Nursing

50 Items
1. The most appropriate nursing order for a patient who develops dyspnea and shortness of
breath would be

a. Maintain the patient on strict bed rest at all times

b. Maintain the patient in an orthopneic position as needed

c. Administer oxygen by Venturi mask at 24%, as needed

d. Allow a 1 hour rest period between activities

Correct B. Rationale: When a patient develops dyspnea and shortness of breath, the orthopneic
position encourages maximum chest expansion and keeps the abdominal organs from pressing
against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24%
would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing
for rest periods decreases the possibility of hypoxia.
2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates
the head of the bed to the high Fowler position, which decreases his respiratory distress. The
nurse documents this breathing as:

a. Tachypnea

b. Eupnca

c. Orthopnea

d. Hyperventilation

Correct C. Rationale:Orthopnea is difficulty of breathing except in the upright position.

Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal
respiration quiet, rhythmic, and without effort.
3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse
is responsible for:

a. Instructing the patient about this diagnostic test

b. Writing the order for this test

c. Giving the patient breakfast

d. All of the above

Correct Answer C. Rationale: A platelet count evaluates the number of platelets in the circulating
blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time.
The physician is responsible for instructing the patient about the test and for writing the order for
the test.
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a
500-mg low sodium diet. These include:

a. A ham and Swiss cheese sandwich on whole wheat bread

b. Mashed potatoes and broiled chicken

c. A tossed salad with oil and vinegar and olives

d. Chicken bouillon

Corre ct Answer B. Rationale:Mashed potatoes and broiled chicken are low in natural sodium
chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are
contraindicated on a low sodium diet.
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an
anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.

b. Reporting an APTT above 45 seconds to the physician

c. Assessing the patient for signs and symptoms of frank and occult bleeding

d. All of the above

Correct Answer D. Rationale: All of the identified nursing responsibilities are pertinent when a
patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds
and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two
and one half the normal levels. All patients receiving anticoagulant therapy must be observed for
signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension,
tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood
pressure should be measured every 4 hours and the patient should be instructed to report
promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy
prolonged menstruation.
6. The four main concepts common to nursing that appear in each of the current conceptual
models are:

a. Person, nursing, environment, medicine

b. Person, health, nursing, support systems

c. Person, health, psychology, nursing

d. Person, environment, health, nursing

Correct Answer D. Rationale :The focus concepts that have been accepted by all theorists as the
focus of nursing practice from the time of Florence Nightingale include the person receiving
nursing care, his environment, his health on the health illness continuum, and the nursing actions
necessary to meet his needs.
7. In Maslows hierarchy of physiologic needs, the human need of greatest priority is:

a. Love

b. Elimination

c. Nutrition

d. Oxygen

Correct Answer D. Rationale :Maslow, who defined a need as a satisfaction whose absence

causes illness, considered oxygen to be the most important physiologic need; without it, human
life could not exist. According to this theory, other physiologic needs (including food, water,
elimination, shelter, rest and sleep, activity and temperature regulation) must be met before
proceeding to the next hierarchical levels on psychosocial needs.
8. The family of an accident victim who has been declared brain-dead seems amenable to organ
donation. What should the nurse do?

a. Discourage them from making a decision until their grief has eased

b. Listen to their concerns and answer their questions honestly

c. Encourage them to sign the consent form right away

d. Tell them the body will not be available for a wake or funeral

Correct Answer B. Rationale:The brain-dead patients family needs support and reassurance in
making a decision about organ donation. Because transplants are done within hours of death,
decisions about organ donation must be made as soon as possible. However, the familys
concerns must be addressed before members are asked to sign a consent form. The body of an
organ donor is available for burial.
9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift.
What should she do?

a. Complain to her fellow nurses

b. Wait until she knows more about the unit

c. Discuss the problem with her supervisor

d. Inform the staff that they must volunteer to rotate

Correct Answer C. Rationale: Although a new head nurse should initially spend time observing
the unit for its strengths and weakness, she should take action if a problem threatens patient
safety. In this case, the supervisor is the resource person to approach
10. Which of the following principles of primary nursing has proven the most satisfying to the
patient and nurse?

a. Continuity of patient care promotes efficient, cost-effective nursing care

b. Autonomy and authority for planning are best delegated to a nurse who knows the
patient well

c. Accountability is clearest when one nurse is responsible for the overall plan and its
implementation.

d. The holistic approach provides for a therapeutic relationship, continuity, and efficient
nursing care.

