Canadian Nursing Health Assessment: A Best Practice Approach 2nd Edition, by Tracey TEST BANK

Chapter 1: The Nurse's Role in Health Assessment Multiple Choice 1.

A) B) C) D)

What is one of the priority goals of nursing practice?

To influence private policy To further the interests of the nursing profession To promote privacy in health care To advocate for patients and communities

Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 5, Advocacy Taxonomic Level: Knowledge Feedback: Nurses engage in many activities in the course of nursing practice.

Among the most important goals of the nurse is the advocacy role of the nurse. This role supersedes the importance of promoting the profession and promoting privacy, even though both are laudable goals. Nurses normally aim to influence public, not private, policy.

2. What do nursing activities that promote health and prevent disease primarily accomplish?

A) Reduce an individual's risk of illness B) Reduce recovery times C) Optimize self-care abilities D) Create home care safety Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: Nursing activities that promote health and prevent illness reduce the risk of disease. These activities are not primarily focused on reducing recovery times,

optimizing self-care, or creating home safety, though each of these outcomes is congruent with the philosophy of health promotion.

3.

A) B) C) D)

The purpose of a health assessment includes what?

Identifying the patient's major disease process Collecting information about the health status of the patient Clarifying the patient's extended health care benefits Explaining the patient's overall health to him or her

Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. The patient's health care coverage is not a component of health assessment, and it is not normally the nurse's role to explain the patient's overall health or identify particular diseases.

4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending primarily on what factor?

A) How much time the nurse has B) The patient's acuity C) The patient's cooperation D) Onset of current symptoms Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Comprehension Feedback: Data that nurses collect during a physical assessment vary depending on a patient's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the patient is, or the onset of the current symptoms.

5. A nursing instructor is discussing the purposes of health assessment. What is a priority purpose of health assessment?

A) To establish a database against which subsequent assessments can be measured B) To establish rapport with the patient and family C) To gather information for specialists to whom the patient might be referred D) To quantify the degree of pain a patient may be experiencing Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. Rapport is important but is not a priority goal of health assessment. It is not normally the nurse's role to gather data for specialists. Pain assessment is an important component of most assessments but is not a primary purpose for assessment.

6. How do nurses primarily facilitate the achievement of high-level wellness with a patient?

A) By encouraging the patient to keep appointments B) By providing information on alternative treatments C) By promoting patients' health D) By providing efficient patient care Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: High-level wellness is a process by which people maintain balance and direction in the most favourable environment. The role of nurses is to facilitate this achievement through health promotion and teaching. Nurses do not necessarily facilitate the achievement of high-level wellness by encouraging patients to keep appointments, providing information on alternative treatments, or providing “efficienct” patient care.

7. The nurse is caring for a patient who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true?

A) The patient stops doing wellness-promoting activities.

B) The patient develops signs and symptoms.

C) The patient begins exercising.

D) The patient verbalizes anxiety over the cost of medications.

Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Evaluation Feedback: The person who moves toward illness and premature death develops signs, symptoms, and disability, which, unfortunately, is when most treatment occurs in the current health care system. The patient who stops performing wellness-promoting activities is not necessarily moving toward death. A patient who begins exercising is moving toward wellness, not illness. The verbalization of anxiety over financial matters is not an indication of illness.

8. Nurses collaborate with individuals, families, groups, and communities to implement health promotion, risk reduction, and disease prevention strategies. What is an example of primary prevention?

A) Conducting a public blood glucose monitoring campaign B) Administering antibiotics to a patient with sepsis C) Providing immunizations to school children D) Screening for high blood pressure Ans: C Age Group: Child and Adolescent Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Difficult Objective: 3 Page and Header: 7, Risk Assessment and Health Promotion Taxonomic Level: Analysis Feedback: Immunizations are an example of primary prevention, while BP and diabetes screening are secondary prevention measures. Active treatment of illness is associated with tertiary prevention.

9. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse primarily use?

A) Rationales B) Canadian Nurses Association recommendations C) Physical assessment skills D) Clinical reasoning Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 9, Clinical Reasoning Taxonomic Level: Analysis Feedback: Nurses use clinical reasoning and critical thinking to formulate diagnostic statements. Rationale, CNA recommendations, and physical assessment skills are not central to the process of formulating diagnostic statements, though each may be integrated into the process.

10. A nurse is caring for three patients whose care involves complex situations and multiple responsibilities. What is most important to resolving problems for this nurse?

A) Intuition B) Physical assessment C) Critical thinking D) Nursing care plan Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 9, Critical Thinking Taxonomic Level: Application Feedback: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems and is more important than intuition. Care plans and physical assessments are not useful in the absence of critical thinking.

11. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Community Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Application Feedback: The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are integrated into nursing but are not frameworks for providing individualized care to a community.

12. Which of the following is a recognized type of nursing assessment?

A) Physical B) Implied C) Mental D) Emergency Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Knowledge Feedback: Three types of nursing assessments are common—emergency, focused, and comprehensive.

13. A nurse performs a comprehensive assessment on a patient. What is a unique component of this assessment?

A) Circulatory assessment B) Assessment of the airway C) Complete health history D) Disability assessment Ans: C Age Group:

All Age Groups

Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Comprehensive Assessment Taxonomic Level: Application Feedback: The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or every 8 hours for patients in intensive care.

Focused assessments and emergency assessments do not include a complete health history.

14. The nurse is admitting a patient to the clinic and performs a focused assessment.

What makes a focused assessment different from a comprehensive assessment?

A) It covers the body from head to toe.

B) It occurs only in the clinic area.

C) It involves all body systems.

D) It is more in-depth on specific issues.

Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Focused Assessment Taxonomic Level: Analysis Feedback: A focused assessment is based on the patient's issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health. It usually involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in-depth on the specific issue(s).

15. A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will primarily provide what type of data?

A) Concrete B) Subjective C) Realistic D) Objective Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual

Competency Category: Changes in Health Difficulty: Easy Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Comprehension Feedback: The physical assessment follows the history and focused interview and includes objective data, which are measurable. Subjective data are gathered during the health history. Concrete and realistic data are distracters for this question.

16. The nurse is performing a health assessment on a new patient. While taking the detailed history, the nurse knows to include what information?

A) Functional status B) Only data involving the patient complaint C) A focused assessment of the patient complaint D) Family history for the past three generations Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Knowledge Feedback: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Family histories generally go back only to grandparents, not great-grandparents.

17. When documenting the results of a health assessment, what principle must the nurse follow?

A) Documentation must be kept secure and private.

B) Documentation must be freely shared with all stakeholders.

C) Documentation becomes a publically accessible record after 7 years.

D) Documentation should be expressed according to the nurse's preferences.

Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Professional Practice Difficulty: Difficult Objective: 7 Page and Header: 14, Documentation and Communication Taxonomic Level: Synthesis Feedback: Legislation regulates the security and privacy of information that is

contained in nursing documentation. Accordingly, it does not become a publically accessible record and is not necessarily shared with all stakeholders. It should be performed in a standardized manner, not guided by the nurse's individual preferences.

18. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment?

A) Body systems B) Head to toe C) Functional D) Comprehensive Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 6 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: A functional assessment focuses on the patterns that all humans share—health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

19. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

A) Body systems B) Comprehensive C) Head to toe D) Functional Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Evaluation

Feedback: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data.

20. A nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what?

A) Body systems B) Functional C) Focused D) Head to toe Ans: D Age Group: Child and Adolescent Chapter: 1 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 5 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: The head-to-toe method is efficient and provides more modesty for patients than other modes of assessment.

Chapter 2: Interviewing and Therapeutic Communication Multiple Choice 1. A nursing instructor is explaining and analyzing nonverbal communication with the nursing class. The instructor explains that facial expressions should be A) humourous.

B) stoic.

C) relaxed.

D) detached.

Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Comprehension Feedback: Facial expressions should be relaxed, caring, and interested. Detached and stoic expressions are likely to hinder partnership, and humourous expressions are inappropriate in many circumstances.

2. A nurse is admitting a new patient who is currently lying in bed. Where should the nurse be positioned?

A) Seated in a chair at eye level with the patient B) Sitting on the side of the bed, looking down at the patient C) Leaning on the nightstand at eye level with the patient D) Standing beside the bed, looking down at the patient Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Application Feedback: To facilitate optimal eye contact, the nurse needs to be at eye level with the patient. Those who stand while patients are in bed will be taller than patients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level

with patients who are in bed during interviews.

3. In some situations, a way to apply nonverbal communication effectively is through silence. The purposeful use of silence during the interview allows patients to do what?

A) Rest and improve health B) Provide accurate answers C) Compensate for decreased levels of consciousness D) Withdraw from the nurse Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 2 Page and Header: 24, Silence Taxonomic Level: Analysis Feedback: The nurse uses silence purposefully during the interview to allow patients time to gather their thoughts and provide accurate answers. He or she also uses silence therapeutically to communicate nonverbal concern. Silence also gives patients a chance to decide how much information to disclose. Silence is not intended to allow withdrawal from the therapeutic relationship.

4. A nurse is interviewing a patient who uses a verbal expression with which the nurse is unfamiliar. What is the most appropriate statement for the nurse to use to clarify the expression's meaning from the patient?

A) Tell me what you mean by ________?

B) I think that expression means ____________.

C) That expression is unclear to me.

D) Where did you hear that expression?

Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 24, Clarification Taxonomic Level: Synthesis Feedback: Clarification is important when the patient's word choice or ideas are unclear. For example, the nurse states, “Tell me what you mean by _____?” Another way to clarify is to ask, “What happens when you _____?” Such questions prompt patients to identify other symptoms or give more information, so that the nurse better

understands. The nurse also can use clarification when the patient's history of illness is confusing. This is superior to guessing or asking the patient where he or she heard the expression.

5. The patient tells the nurse that he is sorry he fell off the roof and broke his leg. The nurse responds by saying, “Oh, you poor thing! I've had injuries too, so I know how you're feeling.” What type of response is this?

A) Empathetic B) Therapeutic C) Sympathetic D) Supportive Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 3 Page and Header: 25, Sympathy Taxonomic Level: Analysis Feedback: Sympathy is feeling what a patient feels from the viewpoint of the nurse.

When the nurse is being sympathetic, he or she is not being therapeutic, because the nurse is interpreting the situation as he or she perceives it. Because this response is nontherapeutic, it is also nonsupportive.

6. A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic?

A) Clarification B) Using technical language C) Summarizing D) Focusing Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 3 Page and Header: 6, Technical or Overwhelming Language Taxonomic Level: Comprehension Feedback: Using technical language often contributes to nontherapeutic communication. The other given options are therapeutic responses.

7. A nurse is preparing to admit a new patient to the unit and is reviewing the patient's record chronologically. In what phase of the interview process are the nurse and the patient?

A) Preinteraction B) Beginning C) Working D) Ending Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 4 Page and Header: 27, Preinteraction Phase Taxonomic Level: Analysis Feedback: In the preinteraction phase, the nurse reviews the record chronologically to detect patterns of illness, such as declining functional status, and to identify how things fit together. This precedes the other listed phases.

8. During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

A) Preinteraction B) Beginning C) Working D) Ending Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 4 Page and Header: 28, Working Phase Taxonomic Level: Comprehension Feedback: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information.

9. The nurse is interviewing a patient from a culture different from that of the nurse.

The nurse works to preserve the code of conduct that shows respect for others. What

is this code of conduct called?

A) Good manners B) Direct communication C) Nonverbal communication D) Communication etiquette Ans: D Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 28, Intercultural Communication Taxonomic Level: Comprehension Feedback: Communication etiquette refers to the code of conduct and good manners that show respect for others. Such etiquette varies between and within cultures.

Options A, B, and C are incorrect.

10. A patient who only speaks Mandarin is admitted to the unit. The patient's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this patient?

A) The sister may not tell the patient exactly what the nurse says.

B) The patient's sister may not understand medical terminology.

C) The sister may not be there every time the nurse needs to talk to the patient.

D) The patient may not want her sister to know her private information.

Ans: D Age Group: Adult Chapter: 2 Client Type: Family Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 30, Working with an Interpreter Taxonomic Level: Evaluation Feedback: Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because patients may not want to share personal information with others. Comprehension and access are not the central problems with using family members to interpret.

11. A nurse is performing an admission assessment on a patient new to the unit.

What would be the best way to phrase a question about the patient's marital status?

A) “Is your spouse living with you?”

B) “Are you living with your spouse?”

C) “Do you live alone or with someone?”

D) “Are you married, divorced, or widowed?”

Ans: C Age Group: Adult Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 30, Gender and Sexual Orientation Issues Taxonomic Level: Synthesis Feedback: An inclusive, sensitive, and ultimately better question by which to determine the patient's marital status is, “Do you live alone or with someone?” This phrasing provides a more direct avenue for finding out about support at home and better reflects diversity and inclusiveness.

12. A pediatric nurse is working in a community health clinic and seeing a 6-year-old boy. What is the most appropriate way to address this child and his parents?

A) Call the child by his legal name and refer to the parents as Mr. and Mrs. B) Call the child by his first name and ask the parents how they prefer to be addressed.

C) Call the child by his first name and refer to the parents as Mr. and Mrs. D) Call the child by his full name and refer to the parents as “mom” and “dad.”

Ans: B Age Group: Adult Chapter: 2 Client Type: Family Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 6 Page and Header: 31, Lifespan Issues Taxonomic Level: Application Feedback: The nurse should refer to children by their first names and ask parents what name they prefer for address. He or she avoids calling parents “mom” or “dad” to maintain professional communication.

13. A clinic nurse is caring for a newborn and her parents. Observing parental behaviour is an important nursing function during this child's well-baby visit. What would the nurse expect during observation?

A) Parents encouraging the baby's happy behaviours.

B) Parents feeding the baby every time she appears upset or cries.

C) Parents ignoring the infant's fussy behaviour.

D) Parents playing with an irritable infant.

Ans: A Age Group: Infant Chapter: 2 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 6 Page and Header: 31, Newborns and Infants Taxonomic Level: Analysis Feedback: The nurse observes parents as they speak to their infants for encouragement of happy behaviours and comfort for crying. Parental behaviour should be appropriate for the situation; a detached or irritable parent is cause for concern. The nurse would not expect to see the parent attempt to solve all problems by feeding the infant.

14. A nurse is interviewing a 76-year-old man who has come to the clinic for the first time. The nurse ensures that every question is absolutely necessary because A) older adults know which subjects are most important.

B) older adults have longer health histories.

C) older adults take more medications.

D) older adults tire more easily.

Ans: D Age Group: Older adult Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 6 Page and Header: 32, Older Adults Taxonomic Level: Comprehension Feedback: It may be necessary to prioritize questions because older adults become tired more easily than younger people. The prioritization of questions asked of an older adult is not indicated by older adults knowing which subjects are more important, having longer health histories, or taking more medications.

15. When dealing with a patient who has impaired hearing, where would the nurse sit to facilitate lip reading?

A) Halfway across the room from the patient B) Next to patient on the side from which he or she hears best C) Closer to the patient than the nurse normally would D) Knee to knee directly in front of the patient Ans: C Age Group: All Age Groups Chapter: 2

Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 7 Page and Header: 32, Patients with Hearing Impairment Taxonomic Level: Application Feedback: The nurse sits closer to patients with hearing impairment to facilitate a setting for lip reading. He or she uses regular speech volume and lip movement but may speak slightly more slowly. If a patient does not understand, the nurse uses other wording because the sounds involved may be better decoded.

16. Patients in health care settings often are anxious. What behaviour would lead a nurse to believe that a patient may be anxious?

A) Short, precise answers B) Constant eye contact C) Defensive tone D) Quiet voice Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 7 Page and Header: 33, Patients with Anxiety Taxonomic Level: Analysis Feedback: Behaviours that indicate anxiety are nail-biting, foot-tapping, sweating, and pacing. The patient's voice may quiver, speech may be rapid, and language or tone may be defensive. These behaviours may be an attempt to relieve anxious feelings. Short answers, eye contact, and a quiet voice are not necessarily indications of anxiety.

17. Nurses weave the individualization of the patient interview through all aspects of the encounter. Consequently, the nurse should avoid assuming that patients follow particular cultural beliefs. In place of making this assumption, what should a nurse do?

A) Assess the degree to which the patient perceives his or her cultural beliefs B) Assess how acculturated the patient is C) Know the mores of the dominant culture D) Know his or her own cultural beliefs Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual

Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 8 Page and Header: 28, Intercultural Communication Taxonomic Level: Application Feedback: The nurse should avoid assuming that patients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Assessment of acculturation and knowledge of the nurse's own cultural beliefs do not necessarily achieve this.

18. When a nurse conducts an interview with a patient, what is the primary underlying purpose?

A) To provide therapeutic communication when indicated B) To prioritize the patient's medical issues C) To assess the patient's functional status D) To identify the patient's diagnoses Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 8 Page and Header: 27, Professional Communication Taxonomic Level: Application Feedback: The nurse's role related to interviewing is to gather information to assess the patient's health status and to provide therapeutic communication when indicated.

The other options are incorrect as they are not the purpose of the nursing interview.

19. When a patient responds to a question with a “yes” or “no” answer, what appropriate responses by the nurse encourage the patient to elaborate?

A) “Go on” B) “I see” C) “Okay” D) “That's interesting” Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 24, Encouraging Elaboration (Facilitation) Taxonomic Level: Application

Feedback: These responses encourage patients to say more and continue the conversation. They show patients that the nurse is interested. The nurse may nod the head or say “Um hum,” “Yes,” or “Go on” to cue patients to keep talking. Responses of “I see”, “That's interesting,” and “Okay” do not encourage elaboration by the patient and are therefore incorrect.

20. A nurse risks indicating to patients that their concerns are not worth discussing by A) being empathetic.

B) providing false reassurance.

C) being sympathetic.

D) giving advice.

Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 3 Page and Header: 24, False Reassurance Taxonomic Level: Comprehension Feedback: By providing false reassurance, the nurse unconsciously indicates to patients that their concerns are not worth discussing. Empathy is a therapeutic response to a patient and is a positive interaction. Being sympathetic does not tend to imply that the patient's concerns are not worth discussing. Not all advice is nontherapeutic.

Chapter 3: The Health History Multiple Choice 1. During the interview process, the nurse obtains what type of data from the patient?

A) Primary B) Secondary C) Objective D) Oral Ans: A Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 38, Primary and Secondary Data Sources Taxonomic Level: Comprehension Feedback: Nurses collect primary data from patients themselves. Secondary data come from family and medical records. Objective data are data that are observed, and these are not necessarily a focus of an interview. Oral data are not a discrete category of data.

2. The nurse is admitting a new patient to the unit. While reviewing old records of this patient, the nurse knows that the data being gathered are what kind of data?

A) Primary B) Secondary C) Subjective D) Objective Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 38, Primary and Secondary Data Sources Taxonomic Level: Comprehension Feedback: Charts and family members are considered secondary data sources. The patient is the source of primary data. Subjective data are data provided to the nurse

by the patient; objective data are data that the nurse observes.

3. The nursing educator is describing different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer?

A) During a hospital admission B) At a clinic visit for a fall C) In the emergency department after a motor vehicle accident D) At a health screening event Ans: A Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 39, Table 3-1 Taxonomic Level: Application Feedback: The comprehensive health history takes place upon a patient's initial admission to the hospital. A comprehensive assessment would not be performed at a screening or health promotion event. Acute injuries normally necessitate a focused or emergency assessment.

4. A nurse is conducting an emergency health history of a patient who has been admitted to the emergency department following a workplace accident. What component should be prioritized in this health history?

A) The patient's genetic predisposition to cancer B) The location and intensity of the patient's pain C) The patient's immunization status D) The patient's current health promotion activities Ans: B Age Group: Adult Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 4 Page and Header: 39, Table 3-1 Taxonomic Level: Application Feedback: In an emergency health history, the focus is on gathering information, so that interventions can resolve the immediate problem. Consequently, pain is a priority over family history, immunizations, and health promotion, though these should be addressed at later points in care.

5. The nurse is gathering a complete history of the patient's present illness. The nurse knows that the most appropriate way to begin to gather this information is by doing what?

A) Assessing the patient's vital signs B) Gathering a complete list of the patient's medications C) Asking open-ended questions D) Asking focused questions Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 40, Present Illness Taxonomic Level: Application Feedback: The nurse collects information about the present illness by beginning with open-ended questions and having patients explain symptoms. The most appropriate way to collect data about the present illness is not to assess the patient's vital signs, gather a complete list of the patient's medications, or ask focused questions.

6. A clinical instructor is discussing with a clinical group how to take a history of the patient's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?

A) Follow the cues of the patient during the interview.

B) Use a written checklist to make sure you cover all necessary areas.

C) Use a head-to-toe approach to make sure you do not miss anything.

D) Use a focused approach, asking only about symptoms of the present illness.

Ans: A Age Group: Age Groups Chapter: 3 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 40, Present Illness Taxonomic Level: Application Feedback: Regardless of the order of data, the nurse guides the conversation following the cues of the patient and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and he or she would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness.

7. A genogram is primarily developed in order to visually portray which of the following?

A) Family values B) Family health patterns C) Family norms D) Nationalities of family members Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Family Competency Category: Changes in Health Difficulty: Easy Objective: 6 Page and Header: 42, Family History Taxonomic Level: Comprehension Feedback: A common tool used to understand family health patterns is the genogram. This graphic representation allows the nurse to map family structures and compile a large amount of information visually. Genograms make it easier for the nurse to identify the complexity of families and validate patterns pertinent to patients.

8. A group of student nurses is presenting information on Gordon's framework for assessing a patient. What type of assessment would they be talking about?

A) Comprehensive B) Focused C) Functional D) Emergency Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 45, Table 3-3 Taxonomic Level: Comprehension Feedback: Functional health patterns are especially important to nursing, because they focus on the effects of health or illness on a patient's quality of life. By using this approach, the nurse can assess the strengths of a patient as well as areas needing improvement.

9. When using Gordon's framework for a health assessment, the nurse asks a patient, “Have you made any changes in your environment because of vision, hearing, or memory decrease?” What functional health pattern is the nurse assessing?

A) Level of consciousness B) Cranial nerve function C) Coping D) Cognition Ans: D Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 45, Table 3-3 Taxonomic Level: Evaluation Feedback: A question to include in review of cognition and perception is whether the patient has made any environmental changes because of vision, hearing, or memory decrease. This does not address coping, CN function, or level of consciousness.

10. The nurse is caring for a 77-year-old woman who has been admitted with a fractured hip. While doing the admission assessment, the patient states, “I tripped over the small rug we have in front of the sink.” What learning need does this indicate?

A) The need to eliminate rugs on the patient's floors.

B) The need to have wall-to-wall carpeting throughout the patient's house.

C) The need for the patient to use a walker when she goes into the kitchen.

D) The need for the patient to be in a wheelchair.

Ans: A Age Group: Older adult Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 45, Box 3-1 Taxonomic Level: Application Feedback: The nurse performs health teaching, based on each patient's needs and priorities, and weaves health promotion and disease prevention into care. Patient teaching about wall-to-wall carpeting or use of a walker or wheelchair is not indicated for this patient. The nurse would teach this patient about the need to eliminate small rugs from the floors of her house in order to prevent future falls.

11. After completing the interview, the nurse analyzes the data collected in order to A) establish a baseline from which to start interviewing the family.

B) develop nursing interventions.

C) communicate information to the physician.

D)

communicate information to other staff members.

Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 49, Applying Your Knowledge Taxonomic Level: Analysis Feedback: The nurse prioritizes, collects, and analyzes subjective and objective data and develops nursing interventions. The nurse does not use the data gathered in the patient interview as a baseline for interviewing the family or for communicating to the physician or other staff members.

12. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?

A) Document according to the orders of the physician.

B) Talk to the patient and document exactly the same.

C) Use medical terminology when documenting in the medical record.

D) Document exactly as the patient speaks.

Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 11 Page and Header: 44, Review of Systems Taxonomic Level: Application Feedback: The nurse documents in the medical record using appropriate medical terminology. When speaking with patients, the nurse uses common lay language, so that patients better understand the questions.

13. The nurse is caring for an 82-year-old man and is reviewing information obtained in the health history assessment. The nurse knows that it is particularly important to identify the pattern of illnesses and recognize how they might be related because this patient is A) in the hospital.

B) stoic.

C) an older adult.

D) chronically ill.

Ans: C Age Group: Adult of Advanced Age Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 12 Page and Header: 49, Older Adults Taxonomic Level: Analysis Feedback: It is important to identify the pattern of the illnesses and recognize how they might be related as the patient is an older adult. The question does not state that the patient is in the hospital, stoic, or chronically ill.

14. Through what process do the patient and the nurse work together to develop a plan of care?

A) Functional assessment B) Use of subjective and objective data C) Therapeutic communication D) Use of Gordon's framework Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 12 Page and Header: 38, Introduction Taxonomic Level: Application Feedback: Through therapeutic communication, the patient and the nurse work together to resolve problems by developing collaborative strategies and solutions.

Therefore, options A, B, and D are incorrect.

15. A nurse is assessing a patient and collecting only the most important information. What type of assessment is the nurse performing?

A) Functional B) Emergency C) Comprehensive D) Focused Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health

Difficulty: Difficult Objective: 3 Page and Header: 39, Table 3-1 Taxonomic Level: Analysis Feedback: In an emergency assessment, nurses collect the most important information and defer obtaining details until patients are stable. They elicit the reason for seeking care along with current health problems, medications, and allergies. A functional assessment focuses on a patient's ability to perform activities of daily living and other patterns in specific areas. A comprehensive assessment involves review of the patient's overall health. A focused assessment emphasizes a specific area but may go into great detail in that area of concern.

16. A student is working with a floor nurse who is admitting a new patient to the unit.

The nurse asks the patient if he has traveled outside North America in the past 12 months. The student knows that this information is part of what aspect of the comprehensive health history?

A) Interests B) Present illness C) Demographical data D) History of illnesses Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 39, Demographical Data or Identifying Data Taxonomic Level: Analysis Feedback: Demographical data include environmental data about exposure to contagious diseases, travel to high-risk areas, and concerns about exposure to pollution, hazards, and allergens. Asking the patient about travel does not involve inquiring about interests, present illness, or history of illnesses.

17. Why is it important for the nurse to reconcile all the hospitalized patient's medications with the medication that the patient regularly takes at home?

A) So the physician can correctly assess the patient B) So the patient's medication record correlates with the patient's medication history C) So the patient continues taking the correct drugs D) So the physician can make sure to change the patient's drugs Ans: C Age Group: All Age Groups Chapter: 3

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 40, Current Medications and Indications Taxonomic Level: Analysis Feedback: For hospitalized patients, the nurse must reconcile all medication lists with the medications taken regularly at home, so that patients continue using the correct drugs. Reconciling the patient's medication lists with the medications he or she takes at home is not done so that the physician can assess the patient, to correlate the medication record with the medication history, or to change the patient's drugs.

18. The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as he or she does the assessment. The instructor explains that the use of the mnemonic is to A) remember the elements that are important to assess for.

B) remember the parts of a focused assessment.

C) remember the order of the assessment.

D) remember how to document assessment findings.

Ans: A Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 40, Present Illness Taxonomic Level: Analysis Feedback: Some providers use a mnemonic to remember the elements that are important to assess for the presenting symptom. OLDCARTS is one example and stands for onset, location, duration, character, associated/aggravating factors, relieving factors, timing, and severity. OLDCARTS does not help a nurse remember the parts of a focused assessment, order of assessment, or how to document findings.

19. While admitting a patient to the unit, the patient states, “I am allergic to sulfa drugs.” How would the nurse follow up this information?

A) Confirm this with family members B) Ask the physician about the plausibility of this complaint C) Ask the patient about the response to the allergen D) Ask the patient about potential alternatives Ans: C Age Group: All Age Groups Chapter: 3

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 40, Current Medications and Indications Taxonomic Level: Application Feedback: Allergies are verified with patients. When asking about allergies, note the type of response such as rash, throat swelling, difficulty breathing, or anaphylactic shock. It is unnecessary to confirm with the patient's family. The nurse would not normally question this with the physician or ask the patient about alternatives.

20. A new patient is admitted to the clinic. The nurse assesses how the effects of illness are affecting the patient's quality of life. What type of assessment is this nurse performing?

A) Comprehensive B) Functional C) Emergency D) Focused Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 7 Page and Header: 40, Functional Goal Taxonomic Level: Analysis Feedback: Functional health patterns are especially important to nursing because they focus on the effects of health or illness on a patient's quality of life.

Chapter 4: Physical Examination Techniques and Equipment Multiple Choice 1. What piece of equipment does the nurse most commonly use to auscultate the patient's abdomen?

A) None B) Fetoscope C) Sonoscope D) Stethoscope Ans: D Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 8 Page and Header: 53, Introduction Taxonomic Level: Knowledge Feedback: The nurse uses a stethoscope to perform auscultation, in which movements of air or fluid are heard in the body over the lungs and abdomen. A fetoscope is used to hear the fetal heartbeat.

2. When caring for patients in any health care environment, what is the most important technique for preventing infection?

A) Sterile technique B) Safe biohazard disposal C) Hand hygiene D) Use of gloves Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 55, Hand Hygiene Taxonomic Level: Application Feedback: The single most important action to prevent infection is hand hygiene.

This does not always necessitate the use of gloves, and it is more important than waste disposal or sterile technique because it is applicable to nearly every patient

encounter.

3. Which of the following is a step involved in the patient-to-patient transmission of pathogens?

A) The nurse uses an alcohol-based hand rub for hand hygiene.

B) The nurse uses nonlatex gloves during patient contact.

C) Organisms survive on the nurse's hands for less than 1 minute.

D) The nurse's contaminated hands come into direct contact with another patient.

Ans: D Age Group: All Age Groups Chapter: 4 Client Type: Group Competency Category: Health and Wellness Difficulty: Difficult Objective: 1 Page and Header: 55, Hand Hygiene Taxonomic Level: Analysis Feedback: Patient-to-patient transmission of pathogens requires five sequential steps: (1) Organisms are present on a patient's skin or immediate environment; (2) organisms are transferred from the patient to the nurse's hands; (3) organisms survive on the nurse's hands for at least several minutes; (4) the nurse omits or performs inadequate or inappropriate hand hygiene; and (5) the nurse's contaminated hands come into direct contact with another patient or environment in direct contact with the patient. The use of gloves (whether latex of nonlatex) inhibits transmission.

4. According to the 2009 guidelines from the Centers for Disease Control and Prevention (CDCP), why are nurses supposed to wear gloves?

A) To help maintain a sterile care setting B) To reduce the risk of infecting personnel C) To prevent sweat from contacting patients' skin D) To reduce the number of bacteria in the health care environment Ans: B Age Group: All Age Groups Chapter: 4 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 55, Hand Hygiene Taxonomic Level: Comprehension Feedback: The CDCP recommends that nurses wear gloves to (1) reduce the risk of personnel acquiring infections from patients, (2) prevent the transmission of flora from health care workers to patients, and (3) reduce transient contamination of the

hands of personnel by flora that can be transmitted from one patient to another. A sterile setting is an unrealistic goal and control of sweat is not a priority, since sweat does not normally carry microorganisms.

5. A nursing instructor is discussing techniques used in the inspection of a patient.

What would the instructor list as a priority when inspecting a patient?

A) Adequate exposure B) Dim lighting C) Therapeutic touch D) Sympathy Ans: A Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 59, Inspection Taxonomic Level: Analysis Feedback: During inspection, adequate exposure of each body part is necessary.

Concurrently, nurses take measures to maintain the privacy of patients through appropriate draping, especially over the breasts in women and genitalia in both men and women. Adequate lighting is essential to observe colour, texture, and mobility.

Therapeutic touch is not a component of inspection; sympathy is often a nontherapeutic aspect of the nurse–client partnership.

6. The nurse is assessing a patient who is new to the unit. During inspection of the patient, what will the nurse do?

A) Tell the patient that modesty is temporarily impossible B) Make sure that the patient is covered C) Look for internal abnormalities D) Smell for odours Ans: D Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 59, Inspection Taxonomic Level: Application Feedback: Nurses perform inspection by consciously observing patients for physical characteristics and behaviours and smelling for odours. The nurse would explain to the patient that every measure will be taken to protect modesty, the patient will have

to be uncovered for inspection, and internal abnormalities cannot normally be seen during inspection.

7. A new graduate nurse is inspecting a patient. What is the most likely challenge that this nurse will face during this aspect of assessment?

A) Maintaining patient modesty B) Learning how to avoid causing pain to the patient C) Identifying subtle differences in assessment findings D) Documenting the results of an inspection Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 59, Inspection Taxonomic Level: Application Feedback: One challenge that beginners face is identifying details and subtle differences. Maintaining patient modesty and documenting normal findings are not normally as difficult. Inspection does not normally cause pain, provided the patient is correctly positioned.

8. The nurse is conducting a comprehensive assessment of a newly admitted patient. The nurse should implement the technique of light palpation in order to assess A) skin colour.

B) internal organs.

C) surface lesions.

D) deep pain.

Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 60, Light Palpation Taxonomic Level: Application Feedback: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site). Light palpation is not appropriate for assessing internal organs, skin colour, or deep pain.

9. Nursing students are in the laboratory practicing deep palpation. The students should aim to palpate to what depth?

A) 1/2 to 1 cm B) 2 to 4 cm C) 1 to 2½ cm D) 4 to 6 cm Ans: B Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 61, Deep Palpation Taxonomic Level: Application Feedback: During deep palpation, pressure is firm enough to depress approximately 2 to 4 cm.

10. When percussing a patient during assessment, where would the nurse expect to find the loudest tones?

A) Over the liver B) Over the bladder C) Over the spleen D) Over the lungs Ans: D Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5, 6 Page and Header: 62, Percussion Taxonomic Level: Application Feedback: The loudest percussion tones are over the lungs and hollow stomach and intestines; the quietest tones are over bone.

11. A patient presents at the clinic complaining of a possible sinus infection. How would the nurse assess the sinuses in this patient?

A) Indirect percussion B) Inspection C) Direct percussion D) Auscultation

Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 62, Direct Percussion Taxonomic Level: Application Feedback: An example of direct percussion is percussion of the sinuses in patients with sinus infections or percussion of the thorax in newborns to assess the air-filled lungs. Indirect percussion, auscultation, and inspection are less likely assessment techniques.

12. A student nurse is spending clinical hours on the medical–surgical unit with an experienced nurse. The student is assessing a patient using indirect percussion. The student should expect to hear what sound while percussing the center of the patient's abdomen?

A) Resonance B) Tympany C) Dullness D) Damping Ans: B Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 62, Indirect Percussion Taxonomic Level: Application Feedback: During indirect percussion, it is easiest to go from the center of the abdomen with tympany and move upward to the liver where dullness is percussed.

13. When performing auscultation, the nurse should use the bell of the stethoscope in an attempt to hear A) low-frequency sounds.

B) infrequently occurring sounds.

C) quiet sounds.

D) abnormal sounds.

Ans: A Age Group: All Age Groups Chapter: 4 Client Type: Individual

Competency Category: Changes in Health Difficulty: Difficult Objective: 7, 8 Page and Header: 63, Auscultation Taxonomic Level: Application Feedback: The bell accentuates low-frequency sounds and is applied lightly to the skin. The bell is not superior to the diaphragm in detecting infrequent, quiet, or abnormal sounds.

14. While beginning an assessment of a patient's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

A) The bell B) The small side of the chestpiece C) The membrane D) The diaphragm Ans: D Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7, 8 Page and Header: 63, Auscultation Taxonomic Level: Application Feedback: Most stethoscopes have a diaphragm and bell on the chestpiece. The bell is used with light skin contact to hear low-frequency sounds, while the diaphragm is used with firm skin contact to hear high-frequency sounds. The small side of the chestpiece is the bell, and a membrane is not part of the stethoscope.

15. Student nurses are in the laboratory learning auscultation techniques. How would they learn to hold the chestpiece on the patient?

A) Place the endpiece between the thumb and the index finger B) Place the index and middle fingers on top of the stethoscope C) Place the endpiece between the index and the middle fingers D) Place the thumb and index finger on top of the stethoscope Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 63, Auscultation

Taxonomic Level: Application Feedback: When holding the chestpiece, the nurse places the endpiece between the index and the middle fingers, not on top of the stethoscope, which distorts the sound.

16. When assessing a patient, inspection is normally the first technique that is used.

What purpose does inspection serve?

A) Gathering information B) Feeling abnormalities C) Observing modesty D) Identifying internal abnormalities Ans: A Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 3 Page and Header: 59, Inspection Taxonomic Level: Comprehension Feedback: Inspection is the first technique of the overall general survey and for each body part, because it provides so much general information. Inspection is the one technique that is performed for every body part and body system. During inspection, the nurse does not use the hands to feel anything. Inspection is not to observe the patient's modesty or to identify anything internal.

17. The clinical instructor is discussing a patient's status with a student nurse. The instructor asks the student why she used light palpation during the assessment. What would be the student's most appropriate response?

A) To identify structural abnormalities B) To hear bowel sounds C) To assess skin texture D) To produce tympany Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 60, Light Palpation Taxonomic Level: Analysis Feedback: Light palpation is appropriate for the assessment of skin surface characteristics, such as texture, surface lesions, lumps, inflamed areas of skin, and structures that are at a depth of about 1 cm. It is not the primary technique for

identifying structural abnormalities and palpation does not assess sound or produce tympany.

18. A nurse in the emergency department is assessing a patient admitted with suspected appendicitis. What type of palpation over the right lower quadrant of this patient would the nurse avoid?

A) All types of palpation B) Light palpation C) Deep palpation D) Moderate palpation Ans: C Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 61, Deep Palpation Taxonomic Level: Application Feedback: Deep palpation should not be used over areas that pose a risk of injuring patients, such as over an enlarged spleen or inflamed appendix.

19. It is necessary to accurately describe the sounds heard while percussing a patient. When subjectively describing the percussion sound as hollow, dull, or boom-like, what is the nurse describing?

A) Quality B) Intensity C) Duration D) Pitch Ans: A Age Group: All Age Groups Chapter: 4 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 62, Table 4-3 Taxonomic Level: Application Feedback: Quality means the subjective description of the percussion sound, such as a low-pitched thud of short duration versus a drum-like sound with high pitch and long duration. The intensity of the sound is its loudness, the duration is how long the sound lasts, and the pitch of the sound is the frequency or how soon the sound oscillates.

Chapter 5: Documentation and Interprofessional Communication Multiple Choice 1. The patient health record is a valuable clinical tool because it serves multiple purposes. Which of the following is NOT a central purpose of the patient health record?

A) Framework for medical information B) Information source for public stakeholders C) Source of evidence for research D) Basis for care planning Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 70, Purposes of the Patient Health Record Taxonomic Level: Analysis Feedback: In addition to being a legal document of patient care and nursing practice, the patient health record is used for communication among health team members, care planning, quality assurance, education, and research. The medical record is not intended to serve as an information source for public stakeholders.

2. A court trial is being conducted over an incident in the operating room. How would the patient health record best be used in this instance?

A) To provide a record of the nurse's intentions B) To provide a record of the actual events that took place C) To provide a record of possible alternative responses to the event D) To provide a record of the physician's priorities Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 70, Legal Document

Taxonomic Level: Application Feedback: The patient record serves as a legal document recording the patient's health status and any care he or she receives. Intentions and priorities may or may not be explicit in the record. Alternative responses may not be evident.

3. Students are learning about the many uses of the patient health record including the performance of an internal audit. What is the primary goal of an internal audit?

A) The evaluation of financial management B) The evaluation of patient nutrition C) The evaluation of care for continual improvement D) The evaluation of timely documentation of pain Ans: C Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 70, Quality Assurance Taxonomic Level: Analysis Feedback: During an internal audit, the goal is to evaluate the care provided for continual improvement. The other cited goals may be examined in other contexts, but they are not the primary goal of an internal audit.

4. A group of students are engaged in reviewing health records of some patients on a unit where they are currently gaining clinical experience. For what purpose should students review patient health records?

A) To appraise the quality of care that nurses provide B) To identify the nursing norms on particular unit C) To verify that laboratory results are accurate D) To better understand complex clinical situations Ans: D Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 71, Education Taxonomic Level: Analysis Feedback: Students in various health care disciplines review patient records to enhance clinical learning and to better understand complex clinical situations. They can access and review records during care delivery. Nursing students do not normally use medical records to compare nursing care provided to a patient population, to

identify the norms on a unit, or to verify that laboratory results are accurate.

5. A computerized charting system has recently been proposed for a large, tertiary care hospital. What has research shown about the use of computerized systems?

A) Patient adherence to treatment increases.

B) Fewer unnecessary drugs are prescribed.

C) Physician notes are more succinct.

D) Patient safety increases.

Ans: D Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 71, Electronic Patient Health Record Taxonomic Level: Analysis Feedback: Although implementing a computerized system is expensive and requires much planning and education, such systems significantly increase patient safety.

Computerized medical records do not necessarily increase adherence, reduce the number of drugs prescribed, or reduce the volume of physicians' notes.

6. A clinical instructor is discussing with students the care that has been provided to a patient. The instructor asks the student why it is important to make timely entries into the medical record. What would be the students' best answer?

A) To have up-to-date information on which to base clinical decisions B) To be able to verify what care has been given C) To communicate intentions with other health care providers D) To be able to update the plan of care Ans: A Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 73, Timely Taxonomic Level: Analysis Feedback: All the responses are correct; however, the best answer is that prompt documentation allows health team members to use up-to-date assessment information to make clinical decisions.

7.

A nurse is preparing to finish a busy shift and is determining what information to

provide to the nurse who will take over the patient assignment. What goal has the Canadian Patient Safety Institute (CPSI) specified around this type of communication?

A) Health care agencies need to standardize their charting.

B) Health care agencies need to develop a standardized approach to handoff communications.

C) Health care agencies need to conform to CPSI communication templates.

D) Health care agencies need to computerize patient health records.

Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Group Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 83, Verbal Handoff Taxonomic Level: Application Feedback: The Canadian Patient Safety Institute encourages agencies to develop a standardized approach to handoff communications, including the opportunity to ask and respond to questions. This scenario does not focus on charting or patient health records.

8. One of the primary goals of nursing is to provide care that is safe to patients. What is among the best ways for nurses to realize this goal?

A) By succinctly charting patient care B) By continually assessing patient laboratory values C) By continual communication with all members of the health care team D) By giving patient care conferences including all members of the health care team Ans: C Age Group: All Age Groups Chapter: 5 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 84, Qualities of Effective Reporting Taxonomic Level: Evaluation Feedback: One of the best ways to provide safe patient care is to continually communicate with all members of the health care team. This supersedes the importance of lab values and inservice education, though each is necessary. Brevity is not a central goal of nursing documentation.

9. A new graduate nurse has just started working. The new nurse asks a more experienced nurse to explain SOAP charting. What would the second nurse explain

that the A in SOAP stands for?

A) Analysis of data to identify a problem B) Application of findings C) Assessment of objective data D) Articulation of the plan of treatment Ans: A Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 80, Table 5-2 Taxonomic Level: Comprehension Feedback: The SOAP format focuses on a single problem and includes subjective (S) assessment findings, objective (O) assessment findings, analysis (A) of the assessment data to identify a problem or indicate whether the problem is improving or worsening, and plan (P) for treating or improving the problem.

10. When an agency has policies that require nurses to write focus notes, the nursing documentation will emphasize A) objective data.

B) areas of strength and weakness.

C) psychosocial deficits.

D) data, action, and responses.

Ans: D Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 82, Focus Note Taxonomic Level: Comprehension Feedback: The focus system of documentation organizes entries by data (D), action (A), and response (R). There is no specific emphasis on objective data, psychosocial issues, or strengths versus weaknesses, though each of these domains may be addressed in focus notes.

11. When a nurse works in a health care agency that charts by exception (CBE), he or she knows that the patient assessment is structured by what?

A) Medical diagnoses B) Patient needs C) Standardized norms

D)

CPSI standards

Ans: C Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 82, Charting by Exception Taxonomic Level: Analysis Feedback: A group may develop the standard of what it considers “normal” in each area of assessment (e.g., respiratory, mobility, and psychosocial). These norms structure the patient assessment. Patient assessments are not structured by CPSI standards, patient needs, or medical diagnoses.

