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NSG 100 EXAM 4
Introduction to Nursing Concepts
Germanna Community College
High-Yield Qs to mirror the Actual Exam
Verified Answers with Rationales
This Exam Features:
NSG 100 Exam 4 – Introduction to Nursing
Concepts – Germanna Community College.
This resource includes high-yield questions
designed to mirror the actual exam , with
verified answers and clear rationales to help nursing students
master key concepts. Ideal for exam prep, concept review, and
confidence building before test day.
The nurse is planning to collect anthropometric data from a client who is being evaluated for undernutrition. Which information should the nurse include? (Select all that apply.) A.Weight B.Food allergies C.Skinfold thickness D.Height E.Capillary blood glucose level
ANSWER: A,C,D Anthropometric data include the client's height, weight, and skinfold thickness. Food allergies are a part of the physical history of digestive problems. Capillary blood glucose level is a laboratory test used to measure the amount of glucose in the client's blood.
Which tool is available to the nurse to assess a client's eating habits? (Select all that apply.) A.Mini - Nutritional Assessment B.Body mass index C.Waist - to - height ratio D.Food dairy E.Food frequency questionnaire
ANSWER: A,D,E Requesting the client keep a food diary for 3 days or more, conducting a food frequency questionnaire including a 24-hour recall of food intake, or performing the six-item Mini-Nutritional Assessment all provide important insight to what and when the client is eating. The nurse can then teach about replacements or changes in food choice, as well as timing of meals. Body mass index and waist-to-height ratio are methods of evaluating under- or over- nutrition but do not provide information about what and when the client is eating.
Review: Terminology 1.Defecation
•Nocturia = A is awakening to void one or more times at night. •Polyuria = D is an excessive output of urine. Polyuria: The excessive passage of urine (at least 2.5 liters per day for an adult) resulting in profuse urination and urinary frequency (the need to urinate frequently). •Urgency=B •Dysuria=C is painful or difficult urination •Anuria refers to very low or no urine production (a daily output less than 100ml) Rarely is there a total absence of urine output. Anuria is synonymous with kidney shutdown or renal failure. •Glycosuria is the presence of sugar in the urine. •Pyuria is pus in the urine.
Urinary Alterations: Matching 1.Stress 2.Urge 3.Overflow 4.Functional 5.Reflex
A.Toileting programs, adaptive equipment B.Frequency, nocturia, small voids C.Neuropathy; trauma D.Urinary retention E.Kegel exercises
1=E: Treatment: Kegel exercises, α-adrenergic agonists 2= B: Presentation: Urinary urgency, frequency, nocturia, bladder contractures, small void 3= D: Etiology: Urinary retention 4= A: Treatment: Toileting programs, adaptive equipment 5= C: Etiology: Neuropathy; trauma
Bowel Alterations: Matching 1.Constipation
2.Diarrhea 3.Impaction 4.Incontinence 5.Hemorrhoids
A.Results from unrelieved constipation B.Inability to control passage of feces and gas to the anus C.A symptom, not a disease D.Dilated, engorged veins in the lining of the rectum E.Fluid and electrolyte imbalances of primary concern
1.Constipation = C 2.Diarrhea = E 3.Impaction = A 4.Incontinence=B 5.Hemorrhoids = D
´Which clinical manifestations should the nurse expect to observe when assessing a client with benign prostatic hyperplasia (BPH)? (Select all that apply.)
A.Hesitancy B.Incontinence C.Empty bladder D.Nocturia E.Weak or intermittent urinary stream
ANSWER: A,D,E Symptoms of BPH include difficulty starting urination (hesitancy), incomplete bladder emptying, increased frequency of urination at night (nocturia), weak or intermittent urinary stream, dribbling at the end of urination, and straining during urination. Incontinence is not a clinical manifestations of BPH.
´The client complains of abdominal pain and distention. Upon questioning, you learn that your client takes daily doses of opiates for chronic back pain.