Correct Answer D. Rationale: Studies have shown that patients and nurses both respond well to
primary nursing care units. Patients feel less anxious and isolated and more secure because they
are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it
related to positive feedback from the patients. They also seem to gain a greater sense of
achievement and esprit de corps.

11. If nurse administers an injection to a patient who refuses that injection, she has committed:

a. Assault and battery

b. Negligence

c. Malpractice

d. None of the above

Correct Answer A. Rationale; Assault is the unjustifiable attempt or threat to touch or injure
another person. Battery is the unlawful touching of another person or the carrying out of
threatened physical harm. Thus, any act that a nurse performs on the patient against his will is
considered assault and battery
12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that
the physician is incompetent, the nurse could be held liable for:

a. Slander

b. Libel

c. Assault

d. Respondent superior

Correct Answer A. Rationale: Oral communication that injures an individuals reputation is

considered slander. Written communication that does the same is considered libel.
13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily
turning away from a 3 month-old infant she has been weighing. The infant falls off the scale,
suffering a skull fracture. The nurse could be charged with:

a. Defamation

b. Assault

c. Battery

d. Malpractice

Correct Answer D. Rationale: Malpractice is defined as injurious or unprofessional actions that

harm another. It involves professional misconduct, such as omission or commission of an act that
a reasonable and prudent nurse would or would not do. In this example, the standard of care was
breached; a 3-month-old infant should never be left unattended on a scale.
14. Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to the
drug. The patient experiences an allergic reaction and has cerebral damage resulting from
anoxia.

b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with
abdominal cramping.

c. The nurse assists a patient out of bed with the bed locked in position; the patient slips
and fractures his right humerus.

d. The nurse administers the wrong medication to a patient and the patient vomits. This
information is documented and reported to the physician and the nursing supervisor.

Correct Answer A. Rationale: The three elements necessary to establish a nursing malpractice are
nursing error (administering penicillin to a patient with a documented allergy to the drug), injury
(cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage).
Applying a hot water bottle or heating pad to a patient without a physicians order does not
include the three required components. Assisting a patient out of bed with the bed locked in
position is the correct nursing practice; therefore, the fracture was not the result of malpractice.
Administering an incorrect medication is a nursing error; however, if such action resulted in a
serious illness or chronic problem, the nurse could be sued for malpractice.
15. Which of the following signs and symptoms would the nurse expect to find when assessing
an Asian patient for postoperative Pain following abdominal surgery?

a. Decreased blood pressure and heart rate and shallow respirations

b. Quiet crying

c. Immobility, diaphoresis, and avoidance of deep breathing or coughing

d. Changing position every 2 hours

Correct Answer C. Rationale:An Asian patient is likely to hide his Pain. Consequently, the nurse
must observe for objective signs. In an abdominal surgery patient, these might include
immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart
rate, shallow respirations (stemming from Pain upon moving the diaphragm and respiratory
muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display
emotion, such as crying.
16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and
severe abdominal Pain. Which of the following would immediately alert the nurse that the patient
has bleeding from the GI tract?

a. Complete blood count

b. Guaiac test

c. Vital signs

d. Abdominal girth

Correct Answer B. Rationale :To assess for GI tract bleeding when frank blood is absent, the
nurse has two options: She can test for occult blood in vomitus, if present, or in stool through
guaiac (Hemoccult) test. A complete blood count does not provide immediate results and does
not always immediately reflect blood loss. Changes in vital signs may be cause by factors other
than blood loss. Abdominal girth is unrelated to blood loss.
17. The correct sequence for assessing the abdomen is:

a. Tympanic Percussion, measurement of abdominal girth, and inspection

b. Assessment for distention, tenderness, and discoloration around the umbilicus.