12. When charting by exception is used in a health care agency, the most important aspect of this method is A) organizing new forms for the nursing staff.

B) identifying the standards and norms for the institution.

C) training new nurses in writing CBE notes.

D) pulling together a group of experts to teach agency staff.

Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 82, Charting by Exception Taxonomic Level: Analysis Feedback: Clearly identifying the standards and norms and educating all users take time and significant commitment from the agency using CBE. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.

13. Nursing students are learning about different methods of charting in the clinical laboratory. What method would they learn that is a shared mental model for improving communication between and among clinicians?

A) SBAR B) CBE C) SOAP D) PIE Ans:

A

Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 84, SBAR Taxonomic Level: Analysis Feedback: SBAR, first developed by Kaiser Permanente in Denver and supported by the Institute for Healthcare Improvement (IHI), is a shared mental model for improving communication between and among clinicians. SOAP, PIE, and CBE are not shared mental models.

14. The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. What would the instructor explain that the situation, background, and assessment are based on in SBAR charting?

A) The patient's background B) Information that the nurse obtains from the family C) Complete and accurate assessment data D) Data in old records Ans: C Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 84, SBAR Taxonomic Level: Application Feedback: This model organizes communication around situation, background, assessment, and recommendations. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. SBAR is not based entirely on the patient's background, what family has to say, or what is in the old records.

15. As part of their orientation, a group of new nursing graduates are improving their skills in SBAR communication. What is the most common use of SBAR? A) Contacting a provider regarding a patient issue B) Structuring communications during handoff C) Delegating care to care aides D) Expressing concern about a patient's condition to family members Ans: A Age Group: All Age Groups Chapter: 5

Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 4 Page and Header: 84, SBAR Taxonomic Level: Application Feedback: Nurses most commonly use SBAR when contacting a provider regarding a patient issue. SBAR also can serve as a method for structuring communication during handoffs or when delegating care; however, none of these is the most common use.

SBAR is not used to communicate with families.

16. A nurse has assessed that a patient's condition is worsening. The nurse is telephoning the primary care provider and providing a report about the patient and her condition. What would be important for the nurse to document after this telephone call?

A) The time B) Information from the previous shift C) Alternative plans for action D) Specialists to whom the patient has been referred Ans: A Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 85, Telephone Communication Taxonomic Level: Application Feedback: It is important to document the call, including the time, who was called, what information the nurse gave to the provider, and what information the nurse received. It is not important to document assessment data from the previous shift or specialists to whom the patient has been referred.

17. A nurse has been called to testify in a lawsuit brought by a patient against members of the care team. This institution uses charting by exception (CBE). What type of legal problems does CBE potentially pose?

A) The charting format is not ethical.

B) Details are often missing.

C) Subjective information is often missing.

D) It reflects poor assessment skills on the part of the nurse.

Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 81, Table 5-2 Taxonomic Level: Analysis Feedback: CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment; CBE is an accepted, ethical form of charting; and the question does not indicate that the assessment skills of the nurse are lacking in any form.

18. A nursing unit is preparing for the implementation of a new, computerized documentation system. How does computerized documentation enhance communication?

A) The content can be altered retroactively.

B) It is legible and time dated.

C) It permits only one user at any particular time.

D) It verifies telephone communication.

Ans: B Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 71, Electronic Patient Health Record Taxonomic Level: Application Feedback: The computerized patient record helps ensure patient safety and enhances communication, because computerized documentation is legible and time dated, increases compliance, permits multiple simultaneous users, and permits surveillance of patient data to identify patients at risk. Retroactive alteration is not normally possible, or acceptable. It is not used to verify telephone communication.

19. A nurse has testified in court about a neonatal death and has insisted the mother was adequately monitored during labour, despite the absence of documentation in the health record. How will the nurse's statement most likely be viewed by the court?

A) The statement must be compared to the nurse's previous practices.

B) The statement must be corroborated by a trustworthy peer.

C) The court will likely not accept the validity of the nurse's statement.

D) The court will accept the nurse's statement in light of the fact that the nurse is a professional.

Ans: C Age Group: Adult Chapter: 5 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 70, Safety Alert 5-1 Taxonomic Level: Analysis Feedback: The nurse must record assessment data, and the time of the assessment.

In the legal world, a typical saying is “If it's not documented, it's not done.”

Consequently, the court is likely to reject the nurse's claims.

20. Which of the following statements best describes an aspect of confidentiality?

A) Nurses avoid discussion of patient concerns with members of other disciplines.

B) Nurses ensure that documentation is witnessed.

C) Nurses only discuss patients' conditions in private settings.

D) Health records are returned to the unit promptly if borrowed off-site.

Ans: C Age Group: All Age Groups Chapter: 5 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 72, Confidential Taxonomic Level: Application Feedback: Nurses should never discuss patients (with or without names) and their situations in public places such as elevators, hallways, or the cafeteria.

Documentation does not need to be witnessed and interdisciplinary communication is not a violation of confidentiality. Records should not normally be borrowed off-site.

Chapter 6: General Survey and Vital Signs Assessment Multiple Choice 1. As part of the general survey, the nurse should shake hands with the patient when first meeting him or her, as long as doing so is culturally appropriate. What is the main purpose of this action?

A) The handshake portrays caring.

B) The handshake demonstrates professionalism.

C) The handshake allows the nurse to get physically close to the patient in a nonthreatening way.

D) The handshake allows the nurse to assess the patient for anxiety.

Ans: A Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 92, General Survey: General Inspection Taxonomic Level: Analysis Feedback: During introductions, the nurse should introduce himself or herself and shake hands with the patient as appropriate to the situation. A handshake not only portrays caring but also allows the nurse to assess the patient. A handshake does not indicate how professional you are; it does not provide a means of getting closer to the patient in a nonthreatening way or allow you to assess how anxious the patient is.

2. The nurse is caring for a newly admitted adult patient. When performing the general survey of this patient, the nurse knows that accurate anthropometric measurements provide critical information about which of the following?

A) Safety B) State of health C) Social development D) Past surgeries Ans: B Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1

Page and Header: 95, Anthropometric Measurements Taxonomic Level: Analysis Feedback: Anthropometric measurements are the various measurements of the human body, including height and weight. They provide critical information about the adult's state of health and the child's growth pattern.

3. A nurse is preparing to take a hospital patient's scheduled vital signs. What is a major reason for assessing vital signs?

A) To gauge cardiopulmonary function B) To determine a patient's long-term prognosis C) To establish objective measurements D) To facilitate the nursing process Ans: A Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 96, Vital Signs Taxonomic Level: Analysis Feedback: Vital signs reflect health status, cardiopulmonary function, and overall body function. They do not form the basis of a long-term determination of the patient's prognosis. Vital signs are objective and are included in the nursing process, but these are not the main purposes for assessing a patient's vital signs.

4. A nurse in the emergency department is admitting an adult patient who is experiencing epigastric pain. The nurse recognizes the importance of an accurate set of initial vital signs because A) the patient is unlikely to have his or her vital signs taken again for several hours.

B) the patient's plan of care will be based solely on the initial set of vital signs.

C) the nurse establishes therapeutic communication and partnership while taking the initial set of vital signs.

D) the initial set of vital signs establishes a baseline for future comparison.

Ans: D Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 96, Vital Signs Taxonomic Level: Evaluation Feedback: The initial set of vital signs provides a baseline. The importance of this

fact supersedes the nurse–patient partnership, even though this is significant. The patient's vital signs will likely be taken frequently in this care setting, and it is inappropriate to base a plan of care on a single set of vital signs.

5. A nurse strives to apply critical thinking to all aspects of care. How does the nurse use critical thinking when accurately assessing vital signs?

A) Performing vital signs measurements in an efficient manner B) Individualizing a patient's assessment to the patient's health needs C) Completing other assessments simultaneous to measuring vital signs D) Respecting patients' privacy when performing assessment of vital signs Ans: B Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 118, Evidence-Informed Critical Thinking Taxonomic Level: Evaluation Feedback: Nurses learn the techniques for assessment of the general survey and vital signs but use critical thinking to individualize assessments of the patient.

Efficiency, multitasking, and respect for privacy are all beneficial, but these do not necessarily reflect critical thinking.

6. A middle-aged patient arrives at the emergency department by ambulance after an accident while playing softball. His left leg is swollen, and he describes his pain as a nine on a ten-point scale. When the nurse assesses the patient's blood pressure, what would he or she expect to find?

A) The blood pressure is lower than the patient's norm.

B) There would be no need to assess the blood pressure.

C) The blood pressure is elevated above the patient's norm.

D) The blood pressure is within normal limits.

Ans: C Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 96, Vital Signs Taxonomic Level: Analysis Feedback: Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure.

7. A 39-year-old man is at the gym exercising and experiences a muscle strain in his upper torso. The paramedics are called; their initial vital sign readings indicate a pulse of 175 beats/minute. This pulse would be considered elevated as a result of what factor?

A) Elevated due to weight B) Elevated due to age C) Elevated due to gender D) Elevated due to activity Ans: D Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 96, Vital Signs Taxonomic Level: Analysis Feedback: Variables that can affect vital signs include pain, stress, anxiety, and activity. The patient's weight is not mentioned in the scenario. A 39-year-old man would not be expected to have an elevated pulse nor would a person's gender be expected to significantly affect the pulse.

8. A 68-year-old woman with chronic obstructive pulmonary disease has come to the clinic for a routine follow-up visit. The nurse escorts the patient to an examination room and measures vital signs. The nurse would expect the patient's vital signs to be A) higher than normal.

B) lower than normal.

C) within normal limits.

D) difficult to assess with normal techniques.

Ans: A Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 96, Vital Signs Taxonomic Level: Analysis Feedback: Many variables can lead to increased vital signs, including pain, stress, anxiety, and activity. It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate appropriately. In general, respiratory distress is likely to cause an increase in vital signs.

9. A nurse is examining a patient's blood pressure readings that have been taken over the past several days. The nurse knows that normal blood pressure levels tend to A) stay consistent throughout the day.

B) follow a diurnal rhythm.

C) rise with the early morning fall of blood glucose levels.

D) change unpredictably.

Ans: B Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 105, Blood Pressure Taxonomic Level: Application Feedback: A daily, circadian (diurnal) cycle of BP occurs, with it increasing late in the afternoon and decreasing in the early morning. Changes in BP are usually attributable to an identifiable cause.

10. A student nurse studying hypertension would learn that major risk factors for this health problem include which of the following?

A) Poor psychological coping and respiratory depression B) Sedentary lifestyle and high fluid intake C) Prolonged stress and heavy alcohol consumption D) Low body mass index and liver disease Ans: C Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Health and Wellness Difficulty: Difficult Objective: 5 Page and Header: 111, Risk Assessment and Health Promotion Taxonomic Level: Comprehension Feedback: Risk factors for hypertension include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease.

11. A nurse is participating in a health promotion workshop at a local community center. What advice should the nurse provide to participants who are motivated to reduce their risk of cardiovascular disease?

A) “Make sure not to have more than one or two alcoholic drinks each day.”

B) “If you are a smoker, you should quit or at least change to light cigarettes.”

C) “Taking a low dose of Tylenol each day can help protect against heart disease.”

D)

“Make sure to visit your family doctor at least twice a year.”

Ans: A Age Group: Adult Chapter: 6 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 5 Page and Header: 111, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: To reduce the risk of heart disease, individuals should limit alcohol to one to two drinks per day. This is more important than visiting one's care provider frequently. Light cigarettes are not less harmful than other cigarettes. Tylenol does not protect against heart disease.

12. A nurse is caring for a 36-year-old woman with a temperature of 38.9°C. The nurse administers Tylenol, two tablets, as per orders. Where is the best place in which to record the effect of the medication administration on the patient's condition?

A) Nurse's notes B) Interdisciplinary notes C) Physician's orders D) Medication administration record Ans: A Age Group: All Age Groups Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 111, Documentation of Expected Findings Taxonomic Level: Application Feedback: The nurse documents measurement of temperature after administration of antipyretics or other therapies in the nurse's notes. He or she would not record the new temperature on the physician's orders, interdisciplinary notes, or MAR. 13. While assessing an adult patient's radial pulse, the nurse detects that the rhythm is irregular. How should the nurse first follow up this finding?

A) Palpate the patient's left and right radial pulse simultaneously B) Listen to the patient's apical pulse for a full minute C) Assess the patient's mobility D) Auscultate the patient's lungs and assess the patient's oxygen saturation Ans: B Age Group:

Adult

Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 101, Rhythm Taxonomic Level: Application Feedback: If a pulse is irregular in rhythm, auscultate an apical pulse for one full minute. Bilateral palpation, assessment of mobility, and lung auscultation are not appropriate responses to this assessment finding.

14. A nurse is caring for a patient who has a diagnosis of dementia is unable to follow verbal instructions. During the assessment of the patient's vital signs, the nurse has assessed the patient's temperature by axilla. The nurse should be aware that this method of temperature assessment is A) less accurate than other methods of temperature measurement.

B) more invasive than most other methods of temperature assessment.

C) highly variable because of the influence of circadian rhythms.

D) found to be unpleasant by most patients.

Ans: A Age Group: Older Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 98, Table 6-1 Taxonomic Level: Analysis Feedback: Axillary readings reflect temperature of the skin surface, which may be variable. This method may be less accurate than oral or rectal. It is neither unpleasant nor highly dependent on circadian rhythms.

15. General survey of a 27-year-old woman reveals that the patient is wearing eccentric makeup and clothes and she has exaggerated movements with highly animated speech. The nurse should perform further assessments related to what potential problem?

A) Impaired coping B) Stroke C) Chronic pain D) Mental illness Ans: D Age Group: Adult Chapter: 6 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 93, Physical Appearance Taxonomic Level: Evaluation Feedback: Eccentric makeup or dress may indicate mania, which is associated with mental illness. This is not synonymous with impaired coping and does not suggest stroke or chronic pain.

16. Student nurses are doing clinical hours on the medical–surgical unit. In this care setting, what additional assessment should the students add to their vital signs assessments?

A) Oxygen saturation B) Cognitive orientation C) Level of function D) Mobility level Ans: A Age Group: All Age Groups Chapter: 6 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 96, Vital Signs Taxonomic Level: Application Feedback: Oxygen saturation is assessed in hospitalized patients. Cognition, mobility, and function may be important assessments, but these are not considered to be components of a set of vital signs.

17. A nurse is caring for an obese male patient with peripheral vascular disease. The nurse uses a Doppler to assess peripheral pulses. What would be the best technique for the use of the Doppler on this patient?

A) Hold the probe firmly against the skin at the expected pulse site B) Hold the probe perpendicular to the skin at the expected pulse site C) Use water to moisten the skin and facilitate sound conduction D) Ask the patient to hold his breath during the assessment Ans: B Age Group: Adult Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 112, Doppler Technique

Taxonomic Level: Application Feedback: The procedure for assessment of the pulse using a Doppler is as follows—(1) apply the gel that is specific for the Doppler to the transducer probe, (2) turn the Doppler on, (3) adjust the volume, (4) touch the probe lightly to the skin at the expected pulse site, (5) hold the probe perpendicular to the skin and move it slowly where you anticipate that the pulse should be until it is located, and (6) wipe off the gel and mark the location of the loudest sound with indelible ink.

18. The nurse is caring for four patients on the short-stay unit. Based solely on the patients' vital signs, which of the following patients would likely cause the nurse greatest concern?

A) A 20-year-old patient with a BP of 103/62 B) A 57-year-old patient with a respiratory rate of 20 breaths/minute C) A 77-year-old patient with a resting heart rate of 69 beats/minute D) An 82-year-old patient with a temperature of 37.2°C Ans: D Age Group: Adult of Advanced Age Chapter: 6 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 97, Temperature Taxonomic Level: Evaluation Feedback: Temperatures considered normal for younger adults may constitute fever in older adults. The other patients represent expected findings for the patients described.

19. The clinic nurse is performing assessments on several male patients. The first man is 52 years old and has an African genetic background. The second man is 54 years old and is Latino. The third man is 50 years old and is First Nations. The fourth man is 60 years old and White. Which of the following patients would the nurse expect to be the tallest?

A) White man B) Man from African background C) Latino man D) First Nations man Ans: A Age Group: Adult Chapter: 6 Client Type: Group Competency Category: Difficulty: Moderate Objective: 8

Changes in Health

Page and Header: 118, Cultural Variations Taxonomic Level: Evaluation Feedback: In men, Whites are typically the tallest, followed by individuals with African genetic backgrounds and then Latinos.

Chapter 7: Pain Assessment Multiple Choice 1. A nurse is aware that the physiology of pain is not yet fully understood. What is the most commonly accepted theory of pain?

A) Pain stimulus theory B) Gate control theory C) Positive feedback theory D) Predisposition theory Ans: B Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 127, Gate Control Theory Taxonomic Level: Knowledge Feedback: Currently, the theory of pain with the widest acceptance is the gate control theory. None of the other listed theories exist.

2. A nurse who works in a high-acuity setting cares for numerous patients who are experiencing acute or chronic pain. The nurse knows that there is a growing understanding of pain in the scientific literature. On what subject does current research on pain primarily focus?

A) The subjective nature of pain B) Cultural influences on pain experience C) Elements that can affect pain inhibition D) The psychology of pain Ans: C Age Group: All Age Groups Chapter: 7 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 127, Gate Control Theory Taxonomic Level: Comprehension Feedback: Current research focuses on those elements that can affect pain inhibition and stop the pain stimulus. The other listed subjects are plausible focuses for

research, but none is predominant.

3. A nurse who cares for postsurgical patients recognizes the importance of understanding the physiology of pain in order to provide adequate pain treatment.

The element of pain transmission that causes nociceptors to perceive a nerve impulse is which of the following?

A) Transduction B) Transmission C) Perception D) Modulation Ans: A Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 127, Nociception Taxonomic Level: Comprehension Feedback: In transduction, noxious stimuli create enough of an energy potential to cause nociceptors (free nerve endings) to perceive a nerve impulse. Transmission is when the neuronal signal moves from the periphery to the spinal cord and up to the brain. Perception is when higher areas of the brain perceive the impulse being transmitted as pain. Modulation is the action of inhibitory and facilitating input from the brain modulating or influencing sensory transmission at the level of the spinal cord.

4. Both the peripheral and the central nervous systems are involved in the transmission of a pain stimulus. When there is continued input from the peripheral nervous system, what can develop?

A) Fibromyalgia B) A peripherally mediated pain syndrome C) Neuronal plasticity D) A centrally mediated pain syndrome Ans: D Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 128, Clinical Significance 7-3 Taxonomic Level: Analysis Feedback: Transmission of a pain stimulus uses two separate but continuous

systems—the peripheral nervous system and the central nervous system. Continued input from the peripheral nervous system can create a centrally mediated pain syndrome, in which pain occurs without a pain stimulus. Fibromyalgia is a chronic pain syndrome. Neuronal plasticity is the term for changes in the transmission of the pain stimulus.

5. A 20-year-old patient's ultrasound is indicative of appendicitis, but the patient is experiencing pain at sites distant from his appendix. What term best describes this phenomenon?

A) Chronic pain B) Cutaneous pain C) Referred pain D) Somatic pain Ans: C Age Group: Adult Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 128, Duration: Acute Pain Taxonomic Level: Analysis Feedback: Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. Chronic pain is pain referred to as persistent. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues and is felt at its origination. Somatic pain originates from skin, muscles, bones, and joints and is felt at its origination.

6. A nurse is caring for a patient who reports constant pain. The nurse knows that constant pain can lead to the modification of the function of the nervous system, which can, in turn, lead to what?

A) Neuronal windup B) Peripheral sensitization C) Neuronal plasticity D) Chronic pain Ans: B Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 129, Form: Neuropathic Pain Taxonomic Level: Analysis

Feedback: Once pain becomes a constant stimulus, the nervous system can modify its function (neuronal plasticity). In turn, this can lead to another phenomenon called peripheral sensitization, by which peripheral nociceptors are sensitized to pain stimuli.

Neuronal windup is produced when repeated assaults on the afferent neurons create enhanced response and increased activity in the central nervous system. Chronic pain is referred to as persistent pain.

7. Pain is often untreated or undertreated; when this occurs, chronic pain may result. What can be the outcome?

A) Chronic desensitization syndrome B) Neoneural syndrome C) Complex regional pain syndrome D) Fibromyalgia pain syndrome Ans: C Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 129, Form: Neuropathic Pain Taxonomic Level: Analysis Feedback: Untreated or undertreated acute pain may lead to chronic pain syndromes, such as complex regional pain syndrome (CRPS), which are difficult to treat. The other listed diagnoses are not actual pain syndromes.

8. What is an excitatory process caused by pain stimuli that involves the spinal nerves and can persist when there is no longer stimulation?

A) Central sensitization B) Neuronal windup C) Peripheral sensitization D) Neuronal plasticity Ans: A Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 129, Form: Neuropathic Pain Taxonomic Level: Analysis Feedback: Central sensitization is an excitatory process involving the spinal nerves and produced by continued pain stimuli that can persist even after peripheral stimulation is no longer present. Neuronal windup is produced when repeated assaults

on the afferent neurons create enhanced response and increased activity in the central nervous system. Peripheral sensitization is when peripheral nociceptors are sensitized to pain stimuli. Neuronal plasticity means the ability of the nervous system to change or alter its function.

9. A 52-year-old woman comes to the clinic reporting pain in her right lower quadrant. When assessing the patient's pain, what elements would the nurse include?

A) Quantity B) Intensity C) Phenomenology D) Mobility Ans: B Age Group: Adult Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5, 7 Page and Header: 131, Subjective Data Collection Taxonomic Level: Application Feedback: In addition to pain intensity, other basic elements of a pain assessment are location, duration, intensity, quality/description, alleviating/aggravating factors, pain management goal, and functional goal. Aggressiveness, phenomenology, and quantity are not parameters for assessment.

10. The nurse observes that a postsurgical patient is grimacing, wincing, and guarding his abdomen. The nurse has assessed the patient for pain, but he bluntly denies that he is having pain. How should the nurse best respond to this patient's denial of pain?

A) Tactfully teach the patient about the benefits of pain control B) Document the patient's lack of insight into his health status C) Bring an analgesic to the bedside and ask the patient to take it D) Ask the patient's family members to encourage him to accept analgesia Ans: A Age Group: Adult Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 131, Subjective Data Collection Taxonomic Level: Application Feedback: Teaching patients about the benefits of controlling pain may help correct misperceptions that some have about tolerating pain stoically rather than taking

medication to relieve it. This should be undertaken before enlisting the help of the family or insisting on pain medication. The patient does not necessarily lack insight into his health.

11. A pediatric nurse is assessing a 4-week-old infant who has just been admitted to the pediatric unit with a diagnosis of possible pyloric stenosis. When assessing this patient, what principle should the nurse recognize?

A) Pain in infants does not normally have an identifiable etiology.

B) Infants are incapable of knowing the social and cultural norms for pain expression.

C) It can be difficult to differentiate between pain and other sources of need or discomfort.

D) Infants have a blunted pain response for the first several weeks of life.

Ans: C Age Group: Infant Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 11 Page and Header: 141, Newborns, Infants, and Children Taxonomic Level: Evaluation Feedback: The difficulty with behavioural pain measures in infants is that they do not discriminate between pain behaviours and reactions from other sources of discomfort. Infants do not have a blunted pain response. It is difficult to diagnose their pain, but this does not mean that it is without cause. Infants obviously are unaware of norms, but this does not directly affect pain assessment at this young an age.

12. A 5-year-old girl is admitted to the postanesthesia care unit after the surgical repair of her fractured femur. What assessment parameters would the nurse address in this child according to the FLACC scale?

A) Lability B) Agitation C) Sleep D) Leg movement Ans: A Age Group: Child and Adolescent Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8, 11 Page and Header: 141, Newborns, Infants, and Children

Taxonomic Level: Analysis Feedback: The FLACC scale uses the indicators of facial expression, leg movement, activity, cry, and ability to console the patient.

13. A nurse in the emergency department is caring for a patient who is nonverbal following a suspected stroke. What would be the best way for the nurse to assess this patient's level of pain?

A) Ask the patient to draw a picture of the pain B) Ask the paramedics what they think is the patient's pain level C) Ask the patient to describe the pain D) Ask the family if they have noticed any changes in the patient's behavior Ans: D Age Group: Adult Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 143, Patients Unable to Report Pain Taxonomic Level: Application Feedback: When attempting to perform a pain assessment on a patient who cannot self-report pain, the nurse should try to identify any potential causes for pain, observe patient behaviours, ask the family or other caregivers if they have noticed any changes in the patient's behaviour, and attempt an analgesic trial. A nonverbal patient cannot describe the pain in spoken words. Asking the patient to draw a picture of pain while in the ED after a stroke would not be the best way to assess the patient's level of pain nor would be asking paramedics what they think about the patient's pain.

14. When a patient with opioid tolerance has an altered physiologic response to pain stimuli, he or she develops a form of pain sensitivity called what?

A) Opioid hyperalgesia B) Pain hyperactivity C) Opioid hypoalgesia D) Pain hypoactivity Ans: A Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 143, Patients With Opioid Tolerance Taxonomic Level: Comprehension Feedback: Patients with a history of opioid tolerance pose difficult challenges to

nurses for pain assessment. They have an altered physiologic response to the pain stimulus, and the repeated use of opioids causes their bodies to become more sensitive to pain. This sensitivity is called opioid hyperalgesia and can occur as soon as 1 month after opioid use begins. Options B, C, and D are distracters for this question.

15. The gate control theory of pain involves several complex, physiological events.

Which of the following is a step for pain transmission in the gate control theory?

A) Unrelieved painful stimulus on a peripheral neuron causes the “gate” to open.

B) The gate opens through repolarization of the nerve fibre.

C) The brainstem recognizes the stimulus as pain.

D) The pain stimulus passes through the efferent pathway.

Ans: A Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 127, Gate Control Theory Taxonomic Level: Comprehension Feedback: The steps for pain transmission in the gate control theory are as follows—(1) Continued painful stimulus on a peripheral neuron causes the “gate” to open through depolarization of the nerve fibre. This is accomplished by ion influx and outflow. (2) The pain stimulus then passes from the peripheral nervous system at a synaptic junction to the central nervous system up the afferent nerve pathways. (3) The pain stimulus passes up through and across the dorsal horn of the spine to the structures of the limbic system and the cerebral cortex. (4) In the cerebral cortex, the stimulus is identified as pain and a response is created. The response, once generated, passes down the efferent pathways where reaction to the pain is created.

16. It is necessary for nurses to assess and reassess a patient's pain level with sufficient frequency. A nurse's institution mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

A) The fact that it takes twice as long for IV pain medication to work than oral medication B) The time it takes a pain medication to decrease pain intensity C) The time it takes a patient to tolerate his or her pain D) The median half-life of an intravenous pain medication Ans: B Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health

Difficulty: Moderate Objective: 8, 10 Page and Header: 144, Reassessing and Documenting Pain Taxonomic Level: Analysis Feedback: Most hospitals have a standard time frame for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously.

They base these time frames on the time it takes a pain medication to provide a noticeable decrease in pain intensity.

17. What is the best description of the pain phenomena felt in rheumatoid arthritis and osteoarthritis?

A) Neuronal windup B) Neuronal plasticity C) Peripheral sensitization D) Central sensitization Ans: A Age Group: All Age Groups Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 129 and 130, Form: Neuropathic Pain Taxonomic Level: Comprehension Feedback: Neuronal windup is produced when repeated assaults on the afferent neurons create enhanced response and increased activity in the central nervous system. Windup can cause tissues in the affected area to become extremely sensitive to pressure in areas not identified usually as painful. Examples of windup include rheumatoid arthritis and osteoarthritis.

18. The nurse is assessing the pain of an 86-year-old man who is recovering from open reduction and internal fixation of his hip. What element of assessment would the nurse prioritize in order to best understand the patient's pain?

A) Sleep patterns B) Family history C) Genetic history D) Social support Ans: A Age Group: Adult of Advanced Age Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 11

Page and Header: 143, Older Adults Taxonomic Level: Analysis Feedback: When assessing pain in older adults, the nurse should be sure to also review the effects of pain on diet, sleep, and mood. Unrelieved pain may lead to insomnia or depression and seriously affect the patient's quality of life. It would not be necessary to assess the family history, genetic history, or elimination pattern to gain insight into the patient's pain level.

19. A 78-year-old patient is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?

A) Older adults have fewer nerve fibres; therefore, they feel less pain.

B) Older adults may be reluctant to report pain.

C) Older adults are usually in chronic pain.

D) Older adults are stoic and expect to be in pain.

Ans: B Age Group: Older adult Chapter: 7 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 11 Page and Header: 143, Older Adults Taxonomic Level: Analysis Feedback: Although pain is prevalent in older patients, some of them see pain as just part of natural aging. They may be reluctant to report pain, because they want their providers to consider them “good patients,” or they may fear that complaints of pain may lead to costly tests or expensive medications that they cannot afford. Older adults do not have fewer nerve fibres, they are not always in chronic pain, and they are not always stoic or expecting to be in pain.

Chapter 8: Nutrition Assessment Multiple Choice 1. A 78-year-old man has been hospitalized with a broken right hip. The nurse assesses the patient, finds signs of malnutrition, and consults the dietician. While reinforcing the dietician's teaching about primary nutrients and their role in maintaining health to the patient and his family, the nurse describes complex carbohydrates as what?

A) Polysaccharides B) Monosaccharides C) Phospholipids D) Carbosaccharides Ans: A Age Group: Older Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 153, Carbohydrates Taxonomic Level: Comprehension Feedback: Complex carbohydrates, known as polysaccharides, consist of starch, glycogen, and fibre. Phospholipids are emulsifiers that occur naturally in many foods and used extensively by the food industry. Monosaccharides and carbosaccharides are distracters for this question.

2. A 13-year-old patient with cancer has been experiencing alopecia (hair loss) during treatment. The patient asks the nurse what hair is made of. What would be the nurse's best answer?

A) “Hair consists mostly of carbohydrates.”

B) “Hair consists mostly of protein.”

C) “Hair consists mostly of inorganic matter.”

D) “Hair consists mostly of cellular waste.”

Ans: B Age Group: Child and Adolescent Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1

Page and Header: 153, Proteins Taxonomic Level: Comprehension Feedback: Body tissues such as muscles, bones, teeth, skin, and hair primarily consist of protein.

3. A nurse bases many nutritional interventions and recommendations on the Canada Food Guide. What is a central recommendation of the Canada Food Guide?

A) Eat a wide variety of different foods B) Whenever possible, avoid foods that contain fat C) Eliminate monosaccharides from the diet D) Eat several small meals each day Ans: A Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 156, Nutritional Guidelines Taxonomic Level: Evaluation Feedback: The emphasis of the Canada Food Guide is on reducing fats, sugars, and sodium, while encouraging more variety. Fats should be eaten in limited quantities but not wholly eliminated. Likewise, monosaccharides do not need to be eliminated from the diet. The Canada Food Guide does not recommend multiple, small meals.

4. A nurse is teaching a class on diet and nutrition to a group of pregnant women.

The nurse should encourage these women to A) decrease intake of grains.

B) eat organic foods.

C) moderately increase their calorie intake.

D) avoid animal sources of protein.

Ans: C Age Group: Adult Chapter: 8 Client Type: Group Competency Category: Health and Wellness Difficulty: Difficult Objective: 3 Page and Header: 156, Women Who Are Pregnant Taxonomic Level: Application Feedback: Women who are pregnant or are lactating require special nutritional considerations for healthy outcomes. They need an additional 350 calories/day in the second trimester and 450 extra calories in the third trimester. An organic diet is not a necessity; grains and animal protein do not need to be avoided.

5. A nurse is caring for a patient who belongs to the Mormon faith. What would be the best breakfast for this patient?

A) Coffee, scrambled eggs, and sausage B) Tea, pancakes, and a grapefruit C) Coffee, oatmeal, sausage, and an English muffin D) Orange juice, French toast, and bacon Ans: D Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 158, Cultural Considerations Taxonomic Level: Application Feedback: Food practices may be based on religious beliefs, such as fasting or abstaining from eating certain foods. Mormons typically avoid coffee, tea, alcohol, and tobacco.

6. A 19-year-old college football player has been hospitalized with a knee injury.

When sending his diet orders to the hospital kitchen, the nurse should recognize the need to include A) extra servings of protein.

B) extra servings of carbohydrates.

C) extra servings of grains.

D) extra servings of fats.

Ans: A Age Group: Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 8 Page and Header: 158, Cultural Considerations Taxonomic Level: Application Feedback: Athletes may require additional protein for muscle building and maintenance. Hospitalized athletes do not generally require extra servings of carbohydrates, grains, or fats.

7. A nurse works in an institution in which nurses are responsible for conducting dietary assessments on patients. What assessment question is most appropriate for determining a patient's eating patterns?

A) “Do you think that you have a healthy diet?”

B) “How would you explain your relationship with food?”

C) “Do you tend to eat regular meals?”

D) “Can you describe a typical day's meals for me?”

Ans: D Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 162, Food and Fluid Intake Patterns Taxonomic Level: Application Feedback: An accurate and objective method of identifying an individual's eating patterns is to ask him or her to describe the specifics of a typical day's meals. The other listed questions are less objective and ask the patient himself or herself to draw conclusions about eating patterns.

8. A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as part of a complete nutrition screening assessment?

A) Physical examination B) Platelet and white blood cell counts C) Allergy testing D) Assessment of deep tendon reflexes Ans: A Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 159, Collecting Nutritional Data Taxonomic Level: Application Feedback: A nutrition screening assessment addresses many parameters and includes a physical examination. It does not normally include reflex testing, platelet and WBC levels or allergy testing, however.

9. When taking a dietary assessment on a newly admitted patient who has had a mild MI and is a vegetarian, what would the nurse know is important to include in dietary teaching?

A) Food–drug interaction with chlorophyll B) Food–drug interaction with melatonin C) Food–drug interaction with green leafy vegetables

D)

Food–drug interaction with animal proteins

Ans: C Age Group: Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5 Page and Header: 161, Medications and Supplements Taxonomic Level: Analysis Feedback: Diet and food intake affect medications. Dark green leafy foods can decrease the effect of some anticoagulants, and many patients who have had MI usually take some kind of anticoagulant. Animal proteins, melatonin, and chlorophyll do not generally react with anticoagulants.

10. A nurse on a medical unit is providing care for several patients who have the potential for malnutrition. Which of the following patients is most likely to be deficient in vitamin K? A) A patient who is a tetraplegic and who has a sacral pressure ulcer B) A patient who has been experiencing idiopathic seizures C) A patient who is a heavy alcohol user and who is withdrawing from alcohol D) A patient who has cellulitis resulting from injection drug use Ans: C Age Group: Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 6 Page and Header: 161, Alcohol and Drug Use Taxonomic Level: Evaluation Feedback: It is common for patients with a high alcohol intake to be deficient in the B vitamins and vitamin K. Wounds, seizures, and infection are not direct risk factors for vitamin K deficit.

11. A nurse conducting a comprehensive nutritional assessment is assisting the patient in completing a 24-hour food recall. Research has shown that in this method of assessment, the patient often A) underestimates high intakes.

B) overestimates high intakes.

C) underestimates liquid intake.

D) overestimates low intakes.

Ans:

A

Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 164, 24-hour Recall Taxonomic Level: Application Feedback: In the 24-hour food recall, the patient tends to overestimate low intakes and underestimate high intakes. To control this tendency, it is important for the nurse to use prompts such as “golf-ball size” or “the size of your fist or thumb.”

12. A middle-aged patient with late-stage colon cancer is being treated on a medical unit. The nurse notes that the patient has extremely little muscle mass or fat stores on her body. What syndrome should the nurse suspect the patient has?

A) Ascites B) Cachexia C) Dehydration D) Infection Ans: B Age Group: Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 169, Physical Assessment Taxonomic Level: Analysis Feedback: Cachexia means a highly catabolic state with accelerated muscle loss and a chronic inflammatory response. It is a distinct syndrome separate from anorexia with the production of proinflammatory cytokines that contribute to the breakdown of fat and muscle protein, causing loss of both muscle mass and fat stores. This process is not indicative of infection, dehydration, or ascites.

13. The triage nurse suspects malnutrition in an 88-year-old man who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition?

A) Muscle twitching B) Seizure activity C) Generalized muscle weakness D) Aggression Ans: C Age Group: Adult of Advanced Age Chapter: 8

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 169, General Appearance Taxonomic Level: Analysis Feedback: Clinical findings of malnutrition can occur throughout the body. Visible signs include muscle wasting, particularly in the temporal area; muscle weakness and decreased muscle size; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, gums, lips, tongue, eyes, and, in men, genitalia. Muscle twitching, seizures, and aggression are not normally associated with malnutrition, though these problems could result from the sequelae of malnutrition.

14. A pediatric nurse recognizes the importance of nutrition among children. What is the most common indicator of nutritional status in infants and children?

A) Appetite B) Number of wet diapers per day C) Growth D) Sleep pattern Ans: C Age Group: Child and Adolescent Chapter: 8 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 175, Infants, Children, and Adolescents Taxonomic Level: Application Feedback: Growth charts are commonly used to indicate nutritional status. As an indication of nutritional status, appetite, number of wet diapers per day, and sleep pattern are generally not used.

15. What amount of weight loss over 36 months is associated with increased mortality among older adults living in the community?

A) 5% B) 10% C) 15% D) 20% Ans: A Age Group: Older Adult Chapter: 8 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate

Objective: 8 Page and Header: 176, Older Adults Taxonomic Level: Comprehension Feedback: Loss of as little as 5% of weight over a 3-year period is associated with increased mortality among older adults living in the community.

16. After assessing a new patient, the nurse documents findings in the patient health record. Which of the following charting entries indicates a normal assessment finding?

A) Breath odour is fruity.

B) Nails are strong.

C) Hair is thin and appears oily.

D) Oral mucosa is pink with white patches.

Ans: B Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 9 Page and Header: 163, Symptoms of Malnutrition Taxonomic Level: Application Feedback: “Nails are strong” is the documentation that represents a normal finding.

“Clothing that is too large” might indicate weight loss. Thin, oily hair is not generally a normal finding nor is white patches on the oral mucosa. A fruity breath odour is an abnormal assessment finding.

17. The nurses on a surgical unit are keeping records of a patient's food intake for the duration of her stay in the hospital. How should the nurse best document the patient's food intake for a particular meal?

A) “Patient ate 75% of breakfast tray.”

B) “Patient consumed a hearty breakfast.”

C) “Patient ate approximately 350 calories for breakfast.”

D) “Patient ate sufficiently at breakfast.”

Ans: A Age Group: All Age Groups Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 165, Direct Observation Taxonomic Level: Application Feedback: Commonly, nurses describe intake as a percentage of the meal eaten, such as 50% of breakfast or 75% of dinner. Calorie counts are indicated for some

patients, but these are not based on nurses' independent estimates. Describing a patient's intake as “hearty” or “sufficient” is subjective and inaccurate.

18. A 58-year-old man is admitted to the observation unit with right lower quadrant pain. He has not kept down any food or drink for 24 hours. His temperature is 38.6°C orally. The patient describes the pain as “achy with periods of sharp, stabbing sensations.” What would be the priority nutritional nursing diagnosis for a patient with these assessment data?

A) Deficient knowledge related to disease process B) Pain related to an inability to tolerate food C) Potential for malnutrition (deficit) related to an inability to tolerate food D) Fluid volume less than body requirements related to an inability to tolerate fluids Ans: D Age Group: Adult Chapter: 8 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 10 Page and Header: 177, Nursing Diagnosis, Outcomes, and Interventions Taxonomic Level: Application Feedback: Fluid volume is generally affected faster than anything else when a patient cannot keep fluids down. A knowledge deficit can only occur once a medical diagnosis is established. Pain is not a nutrition-related nursing diagnosis. Malnutrition does not normally occur immediately upon hospitalization but over a longer period.

Chapter 9: Psychosocial and Cognitive Development Multiple Choice 1. Erikson's model defines a stage that encompasses the “evolutionary development which has made man the teaching, instituting, and learning animal.” What concept does Erikson define in this way?

A) Ego integrity B) Despair C) Generativity D) Stagnation Ans: C Age Group: Adult Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 1, 2 Page and Header: 188, Middle Adult: Generativity Versus Self-Absorption Taxonomic Level: Analysis Feedback: Erikson defines generativity as “encompass[ing] the evolutionary development which has made man the teaching, instituting, and learning animal.”

This is a central aspect of middle adulthood.

2.

A) B) C) D)

Piaget differentiates young adulthood from middle adulthood by the use of what?

Expertise Fluid intelligence Wisdom Cognitive pragmatics

Ans: A Age Group: Adult Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 192, Middle Adult: Cognitive Expertise Taxonomic Level: Comprehension Feedback: Because expertise requires years of experience, learning, and work, middle adults are far more likely to have it compared to young adults. This expertise is one of the defining characteristics of middle adulthood, according to Piaget.

3. The nurse is caring for an older adult client who exemplifies wisdom. According to Piaget, what is a characteristic of wisdom?

A) Focuses on important and difficult matter of life B) Involves the progressive accumulation of firm opinions C) Applies only to nonspecific situations D) Is easily known to the individual who possesses wisdom rather than to others Ans: A Age Group: Older Adult Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1, 2 Page and Header: 192, Older Adult: Wisdom Taxonomic Level: Analysis Feedback: Wisdom refers to an expert knowledge system that appears to focus on important and difficult matters often associated with the meaning of life and the human condition; requires a superior level of knowledge, judgment, and advice; is associated with knowledge that has extraordinary scope, depth, and balance; and is applicable to specific situations. Wisdom combines mind and virtue (character) and is employed for personal well-being as well as for the benefit of humankind. Although difficult to achieve, wisdom is easily recognized by most people, and it represents the capstone of human intelligence. It is not characterized by an accumulation of opinions.

4. A pediatric nurse has learned that the phenomenon of egocentrism is common in young patients. What is egocentrism?

A) Internalized sets of actions that permit children to do mentally what they once did physically B) Centering attention on one aspect of a problem and failing to consider other dimensions C) The belief that inanimate objects are capable of action and have life-like qualities D) The inability to distinguish one's own perspective from another person's Ans: D Age Group: Child and Adolescent Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 188, Toddler and Preschooler: Preoperational Taxonomic Level: Analysis Feedback: Egocentrism is the inability to distinguish one's own perspective from

another person's. Animism is the belief that inanimate objects are capable of action and have life-like qualities. Centration is the child centering attention on one aspect of a problem and failing to consider other dimensions. Piaget defined operations as internalized sets of actions that permit children to do mentally what they once did physically.

5. A nurse is caring for a 75-year-old man who reports that he is becoming “forgetful.” The nurse explains that some parts of memory decrease with aging and some do not. What would the nurse identify happens with aging to the type of memory that corresponds with the retrieval of facts, vocabulary, and general knowledge?

A) Decreases minimally B) Decreases sharply C) Decreases only in patients with disease processes D) Shows a slight increase Ans: A Age Group: Older Adult Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 193, Table 9-2 Taxonomic Level: Analysis Feedback: Semantic long-term memory involves the retrieval of facts, vocabulary, and general knowledge and decreases minimally with aging.

6. The nurse is presenting a class for new mothers and explains that from ages 4 to 8 months infants perform secondary circular reactions. This occurs when A) the infant reproduces an event that initially happened by chance.

B) the infant coordinates schemes and intentionality.

C) the infant becomes more object-oriented, moving beyond being preoccupied with the body.

D) the infant experiments with new behaviour.

Ans: C Age Group: Infant Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 189, Table 9-1 Taxonomic Level: Analysis Feedback: Between ages 4 and 8 months, infants engage in secondary circular reactions, by which they become more object-oriented and move beyond being

preoccupied with the body. The coordination of schemes and intentionality occurs during coordination of secondary circular reactions. Reproducing an event that initially happened by chance represents primary circular reactions. Experimenting with new behaviour occurs during tertiary circular reactions.

7. Erikson theorizes that the school-aged child faces the task of industry versus inferiority. What is the danger in this stage of development?

A) The child will separate himself or herself from others to avoid commitment to intimacy.

