TETS BANK for Essentials for Nursing Practice, 9th Edition by Patricia A. Potter, Anne G. Perry, Pat

Essentials for Nursing Practice / Edition 9 Testbank Chapter 01: Professional Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse uses effective strategies to communicate and handle conflict with nurses and other health care professionals. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? a.Informatics b.Quality improvement c.Teamwork and collaboration d.Evidence-based practice ANS: C Teamwork and collaboration uses effective strategies to communicate and handle conflict. Informatics includes navigating electronic health records. Quality improvement uses tools such as flow charts and diagrams to improve care. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:11 OBJescribe the purpose of professional standards of nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse is employed by a health care agency that provides an informal training session on how to properly use a new vital sign monitor. Which type of education did the nurse receive? a.In-service education b.Advanced education c.Continuing education d.Registered nurse education ANS: A In-service education programs are instruction or training provided by a health care agency or institution designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Some roles for RNs in nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner. There are various educational routes for becoming a registered nurse (RN), such as associate, diploma, and baccalaureate. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:6 OBJ: Discuss the importance of education in professional nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care =

3.A nurse listens to a patients lungs and determines that the patient needs to cough and deep breath. The nurse has

the patient cough and deep breath. Which concept did the nurse demonstrate? a.Accountability

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b.Autonomy c.Licensure d.Certification ANS: B Autonomy is essential to professional nursing and involves the initiation of independent nursing interventions without medical orders. Accountability means that you are professionally and legally responsible for the type and quality of nursing care provided. To obtain licensure in the United States, RN candidates must pass the NCLEXRN examination administered by the individual State Boards of Nursing to obtain a nursing license. Beyond the NCLEX-RN, some nurses choose to work toward certification in a specific area of nursing practice.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 6 OBJ: Discuss the characteristics of professionalism in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4.A registered nurse is required to participate in a simulation to learn how to triage patients who are arriving to the hospital after exposure to an unknown gas. This is an example of a response to what type of influence on nursing? a.Workplace hazards b.Nursing shortage c.Professionalism d.Emergency preparedness ANS: D Many health care agencies, schools, and communities have educational programs to prepare for nuclear, chemical, or biological attack and other types of disasters. Nurses play an active role in emergency preparedness. Workplace hazards include violence, harassment, and ergonomics. A person who acts professionally is conscientious in actions, knowledgeable in the subject, and responsible to self and others. There is an ongoing global nursing shortage, which results from insufficient qualified registered nurses (RNs) to fill vacant positions and the loss of qualified RNs to other professions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:4 OBJ: Discuss the influence of social, political, and economic changes on nursing practices.

TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 5.A nurse is an advanced practice registered nurse (APRN) who cares for geriatrics. This nurse is which type of advanced practice nurse? a.Clinical nurse specialist b.Nurse practitioner c.Certified nurse-midwife d.Certified registered nurse anesthetist ANS: A The clinical nurse specialist (CNS) is an APRN who is an expert clinician in a specialized area of practice, such as geriatrics or pediatrics. The nurse practitioner (NP) is an APRN who provides health care to a group of patients, usually in an outpatient, ambulatory care, or community-based setting. A certified nurse-midwife (CNM) is an APRN who is educated in midwifery and is certified by the American College of Nurse-Midwives. A certified registered nurse anesthetist (CRNA) is an APRN with advanced education in a nurse anesthesia accredited program. =

PTS:1DIF:Cognitive Level: Applying (Application) REF: 8 OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6.A patient does not want the treatment that was prescribed. The nurse helps the patient talk to the primary health care provider and even talks to the primary health care provider when needed. The nurse is acting in which professional role? a.Educator b.Manager c.Advocate d.Provider of care ANS: C As an advocate you act on behalf of your patient, securing and standing up for your patients health care rights. As an educator you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patients progress in learning. Most nurses provide direct patient care in an acute care setting, and this describes the role of provider of care. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 7 OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 7.A nurse must follow legal laws that protect public health, safety, and welfare. Which law is the nurse following? a.Code of Ethics b.Nurse Practice Act c.Standards of practice d.Quality and safety education for nurses ANS: B In the United States each State Board of Nursing oversees its Nurse Practice Act (NPA), which regulates the scope of nursing practice for the state and protects public health, safety, and welfare. The ANAs Code of Ethics for Nurses: Interpretation and Application (2010) provides a guide (not a law) for carrying out nursing responsibilities to ensure high-quality nursing care and provide for the ethical obligations of the profession. The purpose of a standard of care is to describe the common level of professional nursing care to judge the quality of nursing practice. The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the Institute of Medicine.

PTS:1DIF:Cognitive Level: Applying (Application) REF:7 OBJescribe the purpose of professional standards of nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 8.A nurse is directing the care and staffing of three cardiac units. The nurse is practicing in which nursing role? a.Advanced practice registered nurse b.Nurse researcher =

c.Nurse educator d.Nurse administrator ANS: D A nurse administrator manages patient care and the delivery of specific nursing services within a health care agency. An advanced practice registered nurse has a masters degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice. A nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments. The nurse researcher investigates problems to improve nursing care and further define and expand the scope of nursing practice.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 9 OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is presenting at an interdisciplinary meeting about the multiple external forces that are influencing nursing today. Which examples should the nurse include? (Select all that apply.) a.Health care reform b.Threat of bioterrorism c.Population demographics d.Role of nurse manager e.Nursing shortage ANS: A, B, C, E Multiple external forces affect nursing today, including health care reform, demographic changes of the population, increasing numbers of medically underserved, need for emergency preparedness, threat of bioterrorism, workplace issues, and the nursing shortage. Role of nurse manager is not an external force affecting nursing, but is one role of the registered nurse.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:4 OBJ: Discuss the influence of social, political, and economic changes on nursing practices.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse is teaching the staff about the characteristics of a profession. Which information should the nurse include? (Select all that apply.) a.Extended education b.Theoretical body of knowledge c.Code of ethics for practice d.Practice developments e.Provision of a specific service ANS: A, B, C, E Professions possess the following characteristics: An extended education of members and a basic liberal education foundation A theoretical body of knowledge leading to defined skills, abilities, and norms =

Provision of a specific service Autonomy in decision making and practice A code of ethics for practice Practice developments are not a characteristic of a profession, but are essential for nurses to stay current by gaining new knowledge about the latest research and practice developments.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 5 OBJ: Discuss the characteristics of professionalism in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3.A nurse is teaching the staff about Quality and Safety Education in Nursing, which identified six competencies for nursing. Which information should the nurse include in the teaching session? (Select all that apply.) a. Informatics b.Safety c.Health policies d.Informatics e.Quality improvement

ANS: A, B, D, E The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the IOM. The QSEN initiative encompasses the competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Health policy is health related issues at the government level, not a competency.

PTS:1DIF:Cognitive Level: Applying (Application) REF:10 | 11 OBJescribe the purpose of professional standards of nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 4.A nurse wants to become an advanced practice registered nurse (APRN) and have a higher degree of independence. Which advanced roles could the nurse pursue? (Select all that apply.) a.Clinical nurse specialist b.Nurse manager c.Nurse practitioner d.Nurse midwife e.Nurse anesthetist ANS: A, C, D, E The advanced practice registered nurse (APRN) is the most independently functioning nurse. An APRN has a masters degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice. There are four core roles for the APRN: clinical nurse specialist (CNS), nurse practitioner (NP), certified nurse midwife (CNM), and certified RN anesthetist (CRNA).

Nurse managers do not require an advanced degree.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 8 OBJ: Describe the roles and career opportunities for nurses. =

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

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Chapter 02: Health and Wellness Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is assessing a patients stage of behavioral change. Which statement by the patient will indicate to the nurse that the patient is in the preparation stage? a.I started to exercise regularly, but it didnt last long. Ill probably try again in a few weeks. b.I have a problem, and I really think I need to work on it. c.I am really working hard to stop smoking. d.There is nothing that I really need to change.

ANS: A I started to exercise regularly, but it didnt last long. Ill probably try again in a few weeks is the preparation stage. I have a problem, and I really think I need to work on it is the contemplation stage. I am really working hard to stop smoking is the action stage. There is nothing that I really need to change is the precontemplation stage.

PTS:1DIF:Cognitive Level: Applying (Application) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2.A patient is depressed after a divorce and is not eating. The nurse is using Maslow to prioritize care. Which patient need should the nurse address first ? a.Nutrition b.Emotional safety c.Depression d.Love and belonging ANS: A According to Maslow, individuals have to meet lower-level needs before they are able to satisfy higher-level needs. The lowest level on the hierarchy consists of very basic physiological needs such as oxygen, water, food (nutrition), sleep, and sex. The second level on the hierarchy consists of safety needs. The third level on the hierarchy is love and belongingness, which is a desire to belong to groups. The fourth level deals with the need for self-esteem. Depression is not a lower need but a higher need.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:17-18 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 3.A nurse is assessing a patients risk factors for heart disease and finds that the patient has several risk factors. How should the nurse interpret this finding? a.The patient needs surgery for heart disease.

b.The patient has a genetic disease. c.The patient will develop the disease. d.The patient has an increased chance to develop the disease.

ANS: D The presence of a risk factor does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease. Although genetics can be a risk factor, it does not mean the patient has a genetic disease. The patient does not need surgery for heart disease because risk factors only increase the probability of the disease occurring.

PTS:1DIF:Cognitive Level: Applying (Application) REF:21 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 4.To determine a patients external variables for health beliefs and practices, which area should the nurse assess? a.Emotional factors b. Intellectual background c.Developmental stage d.Socioeconomic factors ANS: D External variables for health beliefs and practices include family practices, socioeconomic factors, and cultural background. Emotional factors, intellectual background, and developmental stage represent internal variables.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:20 OBJ: Describe the variables influencing health beliefs and health practices.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5.Which nursing action best represents primary prevention? a.Instructing a healthy individual to get a flu shot on a yearly basis b.Instructing a patient to take blood pressure medication every day c.Instructing a patient to live with a known disability d.Instructing a patient to undergo physical therapy following a cerebrovascular accident ANS: A A healthy individual getting a flu shot is primary prevention. Primary prevention precedes disease or disability or dysfunction. Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Taking blood pressure medication every day is a secondary prevention because the patient is trying to prevent further complications. Physical therapy after a cerebrovascular accident is intended to prevent further complications and deterioration and is tertiary prevention. Instructing a patient to live with a known disability is tertiary prevention.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:21OBJ:Explain the three levels of prevention.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6.A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking.

At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n): a.acute illness. b.tertiary prevention. c.chronic illness. d.internal variable.

ANS: C Chronic illness is one that lasts more than 6 months. Acute illness is short term and intense but resolves. Tertiary prevention strives to prevent complications and deterioration. Internal variables include a patients developmental stage, and intellectual, emotional, and cultural background.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Explain the impact of illness on a patient and family.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 7.Which information by a patient indicates teaching by the nurse was successful for the best definition of health? a.State of complete well-being b.Absence of disease c.Vital signs within normal range d.Maintenance of a normal weight ANS: A The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmary. People without disease are not necessarily healthy. Vital signs within normal range and maintenance of a normal weight do not encompass the holistic definition of health.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 15-16 OBJ: Describe health promotion and illness prevention activities.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 8.A patient with newly diagnosed diabetes is concerned about the risk for developing foot ulcers because the mother had a foot amputated as a result of the disease. This is an example of which of the following? a.Health promotion b.Health practices c.Health beliefs d.Holistic health ANS: C

Health beliefs are a persons ideas and attitudes about health. Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. Holistic health generally is a comprehensive view of a person as a biopsychosocial and spiritual being. Health practices are activities that individuals perform to care for themselves.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:19 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9.A patient with diabetes is diligent about testing blood sugar before meals. Which model is the nurse using when the nurse realizes the patient is taking preventative actions for health and represents the third component of this model? a.B asic Human Needs

b.Health Belief c.Holistic Health d.Tertiary Prevention ANS: B

The third component of the Health Belief model is the likelihood that a patient will take preventative action. The third component of the Basic Human Needs model (Maslow) is love and belonging. The Holistic Health model focuses on physical, social, psychological, and spiritual health and does not contain distinct components. Tertiary prevention is not a health model.

PTS:1DIF:Cognitive Level: Applying (Application) REF:16 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. Which will best assist a nurse in understanding a patients use of tying a silver dollar to the stomach of a newborn infant to heal an umbilical hernia? a.C ultural background

b.Maslows Hierarchy of Needs c.World Health Organizations definition of health d.Primary prevention ANS: A Cultural background influences a persons beliefs, values, and customs. It influences personal health practices.

Maslows Hierarchy of Needs will not help the nurse to understand the behavior because this is a model to help prioritize care. The definition of health by the WHO will not help the nurse to understand the behavior because it is a definition. Primary prevention occurs before a sickness or dysfunction and includes immunizations.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:20 OBJ: Describe the variables influencing health beliefs and health practices.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding?

a.This is an example of a health belief. b.This is an example of health promotion. c.This is an example of a negative health behavior. d.This is an example of a basic physiological human need.

ANS: C Negative health behaviors include activities that are harmful to health, including smoking. Health beliefs are a persons ideas, convictions, and attitudes about health and illness. Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. The lowest level of needs on the hierarchy consists of very basic physiological needs such as oxygen, water, food, sleep, and sex.

PTS:1DIF:Cognitive Level: Applying (Application) REF:16 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 12. When teaching a 15-year-old patient with diverticulitis about foods that should be avoided, a nurse takes the stage of growth and development into consideration. Which factor or variable did the nurse take into consideration?

a.Cultural factor b.External variable c.Socioeconomic factor d.Internal variable ANS: D Internal variables include a persons stage of growth and development, intellectual background, emotional factors, and spiritual factors. External variables include family practices, socioeconomic factors, and cultural background.

PTS:1DIF:Cognitive Level: Applying (Application) REF:19-20 OBJ: Describe the variables influencing health beliefs and health practices.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13.A nurse working in a rural public health clinic is developing a smoking cessation program for patients in the county. This corresponds with Healthy People 2020 s efforts to provide direction for health care efforts on what level? a.National b.Community c.Individual d.Family

ANS: B This is an example of a community program because it is for people in the county. Healthy People 2020 includes 600 objectives written in 42 topic areas to provide direction for health care efforts on an individual, community, and national level. National level would be directed at the entire United States. Individual would focus on one person.

Family would focus on families.

PTS:1DIF:Cognitive Level: Applying (Application) REF:19 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The spouse of a patient with terminal cancer is refusing pain medication for the patient because of previous experiences with soldiers who became addicted to pain medication. A nurse will need to focus on which internal variable when approaching this situation?

a.Developmental stage b.Family practices c.Intellectual background d.Spiritual factors ANS: C Intellectual background is a persons beliefs about health shaped in part by knowledge (or misinformation) about body functions and illnesses, educational background, and past experiences. Spirituality is reflected in how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. A persons concept of illness depends on his or her developmental stage but this scenario is focused on misinformation, not the developmental stage. Family practices is an external variable, not an internal variable.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:20 OBJ: Describe the variables influencing health beliefs and health practices.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 15. When assessing what influences a patients health beliefs and practices, a nurse should consider both internal and

external variables. Which is an example of an external variable? a.Intellectual background b.Emotional factors c.Spiritual factors d.Family practices ANS: D

Family practices is an external variable. Intellectual background, emotion factors, and spiritual factors are internal variable.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:20 OBJ: Describe the variables influencing health beliefs and health practices.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 16.A nurse should emphasize health promotion, wellness strategies, and illness prevention activities as important forms of health care. Which is considered a health promotion strategy? a.Routine exercise b.Stress management class c.Influenza immunization d.Tetanus booster ANS: A Routine exercise is done to promote health and is a health promotion strategy. Influenza immunization and tetanus booster are illness prevention strategies, whereas stress management is wellness education.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 20 OBJ: Describe health promotion and illness prevention activities.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 17.A nurse who works in an inner-city health clinic is scheduling a day for student nurses to assist with a flu immunization clinic. Which of the following best describes this type of activity? a.Primary prevention b.Secondary prevention c.Tertiary prevention d.Health prevention ANS: A Primary prevention decreases the vulnerability of an individual (or population) to disease. Secondary prevention focuses on people who are experiencing health problems. Tertiary prevention occurs when a disability is permanent, irreversible, and stabilized. Health prevention is not a concept nurses promote, whereas health promotion or illness prevention are strategies nurses use.

PTS:1DIF:Cognitive Level: Applying (Application) REF:21OBJ:Explain the three levels of prevention.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 18.A patient is drinking milk that has been fortified with vitamin D. Which type of health promotion strategy is the patient using? a.Active b.Passive c.Environmental d.Sociological

ANS: B With passive strategies of health promotion, individuals gain from the activities of others without acting themselves. For example, the city puts fluoride in the municipal drinking water, or milk manufacturers fortify homogenized milk with vitamin D. With active strategies of health promotion, individuals adopt specific health programs. Weight reduction and smoking cessation programs require patients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk for disease. Environmental and sociological do not relate to health promotion strategies.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 20 OBJ: Describe health promotion and illness prevention activities.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 19.A nurse teaches a patient about physiological risk factors. Which information by the patient indicates more teaching is needed? a.A physiological risk factor is heredity. b.A physiological risk factor is environment. c.A physiological risk factor is pregnancy. d.A physiological risk factor is obesity.

ANS: B The environment is not a physiological risk factor; the other options are physiological risk factors. Physiological risk factors involve the physical functioning of the body. For example, physical conditions such as pregnancy or obesity place increased stress on physiological systems. Heredity or genetic predisposition to specific illness is a major physical risk factor.

PTS:1DIF:Cognitive Level: Applying (Application) REF:21-22 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 20.Upon taking a health history from a patient, the nurse notices the patient uses positive health behaviors. Which behavior did the nurse find? a.Smokes b.Eats poorly c.Has sedentary lifestyle d.Maintains proper sleep patterns ANS: D Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness. Common positive health behaviors include getting immunizations, maintaining proper sleep patterns, getting adequate exercise, and eating healthy foods. Negative health behaviors include activities that are harmful to health such as smoking, abusing drugs or alcohol, following a poor diet, and refusing to take necessary medications.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 16 OBJ: Describe health promotion and illness prevention activities.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 21.A nurse must take into consideration illness behaviors of patients. Which is an internal variable the nurse should assess? a.Social support b.Visibility of symptoms c.Accessibility of the health care system d.Nature of the illness ANS: D Internal variables influence the way patients behave when they are ill. These are a patients perceptions of symptoms and the nature of the illness. External variables influencing a patients illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 25 OBJ: Describe the variables influencing illness behavior.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 22.A nurse allows a patient to place pictures of the family in the room. Which need is being met? a.Basic needs b.Physiological needs c.Self-actualization d.Love and belongingness ANS: D In Maslows hierarchy of needs, the third level on the hierarchy is love and belongingness, which is a desire to belong to groups. It consists of the need to feel love by others and to be accepted. The highest level of needs on the hierarchy is self-actualization, which is the desire to become everything that one is capable of becoming. The lowest level of needs on the hierarchy consists of very basic physiological needs such as oxygen, water, food, sleep, and sex.

PTS:1DIF:Cognitive Level: Applying (Application) REF:18 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 23.Which model exemplifies a patient who states the following, I am responsible for my own health and well-being and I will partner with you (my nurse) to make sure I am ready to be discharged after surgery? a.Basic Human Needs Model b.Absence of Disease Model c.Holistic Health Model d.Healthy People 2020 Model ANS: C

The intent of the holistic health model is to empower patients to engage in their own recovery, thereby assuming

some responsibility for health maintenance. Basic human needs are related to a hierarchy of needs involving lower needs to self-actualization. Healthy People 2020 provides evidenced-based objectives to: (1) achieve increased quality and years of healthy life, and (2) eliminate health disparities. There is no absence of disease model.

PTS:1DIF:Cognitive Level: Applying (Application) REF:19 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 24.A nurse is preparing to help patients with health promotion, wellness education, and illness prevention activities.

Which action should the nurse take first ? a. Explore available support groups. b. Identify risk factors.

c.Provide patient teaching. d.Implement risk factor modification.

ANS: B Identifying risk factors is the first step in health promotion, wellness education, and illness prevention activities.

Once you identify risk factors, implement appropriate and relevant health education programs that help a person to change a risky health behavior. Support groups, teaching, and risk factor modification follow after identifying risk factors.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 25.A smoker has confided to the nurse that he or she feels like a failure because he or she began smoking again after not having had a cigarette for more than a week. What is the nurses best response? a.Lets discuss what triggered you to start smoking again so you can avoid it in the future. b.You understand that smoking is the number one cause of death in the United States, correct? c.Did you know that your insurance premiums will increase if you continue to smoke? d.My mother died last year of lung cancer.

ANS: A Relapse often feels like a failure, but the person needs to view it as a learning process. Discussing possible triggers will allow learning to take place. What he or she learns from relapse can be applied to the next attempt to change.

Saying that smoking is the number one cause of death and insurance premiums will increase do not allow for learning to take place. Saying that your mother died last year of lung cancer does not focus on patient learning, but rather focuses on the nurse, which is inappropriate.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23-24 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 26.A nurse is teaching the staff about the stages of change. Which information should the nurse include in the teaching session? a.Precontemplation, contemplation, preparation, action, maintenance b.Contemplation, preparation, action, maintenance, postmaintenance c.Contemplation, procrastination, preparation, action, maintenance d.Precontemplation, contemplation, preparation, action, engagement ANS: A Precontemplation, contemplation, preparation, action, and maintenance are the five phases of change.

Postmaintenance, procrastination, and engagement are not included in the five stages of change.

PTS:1DIF:Cognitive Level: Applying (Application) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 27.A nurse is caring for a patient who smokes two packs a day. The nurse knows that the patient is in the contemplation stage regarding smoking cessation. What is the nurses best response to help the patient move into the preparation stage? a.You need to stop smoking as soon as possible. b.Smoking will kill you if you dont stop. c.The negative effects of smoking can be reversed. d.Tobacco use killed 435,000 people in 2000.

ANS: C The fact that the negative effects can be reversed may prompt the patient to think about the benefits of quitting and move the patient into the preparation stage of change. You need to stop smoking is a directive and not appropriate.

Tobacco use killed 435,000 does not allow the patient to think about quitting; it just relates facts. Giving an ultimatum by saying that smoking will kill you if you dont stop is inappropriate.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Discuss the nurses role in health and illness.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 28.Which patient should a nurse consider as being the most ill? a.A 25-year-old patient with cystic fibrosis who is attending yoga classes b.A 13-year-old adolescent with newly diagnosed diabetes who does not want to check blood sugar at school c.A 43-year-old patient with breast cancer who has recently adopted a vegetarian diet d.A 77-year-old patient with alcohol hepatitis who attends weekly Alcoholics Anonymous meetings ANS: B A 13 year old who does not want to check blood sugar is the most ill out of the patients listed because illness is not

synonymous with disease; it includes not only the disease, but also the effects on functioning and well-being in all

dimensions. Illness is a state in which a persons physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with previous experience. The 25 year old, the 43 year old, and the 77 year old are taking actions to improve their overall health.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Describe the variables influencing illness behavior.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 29.A registered nurse is working in a community clinic that provides services for chronically ill patients. Which condition would be considered chronic? a.Appendicitis b.Pneumonia c.Flu d.Diabetes ANS: D A chronic illness usually lasts longer than 6 months; diabetes is a chronic illness. Appendicitis, pneumonia, and the flu are considered acute: The symptoms appear abruptly, are intense, and often subside after a relatively short period.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 24 OBJ: Explain the impact of illness on a patient and family.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 30.A nurse is planning to care for a patient with a disease that is a major cause of death and disability in the United States. The nurse is caring for which patient? a.One with an acute disease b.One with a chronic disease c.One with an infectious disease d.One with an exotic disease ANS: B Because of successes in public health, medicine, and biomedical technology, acute and infectious diseases are no longer major causes of death, disease, and disability in the United States. Many health care analysts believe that the heaviest burden of illness today is caused by chronic diseases. Exotic diseases are rare.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 24 OBJ: Explain the impact of illness on a patient and family.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Adaptation 31.A public health nurse knows that for those patients who already have a chronic disease, the best way to help them manage their illness is to take which action? a.Provide holistic patient education. b.Consult with a disease specialist. c.Review their long-term health insurance policy. d.Provide disease-specific patient education.