c. Percussions, Palpation, and Auscultation

d. Auscultation, Percussion, and Palpation

Correct Answer D. Rationale:Because Percussion and Palpation can affect bowel motility and
thus bowel sounds, they should follow Auscultation in abdominal assessment. Tympanic
Percussion, measurement of abdominal girth, and inspection are methods of assessing the
abdomen. Assessing for distention, tenderness and discoloration around the umbilicus can
indicate various bowel-related conditions, such as cholecystitis, Appendicitis and peritonitis.
18. High-pitched gurgles head over the right lower quadrant are:

a. A sign of increased bowel motility

b. A sign of decreased bowel motility

c. Normal bowel sounds

d. A sign of abdominal cramping

Correct Answer C. Rationale :Hyperactive sounds indicate increased bowel motility; two or three
sounds per minute indicate decreased bowel motility. Abdominal cramping with hyperactive,
high pitched tinkling bowel sounds can indicate a bowel obstruction.
19. A patient about to undergo abdominal inspection is best placed in which of the following
positions?

a. Prone

b. Trendelenburg

c. Supine

d. Side-lying

Correct Answer C. Rationale:The supine position (also called the dorsal position), in which the
patient lies on his back with his face upward, allows for easy access to the abdomen. In the prone
position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg
position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is
lower than the legs. In the lateral position, the patient lies on his side.
20. For a rectal examination, the patient can be directed to assume which of the following
positions?

a. Genupecterol

b. Sims

c. Horizontal recumbent

d. All of the above

Correct answer D. Rationale:All of these positions are appropriate for a rectal examination. In
the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming
a 90 degree angle between the torso and upper legs. In Sims position, the patient lies on his left
side with the left arm behind the body and his right leg flexed. In the horizontal recumbent
position, the patient lies on his back with legs extended and hips rotated outward.
21. During a Romberg test, the nurse asks the patient to assume which position?

a. Sitting

b. Standing

c. Genupectoral

d. Trendelenburg

Correct Answer B. Rationale:During a Romberg test, which evaluates for sensory or cerebellar
ataxia, the patient must stand with feet together and arms resting at the sidesfirst with eyes
open, then with eyes closed. The need to move the feet apart to maintain this stance is an
abnormal finding.
22. If a patients blood pressure is 150/96, his pulse pressure is:

a. 54

b. 96

c. 150

d. 246

Correct Answer A. Rationale:The pulse pressure is the difference between the systolic and
diastolic blood pressure readings in this case, 54.
23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8
a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:

a. Infection

b. Hypothermia

c. Anxiety

d. Dehydration

Correct Answer D. Rationale:A slightly elevated temperature in the immediate preoperative or

post operative period may result from the lack of fluids before surgery rather than from Infection.
Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body
temperature.
24. Which of the following parameters should be checked when assessing respirations?

a. Rate

b. Rhythm

c. Symmetry

d. All of the above

Correct Answer D. Rationale:The quality and efficiency of the respiratory process can be
determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
25. A 38-year old patients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse
rate, 88; respiratory rate, 30. Which findings should be reported?