B) The child will not be able to learn to use adult tools.

C) The child will struggle to choose an occupational identity.

D) The child will overmanipulate self and work to repossess the environment in a repetitive fashion.

Ans: B Age Group: Child and Adolescent Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 186, School-Age Child: Industry Versus Inferiority Taxonomic Level: Comprehension Feedback: The danger in this stage is that the child will not be able to learn to use the adult tools and will feel a sense of inferiority and inadequacy. It is difficult for the child to be admitted to an adult role in society without the tools to deal with the technology and economy of the culture. Therefore, option C is incorrect. Option A represents the danger of the young adult stage of development; option D represents the danger of the toddler developmental stage.

8. A pediatric nurse includes assessments related to growth and development during many aspects of care. The nurse should recognize that infants should be expected to double their birth weight by what age?

A) Six months B) Eight months C) Ten months D) One year Ans: A Age Group: Infant Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 196, Table 9-4

Taxonomic Level: Comprehension Feedback: Infants are expected to double their birth weight by 6 months of age.

9. A nurse practitioner is performing a comprehensive assessment of a 14-month-old toddler who has been brought to the clinic by her mother for the treatment of a suspected inner ear infection. At this age, the nurse should expect that the child is able to A) walk and run smoothly.

B) stand alone steadily.

C) climb stairs.

D) walk with some support.

Ans: B Age Group: Child and Adolescent Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 197, Table 9-5 Taxonomic Level: Application Feedback: A child who is 14 months old is normally able to stand alone. He or she will not normally be able to walk without support and may or may not be able to walk with support.

10. A nurse is presenting an educational event for a local community group. What type of intelligence would the nurse tell the group is learned and influenced by the individual person's culture?

A) Pragmatic mechanics B) Cognitive mechanics C) Fluid intelligence D) Crystallized intelligence Ans: D Age Group: Adult Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 192, Middle Adult: Cognitive Expertise Taxonomic Level: Comprehension Feedback: Crystallized intelligence is “accumulated knowledge and skills based on education and life experiences.”

11. A young adult couple adopts an 8-month-old boy. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this patient/family?

A) Visits by a home health nurse to assess the environment for safety and comfort B) Teaching the parents to effectively discipline the infant C) Teaching the parents to teach the child as needed D) Planning respite care for the parents Ans: A Age Group: Infant Chapter: 9 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 9 Page and Header: 200, Pulling It All Together: An Example of Reflection and Critical Thinking Taxonomic Level: Application Feedback: The most appropriate intervention for risk for delayed child development related to recent adoption is to consider a home health nurse visit to assess the environment for safety and comfort. The issues of discipline, respite care, and teaching have no direct connection to the nursing diagnosis.

12. A nurse is providing prenatal care for a 20-year-old woman who is in the second trimester of her first pregnancy. The woman has a long history of substance use, and the nurse is planning interventions to address this because maternal substance use is linked to what nursing diagnosis?

A) Risk for delayed child development B) Risk for parental role conflict C) Risk for caregiver role strain D) Risk for social isolation Ans: A Age Group: Adult Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 7, 9 Page and Header: 200, Table 9-6 Taxonomic Level: Application Feedback: Maternal substance use creates a high risk of delayed child development.

The other listed nursing diagnoses are not as closely linked to the mother's substance use.

13.

In some countries, the transition to adulthood is a long process. What fact often

underlies this phenomenon?

A) These countries value parenting more highly than in other countries.

B) These countries value nuclear families over extended families.

C) These countries have higher education opportunities.

D) These countries do not value independence.

Ans: C Age Group: All Age Groups Chapter: 9 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 194, Cultural Considerations Taxonomic Level: Comprehension Feedback: The transition to adulthood is a long process for some cultures (particularly those with higher education opportunities) and a very short one for others. The process is not related to how much a country values parenting or nuclear family structures. Countries that value independence would be equated with shortened, not prolonged, transitions to adulthood.

14. When Erikson published his theory in1963, he postulated that the end of childhood took place at what point?

A) End of high school B) Puberty C) When the person gets his or her first job D) Teenage years Ans: B Age Group: Child and Adolescent Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 186, Adolescent: Identity Versus Role Confusion Taxonomic Level: Knowledge Feedback: In Erikson's 1963 model, puberty signals the end of childhood.

Employment does not correlate with the end of childhood.

15. Uri Bronfenbrenner postulated that development was continuous. What other fact did Bronfenbrenner emphasize?

A) Development stagnates if the individual is not conscious of the process.

B) Development stops cognitively at older adulthood.

C) Development is important at all ages.

D) Development is independent of the environment.

Ans: C Age Group: All Age Groups Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 186, Psychosocial Development Taxonomic Level: Comprehension Feedback: Bronfenbrenner believed that development is continuous, important at all ages, and an active rather than a passive process. Even though development is active, this does not necessarily imply that it ceases if an individual is not conscious of the process. Bronfenbrenner did not deny the role of environment.

16. A nurse has planned a health promotion initiative that will be group-based. In what life stage, defined by Erikson, is group identity most important?

A) Early adulthood B) School age C) Adolescence D) Young adult Ans: C Age Group: Child and Adolescent Chapter: 9 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 186, Adolescent: Identity Versus Role Confusion Taxonomic Level: Analysis Feedback: Adolescents tend to cling together in cliques and crowds. Doing so helps to protect against the loss of identity through the assumption of a group identity that temporarily defines for the adolescent how to dress, act, and belong. Erikson explained that this behaviour will eventually fall away as the individual defines his or her own identity.

17. The nurse is conducting an admission assessment of an 82-year-old man who is moving from his own apartment to a long-term care facility. What assessment question most directly addresses this man's primary developmental task?

A) “Do you feel like you accommodate change easily?”

B) “How do you like to occupy your time?”

C) “How many children did you and your wife raise?”

D) “What are you most proud of in your life?”

Ans:

A

Age Group: Adult of Advanced Age Chapter: 9 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 6 Page and Header: 188, Late Adult: Ego Integrity Versus Despair Taxonomic Level: Application Feedback: The older adult with ego integrity has come to terms with his or her life choices. A possible way to explore this with a patient or client is to discuss the events or accomplishments that have given the individual pride. The other listed questions do not directly address this developmental task.

Chapter 10: Mental Health Assessment Multiple Choice 1. A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

A) Age B) Occupation C) Environment D) Support systems Ans: A Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 2 Page and Header: 208, Questions to Assess History and Risk Factors Taxonomic Level: Analysis Feedback: Factors that cannot be changed include family history, age, and gender.

Occupation, environment, and support systems are all, to some degree, modifiable.

2. A nursing student is giving an in-service presentation on aggressive behaviour.

What risk factor would the student be sure to include in the presentation?

A) Caucasian ethnicity B) Male gender C) Low education D) Young age Ans: B Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 214, Homicidal Ideation and Aggressive Behaviour Taxonomic Level: Analysis Feedback: Risk factors for aggressive behaviour include male gender, history of violence, and substance abuse. Ethnicity, diagnosis, age, marital status, and education do not reliably identify this behaviour.

3. The nurse is admitting a patient to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this patient's life?

A) MMPI B) ABCT C) CAGE D) HOPE Ans: C Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 211, Substance Use Taxonomic Level: Application Feedback: If alcohol use might be a problem, the CAGE is a quick first-step questionnaire to use as an assessment tool. The MMPI is the Minnesota multiphasic personality inventory used to aide in diagnosing psychological problems. The ABCT is used for assessment of mental status. It includes appearance (posture, movement, hygiene, and dress), behaviour (level of consciousness, eye contact, facial expressions, and speech), cognitive function (orientation, attention span, memory, and judgment), and thought processes and is not a tool. The HOPE tool is used for assessing spirituality.

4. The nurse suspects substance abuse in a 55-year-old patient who has been admitted to the emergency department following a motor vehicle collision. What is the most important reason the nurse would administer the CAGE tool to this patient?

A) The CAGE tool tracks patterns over time.

B) The CAGE tool addresses problems at work.

C) The CAGE tool tracks the progress of the patient's disease.

D) The CAGE tool addresses the patient's possible denial.

Ans: D Age Group: Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 211, Substance Use Taxonomic Level: Analysis Feedback: When screening for substance abuse, the patient may deny a problem.

The CAGE tool is valuable because it addresses this denial. The CAGE tool does not

address problems at work; it does not track the progress of the patient's disease nor does it track patterns over time.

5. An emergency room nurse is assessing a patient's social support system after the patient has been stabilized medically. What assessment question most directly addresses this aspect of mental health?

A) “Do you have a significant other in your life?”

B) “Do you have a formal religious affiliation?

C) “How long have you lived in the community?”

D) “Do you feel like you're good at dealing with anxiety?”

Ans: A Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 210, Support Network Taxonomic Level: Application Feedback: Several questions can be used to ascertain an individual's support system, including “Do you have a significant other in your life?” The other listed questions do not directly address this psychosocial issue.

6. A nurse is utilizing the HOPE assessment tool in a comprehensive assessment of a newly admitted patient. What assessment question should the nurse include in this assessment?

A) “Have you ever felt that you should cut down on your drinking?”

B) “What keeps you going during hard times in your life?”

C) “What goals do you have for your immediate future?”

D) “How would you describe your health, outlook, perseverance, and energy?”

Ans: B Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 212, Box 10-2 Taxonomic Level: Application Feedback: The HOPE assessment is used to assess spiritual beliefs. Identifying a patient's sources of strength is integral to this assessment. This assessment does not address alcohol use or goal-setting, and it is not structured according to health, outlook, perseverance, and energy.

7. When a nurse asks a patient, “Do you have any thoughts of wanting to harm or kill yourself?” for what is the nurse assessing?

A) Suicide attempts B) Suicide means C) Suicide ideation D) Suicide plan Ans: C Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 214, Suicidal Ideation Taxonomic Level: Analysis Feedback: Suicide ideation is assessed by asking, “Do you have any thoughts of wanting to harm or kill yourself?” This question does not specifically assess attempts at suicide, means of suicide, or plans of suicide.

8. While assessing a new patient in the clinic area, the nurse administers an assessment according to the SAD PERSONAS mnemonic. For what is the nurse most likely assessing?

A) Risk of depression B) Risk of self-mutilation C) Risk of violence D) Risk of suicide Ans: D Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 4 Page and Header: 214, Suicidal Ideation Taxonomic Level: Knowledge Feedback: SAD PERSONAS suicide risk assessment—sex, age, depression, previous attempt, ethanol abuse, rational thought loss, social supports lacking, organized plan, no spouse, access to lethal means, sickness. The presence of each factor is given a point value of one. Total scores range from 0 to 10. Higher scores indicate greater patient suicide risk.

9. The nurse is assessing a patient with mental illness who reports hearing voices that are inaudible to others. In order to ensure the patient's safety, what would be the

most important assessment to make?

A) The nature of the voices B) What triggers the voices C) If the patient also sees things D) Whether substance use is associated with the voices Ans: A Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 215, Auditory Hallucinations Taxonomic Level: Synthesis Feedback: If the patient confirms auditory hallucinations, it is important to ask about their nature. Are they hostile or critical? Do they “command” or tell the patient to do things such as harm self or others? The other options are appropriate but do not directly address a safety threat.

10. A mental health nurse is aware of the need to assess for visual hallucinations.

The nurse should be cognizant of what potential causes of visual hallucinations?

A) Multiple sclerosis, alcohol withdrawal, and medication side effects B) Medication side effects, alcohol withdrawal, and Parkinson's disease C) Fluid imbalances, medication side effects, and amphetamine withdrawal D) Narcotic withdrawal, multiple sclerosis, and head injury Ans: B Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 215, Visual Hallucinations Taxonomic Level: Comprehension Feedback: Common causes of visual hallucinations include side effects from medications, alcohol withdrawal, and Parkinson's disease. Generally, multiple sclerosis, amphetamine withdrawal, narcotic withdrawal, fluid imbalances, and head injury do not cause visual hallucinations.

11. A nurse is assessing a pregnant patient who has a history of mental illness.

Pregnancy often requires female patients to A) take their psychiatric medications in divided doses.

B) temporarily stop their prescribed psychiatric medications.

C) increase the dosage of their psychiatric medications.

D)

replace psychiatric medications with herbal remedies.

Ans: B Age Group: Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 216, Women Who Are Pregnant Taxonomic Level: Application Feedback: Pregnancy is associated with relapse in psychotic disorders, and women with a history of depression are at highest risk for an episode during pregnancy or postpartum. Pregnant women experience hormonal changes and also may need to stop psychiatric medications because of side effects in the fetus.

12. The triage nurse on the adolescent unit knows that puberty is associated with an increased incidence of A) hallucinations.

B) mania.

C) depression.

D) bipolar disorder.

Ans: C Age Group: Child and Adolescent Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 208, Questions to Assess History and Risk Factors Taxonomic Level: Knowledge Feedback: Adolescence may be difficult because of hormonal changes as well as growth and developmental stage. Onset of menarche and puberty can contribute to depression. Bipolar disorder, mania, and hallucinations are not linked to the onset of puberty.

13. The nurse has admitted a patient to the adult psychiatric unit who is in a very poor state of hygiene. The nurse should recognize that a long-term lack of self-care may be a consequence of which of the following?

A) Delirium B) Bipolar disorder C) Violence D) Schizophrenia Ans:

D

Age Group: Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 219, A: Appearance Taxonomic Level: Analysis Feedback: Many types of mental health disorders underlie a lack of self-care.

However, this is particularly common among individuals who have schizophrenia.

14. As part of a comprehensive assessment, the nurse is assessing a patient's orientation. When performing this assessment, the nurse should ask which of the following questions?

A) “Can you tell me who the prime minister is right now?”

B) “Where were you born?”

C) “Can you tell me the month and year?”

D) “If you saw a fire, what would you do first?”

Ans: C Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 221, C: Cognitive Function Taxonomic Level: Analysis Feedback: Orientation addresses the patient's knowledge of person, place, and time. Asking the patient to state the month and year assesses his or her knowledge of time. None of the other listed questions elicits any of these three assessment parameters.

15. A nurse is conducting a mini-mental status examination (MMSE) on a 79-year-old patient. During this assessment, the nurse will ask the patient to do which of the following tasks?

A) Solve a simple riddle B) List his or her grandparents' names C) Perform some simple multiplication D) Name some common objects Ans: D Age Group: Older Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health

Difficulty: Moderate Objective: 5 Page and Header: 222, Mini-Mental Status/Mini-Cog Taxonomic Level: Application Feedback: Naming objects is a component of the MMSE. Solving riddles, performing multiplication, and naming relatives are not aspects of this particular assessment.

16. When administering a mini-mental status examination (MMSE) to a patient, the nurse calculates the patient's score as 22. The nurse would be justified in documenting the presence of A) depression.

B) normal mental processes.

C) schizophrenia.

D) cognitive impairment.

Ans: D Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5, 8 Page and Header: 222, Mini-Mental Status/Mini-Cog Taxonomic Level: Analysis Feedback: A score of 23 or lower on the MMSE indicates cognitive impairment. The MMSE is not used to assess for depression or schizophrenia.

17. The nurse notes an acute change in a 38-year-old male patient's mental status.

The patient has gone from being coherent and oriented to person, place, and time to having very disorganized thought processes. After assessment, the care provider has attributed these changes to delirium. What is a possible effect of delirium on the patient?

A) Unconsciousness B) Depression C) Risk for injury D) Risk for situational low self-esteem Ans: C Age Group: Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 10 Page and Header: 223, Assessment of Dementia, Confusion, Delirium, and Depression

Taxonomic Level: Application Feedback: Delirium usually has an acute onset, and disorganized thoughts can place the patient at risk for injury. Delirium generally does not normally cause loss of consciousness, depression, or low self-esteem.

18. The nurse is conversing with a patient in the dayroom of a psychiatric unit. The patient's conversation is incoherent and wandering, with statements that seem illogical and inconsistent. What would these abnormal indications signify to the nurse?

A) The patient is thinking impaired.

B) The patient is depressed.

C) The patient is hallucinating.

D) The patient is under tremendous stress.

Ans: A Age Group: Adult Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 222, T: Thought Processes and Perceptions Taxonomic Level: Analysis Feedback: Illogical, incoherent, irrelevant, wandering, inconsistent, or concrete thought processes are abnormal indications that the patient is thinking less efficiently.

Depression, stress, and hallucinations may be associated with these thinking patterns, but this is not always the case.

19. A patient reports that bugs are crawling under his skin. The nurse knows that this tactile hallucination is often associated with what?

A) Medication side effect B) Methamphetamine use C) Brain tumour D) Parkinson's disease Ans: B Age Group: All Age Groups Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 215, Other Hallucinations Taxonomic Level: Analysis Feedback: Hallucinogen and methamphetamine use is associated with tactile hallucinations. Medications, Parkinson's disease, and brain tumours are less likely to cause these hallucinations.

20. A 17-year-old girl has been brought to the emergency department (ED) by her mother after expressing suicidal ideation. What type of mental health assessment should the ED nurse first perform?

A) Comprehensive assessment B) Psychosocial assessment C) Focused assessment D) Mental illness assessment Ans: C Age Group: Child and Adolescent Chapter: 10 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 205, Role of the Nurse in Mental Health and Psychiatric Assessment Taxonomic Level: Application Feedback: A focused assessment is the collection of specific information about a particular need, concern, or situation (e.g., medication effects, risk for self-harm, risk to harm others, knowledge deficits, or the adequacy of supports and resources).

Because of the girl's risk of harm to herself, a focused assessment is a priority. Mental illness assessment is not a discrete type of assessment.

Chapter 11: Social, Cultural, and Spiritual Health Assessment Multiple Choice 1. A nurse student has learned that cultural competence is considered to be an entry-to-practice competency for registered nurses. What is the primary rationale for this fact?

A) Canadian society has a highly multicultural character.

B) Ethnicity in nursing is part of the holistic process.

C) Cultural considerations strongly affect patients' adherence to treatment.

D) Interdisciplinary collaboration depends on accurate intercultural communication.

Ans: A Age Group: All Age Groups Chapter: 11 Client Type: Population Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 1, 5 Page and Header: 232, Introduction Taxonomic Level: Comprehension Feedback: Given Canada's multicultural composition and the steady influx of new and diverse immigrants, nurses' sensitivity to patients' social and cultural backgrounds and their spiritual beliefs becomes imperative. Ethnicity is not a discrete part of the holistic process. Adherence to treatment and interdisciplinary communication are not the major rationales for cultural competence 2. While writing a class assignment on the history and characteristics of the Canadian health care system, a nursing student has made several references to the Lalonde Report of 1974. This student's assignment most likely focuses on A) the role of complementary and alternative medicine in Canada.

B) the principles and practice of health promotion.

C) the strengths and weaknesses of the western, biomedical model of health.

D) the factors that form the basis of patient autonomy.

Ans: B Age Group: All Age Groups Chapter: 11 Client Type: Population Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 232, Models of Health

Taxonomic Level: Analysis Feedback: In Canada, the health promotion approach began with the groundbreaking Lalonde Report (1974) that introduced four determinants of health (biology, lifestyle, environment, and health care organizations). The Lalonde Report did not focus on patient autonomy, CAM, or the characteristics of the biomedical model of health.

3. A nurse is performing a community assessment on a small town that is a significant distance from the nurse's home. How might the nurse best begin the assessment process for this town?

A) Assess the relationship between the community's social support and industrial activity B) Assess the relationship between the community's level of education and rates of chronic illness C) Assess the relationship between the community's living conditions and divorce rate D) Assess the relationship between the community's median family income and rate of high school graduation Ans: B Age Group: All Age Groups Chapter: 11 Client Type: Community Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 2 Page and Header: 233, Social Assessment of the Community Taxonomic Level: Analysis Feedback: Ideally, the process of community assessment begins with an assessment of various social, economic, environmental, and quality-of-life health indicators and their relationship with the community's health concerns. Examples of findings from a community social assessment include the relationship between social determinants of health (family income, level of education, social support, and living conditions) and chronic illness.

4. A group of community health nurses are implementing the Community as Partner Assessment Model during an initiative. What is a central component of this model?

A) Transcultural assessment of community allies B) Evaluation of the competencies of community leaders C) Systemic evaluation to identify the effects of interventions D) Education about ways to augment community coping Ans: C Age Group: All Age Groups Chapter: 11 Client Type: Individual

Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 4 Page and Header: 233, Social Assessment of the Community Taxonomic Level: Comprehension Feedback: Anderson and McFarlane's model mandates that every community assessment and intervention include systematic evaluation to identify the effects of interventions. Specific evaluation of community “allies” is not noted and the competencies of leaders are not a key focus. Community coping is not a central concept in the Community as Partner Model.

5. A nurse is addressing the shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world. This description best describes what?

A) Society B) Community C) System D) Culture Ans: D Age Group: All Age Groups Chapter: 11 Client Type: Group Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 237, Characteristics of Culture Taxonomic Level: Comprehension Feedback: At the most basic level, culture can be defined as a shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world.

6. A new graduate nurse is attending orientation at a community agency. The staff educator gives a pre-lecture quiz and asks what the goals of a cultural assessment include. What would be the graduate nurse's best answer?

A) Developing and implementing a culturally congruent plan of care B) Identifying acute care needs of the specific person C) Identifying residents' knowledge about cultural beliefs and practices D) Comparing social and health beliefs of health agencies Ans: A Age Group: All Age Groups Chapter: 11 Client Type: Community Competency Category: Nurse-Client Partnership Difficulty: Moderate

Objective: 3 Page and Header: 237, Aims of Cultural Assessment Taxonomic Level: Analysis Feedback: The specific aim of cultural assessment is to provide an all-inclusive picture of the patient's culture-based health care needs by (1) gaining knowledge about the patient's cultural beliefs and practices, including food and eating rituals, daily and nightly personal hygiene rituals, and sleeping habits; (2) comparing culture care needs of the specific person with the general themes of those of similar cultural background; (3) identifying similarities and differences among the cultural beliefs of the patient, health care agency, and nurse; and (4) generating a holistic picture of the patient's care needs, upon which a culturally congruent nursing care plan is developed and implemented.

7. Madeline Leininger has identified aspects of practice that a nurse who provides effective care across cultures must implement. What practice does Leininger emphasize?

A) Understanding that the nurse's own beliefs always interfere with culturally sensitive care B) Identifying the relationship between culture and health C) Awareness of meanings behind the patient's social communications D) Ranking of cultural differences and strengths Ans: B Age Group: All Age Groups Chapter: 11 Client Type: Group Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 3, 6 Page and Header: 237, Cultural Assessment Taxonomic Level: Comprehension Feedback: Leininger proposed essential areas of assessment to better understand the relationship between individuals' culture and health. Cultural beliefs have the potential to inhibit culturally sensitive care, but this is not always the case. The meanings of social communications are not a central priority and cultures are never ranked hierarchically.

8. A nurse is caring for a 58-year-old Southeast Asian man. The nurse knows that incorporating the patient's health beliefs and practices into nursing care will achieve what?

A) Enhancement of his social system B) Enhancement of his cultural connectedness C) Improvement of his health outcomes D) Improvement of communication between him and his family Ans:

C

Age Group: Adult Chapter: 11 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 232, Models of Health Taxonomic Level: Analysis Feedback: Consideration of the patient's cultural background and incorporating his health beliefs and practices in care plans contribute to enhanced patient experiences with health care and improve health outcomes. Incorporating his health beliefs and practices will not enhance this patient's social system or improve communication with him and his family. Cultural connectedness is not a central goal of culturally competent nursing practice.

9. A nurse is conducting an assessment that includes considerations of matters pertaining to the human soul. This best defines which of the following concepts?

A) Culture B) Ethnicity C) Values D) Spirituality Ans: D Age Group: All Age Groups Chapter: 11 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 7 Page and Header: 240, Spiritual Assessment Taxonomic Level: Comprehension Feedback: Spirituality, in the most fundamental sense, pertains to matters of the human soul, be it a state of mind, a state of being in the world, a journey of self-discovery, or a place outside the five senses. This does not define culture, values, or ethnicity.

10. A hospice nurse is admitting a new patient who describes herself as being nominally religious. What might happen with this patient as her illness progresses?

A) Religious activities may lose importance.

B) Religious activities may take a central position in her life.

C) Religious activities may blend with national identity.

D) Religious activities may become formalized.

Ans: B Age Group: Adult Chapter: 11

Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 8, 9 Page and Header: 240, Spiritual Assessment Taxonomic Level: Application Feedback: Even when daily prayers or other religious practices are not a routine part of a patient's life, they often take a central position during life transitions, such as loss of a loved one, accident, or serious illness.

11. A nursing student is helping with a group presentation on social assessment.

What would be most important for the student to include in the group presentation?

A) Social assessment emphasizes the interconnectedness of physical, physiologic, and educational dimensions of health.

B) Social assessment emphasizes the interconnectedness of physical, family, and social dimensions of health.

C) Social assessment emphasizes the interconnectedness of physical, spiritual, and psychic dimensions of health.

D) Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health.

Ans: D Age Group: All Age Groups Chapter: 11 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 233, Social Assessment Taxonomic Level: Comprehension Feedback: Social assessment, integral to quality nursing care at every level, emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health for individuals, communities, and populations studied. Psychic, social, and educational dimensions are not dimensions of health emphasized in the social assessment.

12. The nurse is participating in a group assignment on performing a social assessment on the Hmong society. What would be important to include in this assessment?

A) Population trends and relationships among social variables B) Spiritual architecture of the community C) Individual conflicts within the society D) Occupational relationships and opportunities Ans: A Age Group:

All Age Groups

Chapter: 11 Client Type: Population Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 2 Page and Header: 237, Social Assessment at the Societal Level Taxonomic Level: Application Feedback: At the societal level, social assessment is intended to generate information about population trends and relationships among the social variables and prevalent health concerns. Assessment of a society does not include spiritual architecture, the individual conflicts in the society, or their occupational relationships.

13. A 35-year-old Afghani woman is admitted to the obstetric unit. While doing a transcultural assessment, what should the nurse first do in order to individualize questions for this patient?

A) Ascertain if the patient speaks and understands English B) Remember that 35-year-old Afghani women were not allowed an education in their home country C) Enlist the services of a translator D) Speak only with the patient's husband Ans: A Age Group: Adult Chapter: 11 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 233, Social Assessment of the Individual Taxonomic Level: Application Feedback: The most important transcultural assessment to make with this patient is whether she speaks and understands English. The nurse would need this information prior to asking for a translator, assuming the patient was not allowed an education, or talking only with the husband.

14. A group of nurses are using Madeline Leininger's theory to guide the planning of an intervention. Leininger formulated a theory that highlights what?

A) Social behaviors that determine the success of a community B) Nursing behaviors necessary to carry out an effective cultural assessment C) Nursing behaviors that compare personal philosophies of life and spiritual beliefs D) Behaviors and skills necessary to carry out physical assessment Ans: B Age Group: All Age Groups Chapter: 11 Client Type: Community

Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 237, Aims of Cultural Assessment Taxonomic Level: Comprehension Feedback: Leininger's theory identifies the relationships between cultural variables and health and highlights the nursing behaviors and skills necessary to carry out effective cultural assessment. It does not define “success” of a community, compare personal philosophies, or identify components of physical assessment.

15. The nurse is caring for a hospitalized patient whose culture idealizes a body weight that is higher than Canadian recommendations. While writing the plan of care for this patient, it would be important to include which of the following nursing diagnoses?

A) Risk for Imbalanced Nutrition: Less than Body Requirements B) Risk for Spiritual Distress C) Risk for Deficient Fluid Volume D) Risk for Imbalanced Nutrition: More than Body Requirements Ans: D Age Group: Adult Chapter: 11 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 239, Cultural Food and Nutrition Practices Taxonomic Level: Application Feedback: In many cultures, ideal body weight is higher than guidelines recommend. Such cultures may not consider “dieting” healthy. People may prefer to consume foods high in fat, salt, and cholesterol and low in fruit and vegetables because they believe that it is best for their health. This creates a risk of nutritional excess. Fluid volume deficit, spiritual distress, and malnutrition are less likely. While the patient's diet may be excessive in certain nutrients, the nurse or a dietician would have to do more extensive nutritional assessment to arrive at specific conclusions.

16. When performing an assessment, a nurse chooses to use Roy's framework of health. What would be a priority for this nurse during this assessment?

A) Forming a therapeutic partnership with the patient B) Assessing the patient's knowledge of spirituality and his or her religious beliefs C) Gauging the individual's ability to adapt to changes in health D) Identifying the strengths and weaknesses of the patient's knowledge base Ans: C Age Group: All Age Groups Chapter: 11

Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 232, Models of Health Taxonomic Level: Comprehension Feedback: Roy refers to health as the patient's ability to adapt, compensate, manage, and adjust to physiologic–physical health-related setbacks. Consequently, the individual's knowledge and spirituality may be important considerations but neither is the primary focus of this model.

Chapter 12: Human Violence Assessment Multiple Choice 1. A student nurse is currently participating in a clinical placement in a community that has a high rate of family violence. The student nurse would learn about which of the following types of family violence?

A) Parental discipline B) Elder abuse C) Sibling rivalry D) Spousal neglect Ans: B Age Group: All Age Groups Chapter: 12 Client Type: Community Competency Category: Professional Practice Difficulty: Easy Objective: 1 Page and Header: 249, Family Violence Taxonomic Level: Comprehension Feedback: Types of family violence include child maltreatment, sibling violence, IPV, and elder abuse. They do not include spousal neglect. Discipline is not necessarily synonymous with violence and sibling rivalry may or may not constitute violence.

2. A community health nurse is aware of the need to screen children for violence.

What type of family violence is among the most common types that children experience?

A) Financial abuse B) Sibling violence C) Munchausen's syndrome D) Traumatic stress Ans: B Age Group: Child and Adolescent Chapter: 12 Client Type: Group Competency Category: Professional Practice Difficulty: Easy Objective: 1 Page and Header: 250, Sibling Violence Taxonomic Level: Comprehension Feedback: Sibling violence is among the most common type of violence that children

experience.

3. A nurse is discussing the unacceptably high prevalence of child maltreatment with a colleague. What is the percentage of children who experience four or more different kinds of victimization?

A) 15% B) 25% C) 35% D) 45% Ans: B Age Group: Child and Adolescent Chapter: 12 Client Type: Population Competency Category: Professional Practice Difficulty: Moderate Objective: 2 Page and Header: 250, Child Maltreatment Taxonomic Level: Knowledge Feedback: According to Finkelhor, Ormrod, et al. (2007), about 25% of children experience four or more different kinds of victimization.

4. A 37-year-old woman comes to the emergency department with a broken humerus. The patient lives in an area with a high crime rate and low socioeconomic demographic. During her examination, the patient states, “I was fighting with my husband. He pushed me and I fell, landing on the coffee table. That's how I broke my arm.” Why might this patient be so forthcoming in her disclosure of violence?

A) Decreased social stigma about violence B) Low ethnic rate of acceptance of violence C) Increased cultural statistics on violence D) Decreased environmental pressure for violence Ans: A Age Group: Adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 3, 5 Page and Header: 258, Cultural Considerations Taxonomic Level: Analysis Feedback: The social stigma attached to human violence may vary among cultures.

For example, a patient from a neighborhood with a high rate of violent crime may feel less stigmatized because it is a common occurrence. None of the other listed explanations accounts for the woman's statement.

5. Police bring a patient with substance abuse to the ED after being arrested for a domestic dispute in which he gave his wife a black eye and he experienced a severe laceration. The patient is out of control and verbally abusive toward staff. When a nursing care plan is developed, what would be a priority nursing diagnosis for this patient?

A) Dysfunctional family processes related to spousal neglect B) Risk for violence directed at others C) Risk for posttrauma syndrome D) Sustained maladaptive response to sexual abuse and sexual assault Ans: B Age Group: Adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 5 Page and Header: 258, Nursing Diagnoses, Outcomes, and Interventions Taxonomic Level: Synthesis Feedback: The patient's behaviours are consistent with risk for violence directed at others. The scenario described does not mention spousal neglect, sexual abuse, or sexual assault. This patient is not likely at risk for posttrauma syndrome.

6. An ambulance brings a patient to the hospital after finding her unconscious in an alley. When the patient regains consciousness, responses to assessment questions indicate to the nurse that the patient may have been abused but that the patient appears uncomfortable discussing the events. What open-ended question might be helpful when assessing abuse with this patient?

A) “What can I tell you about abuse?”

B) “I know you have been abused. Please tell me about it.”

C) “Abuse is more prevalent than most people think.”

D) “What would you like me to know about this situation?”

Ans: D Age Group: Adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 4 Page and Header: 253, Interviewing Patients About Human Violence Taxonomic Level: Application Feedback: Open-ended questions, such as “What would you like to know?” “How can I help you understand?” or “What would you like me to know?” are especially helpful if a patient appears uncomfortable. It would be inappropriate for the nurse to ask what she can tell the patient about abuse or to tell the patient that the nurse knows

the patient has been abused. While discussing the prevalence of abuse might help increase the patient's knowledge, it might not make her feel any more comfortable about the situation or ready to share information.

7. During the assessment of a 27-year-old woman at the clinic, the nurse finds indications that the patient is a victim of abuse. When documenting findings, the nurse should A) paraphrase the woman's statements as much as possible.

B) ensure that the documentation is as succinct as possible.

C) use quotations to document the patient's subjective statements.

D) ask the patient to help the nurse draft the documentation.

Ans: C Age Group: All Age Groups Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 6 Page and Header: 256, Documentation Taxonomic Level: Analysis Feedback: Nurses should document subjective data in quotes as much as possible.

This is preferred to paraphrasing and accuracy, not brevity, is a key goal. It is inappropriate to ask the patient to participate in documentation.

8. A 79-year-old man confined to a wheelchair is admitted to the hospital after a fall down a flight of stairs. He is found to have multiple abrasions and bruises in various stages of healing. Abuse is suspected, and an Elder Assessment Inventory is performed. For what risk factor is the nurse assessing?

A) Strained mental health of caregiver B) Independence C) Manipulation by the elder D) Financial instability Ans: A Age Group: Older adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 4 Page and Header: 25, Elder Abuse Taxonomic Level: Analysis Feedback: Factors that put older adults at risk include dependency, cognitive decline, strained mental or physical health of caregivers, and financial issues. A commonly used tool to screen for maltreatment in older adults is the Elder

Assessment Inventory.

9. A caregiver brings a disabled patient to the ED and the caregiver reports that the patient has an altered level of consciousness and refuses to eat. The patient is found to be severely dehydrated. The nurse suspects neglect and asks the caregiver several questions regarding the patient's activities, diet, and care. The caregiver states, “I didn't know it could hurt him if he didn't drink anything.” This is an example of what kind of abuse?

A) Psychological B) Intentional C) Unintentional D) Direct Ans: C Age Group: Adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 5 Page and Header: 251, Violence Against Adults with Disabilities Taxonomic Level: Analysis Feedback: Physical, sexual, psychological, and financial abuse and neglect may be intentional or unintentional. The scenario does not describe psychological abuse or intentional abuse. Direct abuse is a simple distracter for this question.

10. An 86-year-old woman has been admitted to the ED as the victim of elder abuse.

The nurse caring for this patient should be aware of which of the following factors about elder abuse?

A) All victims of elder abuse are victims of polyvictimization.

B) Most perpetrators of elder abuse are strangers to the victim.

C) Elder abuse is rarely physical.

D) Elder abuse can be intentional or unintentional.

Ans: D Age Group: Adult of Advanced Age Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Difficult Objective: 8 Page and Header: 251, Elder Abuse Taxonomic Level: Analysis Feedback: Most cases of elder abuse are perpetrated by a family member. Some victims, but not all, experience polyvictimization. Elder abuse can take many forms, commonly including physical abuse.

11. The nurse is caring for a 32-year-old woman who was admitted to the hospital after being assaulted by her partner. The nursing care plan includes an intervention of developing a safety plan with the patient. The nurse would explain to the patient that a safety plan includes what basic components?

A) Phone numbers of local hospitals and clinics B) Copies of important documents stored in a safe place C) Personal health records from previous hospital admissions D) Location and phone numbers of public transportation Ans: B Age Group: Adult Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 7 Page and Header: 252-254, 258, Nursing Diagnoses, Outcomes and Interventions Taxonomic Level: Analysis Feedback: Basic components of safety plans usually include the following—charged cell phone with preprogrammed emergency phone numbers (or these numbers readily available but not necessarily identifiable to the perpetrator) for police, support people, and safe housing; copies of important or difficult-to-replace documents such as birth certificate or insurance papers stored in a safe place (possibly with support person); change of clothes for self (and children) packed and hidden; extra set of house and car keys; transportation plan; extra money hidden in a safe location; escape plan from potential house or apartment exits; and escape locations/safe places. Basic components of safety plans do not include the phone numbers of hospitals and clinics, personal health records, or the location and phone numbers of public transportation.

12. A nurse is caring for a 23-year-old mother of two small children who has been admitted to the hospital after being raped by her husband. One of this patient's identified needs is a safety plan. What is the first step the nurse would take in helping to develop a safety plan for this patient?

A) Tell the patient why she needs a safety plan B) Ask the patient what she has done in the past to be safe C) Give the patient forms to fill out D) Notify the relevant government ministry of the need for a safety plan Ans: B Age Group: Adult Chapter: 12 Client Type: Family Competency Category: Difficulty: Difficult

Professional Practice

Objective: 7 Page and Header: 258, Nursing Diagnoses, Outcomes and Interventions Taxonomic Level: Application Feedback: Patient needs following violent experiences can be categorized as immediate, transitional, and long-term. Safety planning is key to intervention. If a patient is in an unsafe or potentially unsafe situation, nurses must suggest and encourage a safety plan. The first step is to ask the patient what he or she has done in the past to be safe and then build on this.

13. A woman brings her 14-year-old daughter to the clinic because the teenager gets very anxious every weekday morning. The girl tells the nurse that someone broke into her locker and took some of her personal belongings. From what the patient has reported, the nurse knows to further investigate what kind of human violence with this patient?

A) Sexual abuse B) Child neglect C) School violence D) Child maltreatment Ans: C Age Group: Child and Adolescent Chapter: 12 Client Type: Family Competency Category: Professional Practice Difficulty: Easy Objective: 1 Page and Header: 249, Table 12-1 Taxonomic Level: Analysis Feedback: Crimes at school include theft, simple assault, and serious violent crime.

The scenario does not describe sexual abuse, child neglect, or child maltreatment.

14. A 20-month-old boy has been admitted to the pediatric intensive care unit (PICU) with scald wounds from a pan of hot water. The mother has been charged with child neglect, and the father is in denial of the cause of the injury to his son. A nursing diagnosis of dysfunctional family processes related to child neglect has been identified. The nurse caring for this patient would use what appropriate nursing intervention in the patient's care plan?

A) Acknowledge the emotions experienced during stressful times B) Encourage verbalization of anger against the mother by the father C) Encourage the mother to hire a lawyer for her defense D) Deny the father admission to the patient's hospital room Ans: A Age Group: All Age Groups Chapter: 12 Client Type: Family

Competency Category: Professional Practice Difficulty: Moderate Objective: 5 Page and Header: 258, Table 12-3 Taxonomic Level: Application Feedback: An appropriate nursing intervention would be to acknowledge the emotions family members experience during stressful times. It would not be appropriate for the nurse to encourage the father to speak angrily against the mother or the mother to hire a lawyer. It would not be appropriate to deny the father access to his child's hospital room.

15. Police have accompanied an assault victim to the emergency department and have informed the care team that the patient may have been the victim of a hate crime. What is the defining characteristic of a hate crime?

A) The victim performs an act intended to antagonize the perpetrator.

B) The perpetrator has a personal relationship with the victim.

C) The victim is attacked because of a particular trait.

D) The perpetrator is a repeat offender.

Ans: C Age Group: All Age Groups Chapter: 12 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 1 Page and Header: 252, Hate Crimes Taxonomic Level: Analysis Feedback: A hate crime is defined as one in which a perpetrator chooses a victim because of a characteristic such as genetic background, ethnicity, gender, sexuality, or religion and provides evidence that hate motivated the crime. The victim's actions are not relevant to the definition of a hate crime and a relationship may not exist.

16. A local hospital is preparing to admit a group of individuals who have just been discovered to be the victims of human trafficking. The major perpetrators of human trafficking are those who A) own and manage “sweatshops.”

B) kidnap children to sell for adoption.

C) own and manage commercial “sex trade” businesses.

D) sell people for cheap labor.

Ans: C Age Group: All Age Groups Chapter: 12 Client Type: Individual Competency Category: Professional Practice

Difficulty: Easy Objective: 8 Page and Header: 252, Human Trafficking Taxonomic Level: Knowledge Feedback: Reasons people are trafficked include sexual exploitation, forced marriage, and cheap labor for domestic or commercial purposes. Those who own and manage commercial “sex trade” businesses (i.e., forced prostitution, stripping, pornography, and live sex shows) are the major perpetrators of human trafficking.

17. A community health nurse is preparing an education program that is intended to address the problem of bullying. What qualities does the type of aggression called “punking” or “bullying” have?

A) It is perpetrated by a male upon a female.

B) The behaviour is intended to harm.

C) The behaviour is humorous.

D) The behaviour is a one-time occurrence.

Ans: B Age Group: Child and Adolescent Chapter: 12 Client Type: Group Competency Category: Professional Practice Difficulty: Moderate Objective: 1 Page and Header: 249, Table 12-1 Taxonomic Level: Comprehension Feedback: Punking or bullying is aggression in which (1) the behaviour is intended to harm, (2) the behaviour occurs repeatedly over time, and (3) there is an imbalance of power, with a more powerful person or group attacking a less powerful one. Punking and bullying do not always involve opposite-gender relationships and do not represent humorous behaviours.

Chapter 13: Skin, Hair, and Nails Assessment Multiple Choice 1. A man has suffered some burns in a kitchen accident and presents to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by this man's burn include A) adipose tissue.

B) connective tissue.

C) vernix.

D) blood vessels.

Ans: D Age Group: Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 269, Dermis Taxonomic Level: Analysis Feedback: The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects an infant's skin.

Connective tissue and adipose tissue are found in the subcutaneous layer of the skin.

2. The physiology instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

A) Assists in keeping the skin intact B) Assists in friction protection C) Assists in protection from infection D) Assists in keeping skin dry Ans: B Age Group: All Age Groups Chapter: 13 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 269, Sweat Glands Taxonomic Level: Knowledge

Feedback: Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

3. A patient has been prescribed tetracycline for acne. What is the most important point the nurse should make in patient teaching about this medication?

A) The patient may experience darkened urine.

B) The medication may interfere with the menstrual cycle.

C) The patient may experience photosensitivity.

D) The medication may be inactivated by antacids.

Ans: C Age Group: All Age Groups Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 276, Table 13-2 Taxonomic Level: Application Feedback: Tetracycline can lead to photosensitivity reactions, which usually present as a rash after exposure to the sun. Other medications stimulate phototoxicity, a reaction caused by the drug's molecules absorbing energy from a particular UV wavelength and then damaging surrounding tissues. The result is marked and severely tender sunburn. Tetracycline does not interfere with the menstrual cycle and is not inactivated by antacids. It does not cause a darkening of the urine.

4. A 17-year-old high school student comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the patient also reports that hair is growing on her upper inner thighs. What would the nurse suspect?

A) Gastrointestinal disorder B) Ovarian dysfunction C) Hepatic dysfunction D) Chronic nephrosis Ans: B Age Group: Child and Adolescent Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 6 Page and Header: 290, Inspection: Hair Taxonomic Level: Analysis Feedback: Ovarian dysfunction may be characterized by the presence of hair in the

beard area, abdomen, upper back, shoulders, sternum, and inner upper thighs on female patients. Body hair is not a sign of GI, hepatic, or kidney disorders.

5. The nurse is assessing a 39-year-old woman who has presented at the clinic with a lesion on her left inner thigh. The patient tells the nurse that she discovered the lesion 2 months ago and has noticed no changes in the colour or size of the lesion.

What would be the most appropriate teaching subject for this patient?

