1. Rationale: C is the correct answer because it provides a moist environment for the wound thus promotes healing as it reduces bacterial colonization. The other choices though correct but they cannot explain clearly the importance of wound dressing. A is wrong because it talks about avoiding to touch the wound. B is wrong because it is more on assisting patient’s comfortable position. D is wrong because it is more on the removal of the dressing and checking the condition of wound.
2. Rationale: A is the correct answer because the cause of thermal burns happens usually in the house (e.g. kitchen) which makes a person more prone to hot liquids or flames. B, C, and D are not considered as more frequent types though they may happen at workplace.
3. Rationale: B is the correct answer because it uses age-dependent graphs which are most preferred for children and neonates. A is incorrect because it is more applicable to adults. Children have different body proportions compared to children. C is incorrect because this scale is use to determine the color of the skin to determine the response to the UV light.
4. Rationale: D is the correct answer because it correctly defines the type of burn classification. Subdermal burn appears as white, brown, or deep red with no blisters. Grafting is required and scarring will occur. A is wrong because it only involves epidermis, dermis, and subcutaneous tissue; it appears as with or without blisters. B is wrong because it only involves epidermis and extends into the papillary or superficial layer of the dermis; there are small blisters. C is wrong because it involves only the epidermis and no blisters.
5. Rationale: C is the correct answer because it correctly defines a stage 3 pressure injury. A is wrong because it is a stage 4 pressure injury. B is wrong because it is a stage 2 pressure injury. D is wrong because it is a stage 1 pressure injury. This stage may be difficult to assess especially to individuals who have dark skin tones.
6. Rationale: D is the correct answer because it signifies that pain over the site is a precursor to tissue breakdown. A, B, C, are wrong because they are secondarily check during assessment of the skin and their presence may mean other skin condition.
7. Rationale: A is correct answer because massaging or rubbing any bony prominences will only increase the chance of developing a pressure injury leading to tissue damage. Pillows can be used to avoid pressure injury especially if the patient is positioned properly. B is essential because it allows the body to repair itself. C is essential because good skin hygiene preserves skin integrity. D explains the importance of proper positioning in order to prevent shear and friction.
8. Rationale: C is correct answer because it is associated with a loss of protective sensation (neuropathy) and/or the presence of ischemia with patients having diabetes. A is wrong because it ranges from no pain to severe, constant pain. It is often worse after standing for long periods. B is wrong because it is often accompanied by severe cramping pain in the foot or calf muscle at rest when the legs are elevated.
9. Rationale: A is the correct answer because it is not true that nurses don’t make important decisions, rather they are. These decisions often include the total well-being of their patients. B, C, and D are all options which clearly describe the importance of using critical thinking by the nurses in the work field.
10. Rationale: B is the correct answer because it is in the evaluating stage where a nurse collects the data in order to determine the outcomes. From the outcomes gathered, a nurse compares and relates it to the goals set or the patient. If changes need to be done, it is here where the nurse will continue, modify or terminate the client’s plan. A is wrong because it is the step where the nurse will analyze the data and formulate diagnostic statements. C is wrong because it is a step where a nurse collects, organize and validate the data. D is wrong because it is a step where a nurse implements the interventions planned for the patient.
11. Rationale: D is the correct answer because it is the type of assessment use in order to identify any life threatening problems and/or new or overlooked problems. A is wrong because it is done during several months after initial assessment. B is wrong because it is performed within specified time after admission to a health care facility. C is wrong because it is performed during the ongoing process of nursing care.
12. Rationale: C is the correct answer because an objective data are the ones which can be detected by someone else (observer) and can be measured using accepted standard procedures; this is the reason why it is also termed as signs or overt data. A is wrong because a subjective data is also referred as symptoms or covert data; these type of data is the one that the patient feels. B is wrong because a constant data are information which doesn’t change over a period of time (e.g. blood type). D is completely wrong because it is not included in the types of data that a nurse acquires.
13. Rationale: A is the correct answer because an actual diagnosis is made based on the signs and symptoms present. B is wrong because it “describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement: (NANDA International, 2005, p.277). C is wrong because it is made based on the presence of risk factors that suggest that a problem will likely occur if it is left untreated and/or left unseen by the healthcare team. D is wrong because it is a type of diagnosis which is related to a number of other diagnoses.
14. Rationale: C is the correct answer because Maslow’s hierarchy of needs is not self-centered rather it is problem centered. A, B, and D are all characteristics of Maslow’s hierarchy of needs.
15. Rationale: B is the correct answer because it is one of the needs that Kalish added between the physiologic and safety and security needs of Maslow. A is wrong because affection needs is under the love and belongingness needs of Maslow. C and D are wrong because independence needs and recognition are under the self-esteem needs of Maslow.