ANS: A

The nurse should use a holistic approach to patient education to help patients manage their disease. This education enhances wellness and improves quality of life for patients living with chronic illnesses or disabilities. Consulting with a disease specialist, reviewing insurance, and providing disease-specific education are too narrow a focus.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Discuss the nurses role in health and illness.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 32.A registered nurse in a rehabilitative unit is working with a veteran with chronic back pain that was caused as a result of an injury received while in military service in Iraq. The nurses goal is to assist the veteran to learn selfmanagement skills to help promote health. Which statement by the nurse will best support this goal? a.Do you have plans to return to active duty? b.You need to take your pain medication as prescribed. c.Perhaps you need to consider going to a different health care provider. d.Why dont you keep a log of what causes the pain to become worse?

ANS: D Self-management involves learning about responses to illnesses through daily life experiences and as a result of trial and error. Plans to return to active duty and going to a different health care provider do not focus on responses to the illness (chronic back pain). Just focusing on taking pain medication does not focus on the goal of selfmanagement skills.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Discuss the nurses role in health and illness.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 33.A pregnant mother of two children has been experiencing severe morning sickness and fatigue. Friends and family members have been providing her family with meals, and her husband has been taking responsibility for the housework. This is an example of which type of behavior? a.Illness b.Wellness c.Social d.Antisocial ANS: A Illness behavior often results in patients being released from roles, social expectations, or responsibilities. Wellness behaviors focus on improving health, like jogging. Social behaviors involve groups. Antisocial behavior involves socially unacceptable actions.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 24-25 OBJ: Describe the variables influencing illness behavior.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 34.A patient states, I will avoid social situations where people are drinking alcohol so I am not tempted to start drinking again. The nurse assesses the patient to be in which stage of change? a.Contemplation

b.Precontemplation

c.Maintenance d.Engagement ANS: C Maintenance is the ability for sustained change over time. This stage begins 6 months after action has started and continues indefinitely. It is important to avoid relapse. I have a problem with drinking, and I really think I need to work on it is an example of the contemplation stage. There is nothing that I really need to change is an example of the precontemplation stage.

There is no such stage as engagement.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 35.Which order should the nurse prioritize care for the patient using Maslows theory from lower-level needs to higher-level needs? a. Self-esteem b. Physiological needs c. Self-actualization d. Love and belonging e. Safety and security a.b, e, d, a, c b.d, b, c, a, e c.b, e, d, c, a d.d, b, a, c, e ANS: A Maslows (1987) model describes human needs using a hierarchical pyramid divided into five levels: physiological needs, safety and security, love and belonging, self-esteem, and self-actualization.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:17-18 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.Using the health promotion model while rendering care enables a nurse to do which of the following? (Select all that apply.) a.Help the patient pursue health.

b.Detect the presence of illness. c.Promote health behaviors in a patient. d.Assess a familys response to illness. e.Plan interventions to achieve self-actualization.

ANS: A, C The purpose of the health promotion model is to explain the reasons that individuals engage in health activities and is not for use with families or communities. You will use this model to help your patients carry out healthy behaviors in their daily lives. This model helps the patient pursue health. Self-actualization is the final stage in Maslows hierarchy and does not relate to the health promotion model. This model does not focus on illness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:17 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

Chapter 03: The Health Care Delivery System Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is teaching the importance of breast self-examination to a group of 20-year-old women. The nurse is promoting which type of care? a.Primary b.Secondary c.Tertiary d.Restorative ANS: A Primary care is centered on prevention of disease. Secondary and tertiary care is administered after an illness has been diagnosed. Restorative care occurs after a patient is recovering from an acute illness or for those who have chronic illnesses.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:34OBJescribe the six levels of health care.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2.A patient who needs nursing and rehabilitation after a stroke would benefit most by receiving care at which center? a.Primary care center b.Restorative care center c.Assisted living center d.Respite center ANS: B Restorative care centers provide rehabilitation and nursing care. In primary care centers, health promotion is the major theme. Assisted living centers offer long-term assistance with activities of daily living. Respite centers offer short-term relief to persons who provide full-time care to an older adult.

PTS:1DIF:Cognitive Level: Applying (Application) REF:33 OBJ: Explain the relationship between levels of health care and levels of prevention.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 3.A patient states that he or she cannot afford health care insurance for the family because of a low income. What is the best form of insurance available for this patient? a.Medicaid b.Medicare c.Private insurance d.A managed care organization

ANS: A Medicaid is a form of insurance for low-income families. Medicare is a federally funded health insurance program for people greater than 65 years of age. Private insurance is a fee-for-service plan. A managed care organization (MCO) provides care to a specific group of voluntarily enrolled patients.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 33 OBJ: Compare the various methods for financing health care.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4.A nurse is teaching the staff about managed care. Which information should the nurse include? a.Managed care focuses on long-term care services for skilled nursing. b.Managed care focuses on hospital admissions and illnesses for a group of people. c.Managed care focuses on control over primary health services for a defined population. d.Managed care focuses on decreased access to care while increasing costs.

ANS: C The term managed care describes systems in which the payer has control over primary health care services delivery for a defined patient population. Long-term care insurance focuses on skilled nursing, not managed care.

Managed care focuses on health and staying out of the hospital. Managed care aims to increase access to care while decreasing costs.

PTS:1DIF:Cognitive Level: Applying (Application) REF:32 OBJ:Explain the advantages and disadvantages of managed health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 5.A nurse admits an older adult patient who states that he or she has no living relatives and only two close friends.

Upon admission to the hospital, which action should the nurse initiate first ? a.Implement a process of payment. b.Implement a discharge plan. c.Implement a visit with the family. d.Implement a resource utilization group.

ANS: B Discharge planning with coordination of services begins the moment a patient is admitted to a health care facility.

A resource utilization group is used in long-term care settings to manage patient costs. A visit with the family is not possible because the patient has no living relatives. Upon admission, a process of payment is not a priority for a nurse.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:35 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6.A nurse is asked the most frequently cited reason for death in the world. How should the nurse reply?

a.Technological advances b.Old age c.Cancer d.Poverty ANS: D Poverty is still deadlier than any disease and is the most frequently cited reason for death in the world today.

Technological advances, old age, and cancer are not the most cited reason for death.

PTS:1DIF:Cognitive Level: Applying (Application) REF:45 OBJiscuss the implications that issues challenging the health care system have for nursing.TOP:Nursing Process: Implementation MSC:NCLEX: Reduction of Risk Potential 7.A nurse is teaching the staff about the Prospective Payment System (PPS). Which information should the nurse include in the teaching session? a. PPS establishes cost-based reimbursement for health care. b. PPS provides reimbursement for every service the patient receives. c. PPS establishes reimbursement rates based upon diagnosis-related groups (DRGs). d. PPS provides money to the patient for health promotion use.

ANS: C PPS established diagnosis-related groups (DRGs). Established by Congress in 1983, the PPS eliminated cost-based reimbursement, which is reimbursement for every service the patient receives. Hospitals serving patients using Medicare were no longer paid for all costs incurred in delivering care to a patient. Instead, inpatient hospital services for patients using Medicare were combined into 468 DRGs. PPS provides a preset amount of money to hospitals and health care providers for DRGs, not for health promotion. Managed care focuses on health promotion.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 32 OBJ: Compare the various methods for financing health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8.A 74-year-old patient was admitted to the hospital with diabetic ketoacidosis. How will the hospital be reimbursed by Medicare? a.Based upon the diagnostic-related group b.Based upon the cost of care c.Based upon the actual length of stay d.Based upon the number of medications ANS: A Payment is based upon the diagnostic-related group. Established by Congress in 1983, the prospective payment system eliminated cost-based reimbursement. Hospitals serving patients using Medicare were no longer paid for all costs incurred to deliver care to a patient. Instead, inpatient hospital services for patients using Medicare were combined into 468 diagnosis-related groups. Hospitals receive a set dollar amount for each patient based on the assigned DRG, regardless of the patients length of stay or use of services in the hospital or the number of medications.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 32 OBJ: Compare the various methods for financing health care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A patient tells the nurse that he or she does not understand the purpose of capitation. What is the nurses best response? a.To provide high-quality care at the highest cost to the hospital, not the patient b.To provide the least expensive care for patients regardless of outcomes c.To build a payment plan that includes the best standards of care at the lowest cost d.To ensure that all patients receive the same care for the same cost in all hospitals ANS: C The purpose of capitation is to build a payment plan for select diagnoses or surgical procedures that includes the best standards of care and essential diagnostic and treatment procedures at the lowest cost. Capitation does not cause the hospitals to pay the highest cost but to determine quality care for the lowest cost. Capitation does not provide the least expensive care for patients for outcomes because best standards are the outcome. Capitation does not make all patients receive the same care for the same cost in all hospitals.

PTS:1DIF:Cognitive Level: Applying (Application) REF:32 OBJ:Explain the advantages and disadvantages of managed health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 10.A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use? a.Continuing care b.Preventative care c.Secondary acute care d.Restorative care ANS: B Preventative care includes services such as immunizations, screenings, poison control information, mental health counseling and crisis prevention, and community legislation. Continuing care is assisted living. Secondary acute care involves emergency and radiological procedures. Restorative care involves rehabilitation services and home care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:34OBJescribe the six levels of health care.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11.A registered nurse working as a school nurse for a small poor rural school district has noticed an increase in children arriving at school without having eaten breakfast. The nurse has discussed this issue with the school principal and is working on a proposal to ask the school district to explore a school breakfast program. Which level of care did the nurse use? a.Primary care b.Continuing care

c.Restorative care d.Tertiary care ANS: A In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme. Continuing care involves assisted living and psychiatric day care. Restorative care involves rehabilitation and home care. Tertiary care involves intensive care and psychiatric facilities.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:34 OBJ: Explain the relationship between levels of health care and levels of prevention.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 12.A small business owner has consulted with an occupational health nurse regarding health promotion activities for the employees. The registered nurse explores the possibility of providing an area outside the new office complex where employees can walk during their breaks. Which level of care did the nurse use? a.Continuing care b.Restorative care c.Primary care d.Tertiary care ANS: C In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme. Continuing care involves assisted living and psychiatric day care. Restorative care involves rehabilitation and home care. Tertiary care involves intensive care and psychiatric facilities.

PTS:1DIF:Cognitive Level: Applying (Application) REF:34 OBJ: Explain the relationship between levels of health care and levels of prevention.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 13.A grocery store clerk does not have a family health care provider. The clerk has had a sore throat for the past week and recently began running a fever. The clerk goes to the local community hospitals emergency room for treatment. Which level of care did the clerk use? a.Continuing care b.Restorative care c.Primary care d.Tertiary care ANS: D Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units are sites that provide secondary and tertiary levels of care. Continuing care involves assisted living and psychiatric day

care. Restorative care involves rehabilitation and home care. Primary care involves health promotion such as

prenatal care and well-baby care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:34OBJescribe the six levels of health care.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 14.A retired high school teacher has been admitted to the hospital with complications of diabetes. To ensure the patient is discharged home with the right care, at the right time, and without duplication, which health care reform system was developed? a.The Joint Commission b.National Priorities Partnership c.Accountable Care Organization d.Managed Care ANS: C An ACO works to make sure that patients receive the right care at the right time, without duplication of services or incidence of medical errors. Accountable care organizations (ACO) were developed to coordinate medical care by primary care and specialty physicians, hospitals, and other health care providers with the goal of providing highquality coordinated care. The Joint Commission (2012) requires health care organizations to determine how well an organization meets patient needs and expectations and accredits health care organizations. Managed care focuses on health promotion. The National Priorities Partnership is a group of 51 organizations from a variety of health care disciplines that joined together to work toward transforming health care by focusing on eight national priorities.

PTS:1DIF:Cognitive Level: Applying (Application) REF:40 OBJ:Explain the advantages and disadvantages of managed health care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15.What is the most appropriate time for the nurse to begin discharge planning with a patient? a.The day of patient discharge from the health care agency b.As soon as the insurance provider has been identified c.When the health care provider writes the discharge order d.When the patient is admitted to the health care agency ANS: D Discharge planning begins the moment a patient is admitted to a health care facility. The day of discharge, when the insurance provider has been identified, and when the order is written are too late.

PTS:1DIF:Cognitive Level: Applying (Application) REF:35 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16.Which patient is most in need of discharge planning by the nurse? a.A 29-year-old mother with strong family support who has a healthy newborn

b.A 59-year-old patient with an active lifestyle who has had an appendectomy c.A 64-year-old patient with heart failure who has a limited income d.A 56-year-old patient with a supporting spouse who has had a hysterectomy ANS: C The 64-year-old patient with heart failure has a chronic disease and more risks than the other patients because of age and income. Some patients are more in need of discharge planning because of their risks. For example, some patients have limited financial resources or limited family support; others may have long-term disabilities or chronic illnesses. Early discharge teaching is especially important as a way to decrease readmission to the hospital.

Appendectomy and hysterectomy are acute conditions and do not have as many risks as heart failure. A healthy newborn is stable, whereas heart failure is chronic.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:36 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 17.Which patient is in the most expensive place to deliver care per day? a.A patient in a rehabilitation unit b.A patient in a long-term care facility c.A patient in an intensive care unit d.A patient in a private hospital room ANS: C An intensive care unit is the most expensive delivery site for medical care because each nurse is usually assigned to care for only one or two patients at a time and because of the types of treatments and procedures the patients in the intensive care unit typically require. Rehabilitation units, long-term care facility, and a private hospital room are not as expensive per day as an intensive care unit.

PTS:1DIF:Cognitive Level: Applying (Application) REF:36 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 18.A college student with severe depression was recently admitted to the psychiatric ward of a local hospital. The family is concerned about the student finishing the college term. Which is the best information for the nurse to give regarding how long psychiatric patients are typically hospitalized? a.A relatively short inpatient stay is followed by outpatient treatment. b.A long inpatient hospitalization is normal for the majority of patients. c.Patients with emotional or behavioral problems generally are not hospitalized. d.Most are automatically placed in a long-term care facility.

ANS: A Patients who have emotional and behavioral problems, such as depression, violent behavior, and eating disorders, often require special counseling and treatment in psychiatric facilities. Hospitalization involves relatively short stays with the purpose of stabilizing patients before transfer to outpatient treatment centers. A long inpatient hospitalization, not hospitalized, or placed in a long-term facility are not correct for the typical hospitalization of

psychiatric patients.

PTS:1DIF:Cognitive Level: Applying (Application) REF:36 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19.A 17-year-old patient was seriously injured in a motor vehicle accident and has been transferred from an acute care hospital to a rehabilitation/restorative facility. Which action should the nurse take to ensure the best outcome for this patient? a.Make sure that the patient gets enough rest. b.Push the patient beyond his or her limits. c.Request that nobody visit for the first few days. d.Involve the family early in the rehabilitation process.

ANS: D In restorative settings, nurses recognize that success is dependent on effective and early partnering with patients and their families. Although rest is good, family involvement is the priority. Pushing the patient beyond his or her limit is not helpful. Not letting anybody visit is contraindicated.

PTS:1DIF:Cognitive Level: Applying (Application) REF:37 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20.A patient who experienced a stroke 4 days ago has been discharged from the hospital and will be undergoing outpatient rehabilitation. How should the nurse prepare the patient for this level of care? a.The patient will be admitted to the rehabilitative unit of the hospital. b.The patient will have scheduled appointment times for therapy. c.The patient will have home visits from all members of the multidisciplinary team. d.The patient will be at home for all of the treatments ordered by the primary health care provider.

ANS: B When patients receive rehabilitation services in outpatient settings, patients get treatment at specified times during the week but remain at home the rest of the time. Inpatient rehabilitation services would require admission to an inpatient facility. Some rehabilitation is offered in the home but usually only certain members of the health care team visit. Home rehabilitation services would have the treatments performed in the home, but not for outpatient rehabilitation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:38 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 21.Which other term can the nurse use to describe the Omnibus Budget Reconciliation Act of 1987?

a.Medicaid Act b.Nursing Home Reform Act c.Diagnostic Related Group Act d.Magnet Recognition Act ANS: B The nursing center industry has become one of the most highly regulated industries in the United States. The Omnibus Budget Reconciliation Act of 1987, also known as the Nursing Home Reform Act, raised the standard of services provided by nursing centers. The Medicaid act provides insurance to low-income families. The diagnostic related group was formed from the Medicare Act. The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:39 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 22.A new registered nurse who recently began working in a nursing center has been asked to complete a Resident Assessment Instrument (RAI) on a newly admitted resident. What is the primary purpose of this instrument? a.To provide a database to better understand the health care needs of this population b.To provide the nursing staff with an overall physical assessment of the resident c.To provide statistical evidence to support a universal health care policy d.To provide medications for the residents to take on a daily basis ANS: A The facility needs to complete the RAI on all residents. The RAI consists of the Minimum Data Set (MDS), Resident Assessment Protocols (RAPs), and utilization guidelines of each state. The RAI ultimately provides a national database for nursing facilities so that policy makers will better understand the health care needs of the long-term care population. Although it does provide a physical assessment, the primary purpose is to better understand the needs of this population. It does not provide evidence for a universal health care policy or medications to be used for this population group.

PTS:1DIF:Cognitive Level: Applying (Application) REF:39 OBJiscuss the role of nurses in different health care delivery settings.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 23.An 81-year-old widow with mild dementia has self-care capabilities. The widow recently moved in with her daughter, a 46-year-old working mother with three children. In considering how to have care for her mother when she is working, what is the most appropriate option the nurse should suggest? a.A rehabilitation center b.A nursing center c.An adult day care center d.A hospice center ANS: C Services offered by adult day care centers allow family members to maintain their lifestyles and employment and

still provide home care for their relatives. A hospice is a system of family-centered care that allows patients to live and remain at home with comfort, independence, and dignity while alleviating the strains caused by terminal illness; this is inappropriate because the widow does not have a terminal illness. Rehabilitation is the use of multiple therapies such as physical, psychological, occupational, speech, and social services to help restore a person to the fullest physical, mental, social, vocational, and economic usefulness possible; this is not appropriate because the widow can provide self-care. A nursing center is a nursing home; it is too early for this because the widow can provide self-care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:40 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 24.A 78-year-old widow needs assistance with medications, housekeeping, and laundry, and would like to maintain independence. Which is the best option for the nurse to suggest? a.Assisted living b.Respite care c.Nursing center d.Rehabilitation center ANS: A Assisted living provides independence, security, and privacy at the same time. These facilities promote independence and physical and psychosocial health. Services in an assisted living facility include medication management, exercise and educational activities, social activities, laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. Respite care is a service that provides short-term relief or time off for people providing home care to an ill, disabled, or frail older adult. Nursing center is a nursing home; this is too early to recommend because the widow wants to maintain independence. Rehabilitation is the use of multiple therapies such as physical, psychological, occupational, speech, and social services to help restore a person to the fullest physical, mental, social, vocational, and economic usefulness possible; this is not appropriate because the widow can provide self-care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:39 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 25.Which patient is most suitable for admission into hospice? a.A 63-year-old man with a fractured femur b.A 45-year-old woman with terminal end-stage renal failure c.A 14-year-old patient with leukemia that is in remission d.A 78-year-old patient with dementia that wanders ANS: B A patient entering a hospice is at the terminal phase of illness, and the patient, family, and physician agree that no further treatment will reverse the disease process. A fractured femur, leukemia in remission, and dementia are not conditions that are terminal, and so are not appropriate for hospice.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:40 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 26.A registered nurse has been working for an oncology unit for the past year and has a passion for caring for oncology patients undergoing chemotherapy. Whose responsibility is it for the nurse to become competent in administering chemotherapy? a.The hospital where the nurse is employed b.The charge nurse c.The nurse herself or himself d.The oncologist who admits patients to the unit ANS: C A nurses responsibility is to follow policies and procedures and to know the most current practice standards. As a nurse progresses in a career, it becomes his or her responsibility to obtain necessary continued education and earn certifications when he or she chooses to practice in specialty areas. Nurses must be accountable for their own actions; it is not the responsibility of the hospital, charge nurse, or oncologist for the nurse to be competent.

PTS:1DIF:Cognitive Level: Applying (Application) REF:41 OBJ: Discuss opportunities for nursing within the changing health care delivery system.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A registered nurse working in a restorative care setting will focus on which areas? (Select all that apply.) a.Providing extensive supportive care b.Providing one-on-one care to patients c.Promoting patient self-care d.Promoting independence e.Promoting dying at home ANS: C, D The goals of restorative care are to help an individual regain maximal functional status, thereby enhancing his or her quality of life, and promote patient independence and self-care. A secondary care setting, not a restorative care setting, provides in-depth diagnosis and treatment of illnesses that require extensive, one-on-one complex treatments. Hospice, not restorative care, allows a patient to die at home.

PTS:1DIF:Cognitive Level: Applying (Application) REF:37 OBJ: Explain the relationship between levels of health care and levels of prevention.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse wants to practice using the Institute of Medicine Competencies. Which competencies should the nurse use? (Select all that apply.)

a.Working in interdisciplinary teams b.Using informatics c.Providing physical comfort d.Offering access to care e.Preventing catheter-associated urinary tract infections ANS: A, B In addressing the continued challenges facing the health care system, the Institute of Medicine (2001) identified five interrelated competencies that are essential for all health care workers in the twenty-first century: Working in interdisciplinary teams, using informatics, providing patient-centered care, applying quality management, and employing evidence-based practice. The Picker Institute (2012) identified eight dimensions of patient-centered care that most affect patients experiences with health care: Physical comfort is one of these, as is access to care. The National Database of Nursing Quality Indicators tracts catheter-associated urinary tract infections among other criteria to help determine quality of nursing care.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:41 OBJ: Discuss opportunities for nursing within the changing health care delivery system.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort

Chapter 04: Community-Based Nursing Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A student nurse is beginning the community-based primary care rotation. The student nurse anticipates that the assignment in community-based health care will most likely be at which organization? a.An acute care hospital b.A rehabilitation hospital c.A nursing home d.A high school ANS: D High schools focus on primary rather than acute care and provide knowledge about health and health promotion that occurs outside traditional health care institutions, such as hospitals, rehabilitation hospitals, and nursing homes.

PTS:1DIF:Cognitive Level: Applying (Application) REF:50 | 51 OBJ: Explain the relationship between public and community health nursing.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2.A nurse is practicing as a community health nurse. What is the primary focus of care for this nurse? a.Providing care to subpopulations b.Practicing care in existing services c.Being a specialist in public health science d.Having a case management certification ANS: A The community health nurse provides direct care services to subpopulations within that community. Community health nursing is nursing care provided in the community, with the primary focus on the health care of individuals, families, and groups in the community. A community health nurse is not the same thing as a specialist in public health nursing. A community health nurse does not have to have case management certification. Although the community health nurse may practice care in existing services, the primary focus is on the subpopulations care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:52 OBJ: Differentiate community health nursing from community-based nursing.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3.A community health nurse is using the goals of the Healthy People 2020 to focus care. Which goal is the priority? a.To increase the life expectancy of people in the United States b.To increase the health status of people throughout the world file:///D|/...0for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-04-community-based-nursing-practice.html[21/04/2019 17:42:23]

c.To eradicate the human immunodeficiency virus (HIV) d.To reduce health care costs ANS: A The overall goals of Healthy People 2020 are to increase the life expectancy and quality of life and to eliminate health disparities through an improved delivery of health care services to people in the United States. The focus is on the United States, not the world. It does not focus on one disease or on reducing health care costs.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 51 OBJ: Describe the role of the community health nurse.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. The teen pregnancy rate in one community significantly increased; as a result, the school system was seeing an

increase in the dropout rate of teenage mothers. A nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. Which technique did the nurse use? a. Incorporating immunizations for the infants and mothers

b.Responding to changes within the community c.Influencing chronic environmental factors d.Managing disease ANS: B

Successful community health nursing practice involves building relationships with the community and responding to changes within the community. No immunizations were given. There was no mention of managing disease in this scenario. The nurse did not influence chronic factors.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 53 OBJ: Describe the role of the community health nurse.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 5.A nurse notices that a particular area of the community had food poisoning. The nurse collected data from the people who were affected, identified a local restaurant that served all the people, and determined it was the chicken dish that caused the poisoning. Which community health nurse competency did the nurse demonstrate? a.Public health b.Educator c.Epidemiologist d.Case manager ANS: C As epidemiologist, community health nurses use basic principles of epidemiology such as tracking health problems; collecting and analyzing data to identify disease trends, outbreaks of illnesses, and disease incidence rates; and planning strategies to prevent or contain outbreaks. With the goal of helping patients assume responsibility for their own health care, the role of educator is important in a community-based setting. Case management means making an appropriate plan of care based on assessment of patients and families and coordinating needed resources and services for the patients well-being across a continuum of care. A community health nurse is not the same thing as a public health nurse and is not a competency of community health nursing. file:///D|/...0for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-04-community-based-nursing-practice.html[21/04/2019 17:42:23]

PTS:1DIF:Cognitive Level: Applying (Application) REF:58 OBJescribe selected competencies important for success in community-based nursing practice.TOP:Nursing Process: Evaluation MSC:NCLEX: Safety and Infection Control 6.Upon assessment the nurse finds the following: a 46-year-old immigrant patient from the Czech Republic has diabetes and hypertension and just recently moved in to live with a family member who must travel frequently. The patient speaks English very well. The community health nurse knows that this patient may be vulnerable because of which assessment finding? a.Age b.Immigration status c.Diabetes d.Language ANS: B Vulnerable populations include individuals living in poverty, elderly people, homeless individuals, those in abusive relationships, people with substance abuse problems and/or mental illnesses, and new immigrants. For some immigrants access to health care is limited because of legal status, language barriers and lack of benefits, resources, and transportation. Being 46 years old does not place the patient in the elderly category. Diabetes does not make the patient vulnerable. The patient speaks English, so that is not an issue.