A) Topical treatments for the lesion B) Signs and symptoms of melanoma to guide future self-examination C) Characteristics of different types of lesions D) Protection from sun damage Ans: B Age Group: Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 278, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: It would be important to have the patient observe this lesion over time. A simple method is to use the ABCDEs of melanoma detection—asymmetry, border irregularity, colour, diameter of more than 6 mm, evolution of lesion over time. This form of self-examination is a priority over the other listed topics for health promotion.

6. A first-time mother calls a telephone helpline that is staffed by nurses. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response?

A) “Take the baby to the emergency room to be evaluated.”

B) “Bring your baby to your doctor soon.”

C) “This may be normal in infants.”

D) “This is a sign of a nutritional deficiency. Is your infant eating well?”

Ans: C Age Group: Infant Chapter: 13 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 323, Table 13-22 Taxonomic Level: Application Feedback: With koilonychia (spoon nails), the nails may have transverse and longitudinal concavity, with the appearance of a spoon. This sign may be normal in infants and usually resolves in few months.

7. A pediatric nurse is doing initial shift assessments and one of the patients on the unit is a toddler with pneumonia. How would the nurse assess this patient's skin turgor?

A) Pinch a fold of skin on the child's abdomen B) Pinch a fold of skin on the child's cheek C) Pinch a fold of skin on the child's upper thigh D) Pinch a fold of skin on the child's forearm Ans: A Age Group: Child and Adolescent Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 292, Newborns, Infants, Children, and Adolescents Taxonomic Level: Application Feedback: Turgor in newborns, infants, and young children is best evaluated by gently pinching a fold of abdominal skin and watching the skin recoil to its expected state.

8. As a component of the admission screening assessment of a new patient, a nurse is using the Braden scale to assess an elderly patient's risk for pressure ulcers. During this assessment, the nurse will examine the patient's A) muscle mass.

B) skin pigmentation.

C) nutrition.

D) knowledge of pressure ulcers.

Ans: C Age Group: Older Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 4 Page and Header: 287, Table 13-5 Taxonomic Level: Application Feedback: Assessment parameters of the Braden scale include the patient's usual pattern of food intake. Muscle mass is not a specific focus of assessment and the nurse does not appraise the patient's knowledge around pressure ulcers or pigmentation patterns.

9.

The nurse is performing a generalized assessment of a 79-year-old man who has

come to the clinic for his annual physical examination. The nurse notes that the patient's skin is thin and rough with abrasions. The patient tells the nurse that it seems to take “forever” for scratches to heal, “a lot longer than when I was younger.”

When asked if he has any other problems, the patient says that he occasionally feels cold, even when the thermostat is set at a comfortable temperature. How would the nurse note these findings in the patient's medical record?

A) The patient has abnormal thinning of skin.

B) The patient's integumentary system is within normal limits.

C) The patient states that wounds are taking longer to heal.

D) The patient has an abnormal inability to maintain temperature.

Ans: B Age Group: Older Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 293, Older Adults Taxonomic Level: Evaluation Feedback: Replacement of the epidermal layer decreases with aging, resulting in rougher skin texture and prolonged time for wound healing. These changes affect thermoregulation, resulting in increased hypothermia as well as increased risk for heat stroke.

10. A 6-year-old girl is brought to the pediatric clinic by her mother, who tells the nurse that her daughter has a sore on her leg that “just keeps getting bigger.” On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-coloured crust now covers the area.

The nurse should suspect that the girl may be suffering from which of the following skin disorders?

A) Varicella B) Scabies C) Impetigo D) Rubella Ans: C Age Group: Child and Adolescent Chapter: 13 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 5 Page and Header: 311, Table 13-12 Taxonomic Level: Analysis Feedback: Impetigo is a highly contagious superficial skin infection commonly caused by Staphylococcus aureus or Group A beta-hemolytic streptococci. It is

characterized by vesicles or bullae that eventually rupture and ooze serous fluid that forms the classic honey-coloured crust. Varicella, scabies, and rubella do not have this presentation.

11. A newborn has a small hemangioma on her face. What would be important for the nurse to include when teaching the infant's parents?

A) The hemangioma will likely require surgical removal.

B) The hemangioma will become smaller over the first year of life.

C) The hemangioma is a result of a superficial skin infection.

D) The hemangioma will usually resolve by age 9 years.

Ans: D Age Group: Infant Chapter: 13 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 5 Page and Header: 318, Table 13-16 Taxonomic Level: Application Feedback: Hemangiomas are vascular lesions, present at birth, that rapidly develop and evolve into larger lesions but spontaneously resolve by age 9 years. They are noninfectious.

12. A 63-year-old female patient hospitalized with pancreatitis is having problems performing ADLs. The care aide brushes the patient's hair and tells the nurse that the patient is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse?

A) Abnormal endocrine function B) Abnormal ovarian function C) Abnormal hepatic function D) Abnormal vascular function Ans: A Age Group: Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 290, Palpation: Hair Taxonomic Level: Analysis Feedback: Absent hair bulb may indicate chemical damage to the hair shaft. The presence of the hair bulb may indicate abnormal endocrine function. There is no indication of abnormal ovarian, hepatic, or vascular function.

13. An 81-year-old man presents at the clinic with a painful ulcer on his left great toe. The patient states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect?

A) Infected insect bite B) Arterial ulcer C) Localized necrosis D) Venous ulcer Ans: B Age Group: Adult of Advanced Age Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 322, Table 13-19 Taxonomic Level: Analysis Feedback: Arterial ulcers are usually located distally, such as at the ends of the toes or fingers. Wound edges are sharply defined; the base is pale when elevated and appears ruddy when dependent. These ulcers may be deep, frequently infected, and painful; they exhibit minimal granulation tissue.

14. Parents bring a child to the clinic and report a “rash” on her knee. On assessment, the nurse notes the area to have several reddish-pink lesions covered with silvery scales. What skin disorder would the nurse suspect?

A) Seborrhea B) Cellulitis C) Hemangioma D) Psoriasis Ans: D Age Group: Child and Adolescent Chapter: 13 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 313, Table 13-13 Taxonomic Level: Analysis Feedback: Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears.

Hemangiomas and cellulitis do not typically have a rash-like appearance.

15. The ICU nurse is caring for an acutely ill patient who has begun to exhibit uremic frost. What would this suggest to the nurse?

A) Renal failure B) Cardiovascular failure C) Hepatic failure D) Respiratory failure Ans: A Age Group: All Age Groups Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 300, Table 13-7 Taxonomic Level: Analysis Feedback: Uremic frost is a sign of marked renal failure. This appearance results from precipitation of renal urea and nitrogen waste products through sweat onto the skin.

16. The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient?

A) The patient exhibits no signs or symptoms of infection.

B) The patient changes position every 2 hours.

C) The patient keeps the area clean and dry.

D) The patient understands the etiology of skin breakdown.

Ans: A Age Group: Adult Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 294, Table 13-6 Taxonomic Level: Application Feedback: All options are appropriate outcomes for this patient, but the most important outcome is that the patient exhibits no signs or symptoms of infection.

17. An obese 34-year-old man is undergoing a preoperative examination prior to having surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular

erythematous lesion with satellite pustules. What would the nurse suspect?

A) Roseola B) Candida C) Pityriasis rosea D) Herpes simplex Ans: B Age Group: All Age Groups Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 313, Table 13-12 Taxonomic Level: Analysis Feedback: Candida is a fungal infection commonly found in skinfolds or generally warm and moist areas. Affected sites are the axillae, inframammary areas, and groin.

Satellite pustules are commonly found surrounding the erythematous macular lesion.

This presentation is not characteristic of roseola, pityriasis rosea, or HSV. 18. An 84-year-old woman is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the patient's coccyx. What would the nurse include about this particular finding when documenting in the nurses notes?

A) Causative microorganism B) Recommended treatment C) Other lesions on the body D) Size of the lesion Ans: D Age Group: Adult of Advanced Age Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 296, Key Points Taxonomic Level: Application Feedback: A wound is assessed for location, size, colour, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or treatment recommendations.

Microorganisms are not likely to be present, and the nurse has no way of identifying these.

19. As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or

preschool-aged child?

A) Osteomyelitis B) A hematologic problem C) Immune impairment D) A developmental delay Ans: B Age Group: Child and Adolescent Chapter: 13 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 282, Newborns, Infants, and Children Taxonomic Level: Analysis Feedback: Certain infections, hematologic problems, or coagulopathies present with ecchymoses of the skin. Bruising on the body of a toddler or preschool-aged child is not an indication of osteomyelitis, immune impairment, or developmental delays.

20. A woman and her 14-year-old boy have come to the clinic. The boy has acne lesions and says that he cannot control them. The mother asks the nurse what causes acne. What would be the nurse's best response?

A) Acne is caused by dysfunction of the apocrine glands.

B) Acne is caused by decreased activity of the sebaceous glands.

C) Acne is caused by the impedance of sebum secretion onto the skin's surface.

D) Acne is caused by lysis of skin cells.

Ans: C Age Group: Child and Adolescent Chapter: 13 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 270, Children and Adolescents Taxonomic Level: Comprehension Feedback: As children approach puberty, the apocrine glands enlarge and become active. At puberty, sebaceous glands increase activity, resulting in large amounts of sebum secreted into the hair follicles of the face, neck, chest, and back. Anything impeding sebum secretion onto the skin's surface may result in the formation of closed comedones and ultimately acne.

Chapter 14: Head and Neck with Lymphatics and Vascular Assessment Multiple Choice 1. A nurse is conducting an assessment of a patient's neck and will include palpation of the thyroid isthmus. Where would the nurse find the isthmus?

A) Just above the thyroid cartilage B) Between the thyroid and the cricoid cartilages C) Just below the cricoid cartilage D) In front of the sternocleidomastoid muscle Ans: C Age Group: All Age Groups Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 338, Palpation Taxonomic Level: Application Feedback: Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing.

2. A nurse is landmarking a patient's tracheal region in preparation for a focused assessment. What structure will be found midline in the patient's tracheal area just beneath the mandible?

A) Cricoid cartilage B) Hyoid bone C) Thyroid cartilage D) Adam's apple Ans: B Age Group: All Age Groups Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 328, Trachea Taxonomic Level: Application Feedback: Important landmarks for the head and neck region are in the tracheal

area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible.

3. The nurse is teaching a prenatal class for pregnant women and their partners. The nurse should encourage the women who are participating in the class to A) get regular examinations including B12 screening.

B) get regular examinations including folic acid screening.

C) get regular examinations including thyroid screening.

D) get regular examinations including swallowing assessment.

Ans: C Age Group: Adult Chapter: 14 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 329, Women Who Are Pregnant Taxonomic Level: Application Feedback: Slight enlargement of the thyroid is common in approximately 5% to 10% of women postpartum. As such, thyroid assessment is a relevant assessment priority in women who are pregnant or recently postpartum. It is not generally recommended that pregnant women get screenings for B12 or folic acid. Swallowing assessments are not normally necessary.

4. Parents bring a 10-year-old boy to the emergency department after a bicycle accident. His father tells the nurse that the boy was not wearing a helmet when he ran into a curb and was thrown over the handlebars, striking his head on the sidewalk.

What would be the most important information for the nurse to include in education for this patient and family?

A) Where to find bike safety courses B) Use of safety equipment C) Use of hand signals when bike riding D) Measuring for the right size bicycle Ans: B Age Group: Child and Adolescent Chapter: 14 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 332, Personal History Taxonomic Level: Application Feedback: The nurse may include all the listed information in patient teaching for this patient and his family, but the most important information would be the use of

safety equipment.

5. A clinic patient complains of recurring headaches that are worse when first waking in the morning and when the patient coughs or sneezes. What would be the nurse's most appropriate action?

A) Ask the doctor for an order for an MRI B) Perform a focused assessment C) Prepare the patient for a lumbar puncture D) Perform a cognitive assessment Ans: B Age Group: Adult Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 333, Headache Taxonomic Level: Application Feedback: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment.

6. Paramedics bring a 17-year-old boy to the emergency department after a diving accident. The boy is alert and coherent but in some distress. He tells the nurse, “I think I hit a rock and now I can't feel my arms or my legs.” A rapid physical assessment shows no other apparent injuries. What is essential in this patient's care?

A) Help facilitate a CT scan immediately B) Draw a basic metabolic panel to check for infection C) Immobilize the patient's spine D) Log roll the patient to remove backboard reducing pressure on spine Ans: C Age Group: Child and Adolescent Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 330, Acute Assessment Taxonomic Level: Application Feedback: Patients with acute head injuries and neurologic changes must be quickly and accurately assessed by the health care team. Stabilization of the head and neck is essential to avoid further neurologic injury. Any history of trauma to the head, neck, or both warrants a careful assessment of these structures for bleeding, swelling, loss

of mobility, or pain. Identifying the mechanism of injury helps the nurses to determine which anatomic regions require their focus. It is absolutely essential to keep the spine immobilized to prevent spinal cord injury, and immobilization devices should not be removed until the spine is cleared of injury. Log rolling the patient to remove the backboard reducing pressure would be contraindicated until the spine is cleared.

7. When conducting inspection during a generalized assessment of a new patient, the nurse would assess for which of the following problems?

A) Strain B) Vertebral injury C) Lymph node enlargement D) Limitations in movement Ans: D Age Group: All Age Groups Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 337, Inspection Taxonomic Level: Application Feedback: During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection.

8. A nurse is providing information to a high school health class about alcohol use during pregnancy. The nurse should cite which of the following effects of fetal alcohol syndrome?

A) Hydrocephalus B) Alopecia C) Microcephaly D) Prominent cheek bones Ans: C Age Group: Child and Adolescent Chapter: 14 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 347, Table 14-2 Taxonomic Level: Application Feedback: Physical manifestations of FAS include microcephaly, flattened cheek bones, small eyes, and a flattened upper lip. Children with FAS have multiple developmental and learning disabilities.

9. A 64-year-old patient is admitted to the hospital with severe diarrhea. When assessing the patient, the nurse notes a round “moon” face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?

A) Myxedema B) Cushing's syndrome C) Scleroderma D) Bell's palsy Ans: B Age Group: Adult Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 349, Table 14-3. Head and Neck Conditions More Common in Adults Taxonomic Level: Analysis Feedback: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round “moon” face, fat deposits at the nape of the neck (“buffalo hump”), and sometimes a velvety discoloration around the neck (acanthosis nigra). The scenario does not describe a patient with myxedema, scleroderma, or Bell's palsy.

10. A woman brings her 3-year-old daughter to the pediatric clinic and tells the advanced practice nurse that her child has “lumps in her neck that move around but don't hurt.” On examination, the nurse palpates and notes lymph nodes that are less than 10 mm, nontender, and movable. How would the nurse document this assessment finding?

A) Normal nodes B) Muscular nodes C) Shotty nodes D) Malignant nodes Ans: C Age Group: Child and Adolescent Chapter: 14 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 330, Newborns, Infants, and Children Taxonomic Level: Application Feedback: In children 1 to 5 years of age, nurses may palpate small (< 10 mm), nontender, movable nodes in the head and neck region. These normal findings are

sometimes referred to as “shotty,” because they feel like BB gun pellets or shots. Such nodes would not be described as being malignant or muscular.

11. A patient has sought care for chronic neck pain. What would be the most appropriate initial nursing action in the care of this patient?

A) Work with medical team to evaluate possible surgery B) Discuss pharmacologic interventions C) Assess the patient's knowledge of spinal cord injury D) Assess the characteristics of the patient's pain Ans: D Age Group: Adult Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 9 Page and Header: 333, Neck Pain Taxonomic Level: Application Feedback: The first step would be for the nurse to assess characteristics of the pain.

Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. Knowledge of spinal cord injury is a less important consideration.

12. A 43-year-old woman presents with overwhelming fatigue, reporting, “It seems like I sleep all the time and yet I am still tired” and “I never seem to have the energy to clean my house or cook dinner.” Diagnostic studies of thyroid function have been ordered. What desired outcome might the nurse identify when planning care for this patient?

A) The patient verbalizes increased energy.

B) The patient participates in activities with no change in vital signs.

C) The patient verbalizes desire to participate in physical activities.

D) The patient sleeps 12 hours daily.

Ans: A Age Group: Adult Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 342, Nursing Diagnosis, Outcomes, and Interventions Taxonomic Level: Evaluation Feedback: The patient verbalizes increased energy, and well-being would be the most appropriate outcome. Nothing in the scenario indicates that the patient is having a problem related to her vital signs. The patient is not having a problem with desire to

participate in activities; the problem is her energy level. Twelve hours of sleep daily for an adult is excessive.

13. An 81-year-old man presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?

A) Nodes are nonpalpable.

B) Nodes are delimited on palpation.

C) Nodes appear grown together on palpation.

D) Nodes are demarcated on palpation.

Ans: B Age Group: Adult of Advanced Age Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 338, Palpation Taxonomic Level: Application Feedback: Usually, no lymph nodes are palpable in the adult. If a node is palpable, it is important to describe the following characteristics: location—which lymphatic chain and where along that chain is the node; size—in mm or cm; consistency—how hard or soft is the node; mobility—it should be freely movable; delimitation—there should not be any matting together of lymph nodes.

14. The nurse notes that a patient's thyroid gland appears enlarged and consequently auscultates both lobes of the thyroid. For what is the nurse listening?

A) Rush B) Gurgle C) Murmur D) Bruit Ans: D Age Group: All Age Groups Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 340, Auscultation Taxonomic Level: Application Feedback: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis.

15. A nurse is conducting a focused head and neck assessment of a child who has been brought for care by his mother. The nurse palpates warm, tender lymph nodes bilaterally on the child's neck. In light of this assessment finding, what component of the child's laboratory tests should the nurse prioritize?

A) White blood cell count B) Hematocrit C) Blood urea nitrogen D) Thyroid-stimulating hormone Ans: A Age Group: Child and Adolescent Chapter: 14 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 338, Palpation Taxonomic Level: Evaluation Feedback: Palpable, tender, and warm lymph nodes usually indicate an infection in the area from which the lymph vessels drain to that node. Because of the likely presence of infection, the nurse should pay particular attention to the child's WBC count. This is a priority over values such as hematocrit, BUN, or TSH. 16. Nursing students are learning about assessment of the head and neck. What cultural consideration would the students learn to assess in relation to this area?

A) Shape of the ears B) Shape of the chin C) Shape of the lips D) Shape of the neck Ans: C Age Group: All Age Groups Chapter: 14 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 330, Cultural Considerations Taxonomic Level: Analysis Feedback: The most noticeable difference among racial groups is skin colour. Shape of the eyes, nose, and lips also varies based on background and genetics. Variations in skull or neck shape or size relate more to height and weight than to specific racial or cultural background. Shape of the chin and ears is not closely related to cultural differences.

17. An infant girl is born with microcephaly. The infant also has a depressed nasal bridge, low-set ears, and a protruding tongue. What nursing diagnosis would be appropriate for this patient and her parents?

A) Risk for aspiration related to protruding tongue B) Knowledge deficit related to trisomy 21 C) Impaired hearing related to low-set ears D) Altered breathing related to depressed nasal bridge Ans: B Age Group: Infant Chapter: 14 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 347, Table 14-2 Taxonomic Level: Evaluation Feedback: Down's syndrome (trisomy 21) is a congenital condition that results from either an extra chromosome 21 or a translocation of chromosome 14 or 15 with 21 or 22. Manifestations in the head and neck region include microcephaly, a flattened occipital bone, slanted small eyes, a depressed nasal bridge, low-set ears, and a protruding tongue. The scenario described does not indicate that the infant has difficulty hearing or breathing. There is no evidence of a risk of aspiration.

18. An 84-year-old woman is admitted to the hospital after a fall. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area.

The patient reports tenderness on palpation and movement. What would be a priority nursing diagnosis for this patient?

A) Impaired skin integrity related to bed rest B) Impaired range of motion related to injury C) Risk for impaired skin integrity related to injury D) Neck pain related to possible neck injury Ans: D Age Group: Adult of Advanced Age Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 342, Table 14-1 Taxonomic Level: Application Feedback: The patient's pain would be a priority for assessment and interventions.

The scenario does not indicate that the patient is on bed rest or that the patient has a limited range of motion.

19. A patient presents at the emergency room reporting a headache. What statement by the patient would constitute a “red flag” for priority assessment and treatment?

A) The patient's headache follows a night of heavy drinking.

B) The patient's headache is accompanied by visual disturbances.

C) The patient's headache has not responded to acetaminophen.

D) The patient has a family history of headaches.

Ans: B Age Group: Adult Chapter: 14 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 334, Box 14-2 Taxonomic Level: Analysis Feedback: A headache that is accompanied by visual changes warrants prompt follow-up. A family history of headaches, lack of response to acetaminophen, and headaches associated with alcohol are not “red flags.”

20. The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse cite?

A) Inadequate fluid intake B) High fat intake C) Age younger than 25 years D) Tobacco use Ans: D Age Group: All Age Groups Chapter: 14 Client Type: Group Competency Category: Health and wellness Difficulty: Moderate Objective: 2 Page and Header: 332, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For patients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include excess fat or inadequate fluid intake.

Chapter 15: Eyes and Vision Assessment Multiple Choice 1. A nurse is landmarking the structures of a patient's eye prior to assessment. The nurse should know that the open space between the patient's eyelids is called what?

A) The palpebral fissure B) The limbus C) The lacrimal fissure D) The sclera Ans: A Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1, 2 Page and Header: 352, Extraocular Structures Taxonomic Level: Knowledge Feedback: The palpebral fissure is the almond-shaped open space between the eyelids.

2. The anatomy and physiology instructor is discussing the eye with a group of nursing students. What would the instructor cite as part of the lacrimal apparatus?

A) The optic vein B) The optic plexus C) The choroids D) The coronal vein Ans: C Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1, 2 Page and Header: 353, Intraocular Structures Taxonomic Level: Knowledge Feedback: The choroids, which cover the recessed portion of the eye, are a network of blood vessels to the eye.

3. The nurse is caring for a 15-year-old boy with an eye injury. The patient is inquisitive and asks about the structures of the eye. What would the nurse tell the patient is the largest chamber of the eye?

A) Anterior B) Posterior C) Corneal D) Vitreous Ans: D Age Group: Child and Adolescent Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1, 2 Page and Header: 353, Intraocular Structures Taxonomic Level: Knowledge Feedback: The interior eye has three chambers—anterior, posterior, and vitreous.

The anterior chamber is the space between the cornea in the front and the iris and lens in the back. It contains aqueous humor, produced by the ciliary body; the amount varies to maintain pressure in the eye. The posterior chamber starts behind the iris and goes to the lens. It is also filled with aqueous humor that helps to nourish the cornea and lens. The largest vitreous chamber is adjacent to the inner retinal layer and lens. This chamber is filled with vitreous humor, which is gel-like, holds the retina in place, and maintains the shape of the eyeball.

4. The nursing instructor is discussing glaucoma with clinical students. What would be important to tell the students about mydriatic drops in regard to glaucoma?

A) Mydriatic drops do not affect patients with glaucoma.

B) Mydriatic drops may precipitate acute angle-closure glaucoma.

C) Mydriatic drops constrict the pupils in patients with glaucoma.

D) Mydriatic drops may cause a crisis in patients with open-angle glaucoma.

Ans: B Age Group: Adult Chapter: 15 Client Type: Group Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 369, Assessment of Internal Ocular Structures Taxonomic Level: Application Feedback: Mydriatic drops may precipitate acute angle-closure glaucoma. Those at risk include patients with a history of glaucoma and extremely farsighted patients.

Mydriatic drops do affect patients with glaucoma, they do not constrict the pupils in patients with glaucoma, and they are not known to cause a crisis in patients with open-angle glaucoma.

5. The nurse is assessing the peripheral vision of a 55-year-old patient. What test would the nurse use to assess the boundaries of the patient's peripheral vision?

A) Ishihara card B) Allen test C) Kinetic confrontation D) Cover Ans: C Age Group: Adult Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 363, Kinetic Confrontation Taxonomic Level: Application Feedback: Static and kinetic confrontation tests measure peripheral vision. The static confrontation test assesses peripheral vision in all four quadrants. The kinetic confrontation test assesses the boundaries of peripheral vision. The Allen test is for visual acuity of toddlers. The cover test is for accommodation. The Ishihara card is used for assessing colour vision.

6. When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem is a patient most likely at increased risk for if a first-degree relative has it?

A) Retinoblastoma B) Strabismus C) Retinitis pigmentosa D) Glaucoma Ans: D Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 356, Family History Taxonomic Level: Comprehension Feedback: Glaucoma in a first-degree relative increases the patient's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease.

Retinitis pigmentosa is also a genetic disease, but a patient's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic.

7. A 13-year-old girl is brought to the clinic for a sports physical examination. The patient states that she is going to play goalie on the community field hockey team.

What is the most important teaching opportunity presented for this patient?

A) Use of safety equipment B) Prevention of knee injuries C) Promotion of vision D) Use of correct foot gear Ans: A Age Group: Child and Adolescent Chapter: 15 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 357, Eye Protection Taxonomic Level: Application Feedback: The nurse should assess with each patient the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for patient teaching; for this patient, however, the most important opportunity involves the use of safety equipment.

8. A patient tells the nurse that his eyes “aren't working right.” When the nurse asks what the patient means, the patient states, “It is like one eye is moving faster than the other.” What test would be most appropriate for the nurse to use to assess this patient?

A) Cover B) Kinetic confrontation C) Cardinal directions D) Static confrontation Ans: C Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 365, Cardinal Directions Taxonomic Level: Application Feedback: The cardinal directions of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation.

9. The cup–disc ratio is assessed by the use of the ophthalmoscope. What would the advanced practice nurse know about the cup–disc ratio?

A) It should be 1:1.

B) It occurs only in females.

C) It is genetically determined.

D) It is found only in older adults.

Ans: C Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 7 Page and Header: 369, Assessment of Internal Ocular Structures Taxonomic Level: Application Feedback: Cup–disc ratio is genetically determined and normally equal in both eyes.

Therefore, option A is incorrect. It is not found only in females or only in older adults.

10. The advanced practice nurse is assessing the eyes of a patient with long-standing uncontrolled hypertension. What might the nurse visualize during an assessment with an ophthalmoscope?

A) AV nicking B) Dilated veins C) Dilated arteries D) Lacrimal apparatus Ans: A Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 369, Assessment of Internal Ocular Structures Taxonomic Level: Analysis Feedback: AV nicking results from high blood pressure and retinal hemorrhages in the form of dot-blot spots or flame hemorrhages. Dilated arterioles and venules may be seen, not dilated arteries and veins. Visualization of the lacrimal apparatus does not require an ophthalmoscope.

11. A 45-year-old professional fisherman presents at the ophthalmologist's office after being referred by his family physician. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the patient's right eye. The patient asks the nurse what this growth is. What is the best answer the nurse can give?

A) “It is called hypertrophied conjunctiva.”

B) “It is called a pterygium.”

C) “It is called hypertrophied sclera.”

D) “It is called a cataract.”

Ans: B Age Group: Adult Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 366, Bulbar Conjunctiva Taxonomic Level: Application Feedback: An abnormal thickening of the conjunctiva from the limbus over the cornea is known as a pterygium. It is not known as hypertrophied conjunctiva, cataract, or sclera.

12. When assessing visual acuity in children, what would be the expected normal vision in a toddler?

A) 20/50 bilaterally B) 20/100 bilaterally C) 20/150 bilaterally D) 20/200 bilaterally Ans: D Age Group: Child and Adolescent Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 372, Infants, Children, and Adolescents Taxonomic Level: Knowledge Feedback: Normal findings in toddlers are 20/200 bilaterally.

13. A participant in a prenatal class has asked the nurse about possible visual problems among children. What puts a child at increased risk for visual impairments?

A) Hearing problems B) Asian ethnicity C) Down's syndrome D) Motor problems Ans: A Age Group: Infant Chapter: 15

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 359, Newborns, Infants, and Children Taxonomic Level: Application Feedback: Hearing-impaired infants are at increased risk for visual impairments.

There is not an increased risk for visual impairments in children who are Asian, are born with Down's syndrome, or have motor problems.

14. A mother brings her 2-year-old child to the clinic stating that the child is “cross-eyed.” What test would the nurse perform to test for strabismus?

A) Corneal light reflex B) Cover C) Allen D) Static Ans: A Age Group: Child and Adolescent Chapter: 15 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 364, Assessment of Extraocular Muscle Movements Taxonomic Level: Application Feedback: The corneal light reflex tests for strabismus. The cover test is for presence and amount of ocular deviation. A low light level with no direct light sources shining in the patient's eyes is ideal. At rest, the extraocular muscles have very little activity. The assessment referred to as cardinal fields of gaze allows nurses to detect muscle defects that cause misalignment or uncoordinated eye movements. The static test can help the nurse detect gross differences in all four quadrants of the visual field.

The Allen test tests a toddler's visual acuity.

15. A patient presents at the clinic with painful eyes, blurred vision, and headaches from using the computer all day at work. After a generalized assessment with no abnormal findings, the nurse would note what in reference to the eyes?

A) Presbyopia B) Asthenopia C) Myopia D) Hyperopia Ans: B Age Group: Adult Chapter: 15 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 378, Table 15-4 Taxonomic Level: Analysis Feedback: Asthenopia (eyestrain) develops after reading, computer work, or other visually tedious tasks. The eye muscles tighten after maintaining a constant focal distance. Symptoms include fatigue, red eyes, eyestrain, pain in or around the eyes, blurred vision, headaches, and, rarely, double vision. Presbyopia is considered a normal part of aging. This condition affects near vision and, therefore, is corrected with a convex lens in front of the eye in the form of half-glass or as bottom of a bifocal or multifocal lens if other correction is needed for distance viewing. Hyperopia is farsightedness. Myopia is nearsightedness.

16. A nurse is conducting an assessment of a patient's oculomotor movement.

Normal function of the eye involves what cranial nerve?

A) VI B) VII C) VIII D) IX Ans: A Age Group: All Age Groups Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 361, Table 15-2 Taxonomic Level: Knowledge Feedback: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves—CN II, optic nerve, visual acuity, visual fields, fundoscopic examination; CN III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/accommodation); CN IV, trochlear, cardinal fields of gaze; and CN VI, abducens, cardinal fields of gaze.

17. The nurse is performing visual acuity testing on a 70-year-old woman who has fallen and fractured her femur. What finding would be considered normal for this older adult?

A) Conjunctivitis B) Cataracts C) Increased tear production D) Decreased pupillary response Ans: D Age Group:

Older Adult

Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 372, Older Adults Taxonomic Level: Analysis Feedback: Findings related to aging include loss of adipose tissue in the orbit, decreased tear production, and decreased pupillary response. Conjunctivitis and cataracts are pathological findings in patients of any age.

18. A nursing student is helping to test vision and hearing at the local elementary school. Each child needs to have vision tested and documented. A student's vision has been assessed at 20/20 and the student asks the nurse exactly what this means. How should the nurse respond?

A) “You have the vision of a normal, 20-year-old person.”

B) “You're able to read the text that is in a 20 point font on the chart.”

C) “Twenty feet from the chart, you're able to read what a normal, healthy eye can read.”

D) “Each of your eyes is within 20% of normal.”

Ans: C Age Group: Child and Adolescent Chapter: 15 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 361, Distance Vision Taxonomic Level: Analysis Feedback: Someone with “20/20” (normal) vision can read at 20 feet what the normal eye can read at 20 feet. On top, the nurse marks the distance in feet the patient was from the test (e.g., 20). On bottom, the nurse marks the number under the smallest line of letters the patient correctly identified (e.g., 40, 200). Option A is incorrect because the students are not 20 feet from the eye chart. Students should be able to read the eye chart to the line marked 40 when they are standing 10 feet from the chart. 10/20 indicates near vision; 10/80 indicates the student is farsighted.

Chapter 16: Ears Assessment Multiple Choice 1. A nurse is assessing a child with a suspected ear infection and the nurse is aware that the eustachian tube is a passage between the middle ear and the nasopharynx.

What is the function of the eustachian tube?

A) Helps to regulate pressure in the middle ear B) Protects the middle ear C) Allows for drainage of fluid from the middle ear D) Maintains fluid in the middle ear Ans: A Age Group: Child and Adolescent Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 388, Middle Ear Taxonomic Level: Application Feedback: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. Its primary functions are not fluid drainage, fluid maintenance, or protection.

2. A nurse is conducting a hearing test in the knowledge that the cochlea plays important roles in the physiology of hearing. What is a component of sound that the cochlea interprets?

A) Range B) Direction C) Amplitude D) Decibel Ans: C Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 390, Hearing Taxonomic Level: Comprehension Feedback: The cochlea interprets two components of sound—amplitude (volume)

and frequency (pitch). The cochlea does not interpret range, direction, or decibel.

3. A nurse is conducting a focused ear assessment of a middle-aged patient who has experienced a suspected head injury. When inspecting the patient's tympanic membrane, where would the nurse expect to visualize the malleus?

A) In the anterior aspect B) In the area of the cone of light C) Near the center D) To the left of the cone of light Ans: C Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2, 5 Page and Header: 388, External Ear Taxonomic Level: Application Feedback: The tympanic membrane adheres through its concave shape to the malleus near the center.

4. When reviewing the correct technique for conducting an otoscopic ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?

A) Anterior proximal quadrant B) Anterior superior quadrant C) Anterior medial quadrant D) Anterior inferior quadrant Ans: D Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 401, Otoscopic Evaluation Taxonomic Level: Comprehension Feedback: The healthy tympanic membrane is intact and translucent and allows visualization of the short process of the malleus. The cone of light is visible in the anterior inferior quadrant.

5. An advanced practice registered nurse is working in a family practice clinic with a patient who reports that drainage from her ear is no better despite finishing a course

with prescribed antibiotics. After reviewing the patient's records, what would be the nurse's most appropriate action?

A) Recommend an alternative therapy B) Refer the patient to an otolaryngologist C) Encourage the patient to remain on bed rest temporarily D) Perform the Rinne test.

Ans: B Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 11 Page and Header: 393, Acute Assessment Taxonomic Level: Application Feedback: A patient with a chronically draining ear unresponsive to treatment with antibiotics requires referral to an otolaryngologist. The greatest concern with chronically draining ears is cholesteatoma, an abnormal accumulation of squamous epithelium within the middle ear. The growth can erode the auditory ossicles and cause great damage to the patient's hearing. The APRN would have assessed the patient's ear prior to reviewing the patient's records. It would be inappropriate to perform Rinne test at this time or to recommend alternative therapies. Bed rest is not indicated.

6. A patient presents to the emergency department following a motor vehicle collision in which he sustained a significant blow to the area of his right ear. The patient tells the nurse that something is leaking from the right ear. What should the nurse suspect?

A) Nasal fracture B) Meningitis C) Basilar skull fracture D) Fractured clavicle Ans: C Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 393, Acute Assessment Taxonomic Level: Analysis Feedback: Patients with ear trauma need evaluation for injury to nearby structures, including the brain, basilar skull, and neck. A nasal fracture, fractured clavicle, and meningitis are not likely problems.

7. When assessing the patient's risk for hearing loss, it is important to ask about the history of exposure to noise. What related patient teaching should the nurse prioritize?

A) The need to avoid manual labour B) Techniques for performing ear irrigation C) Instructions for the use of protective ear equipment D) Techniques for resolving previous hearing loss Ans: C Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 393, Assessment of Risk Factors Taxonomic Level: Application Feedback: Patients need to be asked about their exposure to noise and what protective equipment they use. Educating patients on the types, effectiveness, and instructions for the use of protective ear equipment allows them to make decisions based on their needs. It is not normally necessary to avoid manual labour. Hearing loss is usually irreversible and is not rectified by irrigation.

8. When providing patient teaching about the ears, what should the nurse be sure to include?

A) How the patient should clean the ears B) Detailed anatomy and physiology of the ears C) How to use cotton-tipped applicators to clean the middle and inner ear D) Potential infection from self-cleaning of ears Ans: A Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 395, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: It is important to address how the patient cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, patients think that cotton-tipped applicators are for this purpose.

This self-care behaviour is unsafe, placing patients at risk for cerumen impaction.

Nurses should reinforce proper cleaning techniques. Teaching about anatomy and physiology is not normally appropriate.

9. A nurse's assessment of a patient's ears reveals small, painless nodules on the left helix. How would the nurse note this finding in the patient's medical record?

A) Left external ear abnormal; Darwin's tubercle noted at the midpoint of the helix B) Left external ear within normal limits C) Small nodules on the left helix indicating inflammation of the external ear D) Small, painless nodules on the left helix; further evaluation for carcinoma indicated Ans: B Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 9 Page and Header: 398, Inspection Taxonomic Level: Analysis Feedback: Small, painless nodules on the helix are a variation of normal anatomy known as Darwin's tubercle.

10. A nurse is preparing to perform a general assessment of a 47-year-old patient who is new to the clinic. How would the nurse prepare to obtain objective data about the patient's ears?

A) Provide instructions in a quiet voice to test the patient's hearing preliminarily B) Place the patient in semi-Fowler's position on the examination table C) Make sure the patient is comfortable in a quiet room D) Perform the whisper, Weber, and Rinne tests before inspection Ans: C Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 398, Promoting Patient Comfort, Dignity, and Safety Taxonomic Level: Application Feedback: To obtain objective data about the ears, it is best to make sure the patient is comfortable and the room is quiet. It is ideal for the patient's ears to be at the nurse's eye level to facilitate inspection that does not cause discomfort for the patient.

For adults and older children, nurses can perform the examination with the patient sitting on the examination table. Instructions should not be spoken quietly and comfortable positioning must precede hearing tests.

11.

While performing an otoscopic examination of an adult patient's ear, the

advanced practice RN finds white patches on the patient's tympanic membrane. How would the nurse note this finding in the chart?

A) Tympanic membrane abnormal; active infection present B) Tympanic membrane scarred, indicating loss of hearing C) Tympanic membrane visualized with areas of sclerosis noted D) Tympanic membrane within normal limits Ans: C Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 401, Otoscopic Evaluation Taxonomic Level: Analysis Feedback: A variation of normal for the tympanic membrane is sclerosis, or white areas that are visible scars from repeated ear infections. This scarring is not necessarily indicative of hearing loss or an active infection.

12. The pathophysiology instructor is discussing ear problems. What would the instructor cite as an abnormal assessment finding?

A) Tenderness of the mastoid process B) Atrophied lymph nodes C) Tenderness of the apex D) Sclerotic tympanic membrane Ans: A Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 399, Palpation Taxonomic Level: Comprehension Feedback: Normal ear findings on physical assessment are firm auricles without lumps, nonpalpable lymph tissue, nontender ears, and no pain elicited during palpation or manipulation of the auricle. No pain should occur with palpation of the mastoid process. Enlarged lymph nodes indicate pathology or inflammation. Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. Sclerosis of the tympanic membrane is a variation of normal ear findings. Atrophied lymph nodes and tenderness of the apex are not relevant to this assessment.

13. An advanced practice RN is assessing the tympanic membrane of a 15-year-old boy who has come to the clinic. What would the nurse expect to visualize if the patient

has normal otoscopic findings?

A) The arm of the stapes B) The short process of the malleus C) The head of the incus D) The long process of the stapes Ans: B Age Group: Child and Adolescent Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 401, Otoscopic Evaluation Taxonomic Level: Analysis Feedback: During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse would not expect to see the stapes or the head of the incus.

14. Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?

A) Hold the ear at the tragus and lift up and back B) Hold the ear at the pinna and pull down and back C) Hold the ear at the auricle and pull down and back D) Hold the ear at the helix and lift up and back Ans: D Age Group: Child and Adolescent Chapter: 16 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 7, 10 Page and Header: 404, Infants and Children Taxonomic Level: Application Feedback: Hold the patient's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. In children younger than 3 years, the nurse would pull down and back to visualize the tympanic membrane. The nurse always lifts from the helix, not the auricle (pinna) and never from the tragus.

15. A nurse is admitting a 35-year-old man with pneumonia. When reviewing the patient's medical record, the nurse notes that this patient had abnormal findings during the Weber test. What would the nurse know this likely means?

A) The patient has unilateral hearing loss.

B) The patient has loss of high-frequency sounds.

C) The patient has loss of low-frequency sounds.

D) The patient has bilateral hearing loss.

Ans: A Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 401, Weber Test Taxonomic Level: Analysis Feedback: The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC).

16. The advanced practice nurse is assessing the tympanic membrane of a patient.

Once the tympanic membrane has been visualized, the nurse uses the bulb insufflator to observe the movement of the tympanic membrane. When forcing air into the ear canal, what would the nurse expect to note?

A) Negative pressure pulling the tympanic membrane B) Positive pressure pushing down the tympanic membrane C) Negative pressure pushing down the tympanic membrane D) Positive pressure pulling the tympanic membrane Ans: B Age Group: All Age Groups Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 401, Otoscopic Evaluation Taxonomic Level: Application Feedback: Positive pressure forces air into the external auditory canal and pushes down the tympanic membrane. The tympanic membrane moves inward when inflated and outward with release.

17. A female patient, 23 years old, comes to the ED with excruciating pain in her left ear. On assessment, the nurse notes that the patient experiences extreme pain during palpation of the tragus. Which of the following would the nurse suspect?

A) Otitis externa B) Hearing loss C) Foreign body

D)

Impacted cerumen

Ans: A Age Group: Adult Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 399, Palpation Taxonomic Level: Analysis Feedback: Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. It does not indicate hearing loss, foreign body, or impacted cerumen.

18. A nurse is assessing the ears of an 18-month-old patient who has had tympanostomy tubes in place for 6 months. Where in the tympanic membrane would the nurse expect to find the tympanostomy tubes?

A) Inferior portion B) Superior portion C) Medial portion D) Upper right quadrant Ans: A Age Group: Child and Adolescent Chapter: 16 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 10 Page and Header: 404, Infants and Children Taxonomic Level: Evaluation Feedback: Tympanostomy tubes placed to treat recurrent or persistent otitis media should be inserted in the inferior portion of the tympanic membrane with the lumen of the tube patent.

19. A 76-year-old woman presents at the clinic, reporting otalgia in her right ear.

Physical assessment reveals cerumen impacted in the patient's ear. Removing this mechanical blockage may do what for this patient?

A) Increase the size of ear canal B) Provide less rigidity in outer ear C) Improve hearing D) Prevent infection Ans: C Age Group: Older Adult Chapter: 16

Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 10 Page and Header: 405, Older Adults Taxonomic Level: Application Feedback: Removing a mechanical blockage can improve hearing and enhance socialization. It also helps to prevent injury by preserving the sense of hearing.

Removing the mechanical blockage will not increase the size of the ear canal, prevent infection, or provide less rigidity in the outer ear.

Chapter 17: Nose, Sinuses, Mouth, and Throat Assessment Multiple Choice 1. A patient has undergone a septoplasty on an outpatient basis. What is the best description of the nasal septum?

A) The structure that divides the nares B) The lining of the nares C) The lining of lymphatic ducts D) The mound of tissue just posterior to the eustachian tube Ans: A Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 415, Nose Taxonomic Level: Knowledge Feedback: The nasal septum is the center wall of bone and cartilage covered with mucosal membrane that divides the right and left nasal cavities. The internal nose is lined with skin and ciliated mucosa that is known as the vestibule. Just posterior to the eustachian tube opening is a mound of tissue known as the torus tubarius.

2. An oncology nurse is caring for an adult patient newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?

A) Osteomeatal complex B) Rosenmuller's fossa C) Kiesselbach's plexus D) Wharton's ducts Ans: B Age Group: Adult Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 416, Sinuses Taxonomic Level: Application Feedback: Posterior to the torus region is the pharyngeal recess or Rosenmuller's fossa, which is a common site of occult nasopharyngeal malignancies. The middle

turbinate and middle meatus area are known collectively as the osteomeatal complex, which is also the most anatomically significant area involved in chronic sinusitis. The anterior portion of the nasal septum has a rich vascular supply known as Kiesselbach's plexus. The submandibular gland is beneath the body of the mandible. Its Wharton's ducts run deep to the floor of the mouth and open on both sides of the frenulum.