C."Urinary incontinence is less common than is urinary retention." D. "Urinary incontinence and retention are indications of kidney failure."
ANSWER: B More than half of men over 60 report urinary incontinence with treatment of prostate enlargement. Urinary retention is more common in men than it is in women and less common than is urinary incontinence. Urinary retention and incontinence are often associated with prostate issues in the male, not kidney failure, which may manifest as oliguria or anuria.
A client with benign prostatic hyperplasia (BPH) asks the nurse if there are medications that can be used to prevent the need for surgery. Which response by the nurse is accurate?
A."Yes, there are medications that can help control BPH symptoms and reduce the need for surgery." B."There are two classes of medications available for BPH, but they only address lower urinary tract symptoms and do not shrink the prostate." C."There are some medications available, but ultimately they just delay the need for surgery for a short time." D."There are medications, but most of them have serious adverse effects."
ANSWER: A Medications such as alpha-blockers and 5-alpha reductase inhibitors have significantly reduced the need for surgery to control symptoms of BPH. The medications do have several side effects, none of which would likely be considered terrible; in particular, finasteride has no serious adverse effects. The statement that they only delay the need for surgery for a short bit is not a valid statement. Finasteride and dutasteride both cause the enlarged prostate to shrink, thus the statement that they only address lower urinary tract symptoms is not valid.
´The nurse is teaching a community - based group about reproductive health. Which information should the nurse include when discussing benign prostatic hyperplasia (BPH)? (Select all that apply.)
A.BPH is the most common benign tumor in men. B.BPH is considered a precursor to prostate cancer. C.Almost all men will develop BPH if they live long enough. D.Caucasian American men develop symptoms of BPH later than all other races. E.Antioxidant and anti - inflammatory supplements can reduce the risk of BPH.
ANSWER: A,C BPH is the most common benign tumor in men and almost all men will develop BPH if they live long enough. Therefore, the nurse would include these statements in the teaching session. BPH is not considered a precursor to prostate cancer. There is no evidence to support the use of antioxidant or anti- inflammatory supplements to reduce the risk of BPH. Caucasian American men do not develop symptoms of BPH later than all other races. Asian American men develop symptoms later than Caucasian American men.
A breastfeeding mother of a 2 - month - old infant is concerned that her son defecates too frequently. Which response by the nurse should address this mother's concern? A."Feces containing less water may be difficult for infants to expel." B. "The increased frequency in defecation means your baby is at risk of weight loss." C."Your baby should be able to control defecation by now." D."Frequent bowel movements can occur with breastfeeding."
ANSWER: D Frequent bowel movements often occur with breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to pass, the infant is not experiencing hard stools.
D.Poor wound healing E.Constipation
ANSWER: B,C,D Effects of undernutrition of the integumentary system include petechiae, dry brittle hair and nails, poor wound healing, and spoon-shaped nails. Constipation is an effect on the gastrointestinal system. Muscle wasting is an effect of undernutrition on the musculoskeletal system.
The nurse is assessing a client for physical problems that affect food intake. Which factor should the nurse consider? (Select all that apply.) A.Lactose intolerance B.Financial resources C.Trouble swallowing D.Use of supplements E.Problems with dentition
ANSWER: C,E Physical problems that limit or affect food intake include dentition problems and trouble swallowing. Lactose intolerance is an absorption problem that may affect food intake. Financial resources help determine food security. Use of supplements assists in determining the current nutritional status.