a. Respiratory rate only

b. Temperature only

c. Pulse rate and temperature

d. Temperature and respiratory rate

Correct Answer D. Rationale:Under normal conditions, a healthy adult breathes in a smooth

uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal.
A normal adult body temperature, as measured on an oral thermometer, ranges between 97 and
100F (36.1 and 37.8C); an axillary temperature is approximately one degree lower and a
rectal temperature, one degree higher. Thus, an axillary temperature of 99.6F (37.6C) would be
considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a
rate of 88 is normal.
26. All of the following can cause tachycardia except:

a. Fever

b. Exercise

c. Sympathetic nervous system stimulation

d. Parasympathetic nervous system stimulation

Correct Answer D. Rationale:Parasympathetic nervous system stimulation of the heart decreases

the heart rate as well as the force of contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and sympathetic stimulation all increase the heart
rate.
27. Palpating the midclavicular line is the correct technique for assessing

a. Baseline vital signs

b. Systolic blood pressure

c. Respiratory rate

d. Apical pulse

Correct Answer D. Rationale:The apical pulse (the pulse at the apex of the heart) is located on
the midclavicular line at the fourth, fifth, or sixth intercostal space. Base line vital signs include
pulse rate, temperature, respiratory rate, and blood pressure. Blood pressure is typically assessed
at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with
each inspiration and expiration.
28. The absence of which pulse may not be a significant finding when a patient is admitted to the
hospital?

a. Apical

b. Radial

c. Pedal

d. Femoral

Correct Answer C. Rationale:Because the pedal pulse cannot be detected in 10% to 20% of the
population, its absence is not necessarily a significant finding. However, the presence or absence

of the pedal pulse should be documented upon admission so that changes can be identified
during the hospital stay. Absence of the apical, radial, or femoral pulse is abnormal and should be
investigated.
29. Which of the following patients is at greatest risk for developing pressure ulcers?

a. An alert, chronic arthritic patient treated with steroids and aspirin

b. An 88-year old incontinent patient with gastric cancer who is confined to his bed at
home

c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula

d. A confused 78-year old patient with congestive heart failure (CHF) who requires
assistance to get out of bed.

Correct Answer B. Rationale:Pressure ulcers are most likely to develop in patients with impaired
mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric
cancer) and is confined to bed is at greater risk.
30. The physician orders the administration of high-humidity oxygen by face mask and
placement of the patient in a high Fowlers position. After assessing Mrs. Paul, the nurse writes
the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of
the following nursing interventions has the greatest potential for improving this situation?

a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours

b. Place a humidifier in the patients room.

c. Continue administering oxygen by high humidity face mask

d. Perform chest physiotheraphy on a regular schedule

Correct Answer A. Rationale:Adequate hydration thins and loosens pulmonary secretions and
also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea.
High- humidity air and chest physiotherapy help liquefy and mobilize secretions.
31. The most common deficiency seen in alcoholics is:

a. Thiamine

b. Riboflavin

c. Pyridoxine

d. Pantothenic acid

Correcr Answer A. Rationale: Chronic alcoholism commonly results in thiamine deficiency and
other symptoms of malnutrition.
32. Which of the following statement is incorrect about a patient with dysphagia?

a. The patient will find pureed or soft foods, such as custards, easier to swallow than
water

b. Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing

c. The patient should always feed himself

d. The nurse should perform oral hygiene before assisting with feeding.

Correct Answer C. Rationale:A patient with dysphagia (difficulty swallowing) requires assistance
with feeding. Feeding himself is a long-range expected outcome. Soft foods, Fowlers or semiFowlers position, and oral hygiene before eating should be part of the feeding regimen.
33. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the
nurse measures his hourly urine output. She should notify the physician if the urine output is:

a. Less than 30 ml/hour

b. 64 ml in 2 hours

c. 90 ml in 3 hours

d. 125 ml in 4 hours

Correct Answer A. Rationale:A urine output of less than 30ml/hour indicates hypovolemia or
oliguria, which is related to kidney function and inadequate fluid intake.
34. Certain substances increase the amount of urine produced. These include:

a. Caffeine-containing drinks, such as coffee and cola.

b. Beets

c. Urinary analgesics

d. Kaolin with pectin (Kaopectate)

Correct Answer A. Rationale:Fluids containing caffeine have a diuretic effect. Beets and urinary
analgesics, such as pyridium, can color urine red. Kaopectate is an anti diarrheal medication.
35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his
first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that
his vision was unaffected by the surgery. Which of the following nursing interventions would be
appropriate?