3. A nurse is conducting a focused assessment of a 3-year-old girl who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

A) Rosenmuller's fossa B) Wharton's ducts C) Kiesselbach's plexus D) Stensen's duct Ans: C Age Group: Child and Adolescent Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 416, Nerve and Blood Supply Taxonomic Level: Comprehension Feedback: The anterior portion of the nasal septum has a rich vascular supply known as Kiesselbach's plexus. It is often the site of origination for nosebleeds.

4. A group of nursing students is making an oral presentation on the upper respiratory system. What would the group identify as the age when the frontal and sphenoid sinuses emerge in a child?

A) 9 years B) 7 years C) 5 years D) 3 years Ans: D Age Group: Child and Adolescent Chapter: 17 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 419, Infants and Children Taxonomic Level: Knowledge Feedback: The maxillary and ethmoid sinuses are present at birth but small. The frontal and sphenoid sinuses appear by the age of 3 years and continue to develop through adolescence.

5. A community health nurse is leading a health promotion workshop related to the nose, sinuses, mouth, and throat. What topic should the nurse prioritize?

A) Tobacco use B) Management of chronic obstructive pulmonary disease (COPD) C) Mouth breathing D) Alcohol intake Ans: A Age Group: All Age Groups Chapter: 17 Client Type: Community Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 421, Assessment of Risk Factors Taxonomic Level: Application Feedback: Tobacco is associated with numerous health problems that affect the nose, mouth, and throat. Tobacco is a more serious threat than alcohol. COPD is a major health problem, but the disease does not affect a majority of the population.

Mouth breathing is not normally considered problematic.

6. When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate that the patient has a history of allergies?

A) Photosensitivity B) Sedentary lifestyle C) Frequent childhood infections D) Family history of diabetes Ans: C Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 421, Assessment of Risk Factors Taxonomic Level: Analysis Feedback: Frequent upper respiratory infections in childhood should raise the nurse's suspicion of allergy. Chronic inflammation of the respiratory tract may lead to mucosal damage with resultant chronic infections (e.g., sinusitis). The findings of photosensitivity, sedentary lifestyle, or family history of diabetes would not necessarily raise the suspicion of allergy.

7.

A mother brings her 6-month-old son to the clinic for a follow-up assessment after

antibiotic treatment for recurring otitis media. Prolonged use of antibiotics may result in which of the following?

A) Displaced uvula B) Frequent nosebleeds C) Increased mucus production D) White coated tongue Ans: D Age Group: Child and Adolescent Chapter: 17 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 4 Page and Header: 430, Mouth Taxonomic Level: Analysis Feedback: A white coating of the tongue may be oral candidiasis. This condition is very common in patients taking antibiotics. Antibiotic use is not associated with epistaxis, displacement of the uvula, or increased mucus production.

8. The nurse is caring for a 65-year-old patient with a nasogastric feeding tube ordered by the physician. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

A) Deviated septum B) Obstructed turbinate C) Hypoxia D) Hypertrophied adenoids Ans: A Age Group: Older Adults Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 428, Common and Advanced Techniques Taxonomic Level: Analysis Feedback: The hospital RN assesses the patient's nares for patency when inserting a tube into the nose for feeding. A deviated septum or obstructed nares may make insertion difficult. The nares may be obstructed, but the turbinate would not be. The nurse would not suspect hypertrophied adenoids in a 65-year-old patient. Hypoxia would not cause a difficult NG insertion.

9. A patient presents at the urgent care clinic with severe pain and pressure around the eyes. The advanced practice nurse suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease?

A) Transillumination B) Computed tomography (CT) scanning C) Percussion of the sinus cavities D) Magnetic resonance imaging Ans: B Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 429, Sinuses Taxonomic Level: Knowledge Feedback: The gold standard diagnostic technique in evaluating sinus disease is a CT scan. Historically, the sinus cavities are assessed with transillumination, but this method has limited clinical significance and provides inconsistent results.

10. The nurse is caring for a 58-year-old man who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the patient's lips are dry and cracked. What might this indicate?

A) Heat stroke B) Viral infection C) Inadequate hydration D) Allergy Ans: C Age Group: Adult Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 430, Mouth Taxonomic Level: Analysis Feedback: Dryness or cracking may indicate inadequate hydration. Lesions or aphthous ulcers may represent a viral infection. Swelling or edema of the lips suggests allergy. Heat stroke is an unlikely cause of these signs and symptoms.

11. A nurse caring for a patient admitted 2 days ago following a minor cerebral vascular accident notes that the patient is frequently coughing and has audible lung crackles. What would be the most pertinent nursing diagnosis for this patient?

A) Impaired dentition B) Alteration in mobility C) Altered cerebral perfusion D) Impaired swallowing

Ans: D Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 434, Swallowing Evaluation Taxonomic Level: Analysis Feedback: Impaired swallowing is associated with problems in oral, pharyngeal, or esophageal structure or function. Related findings include delayed swallowing; gurgly voice; frequent coughing, choking, or gagging; inability to clear oral cavity; and food falling from the mouth. The scenario described does not mention impaired dentition, alteration in mobility, or altered cerebral perfusion at this point in recovery.

12. The nurse is conducting a comprehensive health assessment of a 55-year-old First Nations man. Which of the following abnormal findings would be most likely in this patient?

A) Bifid uvula B) Gingivitis C) Oral cancer D) Sinus infection Ans: B Age Group: Adult Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 7 Page and Header: 420, Cultural Considerations Taxonomic Level: Analysis Feedback: Rates of gingivitis (inflammation with bleeding of the gums) are high among Latinos and First Nations populations. Gingivitis may progress to periodontal disease with a loss of connective tissue and bone. First Nations men are not at risk for bifid uvula, oral cancer, or sinus infection.

13. An advanced practice RN is conducting the physical assessment of a 5-year-old White girl. The patient's mother states that it seems like her daughter always has a strep throat. This child's health history might indicate the need for what intervention?

A) Dialysis B) Removal of nasal polyps C) Sinus surgery D) Tonsillectomy

Ans: D Age Group: Child and Adolescent Chapter: 17 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 426, Lifespan Considerations Taxonomic Level: Analysis Feedback: Recurrent strep infections are an indication for consideration of removal of the tonsils and adenoids because of the risk of rheumatic fever with resultant heart or kidney disease. Recurrent strep infections do not indicate that a patient has nasal polyps, sinus disease, or kidney disease.

14. During the assessment of an adult patient, the nurse has asked the patient to say “ah” while gently pushing down on the patient's tongue with a tongue depressor.

This action allows the nurse to assess A) the patient's cranial nerve function.

B) the surface of the patient's tongue.

C) the patient's dental health.

D) the patient's gag reflex.

Ans: A Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 430, Mouth Taxonomic Level: Application Feedback: Observing the rise of the uvula allows the nurse to assess the function of the vagus nerve (CNX). It is unnecessary to have the patient say “ah” in order to assess the tongue, teeth, or gag reflex.

15. A community health nurse is discussing oral cancer with a group of adults in response to an individual's question about the disease. The nurse should encourage which of the following behaviours in order to reduce the risk of oral cancer?

A) Avoiding high-salt foods B) Gargling with antiseptic mouthwash regularly C) Avoiding extremes of temperature in food and drink D) Avoidance of using all forms of tobacco Ans: D Age Group: Adult Chapter: 17

Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 420, Cultural Considerations Taxonomic Level: Application Feedback: Most cases of oral and pharyngeal cancer are attributable to tobacco use.

Salt and temperature extremes do not cause cancer, and mouthwashes do not prevent cancer.

16. A nurse is conducting a comprehensive assessment of a newly admitted patient and is assessing the patient's swallowing. Which of the following assessment findings is suggestive of a swallowing deficit?

A) The patient has little interest in food.

B) The patient occasionally drools from the side of his mouth.

C) The patient's voice is quieter than it used to be.

D) The patient avoids fruits and vegetables.

Ans: B Age Group: All Age Groups Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 434, Swallowing Evaluation Taxonomic Level: Analysis Feedback: Drooling is often suggestive of a swallowing deficit. Lack of appetite, avoidance of fruits and vegetables, and a quiet voice are not typically attributable to a swallowing deficit.

17. A nurse is conducting an admission assessment on a 67-year-old man with an intractable oral infection. The patient tells the nurse that he cannot smell things as well as he once could. What should the nurse do?

A) Chart the information in the patient's health record B) Test the patient's ability to smell a noxious substance C) Notify the physician immediately D) Verify the patient's ability to taste all flavours Ans: A Age Group: Older Adult Chapter: 17 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4

Page and Header: 420, Older Adults Taxonomic Level: Application Feedback: Olfactory sensory fibres decrease after the age of 60 years. Because this is a normal, age-related change, the nurse would not conduct tests on the patient's sense of smell or taste nor would he or she notify the physician immediately.

18. A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergies?

A) If a parent has allergies, the child has a 20% chance of developing them as well.

B) Children will normally outgrow their allergies.

C) Allergy can affect any target organ in the body.

D) There are few effective treatments for allergies.

Ans: C Age Group: Adult Chapter: 17 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 421, Assessment of Risk Factors Taxonomic Level: Application Feedback: Allergy can affect any target organ in the body. The nose and respiratory mucosa are the entry port for inhalant allergens. Thus, the nose and respiratory tract are common targets for inflammatory responses from allergen exposure. If one parent has allergies, the child has a 50% chance of developing allergies. Many allergies are lifelong problems; allergies can often be managed and treated successfully.

Chapter 18: Thorax, Lungs, and Respiratory Assessment Multiple Choice 1. When assessing whispered pectoriloquy, the nurse would instruct a patient to do which of the following?

A) Softly repeat the words “one-two-three” B) Say “ninety-nine” C) Cough each time the stethoscope is moved D) Say the letter “e” Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 470, Comprehensive Physical Examination Taxonomic Level: Application Feedback: Softly whispering “one-two-three” while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the patient say “ninety-nine” is used to test bronchophony. Saying the letter “e” is used to test egophony. Having the patient cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.

2. When preparing to examine a patient's thoracic cage, the nurse would begin by locating which of the following landmarks?

A) Sternum B) Suprasternal notch C) Sternal angle D) Sternal border Ans: C Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 453, Anterior Thoracic Landmarks Taxonomic Level: Application Feedback: The sternal angle or angle of Louis, the bony ridge that can be palpated at

the point where the manubrium articulates with the body of the sternum, is a reference point for examining the thorax. The other noted anatomical sites are not used as points or reference for the inspection of the patient's thorax.

3. What would the nurse expect to hear when auscultating the lungs of a patient with unresolved pleuritis?

A) Friction rub B) Decreased breath sounds C) Sibilant wheeze D) Stridor Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 6 Page and Header: 476, Table 18-2 Taxonomic Level: Application Feedback: In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospasms, such as croup.

4. A patient has sustained a brainstem injury. Which of the following would the nurse need to know about this patient's respiratory effort?

A) There is loss of involuntary respiratory control.

B) The patient will respond negatively to increased stimuli.

C) There is a decreased level of carbon dioxide in the blood.

D) The patient's oxygen levels in the blood will be increased.

Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 458, Mechanics of Respiration Taxonomic Level: Synthesis Feedback: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the patient's respiratory effort. The patient's breathing patterns will change according to

cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the patient's respiratory efforts as well as interventions used to sustain these efforts; carbon dioxide levels will likely rise, while oxygen levels may fall.

5. During a health history, an elderly male patient tells the nurse that he “can't breathe well” at night when he is lying down and has trouble sleeping because he wakes up with shortness of breath. The nurse would assess this patient further for which of the following?

A) Pneumonia B) Tuberculosis C) Bronchitis D) Heart failure Ans: D Age Group: Older Adult Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 464, Orthopnea and Paroxysmal Nocturnal Dyspnea Taxonomic Level: Evaluation Feedback: Difficulty breathing when lying supine (orthopnea) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakes a person from sleep) also is associated with heart failure. There is no indication that the patient might have pneumonia, tuberculosis, or bronchitis. These conditions would most likely involve a patient's complaint of cough with or without mucus production.

6. A patient is experiencing an exacerbation of heart failure. This is likely to cause the patient's sputum to be what colour?

A) White B) Yellow C) Pink D) Rust Ans: C Age Group: Older Adult Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 465, Sputum Taxonomic Level: Application Feedback: Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection.

Rust-coloured sputum is associated with tuberculosis or pneumococcal pneumonia.

7. Upon entering the examination room, a nurse observes that the patient is leaning forward with arms supporting her body weight. The nurse would most likely suspect which of the following?

A) Diabetes mellitus B) Pneumonia C) Chronic obstructive pulmonary disease D) System lupus erythematosus Ans: C Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 469, Figure 18-10 Taxonomic Level: Analysis Feedback: The patient is assuming the tripod position, which is often seen in chronic obstructive pulmonary disease. The tripod position is usually not associated with diabetes or systemic lupus. Pneumonia may occasionally prompt the patient to adopt this position, but it is more closely associated with COPD. 8. The nurse assesses chest expansion in a young adult and finds it to be approximately 8 cm. The nurse documents this as which of the following?

A) Limited expansion B) Normal expansion C) Hypoexpansion D) Hyperexpansion Ans: B Age Group: Adult Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 470, Posterior chest Taxonomic Level: Analysis Feedback: Normal chest expansion ranges from 5 to 10 cm symmetrically. A finding of 8 cm would be within the normal parameters.

9. A patient has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?

A) Hyperresonance B) Dullness C) Resonance D) Tympany Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 472, Percussion Taxonomic Level: Analysis Feedback: Hyperresonance would be noted in a patient with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung.

Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.

10. Adventitious sounds are heard when auscultating a newly admitted patient's lungs. Which of the following would the nurse do first?

A) Refer the patient for further medical evaluation B) Auscultate for egophony C) Perform bronchophony D) Have the patient cough and then listen again Ans: D Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 474, Auscultation of Breath Sounds.

Taxonomic Level: Application Feedback: If abnormalities are noted during lung auscultation, the nurse should have the patient cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the patient for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax.

11. A patient who has experienced a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse first suspect?

A) Diabetic ketoacidosis

B) Renal failure C) Narcotic overdose D) Severe brain damage Ans: D Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7, 10 Page and Header: 489, Table 18-6 Taxonomic Level: Analysis Feedback: The respiratory pattern observed is Biot respirations that may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul respirations that are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations.

12. Which of the following would be most important for the nurse to prioritize when performing auscultation of the patient's thorax?

A) Listen at each site for at least one complete respiratory cycle B) Have the patient take shallow breaths through the mouth C) Be alert to the patient's comfort and offer rest period after the assessment is complete D) Auscultate the base at the level of the fourth rib Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 4 Page and Header: 474, Auscultation of Breath Sounds Taxonomic Level: Application Feedback: Although having the patient breathe deeply through the mouth and being alert to the patient's comfort are important when auscultating the lungs, it would be most important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The nurse would auscultate from the apices to the bases at T10 and laterally from the axilla down to the seventh or eighth rib.

13. What type of respiratory pattern would signal the nurse to the fact that a palliative cancer patient is close to death?

A) Biot respiration

B) Tachypnea C) Kussmaul respiration D) Cheyne-Stokes breathing Ans: D Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 489, Table 18-6 Taxonomic Level: Comprehension Feedback: Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from terminal illness. Biot respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Kussmaul respirations are associated with diabetic ketoacidosis.

14. When percussing the scapula of a patient, which of the following would the nurse expect to hear?

A) Resonance B) Dullness C) Flatness D) Hyperresonance Ans: C Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 472, Percussion Taxonomic Level: Comprehension Feedback: Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.

15. A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

A) Midaxillary line B) Vertebral line C) Right midclavicular line

D)

Sternal line

Ans: B Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 455, Reference Lines Taxonomic Level: Application Feedback: The reference lines for the posterior thorax include the vertebral line and the right and left scapular lines. The midaxillary line is a reference line for the lateral aspect of the thorax. The right midclavicular line and sternal line are reference lines for the anterior thorax.

16. When assessing the apices of the lungs, the nurse would landmark them at which position?

A) At the level of the diaphragm B) Near the level of the eighth rib C) Slightly above the clavicle D) At about the tenth rib Ans: C Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 477, Palpation Taxonomic Level: Application Feedback: The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib; posteriorly, the base lies at about the tenth rib.

17. The nurse is assessing the different lobes of a patient's lungs. The nurse must assess which lobe anteriorly?

A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe Ans: D Age Group: All Age Groups Chapter: 18

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 456, Lobes of the Lungs Taxonomic Level: Application Feedback: The right middle lobe of the lung does not extend to the posterior side of the thoracic wall and, thus, must be assessed from the anterior surface alone. The other lung lobes can be assessed anteriorly and posteriorly.

18. A nurse asks a patient to say “ninety-nine” as the nurse palpates the patient's posterior thorax. The nurse is assessing which of the following?

A) Fremitus B) Egophony C) Chest expansion D) Bronchophony Ans: A Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 470, Posterior Chest Taxonomic Level: Application Feedback: Fremitus is assessed by asking a patient to say “ninety-nine” as the nurse palpates the thorax. Bronchophony is assessed by asking the patient to say “ninety-nine” as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner's thumbs move when the patient takes a deep breath. Egophony is assessed by having the patient repeat the letter “e” as the nurse auscultates.

19. After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change?

A) Increased resiliency B) Loss of elasticity C) Increased functional capillaries D) Loss of subcutaneous fat Ans: B Age Group: Older adult Chapter: 18 Client Type: Group Competency Category: Changes in Health

Difficulty: Moderate Objective: 2, 9 Page and Header: 458, Older Adults Taxonomic Level: Application Feedback: Aging leads to a loss of lung elasticity, fewer functional capillaries, and a loss of lung resiliency. There is a loss of subcutaneous fat, but this may make the sternum and ribs appear more prominent on inspection. It does not affect the lungs.

20. Which of the following would be best for a nurse to use when assessing for fremitus in a patient?

A) Dorsal hand surface B) Pads of fingers C) Palmar base (ulnar surface) D) Fist Ans: C Age Group: All Age Groups Chapter: 18 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 470, Posterior Chest Taxonomic Level: Application Feedback: The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion.

Finger pads are used for fine discrimination such as pulses, texture, and size.

Chapter 19: Cardiovascular Assessment Multiple Choice 1. The nurse is preparing to conduct a cardiovascular assessment and is landmarking the relevant anatomical structures. Which of the following anterior neck structures is found in the depression between the trachea and the sternomastoid muscle?

A) Internal jugular vein B) External jugular vein C) Trachea D) Carotid artery Ans: D Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 494, Neck Vessels Taxonomic Level: Application Feedback: The carotid arteries are located in the depression between the trachea and the sternomastoid muscle in the anterior neck. They follow bilaterally along the trachea from clavicle to jaw. Palpation of the carotid arteries normally reveals a strong pulsation.

2. A nurse is aware of sex-based differences in anatomy and physiology that must be integrated into assessment. Across the life span, a nurse knows that the female heart A) is normally smaller than the male heart.

B) weighs more than a male heart.

C) is normally larger than a male heart.

D) normally beats slower than a male heart.

Ans: A Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 494, Anatomy Taxonomic Level: Comprehension

Feedback: The total size of the heart is approximately that of a clenched adult fist.

The female heart is normally smaller and weighs less than the male heart across all age groups.

3. A nurse is conducting cardiac auscultation and knows that the Erb point is the third site for auscultation on the precordium. Where is it located?

A) Fourth left rib space B) Third right rib space C) Fourth right rib space D) Third left rib space Ans: D Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 515, Auscultation of the Precordium Taxonomic Level: Application Feedback: The third left rib space is the third site for auscultation (Erb point). The other options are incorrect.

4.

A) B) C) D)

The sternal angle at the second intercostal space is also known as what?

Erb point Manubrium The aortic area The PMI

Ans: C Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 515, Auscultation of the Precordium Taxonomic Level: Comprehension Feedback: The most important landmark is the sternal angle at the second rib space.

This is the aortic space, which is the starting point for cardiac auscultation.

5. To increase the proportion of adults who engage in physical activity that promotes the development and maintenance of cardiorespiratory fitness, what teaching point should the nurse emphasize with an adult patient?

A) To conduct stretching exercises if the patient's mobility is compromised

B) To exercise 30 to 60 minutes per day C) To “cool down” after exercise so as not to strain muscles D) To exercise for no more than 15 minutes at a time Ans: B Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 505, Control of Weight and Stress Taxonomic Level: Application Feedback: Research is demonstrating that 30 to 60 minutes of physical activity most days reduces cardiovascular risks. Emphasizing the importance of physical activity in promoting health and reducing cardiovascular disease may enhance the patient's understanding. The nurse would identify choices that the patient is willing to engage in and follow his or her progress. The nurse would not review “cooling down” as a health-promotion activity. Stretching does not necessarily foster cardiovascular health.

6. The nurse is caring for a patient who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this patient?

A) Eat high-protein, low-fat meals B) Eat low-fat, low-cholesterol meals C) Eat high-protein, low-carbohydrate meals D) Eat low-cholesterol, low-carbohydrate meals Ans: B Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 505, Control of Blood Pressure and Cholesterol Level Taxonomic Level: Application Feedback: This patient should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the patient to eat high-protein or low-carbohydrate meals.

7. A patient comes to the emergency department and the triage nurse has documented the presence of dyspnea. Dyspnea is defined as A) shortness of breath.

B) painful breathing.

C) rapid breathing.

D)

inability to breathe.

Ans: A Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 9 Page and Header: 506, Dyspnea Taxonomic Level: Knowledge Feedback: Dyspnea is synonymous with shortness of breath. The term does not denote painful breathing, absent breathing (apnea), or rapid breathing (tachypnea).

8. A 62-year-old woman with a diagnosis of chronic heart failure states that she has to get up during the night to urinate. How would the nurse further assess this patient's nocturia?

A) Ask the patient why she thinks she must get up so often B) Ask the patient “Are you tired in the morning because of this?”

C) Ask the patient whether siblings or parents had this problem D) Ask the patient “Have you made any changes because of this?”

Ans: D Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 507, Nocturia Taxonomic Level: Application Feedback: Nocturia is a common symptom associated with the redistribution of fluid from the legs to the core when lying. As the fluid shifts, the kidneys are better perfused, increasing urine production. Patients may avoid drinking water after dinner because of this. The question most pertinent to this scenario is if the patient has made any changes because of this; the effect on the patient's routines and function is a priority. The nurse would not prioritize asking if the patient thinks why this is happening, if the patient is tired in the morning because of the nocturia, or if parents or siblings have had the same problem.

9. An 87-year-old woman has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid pulse is diminished bilaterally, and a systolic bruit is auscultated bilaterally. What would the NP want to have this patient assessed for by a cardiologist?

A) Stenotic aortic valve B) Atherosclerotic pulmonic valve

C) Atherosclerotic stenotic carotid arteries D) Congenital stenotic carotid arteries Ans: C Age Group: Adult of Advanced Age Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 6 Page and Header: 512, Auscultation Taxonomic Level: Analysis Feedback: If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the patient's age would negate the likely existence of a congenital problem.

10. Nursing students are learning how to objectively assess jugular venous pulses.

How would the nursing instructor teach the students to optimally position the patient for this procedure?

A) Have the patient perform a Valsalva manoeuvre for better visualization B) Sit the patient up at a 90°angle C) Position the patient supine D) Place the head of the bed 30° to 45° Ans: D Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 510, Jugular Venous Pulses - Inspection Taxonomic Level: Application Feedback: Positioning of the patient would be with the head of the bed at 30° to 45° to promote visibility of the pulsation. The nurse would remove the pillow to avoid flexing the neck and to improve vein exposure. The right side is easiest to see; it may help for the patient to turn the head away from the side being examined. The nurse would use lighting that emphasizes the shadows of the pulsations versus a bright light. The nurse does not ask the patient to perform the Valsalva manoeuvre.

11. A 79-year-old man has come to the clinic for a routine checkup. He reports general malaise and chronic fatigue, stating “I just can't get out and work in the garden anymore. I really miss it.” The patient has a history of cardiomegaly with a hypertrophied left ventricle. Where would the nurse expect to find the PMI? A) Between the 4th and the 5th ICS at the MCL

B) Lateral and inferior to the 4th and 5th ICS and the MCL C) Lateral and superior to the 4th and 5th ICS and the MCL D) Lower left sternal border Ans: B Age Group: Older Adult Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 7 Page and Header: 514, Inspection of the Precordium Taxonomic Level: Application Feedback: The enlarged heart of cardiomegaly displaces the PMI laterally and inferiorly. The nurse would observe for a heave or lift, which appears as a forceful thrusting on the chest and results from an enlarged left ventricle. A right ventricular heave is observed at the lower left sternal border.

12. The nursing instructor is discussing assessment of the heart with students. A student states that he cared for a patient with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A) A thrill B) A thrust C) A heave D) A normal finding Ans: A Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 514, Palpation of the Precordium Taxonomic Level: Analysis Feedback: Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest. This is not a normal finding.

13. While performing a patient's admission assessment, the emergency department nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound?

A) Paradoxical sound B) Split sound C) Pericardial murmur D) Pericardial friction rub Ans: D Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 517, Extra Sounds Taxonomic Level: Analysis Feedback: The pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the patient is upright and leaning forward. This is not a paradoxical sound, a split sound, or a murmur.

14. A patient presents at the cardiology clinic for a checkup 6 months after MI. The patient is known to have a bundle-branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds?

A) Arrhythmia B) Extra sound C) Wide splitting D) Delayed S1 Ans: C Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 515, Auscultation of the Precordium Taxonomic Level: Analysis Feedback: Wide splitting occurs when a bundle-branch block delays activation of the right ventricle. It also can happen when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle. The nurse would not expect to auscultate an arrhythmia, an extra sound, or a delayed S1.

15. A patient has been admitted to the cardiac unit and test results are available.

The nurse is writing a plan of care for this patient. On what would the nurse primarily base nursing interventions?

A) Patterns of subjective and objective data B) Patterns of test results C) Availability of staff and resources D) Areas that the patient requests Ans: A Age Group: All Age Groups Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 521, Common Laboratory and Diagnostic Testing Taxonomic Level: Application Feedback: The nursing process should be based on the patterns of findings from all available sources, both subjective and objective. The patient's preferences should be integrated into care, but these are not the primary basis of care planning. Available resources must be accommodated, but these are not the major basis for the planning of nursing care.

16. An emergency department nurse is assessing a 62-year-old rancher who arrives at the ED with chest pain. The patient states that the pain gets much worse with movement. What further assessment should the nurse prioritize?

A) Auscultation at the 5th ICS B) Palpation at the PMI C) Inspection of the precordium D) Palpation of the costochondral junction Ans: D Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 514, Palpation of the Precordium Taxonomic Level: Application Feedback: With chest pain that increases with movement, palpation of the costochondral junction is performed to determine if the pain is of musculoskeletal origin. This assessment would be an immediate priority over the other listed assessments.

17. The nurse performs an admission assessment on a 52-year-old woman admitted through the ED with a myocardial infarction. The nurse charts “Swooshing sound heard over right carotid artery.” How should this documentation be corrected?

A) “Murmur heard over right carotid artery”

B) “Split sound auscultated over right carotid artery” C) “Right carotid bruit auscultated” D) Documentation does not need to be corrected Ans: C Age Group: Adult Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 512, Auscultation Taxonomic Level: Application Feedback: Bruits are swooshing sounds similar to the sound of the blood pressure.

They result from turbulent blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. With complete obstruction, no bruit is audible, because no blood gets through. Distinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. Split sounds are not heard over arteries.

18. An 83-year-old woman presents at the office of her primary care physician with fatigue, heart palpitations, and a wet cough. What might the nurse suspect in this patient?

A) Heart failure B) Atrial fibrillation C) Atrial hypertrophy D) Ventricular arrhythmia Ans: B Age Group: Adult of Advanced Age Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 520, Older Adults Taxonomic Level: Analysis Feedback: Symptoms of heart failure include weight gain, shortness of breath, and edema. Symptoms of atrial fibrillation include fatigue, palpitations, and heart failure with loss of the “atrial kick” that supports ventricular filling. Atrial hypertrophy and ventricular arrhythmia are not found more often in the elderly, and they do not have symptoms including a wet cough.

19. What feature of a newborn shunts blood from the right atrium directly into the left atrium, bypassing the lungs?

A) Foramen ovale B) Ductus arteriosus C) Placental insufficiency D) Injection fraction Ans: A Age Group: Infant Chapter: 19 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 500, Newborns and Infants Taxonomic Level: Comprehension Feedback: An open flap in the septum between the left and the right atria is called the foramen ovale. Through this flap, blood is shunted from the right atrium directly into the left atrium, bypassing the lungs. The ductus arteriosus shunts blood that remains in the right ventricle from the pulmonary artery to the aorta.

Chapter 20: Peripheral Vascular and Lymphatic Assessment Multiple Choice 1. A nurse is assessing the lymphatic system of a newly admitted patient. The lymphatic system contributes to homeostasis in which of the following ways?

A) Maintains protein balance B) Promotes vascular tone C) Regulates metabolism D) Hydrates the thymus Ans: A Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 1 Page and Header: 539, Lymphatic System Taxonomic Level: Comprehension Feedback: The lymphatic system consists of the lymph nodes and lymphatic vessels as well as the spleen, tonsils, and thymus. It maintains fluid and protein balance and functions with the immune system to fight infection. The lymph system does not promote vascular tone, hydrate the thymus, or regulate metabolism.

2. The superior vena cava receives deoxygenated blood from which of the following anatomical regions?

A) Lower extremities B) Upper torso C) Abdomen D) Lower torso Ans: B Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 537, Venous System Taxonomic Level: Knowledge Feedback: The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium.

3. A nurse is preparing a teaching plan for a patient newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factor would the nurse include?

A) High-fat diet B) Low-protein diet C) Anaerobic exercise D) Use of smokeless (chewing) tobacco Ans: A Age Group: Adult Chapter: 20 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 542, Box 20-1 Taxonomic Level: Application Feedback: Identifying options for the modification of risk factors can significantly improve the outcome for patients with PAD. The most modifiable risk factors are smoking, high-fat diet, and limited activity level. Low-protein diets and anaerobic exercise are not considered modifiable risk factors for PAD. Smokeless tobacco poses numerous risks to health, but it is not a significant risk factor for PAD. 4. A nurse is caring for a patient with chronic lymphedema. In preparing a teaching plan for this patient, what would be essential for the nurse to address?

A) Exercise plan B) Body image C) Cardiovascular risk factors D) Pathophysiology Ans: B Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8, 9 Page and Header: 544, Patients with Lymphatic Disorders; 570, Table 20-6 Taxonomic Level: Application Feedback: Patients with chronic lymphedema may experience disfigurement that affects their body image and self-esteem. It is essential for nurses to address these areas that affect quality of life. Addressing exercise and pathophysiology is not considered as essential for the nurse to address in teaching as are body image and self-esteem. Lymphedema is not closely associated with subsequent cardiovascular disease.

5. The nursing instructor is discussing the collection of subjective information when assessing patients with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment?

A) Plan for modifying risk factors B) Education on nonmodifiable risk factors C) Identification of cardiovascular risk factors D) History related to grandparents' health Ans: C Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 542, Subjective Data Collection Taxonomic Level: Application Feedback: The subjective portion of the health assessment includes the identification of cardiovascular risk factors and history related to those symptoms that are frequently associated with arterial, venous, and lymphatic disorders. The subjective portion of the health assessment would not include a plan for modifying risk factors, education on nonmodifiable risk factors, or a history of the grandparents' health.

6. A patient with intermittent claudication wonders why the nurse wants to know where he is experiencing cramping when he walks. What would be the nurse's best answer?

A) “The area of pain tells us what treatment will work best for you.”

B) “The area of cramping indicates whether you may have numbness and tingling also.”

C) “The area of pain can help us identify what risk factor is predominant.”

D) “The area of cramping is close to the area where your arteries are blocked.”

Ans: D Age Group: Adult Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 546, Cramping Taxonomic Level: Application Feedback: The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. This information

does not directly inform treatment or link to specific risk factors.

7. When assessing the extremities of a patient, the nurse notes muscle atrophy.

What potential cause should the nurse consider?

A) Peripheral artery disease B) Chronic lymphedema C) Venous insufficiency D) Arterial aneurysm Ans: A Age Group: Adult Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5, 6 Page and Header: 548, Comprehensive Physical Examination: Peripheral Vascular and Lymphatic Systems Taxonomic Level: Evaluation Feedback: PAD may result in muscle atrophy. Hypertrophy may result from activity in which the patient uses one arm more than the other, such as tennis. Muscle atrophy is not caused by chronic lymphedema, venous insufficiency, or arterial aneurysm.

8. When assessing the lymphatic system of a 52-year-old patient, the nurse notes that the patient's epitrochlear nodes are nonpalpable. What does this indicate?

A) Atherosclerosis B) Normal finding C) Possible lymphoma D) No lymphedema Ans: B Age Group: Adult Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 6 Page and Header: 548, Comprehensive Physical Examination: Peripheral Vascular and Lymphatic Systems Taxonomic Level: Analysis Feedback: Normally, the epitrochlear nodes are not palpable. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

9.

When assessing a patient for an acute arterial occlusion, what assessment

parameter should the nurse consider?

A) Pain B) Pliability C) Percussion D) Presence Ans: A Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3, 4 Page and Header: 557, Common Laboratory and Diagnostic Testing Taxonomic Level: Application Feedback: Assessment for acute arterial occlusion involves evaluation of the “Six Ps”—pain, poikilothermia, paresthesia, paralysis, pallor, and pulselessness. Pliability, percussion, and presence are not assessment parameters.

10. A 72-year-old man is brought to the emergency department by his son. The patient reports pain in his back and abdomen and shortness of breath. What might the triage nurse suspect is wrong?

A) Iliac vein obstruction B) Aortic aneurysm C) Lymphadenopathy D) Renal lymph obstruction Ans: B Age Group: Older Adult Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 566, Table 20-5 Taxonomic Level: Evaluation Feedback: Assessment findings associated with aortic aneurysm include chest pain, abdominal pain, back pain, shortness of breath, laterally pulsatile mass on palpation, and a bruit. These symptoms are not indicative of an iliac vein obstruction, lymphadenopathy, or renal lymph obstruction.

11. As part of a comprehensive assessment, the nurse is palpating a patient's peripheral pulses. Which pulse will the nurse locate at approximately the inner third of the antecubital fossa when the patient's palm is held in supination?

A) Epitrochlear B) Radial

C) Ulnar D) Brachial Ans: D Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 4 Page and Header: 548, Comprehensive Physical Examination: Peripheral Vascular and Lymphatic Systems Taxonomic Level: Comprehension Feedback: The brachial pulses are located at approximately the inner third of the antecubital fossa when the palm is held up. It is not usually necessary to palpate the ulnar pulse, which is difficult to locate. The radial pulse site is used when assessing the pulse for vital signs. There is no epitrochlear pulse.

12. As part of a comprehensive assessment, the nurse is palpating a patient's peripheral pulses. What pulse is located in the groove between the medial malleolus and the Achilles tendon?

A) Posterior tibial B) Dorsalis pedis C) Popliteal D) Femoral Ans: A Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 552, Palpation Taxonomic Level: Application Feedback: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse.

It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

13. A patient, newly admitted, has given her health history and undergone her physical assessment. Laboratory data and diagnostic study results have just become available. What is the nurse's next step in caring for the patient?

A) Address the patient's nonmodifiable risk factors for heart disease B) Develop a plan of care C) Inform the patient and family of diagnostic study results D) Start giving medication Ans: B Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 557, Evidence-Informed Critical Thinking Taxonomic Level: Application Feedback: Because of the systemic nature of cardiovascular diseases, nurses must critically investigate far beyond the initial reason for which the patient sought care.

Once the nurse has analyzed the history, physical assessment, laboratory data, and diagnostic study results, the next step is to develop a plan of care. It is the physician's responsibility to inform the patient/family of the results of diagnostic studies.

Medication should be given when ordered, which is not necessarily immediately after test results become available.

14. A patient is given a nursing diagnosis of activity intolerance related to pain and claudication with ambulation. What would be an appropriate intervention for this patient?

A) Teach the patient to mobilize using a wheelchair B) Assess dorsalis pedis and posterior tibial pulse bilaterally C) Gradually increase the patient's level of activity as tolerated D) Assign the patient to bed rest Ans: C Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 558, Nursing Diagnoses, Outcomes, and Interventions Taxonomic Level: Application Feedback: When a patient has insufficient energy to endure or complete required or desired daily activities, an appropriate intervention is to gradually increase activity, refer the patient to physical therapy as indicated, and allow rest periods before and after activity. A wheel chair or bed rest is not likely indicated. Further assessment may be warranted, but this is not an intervention.

15.

The nurse has completed a focused peripheral vascular assessment. How should

the nurse document a normal pulse in the patient's health record?

A) + 2/2 B) + 2/3 C) + 3/3 D) + 2/4 Ans: D Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 549, Box 20-3 Taxonomic Level: Application Feedback: The nurse documents a normal pulse as + 2/4.

16. Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology?

A) Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable B) Left lower leg cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable C) Left extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable D) No changes are necessary.

Ans: A Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 552, Palpation Taxonomic Level: Application Feedback: Appropriate medical terminology would be “left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable.” The term “extremity” is preferred, and the phrase “back knee pulse” is not used.

17. A nurse is conducting health education for a patient who has sought care for the treatment of varicose veins. What should the nurse teach the patient about varicose veins?

A) They are seen less often in obese people.

B) They are caused by lymphedema.

C) They are more common in women.

D) They are caused by an autoimmune response.

Ans: C Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 541, Cultural Considerations Taxonomic Level: Application Feedback: Primary varicose veins are seen more often in people older than 50 years and in those with obesity. Varicose veins are more common in women, which may be related to the increased venous stasis that accompanies pregnancy. Varicose veins are not necessarily the result of lymphedema and they are not caused by an autoimmune response.

18. A community health nurse is choosing appropriate topics for an upcoming health fair that will be attended by older adults. The nurse should be cognizant of the fact that there is a dramatic increase in the incidence of PAD during what time period in a person's life?

A) Sixth decade B) Seventh and eighth decades C) Eighth and ninth decades D) Ninth decade Ans: B Age Group: Older adults Chapter: 20 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 541, Older Adults Taxonomic Level: Knowledge Feedback: Incidence of peripheral arterial disease (PAD) increases dramatically in the seventh and eighth decades of life. Prevalence of PAD in men and women is equal at this stage.

19. When doing a shift assessment on a newly admitted patient, the nurse notes lack of hair on the patient's right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this patient receive?

A) Risk for peripheral neurovascular dysfunction B) Activity intolerance related to pain and claudication with ambulation C) Altered tissue perfusion, arterial related to reduced blood flow D) Pain related to decreased blood flow and altered tissue perfusion Ans: C Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 558, Table 20-2 Taxonomic Level: Application Feedback: Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill.

20. A trauma patient reports pain in his left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present.

What nursing diagnosis might the nurse identify?

A) Pain related to decreased blood flow and altered tissue perfusion B) Activity intolerance related to pain and claudication with ambulation C) Altered tissue perfusion, arterial related to reduced blood flow D) Risk for peripheral neurovascular dysfunction Ans: D Age Group: All Age Groups Chapter: 20 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 558, Table 20-2 Taxonomic Level: Application Feedback: Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction.

Chapter 21: Breasts and Axillae Assessment Multiple Choice 1. An anatomy and physiology instructor is discussing the functions of the breast, and a student asks about the function of Montgomery's glands. What would be the instructor's best answer?

A) “During lactation, they secrete a protective lubricant.”

B) “They are the lactiferous ducts.”

C) “They aid in supporting breast tissue.”

D) “They are lymph nodes in the axillae.”

Ans: A Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 1 Page and Header: 572, Breast Structures Taxonomic Level: Knowledge Feedback: Small sebaceous glands called Montgomery's glands secrete a protective lubricant when a woman lactates. Montgomery's glands are not lactiferous ducts, they do not aid in the support of breast tissue, and they are not lymph nodes in the axillae.

2. A nurse is reviewing the anatomy of the breasts prior to the focused assessment of a female patient. Where are the patient's acini cells located?

A) Nipple B) Lobules of the breast C) Lactiferous ducts D) Breast sinus Ans: B Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 572, Breast Structures Taxonomic Level: Knowledge Feedback: The glandular tissue consists of 15 to 20 glandular lobes in each breast that extend from the nipple in a radial fashion. Within each lobe, 20 to 40 lobules

contain milk-producing acini cells. When milk is produced, it drains into the lactiferous ducts; the milk from each lobe empties into one sinus that terminates at the nipple.

3. When assessing the patient's breasts and the lymphatics of her axillae, where would the nurse locate the patient's central axillary nodes?

A) Inside the upper arm B) Along the lateral edge of the scapulae C) High in the axillae at the top of the ribs D) Inside the lateral axillary fold Ans: C Age Group: All Age Groups Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 573, Axillae and Lymph Nodes Taxonomic Level: Application Feedback: The central axillary (midaxillary) nodes are palpable high up in the axillae at the top of the ribs. These nodes receive lymph from the lateral, posterior, and anterior axillary nodes. The anterior axillary (pectoral) nodes are located inside the lateral axillary fold along the pectoralis major muscle. The lateral axillary (brachial) nodes are located inside the upper arm along the humerus. The posterior axillary (subscapular) nodes lie inside the posterior axillary fold along the lateral edge of the scapulae.

4. When assessing the patient's breasts and axillae, the nurse should be aware that most lymph drains where?

A) Bilateral axillary nodes B) Bilateral mammary nodes C) Ipsilateral mammary nodes D) Ipsilateral axillary nodes Ans: D Age Group: All Age Groups Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 573, Axillae and Lymph Nodes Taxonomic Level: Knowledge Feedback: Most lymph drains into the axillary lymph nodes on the same side (ipsilateral lymph nodes).

5. A nurse is teaching a patient about the Know Your Breasts (KYB) approach to breast health. What would the nurse emphasize?

A) Family history of breast cancer B) Regular self-inspection of the breasts C) Dietary modifications D) The role of exercise in preventing breast cancer Ans: B Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 593, Box 21-1 Taxonomic Level: Application Feedback: The KYB approach emphasizes inspection and palpation of the breasts by the woman herself. It does not prioritize family history, diet, or exercise, though each of the considerations has an impact on health.

6. A nurse is conducting a health education session that addresses breast cancer.

The nurse should identify which of the following as a modifiable risk factor for breast cancer?

A) Obesity B) Age C) Genetics D) Asthma Ans: A Age Group: Adult Chapter: 21 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 580, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: It is important for women to be aware of their specific risk factors for breast cancer. Although many factors are not modifiable, some are. When a patient is aware of her own specific risk factors, she may be more diligent in practicing healthy habits (monthly SBEs, yearly physical examinations, and mammograms, if indicated) and adjust other personal behaviours (especially physical inactivity and obesity).

Asthma is not correlated with breast cancer. Genetics and age are not modifiable risk factors.

7. While assessing a 32-year-old woman new to the clinic, what topic would constitute a subjective assessment finding?

A) The patient's body mass index B) Data about the patient's exercise habits C) Results of inspecting the patient's breasts D) Results of breast palpation Ans: B Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 576, Subjective Data Collection Taxonomic Level: Evaluation Feedback: Self-care behaviours are an example of subjective data. BMI and physical examination results are considered to be objective findings.

8. A nurse is conducting a comprehensive assessment of a patient in her fifties.

Included in the nurse's subjective assessment of the patient's breasts is A) the woman's breast size.

B) results of examining the patient's breast symmetry.

C) the patient's surgical history.

D) the skin tone of the patient's breasts.

Ans: C Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 576, Subjective Data Collection Taxonomic Level: Analysis Feedback: Subjective data collection begins with the current health history related to the breast (such as breast discomfort, masses or lumps, or nipple discharge) and continues with questions related to past history (previous breast disease; surgeries; menstrual, pregnancy, and lactation history; and past hormone replacement therapy), family history (of breast cancer or other breast disease), and personal history (breast trauma, surgery, and self-care behaviours). Examination results are considered objective.

9. When performing a breast assessment on a hospital patient, the nurse practitioner notes scaly lesions that begin at the nipple and move toward a lump behind the patient's nipple well. The NP would know that further assessment for what

health problem would be necessary?