PTS:1DIF:Cognitive Level: Applying (Application) REF:54 OBJ: Explain the characteristics of patients from selected vulnerable populations that influence a nurses approach to care. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A nurse wants to use the most important competency in community nursing. Which competency should the nurse use? a.Caregiver b.Case manager c.Educator d.Epidemiologist ANS: A The most important role is caregiving. Using the nursing process and critical thinking skills, a nurse develops appropriate, individualized nursing care for specific patients and their families. Case management means making an appropriate plan of care based on assessment of patients and families and coordinating needed resources and services for the patients well-being across a continuum of care. Community-based nurses teach their patients individually or in groups. Community health nurses use basic principles of epidemiology, such as tracking health problems; collecting and analyzing data to identify disease trends, outbreaks of illnesses, and disease incidence rates; and planning strategies to prevent or contain outbreaks.

PTS:1DIF:Cognitive Level: Applying (Application) REF:56 OBJescribe selected competencies important for success in community-based nursing practice.TOP:Nursing file:///D|/...0for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-04-community-based-nursing-practice.html[21/04/2019 17:42:23]

Process: Implementation MSC: NCLEX: Management of Care 8.A community health nurse is assessing the structure of a community. Which component will the nurse assess? a.Available health systems b. Available colleges and schools c.Geographical boundaries d.Predominant religious groups ANS: C Geographical boundaries are a component of the structure of a community. Health systems, and available colleges and schools are social systems. Predominant religious groups are a component of the population of a community.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 58 OBJ: Describe elements of a community assessment.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1.A nurse in community-based practice needs a variety of skills and talents while rendering care to patients in the community. Which are competencies of the community health nurse? (Select all that apply.) a.Case manager b.Care giver c.Educator d.Advocate e.Counselor ANS: A, B, C Selected competencies, such as caregiver, case manager, epidemiologist, and educator, are used in the communitybased setting. Advocate and counselor are not competencies.

PTS:1DIF:Cognitive Level: Applying (Application) REF:56 | 58 OBJescribe selected competencies important for success in community-based nursing practice.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A community health nurse is caring for vulnerable populations. The nurse is caring for which patients? (Select all that apply.) a.Patients living at home b.Patients with abusive habits c.Immigration patients d.Middle-aged patients e.Patients living in poverty ANS: B, C, E file:///D|/...0for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-04-community-based-nursing-practice.html[21/04/2019 17:42:23]

Individuals living in poverty, elderly people, homeless individuals, those in abusive relationships, people with substance abuse problems and/or mental illnesses, and new immigrants are examples of vulnerable populations.

Living at home and being middle-aged are not examples of vulnerable populations.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:54 | 56 OBJ: Explain the characteristics of patients from selected vulnerable populations that influence a nurses approach to care. TOP: Nursing Process: Implementation MSC:NCLEX: Safety and Infection Control 3.A nurse is performing a community assessment. Which areas should the nurse include? (Select all that apply.) a.Structure b.Population c.Social systems d.Environment e.Vital signs ANS: A, B, C A complete assessment examines structure or locale, population or people, and social systems. The principles of public health practice aim at achieving a healthy environment in which all individuals may live. Environment and vital signs are not components of a community assessment.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 58 OBJ: Describe elements of a community assessment.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4.A community-based nurse is working with a family. The nurse needs to be knowledgeable in what key areas?

(Select all that apply.) a.Family theory b.Group dynamics c.Political affiliations d.Cultural diversity e.Communication principles ANS: A, B, D, E The context of community-based nursing is family-centered care within the community. This focus requires the nurse to be knowledgeable about family theory, principles of communication, and group dynamics and cultural diversity. Political affiliations are not a key component of family-centered care.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 54 OBJ: Discuss the role of the nurse in community-based practice.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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Chapter 05: Legal Principles in Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which information indicates the nurse has an accurate understanding of the State Nurse Practice Act? a. It is a federal senate bill. b. It is a law enacted by the federal government. c. It is a statute enacted by state legislature. d. It is a judicial decision.

ANS: C Nurse Practice Acts are examples of statutes enacted by state legislatures to regulate the practice of nursing.

Common laws are based on judicial decisions or case law precedent. An example of a judicial decision that guides health care practice is Roe v. Wade , but not the nurse practice act . An example of a federal statute that affects health care practice is the Americans with Disabilities Act, but not the nurse practice act. The nurse practice act is a state law, not a federal senate bill.

PTS:1DIF:Cognitive Level: Applying (Application) REF:63 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 2.A student nurse must pass the NCLEX before practicing as a registered nurse. NCLEX

stands for Examination.

a.Nursing Council of Licensing b.Nightingale Code of Licensure c.Nursing Code of Licensure d.National Council Licensure ANS: D To be licensed in a state, a nurse must have a passing score on the National Council Licensure Examination (NCLEX) to obtain the initial license and meet the educational requirements set by the state. Nursing Council of Licensing, Nightingale Code, and Nursing Code examinations do not exist to practice as a nurse.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:63 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 3.A registered nurse was accused of patient abandonment when the nurse became angry, quit the job, and left the hospital before the end of the shift. This is an example of violating legal standards/guidelines set by which organization? a.The State Department of Health b.The Joint Commission c.The State Board of Nursing file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

d.The National League for Nursing ANS: C Nurse Practice Acts permit the State Board of Nursing to set rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guidelines that define patient abandonment. The State Department of Health, the Joint Commission, and the National League for Nursing do not set the legal rules and regulations for patient abandonment.

PTS:1DIF:Cognitive Level: Applying (Application) REF:63 OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4. An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed.

The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law? a. Misdemeanor b.Tort c.Malpractice d.Felony

ANS: D A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes may carry penalties of monetary restitution, imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations that may carry criminal penalties include practicing nursing without a license and misuse of controlled substances. A misdemeanor is a crime that, although injurious, does not inflict serious harm. Torts are civil wrongful acts or omissions against a person or a persons property that are compensated by awarding monetary damages to the individual whose rights were violated. Malpractice is an example of negligence, sometimes referred to as professional negligence . The law defines nursing malpractice as the failure to use the degree of care that a reasonable nurse would use under the same or similar circumstances.

PTS:1DIF:Cognitive Level: Applying (Application) REF:63-64 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5. The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he

or she will tie the patient down if the patient does not hold still. Which action did the nurse commit? a.Assault b.Unintentional tort c.Battery d.Felony ANS: A

Assault is an intentional threat toward another person that gives that person a reasonable fear of harmful contact.

No actual contact is required for an assault to occur. An example of an assault in nursing practice is to threaten to restrain a patient for an x-ray procedure when the patient has refused consent. Battery is intentional offensive file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

touching without consent or lawful justification. Negligence is an unintentional tort. A felony is a serious offense that results in significant harm to another person or society in general, like misusing controlled substances.

PTS:1DIF:Cognitive Level: Applying (Application) REF:64 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6. Which chart entry by a nurse would require follow up?

a.0815 Patient found on floor. b.0816 Patient assessed and helped back to bed. c.0818 Physician notified of incident. d.0820 Occurrence report completed.

ANS: D Do not document in the nurses notes that an occurrence report was completed . All the other entries are accurate.

Objectively record the details of the event and any statements the patient makes. At the time of the event, always assess the patient thoroughly, and then contact the health care provider to examine him or her.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 66 OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 7. To establish the elements of malpractice against a nurse, which must be proved by the patient?

a.The patient must have been harmed as a result of the injury. b.The patient must have paid for the health care services. c.The patient must show evidence of malicious intent. d.The patient must demonstrate personal accountability.

ANS: A To establish the elements of malpractice, the patient or plaintiff must prove the following: (1) the nurse defendant owed a duty to the patient, (2) the nurse breached that duty, (3) the patient was injured because of the nurses breach of duty, and (4) the patient has accrued damages as a result of the injury. The patient paying, showing evidence of malicious intent, and demonstrating personal accountability are not elements of malpractice.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:64 OBJ:Explain the concept of negligence and identify the elements of professional negligence.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 8. Which behavior is the best way for a nurse to avoid being liable for malpractice?

a.Purchasing quality malpractice insurance coverage on a yearly basis b.Practicing nursing that meets the generally accepted standard of care file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

c.Not sharing his or her last name with patients and families d.Not delegating any tasks to unlicensed assistive personnel ANS: B The best way to avoid being liable for malpractice is to give nursing care that meets the generally accepted standard of care. In a malpractice lawsuit the law uses nursing standards of care to measure nursing conduct and determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances.

Purchasing insurance, not sharing last name, and not delegating tasks are not appropriate behaviors to avoid malpractice.

PTS:1DIF:Cognitive Level: Applying (Application) REF:64 OBJ:Explain the concept of negligence and identify the elements of professional negligence.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A nurse wants to follow nursing standards of care. Which document should the nurse follow? a.World Health Organization guidelines b.National League for Nursing brochure c.Health care facilitys written procedure manual d.Department of Health and Human Services guidelines ANS: C The health care facilitys written procedure manual is defined as a standard of care. Standards of care are defined by the following: (1) State Nurse Practice Acts, (2) state and federal hospital licensing laws and accreditation rules, (3) professional and specialty organizations, and (4) written policies and procedures of the nurses health care facility.

Brochures are not standards of care. World Health Organization and Department of Health and Human Services are not state or federal hospitals or professional and specialty organizations for nurses.

PTS:1DIF:Cognitive Level: Applying (Application) REF:64OBJ:List sources for standards of care for nurses.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 10.What is the nurses best proof against malpractice? a.The nurse supervisors memory of the event b.Recorded documentation written carelessly c.The nurses memory of the event d.Recorded documentation of nursing care ANS: D Documentation of nursing care is the only record of what actually was done for a patient and will serve as proof that a nurse acted reasonably and safely. Nursing notes written at the time of the event, are seen as better evidence of the facts of the event than any one persons memory. Nurses notes written carelessly and without regard to detail or hospital standards of documentation do not reflect well on the health care providers credibility or appearance of accountability to a judge or jury.

PTS:1DIF:Cognitive Level: Applying (Application) REF:66 file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

OBJ:Explain the concept of negligence and identify the elements of professional negligence.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 11.A registered nurse is caring for a patient 2 days after a colon resection. The patient called for assistance to go to the bathroom. Instead of waiting for help, the patient decided to get up without help. The patient fell but was not injured. After contacting the patients primary health care provider, which action should the nurse take next? a.Nothing; the patient was not injured. b.Call the ethics committee. c.Submit an incident report. d.Insist that the patient have a radiograph done.

ANS: C When there is a deviation from the standard of care, such as a patient or visitor falls or an error is made, a nurse makes specific documentation of the event or incident in the form of an occurrence/incident report. The nurse should complete an occurrence report when anything unusual happens that could potentially cause harm to a patient, visitor, or employee. Just because the patient was not injured does not mean the report can be neglected.

The health care provider orders follow-up care or treatment when necessary, not the nurse. The ethics committee is involved in ethical dilemmas, not occurrence/incident reports.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 66 OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12.A nurse completes an occurrence report. Which is the best way for the nurse to document this occurrence? a.Patient found lying on right side on floor. No noted injuries, patient stated, I slipped on a wet spot on the floor. I dont think I am injured. b.Patient slipped on a wet spot on the floor. No noted injuries, physician notified. c.Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified. d.Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled.

ANS: A Objectively record the details of the event and any statements the patient makes. An example is as follows: Patient found lying on floor on right side. Abrasion on right forehead. Patient stated, I fell and hit my head. Patient slipped on wet spot and patient fell while going outside should not be charted unless the nurse actually observed the event; otherwise, chart what found: Patient lying on floor. Patient in too much of a hurry includes subjective assumptions and statements; assigning blame or fault is inappropriate when completing the report.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 66 OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 13.A clinic nurse stopped at an automobile accident to assist. There was one victim who was not breathing. The nurse provided CPR at the scene, but the victim died. The victims family sued the nurse. Which will provide the best protection to the nurse in this case? a.Clinics malpractice insurance policy b.Good Samaritan Law file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

c.State Board of Nursing d.Institute of Medicine ANS: B The Good Samaritan Law protects the nurse because CPR is within a nurses scope of practice. Although Good Samaritan Laws provide immunity to the nurse who does what is reasonable to save a persons life, if the nurse performs a procedure for which he or she has no training, the nurse will be liable for any injury resulting from that act. Therefore, provide only care that is consistent with your level of expertise. The insurance policy, state boards of nursing, and Institute of Medicine do not provide protection to the nurse under the Good Samaritan Law. PTS:1DIF:Cognitive Level: Applying (Application) REF:66 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 14.Which patient would the nurse consider to be competent to give informed consent? a.A 27-year-old unconscious patient b.A 16-year-old emancipated minor c.A 43-year-old patient who is drunk d.A 33-year-old patient who has been declared legally incompetent ANS: B Even though an emancipated minor has not achieved the legal age of consent, he or she may give consent for procedures and treatment. If a patient is unconscious, you need to obtain consent from a person legally authorized to give consent on his or her behalf. A patient who is legally incompetent needs to have the consent of a legal guardian, which is determined through a legal proceeding. A person who is drunk cannot fully understand the procedure and cannot sign the consent form.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:67-68 OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15.A patient is confused and is attempting to get out of the hospital bed. The nurse is tired after working for more than 10 hours and is concerned for the patients safety. What is the best action that the nurse should take to prevent the patient from harm? a.Restrain the patient with wrist restraints. b.Place the patient with a belt restraint in a chair. c.Sedate the patient with medication. d.Ask a family member to sit with the patient.

ANS: D Asking a family member to sit with the patient is the best answer because it does not restrain the patient physically or chemically. The Joint Commission has set guidelines for the use of restraints in hospitals. These regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patients safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

PTS:1DIF:Cognitive Level: Applying (Application) REF:6BJ:List sources for standards of care for nurses.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 16. As part of the admission process the nurse asks if the patient has an advance directive. The patient doesnt know for sure. What is the nurses best response? a. It is autopsy permission. b. It is a living will. c. It is informed consent. d. It is an organ donation card.

ANS: B Many times the decision regarding lifesaving treatment is in writing in the patients living will or advance directive.

Living wills are documents instructing the health care provider to withhold or withdraw life-sustaining procedures in a patient who is terminally ill. Advanced directives are not an organ donation card, nor informed consent, nor autopsy permission.

PTS:1DIF:Cognitive Level: Applying (Application) REF:69 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 17. Which example demonstrates a breach of confidentiality and a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. Giving a report to the oncoming nurse in a conference room

b.Discussing a patients diagnosis with the patients health care provider c.Providing patient information to the nursing assistant caring for the patient d.Sharing with other nurses in the cafeteria that a patient is HIV positive ANS: D Although HIPAA does not require such things as soundproof rooms in hospitals, it does mandate that nurses and health care providers avoid discussing patients in public hallways and provide reasonable levels of privacy in communicating with and about patients in any matter. Issues of disclosure, privacy, and confidentiality are important concerns when working with patients or peers infected with blood-borne illnesses such as human immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis, and sexually transmitted illnesses. Providing continuity of care, giving reports, talking to the health care provider, and providing information to the nursing assistant do not violate HIPAA. PTS:1DIF:Cognitive Level: Applying (Application) REF:70 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 18. An RN has been caring for a patient. The nurse received an erroneous order for a medication. The primary health care provider has a reputation for impatience and irritability. Knowing this health care providers nature, file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

which action by the nurse would be most appropriate? a.Clarify the order with the pharmacy. b.Ask the patient to remember. c.Clarify the order with the primary health care provider. d.Ask another nurse to look at the order to try to clarify it.

ANS: C A nurse will assess all physician or health care provider orders, and if the nurse determines they are erroneous or harmful, obtain clarification from that physician or health care provider. Calling pharmacy, asking the patient, and asking another nurse are not the best ways to handle erroneous orders.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:70 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 19. Which task can a nurse safely delegate to a student nurse who is working as a nursing assistant?

a.Distributing medications to patients b.Administering insulin injections c.Collecting intake and output data d.Assessing patients ANS: C During the time when a student nurse works as an employee of a health care facility, perform only tasks that appear in a job description for a nurses aide or nursing assistant. For example, even if a student nurse has learned how to administer intramuscular medications, do not perform this task as a nurses aide.

PTS:1DIF:Cognitive Level: Applying (Application) REF:71 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 20. Only one nurse was scheduled to care for 12 postsurgical patients with a nursing assistant. The nurse is

concerned for the safety of the patients and the nursing license. What is the most appropriate first step in this situation? a.Contacting the nursing supervisor and documenting the action b.Refusing to care for the patients without appropriate help and leaving c.Contacting the State Board of Nursing and documenting the action d.Contacting the hospital administrator on call to complain and documenting the action ANS: A If a nurse is assigned to care for more patients than is reasonable for safe care, he or she should notify the nursing supervisor. If the nurse is required to accept the assignment, he or she must document this information in writing and provide the document to nursing administrators. Although documentation does not relieve a nurse of responsibility if patients suffer harm because of inattention, it shows that the nurse attempted to act appropriately. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

Refusing to care for the patients without appropriate help and leaving could be regarded as abandonment.

Complaining to the administrator is not the first step, nor is calling the Board of Nursing.

PTS:1DIF:Cognitive Level: Applying (Application) REF:71 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 21.A patient died from suspicious circumstances. What should the nurse do next? a.Notify the coroner. b.Notify the newspaper. c.Chart what the nurse thinks happened. d.Chart opinions from the health care staff.

ANS: A State statutes specify that, when there are reasonable grounds to believe that a patient died as a result of violence, homicide, suicide, accident, or death occurring in any unusual or suspicious manner, you need to notify the coroner. Notifying the newspaper would break confidentiality. Charting must be objective and factual, not what the nurse thinks happened or opinions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:69 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 22.A patient falls out of bed because the nurse did not raise the side rails. Which action did the nurse commit? a.Felony b.Assault c.Battery d.Negligence ANS: D Negligence is conduct that falls below the generally accepted standard of care of a reasonably prudent person. A felony is a serious offense that has a penalty of imprisonment for greater than a year or possibly even death such as practicing nursing without a license. Assault is any intentional threat to bring about harmful or offensive contact with another individual. Battery is any intentional touching without consent.

PTS:1DIF:Cognitive Level: Applying (Application) REF:64 OBJ:Explain the concept of negligence and identify the elements of professional negligence.TOP:Nursing Process: Assessment MSC:NCLEX: Safety and Infection Control 23. Which situation will enable a nurse to use restraints? file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

a.To punish a patient b.To ensure the patients safety c.To retaliate against poor behavior d.To ensure staff convenience ANS: B Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patients safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:68 OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 24. Which information indicates the nurse has an accurate understanding of when the institutions malpractice insurance covers the nurse?

a.While driving to work b.While driving home from work c.While tending to people in the neighborhood d.While working within the scope of employment ANS: D If a nurse works for a health care institution, generally the institutions insurance will cover the nurse during employment. Malpractice insurance usually provides nurses with an attorney, payment of those fees, and payment of any judgment or settlement if a patient sues a nurse for medical malpractice. If a nurse provides care on a voluntary basis outside the health care facility, hospital-provided malpractice insurance would not cover the nurse.

The nurse will need to carry additional insurance. Driving to and from work is not malpractice.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:65 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 25. When a nurse suspects child abuse or neglect, which action must the nurse take?

a.Report it to the proper legal authority. b. Inform the parents that their actions are illegal. c.Call the security department to handle the problem. d.Prevent the parents from seeing the child during hospitalization.

ANS: A Health care providers are required to report incidents such as child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases. Health care providers are provided legal immunity if the report is made in good faith. Not reporting suspected child abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurses responsibility to inform the parents of illegal activity or to prevent the parents from seeing the child. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

PTS:1DIF:Cognitive Level: Applying (Application) REF:72 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 26.A nurse is maintaining precise records regarding the dispensing, wasting, and storage of a drug that is securely locked. Which drug is the nurse administering? a.Routine medication b.Controlled substance c. Over-the-counter medication d.Substance not requiring an order ANS: B Controlled substances are securely locked away, and only authorized personnel have access to them. Maintain precise records regarding the dispensing, wasting, and storage of controlled substances. There are criminal penalties for the misuse of controlled substances. Routine and over-the-counter drugs are not controlled substances.

Controlled substances required an order by a licensed physician or in some states advanced practice nurses.

PTS:1DIF:Cognitive Level: Applying (Application) REF:72 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 27.Which action is the nurse required by law to perform when a patient is admitted? a.Notify the family. b.Notify the attorney. c.Ask how payment will be made. d.Ask about advance directives.

ANS: D The Patient Self-Determination Act (1991) requires health care institutions to inquire whether a patient has created an advance directive, give patients information on advance directives, and document whether a patient states that he or she has an advance directive. Notifying the family and attorney is breaking confidentiality. Asking how payment will be made is not required by law and is not the responsibility of the nurse.

PTS:1DIF:Cognitive Level: Applying (Application) REF:69 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 28.A nurse must ask a family member to consider an organ donation. In which order should the nurse contact the individuals? file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

a. Spouse

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b. Parent c. Guardian d. Grandparent e. Adult son or daughter f. Adult brother or sister a.a, c, e, f, b, d b.a, e, f, b, d, c c.a, e, b, f, d, c d.a, b, e, f, d, c ANS: C You approach individuals in the following order to consider organ or tissue donations: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:69 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is about to administer a medication and notices that the physicians or primary health care providers order looks incorrect regarding the amount of the medication. What should the nurse do? (Select all that apply.) a.Notify the physician or health care provider. b.Do not carry out the order. c.Document the suspicion that the dosage is incorrect. d.Administer the medication. e.Notify the supervisor or nurse manager.

ANS: A, B, E Nurses are responsible for carrying out medical treatment unless the physicians or health care providers order is in error, violates hospital policy, or is harmful to the patient. Therefore it is imperative to assess all orders and, if they appear to be erroneous or harmful to the patient, to obtain further clarification from the physician or health care provider. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

PTS:1DIF:Cognitive Level: Applying (Application) REF:70-71OBJ:List sources for standards of care for nurses.

TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 2.A nurse wants to follow the American Nurses Associations Social Media Policy (2011). Which actions should the nurse take? (Select all that apply.) file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-05-legal-principles-in-nursing.html[21/04/2019 17:42:25]

a.Never name or describe a patient. b.Never have a blog. c.Never post an image of the patient. d.Never disparage a fellow employee. e.Never report breaches of privacy.