a. Encourage the patient to walk in the hall alone

b. Discourage the patient from walking in the hall for a few more days

c. Accompany the patient for his walk.

d. Consuit a physical therapist before allowing the patient to ambulate

Correct Answer C. Rationale: A hospitalized surgical patient leaving his room for the first time
fears rejection and others staring at him, so he should not walk alone. Accompanying him will
offer moral support, enabling him to face the rest of the world. Patients should begin ambulation
as soon as possible after surgery to decrease complications and to regain strength and confidence.
Waiting to consult a physical therapist is unnecessary.
36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by
shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An
appropriate nursing diagnosis would be:

a. Ineffective airway clearance related to thick, tenacious secretions.

b. Ineffective airway clearance related to dry, hacking cough.

c. Ineffective individual coping to COPD.

d. Pain related to immobilization of affected leg.

Correct Answer A. Rationale:Thick, tenacious secretions, a dry, hacking cough, orthopnea, and
shortness of breath are signs of ineffective airway clearance. Ineffective airway clearance related
to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway
clearance. Ineffective individual coping related to COPD is wrong because the etiology for a
nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that
the patient is coping ineffectively. Pain related to immobilization of affected leg would be an
appropriate nursing diagnosis for a patient with a leg fracture.
37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:

a. Dont worry. Its only temporary

b. Why are you crying? I didnt get to the bad news yet

c. Your hair is really pretty

d. I know this will be difficult for you, but your hair will grow back after the completion
of chemotheraphy

Correct Answer D. Rationale:I know this will be difficult acknowledges the problem and
suggests a resolution to it. Dont worry.. offers some relief but doesnt recognize the patients
feelings. ..I didnt get to the bad news yet would be inappropriate at any time. Your hair is
really pretty offers no consolation or alternatives to the patient.
38. An additional Vitamin C is required during all of the following periods except:

a. Infancy

b. Young adulthood

c. Childhood

d. Pregnancy

Correct Answer B. Rationale:Additional Vitamin C is needed in growth periods, such as infancy

and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues.
Other conditions requiring extra vitamin C include wound healing, fever, Infection and stress.
39. A prescribed amount of oxygen s needed for a patient with COPD to prevent:

a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood
(PaCO2)

b. Circulatory overload due to hypervolemia

c. Respiratory excitement

d. Inhibition of the respiratory hypoxic stimulus

Correct Answer D. Rationale:Delivery of more than 2 liters of oxygen per minute to a patient

with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated
respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for
respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not
initially result in cardiac arrest. Circulatory overload and respiratory excitement have no
relevance to the question.
40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is
the most significant symptom of his disorder?

a. Lethargy

b. Increased pulse rate and blood pressure

c. Muscle weakness

d. Muscle irritability

Correct Answer C. Rationale: Presenting symptoms of hypokalemia ( a serum potassium level

below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The
combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium
stores of a patient with GI problems.
41. Which of the following nursing interventions promotes patient safety?

a. Asses the patients ability to ambulate and transfer from a bed to a chair

b. Demonstrate the signal system to the patient

c. Check to see that the patient is wearing his identification band

d. All of the above

Correct Answer D. Rationale:Assisting a patient with ambulation and transfer from a bed to a
chair allows the nurse to evaluate the patients ability to carry out these functions safely.
Demonstrating the signal system and providing an opportunity for a return demonstration ensures
that the patient knows how to operate the equipment and encourages him to call for assistance
when needed. Checking the patients identification band verifies the patients identity and
prevents identification mistakes in drug administration.
42. Studies have shown that about 40% of patients fall out of bed despite the use of side rails;
this has led to which of the following conclusions?

a. Side rails are ineffective

b. Side rails should not be used

c. Side rails are a deterrent that prevent a patient from falling out of bed.