The nurse is planning to teach a class regarding factors that influence food choices. Which factor should the nurse include? (Select all that apply.) A.Emotion B.Availability C.Level of hunger D.Convenience E.Cost
ANSWER: A,B,D,E Factors that affect food choices include cost, emotion, availability, and convenience. Additional factors include taste, smell, habits, packaging, body
image, health, and cultural influences. Level of hunger is not identified as a factor that influences food choices
A nursing assessment of a 14 - year - old client reveals a BMI in the 90th percentile and a lifestyle that includes spending 4 hours a day playing video games and eating supper while watching television. What is the priority nursing diagnosis? A.Disturbed Body Image related to distorted perception of body size and shape B.Delayed Growth and Development related to inappropriate intake C.Imbalanced Nutrition: More Than Body Requirements related to sedentary lifestyle D.Fatigue related to malnutrition
ANSWER: C The most appropriate nursing diagnosis is the one that focuses on the core of the problem. The child is overweight because of poor eating habits and a sedentary lifestyle. Fatigue and altered development would be more appropriate with a child who is not receiving enough calories. While the teen might have altered body image, there are no data given that support that. This nursing diagnosis would be more appropriate with the diagnosis of anorexia nervosa.
The nurse is preparing a teaching session about nutrition for a community health fair. Which information should the nurse include about obesity? (Select all that apply.) A.Portion sizes help control body weight. B.Food choices contribute to the development of obesity. C.Refined foods, animal proteins, and fats contribute to obesity. D.The prevalence of obesity has declined over recent years. E.Preventing obesity lowers the risk of developing hypertension
ANSWER: A,B,C,E Portion sizes and food choices both help control body weight and may help reduce the incidence of obesity. Refined foods, animal proteins, and fat intake
The nurse is providing care to older adult clients at a long - term care facility. Which factor places these clients at risk for urinary incontinence? (Select all that apply.)
A.Age B.Stroke C.Depression D.Frequent travel E.Multiple urinary tract infections (UTIs) in a year
ANSWER: A,B,C,E Risk factors for urinary incontinence include age, gender (women are more susceptible than are men), obesity, smoking, diabetes, inactivity, pregnancy, depression, neurologic disorders (e.g., stroke), two or more UTIs per year, and medications (medications affecting the adrenergic system, diuretics, and calcium channel blockers). Frequent travel is not a risk factor for Urinary incontinence.
Which of the following direct visualization tests uses a long, flexible, fiber - optic lighted scope to visualize the rectum, colon, and distal small bowel?
A.Esophagogastroduodenoscopy (EGD) B.Colonoscopy C.Sigmoidoscopy D.UGI series
ANSWER: B A colonoscopy visualizes the rectum, colon, and bowel using a lighted scope. An esophagogastroduodenoscopy examines the esophagus, stomach, and upper duodenum through an optic scope. A sigmoidoscopy examines the distal sigmoid colon, rectum, and anal canal through a flexible or rigid sigmoidoscope. UGI series involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate.
The nurse is caring for a client in the emergency department who is complaining of severe gas pain. The nurse should anticipate the administration of which medication to the client? A.Bulk - forming agent, such as methylcellulose B.Stool softener, such as ducosate sodium C.Antidiarrheal agent, such as loperamide D.Antiflatuent, such as simethicone
ANSWER: D Simethicone is an antiflatulence agent that breaks up gas bubbles and facilitates their passage. This medication will likely be ordered to address the client's discomfort. Docusate sodium is a stool softener that adds moisture to the stool and can be used to promote bowel movement and reduce constipation. Loperamide is an antidiarrheal agent that promotes absorption of excess fluid in the intestines and reduces diarrhea. Methylcellulose is a bulk- forming agent that increases the amount of water in the stool, making it easier to pass.
Bowel Elimination Medication 1.Metamucil (bulking agent) 2.Senokot (stimulant laxative) 3.Imodium A - D (antispasmotic) 4.Miralax (osmotic laxative)
Implication A.Decrease intestinal peristalsis B.Draw fluids into the intestine from other tissue and blood vessels C.Regular use is not recommended D.Absorb water to form soft stool
1.Metamucil (bulking agent) = D 2.Senokot (stimulant laxative) = C
The nurse is determining if a client is experiencing acute pain. Which finding should the nurse identify as being consistent with this type of pain?