ANS: A, C, D The American Nurses Association has developed a Social Media Policy (2011), which recommends that when using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer. In addition, the professional nurse has an obligation to report breaches of privacy and confidentiality. Never having a blog is not a recommendation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:70 OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

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Chapter 06: Ethics Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A 73-year-old patient with hypertension is awaiting a triple cardiac bypass surgery. The patient is hard of hearing and did not understand what the surgeon said regarding the surgery. The daughter is concerned that the patient does not understand the risks of the surgery. If not clarified, this would be a violation of what principle? a.Autonomy b.Justice c.Fidelity d.Nonmaleficence ANS: A Autonomy refers to a persons independence. As a principle in bioethics, autonomy represents an agreement to respect a patients right to determine a course of action. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence is actively seeking to do no harm.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 77 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 2.A 45-year-old mother of two children has cirrhosis of the liver and is on a waiting list for a liver transplant. She had to meet certain criteria to be eligible to receive a liver. She understands that she is next on the list for a donor liver that matches. This is an example of which ethical principle? a.Autonomy b.Justice c.Fidelity d.Nonmaleficence ANS: B Justice refers to the principle of fairness. In health care, the term is used to reflect a commitment to fair treatment and fair distribution of health care resources. You may find reference to this principle during discussion about issues of access to care. It is not always clear just how to achieve a fair distribution of resources. Autonomy refers to independence and self-determination. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence refers to the fundamental agreement to do no harm.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 3.A registered nurse who works on an oncology unit discussed pain control options that the primary health care provider had ordered with a patient undergoing treatment for pancreatic cancer. The patient requested that the intravenous (IV) pain medication be given on a regular basis. The nurse agreed to provide the IV pain medication as requested and continued to reevaluate the pain levels. The nurse is following which ethical principle? a.Autonomy b.Justice c.Fidelity file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

d.Nonmaleficence ANS: C Fidelity refers to the agreement to keep promises. The principle of fidelity also promotes the obligation of a nurse to follow through with the care offered to patients. Autonomy refers to independence and self-determination, which is what the patient followed, but the question asked for which principle the nurse followed. Justice refers to fairness or equity of health care resources. Nonmaleficence refers to the fundamental agreement to do no harm.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4.A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications and may not recover. The nurse ensures that the patient has been given information regarding the risks and potential benefits of the procedure. The nurse is following which ethical principle? a.Autonomy b.Justice c.Fidelity d.Nonmaleficence ANS: D The principle of nonmaleficence (do no harm) promotes a continuing effort to consider the potential for harm even when it is necessary to promote health. It is helpful in guiding your discussions about new or controversial technologies. Autonomy deals with independence and self-determination. Justice refers to fairness or equity of health care resources. Fidelity refers to maintaining promises and faithfulness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5.A registered nurse is working on a pediatric oncology unit and caring for four children undergoing chemotherapy.

Today a new nursing assistive personnel (NAP) who has passed a competency examination is assigned to the team.

The nurse will delegate a portion of the fundamental nursing tasks to the NAP during the shift, but realizes that he or she is still responsible for his or her own actions and is accountable for the care. The nurse is following which principle of behavior? a.Ethical dilemma b.Code of ethics c.Bioethics d.Feminist ethics ANS: B The code of ethics reflects underlying principles that include responsibility, accountability, respect for confidentiality, competency, judgment, and advocacy. An ethical dilemma exists when the right thing to do is not clear or when members of the health care team cannot agree on the right thing to do. The study of bioethics represents a particular branch of ethics (i.e., the study of ethics within the field of health care). Feminist ethics proposes that we routinely ask how ethical decisions will affect women as a way to repair a history of inequality (Lindeman, 2005).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6.The mother of a 45-year-old patient is a retired physician and requests to discuss the patients plan of care with the nurse caring for the patient. What is the nurses best response to this request? a.I will need to ask permission from my supervisor before I can share that information. b.I will show you the chart, just follow me and we can discuss your questions and concerns. c.I would suggest that you leave me out of your family problems. I am here to care for the patient. d.I will have to get the patients permission before I can share that information.

ANS: D Even family members or friends of the patient are not permitted access to the patients personal health information without the patients consent. Federal legislation known as HIPAA (Health Insurance Portability and Accountability Act of 1996) requires that those with access to personal health information not disclose the information to a third party without patient consent. The nurse does not need to ask permission from the supervisor because HIPAA laws state what the nurse can do. I would suggest that you leave me out of your family problems is inappropriate because it ignores the request of the family member. Showing the chart and discussing the care is a violation of HIPAA. PTS:1DIF:Cognitive Level: Applying (Application) REF: 80 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A nurse bases ethical decisions on the effect, or consequences, an act will have and uses the following guidelines: the greatest good for the greatest number of people. Which ethical system is the nurse using? a.Legal b.Deontology c.Utilitarianism d.Ethics of care ANS: C Utilitarianism guides us to measure the effect, or consequences, that an act will have. The greatest good for the greatest number of people is the guiding principle for action in this system. By comparison, deontology focuses less on consequences and looks to the presence of pure principles of autonomy, justice, fidelity, beneficence, and nonmaleficence. Ethical issues differ from legal issues. Legal issues are resolved by reference to laws that tend to be concrete and publicly determined. Ethics of care suggest that health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring.

PTS:1DIF:Cognitive Level: Applying (Application) REF:81 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 8.A registered nurse has recently been reassigned to the gynecology unit at the hospital. The nurse is strongly against abortion because of religious beliefs and contacts the nursing supervisor regarding the assignment because the unit cares for women who are undergoing abortions. The nurse is having a conflict in which area? a.Confidentiality b.Values file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

c.Social networking d.Culture ANS: B The nurse is having a conflict in values because of religious beliefs and abortion. A value is a personal belief about the worth of an idea, a custom, or an object. Confidentiality is not the issue because no confidences have been broken. Social networking is online communication, which is not the issue in this scenario, values are the issue. The nurse is not having a conflict in culture, but in beliefs and values.

PTS:1DIF:Cognitive Level: Applying (Application) REF:77 OBJ: Describe the process for recognizing and resolving an ethical dilemma.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride the wounds.

The patient is crying and does not want to go to the physical therapy department for treatment. The registered nurse caring for the patient knows that, even though it is uncomfortable, the patient needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which ethical principle? a.Autonomy b.Bioethics c.Justice d.Beneficence ANS: D The principle of beneficence promotes taking positive, active steps to help others. It encourages a nurse to do good for the patient. Beneficence guides decisions in which the benefits of a treatment pose a risk to the patients wellbeing or dignity. Autonomy refers to independence and self-determination. The study of bioethics represents a particular branch of ethics (i.e., the study of ethics within the field of health care). Justice refers to the principle of fairness. In health care the term is used to reflect a commitment to fair treatment and fair distribution of health care resources.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 10. Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, the

nurse recently transferred to a pediatric unit in the hospital. The nurse will be in orientation for several days to learn about the different systems and will need to demonstrate proficiency in various pediatric areas such as medication administration. Which behavior is the nurse demonstrating? a.C ompetency b.Judgment c.Advocacy d.Utilitarianism

ANS: A In the practice of nursing, competence ensures the provision of safe nursing care (proficiency in pediatric medication administration). The agreement to practice with competence is a common denominator for all state regulations and is in the nursing code of ethics. Judgment refers to the ability to form an opinion or draw sound conclusions. Advocacy involves speaking up for patient care issues from your unique perspective and advocating file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

for humane and dignified care. You use a utilitarian ethic when determining the value of something based primarily on its usefulness and effects or consequences. The greatest good for the greatest number of people is the guiding principle for action in this system (utilitarian).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:79 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 11. Which behavior best indicates that the nurse is fulfilling ethical responsibilities? a.D elivers competent care b.Applies the scientific process c.Forms interpersonal relationships d.Evaluates new computerized technologies

ANS: A Delivers competent care is the best example because the American Nurses Association (ANA) and the International Council of Nurses (ICN) publish codes of ethics for nurses that set principles of behavior for nurses to embrace.

They reflect common underlying principles that shape professional nursing practice, including responsibility, accountability, respect for confidentiality, competency, judgment, and advocacy. The scientific process, interpersonal relationships, and new technologies do not indicate ethical behavior like competent care.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:78 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 12.A nurse decides to withhold a medication because it will further lower a patients respiratory rate. In this case, the nurse is practicing what principle? a.Responsibility b.Privacy c.Ethics d.Moral behavior ANS: A Responsibility refers to the execution of duties associated with a nurses role. For example, when administering a medication, you are responsible for assessing the patients need for the medication, giving it safely and correctly, and evaluating the patients response to it. Moral behavior refers to judgment about right and wrong behavior. Ethics refers to the consideration of standards of conduct, particularly the study of right and wrong behavior. A fundamental right of patients is the right to privacy. Privacy becomes a focus of increasing interest as health care becomes digitized, but it is not a focus of this scenario.

PTS:1DIF:Cognitive Level: Applying (Application) REF:78 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

13.A patient is about to undergo a new, controversial bone marrow transplant procedure. The procedure may cause periods of pain and suffering. Although nurses agree to do no harm, this procedure may be necessary to promote health. This is an example of which ethnical principle? a.Autonomy b.Justice c.Fidelity d.Nonmaleficence ANS: D Nonmaleficence refers to the fundamental agreement to do no harm. The principle of nonmaleficence promotes a continuing effort to consider the potential for harm even when it is necessary to promote health. Autonomy refers to a persons independence. Justice refers to the principles of fairness. Fidelity refers to the agreement to keep promises.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 14.A community health nurse states, I wish we had just a portion of the dollars spent repairing atherosclerotic hearts to teach the community about cardiovascular risk factors. The nurses statement stems from what philosophy? a.Deontology b.Feminist ethic c.Utilitarianism d.Ethics of care ANS: C Utilitarianism determines the value of something based primarily on its usefulness. Deontology defines actions as right or wrong according to principles. The feminist ethic asks how ethical decisions will affect women. The ethics of care suggests that health care workers solve ethical dilemmas by the promotion of the fundamental act of caring.

PTS:1DIF:Cognitive Level: Applying (Application) REF:81 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15.A nurse is teaching the staff about the International Council of Nurses Code of Ethics. Which major element of the Code should the nurse include in the teaching session? a.People b.Pride c.Power d.Problems ANS: A The major elements of the Code include: Nurses and People; Nurses and Practice; Nurses and the Profession; and Nurses and Co-workers. It does not include pride, power, and problems.

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REF:80

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OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16.The code of ethics for nursing sets forth ideals of nursing conduct and was developed by what organization? a.The Board of Nursing b.The American Medical Association c.The National League for Nursing d.The American Nurses Association ANS: D The American Nurses Association (ANA) and the International Council of Nurses (ICN) publish codes of ethics for nurses that set principles of behavior for them to embrace. The Board of Nursing regulates nursing programs and nursing practice. The American Medical Association deals with physicians. The National League for Nursing is an agency concerned with nursing education.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:78 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 17.A nurse is processing an ethical dilemma by focusing on relationships and stories of the participants. Which ethical system is the nurse using? a.Deontology b.Utilitarianism c.Feminist ethics d.Ethics of care ANS: D Ethics of care suggest that health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring. Attention to relationships distinguishes the ethics of care from other ethical viewpoints because it does not necessarily apply universal principles that are intellectual or analytical. Deontology defines actions as right or wrong based on right-making characteristics such as truth and justice. You use utilitarian ethics when determining the value of something based primarily on its usefulness and effects or consequences. Feminist ethics proposes that we routinely ask how ethical decisions will affect women as a way to repair a history of inequality.

PTS:1DIF:Cognitive Level: Applying (Application) REF:81 OBJiscuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 18.A nurse is teaching the staff about how to process an ethical dilemma. Which order should the nurse use to present the steps? a. Evaluate the action. b. Negotiate the outcome. file:///D|/...k/test%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-06-ethics.html[21/04/2019 17:42:22]

c. State the problem clearly. d. Gather all relevant information. e. Examine own values and opinions. f.

Consider possible courses of action.

a.d, e, c, f, a, b b.d, e, c, f, b, a c.d, c, e, f, a, b d.d, e, c, b, f, a ANS: B The steps to process an ethical dilemma include the following: (1) Is this an ethical dilemma? (2) Gather all information relevant to the case. (3) Examine and determine your own values and opinions about the issues. (4) State the problem clearly. (5) Consider possible courses of action. (6) Negotiate the outcome. (7) Evaluate the action.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:82 OBJ: Describe the process for recognizing and resolving an ethical dilemma.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. To help the parents resolve this conflict, which steps should the nurse take to process the ethical dilemma? (Select all that apply.) a.Identifying people who can solve this dilemma b.Gathering all relevant information surrounding this dilemma c.Clarifying own values and opinions about the issues d.Consulting a professional ethicist regarding how to proceed with this dilemma e.Considering possible courses of action ANS: B, C, E The nurse should gather all relevant information, clarify own values and opinions about the issue, and consider possible courses of action. Seven steps are used when solving an ethical dilemma: (1) Asking is it an ethical dilemma?, (2) gathering all information, (3) examining and determining ones own values and opinions about the issue, (4) stating the problem clearly, (5) considering possible courses of action, (6) negotiating an outcome, and (7) evaluating the action. Identifying people who can solve this dilemma and consulting a professional ethicist are not steps of the process.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:82 OBJ: Describe the process for recognizing and resolving an ethical dilemma.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

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Chapter 07: Evidence-Based Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.Which organization is preparing future nurses to have the knowledge, skills, and attitudes (KSAs) of evidencebased practices necessary to continuously improve the quality and safety of the health care systems within which they work? a.The Joint Commission b.Quality and Safety Education for Nurses (QSEN) c.The National Database of Nursing Quality Improvement (NDNQI) d.The Agency for Health care Research and Quality (AHRQ) ANS: B Evidence-based practice is also one of the Quality and Safety Education for Nurses (QSEN) competencies, with the overall goal for the QSEN project being to meet the challenge of preparing future nurses to have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work (QSEN, 2012). The Joint Commission provides Patient Safety Goals. All magnetdesignated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI). The database has information on falls, pressure ulcer incidence, and nurse satisfaction. The AHRQ is a national agency that provides important sources of new scientific information that include standards and practice guidelines.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 91 OBJ: Discuss the QSEN competencies for evidence-based practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 2.A registered nurse questioned the nurses on the neonatal intensive care unit about the practice of kangaroo care for neonates. The nurse had read literature supporting the practice, but the nurses that work on the neonatal unit stated that they had never done anything like that at their institution. The nurse continued to ask questions and began a literature review. Which behavior was the nurse demonstrating? a.Variables b.Peer review c.Evidence-based practice d.Process measurement ANS: C Evidence-based practices (EBP) guide nurses and other health care providers in making effective, timely, and appropriate clinical decisions. Nurses and other health care providers can no longer accept and practice the status quo. Greater attention must be given to why certain health care approaches are used, which ones work, and which ones do not. Hypotheses are predictions made about the relationship among study variables (e.g., characteristics or traits that vary among subjects). An example of a research question is: Does the use of chlorhexidine 2% compared with povidone-iodine reduce CLABSI in patients with CVCs? Within that question the author is studying the variables (independent) of chlorhexidine and povidone-iodine solutions as they affect the outcome (dependent variable) of CLABSI in patients. Peer review is the practice of nurses evaluating nurses. A peer-reviewed article is one submitted for publication and reviewed by a panel of experts familiar with the topic or subject matter of the article. When you implement a practice change, you sometimes want to monitor whether or not the process or protocol was implemented. This requires a process measurement. The nurse has not implemented kangaroo care (only reviewed literature), so there is no need for a process measurement.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 89-90 OBJ: Discuss ways to apply evidence in nursing practice. file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3.A registered nurse wants to review the latest information regarding prevention of a health care acquired infection.

Where is the best place for the nurse to obtain this information? a.Online information b.Peer-reviewed nursing journal c.Latest edition of a nursing textbook d.Most recent edition of a popular magazine ANS: C The best scientific evidence comes from well-designed, systematically conducted research studies, usually found in peer-reviewed scientific journals. A good textbook incorporates current evidence into the practice guidelines and procedures it describes. However, a textbook relies on the scientific literature, and sometimes information on a particular topic is outdated by the time a book is published. Peer-reviewed material is better than online information or recent popular magazines.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4.A 15-year-old patient was admitted to the hospital with a bowel obstruction. The patient underwent surgery and was experiencing postoperative pain. The nurse caring for the patient had recently read a research article in which a study had been done with neonatal (infant) patients and the use of therapeutic touch to assist with pain control.

Which factor is most important for the nurse to consider in this case when applying research to clinical practice? a.The patients gender b.The patients preference c.The patients allergies d.The patients roommate ANS: B Using clinical expertise and considering patients values and preferences ensures that a nurse will apply the available evidence to practice both safely and appropriately. Even when you use the best evidence available, application and outcomes differ based on your patients values, state of health, preferences, concerns, and/or expectations. Patients allergies, gender, and roommate are not important in this scenario as it does not affect therapeutic touch.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:91 OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 5.A nurse is using evidence-based practice (EBP) to provide care. Which action should the nurse take first ? a.Collect the most relevant and best evidence. b.Integrate evidence with ones clinical expertise. c.Critically appraise the evidence gathered. d.Ask a clinical question. file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

ANS: D EBP is a systematic approach to determine the most current and relevant evidence on which to base patient care decisions. Melnyk and Fineout-Overholt recommend a six-step process for EBP: (1) Ask a clinical question; (2) Collect the most relevant and best evidence; (3) Critically review and evaluate/appraise the evidence gathered; (4) Combine/Integrate evidence with ones clinical expertise and patient preferences and values in making a practice decision or change; (5) Evaluate the practice decision or change; (6) Communicate results of the change. Collecting the best evidence is step 2. Integrating evidence is step 4. Critically appraising the evidence is step 3.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6. The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. The nurse manager wants to address this situation using evidence-based practice.

Which type of trigger did the nurse manager use? a. Literature-focused trigger

b.Problem-focused trigger c.Knowledge-focused trigger d.Expectations-focused trigger ANS: B A problem-focused trigger is one you face while caring for patients or a trend you see on a nursing unit. A knowledge-focused trigger is a question that arises as a result of new information available on a topic, such as current information in literature. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursing-unit issues. It does not include literature or an expectations trigger.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 91-92 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. The nurse would like to apply the research findings to the unit. How did the nurse formulate the clinical question? a.Measurement-focused trigger b.Problem-focused trigger c.Knowledge-focused trigger d.Expectations-focused trigger ANS: C A knowledge-focused trigger is a question that arises as a result of new information available on the topic. For example, What is the current evidence for the best way to educate patients with low health literacy? A problemfocused trigger is one you face while caring for patients or a trend you see on a nursing unit. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursingunit issues. It does not include measurement or expectation focuses.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 91-92 OBJ: Describe the steps of evidence-based practice. file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 8.A nurses manager has suggested that a nurse formulate a PICO question to clarify the topic before doing a literature review. When the nurse asks what the acronym PICO stands for, how should the nurse manager respond? a.Policy, information, comparison, outcome b.Patient, information, collection, outcome c.Patient, intervention, comparison, outcome d.Policy, intervention, communication, outcome ANS: C P: Patient population of interest. Identify patients by age, gender, ethnicity, disease, or health problem.

I: Intervention of interest. Which intervention do you want to use in practice (e.g., a treatment, diagnostic test, educational approach)?

C: Comparison of interest. What is the usual standard of care or current intervention that you now use in practice?

O: Outcome. What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)?

Policy, information, comparison, collection, and communication are not included in PICO. PTS:1DIF:Cognitive Level: Applying (Application) REF:92OBJevelop a PICO or PICOT question.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 9.A nurse working on a PICO question has found a large amount of literature available on the topic with multiple studies that have been published. Which type of study should have the best evidence? a.Meta-analysis of randomized control trials b.Opinion of an expert committee c.One well-designed randomized control trial d.Systematic review of descriptive and qualitative studies ANS: A Systematic reviews or meta-analyses are state-of-the-science summaries from an individual researcher or panel of experts and are on the highest level of the hierarchy. These research summaries are the perfect answers to PICO(T) questions because the researchers have rigorously summarized all current evidence on the question. A single RCT is not as conclusive as a review of several RCTs on the same question. Opinion of an expert committee is on the lowest level of the hierarchy of evidence. Systematic review is above opinions but is below meta-analysis on the hierarchy of evidence.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 93-94 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10.A registered nurse is concerned about the patients perceptions and feelings about the quality of life that they experience after a diagnosis of liver cancer. Which is the most appropriate type of research study the nurse should use to gather information about this situation? a.Quantitative study b.Randomized trial

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c.Qualitative study

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d.Case controlled study ANS: C Qualitative research offers analysis of interviews, observations, and/or surveys to measure peoples perceptions, feelings, or views of phenomena about which little is known. Randomized trial has participants divided into groups to test for the same outcome to determine if there is a difference in the effect of a treatment or intervention compared with a standard of care. A case control study compares patients who have a disease or outcome of interest with patients who do not have the disease or outcome. The researcher looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and disease. If quantitative data such as physical measurements and scores on surveys are collected, statistical results from the study are explained. Quantitative data do not focus on perceptions and feelings.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:94 OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 11.A nurse works for a facility in which the facility sends information to The National Data Base for Nursing Quality Improvement (NDNQI) regarding patient falls, pressure ulcer incidence, and nursing satisfaction. The nurse works at which facility? a.The Joint Commission b.A magnet-designated hospital c.The Centers for Disease Control and Prevention d.The American Association of Critical Care Nurses ANS: B All magnet-designated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI). The database includes information from Magnet hospitals on falls, pressure ulcer incidence, and nurse satisfaction. The Joint Commission produces patient safety goals. The Centers for Disease Control and Prevention help produce guidelines for clinical practice. American Association of Critical Care Nurses provides standards and practice guidelines for critical care nurses.

PTS:1DIF:Cognitive Level: Applying (Application) REF:92 OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 12.A student nurse is looking for research articles that can be used to complete a research paper. Where can the nursing student look to quickly find out if an article is research or clinically based? a.p value b.Abstract c.Analysis d.Literature review ANS: B An abstract is a brief summary of the article that quickly shows whether the article is research or clinically based. file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

An abstract summarizes the purpose of the study or clinical review, the major themes or findings, and the implications for nursing practice. A good author offers a detailed background of previous studies and the level of evidence or clinical information that exists about the topic of the article, which is called the literature review.

Analysis is the section that explains how the data collected in a study are analyzed. The p value (usually set at 0.05) is a probability level that tells you whether the difference between two groups was likely related to the intervention or if it was simply a difference by chance.

PTS:1DIF:Cognitive Level: Applying (Application) REF:95 OBJ:Explain how critiquing the scientific literature leads to best evidence for practice changes.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 13.A nurse working in an acute care setting wanted to determine the most accurate way to take patients temperatures. The nurse noticed that the tympanic thermometers used by the unit were often not accurate. The nurse found that the literature showed tympanic thermometers were not the most accurate method of obtaining a temperature. The nurse wants to change the nursing practice of the unit. What is the nurses most logical next step? a.Discuss the findings with a patient to gain support. b.Tell the aides to stop taking temperatures. c.Share the findings with the nursing policy and procedure committee. d.Write an editorial in the public newspaper to bring the community into the process.

ANS: C A key feature of a practice environment that supports the use of best evidence is requiring clinical practice policies and procedures to be evidence based. Many organizations involve staff nurses and research-prepared advanced practice nurses in reviewing scientific articles relevant to policies and procedures and then making appropriate revisions. Policies and procedures are important tools for supporting hospital-based nurses in using evidence in their everyday practice and promoting positive patient outcomes. Discussing results with the patient will not get the procedure changed. Telling the aides to stop taking the temperatures is dangerous. Writing an editorial in the public newspaper is inappropriate to effect change on the unit. First follow policies and procedures of the agency in which one works.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 97 OBJ: Identify ways to sustain knowledge in evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14. After a practice change has taken place in an organization because of a nurse following evidence-based practice

in a task force, which final step should the nurse take? a.Evaluate b.Encourage c.Engage d.Execute ANS: A

After applying evidence in practice, the next step is to evaluate the effect. Newhouse and White (2011) recommend that to be successful in changing practice within an organization, it is essential to Engage, Educate, Execute, and Evaluate. Engage and execute have already occurred because the change has taken place. Encourage is not a step in the evidence-based process.

PTS:1DIF:Cognitive Level: Applying (Application) file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

REF: 96-97 OBJ: Identify ways to sustain knowledge in evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 15. The nursing unit staff has used evidence-based practice to implement a practice change. What is the next step in

the process the nursing staff should implement? a.R eview literature. b.Engage companies. c.Measure outcomes. d.Ask a clinical question.

ANS: C After implementing the change, the practice decision or change should be evaluated by using outcome or process measurements. Remember the O in your PICO(T) question. It represents the outcomes you choose to measure as you integrate the evidence. These outcomes tell you how well the evidence-based intervention works. Reviewing literature and asking a clinical question occurred before the change. Companies are not a part of this process.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 | 97 OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. At a health care organization, patients are turned every 2 hours to help prevent pressure ulcers. Because of this nursing intervention, patients exhibit far fewer pressure ulcers than the national average. Which term should the nurse use to describe this finding? a.S entinel event

b.Qualitative research c.Manuscript narrative d.Nursing-sensitive outcome ANS: D A nursing-sensitive outcome focuses on how patients and their health care problems are affected by nursing interventions (ONS, 2012). Nursing-sensitive outcomes look at the effects of interventions within the scope of nursing practice. Sometimes a problem is presented to a committee in the form of a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury of a patient. Qualitative research is analysis of interviews, observations, and/or surveys to measure peoples perceptions, feelings, or views of phenomena about which little is known. Manuscript narrative is the middle section or narrative of a manuscript that differs according to the type of evidence-based article it is.