A) Mastalgia B) Lipoma C) Fibroadenoma D) Paget disease Ans: D Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 5, 6 Page and Header: 582, Examples of Questions to Assess Symptoms/Signs; 600, Table 21-4 Taxonomic Level: Analysis Feedback: Paget disease produces scaly lesions that begin at the nipple and progress to a lump behind the nipple well. Severe pain (mastalgia) is more likely to result from trauma or infection. Single breast masses can indicate benign conditions (e.g., cysts, fibroadenoma, fat necrosis, lipoma) or more serious conditions (e.g., cancer).

10. Breast self-examination is most accurate when the woman's breasts are least congested and smallest. The nurse knows this would be what days of the menstrual cycle?

A) 1 to 3 B) 3 to 5 C) 5 to 7 D) Day of ovulation Ans: C Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 584, Promoting Patient Comfort, Dignity, and Safety Taxonomic Level: Application Feedback: The best time to examine the breasts is when they are least congested and smallest (in adult women, days 5 to 7 after the onset of menstruation and up to day 13).

11. A 57-year-old woman has reported to the nurse that she is increasingly fatigued and has an area on her breast that looks dimpled and “like orange peel.” What would this assessment finding suggest to the nurse?

A) Early cancer B) Fibroadenoma C) Fibrocystic disease D) Blocked lymph drainage Ans: D Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 584, Comprehensive Physical Assessment Taxonomic Level: Analysis Feedback: Peau d'orange appearance is caused by breast edema from blocked lymph drainage and indicates advanced cancer. Orange peel dimpling does not indicate early cancer, fibroadenoma, or fibrocystic disease.

12. When assessing a patient's breasts, it is important for the patient to lift her arms over her head. Why is this action an assessment priority?

A) It adds tension to suspensory ligaments.

B) It causes dimpling and retraction.

C) It de-emphasizes suspensory ligament retraction.

D) It accentuates signs of unilateral nipple inversion.

Ans: A Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 584, Comprehensive Physical Assessment Taxonomic Level: Application Feedback: Lifting the arms over the head adds tension to the suspensory ligaments and accentuates any dimpling or retraction. Lifting of the arms does not accentuate signs of unilateral nipple inversion, nor does it de-emphasize suspensory ligament retraction.

13. A 37-year-old woman is 2 days postoperative after a right breast mastectomy.

Included in the discharge teaching is care of the surgical incision. What would be the most appropriate intervention for this patient?

A) Provide for a home health nurse to assist in care of the incision B) Teach the patient to cleanse the incision with hydrogen peroxide C) Make a referral to the wound care nurse D) Teach the patient the signs and symptoms of wound infection

Ans: D Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 590, Examining the Patient Postmastectomy Taxonomic Level: Application Feedback: Early identification of infection is a priority in the care of the postmastectomy patient. A home health referral and wound care referral would not normally be necessary and hydrogen peroxide is not normally used to cleanse wounds.

14. A nurse is providing patient teaching related to the Know Your Breast (KYB) approach to a 67-year-old woman. When would be the best time during the month for this patient to perform inspection and palpation?

A) First day of each month B) Last 2 weeks of month C) First 2 weeks of month D) A convenient day of each month Ans: D Age Group: Older Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 592, Older Adults Taxonomic Level: Application Feedback: With the cessation of menses, hormonal changes no longer affect the breasts. For this reason, patients can choose a convenient day of each month to perform KYB activities (e.g., first day of the month).

15. When assessing a patient's breasts, what sign or symptom is suggestive of a malignancy?

A) Hyperpigmentation B) Erythema C) Pallor D) Consistent firmness Ans: A Age Group: All Age Groups Chapter: 21

Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6, 7 Page and Header: 585, Colour and Texture Taxonomic Level: Analysis Feedback: Redness (erythema) and heat can indicate infection or inflammation.

Hyperpigmentation can signify cancer. Pallor and consistent texture are not closely associated with cancer.

16. A nurse is working with a group of elementary school teachers and informs them that female students from what ethnic background tend to experience the earliest onset of breast development?

A) African B) Caucasian C) Asian D) First Nations Ans: A Age Group: Child and Adolescent Chapter: 21 Client Type: Group Competency Category: Health and Wellness Difficulty: Easy Objective: 8 Page and Header: 574, Children and Adolescents Taxonomic Level: Knowledge Feedback: Breast development begins at a mean age of 10 years for Caucasian girls and 9 years for African Canadian girls. Asian and First Nations girls do not typically experience this early of an onset of breast development.

17. A man brings his 14-year-old son to the clinic because the boy is embarrassed by his tender and enlarged breasts. What would be an appropriate nursing intervention for this patient?

A) Teach the patient self-breast examination B) Encourage the patient to verbalize feelings C) Prepare the patient for further testing D) No intervention is needed because findings are within normal limits.

Ans: B Age Group: Child and Adolescent Chapter: 21 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 8, 9

Page and Header: 576, Male Breasts Taxonomic Level: Analysis Feedback: During midpuberty, one or both male breasts commonly and temporarily enlarge as a result of changing hormone levels, a condition referred to as gynecomastia. Pubescent males also may develop breast buds or tenderness, which also is usually temporary. Almost one third of adolescent males have these conditions, which usually resolve in 1 to 2 years. The breasts may also enlarge in adolescent males from adipose tissue related to obesity. It is important to investigate feelings related to body image and sexual identity in adolescent males with enlarged breasts.

18. The nurse practitioner is examining a 41-year-old patient and notes an axillary lymph node approximately 1.5 cm in size, tender, painful, and movable. The NP also notes an erythematous 3-cm abrasion on the patient's upper arm. What nursing diagnosis would the NP include in the plan of care?

A) Infectious process related to abrasions B) Anxiety related to possible diagnosis of breast cancer C) Inflammation related to abrasions D) Risk for falls Ans: B Age Group: Adult Chapter: 21 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 595, Table 21-3 Taxonomic Level: Analysis Feedback: The greatest fear a woman has related to these symptoms is that she has breast cancer, although often the cause is benign. The scenario describes inflammation at the sight of the abrasion; it does not state that the patient has an infectious process. Falls are not a likely priority.

19. A 32-year-old mother of three young children is newly diagnosed with breast cancer. The patient tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the priority nursing diagnosis?

A) Anxiety B) Confusion C) Grieving D) Altered sleeping pattern Ans: C Age Group: Adult Chapter: 21 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 595, Table 21-3 Taxonomic Level: Analysis Feedback: Manifestations of grieving related to loss of breast, functional ability, and cancer diagnosis include sadness, crying, anger, depression, altered eating and sleep patterns, and reliving of past experiences. Anxiety and confusion are less evident and sleep patterns are likely symptomatic of the patient's grief.

Chapter 22: Abdominal Assessment Multiple Choice 1. A nurse is landmarking a patient's abdominal region prior to assessment. The nurse should know that the patient's linea alba is located where?

A) Middle of the ventral abdominal wall B) Lower edge of the costal margin C) Anterior–superior iliac spine of the iliac bones D) Xiphoid process of the sternum Ans: A Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1 Page and Header: 603, Anatomical Landmarks Taxonomic Level: Knowledge Feedback: Four layers of large, flat muscles form the ventral abdominal wall and are joined at the midline by a tendinous seam, the linea alba.

2. The anatomy class is learning about the abdomen. The instructor would tell the class that the abdominal cavity is bordered on the back by A) the lower rib cage.

B) the vertebral column.

C) the kidneys.

D) the midaxillary lines.

Ans: B Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1, 2 Page and Header: 603, Anatomical Landmarks Taxonomic Level: Knowledge Feedback: The abdominal cavity is bordered in the back by the vertebral column and paravertebral muscles and at the sides and front by the lower rib cage and abdominal muscles. This makes the other options incorrect.

3. Changes in patient's health status have necessitated removal of a patient's spleen. What is one of the functions of the spleen?

A) Stores albumin B) Produces white blood cells C) Stores vitamin E D) Activates B and T lymphocytes Ans: D Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 606, Blood Vessels, Peritoneum, and Muscles Taxonomic Level: Knowledge Feedback: The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The spleen does not store albumin or vitamin E, nor does it produce white blood cells.

4. A public health nurse is planning educational interventions for an upcoming campaign. What is a priority focus area for GI tract health?

A) Constipation prevention B) Colorectal cancer screening C) Innovations in hepatitis treatment D) Abdominal auscultation Ans: B Age Group: All Age Groups Chapter: 22 Client Type: Community Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 611, Topics for Health Promotion Taxonomic Level: Application Feedback: Colorectal cancer screening is a priority for health promotion related to the GI tract. This supersedes the importance of constipation prevention, even though this is a relevant topic. Abdominal auscultation is not a priority and it is not normally necessary to elaborate on hepatitis treatment modalities.

5. When assessing a clinic patient, the nurse asks if the patient has ever had varicella. The nurse knows that varicella always precedes what?

A) Impetigo

B) Shingles C) Hepatitis D) Measles Ans: B Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 608, Personal History Taxonomic Level: Knowledge Feedback: Varicella, which always precedes herpes zoster (shingles), may appear along a dermatome on one side of the abdomen and back. Varicella does not result in impetigo, hepatitis, or measles.

6. The nurse is admitting a new patient to the floor and asks if the patient has any dizziness. What is one of the reasons why the nurse does this?

A) To assess for spleen abnormalities B) To assess for pancreatic problems C) To check for possible dehydration D) To check for an absorption problem Ans: C Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 608, Current Concerns Taxonomic Level: Analysis Feedback: Dizziness may result from possible dehydration linked to inadequate fluid or caloric intake. The heart is not within the abdomen. Pancreatic problems do not cause dizziness. An absorption problem would not cause dizziness in and of itself.

7. A student is performing a comprehensive physical assessment on a patient. While assessing the patient's abdomen, the student percusses the spleen. What sound would be normal for the student to hear?

A) Tympany B) Dullness C) Hollow sound D) Friction rub Ans:

A

Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5, 8 Page and Header: 630, Examples of Documentation for Abdomen Assessment Taxonomic Level: Analysis Feedback: The student would percuss at the lowest intercostal space at the left MAL. He or she would ask the patient to take a deep breath and hold it, and then he or she would percuss again. Tympany is normal, but with splenomegaly, tympany turns to dullness on inspiration.

8. When assessing a newly admitted patient, the nurse has conducted a liver span test. What clinical information would the nurse gain from conducting this test?

A) The size of the patient's liver B) The density of the patient's liver C) The level of metabolic function of the liver D) The anatomical relationship between the liver and spleen Ans: A Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 623, Liver Taxonomic Level: Comprehension Feedback: A liver span test gives you an estimate of the size of the liver in the right midclavicular line (MCL). A liver span test does not indicate the density or function of the liver. As well, the test does not identify the relationship between the liver and spleen.

9. The emergency department nurse is getting a shift report about an African Canadian who is reported to have jaundice and splenomegaly. What would the nurse suspect this patient's medical diagnosis to be?

A) Liver disease B) Leukemia C) Sickle cell anemia D) Colon cancer Ans: C Age Group: Adult Chapter: 22 Client Type: Individual

Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 631, Cultural Considerations Taxonomic Level: Analysis Feedback: African Canadians more commonly present with sickle cell anemia, glucose-6-phosphate dehydrogenase deficiency, and lactose intolerance. Those with sickle cell disease may have splenomegaly and jaundice on examination. This ethnic background and clinical presentation are not closely associated with liver disease, leukemia, or colon cancer.

10. While auscultating a patient's abdomen, the student notes abnormal bowel sounds. The nurse's preceptor asks the student to describe the sounds, and the student describes them as high-pitched, rushing sounds. The preceptor, an experienced nurse, would know that these sounds indicate what?

A) Diarrhea B) Adynamic ileus C) Intestinal fluid D) Partial intestinal obstruction Ans: D Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 620, Auscultation Taxonomic Level: Analysis Feedback: High-pitched, rushing sounds indicate partial intestinal obstruction.

Increased bowel sounds occur with diarrhea and early intestinal obstruction.

Decreased bowel sounds occur with adynamic ileus and peritonitis. High-pitched, tinkling bowel sounds indicate intestinal fluid, air under tension in a dilated bowel, and inadequate bowel sounds.

11. The nurse is caring for a patient who is vomiting. When inspecting the vomitus, the nurse notes that it has an appearance of coffee grounds. This would indicate what to the nurse?

A) Digested blood B) Decreased peristalsis C) Active bleeding D) Undigested blood Ans: A Age Group: All Age Groups Chapter: 22

Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 619, Inspection Taxonomic Level: Analysis Feedback: Medications or diseases may cause emesis. Green emesis usually results from reduced peristalsis with irritation. Coffee-ground emesis is digested blood; bloody emesis is an active bleed with undigested blood.

12. The nurse is assessing a patient and notes dullness to percussion in the lowest point of the patient's abdomen. When rolling the patient to the left, the nurse notes that there is now dullness on the left side. The nurse is aware that this may indicate ascites, which can be caused by A) chronic heart failure or pyelonephritis.

B) cirrhosis or liver cancer.

C) metastatic neoplasms or coronary artery disease.

D) ruptured spleen or excess fat intake.

Ans: B Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 628, Assessing for Ascites Taxonomic Level: Comprehension Feedback: Ascites is the accumulation of fluid in the abdomen and is typically caused by cirrhosis or malignant neoplasms of the liver.

13. An emergency department nurse is caring for a 17-year-old patient who has severe pain in the umbilical area. Documentation shows that the patient exhibits a positive Rovsing sign. What might this patient's medical diagnosis be?

A) Gastroenteritis B) Liver disease C) Appendicitis D) Enlarged spleen Ans: C Age Group: Child and Adolescent Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9

Page and Header: 641, Table 22-5 Taxonomic Level: Knowledge Feedback: Rovsing sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen.

14. A nurse is mentally reviewing the anatomy of a patient's abdominal region prior to assessment. What organ in the abdomen provides the blood vessels to the intestinal tract?

A) Mesentery B) Aorta C) Peritoneum D) Spleen Ans: A Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 606, Blood Vessels, Peritoneum, and Muscles Taxonomic Level: Knowledge Feedback: The fan-like mesentery supplies blood vessels and nerves to the intestinal tract. The aorta, peritoneum, and spleen do not perform this role.

15. Nursing students are learning how to identify different areas of the abdomen.

What is the lower middle area called?

A) Epigastric B) Hypogastric C) Hypochondriac D) Inogastric Ans: B Age Group: All Age Groups Chapter: 22 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 603, Reference Lines Taxonomic Level: Knowledge Feedback: The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbical, left lumbar, right inguinal, hypogastric, and left inguinal.

Chapter 23: Musculoskeletal Assessment Multiple Choice 1. A 23-year-old female athlete presents with pain in her tibiotalar joint. The terms used to describe the movements at this joint are what?

A) Adducting and abducting B) Dorsiflexion and plantar flexion C) Supination and pronation D) Rotation and supination Ans: B Age Group: Adult Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 651, Ankle and Foot Taxonomic Level: Knowledge Feedback: The terms used to describe the movements of the tibiotalar joint are dorsiflexion and plantar flexion. No other movements are possible at this joint.

2. A nurse is reading the radiology report about a patient on an orthopedic unit. The report describes in detail some characteristics of the patient's metacarpophalangeal joint. Where is this joint located?

A) In the finger B) In the hand C) Between the hand and the finger D) In the distal foot Ans: C Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 649, Wrist and Hand Taxonomic Level: Knowledge Feedback: The metacarpophalangeal (“first knuckle”) and intraphalangeal joints (“second knuckle” and “third knuckle”) permit finger movement.

3. A toddler has been diagnosed with genu valgum, which has an effect on her ambulation. What is the other name for this disease?

A) “Club foot” B) “Flat feet” C) “Bowlegs” D) “Knock knee” Ans: D Age Group: Child and Adolescent Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 693, Table 23-13 Taxonomic Level: Comprehension Feedback: Many children have a temporary period of genu valgum, but persistent knock knee may be genetic or the result of metabolic bone disease.

4. A nurse is assessing a newly admitted, elderly patient according to the Morse Fall Scale. When determining the patient's score on this assessment scale, the nurse will consider the patient's A) cognition.

B) continence.

C) motivation.

D) body mass index (BMI).

Ans: A Age Group: Older Adult Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3, 4 Page and Header: 682, Box 23-1 Taxonomic Level: Application Feedback: The Morse Fall Scale considers variables such as mental status, history of falls, diagnoses, ambulatory aids, and use of IVs. Continence, motivation, and BMI are not assessment parameters of the Morse Fall Scale.

5. At birth, an infant is diagnosed with congenital hip dislocation. What is a confirmatory test for this disease?

A) Barlow-Ortolani manoeuvre B) Heberden test C) Bouchard test

D)

Phalen test

Ans: A Age Group: Infant Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 7 Page and Header: 682, Newborns, Infants, and Children; 683, Figure 23-29; 694, Table 23-13 Taxonomic Level: Application Feedback: In congenital hip dislocation, the head of the femur is displaced from the acetabulum. This condition is seven times more common in females. Signs include asymmetric gluteal creases, uneven limb length, and limited abduction of the flexed thigh. Diagnosis for newborns is a positive Barlow-Ortolani sign. Older children will have a positive Trendelenburg sign. Heberden nodes are hard, nontender bony growths on the distal intraphalangeal joints, while Bouchard nodes are the same finding on the proximal intraphalangeal joints. The Phalen test is positive in carpal tunnel syndrome.

6. A patient's recent falls have been attributed to a balance disorder. What would be an advanced method of assessing balance in this patient?

A) Walking with the eyes closed B) Deep knee bends C) Romberg test D) Phalen test Ans: C Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 663, Balance Taxonomic Level: Application Feedback: To assess balance, the nurse asks the patient to walk on tiptoes, on heels, in heel-to-toe fashion (tandem walking), and backward. The patient should also step to each side and sit down and stand. Advanced assessment of balance includes the Romberg test, standing, and hopping on one foot. The Phalen test is positive in carpal tunnel syndrome. Deep knee bends are not used to assess balance.

7. An older adult patient comes to the clinic and reports a sore knee. The nurse notes occasional popping and cracking noises when the patient attempts to bend the knee.

The patient exhibits signs of pain by her facial expression. The nurse knows that the

popping and cracking noises should be charted as what?

A) Crepitus B) Grating C) Tactile emphysema D) Popping and cracking noises Ans: A Age Group: Older Adult Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 664, Palpation Taxonomic Level: Application Feedback: Crepitus may be heard as a popping sound and may be felt as grating in the joint as it moves. Therefore, other options are incorrect.

8.

A) B) C) D)

When assessing a patient's strength, it is necessary to compare one side to the other. assess the left and right extremities at the same time. compare upper and lower extremities. assess upper and lower extremities at the same time.

Ans: A Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 664, Palpation Taxonomic Level: Application Feedback: When assessing muscle tone and strength, it is necessary to compare one side to the other. It is not necessary to perform simultaneous comparisons, however, or to directly compare upper extremities to lower extremities.

9. A patient is admitted to the unit. The nurse notes that the health record for this patient lists a score of 75 per the Morris Fall Risk scale. What would be an appropriate nursing intervention?

A) Restrain the patient B) Use environmental cues C) Encourage the patient to ambulate independently D) Encourage the patient to use canes bilaterally Ans:

B

Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Health and Wellness Difficulty: Difficult Objective: 8 Page and Header: 682, Box 23-1 Taxonomic Level: Application Feedback: A score of 51 indicates a risk for falling and indicates a need for preventive interventions. Examples include frequent reminders, a bed alarm, or environmental cues. Restraints and bilateral use of canes are not typical interventions.

10. Which of the following tools would an advanced practice nurse be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a patient?

A) Flashlight B) Gradiometer C) Thermometer D) Goniometer Ans: D Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 662, Equipment; 664, Joint Range of Motion.

Taxonomic Level: Comprehension Feedback: A goniometer measures the angle at which a joint can flex or extend.

Nurses do not use thermometers, flashlights, or gradiometers during common musculoskeletal assessments.

11. A nurse has just finished assessing a patient's spine and neck muscles. How would the nurse document normal findings?

A) C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender B) All findings within normal limits C) Neck assessment WNL D) C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender Ans: D Age Group: All Age Groups Chapter: 23

Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 651, Spine; 667, Inspection Taxonomic Level: Application Feedback: Normal findings are that the patient's C7 and T1 spinous processes are prominent. The paravertebral, sternocleidomastoid, and trapezius muscles are fully developed, symmetrical, and nontender. Therefore, the other listed options are incorrect.

12. The nurse is assessing the musculoskeletal system of a 17-year-old boy for participation in athletics. The nurse would expect to find that this patient's bones are what as compared to a female of the same age?

A) No difference B) Larger and stronger C) Longer and stronger D) More curved Ans: B Age Group: Child and Adolescent Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 8 Page and Header: 653, Cultural Considerations Taxonomic Level: Analysis Feedback: Gender affects the skeletal system. Males have larger and stronger bones than women; therefore, males are less prone to problems related to osteoporosis.

Male bones are not the same as female bones; they are not necessarily longer and they do not have a greater curvature.

13. Many variations related to ethnicity are visible in the musculoskeletal system.

Which of the following is an accurate characterization of typical variations?

A) Caucasians have intermediate curves in their femurs.

B) Asian Canadians have denser bones than other races.

C) Aboriginal Canadians typically have straight femurs.

D) African Canadians have low bone density.

Ans: A Age Group: All Age Groups Chapter: 23 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate

Objective: 8 Page and Header: 653, Cultural Considerations Taxonomic Level: Knowledge Feedback: The curvature of long bones results from both ethnicity and body weight.

African Canadians have straight femurs, while Aboriginal Canadians have anteriorly curved femurs. The femoral curve in Caucasians is intermediate. Asian ethnicity is not noted to be linked to increased bone density.

14. The nurse is receiving report on an adult patient with a nursing diagnosis of activity intolerance. What would likely be the most appropriate nursing intervention for this patient?

A) Use orthopedic footwear B) Promote reconditioning C) Promote bed rest D) Promote nutrition Ans: B Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 684, Table 23-9 Taxonomic Level: Application Feedback: For the patient with activity intolerance, the nurse would determine the cause of intolerance and promote reconditioning. For many patients, footwear is not going to solve the problem of activity tolerance. Bed rest is usually counterproductive, and nutrition alone will not resolve activity intolerance, though adequate nutrition is necessary for the maintenance of normal activity.

15. The nurse is developing a plan of care for a patient found to have a new onset of weakness that limits her ability to dress herself. What would be the most relevant nursing diagnosis for this patient?

A) Activity intolerance B) Self-care deficit C) Impaired physical mobility D) Impaired walking Ans: B Age Group: All Age Groups Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5, 9

Page and Header: 684, Table 23-9 Taxonomic Level: Analysis Feedback: Self-care deficit is defined as the inability to perform activities of daily living independently.

16. An 87-year-old patient has been admitted to the gerontology unit. This patient has problems with fine motor movement. The nurse should anticipate that this patient will require assistance with A) opening packages and feeding herself.

B) identifying the need to void.

C) using assistive devices for ambulation.

D) transferring from her bed to the commode.

Ans: A Age Group: Adult of advanced age Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 663, Coordination Taxonomic Level: Application Feedback: Fine motor skills are necessary to perform tasks such as opening packages and manipulating eating utensils. Fine motor skills are not needed to identify elimination needs. Assistive devices and transfers are more dependent on gross motor skills.

17. A 13-year-old boy is brought to the emergency department with an injury to his left ankle after a skateboard accident. Diagnostic imaging shows a fracture across the epiphyses. The doctor explains that the patient may not have full ROM and that his left leg may be shorter than his right leg. The parents ask why one leg may be shorter than the other. What would be the nurse's best answer?

A) “The epiphysis is the growth plate.”

B) “The fracture crosses the part of the bone where the bone lengthens.”

C) “Any fracture of a bone has the potential of decreasing length in the leg bone.”

D) “Bone growth in boys generally stops about this time.”

Ans: B Age Group: Child and Adolescent Chapter: 23 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2, 8 Page and Header: 652, Infants and Children Taxonomic Level: Application

Feedback: Bones elongate by increasing the cartilage at epiphyses, or growth plates, at the ends of long bones. The cartilage later calcifies. This lengthening continues until approximately 21 years, when the epiphyses close. Any injury to the epiphyses before closure may result in bone deformity.

Chapter 24: Neurological Assessment Multiple Choice 1. Which of the following would the nurse expect to assess if a patient has a lesion of the sympathetic nervous system?

A) Bilateral dilated pupils B) Unilateral dilated pupil C) Argyll Robertson pupils D) Constricted pupil unresponsive to light Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 750, Table 24-9 Taxonomic Level: Analysis Feedback: A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve III. Argyll Robertson pupils are associated with central nervous system syphilis, meningitis, brain tumour, or alcoholism.

2. A patient has sustained an injury to the cerebellum. Which of the following areas would be the nurse's primary area for assessment?

A) Judgment B) Mood and affect C) Cardiac function D) Coordination Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 725, Coordination (Cerebellar Function) Taxonomic Level: Application

Feedback: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination.

3. A neurological nurse is caring for a patient whose recent level of consciousness has been described as stupor. The nurse would expect that this patient A) has significant lapses in memory.

B) is exhibiting irrational behaviour.

C) is unconscious.

D) can be roused only by vigorous stimulation.

Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9, 10 Page and Header: 718, Table 24-3 Taxonomic Level: Application Feedback: Stupor is defined as being present when the patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation. Consequently, the patient would not be exhibiting irrational behaviour or memory deficits.

4. The nurse assesses brisk reflexes in a patient. The nurse would document this finding as which of the following?

A) 1 + B) 2 + C) 3 + D) 4 + Ans: C Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 730, DTRs Taxonomic Level: Application Feedback: Brisk reflexes or reflexes that are more active than normal are documented as 3 +. Reflexes that are decreased and less active than normal are documented as 1 +, reflexes that are normal are documented as 2 +, and reflexes that are hyperactive and very brisk with rhythmic oscillations are documented as 4 +.

5. A nurse is having difficulty eliciting a patellar reflex from a neurological patient.

Which of the following would be most appropriate for the nurse to have the patient do?

A) Lock his fingers together and pull against each other B) Clench his jaw tightly C) Squeeze his thigh with his opposite hand D) Stretch his arms overhead Ans: A Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5 Page and Header: 731, Table 24-5 Taxonomic Level: Application Feedback: Having the patient interlock his or her hands is a reinforcement technique that aids in enhancing the reflex response in the legs. Clenching the jaw or having the patient squeeze one thigh with the opposite hand would be a reinforcement technique for testing arm reflexes. Stretching the arms overhead would be inappropriate.

6. Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the patient's trigeminal nerve?

A) Ask the patient to differentiate sharp and dull sensations on his or her face B) Have the patient smile, frown, and wrinkle the forehead C) Palpate the temporal and masseter muscles while the patient clenches his or her teeth D) Assess dilatation of pupils with direct light Ans: C Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 8 Page and Header: 719, Cranial Nerve Testing Taxonomic Level: Application Feedback: To test the motor function of the trigeminal nerve (CN V), the nurse would ask the patient to clench the teeth and palpate the temporal and masseter muscles for contraction. Touching the patient's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the patient frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VI).

Assessing pupillary dilation tests the oculomotor (CN III) nerve.

7.

Which of the following assessment findings would lead the nurse to suspect that a

patient has Bell palsy?

A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side Ans: B Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 8 Page and Header: 720, Table 24-4 Taxonomic Level: Evaluation Feedback: Inability to close eyes, wrinkle forehead, or raise forehead, along with paralysis of the lower part of the face on the affected side is seen with Bell palsy.

Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma.

Paralysis, not muscle spasm, occurs with Bell palsy.

8. When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

A) Stationary soft palate on phonation B) Deviation of uvula when the patient says “ah” C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 8 Page and Header: 719, Cranial Nerve Testing Taxonomic Level: Analysis Feedback: Normal findings associated with testing CN IX and CN X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.

9. The nurse is preparing to assess balance in an older adult patient. Which of the following tests would the nurse plan on possibly omitting from the exam?

A) Romberg test B) Tandem walking

C) Gait assessment D) Hop on one foot Ans: D Age Group: Older adult Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 735, Older Adults Taxonomic Level: Application Feedback: Hopping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the patient at risk. The nurse needs to ensure the patient's safety by standing close by, especially with tandem walking and Romberg testing because some older patients may have difficulty with maintaining balance. However, these tests would not be omitted. Older patients may have a slow uncertain gait. This test, however, would not be omitted.

10. When explaining to a colleague how to test graphesthesia, which of the following would the nurse include?

A) The patient will close the eyes and identify what number the nurse writes in the palm of the patient's hand with a blunt-ended object.

B) The patient is to identify the numbers of points felt when the nurse touches the patient with the ends of two applicators at the same time.

C) The nurse will simultaneously touch the patient in the same area on both sides of the body and the patient will identify where the touch occurred.

D) The nurse will briefly touch the patient and the patient will need to identify where the touch occurred.

Ans: A Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 728, Discriminative Sensations Taxonomic Level: Application Feedback: Graphesthesia is the ability to identify what is being drawn on the patient's body when the patient's eyes are closed. Two-point discrimination is tested by having the patient identify the number of points felt when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the patient in the same area on both sides of the body at the same points and having the patient identify the area touched. Point localization is tested by briefly touching the patient and then asking the patient to identify the points touched.

11. When documenting the findings of a neurologic assessment, which of the following guidelines should the nurse follow?

A) Verify the data with the patient before documenting B) Describe the patient's response C) Label the patient's behaviour D) Record objective data solely Ans: B Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 736, Serial Neurological Assessment and Documentation Taxonomic Level: Application Feedback: When documenting the neurologic assessment findings, it is important to describe the patient's response rather than label the behaviour. Subjective and objective data must be documented and these are not normally verified with the patient.

12. During the Romberg test, a patient is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 725, Techniques and Expected Findings; 752, Table 24-11 Taxonomic Level: Analysis Feedback: A wide-based, staggering, unsteady gait and positive Romberg test (patient unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the patient drags the toes of the leg or circles it stiffly outward and forward. A parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.

13. A patient who has recently experienced a stroke and currently has spontaneous eye opening follows commands accurately. The patient is oriented to name but not to time or place. What is this patient's score on the Glasgow Coma Scale?

A) 10 B) 12 C) 14 D) 16 Ans: C Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 717, Box 24-2 Taxonomic Level: Application Feedback: Spontaneous eye opening represents four points on the GCS and following commands earns six points. Confused conversation, however, results in four points.

14. When preparing to test a patient for meningeal irritation, which of the following would be most important for the nurse to do first?

A) Check for evidence of fever and chills B) Ensure the patient has no injury to the cervical spine C) Position the patient prone D) Check for a Babinski reflex Ans: B Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 2 Page and Header: 736, Assessment of Meningeal Signs Taxonomic Level: Application Feedback: Before testing a patient for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise, injury could occur because testing involves flexing the neck.

15. When evaluating a patient's risk for cerebrovascular accident, which patient would the nurse identify as likely being at highest risk?

A) 42-year-old Caucasian woman who smokes B) 68-year-old African Canadian male with hypertension C) 55-year-old Caucasian male who has two beers a week

D)

35-year-old African Canadian who has sleep apnea

Ans: B Age Group: Older Adult Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 699, Clinical Significance 24-1; 709, Questions to Assess History and Risk Factors/Rationale; 710, Stroke Prevention Taxonomic Level: Evaluation Feedback: Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African background, hypertension, smoking, chronic alcohol intake (more than three drinks per day), and sleep apnea among others. In the patients listed, the 68-year-old African Canadian male with hypertension has the greatest risk due to his age, race, and hypertension. The other patients would be at risk, but the risk would likely be less.

16. A nurse is preparing to assess the cranial nerves of a patient and is about to test CN I. Which of the following would the nurse do?

A) Use a Snellen chart to test visual acuity B) Ask the patient to identify scents C) Test extraocular eye movements D) Perform the Weber test Ans: B Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 720, Table 24-4 Taxonomic Level: Application Feedback: Cranial nerve I is the olfactory nerve, which would be tested by having the patient occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).

17. A nursing instructor is describing the peripheral nervous system to a group of students; the instructor would explain that there are how many pairs of spinal nerves?

A) 8 B) 11 C) 24

D)

31

Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 705, Spinal Nerves Taxonomic Level: Knowledge Feedback: The peripheral nervous system consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves.

18. Which of the following would lead the nurse to suspect meningeal irritation?

A) Hips and knees remain relaxed and motionless when the neck is flexed.

B) Reports of decreased pain with flexion of the hips and knees C) Discomfort behind the knee with full extension of the leg D) Pain and flexion of the hips and knees with neck flexion Ans: D Age Group: All Age Groups Chapter: 24 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 736, Assessment of Meningeal Signs Taxonomic Level: Analysis Feedback: Pain and flexion of the hips and knees are positive Brudzinski signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the patient's leg is flexed at both the hip and the knee and then straightened are positive Kernig signs suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig sign occurs in many normal people.

Chapter 25: Male Genitalia and Rectal Assessment Multiple Choice 1. A nurse is reviewing male anatomy and physiology prior to conducting a genitourinary assessment. Where is the corona of the patient's penis found?

A) At the base of the glans B) At the root of the penis C) At the tip of the glans D) At the root of the corpus spongiosum Ans: A Age Group: All Age Groups Chapter: 25 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 1 Page and Header: 756, External Genitalia Taxonomic Level: Knowledge Feedback: The urethra is located in the middle of the corpus spongiosum, which ends in the cone-shaped glans with its expanded base or corona.

2. During health class, a student asks the school nurse about the function of the testicles. What would be the nurse's best reply?

A) To produce smegma B) To produce testosterone C) To produce estrogen D) To produce ejaculatory fluid Ans: B Age Group: Child and Adolescent Chapter: 25 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 757, Testes Taxonomic Level: Knowledge Feedback: The functions of the testicles are to produce spermatozoa (sperm) and testosterone. The function of the testicles is not to produce smegma, estrogen, or ejaculatory fluid.

3. The nurse is conducting a focused assessment of a male patient. Where will the nurse landmark the patient's rectum?

A) Inferior to the anus B) At the junction of the sigmoid and transverse colon C) Superior to the anus D) Superior to the rectal ampulla Ans: C Age Group: All Age Groups Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 758, Rectum Taxonomic Level: Application Feedback: The rectum is approximately 12 cm long and is superior to the anus.

4. In men, what anatomical structures are located on either side of the urethra just below the prostate gland?

A) Skene glands B) Bartholin glands C) Seminiferous glands D) Bulbourethral glands Ans: D Age Group: All Age Groups Chapter: 25 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 757, Secretory Structures Taxonomic Level: Knowledge Feedback: The bulbourethral glands are located on either side of the urethra immediately below the prostate gland. Skene and Bartholin glands are not found in males.

5. One of the major health promotion goals is to reduce the proportion of adolescents and young adults with sexually transmitted infections (STIs). What subject would be most appropriate to teach male members of this population to reduce the incidence of STIs? A) Use of a diaphragm B) E. coli infections C) Modes of transmission

D)

Use of spermicides

Ans: C Age Group: All Age Groups Chapter: 25 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 761, Box 25-1 Taxonomic Level: Application Feedback: To reduce the proportion of adolescents and young adults with STIs, teaching would be on modes of transmission and condom use. Providing education on the use of a diaphragm, E. coli infections, or use of spermicides would not be appropriate educational topics for this scenario.

6. A 47-year-old man comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, “Do you have any current or chronic illnesses such as diabetes, hypertension, neurologic impairment, respiratory problems (asthma, COPD, chronic bronchitis), or cardiovascular disease?” Why does the nurse ask this question?

A) To assess risk for erectile dysfunction B) To refer the patient to a pulmonologist C) To assess risk for incontinence D) To determine the need for involvement from an internist Ans: A Age Group: Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2, 3 Page and Header: 761, Personal History Taxonomic Level: Analysis Feedback: Men with diabetes, hypertension, neurologic impairment, respiratory problems (asthma, COPD, chronic bronchitis), or cardiovascular disease are at increased risk for erectile dysfunction.

7. The nurse is conducting an examination of a 27-year-old male's genitalia during his annual physical examination. The patient has an erection, and the nurse reassures him that this is a normal physiologic response and continues the examination. Why would the nurse continue with the examination at this time?

A) The nurse will obtain more accurate data if the patient is focused on his erection.

B) Stopping the assessment could cause further embarrassment.

C) It is to demonstrate to the patient that he has a normal sexual response.

D)

It is better to assess the penis when it is erect.

Ans: B Age Group: Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 767, Clinical Significance 25-3 Taxonomic Level: Analysis Feedback: If the patient has an erection during the physical examination, reassure him that this is a normal physiologic response to touch that he could not have prevented. Do not stop the examination—doing so could cause further embarrassment.

8. During the examination of a 72-year-old man, the nurse practitioner (NP) learns the patient has a history of BPH. During a digital rectal exam, how would the NP expect the patient's prostate gland to feel?

A) Tender B) Hard, nodular C) Rubbery D) Firm, nontender Ans: C Age Group: Older adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 771, Prostate Taxonomic Level: Evaluation Feedback: A rubbery or boggy glandular consistency suggests BPH, a common finding in men older than 60 years. A tender testicle, one that is hard and nodular, or a firm and nontender testicle is not indicative of BPH. 9. While preparing to conduct a rectal examination on a 67-year-old man, the nurse notes the patient has a history of cancer. The nurse should know that peritoneal metastases create what in the peritoneum?

A) Nodularity B) Edema C) Anal inflammation D) Extreme rectal pain Ans:

A

Age Group: Older Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 771, Anus Taxonomic Level: Knowledge Feedback: Because the anterior rectal wall is in contact with the peritoneum, the nurse may be able to detect the tenderness of peritoneal inflammation and nodularity of peritoneal metastases. Peritoneal metastases do not cause edema, anal inflammation, or extreme rectal pain.

10. The nurse is caring for a 72-year-old man who is postoperative day one following surgery on his rectum and perineum. What would be an appropriate intervention for this patient?

A) Explain the procedure to the patient B) Teach the patient exercises to strengthen the pelvic floor C) Administer enemas PRN D) Teach the patient how to keep the rectum clean Ans: B Age Group: Older Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 774, Nursing Diagnosis, Outcomes, and Interventions Taxonomic Level: Application Feedback: Teaching the patient exercises to strengthen the pelvic floor will help restore function to the area. It would not be appropriate to explain the procedure to the patient, because the procedure has already been done. The nurse cannot teach the patient how to keep the rectum clean, because the rectum is an internal organ of the body. Enemas would be contraindicated following rectal surgery.

11. A clinic nurse is admitting a 16-year-old boy with complaints of itching and burning in his penis. He tells you “I am sure I have an STI. This will be the third one in 6 months.” What intervention would be most appropriate with this patient?

A) Provide samples of spermicides to the patient B) Provide the patient with educational material on testicular cancer C) Assess the patient's knowledge and understanding of safe sexual practices D) Teach the patient correct measures to prevent pregnancy Ans: C Age Group:

Child and Adolescent

Chapter: 25 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 774, Table 25-2 Taxonomic Level: Synthesis Feedback: The nurse needs to assess this patient's knowledge and understanding of safe sexual practices to ensure correct teaching and prevention. Spermicides will not protect the patient from future STIs. The patient's situation does not involve testicular cancer. The patient's most immediate problem is recurring STIs, not pregnancy prevention.

12. The nurse is documenting current health concerns during the health history of a 63-year-old man. What information related to genitourinary health should the nurse prioritize during this phase of assessment?

A) Number of sexual partners B) Knowledge of STIs C) Fluid intake D) Previous genitourinary problems Ans: D Age Group: Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 761, Medical and Surgical History Taxonomic Level: Application Feedback: Identification of previous problems may help when documenting current health concerns. The other given topics are all relevant, but previous problems are a key focus during the health history.

13. A patient has asked about the process of sperm production. How often is mature sperm generated?

A) Every 90 days B) Every 75 days C) Every 60 days D) Every 45 days Ans: A Age Group: Adult Chapter: 25 Client Type: Individual Competency Category: Health and Wellness

Difficulty: Easy Objective: 1 Page and Header: 757, Testes Taxonomic Level: Knowledge Feedback: Mature sperm is generated approximately every 90 days.

14. A 76-year-old man has come to the clinic for his annual physical examination.

The nurse knows that the fibromuscular structures of the prostate gland in this patient have likely atrophied with aging. What health problem may disguise this age-related change in physiology?

A) Prostate nodules B) Benign prostatic hyperplasia (BPH) C) Perineal cancer D) Penile cancer Ans: B Age Group: Older Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 3 Page and Header: 760, Older Adult Taxonomic Level: Comprehension Feedback: As the male ages, the fibromuscular structures of the prostate gland atrophy. Ironically, benign hyperplasia of the glandular tissue often obscures the atrophy of aging. Prostate nodules, perineal cancer, and penile cancer would not obscure this natural physiologic process.

15. A 19-year-old man has come to the emergency department with purulent drainage from an area on his penis that was pierced 48 hours ago. What would be most important for the nurse to discuss with the patient?

A) Treatment and avoidance of infection B) Significance of the piercing to the patient C) Where the piercing was done D) Sensation in the area of the piercing Ans: A Age Group: Adult Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 760, Cultural Considerations Taxonomic Level: Application

Feedback: In the last 10 years, genital piercing has increased in popularity.

Nevertheless, it can be an unexpected finding for the nurse during an assessment of the male genitalia. In a professional nonjudgmental manner, it is important to talk to the patient about the care of the piercing. Because this site is very prone to infection, discussion should involve how the patient cleans the piercing and ways to avoid infection. It would not be as important for the nurse to elicit from the patient the significance of the piercing, the sensation in the area of the piercing, or where the piercing was done.

16. A 17-year-old male patient is admitted to the emergency department with an acute scrotum. One nursing diagnosis for this patient is severe pain related to acute scrotum. What condition has the potential to cause a medical diagnosis of acute scrotum?

A) Hernia B) Hydrocele C) Orchiectomy D) Phimosis Ans: A Age Group: Child and Adolescent Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 760, Acute Assessment Taxonomic Level: Analysis Feedback: Six conditions can result in an acute scrotum: ischemia, trauma, infectious conditions, inflammatory conditions, hernia, and acute situations accompanying a chronic condition (e.g., testicular tumour with rupture). Although differential diagnosis is broad, an accurate physical assessment and history can often accurately define the condition. Hydroceles, phimosis, and orchiectomies do not cause this problem.

17. A 49-year-old man comes to the clinic complaining of awakening at night to void every 2 hours. The patient has a history of bladder irritation. What would be an appropriate nursing diagnosis for this patient?

A) Ineffective sexuality pattern B) Risk for infection C) Risk for urge incontinence D) Urinary retention Ans: C Age Group: Adult Chapter: 25 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 774, Table 25-2 Taxonomic Level: Analysis Feedback: The most appropriate nursing diagnosis is risk for urge incontinence related to irritation of bladder. Risk factors for this diagnosis are voiding more than once every 2 hours and awakening at night. Irritation is not synonymous with infection and there is no evidence of sexual dysfunction or urinary retention.

18. An uncircumcised male with poorly controlled diabetes is being seen in the clinic.

The patient is found to have scars and narrowing of the urethral opening. What condition would the nurse suspect?

A) Balanoposthitis B) Epispadias C) Paraphimosis D) Phimosis Ans: A Age Group: All Age Groups Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 779, Table 25-4 Taxonomic Level: Analysis Feedback: Balanitis or balanoposthitis is inflammation of the glans and prepuce and occurs in uncircumcised men, many of whom have poorly controlled diabetes. Scars and narrowing of the urethral opening may cause inflammation, infections, and foul discharge. The scarring may make it difficult to clean under the foreskin.

19. A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition?

A) Phimosis B) Hypospadias C) Epispadias D) Paraphimosis Ans: B Age Group: Infant Chapter: 25 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate

Objective: 6 Page and Header: 779, Table 25-4 Taxonomic Level: Analysis Feedback: With hypospadias, the urethral meatus opens on the ventral side of the penis. The deviation of the meatus makes it difficult to urinate when standing. The physical appearance of the penis is altered, sometimes causing body image disturbances. Phimosis is when the prepuce cannot be retracted over the glans.

Paraphimosis occurs when the retracted prepuce cannot be placed back over the glans. Epispadias occurs when the urethral meatus opens on the dorsal surface of the penis.

