Nursing Acceleration Challenge Exam I PN-RN Foundations of Nursing 1 — Questions and Answers
Question 1: According to Maslow's Hierarchy of Needs, which patient need should a nurse address first when a patient reports both anxiety about surgery and difficulty breathing?
- Anxiety about the surgical procedure
- Difficulty breathing (Correct answer)
- Fear of postoperative pain
- Concern about body image changes
Correct answer: Difficulty breathing
Maslow's hierarchy places physiological needs at the base; oxygenation and breathing are survival needs that must be addressed before psychological needs such as anxiety or fear.
Question 2: A nurse documents: 'Patient reports pain of 7/10 in the lower abdomen. Abdomen is rigid and tender on palpation. Nurse suspects possible bowel obstruction and notified physician.' Which component of SOAP documentation is represented by the nurse's clinical interpretation?
- Subjective
- Objective
- Assessment (Correct answer)
- Plan
Correct answer: Assessment
The Assessment component of SOAP documentation reflects the nurse's clinical judgment or interpretation of the subjective and objective data gathered, such as suspecting a bowel obstruction based on findings.
Question 3: A nurse is preparing to change a wound dressing for a patient with methicillin-resistant Staphylococcus aureus (MRSA). In addition to standard precautions, which transmission-based precaution category is required?
- Droplet precautions
- Airborne precautions
- Contact precautions (Correct answer)
- Protective environment precautions
Correct answer: Contact precautions
MRSA is spread through direct or indirect contact with infected wounds or colonized skin; contact precautions, including gloves and gown, are required in addition to standard precautions to prevent transmission.
Question 4: Florence Nightingale's Environmental Theory of nursing emphasizes that healing is best supported by:
- Administering medications at prescribed intervals
- Modifying the patient's environment to support natural healing processes (Correct answer)
- Teaching patients to perform their own self-care
- Encouraging patients to express their feelings openly
Correct answer: Modifying the patient's environment to support natural healing processes
Nightingale's theory holds that nurses should manipulate environmental factors — such as ventilation, light, cleanliness, and noise — to create conditions in which the body can heal itself naturally.
Question 5: A nurse asks an anxious patient, 'It sounds like you're worried about going home alone after surgery. Can you tell me more about that?' This is an example of which therapeutic communication technique?
- Giving advice
- Closed-ended questioning
- Reflection and open-ended questioning (Correct answer)
- Providing false reassurance
Correct answer: Reflection and open-ended questioning
Reflection mirrors the patient's feelings back to them to confirm understanding, while the open-ended question invites the patient to elaborate; together they promote therapeutic dialogue and show empathetic listening.
Question 6: During a patient assessment, a nurse observes that the patient's skin is yellow-tinged, and the patient reports itching. The nurse recognizes these findings as:
- Cyanosis, indicating poor oxygenation
- Jaundice, suggesting possible liver or biliary dysfunction (Correct answer)
- Pallor, reflecting anemia
- Erythema, indicating local inflammation
Correct answer: Jaundice, suggesting possible liver or biliary dysfunction
Yellow discoloration of the skin and sclera (jaundice) results from elevated bilirubin and is associated with liver disease, bile duct obstruction, or hemolytic conditions; pruritus commonly accompanies jaundice due to bile salt deposits in the skin.
Nursing Acceleration Challenge Exam I PN-RN Foundations of Nursing 1
According to Maslow's Hierarchy of Needs, which patient need should a nurse address first when a patient reports both anxiety about surgery and difficulty breathing?