PTS:1DIF:Cognitive Level: Applying (Application) REF:98 OBJ: Discuss ways to measure outcomes for an evidence-based practice change.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 17. The quality improvement or performance improvement (QI/PI) process should begin at which level of nursing?

a.Staff nurse b.Nurse manager c.Nurse administrator d.Advanced practice registered nurse file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

ANS: A The QI/PI process begins at the staff level, where all disciplines become involved in identifying quality problems.

Although all those listed can do QI/PI, the process begins at the staff level.

PTS:1DIF:Cognitive Level: Applying (Application) REF:100 OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.The nurse is investigating an area of practice in which no research evidence is available. What types of nonresearch information should the nurse consider? (Select all that apply.) a.Performance improvement and risk management data b.International, national and local standards of care c.Study with pre- and post-test design d.Benchmarking e.Retrospective or concurrent chart reviews ANS: A, B, D, E Other sources of information from non-research evidence include: performance improvement and risk management data, international, national and local standards of care, infection control data, benchmarking, clinicians expertise, and retrospective or concurrent chart reviews. Study with a pre- and post-test design is a research study. The question asked for non-research information.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2.A nurse is describing types of performance improvement models. Which information should the nurse include?

(Select all that apply.) a.Six Sigma b.Balanced scorecard c.Plan-Do-Study-Act d.Root cause analysis e.Human subjects committee ANS: A, B, C, D Performance improvement models include Six Sigma, balanced scorecard, Plan-Do-Study-Act, and root cause analysis. Research studies must be approved by an institutional review board (IRB), also called a human subjects committee , which is not involved with performance improvement models but with research.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:101 OBJ: Discuss the relationship between evidence-based practice and the improvement of the safety and quality of nursing practice. TOP: Nursing Process: Implementation file:///D|/...sentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-07-evidence-based-practice.html[21/04/2019 17:42:15]

MSC: NCLEX: Management of Care

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Chapter 08: Critical Thinking Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A registered nurse is caring for a patient in the trauma unit who had been involved in a motor vehicle accident.

Although the patient denied pain, during the nurses assessment, the nurse observed that the patient groaned when moving and was protective of the right arm. The nurse believed the patient had pain and reported it to the primary health care provider, who ordered a radiograph (x-ray) of the right arm. The radiograph revealed a fractured arm.

Which technique did the nurse use? a.Intuition b.Critical thinking c.Perseverance d.Reflection ANS: B The nurse used critical thinking. Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information related to the issue (e.g., clinical data about a patient), evaluating information (including assumptions and evidence), and drawing conclusions. Intuition is an inner sensing or gut feeling that something is so. Reflection is a part of critical thinking that involves the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Perseverance means to also keep looking for additional resources until you find a successful approach.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 106 OBJ: Discuss the nurses responsibility in making clinical decisions.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 2.A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during the shift. The nurse remembers that this was similar to a situation that happened in the past when a patient developed an internal bleed. Based upon the nurses thoughts, which skill did the nurse use? a.Intuition b.Critical thinking c.Nursing process d.Reflection ANS: D The nurse is using reflection when thinking about a situation in the past that was similar. Reflection is a part of critical thinking that involves the process of purposefully thinking about or recalling a situation to discover its purpose or meaning. Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information related to the issue (e.g., clinical data about a patient), evaluating information (including assumptions and evidence), and drawing conclusions. Intuition is an inner sensing or gut feeling that something is so. The nursing process is a five-step approach that incorporates diagnostic reasoning and clinical decision making.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 107 OBJ: Describe how reflection improves clinical decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 3.A nurse is admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patients daughter and son-in-law are present. The nurse notices that the patient does not make eye contact when answering questions and the nurse senses that something is not right about the situation. Which technique did the file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

nurse use? a.Intuition b.Critical thinking c.Nursing process d.Reflection ANS: A The fact that the nurse senses something is not right about the situation is intuition. Intuition is the inner sensing or gut feeling that something is so. For example, a nurse walks into a patients room and, by looking at the patients appearance without the benefit of a thorough assessment, senses that he or she has worsened physically. Reflection is a part of critical thinking that involves the process of purposefully thinking about or recalling a situation to discover its purpose or meaning. Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information related to the issue (e.g., clinical data about a patient), evaluating information (including assumptions and evidence), and drawing conclusions. The nursing process is a five-step approach that incorporates diagnostic reasoning and clinical decision making.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 108 OBJ: Discuss the nurses responsibility in making clinical decisions.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 4.A student nurse is administering an enema with an instructor in the room. The patient states that he or she can no longer hold the enema solution. The student nurse acknowledges the patients request and begins to tell the patient to go to the bathroom but asks the instructor if this is OK. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylors model? a.Level 1: Basic b.Level 2: Complex c.Level 3: Commitment d.Level 4: Expert ANS: A The student nurse is at the basic level because he or she asked the instructor what to do. At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. Complex critical thinkers begin to separate themselves from experts. In complex critical thinking you learn to synthesize knowledge. This means that you develop a new thought or idea based on your experience and knowledge over time. The third level of critical thinking is commitment. You anticipate the need to make choices without assistance from others. You accept accountability for whatever decisions you make. There is no level 4 in this model.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:109 OBJ: Describe the components of a critical thinking model for clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 5.A nurse is describing risk taking, creativity, and integrity in nursing care. What is the nurse explaining? a.Attitudes of critical thinking b.Competencies of critical thinking c.Standards for critical thinking d.Nursing process for critical thinking file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

ANS: A The fourth component of the critical thinking model is attitudes. Paul (1993) identifies 11 attitudes that are central features of a critical thinker of which risk taking, creativity, and integrity are examples. Kataoka-Yahiro and Saylor (1994) describe critical thinking competencies as the cognitive processes a nurse uses to make judgments about the clinical care of patients. There are three competencies: general critical thinking (scientific method, problem solving, and decision making), specific critical thinking in clinical situations (clinical inference, diagnostic reasoning, and clinical decision making), and specific critical thinking in nursing (nursing process). The standards for critical thinking include intellectual standards and professional standards. The nursing process is a five-step approach that incorporates diagnostic reasoning and clinical decision making.

PTS:1DIF:Cognitive Level: Applying (Application) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6.A nurse is using the scientific method to solve a patient situation. Which action should the nurse take first ? a.Collect data. b.Identify a problem. c.Formulate a question. d.Evaluate the results.

ANS: B Identifying the problem is the first step in the scientific method. The steps of the scientific method are as follows: Identify the problem; Collect data; Form a question or hypothesis; Test the question or hypothesis; Evaluate results of the study. Collect data is the second step. Formulate a question is the third step. Evaluate the results is the last step.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 110 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A registered nurse is explaining a procedure to a patient who speaks another language. Which action by the nurse reflects critical thinking? a.Teach with unfamiliar explanations. b.Explain using medical jargon. c.Use vague descriptions. d.Obtain an interpreter.

ANS: D Critical thinkers use language precisely and clearly. If you do not obtain a professional interpreter when communicating with patients who speak a different language, you are taking the risk of miscommunicating important information. When you use incorrect terminology, jargon, or terminology with which a patient is unfamiliar, or vague descriptions, communication is ineffective.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 108 OBJ: Discuss the nurses responsibility in making clinical decisions.

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8.A patient receiving blood after an abdominal surgery notified the nurse that the IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked.

On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which behavior on the part of the nurse? a.Effective problem solving b.Diagnostic reasoning c.Scientific method d.Commitment level of critical thinking ANS: A Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options, which the nurse did in this scenario. In commitment, you anticipate the need to make choices without assistance from others. The nurse did not anticipate the need as evidenced by the fact the nurse did not fully investigate until the second time. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. In diagnostic reasoning, the information a nurse collects and analyzes leads to a diagnosis of a patients condition. Nurses do not make medical diagnoses; they make nursing diagnoses, which is a part of diagnostic reasoning. This scenario deals with an equipment problem, not a patient health problem (diagnostic reasoning).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss the nurses responsibility in making clinical decisions.

TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 9.A patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that the patient may have an infection and notifies the primary health care provider of the change in the patients condition. This concern is based on the nurses experience as a pediatric nurse. The nurses ability to make a tentative conclusion regarding this patients situation based on observed data is known as what? a.Scientific method b.Clinical inference c.Effective problem solving d.Data collection ANS: B The nurse used clinical inference because of previous experience as a pediatric nurse and pieces of evidence of acute pain and a high fever. Clinical inference is the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and is making a tentative conclusion.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:111 OBJ: Explain the relationship between clinical experience and critical thinking. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 10.A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patients white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection . The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation? a.Medical diagnosis b.Scientific method c.Diagnostic reasoning d.Data collection ANS: C The nurse used diagnostic reasoning by using data (low white blood cells and little energy) to arrive at a patients health problem/nursing diagnosis ( Risk for Infection ). Diagnostic reasoning is the analytical process for determining a patients health problems. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis: Risk for Infection.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 11.A nurse is caring for an elderly lady who recently experienced a stroke and who coughs/chokes after eating or drinking. The nurse knew that the patient was at risk for aspiration because of the stroke and was concerned that the patient may have impaired swallowing. The nurse develops a care plan based on the nursing diagnosis Impaired Swallowing . Which skill is the nurse using to make this nursing diagnosis? a.Medical diagnosis b.Scientific method c.Diagnostic reasoning d.Data collection ANS: C The nurse used diagnostic reasoning to arrive at a nursing diagnosis. During diagnostic reasoning, the information a nurse collects and analyzes leads to a diagnosis of a patients condition. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis: Impaired Swallowing.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 12.Which situation represents a nurse using clinical decision-making skills? file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

a.Collecting information about a patient and coming to a conclusion about his or her health problems b.Developing a new idea based on experience and knowledge over time c.Selecting appropriate treatment after forming diagnostic conclusions d.Clarifying the problem and analyzing possible causes ANS: C Clinical decision making is a problem-solving activity that focuses on selecting appropriate treatment after forming diagnostic conclusions. Clinical decision making requires careful reasoning so that a nurse chooses the option for the best patient outcome on the basis of the patients condition and priority of the problem. Collecting information about a patient and coming to a conclusion about his or health problems is diagnostic reasoning. Clarifying the problem and analyzing possible causes is a part of problem solving. In complex critical thinking you learn to synthesize knowledge. This means that you develop a new thought or idea based on your experience and knowledge over time.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:112 OBJ: Describe the components of a critical thinking model for clinical decision making.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 13.A new registered nurse working for a busy unit of an acute care teaching hospital begins the shift with four patients. Which patient should the nurse attend to first ? a.Patient who needs assistance in ambulating the hall b.Patient whose blood pressure suddenly drops and who passes out (faints) c.Recovering stable surgical patient whose family has just arrived d.Recovering patient who is resting quietly watching television ANS: B A patients whose blood pressure drops and faints needs to be addressed first. Critical thinking and clinical decision making are complicated because nurses care for multiple patients in fast-paced and unpredictable environments.

When you work in a busy setting, use criteria such as the clinical condition of a patient (stable vs. unstable), Maslows hierarchy of needs (patients blood pressure is an active lower need problem), the risks involved in treatment delays (if the blood pressure is not treated the patients condition could get worse), and patients expectations of care to decide which patients have the greatest priorities. A patient who needs assistance in ambulating the hall can be delegated to the nursing assistant personnel. The surgical patient is stable so does not need to be addressed first. The recovering patient resting quietly is not a priority.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 112 OBJ: Discuss the nurses responsibility in making clinical decisions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14.A nurse is teaching a group of nursing students about the nursing process. In which order should the nurse list the steps? a.Assessment, diagnosis, planning, implementation, and evaluation b.Diagnosis, assessment, planning, implementation, and evaluation c.Planning, evaluation, diagnosis, implementation, and assessment d.Evaluation, diagnosis, planning, implementation, and assessment ANS: A The nursing process is a systematic process that incorporates diagnostic reasoning and clinical decision making file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

through five steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step, not diagnosis, planning, or evaluation.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:112-113 OBJiscuss the relationship of the nursing process to critical thinking.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 15.Upon checking a medication order, the nurse notices that the dosage is more than three times the normal range for this medication. The nurse calls the primary health care provider to question the order. Which critical thinking attitude did the nurse use? a.Confidence b.Risk taking c.Fairness d.Curiosity ANS: B If your knowledge causes you to question a health care providers order, do so. This illustrates risk taking. To be confident is to feel certain in your ability to accomplish a task or goal such as performing a nursing procedure or making a diagnostic decision; do not let a patient think that you are unsure of performing care safely. Fairness is listening to both sides in any discussion and dealing with situations justly. Curiosity is always asking why.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP:Nursing Process: Evaluation MSC: NCLEX: Pharmacological and Parenteral Therapies 16.A nurse is caring for a patient who underwent an above-the-knee amputation that requires a dressing change, a skill the nurse has never done. The nurse asks another nurse to help with the dressing change for the amputated leg.

The nurse is demonstrating which critical thinking attitude? a.Humility b.Confidence c.Risk-taking d.Fairness ANS: A Critical thinkers who use humility admit what they do not know and try to find the knowledge they need to make a proper decision. Humility is recognizing when one needs more information to make a decision. When a nurse is new to a clinical division and unfamiliar with the patients, he or she should ask for an orientation to the area and ask nurses regularly assigned to the area for assistance. If your knowledge causes you to question a health care providers order, do so. This illustrates risk taking. To be confident is to feel certain in your ability to accomplish a task or goal such as performing a nursing procedure or making a diagnostic decision; do not let a patient think that you are unsure of performing care safely. Fairness is listening to both sides in any discussion and dealing with situations justly.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Basic Care and Comfort 17.A student nurse in the last semester of nursing school found that keeping a journal of clinical experiences helped the student nurse understand why certain actions were taken and to evaluate whether there was a better way of approaching the task. The student nurse has found that this has helped strengthen critical thinking skills. Which skill for developing critical thinking did the student nurse use? a.Professional standards b.Nursing process c.Concept mapping d.Purposeful reflection ANS: D Purposeful reflection leads to a deeper understanding of issues and the development of judgment and skill. One activity that will help a nurse develop into a critical thinker is reflective journaling. A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. The nursing process is a systematic process that incorporates diagnostic reasoning and clinical decision making through five steps: assessment, diagnosis, planning, implementation, and evaluation. Professional standards for critical thinking refer to ethical criteria for nursing judgments (e.g., advocacy, patient autonomy, and beneficence), evidence-based criteria used for assessment and evaluation, and criteria for professional responsibility.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 118 OBJ: Describe how reflection improves clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 18.A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patients problems and appropriate nursing interventions. What is the best tool that the nurse can use to synthesize data into meaningful information? a.Concept map b.Reflective journal c.Plan of care d.Intellectual standards ANS: A A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. Concept maps are visual road maps that highlight the meanings of these relationships. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. In the nursing process, a plan of care is written to guide nursing care, but it does not show relationships as well as does a concept map. Paul (1993) identified 14 intellectual standards universal for critical thinking. An intellectual standard is a guideline or principle for rational thought, but it does not show relationships like a concept map does.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 118 OBJ: Discuss the nurses responsibility in making clinical decisions. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 19.A nurse walks into a room and finds a patient to be severely confused. The nurse examines and observes the patient closely and thinks about other situations with severely confused patients before making a nursing diagnosis.

Which skill is the nurse using? a.Clinical inferences b.Reflective journaling c.Accountability d.Intuition ANS: A Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. Intuition is an inner sensing or gut feeling about something. Accountability refers to being answerable for ones actions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 20.A nurse is using scientific knowledge and experience to choose strategies to use in the care of a patient. Which critical thinking skill is the nurse using? a.Analysis b.Evaluation c.Explanation d.Self-regulation ANS: C Scientific knowledge and experience to choose strategies you use in the care of patient is explanation; it supports your findings and conclusions. Analysis is being open-minded as you look at information about a patient. Do not make careless assumptions in analysis. Evaluation is looking at all situations objectively and systematically and using criteria to determine results of nursing actions. Self-regulation is reflecting on your experiences and identifying ways you can improve your own performance.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 107 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 21.A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge. Which concept for a critical thinker is the nurse using? a.Maturity b.Analyticity c.Systematicity d.Inquisitiveness ANS: B Analyticity is being alert to potentially problematic situations and using evidence-based knowledge. Maturity is reflecting on your own judgments and realizing multiple solutions are acceptable. Systematicity is being organized, file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

focusing, and working hard in any inquiry. Inquisitiveness is being eager to acquire knowledge and learning explanations even when applications of the knowledge are not immediately clear and to value learning for learnings sake.

PTS:1DIF:Cognitive Level: Applying (Application) REF:107OBJescribe characteristics of a critical thinker.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 22.A surgical unit uses Betadine to prep the skin before surgery. A nurse is using the scientific method to decide if soap and water is better than Betadine for preparing the skin for surgery. A nurse washes one group of patients with soap and water and washes another group of patients with Betadine. Which step did the nurse implement? a.Identifying the problem b.Forming the question or hypothesis c.Answering the question or hypothesis d.Evaluating the results of the test or study ANS: C When the nurse washes one group with soap and water and the other with Betadine, the nurse is answering the question or hypothesis. Identifying the problem would be an increase in infections or adverse reactions from Betadine. Forming the question or hypothesis would be, Does soap and water vs Betadine reduce the incidence of infections or adverse reactions? Evaluating the results would occur when the nurse compared the incidence of infection or adverse reactions for each of the two groups.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 110 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 23.Which patient situation indicates the nurse used fairness? a.The nurse used original thinking to find solutions outside the standard routine. b.The nurse asked why the interventions were used to help the patient. c.The nurse did not allow personal attitudes to influence delivery of care. d.The nurse followed the six rights when giving medication to a patient.

ANS: C Fairness means the nurse deals with situations justly. This means that bias or prejudice does not enter into a decision. For example, regardless of how you feel about obesity, you do not allow personal attitudes to influence the way you deliver care to patients who are overweight. Creativity involves original thinking. This means you find solutions outside of the standard routines of care while still following standards of practice. A critical thinkers favorite question is, Why? and represents curiosity. Following the six rights is being responsible and accountable.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 24. Which information indicates the nurse has a correct understanding of critical thinking? a. It is a continuous process characterized by open-mindedness. b. It is the same thing as the nursing process. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

c. It is a haphazard method of providing nursing care. d. It is moving from writing a plan of care to thinking.

ANS: A Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant. It is not the same thing as the nursing process, but the nursing process is a specific critical thinking competency. It is not a haphazard method; it is logical, with attitudes and standards. Although critical thinking helps write a care plan, actually writing a care plan is a step (planning) in the nursing process.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 106 OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 25. While a nurse is assessing a patients chest pain, the patient states, The pain hurts in the middle of my chest. The

nurse asks, Can you tell me where the pain is exactly and describe what it feels like? Which attitude for critical thinking is the nurse using? a.Integrity b.Discipline c.Planning d.Nursing diagnosis ANS: B

The nurse is being thorough, which is using the critical thinking attitude of discipline. A disciplined thinker misses few details and follows an orderly or systematic approach when collecting information, making decisions, or taking action. A person of integrity is honest and willing to admit to any mistakes or inconsistencies in his or her own behavior, ideas, and beliefs. Planning and nursing diagnosis are steps in the nursing process, not attitudes for critical thinking.

PTS:1DIF:Cognitive Level: Applying (Application) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort MULTIPLE RESPONSE 1.A nurse is teaching the staff about the major elements in the critical thinking model. Which information should the nurse include in the teaching session? (Select all that apply.) a.Intricate b.Attitudes c.Standards d.Experience e.Competence ANS: B, C, D, E According to the model, there are five elements of critical thinking: knowledge base, experience, competence (e.g., problem solving or clinical decision making), attitudes, and standards. Intricate is not an element in the critical thinking model.

file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:113 OBJ: Describe the components of a critical thinking model for clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-08-critical-thinking.html[21/04/2019 17:42:19]

Chapter 09: Nursing Process Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process? a.Assessment b.Implementation c.Evaluation d.Diagnosing ANS: A Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patients current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves.

PTS:1DIF:Cognitive Level: Applying (Application) REF:124OBJescribe each step of the nursing process.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2. The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in

which component of the nursing process? a. Evaluation b.Diagnosis c.Assessment d.Planning

ANS: C The nurse is in the assessment phase. An assessment database includes a patients comprehensive health history, which includes information about a patients physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 124 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3.A postoperative patient is continuing to have incisional pain. As part of the nurses assessment, the nurse notes that the patient is grimacing when he or she changes position. The patients grimace can be useful in the assessment and can be described as which of the following? file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

a.Cue b.Inference c.Diagnosis d.Health pattern ANS: A Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An inference is your judgment or interpretation of these cues. Gordons functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4.A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as? a.Cue b.Inference c.Diagnosis d.Health pattern ANS: B The nurse made a judgment, which is an inference, that the patient is experiencing pain. An inference is a nurses judgment or interpretation of a cue. A cue is information that you obtain through use of the senses. Gordons functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat such as impaired tissue perfusion.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a.Heart rate of 96 b.Incisional erythema c.Emesis of 150 mL d.Sharp, burning pain ANS: D Sharp, burning pain is subjective. Subjective data are patients verbal descriptions of their health problems. Only patients provide subjective data. Heart rate, incisions, and emesis are all objective data. Objective data are observations or measurements of a patients health status.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 6.The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective? a.The patients toes of right foot are warm and pink. b.The patient reports a dull ache in the right hip. c.The patient says feels tired all the time. d.The patient is concerned about insurance coverage.

ANS: A Toes pink and warm are objective data. Objective data are observations or measurements of a patients health status.

Subjective data are patients verbal descriptions of their health problems. Only patients provide subjective data.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened? a.Appears to be in pain as evidenced by grouchy behavior b.Behavior is inappropriate, requests registered nurse do the assessment c.States, I want a registered nurse to do my assessment d.Is grumpy, registered nurse notified ANS: C When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive statements. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:126 | 131 OBJ: Explain the relationship between critical thinking and steps of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8.A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patients spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurses behavior? a.The patient is exhibiting confusion. b.The spouse is being obnoxious. c.The patient is the best source of information. d.The spouse is too controlling.

ANS: C A patient is usually the best source of information. A patient who is alert and answers questions appropriately file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. There is no evidence in the scenario to indicate confusion on the patients part or that the spouse was obnoxious or too controlling. The nurse needs more data before saying the spouse is obnoxious or controlling.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 127 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed? a.Patient chart b.Patient c.Parents d.Surgeon ANS: C Family members and significant others are primary sources of information for infants, children, critically ill adults, patients with mental handicaps, or patients who are unconscious or have reduced cognitive function. The patient is too young. The patients chart is a source but not a primary source. The parents are a better source than the surgeon.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 127 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10.A nurse is interviewing a patient being admitted to the hospital for surgery. During the interview, the nurse introduces self and explains that will be gathering some information. The nurse is in which phase of the interview? a.Orientation b.Working c.Assessment d.Termination ANS: A The orientation phase begins with introducing oneself and ones position and explaining the purpose of the interview. The nurse explains to patients why the data are being collected and assures the patient that the information will remain confidential and will be used only by health care professionals who provide his or her care.

During the working phase you gather information about a patients health status. When the interview comes to an end, this is called termination. Assessment is the first step in the nursing process, not the first step in an interview.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 128 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 11.A nurse is teaching the staff about the phases of the interview process. Which information should the nurse include in the teaching session? a.Orientation, working, termination b.Orientation, assessment, evaluation c.Planning, assessment, termination file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

d.Planning, assessment, evaluation ANS: A The three phases of the interview process are orientation, working, and termination. Assessment, evaluation, and planning are phases in the nursing process.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 128-129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12. Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?

a.Let us help you. b.Did you seek help when it first started? c.Tell me about the problems you are having. d.Do you have a family history of this problem?