A.Pulse rate and respiratory rate are decreased, and blood pressure is increased. B.Respiratory rate and blood pressure are normal. C.Pulse rate, respiratory rate, and blood pressure are increased. D.The client is calm; pupils are constricted.
ANSWER: C In acute pain, the sympathetic nervous system increases the client's pulse rate, respiratory rate, and blood pressure. The client may become diaphoretic, and the pupils will dilate. The client may also be restless and anxious.
A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to:
A. Call the patient's health care provider. B. Administer pain medication as ordered. C. Check the patient's vital signs. D. Assess the characteristics of the pain.
ANSWER: D It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number. •Ask about pain regularly. Assess pain systematically. •Choose pain control options appropriate for the patient, family, and setting. •Deliver interventions in a timely, logical, and coordinated fashion.
The nurse collects data from a client with suspected osteoarthritis. The nurse elicits information that will confirm which manifestations of osteoarthritis?
A.Elevated sedimentation rate B.Pain and stiffness associated with prolonged inactivity
C.Elevated white blood cell count D.Positive rheumatoid factor
ANSWER: B Pain and stiffness associated with prolonged inactivity is characteristic of osteoarthritis. An elevated sedimentation rate and positive rheumatoid factor are characteristics of rheumatoid arthritis. There are no lab tests that diagnose osteoarthritis. An elevated white blood cell count is not characteristic of this disease.
A 63 - year - old client has recently been diagnosed with osteoarthritis (OA) and the nurse is teaching the client about activities to manage the disease. The nurse includes which teaching?
A.Ice painful joints for 60 minutes. B.Perform vigorous exercise. C.Take cod liver oil as a supplement. D.Do not overuse affected joints.
ANSWER: D Symptoms of joint pain and swelling will increase if the affected joint is overused or stressed. To avoid skin injury, application of hot packs should not exceed 20 minutes, and cold packs should be applied for no more than 10- 30 minutes. Mild exercise balanced with rest is best for the affected areas.
A client who is obese and who has Osteoarthritis is being managed pharmacologically with acetaminophen therapy. The nurse determines that additional teaching is needed when the client makes which statement?
A."I take my acetaminophen when I have extreme pain or stiffness." B."I use heat sometimes to help reduce my pain and stiffness." C."I realize the importance of quality rest and sleep to feel my best." D."I started an exercise program to lose weight."
A patient with chronic low back pain who took an opioid around - the - clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:
A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependence.
ANSWER: D Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence does not imply addiction but rather is a state of adaptation manifested by a drug withdrawal syndrome.
Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a decrease of one or more effects of the drug over time. Drug tolerance does not imply addiction. Instead, tolerance is the diminution of one or more of a drug's effects resulting from repeated use over time. Pseudoaddiction: A drug-seeking behavior that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
The teaching plan for a patient with diarrhea should include which intervention?
A.Drinking at least eight glasses of fluid each day B.Eating foods low in sodium and potassium C.Limiting the amount of soluble fiber in the diet D.Eliminating whole - wheat and whole - grain breads and cereal
ANSWER: A
Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help form the stools so should be increased. Whole- grain products contain fiber.
The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice?
A.Hot dog on a bun B.Grilled chicken C.Tuna sandwich on white bread D.Spinach salad with dressing
ANSWER: D Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using or adding whole-grain products
The nurse is assessing an older adult client who presents with fecal incontinence. Which statement by the nurse indicates understanding of the etiology of fecal incontinence?
A."Fecal incontinence is abnormal and should be addressed in clients who are cognitively intact and physically able." B."Older adults with fecal incontinence are not candidates for treatment to alleviate their condition." C."Older adults are not at an increased risk for fecal incontinence." D."Fecal incontinence is a normal response to the aging process."
ANSWER: A The causes of fecal incontinence are multifactorial. Fecal incontinence is abnormal and should never be considered a normal part of the aging process. Older adults are at increased risk for fecal incontinence due to chronic disease,