Chapter 26: Female Genitalia and Rectal Assessment Multiple Choice 1. A nurse is teaching a sex education class at the local high school. In a pre-lecture quiz, the nurse asks what the two small folds that extend from the clitoral hood to the posterior fourchette of the vagina are called. What would be the correct answer?

A) Labia minora B) Labia majora C) Posterior fourchette D) Vestibule Ans: A Age Group: Child and Adolescent Chapter: 26 Client Type: Group Competency Category: Health and Wellness Difficulty: Easy Objective: 1 Page and Header: 790, External Genitalia Taxonomic Level: Knowledge Feedback: The ventral surface of the glans is known as the frenulum and is where the labia minora, two small folds that extend from clitoral hood to the posterior fourchette of the vagina, fuse.

2. A student nurse is caring for a patient who is postoperative day one following a hysterectomy. The clinical instructor asks the students what ligaments support the uterus. Which of the following responses is correct?

A) Ordinal B) Cardinal C) Distal D) Proximal Ans: B Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 790, Uterus Taxonomic Level: Knowledge Feedback: The freely mobile uterus is supported bilaterally by the round, cardinal,

uterosacral, and broad ligaments.

3. During a health class, a participant asks the nurse where in the body fertilization most often takes place. What would be the nurse's best answer?

A) Ovary B) Fimbriae C) Ampulla D) Fallopian tube Ans: C Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 790, Fallopian Tubes Taxonomic Level: Knowledge Feedback: Fertilization most often occurs in the ampulla portion of the fallopian tubes. Fertilization does not generally take place in the ovary or the fimbriae.

“Fallopian tube” is a more general response than the correct answer.

4. A nurse is reviewing a female patient's diagnostic imaging results with a colleague. What ligament holds the patient's ovaries in place?

A) Infundibuloabdominal B) Pelvic C) Round D) Infundibulopelvic Ans: D Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Health and Wellness Difficulty: Difficult Objective: 1 Page and Header: 791, Ovaries Taxonomic Level: Knowledge Feedback: The ovaries are held in place by ligaments called the infundibulopelvic and ovarian ligaments.

5. In what Tanner stage is female pubic hair darker, coarser, and curled, spreading sparsely over the junction of the mons pubis?

A) Stage 1 B) Stage 2

C) Stage 3 D) Stage 4 Ans: C Age Group: Child and Adolescent Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 793, Table 26-1 Taxonomic Level: Analysis Feedback: In Tanner Stage 3, hair is considerably darker, coarser, and more curled.

It spreads sparsely over the junction of the mons pubis. Stage 1 has no pubic hair; Stage 2 has long, slightly pigmented, downy hair that is straight or only slightly curled chiefly along the labia. Stage 4 has pubic hair that is adult in type, but the area covered by it is still considerably smaller than in most adults. There is no spread to the medial surface of the thighs.

6. A pediatric nurse is aware that cultural considerations influence the onset of puberty. In African Canadian girls, puberty may sometimes begin before what age?

A) 8 years B) 9 years C) 10 years D) 11 years Ans: A Age Group: Child and Adolescent Chapter: 26 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 792, Infants, Children, and Adolescents Taxonomic Level: Knowledge Feedback: African Canadian girls may begin puberty before 8 years.

7. A 74-year-old woman comes to the clinic for her yearly examination. What would be an appropriate question to ask this patient during the nursing assessment?

A) What do you know about safer sex?

B) Are your relationships fulfilling?

C) Are you sexually active?

D) When did you and husband stop sexual activity?

Ans: C Age Group:

Older Adult

Chapter: 26 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 803, Older Adults Taxonomic Level: Application Feedback: Regular sexual activity is normal in older women and encouraged unless it causes pain. Determining the patient's sexual activity must precede sexual health education. Asking if the patient has fulfilling relationships is vague and imprecise.

8. A 16-year-old girl has been brought to the clinic by her mother, who reports that her daughter has a boyfriend with whom she is considering becoming sexually active.

What should the nurse do to make the patient as comfortable as possible during the nursing assessment?

A) Reassure the patient that all information is kept confidential B) Speak with the mother in private before the assessment C) Speak with the patient and her mother with a witness present D) Ask the patient if she would like to have a friend present for the assessment Ans: A Age Group: Child and Adolescent Chapter: 26 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 3, 4 Page and Header: 792, Infants, Children, and Adolescents Taxonomic Level: Application Feedback: When obtaining the history, the room should be private and comfortable, and the nurse should be seated at eye level or lower to the patient. The nurse should reassure the patient that all information is kept confidential. Witnesses and the patient's peers are not necessary. It would be inappropriate to speak with the mother about the patient without the patient being present.

9. A 24-year-old woman presents at the clinic stating, “I think I have a yeast infection.” The nurse notes this is the third time in the past 90 days that this patient has been to the clinic for yeast infections. What should the nurse consider as a comorbidity with this patient?

A) Recreational drug use B) Diabetes C) Infectious hepatitis A D) Cervical cancer Ans: B Age Group:

Adult

Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5, 6 Page and Header: 795, Personal History Taxonomic Level: Analysis Feedback: A patient with recurring yeast infections should be evaluated for diabetes and HIV. Yeast infections are not directly associated with drug use, hepatitis, or cervical cancer.

10. A public health goal is to reduce the proportion of adolescents and adults with chlamydia, gonorrhea, syphilis, genital herpes, pelvic inflammatory disease, and HIV infections. What related health promotion measure would be most important to teach a patient?

A) Teach that “the pill” helps guard against STIs B) Provide information on HIV prevention through use of oral contraceptives C) Provide information about oral sex and its risks D) Teach about use of condoms, especially for those not in monogamous relationships Ans: C Age Group: Adult Chapter: 26 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 795, Personal History Taxonomic Level: Application Feedback: Oral contraceptives do not protect against STIs. Adolescents need information about oral sex and its risks, including transmission of STIs. Condom use is especially important for those not in monogamous relationships.

11. The nurse practitioner is performing a pelvic examination on a 33-year-old gravida 4 para 4 during her annual examination. With an index finger inserted into the patient's vagina, the nurse asks the patient to bear down slightly. For what is the nurse assessing?

A) Vaginal tone B) Rectocele C) Cystocele D) Pelvic organ prolapse Ans: D Age Group: Adult Chapter: 26

Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 807, Internal Genitalia Taxonomic Level: Application Feedback: This measure tests for prolapse of the pelvis. To check vaginal tone, the nurse would ask the patient to squeeze the vaginal muscles around the examiner's index finger. Rectocele and cystocele are not assessed for in this manner.

12. A nurse has encouraged a 22-year-old college student to begin having regularly scheduled Papanicolaou tests in order to screen for A) cervical cancer.

B) vaginal cancer.

C) ovarian cancer.

D) labial cancer.

Ans: A Age Group: Adult Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 4 Page and Header: 795, Personal History Taxonomic Level: Knowledge Feedback: The Papanicolaou or Pap smear is a screening tool for cervical neoplasia.

It is not a screening tool for vaginal, ovarian, or labial cancer.

13. A nurse is preparing to begin a comprehensive assessment of a female patient's genitalia. Inspection of the female external genitalia begins with what?

A) Inguinal area B) Mons pubis C) Pubic hair D) Skin Ans: B Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 806, External Genitalia Taxonomic Level: Application Feedback: Inspection begins with the mons pubis. Inspection of the inguinal area,

pubic hair, and skin follows inspection of the mons pubis.

14. When assessing a new female patient, 45 years old, the nurse notes a recent history of stress incontinence. For what nursing diagnosis is the patient most likely at risk?

A) Deficient fluid volume B) Spiritual distress C) Ineffective sexuality patterns D) Self-care deficit Ans: C Age Group: Adult Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7, 9 Page and Header: 818, Table 26-2 Taxonomic Level: Application Feedback: Alterations in normal body function, such as incontinence, can precipitate ineffective sexuality patterns. Spiritual distress may be plausible but is less likely than impaired sexuality. The patient is not likely at risk of self-care deficit or deficient fluid volume.

15. An advanced practice nurse is explaining the procedure and rationale for an upcoming rectovaginal examination. What is the purpose of the rectovaginal examination?

A) Palpate the vaginal wall for evidence of a cystocele B) Palpate the vaginal wall for evidence of a rectocele C) Palpate the vaginal wall for evidence of uterine prolapse D) Palpate the vaginal wall for evidence of a urethral caruncle Ans: B Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 814, Rectovaginal Examination Taxonomic Level: Application Feedback: This examination is used to evaluate any rectocele (bulging of rectum into the vagina) or rectovaginal fistula (opening between the vagina and the rectum allowing feces to enter the vagina). This examination is not performed to assess for uterine prolapse, urethral caruncle, or cystocele.

16. When doing a bimanual examination of the ovaries, the examiner palpates quickly and gently. Why should this part of the examination be brief?

A) If palpated, ovaries feel like a large walnut.

B) Ovaries have no feeling.

C) Ovaries are similar to gonads in their sensitivity.

D) The ovary changes shape when palpated.

Ans: C Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 812, Bimanual Examination Taxonomic Level: Application Feedback: The ovaries are similar to gonads in their sensitivity, and so palpation is done quickly and gently to avoid discomfort. The ovary is often not felt, especially in older menopausal women, but it can sometimes be palpated. In such cases, it should feel like a small almond.

17. A nurse practitioner documents as follows—“Patient reports pain and tenderness over area of right ovary and a history of irregular menses.” With which of the following diagnoses are these findings consistent?

A) Ovarian cyst B) Salpingitis C) Pelvic inflammatory disease D) Ovarian cancer Ans: A Age Group: All Age Groups Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 812, Bimanual Examination Taxonomic Level: Analysis Feedback: With an ovarian cyst, there may be pain, tenderness over the ovary, irregular menses, and intraperitoneal bleeding if it ruptures. A solid ovarian mass raises the possibility of ovarian cancer, which is the second most frequent reproductive cancer. Salpingitis and PID are different names for the same condition, which does not manifest with these findings.

18.

A 36-year-old woman presents at the clinic with a grayish vaginal discharge that

has a “fishy” odour. What should the nurse suspect?

A) Candidiasis B) Bacterial vaginosis C) Chlamydia D) Gonorrhea Ans: B Age Group: Adult Chapter: 26 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 823, Table 26-3 Taxonomic Level: Analysis Feedback: Bacterial vaginosis presents with a creamy white to gray secretion that coats the vaginal walls. This finding is not consistent with candidiasis, chlamydia, or gonorrhea.

Chapter 27: Women Who Are Pregnant Multiple Choice 1. While assessing a newly pregnant patient, the nurse asks about a family history of genetic illnesses. The patient states that her mother has diabetes. For which of the following is this patient at increased risk?

A) Diabetes B) Hypertension C) Having a low birth weight D) Seizures Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2, 7 Page and Header: 841, Family History Taxonomic Level: Analysis Feedback: A positive family history of diabetes may increase the patient's risk for it as well. Patients with a family history of diabetes are not at increased risk for hypertension, low birth weight, or seizures.

2. An obstetric patient has a history of psychiatric illness. Which of the following mental health problems would the nurse assess for exacerbations of in a pregnant patient?

A) Mania B) Psychosis C) Depression D) Delirium Ans: C Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 839, Personal History Taxonomic Level: Analysis Feedback: Patients with a history of depression, anxiety, or eating disorders are at

risk for exacerbations during pregnancy and postpartum. Exacerbations of mania, psychosis, and delirium are less likely than an exacerbation of depression.

3. By the time a woman is 36 weeks' gestation, where would the nurse expect to find the uterus?

A) At the umbilicus B) Halfway between the umbilicus and bottom edge of the ribcage C) Near the bottom of the sternum D) Under the edge of the ribcage Ans: C Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1, 6 Page and Header: 853, Abdomen Taxonomic Level: Knowledge Feedback: By 20 weeks' gestation, the uterus is at about the umbilicus; by 36 weeks, it nears the bottom of the sternum.

4. The nursing instructor is teaching students about normal changes during pregnancy. The instructor talks about diastasis recti. What physiological phenomenon is the instructor describing?

A) Separation of the muscles of the abdominal wall B) Raising of the uterus into the abdomen C) Relaxation of the kidneys D) Movement of the bladder to the rear of the pelvis behind the uterus Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 853, Abdomen Taxonomic Level: Comprehension Feedback: By 20 weeks' gestation, muscles of the abdominal wall may begin to separate (diastasis recti) and not return to normal approximation until several weeks after childbirth. The term diastasis recti does not refer to the raising of the uterus into the abdomen, relaxation of the kidneys, or movement of the bladder.

5.

A patient of normal weight and new to the obstetric clinic asks the nurse how

much weight she should expect to gain during the first trimester of her pregnancy.

What is the best response the nurse can give?

A) “You'll actually lose a little bit of weight in the first trimester.”

B) “You can expect to maintain your normal weight or perhaps gain a small amount.”

C) “Ideally, you should gain between three and five kilograms during the first trimester.”

D) “The more weight you can gain, the healthier your baby will be.”

Ans: B Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 848, Nutrition Taxonomic Level: Application Feedback: Most women gain very little weight (if any) in the first trimester. Typical gains are less than 3 kg partly because of morning sickness for those who have it.

Maximizing weight gain is not an appropriate goal.

6. A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this portion of her pregnancy. What is the nurse's best answer?

A) 0.5 kg/week B) 1 kg/week C) 1.5 kg/week D) 2 kg/week Ans: B Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 848, Nutrition Taxonomic Level: Knowledge Feedback: Woman of expected prepregnant weight for height (or body mass index [BMI]) is that she will gain about 4.5 kg by 20 weeks and about 0.5 kg/wk for the remaining 20 weeks.

7. A patient in her third trimester comes in for a routine prenatal visit. The nurse places her in a comfortable position and attaches the tocodynamometer and ultrasound monitor to the patient's abdomen. What is the purpose of this test?

A) Assesses readiness for dilation B) Assesses fetal position C) Assesses fetal well-being D) Assesses readiness for delivery Ans: C Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 855, Nonstress Test (NST) Taxonomic Level: Analysis Feedback: During the third trimester, the patient may be scheduled for a nonstress test (NST) in conjunction with her prenatal visit. The purpose of the NST is to assess fetal well-being using ultrasound and a tocodynamometer.

8. At each prenatal visit, a patient provides a urine sample to the health care provider. What is this urine sample tested for at each visit?

A) Protein and glucose B) Glucose and white blood cells C) Protein and albumin D) White blood cells and albumin Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 837, Role of the Nurse in the Outpatient Setting Taxonomic Level: Application Feedback: Typically, the nurse weighs the patient, records her blood pressure, assesses her urine for protein and glucose, and identifies any problems or concerns. A patient's urine is not tested for white blood cells or albumin.

9. The nurse is teaching a prenatal class to a group of expectant mothers and their partners. What would be the primary method of prevention that the nurse would focus on related to hemorrhoids and constipation during pregnancy?

A) Take a laxative daily B) Decrease the intake of fibre C) Increase the intake of protein D) Increase exercise if possible

Ans: D Age Group: Adult Chapter: 27 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 853, Abdomen Taxonomic Level: Application Feedback: Pregnant women are at risk for constipation. Straining during bowel movements can also cause painful or itchy hemorrhoids. The primary way to prevent hemorrhoids is to prevent constipation by increasing exercise and intake of fibre and water. The nurse would not encourage a pregnant woman to use a daily laxative.

Increasing protein is not a method to prevent constipation and hemorrhoids.

10. A 15-year-old girl comes to the clinic and reports that she thinks she is pregnant.

A pregnancy test is positive. While developing a care plan for this patient, the nurse should consider the patient's age and the associated risk factors, which include what?

A) Paralytic ileus B) Preeclampsia C) Excess weight gain during pregnancy D) Gestational diabetes Ans: B Age Group: Child and Adolescent Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 839, Personal History Taxonomic Level: Analysis Feedback: Teens who are pregnant have increased nutritional requirements because they, too, are still growing. In addition, their pelvises may not be fully developed.

These teens are at increased risk for complications, especially preeclampsia. Pregnant teens are not documented as being at increased risk for excess weight gain, paralytic ileus, or gestational diabetes.

11. A patient at 39 weeks' gestation presents at the labour and delivery suite saying that she is in labour. She reports that her water has not broken yet. Physical assessment reveals that the patient is not in true labour. The nurse explains that what the patient is feeling are Braxton Hicks contractions. What assessment finding would tell the nurse that these contractions are, in fact, Braxton Hicks?

A) The contractions are 45 seconds to one minute in duration.

B) The contractions are regularly spaced.

C) The contractions are not painful.

D)

The contractions resolve when the woman changes position.

Ans: D Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 846, Braxton Hicks Contractions Taxonomic Level: Analysis Feedback: Braxton Hicks contractions prepare the body for labour. They are usually irregular in frequency and duration, with fewer than five in 1 hour. They are also short (<30 seconds) but may be painful. These contractions may begin as early as the second trimester, especially for patients who have had babies before, but are more common in the third trimester. They often resolve with position changes, a hot shower, hydration, or relaxation.

12. A patient presents at the emergency department. During the assessment, the nurse notes the following—patient is a 22-week primipara, age 25, pulse 82, BP 110/76, temperature 38.5°C. Following diagnostic evaluation, the patient is diagnosed with pyelonephritis. What would be the treatment of choice?

A) Hospitalization and intravenous antibiotics B) Oral antibiotics and bed rest at home C) Hospitalization and intravenous hydration D) Home care and oral hydration and antibiotics Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 838, Acute Assessment Taxonomic Level: Application Feedback: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 38°C. While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal.

13. An obstetrical nurse has completed an admission assessment of a patient who is in early labour. During the assessment, the nurse has asked the woman about her

religious preference? What is the purpose of this assessment question?

A) To know whom to call if the patient asks for a cleric B) To identify religious beliefs that may affect the mother or the fetus C) To aid in research on how many births occur yearly in a religious denomination D) To have a cleric of the right denomination in the hospital during the birth Ans: B Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 9 Page and Header: 839, Personal History Taxonomic Level: Analysis Feedback: Some cultures or religions have important childbirth rituals, which may influence the role of the baby's father during labour, preferred anesthesia for surgery, handling of the newborn, or required or prohibited foods during the postpartum period. The purpose of this assessment question is not centered around the need for a cleric or record-keeping.

14. A woman in her second trimester of pregnancy calls the obstetrician's office and tells the nurse that she is having pains all around her umbilicus. What would be the nurse's best response?

A) “You are probably having growing pains. There is nothing to worry about.”

B) “These pains are likely caused by the stretching of ligaments as your uterus grows. They are nothing to worry about.”

C) “These are called Braxton Hicks contractions. They are a kind of 'practice' for when the baby is born.”

D) “You are having preterm labour. Go to the emergency room right away.”

Ans: B Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 845, Periumbilical Pain Taxonomic Level: Application Feedback: About halfway through pregnancy, women commonly feel a stretching pain all around the umbilicus. The pain is similar to “growing pains,” which usually subside by the end of the first trimester. However, these second-trimester pains are similar in origin, resulting from additional ligaments stretching as the uterus accommodates the growing fetus. These are not growing pains, per se, nor are they Braxton Hicks contractions or preterm labour.

15. The nurse is assessing a 27-year-old woman pregnant for the first time during her initial visit to the obstetric clinic. The patient is currently at 8 weeks' gestation.

During the assessment, the patient reports that she is experiencing sharp, stabbing pains in her lower abdomen, especially when she changes position. How should the nurse respond to this patient's statement?

A) The nurse should facilitate further assessment and diagnostic testing.

B) The nurse should assess the patient for constipation or fecal impaction.

C) The nurse should report that the patient is in preterm labour.

D) The nurse should document the presence of Braxton Hicks contractions.

Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 7 Page and Header: 844, Growing Pains Taxonomic Level: Synthesis Feedback: In the first trimester, sharp pains in the lower abdomen are common.

Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short (<5 seconds) and have a stabbing quality. They are not repetitive but are often associated with position changes or, later, fetal movements. Even though growing pains are benign, there are numerous other causes of abdominal pain, many of which hold the potential for serious harm. For this reason, it is important to rule out other etiologies. The nurse would not characterize these pains as preterm labour or Braxton Hicks contractions. Constipation is unlikely to cause stabbing pain.

16. A patient from which of the following geographical regions would most likely have undergone female circumcision?

A) South America B) Africa C) Pacific Islands D) Eastern Europe Ans: B Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 9 Page and Header: 838, Cultural Considerations Taxonomic Level: Knowledge Feedback: In Africa, in some cultures in Asia and the Middle East, and in some

immigrant communities in Europe and North America, woman may undergo female genital mutilation. This practice reduces the size of the female introitus, which requires assessment before childbirth.

17. A 42-year-old woman has just found out that she is pregnant for the first time.

Mothers of advanced maternal age are at increased risk for what?

A) Genetic anomalies in the fetus B) Pyelonephritis C) Gestational diabetes D) Cephalopelvic disproportion Ans: A Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 839, Personal History Taxonomic Level: Analysis Feedback: Mothers of advanced maternal age (AMA) are those who will be 35 years or older at the estimated date of birth. They are at increased risk for miscarriage and genetic anomalies and may have increased preexisting health problems (e.g., fibroids, advanced endometriosis, hypertension). They are not at increased risk for gestational diabetes, pyelonephritis, or cephalopelvic disproportion.

18. A woman who is 18 weeks pregnant has presented to a community laboratory for testing that will include a triple screen. This blood test will assess for which of the following?

A) Group B streptococcus B) Gestational diabetes C) Human papillomavirus D) Genetic abnormalities Ans: D Age Group: Adult Chapter: 27 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 856, Table 27-2 Taxonomic Level: Knowledge Feedback: The triple screen or quad screen assesses for Down syndrome and other trisomies, neural tube defects, gastroschisis, and other fetal anomalies. It does not test for GBS, HIV, or HPV.

Chapter 28: Newborns and Infants Multiple Choice 1. During a class on growth and development, students learn that the motor development of infants follows a predictable pattern. What is a characteristic of this pattern?

A) Dependent to independent B) Central to distal C) Fine to gross D) Right to left Ans: B Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 864, Motor Development Taxonomic Level: Comprehension Feedback: Motor development progresses in predictable patterns—cephalocaudally, central to distal, and gross to fine. Motor development does not progress right to left or from dependent to independent.

2. A young mother asks the clinic nurse how her baby is going to learn to talk. What process should the nurse describe to the mother?

A) Pretending B) Overcoming frustration C) Interacting with the environment D) Problem-solving Ans: C Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 864, Language, Psychosocial, and Cognitive Development Taxonomic Level: Application Feedback: The infant learns language through listening, watching, and interacting with the environment. The infant does not learn to speak through pretending,

problem-solving, or overcoming frustration.

3. A long and difficult labour results in the birth of a baby girl. The nurse knows that a component of the acute assessment of this infant includes what question?

A) How is the mother coping?

B) Is the newborn responsive to sound?

C) What is the newborn's blood pressure?

D) What is the newborn's colour?

Ans: D Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 2 Page and Header: 864, Acute Assessment Taxonomic Level: Application Feedback: Acute assessment involves the Apgar score, which includes an assessment of the infant's skin colour. Response to sound, the mother's coping, and the infant's blood pressure are not components of this acute assessment.

4. Parents bring an 8-month-old boy to the emergency department, reporting that their son “just isn't acting right.” Nursing assessment shows that the infant's pulse is 165 beats/minute. Respiratory rate, blood pressure, and temperature are within normal limits. Mild nasal flaring is noted. What should the triage nurse first suspect?

A) Neurological deficits B) Foreign body in trachea C) Sepsis D) Respiratory distress Ans: D Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 7 Page and Header: 864, Emergent Concerns Taxonomic Level: Analysis Feedback: Many emergent situations for the newborn involve respiratory decompensation. Signs of newborn respiratory distress include increased respiratory and heart rates, nasal flaring, and intercostal and substernal retractions. The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). A respiratory etiology is more likely than an obstruction, sepsis, or neurological deficits.

5. Students are preparing a class presentation on health promotion measures for new parents. When teaching about creating a healthy sleep environment for an infant, what should the students prioritize?

A) Explain the importance of making the infant as warm as possible for sleep B) Teaching parents how to position pillows for their infants C) Teaching parents the potential benefits of sleeping with their infants D) Teaching parents to position their infants supine for sleep Ans: D Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 866, Box 28-1 Taxonomic Level: Application Feedback: Parents should be taught to always place their baby on his or her back to sleep. Co-sleeping, the use of pillows, and making the infant too warm are potential threats to the infant's health.

6. A mother brings her 6-month-old boy to the clinic and tells the nurse that her son “seems to get one cold after another.” What would be a priority assessment question for the nurse to ask?

A) Was the infant vaccinated at birth?

B) Has the infant traveled with the family recently?

C) Has the infant had trouble breathing?

D) Does the infant tend to get a runny nose?

Ans: C Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 6 Page and Header: 869, Respiratory Concerns/Distress Taxonomic Level: Analysis Feedback: Complaints related to respiratory distress are a priority, especially compared with issues related to travel and rhinorrhea. Immunizations are not given at the time of birth.

7. The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks the mother numerous questions about

the onset and character of the rash as well as associated symptoms. Why would it be important for the nurse to ask these questions?

A) It helps the nurse conceptualize the rash.

B) It tells the nurse identify how the infant is coping with the rash.

C) It helps the nurse know if the mother is exaggerating the seriousness of the rash.

D) It helps the nurse identify possible causes.

Ans: D Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 4, 5 Page and Header: 869, Skin Conditions Taxonomic Level: Application Feedback: These questions help pinpoint possible causes. Many skin conditions have predictable patterns of spread, parts of the body affected, and associated symptoms, such as pruritis (itching). The nurse is not primarily motivated by conceptualizing the rash or determining if the mother is “exaggerating.” The infant's response to the rash (e.g., itching or rubbing) is relevant, but coping is not possible to assess in a child who is this young.

8. A neonatal nurse is assessing the neurologic status of a newborn boy. What area would the nurse be primarily assessing?

A) Skin colour B) Weight and length C) Reflexes D) Ability to eat Ans: C Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 872, Reflexes Taxonomic Level: Application Feedback: Evaluation of newborn reflexes gives information about neurologic status. Skin colour, weight, length, and intake are less direct indicators of neurological status.

9. The advanced practice nurse (APN) is using an otoscope to assess the ears of a 1-year-old. What would it be important for the APN to do?

A) Pull the child's ear lobe up and back

B) Brace the hand holding the otoscope against the infant's face C) Have the infant supine with the head held by the nurse D) Have the infant sit with the head held by the nurse Ans: B Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 882, Ears Taxonomic Level: Application Feedback: The nurse always braces the hand holding the otoscope against the infant's face, so that if the infant moves, the otoscope moves with him or her to avoid injuring the tympanic membrane. Pulling the lobe up and back is for assessing the ears of an adult. The parent would hold the infant's head, while the infant sits on the parent's lap.

10. While assessing a 6-week-old infant new to the clinic, the nurse notices that the infant's ears fall below the imaginary line that runs from the inner canthus of the eye to the outer canthus and ear. What might indicate to the nurse that this finding is a normal variant in this case?

A) The mother has low-set ears.

B) There is no normal variant for low-set ears.

C) All infants tend to have low-set ears before 2 months.

D) The child also has many a prominent birthmark.

Ans: A Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 882, Ears Taxonomic Level: Evaluation Feedback: It may be helpful to note if either parent has low-set ears. If so, then the low-set ears may be an inherited normal variant.

11. The nurse is assessing a 4-month-old infant who appears very pale but is exhibiting cyanosis. What pathophysiological phenomenon is suggested by the presence of cyanosis?

A) Inadequate oxygenation B) Carbon monoxide toxicity C) Regional infection

D)

Diaphragmatic weakness

Ans: A Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 8 Page and Header: 883, Thorax and Lungs Taxonomic Level: Analysis Feedback: Cyanosis is an indicator of inadequate oxygenation. It is not indicative of carbon monoxide poisoning, infection, or weakness of the infant's diaphragm.

12. A Caucasian newborn is noted to have a yellowish tinge to his skin and sclera.

Laboratory testing shows him to have an elevated bilirubin level. What independent nursing intervention is appropriate for this patient?

A) Initiate measures that will promote early feeding B) Temporarily withhold feeding until a physician gives an order for it to begin C) Withhold feeding until bilirubin levels drop D) Immediately start phototherapy Ans: A Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 887, Table 28-4 Taxonomic Level: Synthesis Feedback: Early feeding stimulates stooling and subsequent removal of bilirubin.

The nurse would not withhold feeding for the child with an elevated bilirubin level or start phototherapy without an order.

13. An infant has a nursing diagnosis of ineffective thermoregulation related to immaturity of neurologic and endocrine systems. The infant's temperature remains low. What nursing intervention would be important?

A) Obtain an order for phototherapy B) Keep the newborn's head covered C) Temporarily disallow the family from holding the infant D) Change the infant's diaper at least every hour Ans: B Age Group: Infant Chapter: 28

Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9, 10 Page and Header: 887, Table 28-4 Taxonomic Level: Application Feedback: For this infant, keeping the head covered to help regulate body temperature is the most important intervention. Phototherapy is used for the treatment of hyperbilirubinemia, not impaired thermoregulation. Not allowing the family to hold the infant and changing the diaper every hour are not necessary interventions for this scenario.

14. What common newborn assessment finding varies most widely according to the genetic background of the infant?

A) Waist circumference B) Length C) Leg length D) Shoulder width Ans: B Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 887, Cultural Considerations Taxonomic Level: Analysis Feedback: The length and weight of the newborn and infant varies according to genetic background, so ranges outside of usual may be normal for some patients. Leg length, waist circumference, and shoulder width are not normally assessed on a newborn.

15. When assessing a newborn, the nurse finds areas at the base of the infant's spine that appear to be bruises. The nurse knows that these areas are most common in infants of which of the following genetic backgrounds?

A) Pacific Islander B) Mediterranean C) African Canadian D) Caucasian Ans: C Age Group: Infant Chapter: 28 Client Type: Group Competency Category:

Changes in Health

Difficulty: Moderate Objective: 9 Page and Header: 887, Cultural Considerations Taxonomic Level: Comprehension Feedback: Mongolian spotting is more common in infants of African Canadian, Asian, and First Nations origin.

16. A nurse is teaching a prenatal class to first-time mothers and their partners.

What risk reduction topic should the nurse be sure to include in teaching?

A) Choking prevention B) Technique for bundling the baby C) Vitamin C supplementation D) Sleep scheduling Ans: A Age Group: Adult Chapter: 28 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 866, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: The leading cause of injury-related death for infants is choking and suffocation. Parents require anticipatory guidance to avert such forms of preventable injury and illness. This is a priority over sleep scheduling and correct bundling, though these subjects have merit. Babies often need vitamin D supplementation.

17. The nurse is admitting an 8-month-old infant to the pediatric unit. Vital signs are T 36.4°C, heart rate 160 bpm, and respiratory rate 38 beats/minute. The patient exhibits circumoral cyanosis and nasal flaring. Auscultation reveals diminished lung sounds in the bases of both lungs and grunting. What nursing diagnosis would be appropriate when writing the care plan for this child?

A) Inadequate gas exchange related to pneumonia B) Respiratory decompensation related to inability to breathe C) Cardiac decompensation related to tachycardia D) Inadequate tissue perfusion related to heart rate Ans: A Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 10 Page and Header: 887, Table 28-4

Taxonomic Level: Synthesis Feedback: The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). Moderate respiratory distress includes nasal flaring, retractions of the chest wall, grunting auscultated with a stethoscope, cyanosis on room air, and abnormal blood gas values. Severe distress is indicated by increasing work of breathing, deep retractions, audible grunting, and central cyanosis. Nothing in the scenario indicates cardiac decompensation and subsequent inadequate tissue perfusion. While the patient is having difficulty breathing, the child is not totally unable to breathe.

18. The nurse assessing a 7-month-old child in the clinic asks the mother if she has childproofed the home. For what would the nurse be assessing when asking this question?

A) Parenting ability B) Risk factors C) Environmental stimulus D) Health status Ans: B Age Group: Infant Chapter: 28 Client Type: Family Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 865, Assessment of Risk Factors Taxonomic Level: Comprehension Feedback: This question involves an assessment of risk factors. It is not being asked to assess parenting, environmental stimulus, or the infant's health status.

19. During the acute assessment of an infant who was born one minute ago, the nurse documented the infant's Apgar score. What Apgar score would constitute an expected finding at this time?

A) Between four and six B) Five C) Ten D) Eight to nine Ans: D Age Group: Infant Chapter: 28 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 864, Acute Assessment

Taxonomic Level: Analysis Feedback: Apgar scores are initially expected to be 8 or 9, which then improve to 8 to 10 after 5 minutes.

Chapter 29: Children and Adolescents Multiple Choice 1. The nurse is assessing a 14-year-old boy who has reached puberty. What glands would the nurse know have become active?

A) Eccrine B) Apocrine C) Pineal D) Parathyroid Ans: B Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1, 4 Page and Header: 911, Skin, Hair, and Nails Taxonomic Level: Knowledge Feedback: Apocrine (sex) glands become active at puberty. The other listed glands are active from birth.

2. A 17-year-old male athlete comes to the clinic for a sports screening examination.

He tells the nurse that he “parties” every weekend. What is the most appropriate topic for patient teaching with this patient?

A) Assertiveness training B) Nutrition for athletes C) Physiologic changes in adolescence D) Drinking and driving Ans: D Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 2 Page and Header: 905, Preventing Drunk Driving Taxonomic Level: Application Feedback: “Partying” is a word teens often use to indicate use of alcohol or drugs.

Because the patient is of legal driving age, he is at risk for motor vehicle accidents related to driving under the influence of substances. While the other topics may

represent relevant teaching areas, the biggest concern involves the patient's drinking.

3. A 16-year-old girl shows symptoms of human papillomavirus (HPV) during a health surveillance visit. What is the first action the nurse should take to educate her about her condition?

A) Reassure the girl that findings will remain confidential B) Recruit the help of the child's parents C) Explain how girls are more susceptible to sexually transmitted infections (STIs) D) Confront the girl about engaging in unprotected sex Ans: A Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 903, Risk Factors Taxonomic Level: Application Feedback: To help the child understand her situation, the first thing to do is reassure her this will be kept confidential, even from her parents. Explaining her susceptibility to infection and describing all the risks of unprotected sex will be ineffective if the child is worried about confidentiality. Also, being open and respectful of the child's decision to have sex will greatly help deliver preventative messages. The nurse should not necessarily assume that the girl engaged in unprotected sex, since many forms of contraception do not prevent HPV transmission.

4. A 7-year-old boy comes to the emergency department with abdominal pain. The nurse notes that when the child walks to the treatment room, he is walking on his toes. What should the nurse first suspect is wrong with this child?

A) Incarcerated hernia B) Appendicitis C) Testicular torsion D) Wilms tumour Ans: B Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 907, Abdominal Pain Taxonomic Level: Analysis Feedback: If the child points to the right lower quadrant (RLQ) or only tiptoes, appendicitis should be ruled out with abdominal scans. This presentation is not typical

of hernias, Wilms tumour, or testicular torsion.

5. A 13-year-old girl is visiting the pediatric clinic for leg pain. Her mother states that she has been limping for “2 or 3 weeks.” What does the nurse know needs to be ruled out?

A) Dislocation B) Compound fracture C) Growing pains D) Graves disease Ans: A Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 907, Leg Pain Taxonomic Level: Analysis Feedback: If the child consistently limps, then fractures, dislocations, and bone tumours should be ruled out. A compound fracture comes through the skin and is easily visible. Graves disease is associated with hyperthyroidism and would have nothing to do with leg pain. Growing pains would be unlikely to cause limping.

6. The nurse is assessing siblings, 8 and 12 years old. They are recent immigrants to Canada and this is their first visit to the clinic. When doing the initial assessment, the nurse would assess their nutrition by asking what question?

A) Do you eat pork?

B) Do your grandparents live with you?

C) Is family food prepared at home?

D) Are you hungry right now?

Ans: C Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Health and Wellness Difficulty: Difficult Objective: 3 Page and Header: 908, Cultural Considerations Taxonomic Level: Evaluation Feedback: Questions about nutrition include who eats together, what is eaten, where food is obtained, who prepares food, and how food is prepared. These norms contribute to the health of the child and are important components of a nutritional assessment. These norms are not known unless the provider asks about them. They are different for each family based not on race but on familial cultural norms.

Information about consumption of pork and whether grandparents live with the children would not shed direct light on the children's nutrition. Hunger at the time of assessment does not normally allow for meaningful conclusions.

7. According to health promotion agency Healthy Canadians, within what context should the nurse address the child's health needs?

A) School and extended family B) Community and health care facilities C) Family and community D) Family and school Ans: C Age Group: Child and Adolescent Chapter: 29 Client Type: Population Competency Category: Health and Wellness Difficulty: Easy Objective: 2 Page and Header: 900, Introduction Taxonomic Level: Knowledge Feedback: The Child Health divisions of the Public Health Agency of Canada (2011) and Healthy Canadians (2011) are national health promotion and injury prevention agencies that address children's health needs within the context of family and community.

8. When working with children, what diagnostic tests are indicated specifically for well-child examinations?

A) Lead levels B) Tuberculosis tests C) Urinalysis D) None of the above Ans: D Age Group: Child and Adolescent Chapter: 29 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 919, Common Laboratory and Diagnostic Testing Taxonomic Level: Application Feedback: No laboratory or diagnostic tests are recommended specifically for children and adolescents. Blood chemistry screening, hemoglobin (for anemia screening in patients 5 years or older), tuberculin skin screening (for children at average risk), and urinalysis are recommended when clinically indicated.

9. A 12-year-old girl has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this child, what would be the most appropriate intervention?

A) Provide information for age-appropriate community activities B) Identify normal findings in the child C) Assess the parenting skills of the child's mother and father D) Provide information that contributes to an improved state of health Ans: D Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 919, Clinical Reasoning Taxonomic Level: Application Feedback: The most pertinent intervention is to provide information that contributes to an improved state of health. Parenting would be assessed throughout childhood but is not the most appropriate intervention for a child with pneumonia. Identifying normal findings is not a priority. Age-appropriate community activities are not a concern for a child with a respiratory infection.

10. The nurse is doing an initial assessment on an 8-year-old admitted to the pediatric unit in sickle cell crisis. When inspecting the child's eyes, the nurse finds that they are normal. How would the nurse chart these findings?

A) Eyes are PERRL(A) with corneal light reflexes equal bilaterally.

B) Eyes are PERRL(A); EOMs are at 180 degrees; corneal light reflexes are equal.

C) Eyes are WNL. D) Eyes are PERRL(A) with EOMs at 180 degrees bilaterally.

Ans: B Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5, 8 Page and Header: 911, Eyes and Vision Taxonomic Level: Application Feedback: Normal findings would be documented as follows—Eyes are PERRL(A).

EOMs are at 180 Degrees. Corneal light reflexes are equal. There is no deviation during the cover and alternate cover tests. Fundoscopic examination reveals a distinct disc with no vessel nicking. This makes the other given options incorrect.

11. The nurse is assessing vision and hearing for several students. At what age does visual acuity approximate that of the healthy adult?

A) 5 to 6 B) 4 to 5 C) 6 to 7 D) 3 to 4 Ans: A Age Group: Child and Adolescent Chapter: 29 Client Type: Group Competency Category: Health and Wellness Difficulty: Moderate Objective: 5 Page and Header: 911, Eyes and Vision Taxonomic Level: Knowledge Feedback: By 5 to 6 years, normal visual acuity should approximate that of adults.

12. A participant in a health fair asks a student nurse, “What is the most common infectious disease of childhood?” What would be the student nurse's best answer?

A) Dental caries B) Otitis media C) Thrush D) Otitis externa Ans: A Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 914, Nose, Mouth, and Throat Taxonomic Level: Knowledge Feedback: Dental caries are the most common infectious disease in childhood. Otitis media and thrush are common infectious diseases but not the most common in childhood. Otitis externa is a common finding, but again, not the most common.

13. A mother brings her young son to the clinic and explains to the nurse that her son appears to turn blue sometimes when he is playing. The nurse assesses the child's pulses and notes a significant difference in the pulses in the upper and lower extremities. Which of the following health problems would account for this unexpected assessment finding?

A) Tetralogy of Fallot B) Coarctation of the aorta C) Femoral artery aneurysm

D)

Transposition of the great vessels

Ans: B Age Group: Child and Adolescent Chapter: 29 Client Type: Family Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 917, Peripheral Vascular Taxonomic Level: Analysis Feedback: Coarctation of the aorta can present with unequal pulses between the upper and lower extremities. None of the other options present in the manner described in the scenario.

14. A 5-year-old girl arrives at the emergency department with severe abdominal pain and tenderness. The nurse would expect this child to be evaluated for A) stomach virus.

B) incarcerated umbilical hernia.

C) gastroesophageal reflux disease (GERD).

D) appendicitis.

Ans: D Age Group: Child and Adolescent Chapter: 29 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 5 Page and Header: 917, Abdomen Taxonomic Level: Analysis Feedback: Significant abdominal tenderness requires further evaluation for appendicitis, Crohn disease, ulcerative colitis, and gastroenteritis. The child would not be evaluated for a stomach virus until the more emergent conditions were ruled out.

These symptoms are not consistent with an incarcerated umbilical hernia or GERD. 15. A woman brings her 7-year-old son to the clinic. The mother states that she was giving her son a bath and noted redness and excoriation around his anus. The nurse would expect this patient to be evaluated for what?

A) Crohn disease B) Constipation C) Hemorrhoids D) Yeast infection Ans: B Age Group:

Child and Adolescent

Chapter: 29 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 919, Male and Female Genitalia Taxonomic Level: Analysis Feedback: Rectal irritation or fissures require further evaluation for constipation, worms, or sexual abuse. Rectal fissures or irritation are not indications of hemorrhoids or a yeast infection. Crohn disease is typically associated with frequent bowel movements and abdominal pain.

Chapter 30: Older Adults Multiple Choice 1. When caring for an older adult, the nurse would know that wound healing rate reduces normally with aging by A) 20%.

B) 30%.

C) 40%.

D) 50%.

Ans: D Age Group: Older Adult Chapter: 30 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 926, Skin, Hair, and Nails Taxonomic Level: Knowledge Feedback: Decreased mitotic activity of cells that accompanies aging normally leads to a 50% reduction in rate of wound healing.

2. A 77-year-old patient comes to the clinic and reports difficulty with driving at night. What would be the most appropriate response from the nurse?

A) “It is nothing to worry about.”

B) “It's just something that happens with aging.”

C) “With aging, the pupils do not respond to light as quickly.”

D) “This can be serious and needs to be evaluated by the physician immediately.”

Ans: C Age Group: Older adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 1, 2 Page and Header: 926, Eyes and Vision Taxonomic Level: Application Feedback: Slowed pupillary responses lead to a difficulty in accommodating to changes in light, difficulty with night driving, and problems with glare. This explanation is more helpful than simply characterizing the problem as “something that happens.” The patient's statement requires follow-up, but it is not an emergency.

3. What screening tool is most commonly used to identify older adults at high nutritional risk who may need interventions to improve nutritional status?

A) LAWTON B) DETERMINE C) FIM D) KATZ Ans: B Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4, 5 Page and Header: 931, Personal History Taxonomic Level: Knowledge Feedback: The screening tool DETERMINE identifies older adults at high nutritional risk who may require interventions to improve nutritional status. The LAWTON measures ADL capabilities, as do the FIM and the KATZ. 4. During a home visit, the nurse is assessing the medication history of a patient who lives alone and has had a recent history of delirium. The patient states that she takes her medications as prescribed, but there has been evidence in the past of missed doses. How should the nurse best corroborate the patient's claim?

A) Speak to the pharmacist who filled the patient's prescriptions B) Ask the patient if there is anyone who can confirm that she is taking her medications as prescribed C) Ask the patient to describe her daily routing around taking her medications D) Compare the number of pills on hand to the date the prescription was filled Ans: D Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Health and Wellness Difficulty: Difficult Objective: 5 Page and Header: 933, Medications/Polypharmacy Taxonomic Level: Application Feedback: Nurses can identify accuracy by calculating how many days are between today's date and the refill date, noting how many pills the pharmacist included and counting out the number of tablets left in the container to obtain an estimate of pills taken. The pharmacist would not likely be of assistance. Many patients do not have another person who could confirm accuracy. Asking the patient to describe her routine may be useful but would constitute subjective data.