ANS: C Initially use open-ended questions/comments. The use of open-ended questions/comments prompts patients to describe a situation in more than one or two words. This technique leads to a discussion in which patients actively describe their health status. Once patients tell their story, focus on the symptoms that the patient identifies and ask closed-ended questions that limit his or her answers to one or two words such as yes or no or a number or frequency of a symptom. The questions that start with Do and Did are closed-ended. Let us help you will not get the patients perspective.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 13. As a nurse is obtaining a health history from a patient, the nurse uses comments such as go on. Which technique is the nurse using?

a.Cues b.Inferences c.Back-channeling d.Termination ANS: C This is known as back-channeling, which is the practice of giving positive comments such as all right, go on, or uhhuh to the speaker. These indicate that a nurse has heard what the patient says and is attentive to hear the full story.

A cue is information that you obtain through use of the senses. An inference is your judgment or interpretation of these cues. Termination is the last phase of the interview in which the interview comes to an end.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14.A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall. The patients spouse accompanied the patient to the hospital and is being interviewed by the nurse.

Which question should the nurse ask to quickly focus on the patients symptoms? file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

a.What made you choose this hospital? b.How long did the seizure last? c.Tell me how the seizure disorder has affected the family. d.Tell me why you brought your spouse to the hospital today.

ANS: B How long did the seizure last? is the question that will quickly focus on the patients symptoms. Once patients tell their story, use a problem-seeking interview technique. This approach takes the information provided in the patients story and then more fully describes and identifies specific problem areas. For example, focus on the symptoms the patient identifies and ask closed-ended questions that limit the patients answers to one or two words such as yes or no or a number or frequency of a symptom. What made you choose this hospital does not focus on the seizure. Tell me will not get information quickly as these are open-ended.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 15.A patient is admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems. What is the nurse doing? a.Making a medical diagnosis b.Performing a physical examination c.Making an evaluation d.Performing data validation ANS: B A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell.

A complete examination includes a patients height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems. Nurses make nursing diagnoses, not medical diagnoses, after assessment of data. Evaluation is the last step of the nursing process. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves. Validation of assessment data is the comparison of data with another source to confirm accuracy.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 16.When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke.

The patient denies any problems and states that does not require assistance. After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction? a.Verbal behavior b.Physical assessment c.Nursing diagnosis d.Nonverbal behavior ANS: D Observation of the level of function is different from what a nurse learns about function during the interview. A file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

nurse observes what the patient does, such as self-feeding or making a decision, rather than what the patient says he or she can do. The level of function involves a persons ability to perform during everyday activities.

Observation of the patients behavior for level of function differs from a physical assessment. The hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength. Verbal behavior is what the patient says. A nursing diagnosis would be self-care deficit.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 129-130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17.A 67-year-old male patient of French heritage is admitted to the hospital. The patient is interviewed by a nurse from a Korean family. The nurse did not make eye contact with the patient while conducting the interview. This disturbed the patient because the patient thought that the nurse might be trying to hide something. Which factor most likely influenced the behavior of the nurse and patient? a.Culture b.Validation c.Collaborative problem d.Defining characteristics ANS: A Communication and culture are interrelated in the way individuals express feelings verbally and nonverbally. When a nurse learns the variations in how people of different cultures communicate, he or she will likely gather more accurate information from patients. Validation of assessment data is the comparison of data with another source to confirm accuracy. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. Defining characteristics are the clinical criteria or assessment findings that support an actual nursing diagnosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18.A nurse wants to provide patient-centered care to a patient of another culture. Which question is the most culturally sensitive when talking about a patients illness? a.What do you call your problem? b.How long has your child had the runs? c.When did you last void today? d.Has anyone else in your family had diarrhea?

ANS: A To start an assessment, Seidel and others (2011) offer useful questions to begin to explore a patients illness or health care problem in context of the patients culture: What do you call your problem? A different culture may not know what the runs means. Most people do not know what void (urinate) means. Has anyone else in your family had diarrhea is not as culturally sensitive as finding out what the problem is according to the patients culture.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19.Which action by the nurse is the final step in a complete assessment? file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

a.Forming diagnostic conclusions b.Documentation of findings c.Auscultation d.Palpation ANS: B Communication of assessment findings, either verbally or through documentation, is the last step of a complete assessment. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. The techniques of a physical examination include inspection, palpation, percussion, auscultation, and smell. After reviewing and validating a patients assessment, the next step of the nursing process is to form diagnostic conclusions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:131OBJescribe each step of the nursing process.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 20.A patient with bilateral pneumonia is admitted to the intensive care unit. The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia . What made the nurse classify this as a collaborative problem? a. It requires ensuring adequate hydration. b. It requires monitoring for signs of acid-base imbalance. c. It requires evaluating the effects of positioning on oxygenation. d. It requires both nursing and physician-prescribed interventions.

ANS: D A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians. Adequate hydration, acid-base imbalance, and oxygenation do not make a collaborative problem.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 131 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 21.A patient states, Im burning up, and I have a fever. The nurse takes the patients temperature, observes the skin for flushing, and feels the skin temperature. This is an example of subjective data. a.validating b.clustering c.reviewing d.documenting ANS: A Validation of assessment data is the comparison of data with another source to confirm accuracy. The nurse reviews data to validate that measurable, objective physical findings support subjective data. A data cluster is a set of signs or symptoms that are grouped in a logical order. When a nurse reviews a patients subjective data, the nurse is examining the patients own interpretation of his or her condition. Documenting information includes the written details of the assessment.

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REF: 130 | 137 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 22.Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg. The nurse obtained which type of data? a.Personal b.Demographic c.Subjective d.Objective ANS: D Objective data are observations or measurements of a patients health status. Personal and demographic data refer to patients name, age, sex, and so on. Subjective data are patients verbal descriptions about their health problems.

Demographic data includes birth, gender, address, family members names and addresses.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 23.A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy. The chemotherapy has caused the patient to not eat. Which nursing diagnosis should the nurse use to develop the plan of care? a. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake b. Imbalanced Nutrition: Less Than Body Requirements Related to Cancer c. Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight d. Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy

ANS: A Imbalanced Nutrition: Less Than Body Requirement is the diagnostic label, whereas decreased food intake is the state of related factor(s) or etiology. The identification of a nursing diagnosis flows from the assessment and diagnostic process. Nursing diagnoses are worded in a two-part format: the diagnostic label followed by a statement of a related factor. Identify the patients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Breast cancer is a medical diagnosis. Identify the problem and etiology to avoid a circular statement. Such statements are vague and give no direction to nursing care. Less than body requirements and loss of weight is circular. Avoid legally inadvisable statements that imply blame, negligence, or malpractice. The diagnosis that states insufficient prescription of chemotherapy implies that the health care provider gave an inadequate prescription.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:135-136 | 137-139 OBJ: Describe the way in which defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 24.A nurse develops a nursing diagnosis for a patient. What is the rationale for the nurses actions? a.It allows a nurse to compete with physicians or health care providers. b. It allows a nurse to develop an individualized plan of care. c. It allows a nurse to treat nursing problems and medical problems. d. It allows a nurse to manage patient care for the entire health team. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

ANS: B The diagnostic process results in the formation of a total diagnostic statement that allows a nurse to develop an appropriate, patient-centered plan of care. A nursing diagnosis provides direction for nursing, not for medical problems or for the entire health team. It is not used to compete with physicians or health care providers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 136 OBJ: List the steps of the nursing diagnostic process.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 25.A patient is suffering from shortness of breath. How should the nurse write the expected outcome for this patient? a.The patient will be comfortable by the morning. b.The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift. c.The patient will not complain of breathing problems. d.The patient will appear less short of breath.

ANS: B Each patient outcome contains the following aspects in order to be correctly written: (1) patient-centered, (2) singular, (3) observable, (4) measurable, (5) time limited, (6) mutual factors, and (7) realistic. Comfortable is not measurable. Outcome that deals with no complaints of breathing is lacking the time limited guideline. Patient will appear less short of breath is not a correct statement because there is no specific observable behavior for appears less short of breath.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:142 OBJiscuss the difference between a goal and an expected outcome.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 26.A nurse is caring for a patient and performs several interventions. Which action by the nurse is an independent nursing intervention? a.Turning every 2 hours b.Administering a medication c.Inserting an indwelling catheter d.Starting an intravenous (IV) for intravenous fluids ANS: A According to state Nurse Practice Acts, independent nursing interventions pertain to ADLs (turning), health education and promotion, and counseling. Nurse-initiated interventions are the independent nursing interventions or actions that nurses initiate. Physician-initiated interventions are dependent nursing interventions or actions that require an order from a physician or another health care professional. Administering a medication, implementing an invasive procedure (catheter and intravenous fluids), and preparing a patient for diagnostic tests are examples of such interventions.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 143 OBJ: Discuss the process of selecting nursing interventions.

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27.A nurse is writing a care plan for a newly admitted patient. Which outcome statement did the nurse correctly write? a.The patient will eat 80% of all meals. b.The nursing assistant will set up the patient for a bath every day. c.The nursing assistant will ambulate the patient three times a day by May 30. d.The patient will identify the need to increase dietary intake of fiber by July 4.

ANS: D The patient will identify the need to increase dietary intake of fiber by July 4 is measurable, reliable, valid, and focuses on the patient. Expected outcomes are measurable criteria to evaluate goal achievement. These measurable effects relate to a change in a patients physical condition or behavior that results from individualized nursing interventions. Outcomes should be measurable, reliable, valid, suited to the patient, and sensitive to change. Eat 80% of meals has no time frame. The nursing assistant is not the focus the patient is. Also, the nursing assistant will ambulate the patient or set the patient for a bath are interventions, not outcomes.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:141 OBJiscuss the difference between a goal and an expected outcome.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 28.A home health nurse is providing care to a patient. Which action by the nurse is a physical care technique? a.Dressing a patient b.Assisting a patient to learn how to shop c.Performing range-of-motion exercises d.Administering cardiopulmonary resuscitation ANS: C Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises). Dressing a patient is an activity of daily living. Shopping is an instrumental activity of daily living. Cardiopulmonary resuscitation is a lifesaving measure.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 154 OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 29.A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN). Which situation indicates the nurse needs more instruction on delegation? a. LPN to change a sterile dressing b. NAP to provide skin care c. NAP to insert an indwelling catheter d. LPN to administer an enema

ANS: C The question indicates the nurse made an incorrect delegation assignment. An NAP cannot insert indwelling catheter, an LPN or RN can do that skill. Noninvasive and frequently repetitive interventions such as skin care, ambulation, grooming, and hygiene measures are examples of activities that you assign to NAP such as certified nurse assistants. Licensed practical nurses perform these measures in addition to medication administration and many invasive tasks (e.g., dressing care and catheterization). It is appropriate for an RN to delegate, a sterile file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

dressing change and enema to an LPN. It is appropriate for an RN to delegate skin care to an NAP. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 155 OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 30.A patient has an outcome of ambulating three times a day. The patient does not ambulate the entire day. What should the nurse do next? a.Walk the patient. b.Reassess the patient. c.Change the goal for the patient. d.Continue with the plan for the patient.

ANS: B When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. The plan cannot continue because the goal was not met. The goal cannot be changed and walking the patient cannot occur until reassessment has been completed.

PTS:1DIF:Cognitive Level: Applying (Application) REF:157 OBJ: Describe how to evaluate nursing interventions selected for a patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 31.A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status. What should the nurse do next? a.Modify the care plan. b.Discontinue the care plan. c.Create a nursing diagnosis that states goals have been met. d.Reassess the patients response to care and evaluate interventions.

ANS: B After a nurse determines that expected outcomes and goals have been met and evaluation confirms it, the nurse discontinues that portion of the care plan. The nurse modifies a care plan when goals are not met. Create a nursing diagnosis occurs after assessment, not during evaluation. Reassessing the patient occurs if the goals are not met.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:157OBJescribe each step of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 32.A nurse is evaluating care for a patient. Which action should the nurse take? a.Compares patient findings with the goals and outcomes b.Determines if interventions were completed c.Develops a nursing diagnosis d.Writes a care plan ANS: A file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-09-nursing-process.html[21/04/2019 17:42:19]

During evaluation you compare your findings with the goals and expected outcomes set for your patient. You conduct an evaluation to determine if expected outcomes are met, not if nursing interventions were completed.

Develops a nursing diagnosis is the second step of the nursing process (diagnosis), not the last (evaluation). Writes a care plan occurs in the planning phase.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:156OBJescribe each step of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.The nurse is beginning an assessment of a newly admitted patient. What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.) a.Functional Health Patterns b.Nursing Diagnosis c.Problem-Focused Approach d.Nursing Intervention Classification e.Nursing Outcome Classification ANS: A, C There are two approaches for a comprehensive assessment. Gordons Functional Health Patterns involves use of a structured database format, based upon an accepted theoretical framework or practice standard. Another approach for conducting a comprehensive assessment is the problem-focused approach. The nurse should focus on the patients situation and begin with problematic areas. By using Nursing Intervention Classification nurses learn the common interventions recommended for the various NANDA-I nursing diagnoses. The Nursing Outcome Classification system is a classification system of nursing-sensitive outcomes. One of its purposes is to identify, label, validate, and classify nursing-sensitive patient outcomes. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat and occurs after assessment.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

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Chapter 10: Informatics and Documentation Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality patient care? a.Cost of care per patient day b.Number of registered nurses c.Absence of sentinel events d.Documentation audits ANS: D Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 163 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 2.A registered nurse is caring for an older adult patient with lung cancer. The daughter, who is also a nurse, asks to see the chart. What is the nurses best response? a.Come with me and we will look at it together. b.Im sorry; this information is confidential. c.Let me ask my supervisor if it is okay. d.You should know better than to ask me that.

ANS: B Do not disclose information about patients status to other patients, family members (unless granted by the patient), or health care staff not involved in their care. Looking at it together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. Saying, You should know better than to ask me that is inappropriate and condescending.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:163 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 3.A nursing student is working on a clinical assignment. Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor? a.Patient room number b.Patient date of birth c.Patient medical record number d.Patient nursing diagnosis ]

ANS: D The nursing diagnosis is acceptable information to give to a nursing instructor. To further maintain confidentiality and protect patient privacy, make sure written materials used in student clinical practice do not have patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information.

PTS:1DIF:Cognitive Level: Applying (Application) REF:163 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Planning MSC: NCLEX: Management of Care 4.A nurse is working in an agency with standards that require a nurses documentation to be within the context of the nursing process. The nurse is working for which agency? a.Centers for Disease Control and Prevention accredited hospital b.World Health Organization hospital c.The Joint Commission accredited hospital d.Agency for Healthcare Research and Quality hospital ANS: C The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning.

Other standards include those directed by state and federal regulatory agencies such as HIPAA, as enforced through the Department of Justice, and the Centers for Medicare and Medicaid Services.

PTS:1DIF:Cognitive Level: Applying (Application) REF:164 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 5.Which information indicates the nurse has a correct understanding of the purpose of a patients medical record? a.To invoice the nurse for reimbursement b.To protect the patient in case of a malpractice suit c.To ensure everyone is working toward a common goal of providing safe care d.To contribute to a worldwide databank for trends in health care ANS: C The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care. Documentation can be used for reimbursement but it is not to invoice the nurse, but to invoice patients and/or insurance companies. It protects the clinician in cases of a malpractice suit, not the patient.

It does not contribute to a worldwide databank for trends in health care, but it can be used for medical or nursing research.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 164 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care ]

6.A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patients chart. Which entry is the best way that the nurse should document what happened? a.Patient stated that fell while going to the bathroom. Physician notified. b.Nobody available to answer call bell; patient got up on own and fell. c.Patient fell because of unsafe staffing levels on unit. d.Patient waited as long as possible but nobody there to help and fell.

ANS: A Charting should be factual. Patient stated that fell is the most factual. Do not write retaliatory or critical comments about patient or care by other health care professionals. Statements that are retaliatory or critical can be used as evidence for nonprofessional behavior or poor quality of care. Nobody available to answer call bell, fell because of unsafe staffing levels, or nobody to help are all retaliatory or critical comments and should not be used.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:165 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 7.A registered nurse is documenting patient assessments. Which documentation written by the nurse is most clear? a.Seems comfortable at this time. b. Is asleep, appears not to be experiencing pain. c. Apparently is not in pain because patient didnt rate it high on the scale. d.States pain is a 2 on a 0 to 10 scale.

ANS: D States pain is a 2 is factual. To be factual, avoid words such as appears , seems , or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:166 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 8.A patient states that he or she is experiencing pain in the lower back. What is the best way for the nurse to document this subjective information? a.Seems back is hurting. b.States My lower back hurts. c.Grimaces when moving; I believe patient has lower back pain. d.Appears to be uncomfortable with lower back pain.

ANS: B The only subjective data included in a record are what the patient says. Write subjective information with quotation marks, using the patients own words. For example, a patients statement of My lower back hurts is subjective and acceptable documentation. Seems and appears should be avoided. A factual record contains descriptive, objective ]

information about what you see, hear, feel, and smell, not the nurses opinions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:166 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 9. Which documentation by the nurse best describes patient data?

a.Moderate amount of clear yellow urine voided. b. Voided 220 mL clear yellow urine. c. A small amount of urine voided into absorbent pad. d.Patient incontinent of urine.

ANS: B The use of precise measurements makes documentation more accurate. For example, documenting Voided 450 mL clear urine is more accurate than Voided an adequate amount. Small and moderate are not as accurate as precise measurement. Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:167 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 10. Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?

a.Sm. amt. of emesis. b.150 mL of cloudy dark yellow urine. c.Had a good day. d.Looks bad.

ANS: B 150 mL of cloudy dark yellow urine is the best. The use of precise measurements makes documentation more accurate. To avoid misunderstandings and promote patient safety, write out any abbreviations that are possibly confusing. Avoid using generalized, empty phrases, such as had a good day. Be objective and factual; do not use looks bad because it is vague and too general.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:166 | 167 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 11. Which documentation by the nurse is most appropriate?

a.The patient states would except moving to a semi-private room. ]

b.Developed aspiration pneumonia due to dysphasia. c.Bruise noted on right side over fractured abdimin. d.Right jugular vein distended.

ANS: D Right jugular vein distended is the only entry without spelling errors. Correct spelling demonstrates competency and attention to detail. Misspelled words lead to confusion. For example, often words sound the same but have different meanings such as accept and except or dysphagia and dysphasia. Misspellings and incorrect use of terms alters the intended meaning. Not only is abdomen misspelled, but an abdomen cannot be fractured.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:167 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 12.A nurse is documenting the last entry for the day. It is 3:15 PM and the agency uses military time. Which time should the nurse enter? a.315 b.0315 c.1315 d.1515 ANS: D 3:15 is 1515 in military time (1200 + 315 = 1515). The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. For example, 10:22 AM is 1022 military time; 1:00 PM is 1300 military time.

PTS:1DIF:Cognitive Level: Applying (Application) REF:168 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 13.Which information by a nurse indicates more teaching is needed about The Joint Commissions requirements for writing plans of care? a.A care plan must be developed for patients in a clinic. b.A care plan must be developed for patients in an acute care hospital. c.A care plan must be developed for patients in a rehabilitation agency. d.A care plan must be developed for patients in an extended care facility.

ANS: A The question indicates the nurse needs more teaching and The Joint Commission does not require a care plan for clinic patients. The Joint Commission standards require that a care plan, also called a plan of care, be developed for all patients on admission to acute, subacute, rehabilitation, or extended care agencies.

PTS:1DIF:Cognitive Level: Applying (Application) REF:169 ]

OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 14.A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation. The nurse charts the following: Discuss alternatives for pain control. Which component of SOAP did the nurse chart? a.S b.O c.A d.P ANS: B Discuss alternatives for pain control is a Plan. SOAP is an acronym for the following: S: Subjective data (verbalizations of the patient) O: Objective data (data that are measured and observed) A: Assessment (diagnosis based on the subjective and objective data) P: Plan (what the caregiver plans to do) PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 15.A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE. What will the nurse be charting? a.Problem, intervention, evaluation b.Patient, interview, evaluation c.Population, intervention, encourage d.Plan, interview, enhance ANS: A PIE is an acronym for problem , interventions , evaluation as follows: P: Problem or nursing diagnosis applicable to patient I: Interventions or actions taken E: Evaluation of the outcomes of nursing interventions The PIE format simplifies documentation by unifying the care plan and progress notes into a complete record. PIE does not include patient, population, or plan. It also does not have encourage or enhance.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16.A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with ]

the acronym DAR. What will the nurse be charting? a.Data, assessment, reaction b.Data, assessment, recommendation c.Data, actions, response d.Data, actions, recovery ANS: C Each entry includes data, actions, and patient response (DAR) for the particular patient situation. Focus charting (DAR) is a unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom, a condition, a behavior, or a significant event. There are no reaction, recommendation, recovery, or assessment in DAR. PTS:1DIF:Cognitive Level: Applying (Application) REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 17.A registered nurse recently changed jobs and is now working in home health. What must the nurse chart to obtain reimbursement from Medicare, Medicaid, and private insurance companies? a.Patients response to care b.Whether patient had a good or bad day c.Whether family liked nurse or not d.Patients number of marriages ANS: A When you provide home care, your documentation must specifically address the category of care and your patients response to care. Good or bad day is not factual or objective information. Whether family liked nurse or not and the number of marriages does not affect reimbursement.

PTS:1DIF:Cognitive Level: Applying (Application) REF:172 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 18.The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing, which are determined by an acuity system. The nurse manager notices that the acuity level is high. What should the nurse manager do? a.More staff may be needed. b.Talk to the patients. c.Less staff may be needed. d.Talk to the families.

ANS: A A high acuity means more staff may be needed. An acuity recording system determines the hours of care for a nursing unit and the number of staff required to care for a given group of patients. A low acuity would mean less staff is needed. Talking to the patients or family is not related to the acuity level.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) ]

REF:171OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 19.A nurse began working at a local hospital and learned that the hospital had just instituted a hand-off protocol.

What will the nurse be doing? a.Performing transfer reports b.Completing IV fluid flow sheets c.Using standardized care plans d.Reviewing laboratory reports ANS: A Examples of hand-off reports include change-of-shift reports and transfer reports. A hand-off report occurs any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. Flow sheets are part of the permanent health record and provide a quick and easy reference for assessing changes in a patients status. Standardized care plans, based on institution standards of nursing practice, are preprinted established guidelines of care for patients with similar health problems. The laboratory submits a written report providing the results of diagnostic tests.

PTS:1DIF:Cognitive Level: Applying (Application) REF:172 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 20.A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale. Which component of SBAR did the nurse communicate? a.S b.B c.A d.R ANS: C For assessment (A) data include significant findings in your head-to-toe physical assessment, recent vital signs, current treatment measures, restrictions, recent laboratory results and diagnostics, and pain status. Some institutions use SBAR, an acronym that stands for situation, background, assessment, and recommendation. SBAR standardizes telephone communication of significant events or changes in a patients condition. Therefore it is a communication strategy designed to improve patient safety. When describing the situation (S), you include the admitting and secondary diagnoses and the problem your patient is having as the current issue. Background (B) information includes pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. Provide your recommendation (R), in which you suggest a plan of care and request orders and other needs to be addressed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 174 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 21.A nurse records the following at 1800: patient states that the abdominal pain is worse now than last nightBetty Smith, RN. The nurse is using which type of charting? ]

a. PIE documentation b. SOAP documentation

c.Narrative charting d.Charting by exception ANS: C Narrative charting uses a storylike format to document information specific to patient conditions and nursing care.

PIE charting focuses on problem, intervention, and evaluation. SOAP documentation addresses subjective data, objective data, assessment, and the plan. Charting by exception reduces the time required to complete documentation, using a flow sheet to indicate normal findings or routine interventions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22.A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway. The nurse completes this report for what purpose? a.To exchange information among health care members b.To provide information about patients on one unit to another c.To prevent a legal lawsuit from the patient d.To aid in the hospitals quality improvement program ANS: D Incident reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future reoccurrence. A report is an exchange of information between health care members. Transfer reports involve communication of information about patients from one nurse on the sending unit to the nurse on the receiving unit. Occurrence reports do not prevent lawsuits.

PTS:1DIF:Cognitive Level: Applying (Application) REF:175OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 23.After a nurse receives a medication telephone order for a patient, what is the proper action? a. Withholding the medication until the physician or health care provider signs the order

b.Verifying the physicians or health care providers order with the pharmacy c.Reading it back to the person who gave the order d.Clarifying the new medication order with another registered nurse ANS: C

The nurse receiving a verbal order or telephone order writes down the complete order or enters it into the computer as it is being given. Then the nurse reads it back, called read-back, and receives confirmation from the person who gave the order. The medication will still be given because in most institutions the health care provider has 24 hours to sign the order. Verification is in the read back with the person who ordered the medication, not with pharmacy or another nurse.