16. Rationale: D is correct because a Denver Developmental Screening Test is an example of screening survey and/or procedures. A and C are wrong because they are both primary level of prevention. B is wrong because it is an example of a tertiary level of prevention.
17. Rationale: A is correct because it correctly defines the contemplation stage. B is wrong because it is the preparation stage. C is wrong because it is the action stage. D is wrong because it is the maintenance stage.
18. Rationale: D is correct because this model considers that sickness is the inability to fulfill one’s role. A is wrong because this model deals about how an individual adapts with his environment towards to good health. Both B and C are wrong because they are not included in the accepted models of health and illness.
19. Rationale: C is the correct answer because lack of body nutrients predisposes a certain individual in acquiring a disease; other example include environmental factor or stress factor. A and B are both wrong because climate and economic level are all example of environment factor. D is wrong because family history is an example of host factor; other example includes age and lifestyle habits.
20. Rationale: A is correct because it is not included in the four aspects; it is not true that clients are held responsible for their condition. B, C, and D are all included in the four aspects of sick role.
21. Rationale: B correctly describe the about growth and development. A is wrong because the pace of growth and development is uneven; as such, growth is greater during infancy compared to childhood. C is wrong because development becomes increasingly differentiated, i.e. it starts in a generalized response to a skilled specific response. D is wrong because development proceeds from single acts to integrated acts.
22. Rationale: D is correct because this nursing intervention is very important in toddlerhood stage. A is wrong because it is important during adolescence stage. B is wrong because it is important during neonatal stage. C is wrong because it is important in the preschool stage.
23. Rationale: B is correct because during this age that anal stage happens. A is wrong because it happens during latency stage. C is wrong because it is just a diversion to the choices. D is wrong because it happens during the phallic stage.
24. Rationale: A is correct because it is the right negative resolution during early childhood; others include compulsive compliance and defiance. B and C are both wrong because they happen during infancy stage. D is wrong because it happens during late childhood stage.
25. Rationale: C is the correct term for the definition given above. A is wrong because accommodation is defined as the process of change where cognitive processes mature sufficiently to allow an individual to solve problems that were unsolvable before. Both B and D are wrong because they mean the same thing; it is the ability to deal with the demands in the environment.
26. Rationale: A is correct because a low stress level will result to a less risk of low birth weight baby. B, C, and D are all maternal factors that contribute to the higher risk of low birth weight babies.
27. Rationale: C is correct because tonic neck reflex is the other term for fencing reflex; it is defined as the postural reflex which disappears after 4-6 months. A is wrong because Babinski reflex is characterized as rising of the big toe and fanning out of other toes when the sole of the foot is being stroked. B is wrong because it is also known as the walking or dancing reflex which disappears at about 2 months. D is wrong because a palmar reflex happens when a small object is placed against the palm of the hand causing the fingers to curl on it.
28. Rationale: D is correct because according to Erikson the resolution of this stage will determine how a person will handle to resolve the next stages to come. A, B, and C are all diversion to the question.
29. Rationale: A is correct because the statement acknowledges the patient in a nonjudgmental way. B is wrong because it uses a presenting reality technique. C is wrong because it uses an offering self technique. D is wrong because it uses an open-ended questions technique.
30. Rationale: C is correct because it describes how a nurse clearly applies the humanistic theory towards his patient. D is wrong because the nurse applies the cognitive theory. A and B are both wrong because they describe a nurse who uses the behavioristic theory.
31. Rationale: A is correct because an adult will response to either new or same situations based on the previous experiences that they encountered. B is wrong because people will mature from dependence to independence. C is wrong because an adult’s readiness is related to developmental task or social role. D is wrong because adult is more oriented in learning when the materials are presented immediately and not in the future.
32. Rationale: D is correct because it indicates that a patient may have a problem with his health literacy level. A, B, and C are not client behaviors that will indicate a health literacy problem to a patient.
33. Rationale: C is correct because a minimal leader activity level depicts a laissez-faire style which is why it is considered as inefficient. A and B are both wrong because they are both high in terms of leader activity level.
34. Rationale: B is correct because evaluation of care effectiveness should be done by nurses; unlicensed assistive personnel are not required to create a nursing care plan. A, C, and D are tasks which can be delegated to unlicensed assistive personnel.
35. Rationale: D is the answer because the limbs should not be far from the body but rather close to it. A, B, and C are all nursing interventions that can be done to patients with hypothermia.
Source: Kozier & Erb’s Fundamentals of Nursing 8th Edition