5. A student is giving an oral presentation in his geriatric nursing class about insomnia. The student is aware of the high incidence and prevalence of this problem among older adults. What is a risk factor that the student should cite?

A) Being married B) Female gender C) Fluid volume deficit D) Large number of adult children Ans: B Age Group: Older Adult Chapter: 30 Client Type: Population Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 935, Focused Health History Related to Common Symptoms/Signs Taxonomic Level: Analysis Feedback: Insomnia may be either acute or chronic. It may affect falling asleep, staying asleep, or early morning wakening. Risk factors include female gender, increased age, medical or psychiatric illness, and shift work. Fluid imbalance, being married, and having numerous adult children are not linked to insomnia.

6. A nurse is caring for a 72-year-old woman who may be a victim of elder abuse.

When asking the patient if someone has hurt her, the nurse knows that many times elder abuse is not reported because A) some patients are ashamed to admit being hurt by someone.

B) some patients do not remember being hurt.

C) some patients do not think that health care providers can help them.

D) some patients do not think that they are being abused.

Ans: A Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 8, 9 Page and Header: 936, Abuse Taxonomic Level: Comprehension Feedback: Many victims of elder abuse are isolated; some are ashamed and embarrassed or feel guilt and self-blame. In addition, some elders experience fear of reprisal, retribution from caregivers, or losing their home or independence. Others are pressured by relatives not to report. Failure to report elder abuse is usually not the result of forgetfulness, skepticism of the ability of health care providers to give

assistance, or comprehension about what is happening.

7. A patient has come to the clinic for a routine checkup. She is 77 years old, weighs 80 kg, stands 160 cm tall, and lives alone. Her BP is 147/89, pulse is 80, and respirations are 18. The nurse is planning her patient teaching. What is an appropriate topic to include in this patient's teaching?

A) Keeping floors clear B) Maintaining social contacts C) Encouraging a diet that supports a normal BMI D) Providing information on diabetes treatment Ans: C Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6, 7 Page and Header: 950, Nursing Diagnosis, Outcomes, and Interventions Taxonomic Level: Analysis Feedback: The patient's current BMI is high, due to her comparatively heavy weight and short stature. Thus, the most pressing concern is for the older adult to follow a diet that would support a normal BMI. Nothing in the scenario describes safety risks at home, social isolation, or current diabetes.

8. A patient has just been diagnosed with osteopenia. To help prevent progression to osteoporosis, the nurse would teach this patient about what?

A) Vitamin D supplements B) Vitamin E supplements C) Vitamin B12 supplements D) Vitamin A supplements Ans: A Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 2 Page and Header: 934, Risk Assessment and Health Promotion Taxonomic Level: Application Feedback: Vitamin D and calcium supplementation as appropriate can help prevent osteoporosis. Bone density is not directly dependent on vitamin E, A, or B12 intake.

9.

The nurse is preparing to conduct an admission assessment on a 76-year-old

man. In order to promote communication, what would be important to do before interviewing this patient?

A) Make sure the door is not blocked B) Speak in a louder than normal voice and use simple phrases C) Provide the patient with a hearing aid D) Reduce or eliminate background noise Ans: D Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 6 Page and Header: 929, Interviewing the Older Adult Taxonomic Level: Application Feedback: It is essential to reduce or eliminate background noise as much as possible when carrying on conversations. This includes turning off the television or radio in the patient's room and closing the door to reduce sounds of telephones, beepers, alarms, or pagers. Before beginning the interview, it would not be necessary to make sure the door is not blocked or to speak in a louder than normal voice. The scenario does not say that the patient requires a hearing aid.

10. The nurse is admitting an 82-year-old woman to the short stay unit for same-day surgery. What information should the nurse try to have before beginning the interview process?

A) The patient's view of her own health B) Whether the patient uses a cane C) The patient's medical prognosis D) The patient's educational level Ans: D Age Group: Adult of Advanced Age Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 6 Page and Header: 929, Interviewing the Older Adult Taxonomic Level: Application Feedback: Consideration of the patient's educational level is critical, and interview questions should match the older adult's knowledge level. It would not be necessary to know the patient's view of her health status or use of assistive devices prior to the interview; these data would be revealed during the interview itself. It is not necessary to know the patient's prognosis before beginning the interview.

11. The nurse is performing a home visit to an 85-year-old man who lives alone. The nurse notes that the patient has poor hygiene and that his dress is inappropriate for the time of year. The nurse knows that these findings might be caused by what?

A) Sensory changes B) New onset of bipolar disorder C) Decreased functional ability D) Cultural differences Ans: C Age Group: Adult of Advanced Age Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 939, General Survey Taxonomic Level: Analysis Feedback: Poor hygiene and inappropriate dress may indicate decreased functional ability or may result from medications, infection, dehydration, or nutritional status.

Sensory changes can affect an older adult's choice of dress but are less likely to cause poor hygiene. Bipolar disorder is unlikely to have a new onset late in life and culture is unlikely to underlie poor hygiene.

12. The nurse is caring for a new 79-year-old patient whose gait is characterized by steps that are uneven and shorter than most adults. How should the nurse explain this phenomenon?

A) The patient has a narrower base of support.

B) The patient walks bent forward.

C) The patient's age makes this a normal phenomenon.

D) The patient has loss of balance.

Ans: C Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 939, General Survey Taxonomic Level: Analysis Feedback: By the eighth or ninth decade, physical appearance changes, with sharper body contours and more angular facial features. Posture tends to have a general flexion, and the patient's gait tends to have a wider base of support to compensate for diminished balance. Steps tend to be shorter and uneven. The patient may need to use the arms to help aid in balance.

13. An older adult patient comes to the dermatology clinic to have a cancerous lesion removed from the palm of his hand. The nurse knows that cancer on the palm of the hand is more common in A) Caucasians.

B) African Canadians.

C) Asians.

D) First Nations.

Ans: B Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 947, Cultural Considerations Taxonomic Level: Knowledge Feedback: Skin cancers are more common on the palms, soles, and nail beds in African Canadians.

14. A nurse who provides care on the gerontology unit of a hospital is preparing to conduct a comprehensive admission assessment of a female patient. Which of the following principles should the nurse integrate into this assessment?

A) Break up the assessment into more than one session in order to avoid fatiguing the patient B) Explain to the patient that her responses will determine how quickly she will recover C) Conduct the assessment spontaneously throughout the day rather than at the patient's bedside D) Ask the patient's family members to provide confirmation of the patient's responses Ans: A Age Group: Older adult Chapter: 30 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 4 Page and Header: 949, Organizing and Prioritizing Taxonomic Level: Application Feedback: Assessment of the older adult usually proceeds from general to specific and from head to toe and may need to be conducted over several visits to avoid tiring the patient. However, the assessment should still be conducted explicitly and at the bedside or another private location. It is not normally necessary to ask family members to confirm findings, except when there is a justifiable reason to doubt the patient's response. The patient's responses will not directly influence the speed of her

recovery.

15. The nurse is doing a shift assessment on a 72-year-old patient with diabetes who has a 60 pack-year history of smoking. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler ultrasound. When reviewing previous assessment findings, the nurse reads that the patient's pulses were weakly palpable. What would be the first nursing action?

A) Notify the primary provider B) Reevaluate the pulse again the next day C) Reevaluate the pulse after mobilizing the patient D) Determine if the patient has a history of heart disease Ans: A Age Group: Older adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8, 10 Page and Header: 945, Peripheral Vascular Taxonomic Level: Application Feedback: Absent peripheral pulses are of great concern and should be noted in the record. The primary provider should be contacted if this finding is new. It is more common in a person with a long history of smoking or who has diabetes; it can seriously interfere with wound healing. Assessing for a history of heart disease does not take precedence over notifying the primary provider.

16. A care aide tells the nurse that an older adult patient has a pulse of 105 beats/minute. This pulse rate should be followed up promptly because A) older adults have poor cardiac reserves.

B) the patient is likely taking too many medications.

C) the patient needs to be reassured that providers care about him or her.

D) older adults usually have lower than normal pulse rates.

Ans: A Age Group: Older Adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 944, Heart and Neck Vessels Taxonomic Level: Analysis Feedback: Pulses greater than 100 are abnormal and should be taken seriously.

Because of their poor cardiac reserves, older adults do not tolerate these pulse rates well for long periods. The scenario does not mention the patient's medications. Pulse

rates on older adults often run in the 50 to 60 bpm range, but not always. While patients can benefit from reassurance, this is not the primary concern in this scenario.

17. The daughter of a palliative patient calls the clinic and asks to speak to the nurse. The daughter tells the nurse that her mother is taking morphine for advanced cancer and has become constipated. What would be the nurse's best response?

A) “People can become constipated for no reason at all.”

B) “People can become constipated when they eat a lot of fibre.”

C) “People can become constipated when taking those medications.”

D) “People can become constipated when they are under significant stress.”

Ans: C Age Group: Older Adult Chapter: 30 Client Type: Family Competency Category: Changes in Health Difficulty: Moderate Objective: 8 Page and Header: 952, Pulling It All Together: An Example of Reflection and Critical Thinking Taxonomic Level: Application Feedback: Constipation is usually related to multiple medications, inactivity, and low fluid/bulk intake. Eating a large amount of fibre does not normally cause constipation.

There is generally an identifiable reason for constipation.

18. The hospital nurse is caring for an older adult who is not eating because “it doesn't taste like what I eat at home.” What would be an appropriate nursing intervention for this patient?

A) Serve five to six small meals per day rather than three larger meals B) Arrange for the patient's family to bring in his favorite foods C) Serve in-between-meal snacks D) Serve more sweets and simple carbohydrates to the patient Ans: B Age Group: Older adult Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 950, Nursing Diagnosis, Outcomes, and Interventions Taxonomic Level: Application Feedback: Assessing food preferences and obtaining favorite foods should help promote intake. Serving more meals or in-between-meal snacks will not help if the patient does not like the food. The scenario does not say the patient likes sweets, and serving many sweets would not promote optimal nutrition.

19. A gerontological nurse has created a nursing care plan for an 81-year-old patient and documented the plan in the patient's health record. The nursing care plan should be based primarily on A) objective data.

B) subjective data.

C) assessment data.

D) a preprinted care plan.

Ans: C Age Group: Adult of Advanced Age Chapter: 30 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 10 Page and Header: 952, Pulling It All Together: An Example of Reflection and Critical Thinking Taxonomic Level: Application Feedback: The nurse uses assessment data to formulate a nursing care plan with patient outcomes and interventions. The nurse uses both objective and subjective data, but neither is used in isolation. The nurse may use a preprinted care plan, but this must reflect individualized assessment data.

Chapter 31: Assessing Individuals Who Are Obese 1. The nurse is having difficulty palpating a vein when preparing to insert an intravenous catheter into a client’s arm who has a body mass index of 38 kg/m2.

Which actions would the nurse take to increase the likelihood of successful intravenous catheter insertion? Select all that apply.

A. Ask client to keep arm flexed while assessing for vein location.

B. Apply a warm compress to the client’s arm for 10-20 minutes.

C. Apply a blood pressure cuff to use as in place of a tourniquet.

D. Use bright lighting to better visualize the client’s skin and veins.

E. Rub and slap surface of the client’s skin to encourage venous dilation.

Answer: B, C, D Rationale: Due to additional adipose tissue venipuncture and intravenous catheter placement can be more challenging in the client with obesity. Strategies to make veins easier to palpate and visualize include extending the arm to stretch the skin and thin the adipose layer rather than flexing the arm which would make locating a vein more difficult. Warm compresses can encourage vasodilation and make veins easier to palate. Using a blood pressure cuff in place of a tourniquet allows the nurse to better adjust the occlusion pressure which can prevent veins from collapsing. The nurse should also take the time to establish good lighting to increase the chances of successfully locating a vein. Slapping or rubbing the client’s skin is not a recommended approach and does not promote dilation of the vessel.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 44, Common Laboratory and Diagnostic Testing

2. The nurse assesses a client’s body mass index (BMI) as 34 kg/m2. To accurately determine the need for medical intervention, the nurse would collect which additional assessments in addition to the BMI? Select all that apply.

A. Blood pressure B. History of weight gain C. Gender D. Fasting glucose levels E. Level of dyspnea F. Psychopathology Answer: A, D, E, F Rationale: While measuring BMI can help categorize obesity, additional assessments are needed to guide interventions. Such additional assessments are included in the Edmonton Obesity Staging System (EOSS). This 5-stage scale considers obesity-related comorbidities (such as hypertension, dyslipidemia, glucose intolerance/type 2 diabetes), physical symptoms (such as dyspnea and joint pain) and psychological well-being. By staging the degree of negative health effects in addition to the client’s BMI, a more individualized and appropriate plan of care can be created. The client’s history of weight gain will not be an important factor in the current plan of care. Unlike the related assessments listed, gender does not directly inform the interventions for obesity-related health issues.

Question format: Multiple Select Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 4, Edmonton Obesity Staging System (EOSS) 3. The nurse is assessing a group of obese clients. Which client will the nurse identify as presenting with the most significant risk factor for heart disease?

A. 50-year-old woman with a body mass index of 34 kg/m2 B. 65-year-old man with a waist circumference of 135 cm C. 65-year-old man with a body mass index of 30 kg/m2

D. 55-year-old woman with a waist circumference of 85 cm Answer: B Rationale: When considering risk for heart disease among middle-and-older-aged clients, the nurse uses waist circumference to help stratify risk as this represents increased visceral fat. The 65-year-old male client with a waist circumference of 135 cm meets the criteria for increased risk for heart disease, stroke, and diabetes.

A man of the same age and a BMI of 30kg/m2 is in the borderline of obesity.

Without this client’s abdominal circumference, we cannot know if his risk for heart disease is as high as the client with the elevated waist circumference. The woman with a body mass index of 34 kg/m2 has class 1 obesity but again, without the waist circumference, this value alone tells us less about cardiovascular risk. Often obese women can be pear-shared which carries a lower risk for cardiovascular disease compared to abdominal obesity. The woman with an 85 cm waist circumference is below the level determined to increase risk for cardiovascular disease which is 88 cm.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Management of Care Integrated Process: Nursing Process Reference: p. 15, Torso 4. The nurse is creating a peer support health program about obesity for a group of school age children. Which approaches would the nurse include? Select all that apply.

A. Teaching about marketing strategies used by food companies B. Inquiring about the participants’ interests and hobbies C. Exploring the participants’ self-image and self-esteem D. Asking participants to comment on each other’s appearance E. Performing a group assessment of weight and body fat content Answer: A, B, C

Rationale: When creating a peer-based health promotion program in school aged children, the nurse is sensitive to the participants’ specific needs. School-aged and adolescent children have been shown to be particularly targeted by food marketing.

Helping the participants become more aware of marketing strategies helps them become more informed consumers. Exploring the participants’ personal interests and self-concept helps the nurse tailor activities for the group and allows participants to discover common interests and common feelings, encouraging them to offer support to one another. The nurse discourages participants from commenting on each other’s appearance to move the focus away from physical appearance and prevent embarrassing exchanges. Similarly, the nurse would not assess the participants’ weight or body fat content to protect privacy and to reduce the risk of participants focusing on comparing their physical appearance to others’.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 50, Children and Adolescents 5. The home health nurse notes a client with a body mass index of 40 kg/m2 is having increasing difficulty managing meal preparation due to mobility issues.

Which action would the nurse take to best address the client’s functional limitations?

A. Arrange for a meal preparation service B. Help the client plan easy-to-prepare meals C. Arrange for assessment by an occupational therapist D. Provide the client with mobility aids such as a walker.

Answer: C Rationale: The best action by the nurse is to arrange for assessment by an occupational therapist (OT). The OT assessment can best inform the other interventions which may include mobility aids or alternate meal preparation

approaches. Without the OT proper assessment, however, the nurse cannot be sure the client is getting the best options to suit their functional level.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Analyze Client Needs: Management of Care Integrated Process: Nursing Process Reference: p. 7, Day-to-Day Struggles 6. A client with class 2 obesity is newly admitted for a urinary tract infection (UTI) that progressed to urosepsis. The client is currently receiving fluid resuscitation.

The client admits to not seeking attention for the UTI despite having progressive symptoms for over a week. What should the nurse assess as a current priority based on this information?

A. The client’s past experiences and relationships within healthcare systems B. The client’s knowledge about the relationship between obesity and UTIs C. The client’s ability to perform hygiene care of the perineal and genital areas D. The client’s readiness for incorporating lifestyle changes to improve health Answer: A Rationale: The fact that the client was aware of symptoms but did not seek attention should be addressed by the nurse. Failure to seek attention could be related to poor relationships or negative past experiences within healthcare systems. Stigma and shame have been shown to prevent clients with obesity from seeking medical attention. Because the nurse needs to establish a positive rapport with the client, this information is relevant in this moment. While acutely ill, the nurse should defer discussions about long-term lifestyle changes. These conversations are best saved for when the client is stable and at baseline functioning. Similarly, while acutely ill, the nurse and other staff can assist the client with hygiene. The nurse may assess selfcare abilities once the client is stable.

The client’s knowledge about the links between UTIs and obesity are not relevant in this moment because the client cannot alter the fact that they are obese or that they currently have a UTI. Focusing on this now could add to feelings of shame.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 10, Weight Bias 7. The nurse assesses the vital signs of a client with class II obesity. The nurse applies knowledge regarding which physiological effects of obesity when assigning significance to the assessment findings? Select all that apply.

A. The strength of the client’s pedal pulses may appear diminished upon palpation.

B. The client’s baseline body temperature may be slightly higher than non-obese clients.

C. Diminished breath sounds may be present but may not represent a respiratory issue.

D. The client will have a decreased baseline respiratory rate compared to non-obese clients.

E. Pulse oximetry may be artificially elevated as blood vessels are closer to the skin’s surface.

Answer: A, B, C Rationale: Due to adipose tissue, peripheral pulses may be difficult to palpate, and sometimes Doppler ultrasound may be required. The nurse does not record the pulses as weak or absent but rather difficult to palpate. Clients with obesity often have a higher mean body temperature between 0.3 to 0.5°F (0.15 to 0.25°C) higher. Excess adipose tissue may also make pulse oximetry more difficult to obtain and it would not be artificially elevated but may not register or be artificially low.

Baseline respiratory rate is often elevated due to increased work of breathing and increased energy expenditure. Breath sounds may be diminished due to the increased tissue through which auscultation must be done but this would not indicate a respiratory issue.

Question format: Choice Multiple Chapter: 31

Cognitive Level: Apply Client Needs: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 12, Vital Signs 8. The nurse is assessing the skin of an obese client. For which risk factors will the nurse assess as increasing the risk for skin breakdown in this client? Select all that apply.

A. Increased areas of exposure to air B. Dryness in the folds of the skin C. Areas of skin-on-skin friction D. Presence of a large pannus E. Presence of peripheral edema Answer: C, D, E Rationale: Increased risk for skin breakdown in the obese client is often related to decreased vascularity of adipose tissue and chronic skin-on-skin friction due to skin folds. Decreased exposure to air, not increased also contributes. Skin folds trap moisture which can lead to breakdown. Dryness in skin folds would decrease the risk for breakdown. Having a large abdominal pannus is a source of a skin-on-skin friction and may also make it difficult for the client to keep genitalia clean and dry.

Clients with obesity are more prone to venous insufficiency and peripheral edema which can lead to venous stasis ulcers, cellulitis, and other skin complications.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 13, Skin 9. A 35-year-old client who is overweight is attending melanoma screening clinic.

The nurse notes no lesions suspicious for melanoma but does note the client has

numerous skin tags. Which question would the nurse ask the client related to the presence of skin tags?

A. “Do you wear sun screen when outdoors?”

B. “Have you had your blood glucose levels checked?”

C. “Do you have a history of eczema or allergies?”

D. “How long have you had these skin tags?”

Answer: B Rationale: Because the presence of skin tags has been associated with metabolic syndrome and type 2 diabetes, the nurse should enquire about the client’s blood glucose levels. Being under the usual screening age of 40 for type 2 diabetes, this client may not have had levels checked and being overweight increases the client’s risk. Skin tags are benign and not related to sun exposure, eczema, or allergies.

The length of time the client has had skin tags is not important and will not alter the focus which should be on early identification and treatment of metabolic syndrome or type 2 diabetes.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 13, Skin 10. A young adult client with class II obesity and venous insufficiency is admitted for treatment of cellulitis of the left lower leg. Today the client has a sudden onset of dyspnea with tachypnea, and decreased oxygen saturation, but no adventitious breath sounds. Which assessment will the nurse perform as the priority?

A. Daily weight and fluid balance B. Appearance of lower legs C. Neurological assessment D. Evidence of gastrointestinal bleeding Answer: B The hospitalized obese client with venous insufficiency is at increased risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). The dyspnea and drop in

oxygen saturation should make the nurse focus on a respiratory complication such as PE. Also, PE often does not present with obvious changes in breath sounds. This makes assessing the lower legs most relevant as it can help identify potential DVT. Daily weight and fluid balance would be relevant if the nurse suspected pulmonary edema as the cause but given the lack of adventitia and the client’s age, this is far less likely. There is no indication in the scenario that this young client has any alteration in mentation, so a neurological focus is not warranted. If the client were to experience acute blood loss due to gastrointestinal bleeding, there would not be a drop in oxygen saturation so this focus is not warranted by the findings.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 14, Torso 11. A client with class III obesity and obstructive sleep apnea (OSA) reports not using the prescribed continuous positive airway pressure (CPAP) machine as the mask is uncomfortable. What information would the nurse provide as a priority?

A. “It is common for clients to report difficulty with the mask, but you will adjust to it over time.”

B. “Your healthcare provider prescribed this important treatment based on your sleep study results.”

C. “Treating OSA effectively can prevent serious complications such as cardiovascular diseases.”

D. “Losing weight could resolve your OSA so you would not need to use the CPAP machine.”

Answer: C Rationale: The nurse’s priority is teaching the client about the consequences of not using the CPAP as prescribed. By teaching the client about the potential for serious complications related to cardiovascular complications from OSA, the client is better able to make an informed treatment choice. Simply telling the client the treatment

was prescribed based on test results does not inform the client about the risks of not adhering to the treatment. Stating the client will adjust is also not informative as to the risks. While weight loss can assist in the treatment of OSA, this is a longterm goal and does not replace the need for CPAP as currently prescribed.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 14, Torso 12. A young adult female client with a body mass index of 35 kg/m2 reports dysmenorrhea and a recent increase in facial hair growth. Based on these reports, for which condition would the nurse assess the client?

A. Endometriosis B. Metabolic syndrome C. Pelvic inflammatory disease D. Sexually transmitted infections Answer: B Rationale: Given the client’s age, weight, gender, and symptoms of dysmenorrhea and facial hair growth, the nurse should suspect polycystic ovary syndrome (PCOS).

Polycystic ovary syndrome is a common endocrinopathy that occurs in 7-10% of overweight women of childbearing age. Due to high androgen levels effects such as hair growth and acne are seen. There is also ovulatory dysfunction which can cause infertility. Metabolic syndrome is highly correlated with PCOS and increases the client’s risk for type 2 diabetes and cardiovascular diseases. Therefore, the nurse would also assess the parameters of metabolic syndrome including abdominal circumference, lipid profile, blood pressure, and blood glucose level. Neither sexually transmitted diseases nor the related condition of pelvic inflammatory disease would lead to hair growth. Endometriosis is a condition where endometrial tissue exists outside the uterus and can cause dysmenorrhea but would not contribute to hair growth.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 17, Endocrine and Metabolic Functioning 13. A client with class III obesity is admitted for a biopsy procedure related to a suspected new diagnosis of esophageal cancer. What would the nurse focus on when teaching the client during this admission? Select all that apply.

A. Long-term lifestyle changes to assist with weight loss B. Pre-and-post biopsy procedure routines and interventions C. Signs and symptoms of complications from the biopsy procedure D. The connections between obesity and esophageal cancer E. How client should follow-up and obtain biopsy results Answer: B, C, E The client is undergoing an invasive procedure for a potentially fatal condition. In this situation, it is not appropriate for the nurse to focus on long-term lifestyle changes. Instead, the nurse focuses on teaching the client about the procedure itself including what to expect and how to identify complications. The nurse will also ensure the client knows how to obtain the results. Teaching the client about obesity as a risk factors for developing esophageal cancer is not helpful. If the client has this form of cancer, it cannot be prevented by losing weight now and focusing on the connection between obesity and cancer may bring the client guilt and shame. If the biopsy results are negative, it would be appropriate at that time to focus on health promotion and illness prevention. Currently, health promotion is not the priority.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation

Reference: p. 21, Health Promotion 14. The nurse is assessing heart sounds on a client with a body mass index of 47 kg/m2 and notes the sounds are distant. Which actions would the nurse take to better assess the client’s heart sounds? Select all that apply.

A. Have the client lie on the right side B. Have the client sit up and lean forward C. Reduce any unnecessary noise from the area D. Close eyes while auscultating sounds E. Ask the client to bear down while auscultating Answer: B, C, D Rationale: Due to increased distance between the heart and the stethoscope, altering the client’s position to either left-side lying or leaning forward can move the heart closer and make auscultation easier. Right-side lying would shift the heart further from the body surface. Removing unnecessary ambient noise and closing one’s eyes can also make auscultation easier. There is no benefit to having the client bear down during auscultation.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 38, Torso 15. A client with class II obesity, gastroesophageal reflux disease (GERD), and type 2 diabetes is admitted for intravenous antibiotic treatment of an infected diabetic foot ulcer. Which interventions will the nurse include in the plan of care? Select all that apply.

A. Assess client’s skin folds and oral cavity daily B. Position client with head of bed elevated C. Elevate affected foot on two pillows D. Offer only low or no-calorie snacks

E. Request assessment by a Registered Dietician Answer: A, B, E Rationale: The client with obesity and who is on antibiotic therapy will be at an increased risk for yeast (Candida albicans) infection. Therefore, the nurse assesses skin folds, groin, and oral cavity as these are frequent sites of yeast infection.

Because of the diagnosis of GERD, the head of the bed should be slightly elevated to reduce the risk for reflux and aspiration. The nurse should not independently decide that the client should only have low or no-calorie snacks. The need for wound healing, having an active infection, and the diagnosis of diabetes make the client’s nutritional needs complex. Instead of making this decision, the nurse would consult to a Registered Dietician for an assessment. Having a diabetic foot ulcer is evidence of poor arterial blood supply (peripheral artery disease). The nurse should not elevate the foot above the level of the heart as this will further decrease blood supply to the foot and impede healing.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 39, Torso 16. The nurse has just received report a group of clients on a bariatric surgical unit.

Which client will the nurse assess first? The client who is A. two days post gastric bypass who is due to ambulate with stand-by assist.

B. one day post gastric sleeve surgery who reports 3 on 10 abdominal pain.

C. on-call to the operating room and due for intravenous prophylactic antibiotics.

D. six hours post gastric bypass and due for routine vital sign reassessment.

Answer; C Rationale: The nurse needs to ensure the client who is on-call to surgery has the prophylactic antibiotic started as prescribed and needs to ensure all other preoperative checks have been completed to avoid any delay in the procedure. Due to the time-sensitive nature of the pre-operative client’ situation, this is the nurse’s

priority. The nurse needs to assess and treat the client who had gastric sleeve postoperative pain, and this would be the nurse’s second priority. There is no indication the client who is 6 hours post-operative has had any unstable vital signs. This routine assessment can be deferred until after the pre-operative client and the client with pain are addressed. Lastly, the nurse can delegate ambulation of the client who is two days post gastric bypass surgery.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Analyze Client Needs: Management of Care Integrated Process: Nursing Process Reference: p. 39, Torso 17. The nurse is assessing a client who underwent roux-en-Y surgery 6 months ago. Which areas will the nurse assess for potential complications from the procedure? Select all that apply.

A. Skin, hair, and nails B. Hemoglobin levels C. Urine output and appearance D. Abdominal discomforts E. Bowel movements Answer: A, B, C, D, E Rationale: In roux-en-y, or gastric bypass surgery, the size of the client’s stomach is greatly reduced which creates early satiety and promotes weight loss. Some potential long-term complications after this procedure include nutritional deficiencies which can lead to anemia and integumentary changes making assessment of hemoglobin, skin, hair, and nails relevant. After this procedure, clients can be at an increased risk for kidney stone formation so urinary assessment is warranted. Adhesions can form postoperatively that can lead to abdominal discomfort and potential bowel obstruction. Changes in bowel movements ranging from constipation to diarrhea can occur in the bariatric client and can be evidence of the need for intervention so should be assessed.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 27, Surgical Health-Promoting Options 18. A client with a body mass index of 65 kg/m2 has been told the risks for performing gastric bypass surgery (roux-en-Y) are too great due to the client’s abdominal obesity. The client is discouraged at this news and asks the nurse what options there are now. What information would the nurse share with the client?

Select all that apply.

A. “The bariatric surgeon may be able to set up a weight loss program to help you meet a safe weight for surgery.”

B. “Sometimes there are alternate surgeries that can be done for clients who are not candidates for roux-en-Y.” C. “It is better for you to lose weight naturally if you can. The surgery carries risks that lifestyle changes do not.”

D. “Sometimes these procedures are available out of the country for a fee. If you have the resources, this may be an option.”

E. “It is best to be safe when it comes to a major surgery like this. It is a good thing that your doctor is being careful.”

Answer: A, B Rationale: For clients with a BMI over 60 kg/m2, roux-en-Y may be deemed too risky. In these cases, stepwise surgical approaches can be used where a gastric sleeve procedure is performed and then converted to duodenal switch. The client could also lose weight in order to meet the safe threshold for the roux-en-Y procedure. While it may be true that “natural” weight loss carries less risks, if the client was being referred for bariatric surgery, this was deemed a necessary approach meaning less invasive approaches have not been successful.

Oversimplifying the client’s treatment options is not helpful. The nurse would not encourage the client to seek care outside of the country at a fee-based clinic as this

could put the client at risk for substandard care and serious complications. While it may be positive that the surgeon is following protocols to keep the client safe, this response does nothing to address the client’s options going forward.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 26, Vertical Sleeve Gastrectomy 19. The nurse is assessing a client with a body mass index of 48 kg/m2 and notes the oxygen saturation taken on the index finger is 86% despite the client having no respiratory difficulty and clear breath sounds. Which action would the nurse take in response to these findings?

A. Obtain a reading using an oximeter sensor designed to be used on the client’s forehead.

B. Apply oxygen at 10 liters via facemask and notify the heath care provider of the change.

C. Document the oxygen saturation results and reassess respiratory status in 15 minutes.

D. Have the client perform deep breathing and coughing and recheck the saturation level.

Answer: A Rationale: The nurse would recognize the result may be inaccurate given the client’s lack of symptoms or signs of respiratory difficulty. Excess adipose tissue has the potential to interfere with the accuracy of oxygen saturation readings so in order to obtain a more accurate reading the nurse would obtain a sensor that can be used on an area with less adipose tissue. The nurse should not delay this assessment as some serious respiratory issues may not present with overt symptoms and an accurate value needs to be determined. Because accuracy is in question, the nurse should not treat the client for hypoxemia until the client’s

accurate saturation is known. Since the client’s chest sounds are clear, deep breathing and coughing is not indicated.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 38, Pulse oximetry 20. The nurse is assessing a client with class II obesity who is suspected of having obstructive sleep apnea. The nurse places the measuring tape at which point on the client’s neck when measuring the client’s neck circumference?

A. Superior to the jugular notch B. Superior to the cricoid cartilage C. At the level of the mandibular angle D. At the level of the hyoid bone Answer: B Rationale: In clients with obesity, greater neck circumference is associated with higher risk for obstructive sleep apnea. The landmark for accurate measurement of neck circumference is superior to the cricoid cartilage which is close to the middle of neck located between the jugular notch and hyoid bone. Measuring near the jugular notch is at the top of the sternum which is too low, and the hyoid bone is too high on the neck. The mandibular angle is at the jaw line and is not located on the client’s neck.

Question format: Multiple Choice Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 38, Head and Neck

21. The nurse performs a height and weight measurements on a 4-month pregnant client. The client is 5 feet 4 inches (163 cm) and 230 pounds (104.3 kg). The client remarks that she has gained 10 pounds in the past month but that she is “eating for two”. Which teaching points would the nurse provide in response? Select all that apply A. “Your current body mass index places you in the obese category and this carries many health risks.”

B. If you change your eating now, it is possible for you to be at a normal body mass index by your delivery date.”

C. “Being overweight while pregnant increases your risk for blood clots, diabetes, and premature delivery.”

D. “It will be important to control the rate of weight gain during your pregnancy to reduce the risks to you and the baby.”

E. “It is important that you do not diet while pregnant. You can focus on losing weight once the baby is born.”

Answer: A, C, D Rationale: The nurse notes that the client’s height and weight places her in the obese range of body mass index (about 39 kg/m2) and should inform the client of this fact. During pregnancy, obesity presents several risks to the mother and the fetus including thromboembolism, preeclampsia, gestational diabetes, increased need for cesarean deliveries, and premature delivery. The client’s weight gain is excessive for the time period and stage of pregnancy so the nurse would inform the client of these potential complications so she knows the consequences if this weight gain should continue. Weight gain can be controlled during pregnancy with a proper diet so the nurse would not tell the client not to alter her diet during the pregnancy.

However, the nurse would not tell the client she could achieve a normal BMI by the time of delivery as this would require a weight loss of over 80 pounds (37 kg) which would be too aggressive during pregnancy.

Question format: Choice Multiple Chapter: 31 Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 48, Women Who Are Pregnant

Chapter 32: A Complete Health Assessment Multiple Choice 1. A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new patient. What would be the instructor's best response?

A) “A new patient needs a more complete assessment because you don't know what is happening with them.”

B) “A comprehensive assessment is a better assessment than any type.”

C) “The comprehensive health assessment gives the nurse an overall impression of the patient and his or her condition.”

D) “You need to know what is going on with the patient at that particular point in time.”

Ans: C Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 1 Page and Header: 960, Introduction Taxonomic Level: Comprehension Feedback: The comprehensive health assessment integrates all body systems; findings help the nurse form an overall impression of the patient and his or her condition. While many new patients do need more complete assessments, there are times when new patients first require emergency or focused assessments.

Comprehensive assessments are not qualitatively better than focused or emergency assessments if used at inappropriate times or settings. A focused assessment is just as likely to help the nurse determine what is going on with the patient at that point in time as a comprehensive assessment is.

2. When conducting a focused health assessment, the nurse asks questions specifically targeting A) the patient's previous medical history.

B) the patient's prognosis.

C) common diagnoses and health problems.

D) issues and symptoms specific to the patient.

Ans: D Age Group: Adult Chapter: 32 Client Type: Individual

Competency Category: Changes in Health Difficulty: Moderate Objective: 2, 4 Page and Header: 964, Focused Health History Related to Common Symptoms Taxonomic Level: Application Feedback: The nurse focuses questions on issues and symptoms specific to the patient. In this way, the patient is viewed as a person who has multiple things that are affected by the health status. These questions are related to the primary problems and concerns for the patient, included in each system-specific chapter. A focused assessment does not ask questions specifically about overall medical history, prognosis, or other diagnoses and symptoms.

3. A nurse is collecting subjective data as part of a comprehensive assessment.

Which of the following topics would be considered to be subjective data?

A) Identification of risk factors B) Findings from percussion C) Assessment of skin colour D) Auscultated sounds Ans: A Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 2 Page and Header: 960, Subjective Data Collection Taxonomic Level: Comprehension Feedback: Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated and percussed sounds and visualized signs are part of objective data collection.

4. When collecting subjective data, the nurse gives the patient time and encouragement to do what?

A) Create a plan of care B) Evaluate caregivers C) List common findings D) Tell his or her story Ans: D Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate

Objective: 5 Page and Header: 960, Subjective Data Collection Taxonomic Level: Application Feedback: The nurse gives the patient time and encouragement to tell his or her story and experience of health or illness. Doing so provides an opportunity for the patient to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the patient's family history and health concerns, but the nurse would steer the conversation away from social discussions of the patient's family and the evaluation of caregivers. Common findings are part of objective data collection and are driven by the health provider, not the nurse. The care plan is informed by the patient's priorities but is created by the nurse.

5. A nursing instructor is explaining to students about primary prevention services that nurses offer as part of their professional responsibilities. What would the instructor list as an example of these services?

A) Palpation B) Auscultation C) Screening D) Rehabilitation Ans: C Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 3 Page and Header: 960, Assessment of Risk Factors Taxonomic Level: Comprehension Feedback: Screening and resulting teaching are primary prevention services that nurses offer as part of their professional responsibilities. Palpation and auscultation are techniques of physical examination. Rehabilitation is a tertiary prevention service.

6. The nurse is assessing the risk factors of a new clinic patient. These risk factors are assessed according to what?

A) The individual's age B) The individual's threats to health C) The individual's gender D) The individual's lifestyle Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health

Difficulty: Moderate Objective: 2 Page and Header: 960, Assessment of Risk Factors Taxonomic Level: Knowledge Feedback: The nurse assesses risk factors according to the individual's risks (e.g., injury in a teenager, genetic diseases in a pregnant woman). The other listed options all have some component of the correct answer, but threats to health (i.e., risks) are the primary focus of risk factor assessment.

7. The nurse is conducting a head-to-toe assessment on a patient. Which of the following components of assessment addresses the health of the patient's endocrine system?

A) Assessment of thirst and for excessive urination B) Assessment of the patient's normal bowel pattern C) Assessment of the patient's self-report of mood and affect D) Assessment of the patient's skin colour and skin integrity Ans: A Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6, 8 Page and Header: 963, Review of Systems Taxonomic Level: Analysis Feedback: Assessment for thirst and excessive urination are related to the pathophysiology of diabetes, one of the most common and serious endocrine disorders. Skin can also be affected by endocrine disorders but to a lesser extent than the signs and symptoms of diabetes. Bowel function and mental status are influenced by the endocrine system, but these changes are less common than the cardinal signs of diabetes.

8. While assessing a patient's eyes, the nurse notes a depressed corneal response.

In what patient would this finding be considered normal?

A) No patient B) A wearer of contact lenses C) A patient with a history of macular degeneration D) An older adult patient Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult

Objective: 6 Page and Header: 966, Head Taxonomic Level: Application Feedback: Depressed or absent corneal response is common in contact lens wearers. This is not the case with all older adults or patients who have macular degeneration.

9. The nurse is assessing a 77-year-old patient who complains about being “very tired” all the time. What is the best way to assess this patient?

A) In a warm, well-lighted room B) Divided over several time periods C) Like all other patients D) Slowly in a draft-free room Ans: B Age Group: Older Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 974, Lifespan and Cultural Considerations Taxonomic Level: Application Feedback: The older adult may fatigue easily and need to have the assessment divided over several time periods. A draft-free, warm, well-lighted room may be beneficial but is not the most correct answer for this scenario. The nurse would not assess this patient like all other patients.

10. When considering the culture of a patient, the nurse would be aware that in some cultures A) a health care provider of the same gender is preferred.

B) only a male health care provider is acceptable.

C) a chaperone always has to be with the patient.

D) a translator is always necessary.

Ans: A Age Group: Adult Chapter: 32 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 5 Page and Header: 974, Lifespan and Cultural Considerations Taxonomic Level: Analysis Feedback: Some men or women, especially in some cultures, prefer to have a health care provider of the same gender. It is not common for a culture to ascribe all

caregiving duties to males or to require continuous chaperoning. Translators may or may not be necessary.

11. The nurse is conducting a comprehensive assessment of an adult client and needs to determine the presence or absence of bowel motility. How should the nurse conduct this portion of the assessment?

A) Palpate the patient's abdomen B) Assess for the presence of an abdominal fluid wave C) Auscultate the patient's abdomen D) Inspect the patient's abdomen for distention Ans: C Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 4 Page and Header: 970, Abdomen Taxonomic Level: Application Feedback: Bowel sounds are an indication of bowel motility. Motility cannot be ascertained from inspection or palpation, though the absence of bowel motility would influence these assessments. A fluid wave test is conducted to determine the presence of ascites.

12. The nurse is palpating the abdomen of a patient newly admitted to the unit.

What would be an abnormal finding?

A) Softness B) Guarding C) Nonpalpable organs D) Nontender areas Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 970, Abdomen Taxonomic Level: Analysis Feedback: Abnormal findings on abdominal palpation are large masses, hardness, tenderness with guarding or rigidity, and rebound tenderness. The nurse would expect the abdomen to be soft and nontender, with generally nonpalpable organs.

13. When doing a shift assessment on a new patient, the nurse notes that the patient's popliteal pulses are within normal limits. How would the nurse chart this?

A) Popliteal pulses + 1 B) Popliteal pulses + 2/4 C) Popliteal pulses + 4/4 D) Popliteal pulses + 1 to + 4 Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 971, Lower Extremities Taxonomic Level: Application Feedback: Correct documentation of expected popliteal pulses would be “popliteal pulses + 2/4.”

14. The nurse is caring for a 64-year-old patient who has presented to the emergency department with an exacerbation of his long-standing chronic obstructive pulmonary disease (COPD). The care team has protected the patient's airway and breathing and the nurse is now inspecting the shape of the patient's thorax in order to identify A) flail chest.

B) barrel chest.

C) scoliosis.

D) kyphosis.

Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 8 Page and Header: 969, Anterior Thorax Taxonomic Level: Analysis Feedback: A barrel chest is a change in thoracic structure that is characteristic of COPD. Flail chest, scoliosis, and kyphosis are not associated with this presentation and history.

15. A nurse is caring for a patient with inflammatory bowel changes and has identified a nursing diagnosis of “diarrhea related to inflammatory changes in the bowel.” What would be an appropriate intervention for this diagnosis?

A) Use a heat or cold pack for pain relief

B) Ensure adequate hydration and electrolyte replacements C) Provide periods of rest by clustering care D) Gather resources for home care and daily activities Ans: B Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 976, Table 32-3 Taxonomic Level: Application Feedback: An appropriate intervention for diarrhea is to ensure adequate hydration and electrolyte replacements. Pain relief measures, rest, and home care resources would not be primary concerns in this case.

16. A new patient presents at the clinic and reports difficulty hearing. During the interview, the patient asks the nurse to repeat questions several times. Examination of the ears reveals large amounts of cerumen filling the canals bilaterally. What would be an appropriate outcome for this patient?

A) Hearing will be restored to within normal limits.

B) The patient will learn to safely clean ears with cotton swabs.

C) Ears will be cleaned at the clinic with hearing improved.

D) The patient will demonstrate acceptable hygiene.

Ans: C Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 968, Ears Taxonomic Level: Application Feedback: The appropriate outcome is for ears to be cleaned with correct technique at the clinic and the patient subsequently reporting improved hearing. “Normal hearing” represents an outcome that is too vague. Cotton swabs should not be used to clean the ears. Cerumen accumulation is not necessarily indicative of inadequate hygiene.

17. A nurse has conducted a screening assessment of an adult patient. How should the nurse best follow up the findings from this assessment?

A) Arrange for the patient to meet with his or her primary care provider B) Write down the findings and present them to the patient C) Analyze the findings with a colleague

D)

Perform appropriate patient teaching

Ans: D Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 9 Page and Header: 960, Assessment of Risk Factors Taxonomic Level: Synthesis Feedback: An appropriate, and important, response to screening assessment is to perform necessary patient teaching. Referrals may or may not be necessary and assessment findings are not normally analyzed with a colleague. Patients are not normally provided with written results of screening, though this may sometimes be appropriate.

18. What type of assessment would a hospital nurse perform when a patient is first admitted to an inpatient unit?

A) Screening B) Focused C) Acute D) Comprehensive Ans: D Age Group: Adult Chapter: 32 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 960, Introduction Taxonomic Level: Knowledge Feedback: The nurse in the hospital performs a comprehensive assessment of the patient on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay.