Free NNAAP Basic Nursing Skills Questions and Answer β Questions and Answers
Question 1: What needs of a patient does a nurse address?
- Physical
- Emotional
- Mental
- All of the above (Correct answer)
Correct answer: All of the above
Nurses address a patient's physical needs through medical care, administer emotional support to alleviate stress, and attend to mental well-being by considering cognitive aspects. Their holistic approach ensures comprehensive care, fostering overall health and recovery for individuals under their supervision.
Question 2: A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
- Elevate leg on 2 pillows (Correct answer)
- Apply support stockings
- Apply warm compresses
- Maintain complete bed rest
Correct answer: Elevate leg on 2 pillows
Elevating the leg on two pillows is a nursing intervention commonly used to manage thrombophlebitis. By elevating the leg, the goal is to reduce swelling and enhance venous return, helping to alleviate symptoms and promote healing. This position aids in preventing stasis of blood in the affected leg and may contribute to overall comfort.
Question 3: Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones?
- Engorgement of the breasts (Correct answer)
- Mongolian spots
- Edema of the scrotum
- Lanugo
Correct answer: Engorgement of the breasts
Engorgement of the breasts is an example of a variation in the newborn resulting from the presence of maternal hormones. During pregnancy, maternal hormones stimulate the development of the mammary glands in the fetus. After birth, the sudden withdrawal of these hormones can lead to breast engorgement in both male and female infants. This is a temporary and normal variation that typically resolves on its own as the infant's body adjusts to the postnatal environment.
Question 4: The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds
- The complaints of at least 3 common findings.
- The absence of any opportunistic infection.
- CD4 lymphocyte count is less than 200. (Correct answer)
- Developmental delays in children.
Correct answer: CD4 lymphocyte count is less than 200.
CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these β the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.
Question 5: The nursing care plan for a client with decreased adrenal function should include
- Encouraging activity
- Placing client in reverse isolation
- Limiting visitors
- Measures to prevent constipation (Correct answer)
Correct answer: Measures to prevent constipation
For a client with decreased adrenal function, such as in Addison's disease or secondary adrenal insufficiency, the nursing care plan should include measures to prevent constipation. Decreased adrenal function can lead to gastrointestinal symptoms, including a sluggish bowel due to reduced cortisol levels, which can necessitate measures to promote regular bowel movements.
Question 6: The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- Administration of cough suppressants
- Increasing oral fluid intake to 3000 cc per day (Correct answer)
- Maintaining bed rest with bathroom privileges
- None of the above
Correct answer: Increasing oral fluid intake to 3000 cc per day
Increasing oral fluid intake to 3000 cc per day is a reasonable and supportive intervention for a client with pneumococcal pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to mobilize and clear. While chest physiotherapy is a more direct method for removing secretions, promoting hydration is a valuable complementary measure. It is essential to consider a holistic approach to care, combining strategies that support both hydration and respiratory clearance for optimal outcomes in pneumonia management.
Question 7: While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
- Compulsive behavior
- Sense of impending doom (Correct answer)
- Fear of flying
- Predictable episodes
Correct answer: Sense of impending doom
A sense of impending doom is a common and characteristic symptom of panic attacks in individuals with panic disorder. It is often described as an overwhelming feeling of fear, apprehension, or impending catastrophe. This symptom distinguishes panic disorder from other anxiety disorders. Compulsive behavior, fear of flying, and predictable episodes may be associated with other anxiety disorders but are not as specific to panic disorder.
Question 8: The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
- Reports of difficulty falling and staying asleep
- Expression of persistent suicidal thoughts
- Lack of enjoyment in usual pleasures (Correct answer)
- Reduced senses of taste and smell
Correct answer: Lack of enjoyment in usual pleasures
Anhedonia is a key symptom of depression and is characterized by a diminished ability to experience pleasure or interest in activities that were previously enjoyable. It can affect various aspects of life, including hobbies, social interactions, and other activities that used to bring joy. The other options, such as difficulty sleeping, persistent suicidal thoughts, and reduced senses of taste and smell, are associated with depression but do not specifically represent anhedonia.
Question 9: The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
- Perform defibrillation
- Administer epinephrine as ordered
- Assess for presence of pulse (Correct answer)
- Institute CPR
Correct answer: Assess for presence of pulse
Artifact can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the clientβs pulse.
Question 10: A nurse evaluating a special needs 2-year-old in a clinic should stress which goal when talking to the child's mother?
- Teaching the child self care skills
- Preparing for independent toileting
- Promoting the child's optimal development (Correct answer)
- Helping the family decide on long term care
Correct answer: Promoting the child's optimal development
Promoting optimal development is a key focus in the care of special needs children. This involves addressing the child's individual needs, milestones, and abilities, and providing interventions and support to maximize their overall development. While aspects of self-care skills and toileting may be part of the child's development plan, the overarching goal is to ensure the child reaches their highest potential in all aspects of growth and development.
Question 11: Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:ο»Ώ
- Pulse rate greater than 100 beats per minute
- Blood pressure of 140/90
- Respiratory rate greater than 20 breaths per minute (Correct answer)
- Frequent bowel sounds
Correct answer: Respiratory rate greater than 20 breaths per minute
Tachypnea is a medical term used to describe rapid and shallow breathing, characterized by a respiratory rate greater than 20 breaths per minute. In Jake's case, his respiratory rate of 30 breaths per minute indicates tachypnea. This condition can be a symptom of various underlying health issues, such as heart or lung problems, infection, or anxiety. The nurse's documentation of Jake's tachypnea will help inform the healthcare team of his condition and guide further assessment and treatment.
Free NNAAP Basic Nursing Skills Questions and Answer
What needs of a patient does a nurse address?