d. Side rails are a reminder to a patient not to get out of bed

Correct Answer D. Ratioanle:Since about 40% of patients fall out of bed despite the use of side
rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the
patient should not get out of bed. The other answers are incorrect interpretations of the statistical
data.
43. Examples of patients suffering from impaired awareness include all of the following except:

a. A semiconscious or over fatigued patient

b. A disoriented or confused patient

c. A patient who cannot care for himself at home

d. A patient demonstrating symptoms of drugs or alcohol withdrawal

Correct Answer C. Rationale: A patient who cannot care for himself at home does not necessarily
have impaired awareness; he may simply have some degree of immobility.
44. The most common injury among elderly persons is:

a. Atheroscleotic changes in the blood vessels

b. Increased incidence of gallbladder disease

c. Urinary Tract Infection

d. Hip fracture

Correct Answer D. Rationale:Hip fracture, the most common injury among elderly persons,
usually results from osteoporosis. The other answers are diseases that can occur in the elderly
from physiologic changes.
45. The most common psychogenic disorder among elderly person is:

a. Depression

b. Sleep disturbances (such as bizarre dreams)

c. Inability to concentrate

d. Decreased appetite

Correct Answer A. Rationale:Sleep disturbances, inability to concentrate and decreased appetite

are symptoms of depression, the most common psychogenic disorder among elderly persons.
Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and
irritability. Depression typically begins before the onset of old age and usually is caused by
psychosocial, genetic, or biochemical factors
46. Which of the following vascular system changes results from aging?

a. Increased peripheral resistance of the blood vessels

b. Decreased blood flow

c. Increased work load of the left ventricle

d. All of the above

Correct Answer D. Rationale:Aging decreases elasticity of the blood vessels, which leads to
increased peripheral resistance and decreased blood flow. These changes, in turn, increase the
work load of the left ventricle.
47. Which of the following is the most common cause of dementia among elderly persons?

a. Parkinsons Disease

b. Multiple Sclerosis

c. Amyotrophic Lateral Sclerosis (Lou Gerhigs disease)

d. Alzheimers Disease

Correct Answer D. Rationale:Alzheimer;s disease, sometimes known as senile dementia of the

Alzheimers type or primary degenerative dementia, is an insidious; progressive, irreversible,
and degenerative disease of the brain whose etiology is still unknown. Parkinsons Disease is a
neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors,
muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple Sclerosis, a progressive,
degenerative disease involving demyelination of the nerve fibers, usually begins in young
adulthood and is marked by periods of remission and exacerbation. Amyotrophic Lateral
Sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in
atrophy of all the muscles; including those necessary for respiration.
48. The nurses most important legal responsibility after a patients death in a hospital is:

a. Obtaining a consent of an autopsy

b. Notifying the coroner or medical examiner

c. Labeling the corpse appropriately

d. Ensuring that the attending physician issues the death certification

Correct Answer C. Rationale:The nurse is legally responsible for labeling the corpse when death
occurs in the hospital. She may be involved in obtaining consent for an autopsy or notifying the
coroner or medical examiner of a patients death; however, she is not legally responsible for
performing these functions. The attending physician may need information from the nurse to
complete the death certificate, but he is responsible for issuing it.
49. Before rigor mortis occurs, the nurse is responsible for:

a. Providing a complete bath and dressing change

b. Placing one pillow under the bodys head and shoulders

c. Removing the bodys clothing and wrapping the body in a shroud

d. Allowing the body to relax normally

Correct Answer B. Rationale:The nurse must place a pillow under the decreased persons head
and shoulders to prevent blood from settling in the face and discoloring it. She is required to
bathe only soiled areas of the body since the mortician will wash the entire body. Before
wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes
and mouth.
50. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a
major nursing priority is to:

a. Protect the patient from injury

b. Insert an airway

c. Elevate the head of the bed

d. Withdraw all pain medications

Correct Answer A. Rationale:Ensuring the patients safety is the most essential action at this
time. The other nursing actions may be necessary but are not a major priority.