PTS:1DIF:Cognitive Level: Applying (Application) REF:175 OBJ: Describe methods for interdisciplinary communication within the health care team. ]

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 24.A nurse is giving a change-of-shift report. Which action should the nurse take? a.Exchange judgments made about the patients attitudes. b. Include a description of how to perform procedures. c.Provide a concise and organized description of the patients normal findings. d.Make walking rounds with the nurse coming on duty to review the patients status and needs.

ANS: D A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Walking rounds allow the nurse to obtain immediate feedback when questions arise about a patients plan of care. Walking rounds are one type of shift report used by health care facilities. Report elements should not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about a patient or family. A description of how to perform procedures is located in a policy and procedure manual.

PTS:1DIF:Cognitive Level: Applying (Application) REF:174 OBJescribe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 25.A nurse is using critical pathways to care for a patient. Which area will the nurse address according to the pathway? a.Activity b.Nursing diagnosis c.Times to chart d.Admission form ANS: A Critical pathways are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning. The case management plan incorporates critical pathways, which standardize practice and improve interdisciplinary coordination. The admission form allows the admitting nurse to make a thorough assessment (e.g., biographical data, physical and psychosocial/cultural assessment, and review of health risk factors) and identify relevant nursing diagnoses or problems for the patients care plan. Nursing diagnoses are used in the nursing process, not with critical pathways. Times to chart are not addressed in the critical pathway.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 26.A nurse is preparing a discharge summary. Which item should the nurse include? a.Provision for follow-up care b.Patient status at admission c.Standardized nursing care plan d.Detailed description of nursing procedures ANS: A ]

A nursing discharge note needs to cover the reason for hospitalization, procedures performed, care, treatment, and services provided, patient status at discharge, information provided to the patient and family, and provisions for follow-up care. Patient status at discharge, not admission, is included. Standardized nursing care plans are based on the institutions standards of nursing practice and are preprinted established guidelines of care for patients with similar health problems. Detailed descriptions of nursing procedures are located in policy and procedure manuals, but not in a discharge summary.

PTS:1DIF:Cognitive Level: Applying (Application) REF:171OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 27.A nurse is teaching the staff about informatics and describing the key concepts. Which information should the nurse include during the teaching session? a.Wisdom b.Charting c.Assessment d.Evaluation ANS: A The concepts are data, information, knowledge, and wisdom. Wisdom answers the why. Charting is documentation.

Assessment and evaluation are included in the nursing process.

PTS:1DIF:Cognitive Level: Applying (Application) REF:176 OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 28.A nurse is using a computer to locate and review laboratory test results, and chart and order sterile supplies.

What type of system is the nurse using? a.Clinical information system b.Computerized provider order entry system c.Administrative information system d.Clinical decision support system ANS: A Clinical information systems can be used by any clinician, including nurses, to plan, implement and evaluate care and can be used for charting, reviewing laboratory test results, and ordering sterile supplies. Administrative information systems comprise databases such as payroll, financial, and quality assurance systems. Computerized provider order entry (CPOE) refers to a process by which the health care provider directly enters orders for patient care into the hospital information system. The clinical decision support system (CDSS) links the nurse to the latest evidence-based practice guidelines at the point of care.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 177 OBJ: Discuss advantages of computerized documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 29.Which action should the nurse take when handling and disposing of patient information? a.Keep patient information to take home for disposal. ]

b.Use programmed speed-dial keys when faxing. c.Throw hand-written notes about the patient in the trash. d.Place fax machines in a public place.

ANS: B Use programmed speed-dial keys when faxing to eliminate the chance of a dialing error and misdirected information. Place fax machines in a secure area, not a public area. Patient information must be shredded, and taking patient information home or throwing in the trash is breaking confidentiality.

PTS:1DIF:Cognitive Level: Applying (Application) REF:179-180 OBJ: Discuss advantages and disadvantages of standardized documentation forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation?

(Select all that apply.)

a.To aid in clinical research b.To maintain a legal and financial record of care c.To include a step-by-step description of how to perform procedures d.To evaluate quality process and performance improvement e.To communicate patient needs and progress toward meeting outcomes ANS: A, B, D, E Documentation serves multiple purposes, including communication, legal documentation, reimbursement, education, research, and quality process and performance improvement. Step-by-step description of how to perform procedures is in a policy and procedure manual, not a chart.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 164 | 166 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 2. Which benchmarks will indicate to the nurse that the agency has computerized information systems that

demonstrate meaningful use? (Select all that apply.) a. Improves quality and safety b. Improves patient compliance c. Improves care coordination d. Improves public health e. Improves hospitals reputation

ANS: A, C, D Meaningful use refers to the level with which information technology is available and used to support clinical decision making to improve quality, safety, and efficiency; reduce health disparities; engage patients and families in their health care; improve care coordination; improve population and public health; and maintain privacy and security. Patient compliance and hospitals reputation are not benchmarks for the mandates from the Patient Protection and Affordable Care Act. PTS:1DIF:Cognitive Level: Applying (Application) ]

REF:168-169 OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 3. Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that

apply.)

a.Never share passwords with co-workers. b.Only the supervisor should have the nurses password and it should be stored in a protected place. c.Leave the computer terminal unattended when logged on. d.Avoid leaving patient information displayed on a computer where others can see it. e.Keep the same password for as long as the nurse works at the agency.

ANS: A, D To protect patient confidential data the nurse should never share passwords and should change them as directed.

Avoid leaving patient information displayed on a computer where others can see it. Avoid leaving the computer terminal unattended when logged on. A good system requires frequent changes in personal passwords to prevent unauthorized persons from accessing and tampering with records.

PTS:1DIF:Cognitive Level: Applying (Application) REF:169 OBJ: Discuss advantages and disadvantages of standardized documentation forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

]

Chapter 11: Communication Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse who works for an oncology unit is preparing to bathe a patient who recently underwent surgery to remove an abdominal tumor. Before beginning the bath, the nurse explains the procedure. Which of the following best describes the nurses communication role? a.Channel b.Receiver c.Message d.Sender ANS: D The nurse is the sender in this scenario. The sender is the person who delivers the message. The roles of sender and receiver change back and forth as two persons interact. The message is sent to a receiver, in this case the patient.

The message is the content of the conversation; in this scenario explaining what will happen is the message. The channel is the means of conveying and receiving messages through visual, auditory, and tactile senses, the nurses spoken words in this scenario.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 185 OBJ: Describe the elements of the communication process.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 2.A patient is being cared for by a nurse. The patient has questions regarding what time the surgery is scheduled.

When the nurse responds to the question, the nurse is assuming which communication role? a.Channel b.Receiver c.Message d.Sender ANS: D The nurse is the sender in this scenario because the nurse responds by speaking and sending a message, rather than just receiving the message. The sender is the person who delivers the message. The roles of sender and receiver change back and forth as two persons interact. The message is sent to a receiver, in this case the patient. The message is the content of the conversation; in this scenario the time of the surgery is the message. The channel is the means of conveying and receiving messages through visual, auditory, and tactile senses, the nurses spoken words in this scenario.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 185 OBJ: Describe the elements of the communication process.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 3.A registered nurse is a new nurse manager who needs to council an employee regarding attendance. Because the nurse manager is new to the position, the nurse is rehearsing what is planning to say to the employee before the meeting. The nurse is using which form of communication? a.Interpersonal b.Intrapersonal c.Public file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

d.Private ANS: B Intrapersonal communication, also called self-talk, is a powerful form of communication that occurs within an individual. People talk to themselves by forming thoughts internally that strongly influence perceptions, feelings, behavior, self-concept, and performance. Self-talk is a mental rehearsal for difficult tasks or situations so that individuals deal with them more effectively. Interpersonal communication is interaction that occurs between two people or within a small group. When the nurse actually talks to the employee, it is called interpersonal communication. Public communication is the interaction of one individual with large groups of people. Private is not a level of communication.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:186 OBJescribe the levels of communication and their uses in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 4.A nurse is working in a busy emergency department of an urban hospital. The family of a patient brought in by ambulance asks the nurse what the doctor meant when he or she said that the patient was coding . In this situation, the word coding is an example of which of the following? a.Denotative meaning b.Connotative meaning c.Intonation d.Pacing ANS: A Coding in this instance is a denotative meaning. A single word sometimes has several meanings. Individuals who use a common language share the denotative meaning of a word. The word baseball has the same meaning for all individuals who speak English, but the word code denotes cardiac arrest primarily to health care providers. The connotative meaning is the shade or interpretation of the meaning of a word, which is influenced by the thoughts, feelings, or ideas that people have about the word. Tone of voice and volume dramatically affect the meaning of a message, and emotions directly influence tone of voice, which is intonation. Pacing can involve talking rapidly, using awkward pauses, or speaking extremely slowly and deliberately, conveying different meanings.

PTS:1DIF:Cognitive Level: Applying (Application) REF:186 OBJescribe the levels of communication and their uses in nursing.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5.A patient asked a nurse when the primary health care provider would make rounds. The nurse was taking another patient for a stat test and replied very quickly, I have no idea. The patient most likely interpreted the nurse as uncaring because of which factor? a. Vocabulary

b.Pacing c.Timing d.Personal appearance ANS: B Because the nurse replied very quickly it is pacing. Talking rapidly, using awkward pauses, or speaking extremely file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

slowly and deliberately conveys an unintended message. Vocabulary is the senders words and phrases. I have no idea is vocabulary that is understandable. Timing is critical in communication. The nurse used timing appropriately by answering the patients question. Personal appearance is not an issue in this scenario.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 186 OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 6.A 9-year-old patient who is hospitalized for bowel surgery appears very frightened. To appear less threatening to the child, which action should the nurse take? a.Stand over the bed when talking to the patient. b. Sit in a chair next to the bed when talking to the patient. c.Maintain constant eye contact with the patient at all times. d.Stay within 12 inches of the patient when talking to the patient.

ANS: B The nurse should sit in a chair next to the bed. A nurse appears less dominant and less threatening when interacting at the patients eye level. Looking down on a person (standing by the bed) establishes authority, but interacting at the same eye level indicates equality in the relationship. Constant eye contact can be intrusive or threatening to some people. Twelve inches is within the intimate zone and can be threatening.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 188 OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7.A nurse went into a patients room at 0900, shortly after the patient was told that he or she had liver cancer. The patient asked the nurse to stay because he or she did not want to be alone. The nurse stood very close to the patient, held the patients hand, and told the patient that he or she had plenty of time. A few minutes later, the nurse thought to check the time on the wristwatch because the nurse was supposed to take another patient for a test at 0945. The patient saw the nurse look at the wrist watch and told the nurse it was now okay to be alone. What was the most likely reason the patient said it was okay for the nurse to leave? a. Invasion of personal space b. Verbal communication

c.Nurses gesture d.Intonation ANS: C

The nurses gesture of looking at the wrist watch most likely caused the request. Gestures alone carry specific meanings, or they may create messages with other communication cues. There was no invasion of personal space because the patient allowed the nurse to sit very close and hold hands. There was no inappropriate verbal communication (words or phrases), nor was there any inappropriate intonation (tone of voice).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 188 OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 8.A registered nurse is caring for a postoperative patient who is experiencing respiratory distress after the administration of pain medication. The nurse called the patients primary health care provider immediately. The information regarding the patient was conveyed using the SBAR format. Which information did the nurse convey file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

to the primary health care provider? a.Situation, background, assessment, recommendation b.STAT, background, assessment, requirement c.Status, background, analysis, recommendation d.Setting, belief, assessment, requirement ANS: A SBAR stands for situation, background, assessment, and recommendation. Use of common language when communicating critical information helps prevent misunderstandings. SBAR has become a best practice for standardizing communication between health care providers. SBAR does not contain STAT, status, setting, analysis, belief, or requirement.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 190 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 9.Which behavior by the nurse would be considered most professional? a.Addressing a patient by dear b.Wearing small earrings c.Being task oriented d.Avoiding troublesome patients ANS: B Wearing small earrings is the most professional. The patients acceptance of a nurse as a professional often depends on the manner in which he or she presents a professional and caring image. Verbal and nonverbal behaviors influence the helping relationship. Professional appearance, demeanor, and behavior are important in establishing trustworthiness and competence. Calling a patient honey, dear, grandpa, or sweetheart rather than by a personal name is inappropriate. Being task oriented, or making a technical procedure (e.g., administration of a medicine) your priority, is another way of not being emotionally available. Do not avoid patients whose behavior is troublesome.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:192 OBJ: Identify features and expected outcomes of the nurse-patient relationship.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10.When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient? a.Using a cultural joke to break the ice b.Stereotyping the patient within his or her culture c.Considering the context of the patients background d.Assuming the patient or the family member speaks English ANS: C When a patient is from another culture, the nurse should consider the context of the patients background. Accept patients rights to adhere to cultural customs and norms. Persons of different cultures use different types of verbal and nonverbal cues to convey meaning. A nurse should make a conscious effort not to interpret messages through his or her own cultural perspective; instead, a nurse considers the context of the other individuals background. file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

Avoid stereotyping persons from other cultures or making jokes about them. With patients from another culture, the nurse cannot assume the patient or family members can speak English.

PTS:1DIF:Cognitive Level: Applying (Application) REF:194 OBJ: Explain the focus of communication within each phase of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 11.A patient had a stroke that left the patient aphasic. A nurse is working on a plan of care. Which nursing diagnosis should the nurse use to describe the patients aphasia? a. Impaired Verbal Communication b. Anxiety c. Impaired Social Interaction d. Ineffective Coping

ANS: A Impaired Verbal Communication is the nursing diagnostic label to describe a patient who has limited or no ability to communicate verbally. This diagnosis is useful for a wide variety of patients with special problems and needs related to communication. It is defined as difficulty or inability to use or understand language in interpersonal reactions. Anxiety is not the same thing as aphasia. Although impaired social interactions could be used, based upon the question (diagnosis for patients aphasia), impaired verbal communication is most appropriate. There are no data in the scenario to say the patient is not interacting with others. There are no data to support ineffective coping; it just says the patient is aphasic but no data address coping.

PTS:1DIF:Cognitive Level: Applying (Application) REF:195 OBJ: Explain the focus of communication within each phase of the nursing process.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 12.A patient is aphasic from a recent stroke. The nurse is taking a multidisciplinary approach to this patients care.

Who would be most appropriate for the nurse to collaborate with regarding the patients aphasia? a. Interpreter b.Speech therapist c.Physical therapist d.Mental health nurse specialist

ANS: B Speech therapists help patients with aphasia. The nurse should collaborate with other health care providers who have expertise in communication strategies. Interpreters are invaluable when a patient speaks a foreign language.

Mental health advanced practice nurses help in communicating with angry or highly anxious patients. Physical therapist would help with mobility issues.

PTS:1DIF:Cognitive Level: Applying (Application) REF:195 OBJ: Explain the focus of communication within each phase of the nursing process.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

13.A nurse is spending time with a patient, who has recently been diagnosed with breast cancer. The patient states that he or she is frightened about the diagnosis and feels overwhelmed. The nurse responds, It sounds to me like you are feeling very scared right now. Which communication technique did the nurse use? a.Sympathy b.Empathy c.Focusing d.Self-disclosure ANS: B Empathy is the ability to understand and accept another persons perspective. Although no one can ever totally know anothers experiences, a nurse can try to understand what the person is experiencing. Focusing directs conversation to a specific topic or issue when a discussion becomes unclear. Self-disclosures are personal statements intentionally revealed to the other person. Sympathy is the concern, sorrow, or pity that you feel for a patient when you personally identify with his or her needs. Unlike empathy, which tries to understand a patients experience, sympathy takes a subjective look at the patients world (Oh, I know just what you mean. I hate feeling that way.).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 195 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14.A patient has just been admitted to the hospital with a broken hip from a fall in the home. The nurse admitting the patient is practicing active listening. Which behavior best conveys to the patient that the nurse is using active listening? a.Keeping arms crossed b.Sitting facing the patient c.Standing facing the patient d.Leaning away from the patient ANS: B The best behavior is sitting facing the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient. Several nonverbal skills facilitate attentive listening, which are identified by the acronym SOLER: S it facing the patient.

O bserve an open posture.

L ean toward the patient.

E stablish and maintain eye contact.

R elax.

Keeping arms crossed is a closed posture. Leaning toward, not away, from the patient is active listening. Sitting, not standing, is best.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 196 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15.A nurse is caring for a patient who is having abdominal pain and is experiencing difficulty sleeping. The nurse file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

sits at the bedside of the patient and takes the patients hand. The patient quickly pulls back. How should the nurse

file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

interpret this patients behavior? a.The patient is uncomfortable with being touched. b.The patient is unable to express feelings. c.The patient has impaired social skills with others. d.The patient has difficulty with nonverbal communication.

ANS: A Nurses need to remain sensitive to his or her responses as well as the patients feelings. If a patient refuses to hold a nurses hand while in pain or pulls away from physical contact, this signals that the patient is uncomfortable with being touched by the nurse. It does not imply impaired social skills, inability to express feelings, or difficulty with nonverbal communication.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 199 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 16.A nurse is assisting in the admission of a patient to the orthopedic unit of the hospital and is obtaining information for the database. Which technique is the best way for the nurse to obtain information from the patient? a.Ask personal questions so as to show interest. b.Use medical vocabulary to appear competent. c.Ask why the patient waited so long to get treatment. d.Use silence while the patient collects his or her thoughts.

ANS: D Most people have a natural tendency to fill empty spaces with words, but sometimes silence is useful when they face decisions that require much thought. Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses or behaviors in others. Asking irrelevant personal questions simply to satisfy your curiosity is inappropriate and invasive and nontherapeutic. Limit questions to health-related information. Health care professionals have their own culture and language. Using technical words in discussions with patients can cause confusion and anxiety. Avoid excessive use of such terms or translate them into lay terms.

Sometimes asking why implies an accusation and results in resentment, insecurity, and mistrust.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 196 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 17.A nurse gives a hand-off report to the oncoming staff nurse. Which type of communication does this illustrate? a.Gossip b.Validation c.Interpersonal d.Intrapersonal ANS: C Interpersonal communication is interaction that occurs between two people or within a small group. Gossiping violates confidentiality. The act of validation requires comparing data with another source. Intrapersonal communication occurs within the individual, consisting of self-talk, self-verbalization, or inner thoughts.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

REF:186 OBJescribe the levels of communication and their uses in nursing.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 18.A nurse is caring for a patient who is visually impaired. Which technique should the nurse use to facilitate communication? a.Touch the patient before speaking. b.Identify self when entering the room. c.Quietly leave the room when finished. d.Keep the room dimly lit for calmness.

ANS: B For a visually impaired patient, identify yourself when entering the room. The nurse should communicate verbally before touching the patient who is visually impaired. Notify the patient when leaving the room; do not quietly leave the room when finished as the patient will think you are still in the room. Ensure that lighting is adequate for the patient to see the speaker; do not keep it dimly lit.

PTS:1DIF:Cognitive Level: Applying (Application) REF:200 OBJ: Explain techniques used to assist patients with special communication needs.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19.A nurse is caring for a patient who cannot speak clearly. Which technique should the nurse use to enhance conversation with this patient? a.Speak loudly. b. Finish the patients sentences. c. Ask question that require yes or no answers. d. Avoid communication aids to prevent embarrassment.

ANS: C For patients who are mute, unable to speak, or cannot speak clearly, ask simple questions that require yes or no answers. Use normal volume and do not shout or speak too loudly. Do not finish the patients sentences. Use communication aids as needed; do not avoid them.

PTS:1DIF:Cognitive Level: Applying (Application) REF:200 OBJ: Explain techniques used to assist patients with special communication needs.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 20.A nurse forms a contract with the patient to specify roles during a therapeutic helping relationship. The nurse is in which phase of the therapeutic relationship? a.Working b.Termination c.Pre-interaction d.Orientation ANS: D file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

During the orientation phase when you and the patient meet and get to know one another is the time when the contract is formed. During the working phase the nurse and patient work together to solve problems and accomplish goals. During the termination phase the helping relationship is ended. In the pre-interaction stage the nurse gathers information from various sources about the patient.

PTS:1DIF:Cognitive Level: Applying (Application) REF:190 OBJescribe a nurses focus within each phase of a therapeutic nurse-patient relationship.TOP:Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 21.A nurse enters a patients room and sees the patient grimacing with each movement. When the nurse asks in a normal tone of voice how the patient is feeling, the patient states that he or she feels fine. Which finding will the nurse classify as nonverbal communication? a.The nurses tone of voice is normal. b.The patient states that he or she feels fine. c.The nurse asks how the patient is feeling. d.The patient grimaces with each movement.

ANS: D The patient grimacing with each movement is nonverbal communication. Nonverbal communication includes messages sent through the language of the body, without the use of words. Nonverbal forms of communication include use of facial expressions, eyes, gestures, posture, and physical appearance. Nonverbal communication often reveals physical feelings. Tone of voice, asking questions, and saying that he or she feels fine are examples of verbal communication. Verbal communication involves the use of words or phrases and includes intonation, pacing, denotative and connotative meanings, volume, clarity, brevity, timing and relevance.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 187 OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 22. While a patent is being interviewed by the nurse, a family member states, What my father really means is that he doesnt know for sure what the physician meant about the medical diagnosis. Which communication technique did the family member use?

a.Focusing b.Clarifying c.Summarizing d.Sharing observations ANS: B The family members statement is clarifying. Clarifying validates whether the person interpreted the message correctly. Focusing directs conversation to a specific topic or issues when a discussion becomes unclear.

Summarizing provides a concise review of main ideas. Sharing observations is commenting on a patients appearance and how he or she sounds and acts such as, I see you didnt eat any breakfast.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 196 OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

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23. Which technique should the nurse use when providing information to a patient with a health literacy level of fifth grade?

a.Use the passive voice of language. b.Present the most important information first. c.Shift from subject to subject until the patient responds. d.Explain using jargon so the patient will understand others on the health care team.

ANS: B To promote understanding in a patient with a health literacy level of fifth grade is to present the most important information first. Use the active voice instead of passive. Break complex information into understandable chunks; do not shift from subject to subject. Use simple language, avoid medical jargon.

PTS:1DIF:Cognitive Level: Applying (Application) REF:189 OBJ: Discuss the principles of plain language for promoting health literacy.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 24. Which technique by the nurse will facilitate communication with an older adult?

a.Have the TV play lightly in the background. b.Ask several questions in a row. c.Allow reminiscing. d.Use long sentences.

ANS: C Allow older adults the opportunity to reminisce. Reminiscing has therapeutic properties that increase the sense of well-being. During conversation maintain a quiet environment that is free from background noise (turn off the TV).

Allow time for conversation; do not ask several questions in a row. Avoid long sentences to explain the subject.

Try to keep it short, simple, and to the point.

PTS:1DIF:Cognitive Level: Applying (Application) REF:201 OBJ: Discuss effective communication for patients of varying developmental levels.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1.A nurse has just admitted a 5-year-old child for suspected appendicitis. Which therapeutic communication techniques should the nurse use while communicating with this child? (Select all that apply.) a.Avoid sudden movements or gestures. b.Use simple, direct language. c.Sit at the childs eye level. d.Tell the child exactly what can do. e.Use drawing or toys as needed.

ANS: A, B, C, E Sudden movements or gestures can be frightening so they need to be avoided. When giving explanations or directions, use simple, direct language and be honest. Meet a child at eye level. Drawing and playing with young file:///D|/...bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-11-communication.html[21/04/2019 17:42:17]

children allows them to communicate nonverbally (making the drawing) and verbally (explaining the picture).

Telling the child exactly what can do is inappropriate. Remain calm and gentle and, if possible, let a child make the first move.

PTS:1DIF:Cognitive Level: Applying (Application) REF:201 OBJ: Discuss effective communication for patients of varying developmental levels.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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Chapter 12: Patient Education Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse has been asked to prepare patient education for Spanish-speaking patients regarding diabetes. This information will be available to patients in the diabetes clinic. What is the primary goal for this patient education? a.To reduce the legal liability of the clinic b.To teach Spanish-speaking patients some English c.To assist Spanish-speaking patients to reach optimal health d.To provide information so they can make a decision between oral and injectable medications ANS: C The goal of patient education is to assist individuals, families, communities, or populations in achieving optimal levels of health, safety, and independence. The goal of patient education is not to reduce the legal liability, teach English, or make decisions about the different types of medications.

PTS:1DIF:Cognitive Level: Applying (Application) REF:203OBJ:Identify the purposes of patient education.

TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2.A patient with newly diagnosed diabetes is being discharged from the hospital. The patient will be going to an outpatient diabetic center to learn more about diet, exercise, disease management, and insulin administration.

Which statement made by the patient indicates that effective teaching can take place? a.I dont want to get sick again so I will do what is needed. b.I am so happy to be going home so I dont have to eat hospital food anymore. c.I will be glad when they find a cure for diabetes. d.I dont think I will need to take insulin for very long because I already feel better.

ANS: A Generally teaching and learning begin when a person identifies a need for knowing or acquiring an ability to do something. Focusing on hospital food, finding a cure, and not taking medications because feeling better indicate the patient is not motivated to learn at this time.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:204 OBJifferentiate factors that determine readiness to learn from those that determine ability to learn.TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 3. The parents of a 3-month-old infant are preparing to take their child home from the hospital. Before being

discharged, the parents must be educated on infant CPR. What is the most appropriate learning objective for this situation? a.The parents will be able to understand CPR skills. b.The parents will demonstrate infant CPR skills. c.The infant will not require further hospitalization. file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

d.The parents will call the hospital for help.

ANS: B A learning objective describes what the patient or guardian(s) will be able to do after successful instruction. The objective contains an active verb describing what the learner will do after the objective is met (demonstrate).

Understand does not specify the behavior or content to be learned and is not an active verb. The learning objectives should focus on the parents as they are the learners; it should not focus on the infant. The parents should call the hospital for help but this does not relate to the skill being taught, CPR. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:204-205 | 213 OBJ:Compare the nursing and teaching processes. Write learning objectives for a teaching plan.TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. Which finding will best indicate to the nurse that the teaching about a dressing change was successful?

a.The patient understands how to change an abdominal dressing. b.The patient acknowledges the principles of an abdominal dressing change. c.The patient correctly demonstrates an abdominal dressing change as taught. d.The patient states, Yes, I know how to change the dressing.

ANS: C Demonstration is the best method to evaluate a psychomotor skill. Examples of evaluating the effectiveness of teaching include having patients show how to perform a newly learned skill (e.g., self-catheterization) or asking patients to explain how they will incorporate newly ordered medications into their daily routines. Evaluating the effectiveness of teaching for a psychomotor skill includes a demonstration, not understanding or acknowledging.

Just stating, Yes does not indicate learning like a demonstration does.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:204OBJ:Identify methods for evaluating learning.

TOP: Nursing Process: Evaluation MSC: NCLEX: Basic Care and Comfort 5.A patient recently had a stroke and suffered right-sided weakness. The patient is being discharged from a rehabilitation hospital after learning to use a walker. Which learning domain was primarily used to teach the patient to be independent with the walker? a.Psychomotor b.Affective c.Cognitive d.Motivational ANS: A Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Examples of psychomotor learning include learning to walk with a walker or giving an insulin injection.

Affective learning includes the patients feelings, attitudes, opinions, and values. Cognitive learning includes what the patient knows and understands. All intellectual behaviors are in the cognitive domain. Motivation is an internal impulse, such as an emotion or need, which prompts, guides, and sustains human behavior.

PTS:1DIF:Cognitive Level: Applying (Application)

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REF:206OBJescribe the domains of learning.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 6.Which patient is the most likely to be motivated to learn? a.A 23-year-old smoker being taught about weight control b.A 45-year-old man being taught about importance of prostate cancer screening c.A 63-year-old knee replacement patient being taught postsurgical knee rehabilitation d.A 15-year-old girl being taught about safe sex ANS: C Motivation to learn is often dependent on the patients situation, needs, previous knowledge, attitudes, and sociocultural factors. For example, patients who need knowledge for survival or to return to a previous level of functioning (knee replacement for knee rehabilitation) have a stronger motivation to learn than patients who need knowledge for promoting health. Weight control, prostate cancer screening, and safe sex are all related to promoting health rather than survival or returning to a previous level of functioning.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:206 OBJifferentiate factors that determine readiness to learn from those that determine ability to learn.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7.A postsurgical patient is being taught about wound care before being discharged from the hospital and is in a semiprivate room with another patient. The other patient is upset with a family member and is crying. The television is on to try to provide some distraction from the roommate. Which action should the nurse take to best facilitate patient education for wound care? a.Explain to the patient that everything is in the handout. b.Take the patient to a quiet area to do the patient teaching. c.Ask the roommate to please be considerate of the patient because patient education is occurring. d.Request that a home health nurse follow up with the patient at home to teach about wound care.

ANS: B A quiet area is needed for learning. Before learning anything, patients must be able to pay attention to or concentrate on the information they will learn. Physical discomfort, anxiety, and environmental distractions make it more difficult for a patient to concentrate. It is not appropriate to refer the patient to a handout. Asking the roommate to be considerate is inappropriate because the roommate is distraught. Home health nursing is not needed at this time.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:206 | 209 OBJ: Describe the characteristics of an environment that promotes learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8.A nurse will be teaching a prepared childbirth class for the first time at a neighborhood church. The nurse has gone to the church to determine which room would be best suited to teach a group of six couples. Which room configurations would be most appropriate for teaching this group? a.A small carpeted room with no furniture file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

b.A large auditorium with a stage and theater-style seating c.A lunchroom with stationary tables and chairs d.A Sunday-school classroom with tables and chairs ANS: D A Sunday-school classroom allows everyone to be seated comfortably and within hearing distance of the teacher and, the room can comfortably hold all members of the group. Arranging the group to allow participants to observe one another (e.g., in a circle) further enhances learning. A small carpeted room would not allow much room for six couples. A large auditorium is too big. Stationary tables and chairs do not allow for rearranging if needed, and a lunchroom is usually too big.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:209 OBJ: Describe the characteristics of an environment that promotes learning.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9.A patient who is a migrant farm worker did not graduate from high school and speaks English as a second language. The nurse will be providing discharge teaching after a hysterectomy. The nurse is concerned about the patients ability to understand the discharge instructions. Which of the following should be of most concern in this situation? a.Motivation b.Developmental stage c.Health literacy d.Psychomotor learning ANS: C Health literacy includes patients reading and math skills, comprehension, the ability to make health-related decisions, and successful functioning as a consumer of health care. It is a strong predictor of health status and patient outcomes. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Developmental stage is not as important as health literacy and developmental stage is more important when teaching children. Motivation is an internal impulse, such as an emotion or need, which prompts, guides, and sustains human behavior.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:211 OBJ: Discuss ways to adapt teaching approaches for patients with low health literacy.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10.A patient was recently diagnosed with heart failure. The health care provider has ordered a low-sodium diet. A nurse is planning patient education for diet instruction. Which information should the nurse present first? a.How much daily intake of sodium is recommended b.How to read food labels at the grocery store c.How to understand the metric system of measurement d.How to cook different meals with low-sodium foods

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ANS: A Present the daily intake of sodium first because material should progress from simple to complex because a person learns simple facts and concepts before learning how to make associations or complex interpretations of ideas.

How to read food labels, the metric system, and how to cook different meals are more complex than the daily intake of sodium.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 215 OBJ: Identify the principles of effective teaching and learning.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 11.A nurse who works in a diabetes clinic has been asked to help a 12-year-old male patient learn to give his own insulin injections. The nurse demonstrates the technique on a teaching manikin and then asks the patient to demonstrate the task on the manikin while providing assistance. Which teaching approach did the nurse use? a.Entrusting b.Telling c.Participating d.Reinforcing ANS: A The entrusting approach provides the patient the opportunity to manage self-care. The patient accepts responsibilities and correctly performs the task while a nurse observes the patients progress and remains available for assistance. Telling involves explicit instructions with no feedback. Participating involves mutual goal setting with the patient helping decide the content. Reinforcing is using a stimulus that increases the probability of a response.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:217 OBJ: Describe ways to adapt teaching for patients with different learning needs.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 12.A pediatric nurse who works evenings on a surgical floor in a childrens hospital has been working with a 5year-old patient who has undergone abdominal surgery. The nurse gives the patient a sticker each time the incentive spirometer is used. What type of reinforcement did the nurse use? a.Social b.Material c.Activity d.Negative ANS: B Examples of material reinforcers are food, toys, and music. These work best with young children. Use social reinforcers (e.g., smiles, compliments, words of encouragement, or physical contact) to acknowledge a learned behavior. Activity reinforcers (e.g., physical therapy) rely on the principle that a person is motivated to engage in an activity if there is an opportunity to participate in more desirable activity upon completion of this first activity.

Negative reinforcement (frowning) may work but people usually respond better to positive reinforcement. file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

PTS:1DIF:Cognitive Level: Applying (Application) REF: 217 OBJ: Identify the principles of effective teaching and learning.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 13.A nurse is preparing to take a 5-year-old childs blood pressure. What is the best way for the nurse to reduce the childs anxiety about this procedure? a.Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient. b.Explain to the patient that the blood pressure is a vital sign that the doctor has ordered. c.Tell the child that the blood pressure cuff will hug the arm. d.Ask the childs mother to step outside the room because children frequently do better when alone.

ANS: C Describe physical sensations that will occur during the procedure by telling the child that the cuff will hug the arm.

Providing information about procedures helps patients feel less anxious because they understand what to expect during the procedure. When preparatory instructions accurately describe the actual experience, the patient is able to cope more effectively with the stress from procedures and therapies. Doing nothing does not prepare the patient properly or address the anxiety. A 5 year old will not understand the term vital signs . Involve the parents with young children.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:212 | 217 OBJescribe ways to incorporate teaching with routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14.An 8-year-old boy has been diagnosed with diabetes. A nurse is teaching his mother how to plan meals that are appropriate for him. The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her. What type of teaching method did the nurse use? a.Simulation b.Role-play c.Analogy d.Demonstration ANS: A Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion, the nurse presents a problem or situation pertaining to the patients learning for patients to solve. During role-play, your patients play themselves or someone else in the situation. Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable.

Demonstrations are useful methods for teaching psychomotor skills.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 219 OBJ: Identify the principles of effective teaching and learning.

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15.A nurse is discharging a patient who required teaching about how to change a foot dressing. The nurse wants to ensure that the patient understands the signs and symptoms of infection and is preparing written materials the patient can take home and refer to as needed. Because the nurse does not know the patients reading ability, at which grade level should the nurse prepare the written materials? a.Fifth b.Sixth c.Eighth d.Ninth ANS: A Individualize teaching materials to meet the patients needs and match the patients reading level; if a nurse does not know the patients reading level, information should be provided at a fifth-grade or lower level. Sixth-, eighth-, and ninth-grade levels are too high.

PTS:1DIF:Cognitive Level: Applying (Application) REF:219 OBJ: Describe ways to adapt teaching for patients with different learning needs.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 16.A 75-year-old patient who is being discharged home after a stroke has no use of the right hand. Which teaching strategy is best for the nurse to use for this patient? a.Provide all the teaching at once, immediately before going home so the patient will remember it. b.Teach the patient with the aid of a computer to demonstrate that the discharge instructions are on the hospital webpage. c.Teach the patient using generic patient discharge information about strokes. d.Provide information based on the patients needs in frequent sessions.

ANS: D Effective teaching strategies for the older adult include providing individualized information that is based on what the patient needs to know and presenting information slowly in frequent sessions. Allow more time for older learners to demonstrate learning. Do not provide the teaching all at once; use frequent sessions. Because the patient has no use of the right hand, navigating the computer could be cumbersome. The older adult needs individualized, not generic, information.

PTS:1DIF:Cognitive Level: Applying (Application) REF:218 OBJ: Describe ways to adapt teaching for patients with different learning needs.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 17.A nurse needs to begin teaching about crutch walking with a 14-year-old patient. Which action should the nurse take first? a.Motivate the patient to comply with the use of crutches. b.Prevent diseases and learn good health promotion activities for crutch walking. c.Allow the entire health care team to give the patient a variety of strategies for crutch walking. file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

d.Determine the patients level of knowledge and perception of the learning needed for crutch walking.

ANS: D Determining a patients level of knowledge is the first step. Assess the patients level of knowledge, intellectual skills, and literacy level before beginning a teaching plan. The first step is not to motivate a patient. A patients motivation to learn is an important factor; however, a patients motivation helps to determine if the patient is prepared and willing to learn, not what needs to be taught. Health education is not focused on disease prevention as a primary goal, but on assisting patients to achieve optimal levels of health. Although the entire health care team may be involved with patient education, the educator must select the appropriate teaching strategy for the patients ability to learn.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 207 OBJ: Use the nursing process to make a teaching plan of care.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 18.A patient needs to take daily injections of a blood thinner for 7 days after hospital discharge. The nurse observes the patients self-administration technique. What type of learning occurred? a.Affective b.Cognitive c.Motivational d.Psychomotor ANS: D Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Affective learning includes the patients feelings, attitudes, opinions, and values. Cognitive learning includes what the patient knows and understands. All intellectual behaviors are in the cognitive domain. A patients motivation to learn is an important factor; however, it is not a type of learning; it helps to determine if the patient is prepared and willing to learn.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:206OBJescribe the domains of learning.

TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 19.A nurse is preparing to teach a patient about ostomy care. The patient appears anxious and is crying. What should the nurse do? a.Let the patient know it is time to learn about ostomy care. b.Postpone the teaching session about ostomy care. c.Show a video about ostomy care. d.Implement role-play.

ANS: B Any condition (e.g., fatigue, breathing difficulty, or depression) that drains a persons energy impairs the ability to learn. Postpone teaching when an illness becomes aggravated by complications such as pain, fever, or respiratory difficulty. Letting the patient know it is time to learn, implementing role-play, and showing a video will not enhance learning. The crying needs to be addressed first. file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

PTS:1DIF:Cognitive Level: Applying (Application) REF:209 OBJ: Describe the characteristics of an environment that promotes learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20.Which behavior by a new nurse will cause the nurse manager to intervene? a.Initiates teaching of a patient b.Uses discovery learning techniques with a patient c.Assigns nursing assistive personnel to teach a patient d.Implements the teach-back method to evaluate patient understanding ANS: C In most situations it is not appropriate to delegate educational interventions to nursing assistive personnel (NAP); therefore the nurse manager would have to intervene. Nurses should initiate teaching; that is a component of the nurses role. Discovery is a useful technique for teaching problem-solving application and independent thinking.

Regardless of the method used to teach, use the teach-back method to evaluate the patients understanding of the material.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 215 OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 21.A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. Which technique did the nurse use? a.Analogy b.Discovery c.Role-playing d.Demonstration ANS: A Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Discovery is a useful tool for teaching problem solving and is a technique for cognitive learning.

During role-play your patients play themselves or someone else in the situation. Demonstrations are useful when teaching psychomotor skills.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 218 OBJ: Identify the principles of effective teaching and learning.

TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1.A patient must learn to apply a lower leg orthotic device but has a minor paralysis of the right upper extremity.

Before teaching this skill, the nurse must assess the patients physical capabilities. Which areas will the nurse assess? (Select all that apply.) a.Size b.Strength file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

c.Coordination d.Sensory acuity e.Learning environment ANS: A, B, C, D The nurse is assessing physical capability, which includes size, strength, coordination, and sensory acuity. Size refers to height and weight. Strength refers to the patients ability to follow a regimen. Coordination refers to dexterity needed. Sensory acuity includes visual, auditory, tactile, gustatory, and olfactory sense. Although the learning environment should be assessed, it is not a component of a patients physical capabilities.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 209 OBJ: Use the nursing process to make a teaching plan of care.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2.The nurse must teach grieving patients about future skills and knowledge. Which patients will most likely be ready to learn? (Select all that apply.) a.A patient in denial b.A patient in anger c.A patient in bargaining d.A patient in resolution e.A patient in acceptance ANS: D, E Patients in resolution and acceptance are ready to learn about future skills and knowledge. Patients in denial, anger, and bargaining should only be taught in the present tense (explain current therapy); they are not ready to accept future learning.

PTS:1DIF:Cognitive Level: Applying (Application) REF:208 OBJifferentiate factors that determine readiness to learn from those that determine ability to learn.TOP:Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 3.A nurse wants learning to take place in the affective domain of learning. Which techniques should the nurse implement that are the best for this type of learning? (Select all that apply.) a.Lecture b.Practice c.Discussion d.Role play e.Return demonstration ANS: C, D Teaching methods for affective learning include role-play and discussion. Lecture is effective for cognitive learning. Practice and return demonstration are best for psychomotor learning.

PTS:1DIF:Cognitive Level: Applying (Application) REF:21BJescribe the domains of learning. file:///D|/...ank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-12-patient-education.html[21/04/2019 17:42:21]

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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Chapter 13: Managing Patient Care Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A registered nurse works as a case manager in the local hospital. What primary role will the nurse be fulfilling? a.Coordinating care for patients with a specific condition b.Only working with primary health care providers c.Directing care of all patients in the hospital setting d.Providing direct care to specific patients ANS: A What is unique about case management is that clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific case types, focusing on length of stay and improving clinical outcomes (e.g., patients with specific diagnoses presenting complex nursing and medical problems such as heart failure or diabetes). Case managers work with social services, dietitians, and physical therapists to name a few.

Case managers do not care for all patients, just a specific case type. Case managers do not provide direct care.

Instead they collaborate with and supervise the care that other staff members deliver.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 228 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse manager is interested in supporting more involvement of the staff nurses on the unit. What is one approach the nurse manager can take to facilitate this involvement? a.Inform the staff of decisions made. b.Use decentralized management. c.Avoid unit goals. d.Discourage input from other personnel.

ANS: B Decentralized management , in which decision making is made at the staff level, is very common within health care organizations. Advantages of decentralization include increased morale and improved interpersonal relationships among staff. Staff members feel more important and are more willing to contribute. The staff should be making the decisions, not being informed of decisions made. To make decentralized decision making work, managers need to move it down to the staff level. On a nursing unit it is important for all staff members (RNs, LPNs, and LVNs), nursing assistive personnel (NAP), and unit secretaries to feel involved, particularly with issues affecting their ability to care for patients. One of the responsibilities of a nurse manager is to help the staff establish annual goals for the unit. Avoiding unit goals will decrease involvement, not increase the participation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:228 OBJ: Discuss the ways in which a nurse manager supports staff involvement in a decentralized decision-making model. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3.A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patients diet. As the staff delivers the plan of care the primary nurse evaluates whether the plan is working. Which attribute is the primary nurse displaying? file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

a.Responsibility b.Interprofessional collaboration c.Delegation d.Staff involvement ANS: A Responsibility refers to the duties and activities that an individual is employed to perform. For example, a primary nurse is responsible for completing a nursing assessment of all assigned patients and developing a plan of care that addresses each of the patients nursing diagnoses. As the staff delivers the plan of care, the primary nurse is responsible for evaluating whether the plan is successful and what to do when it is not successful. Staff involvement is not the attribute the primary nurse is displaying. This is the nurses responsibility. Delegation is the process of assigning part of one persons responsibility to another qualified person in a specific situation. The nurse developed the care plan and followed up, which is responsibility, not delegation. Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. This scenario did not use other health professionals; it involved just the nursing aspect.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 228-229 OBJ: Describe the elements of decentralized decision making.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4.A registered nurse delegates vital signs on a patient to the unlicensed assistive personnel (UAP). The nurse reviews the documented vital signs from the UAP to determine if they are within normal parameters for the patient.

The nurse in this example is demonstrating which attribute when following up on the vital signs? a.Interprofessional collaboration b.Staff education c.Accountability d.Delegation ANS: C Accountability refers to liability or individuals being answerable for their actions. It involves follow up and a reflective analysis of your decisions to evaluate their effectiveness. A primary nurse delegates responsibility but is accountable for his or her patients outcomes. Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. A nurse and a UAP are not from different disciplines. Following up is not an example of delegation; the nurse did it. Delegation is the process of assigning part of one persons responsibility to another qualified person in a specific situation. When the nurse assigned the vital signs that is delegation. Staff education involves planning in-service training sessions, sending staff members to professional conferences, and having staff members present case studies or practice issues during staff meetings.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 229 OBJ: Describe the elements of decentralized decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5.A nurse is using SBAR. Which information will the nurse report for the B? a.The patient had a broken right leg with a cast applied 2 days ago. b.The toes are cool and pale. c.The patient is reporting severe pain10 out of 10even after pain medication was given. d.The nurse requests that the primary health care provider examine the patient.

ANS: A file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

B stands for background. The information for the patients background is the following: the patient had a broken right leg with a cast applied 2 days ago. Structured communication techniques used by health care teams that improve communication include: briefings or short discussions among team member; group rounds on patients; and use of Situation-Background-Assessment-Recommendation (SBAR) when sharing information. S is the situation.

The patient is reporting severe pain10 out of 10even after pain medication was given. A is assessment. The patients toes are cool and pale. R is the recommendation. The nurse requests that the primary health care provider examine the patient.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:233 OBJescribe the process of interprofessional collaboration among nurses and health care providers.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 6.A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia (VAP). To achieve this outcome, the nurse delegates the following to the unlicensed assistive personnel: Please perform oral care on the patient every 2 hours. In this situation oral care would include using the special swabs we have for our patients on VAP precautions so we can prevent pneumonia. Which of the five rights of delegation did the nurse use? a. Right route b. Right direction/communication c. Right dose d. Right supervision

ANS: B The nurse used right direction/communication. Give a clear, concise description of the task, including its objective, limits, and expectations. Communication must be ongoing between the nurse and nursing assistive personnel during a shift of care. The nurse did not use right supervision in this scenario. To provide right supervision, provide appropriate monitoring, evaluation, intervention as needed, and feedback. Nursing assistive personnel should feel comfortable asking questions and seeking assistance. There is no right dose or route in the five rights of delegation; right dose and route are included in the rights of medication administration.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:234 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A patient is admitted to the hospital for hip replacement surgery after falling at home and breaking a hip. The patient has developed pneumonia while in the hospital and has required frequent suctioning from the tracheostomy.

The nurse decides to delegate I&O to the unlicensed assistive personnel but does not delegate suctioning. This is an example of which of the five rights of delegation? a. Right task b. Right direction/communication c. Right intervention d. Right supervision

ANS: A This is the right task because the nurse delegated I&O, but not tracheostomy suctioning. The right task is one that file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

you can delegate for a specific patient, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal potential risk. Right direction/communication involves the following: Give a clear, concise description of the task, including its objective, limits, and expectations. Communication must be ongoing between the nurse and nursing assistive personnel during a shift of care. There is no right for an intervention. Right supervision includes the following: Provide appropriate monitoring, evaluation, intervention as needed, and feedback. Nursing assistive personnel should feel comfortable asking questions and seeking assistance.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:234 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 8.A nurse is in the acute care unit caring for a 67-year-old patient with a varicose ulcer in the right lower leg. The wound has been healing well but will require a dressing change during the shift. What priority level should the nurse classify this problem? a.High priority b.Low priority c.Mid priority d.Intermediate priority ANS: D Intermediate priority problems are nonemergency, nonlife-threatening actual or potential needs that the patient and family are experiencing. Anticipating teaching needs of patients related to a new drug or taking measures to decrease postoperative complications are examples of intermediate priorities. High priority is an immediate threat to a patients survival or safety, such as a physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack. Low priority problems are actual or potential problems that may not be directly related to the patients illness or disease. They are often related to the patients developmental and/or longterm health care needs (e.g., teaching for self-care in the home before discharge of a patient who has just been admitted to the hospital). There is no mid priority label.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:231 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A new nurse would like to work where clinical performance is valued and in an environment that uses evidencebased practice. Given the new nurses goals, which organization would be the best for this nurse? a.Private hospitals b.Community hospitals c.Not-for-profit hospitals d.Magnet-designated hospitals ANS: D A magnet-designated hospital will fit this new nurses goals better than a private, community, or not-for-profit hospital. Typically a magnet hospital has a system to recognize and reward nurses for clinical performance, has research programs, and uses evidence-based practice.

PTS:1DIF:Cognitive Level: Applying (Application) file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

REF: 226 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 10.A nurse has worked in a variety of nursing areas and would like to find a unit within the hospital that mirrors the nurses own professional values. The best way for the nurse to find a unit that would be a good fit is for the nurse to examine which document? a.Hospital mission statement b.Unit policies and procedures c.Unit philosophy of care d.Hospital vision statement ANS: C A philosophy of care incorporates the professional nursing staffs values and concerns for the way that they view and care for patients. For example, a philosophy addresses the nursing units purpose, how staff will work with patients and families, and the standards of care for the work unit. A philosophy is a vision for how to practice nursing. A hospitals mission statement and/or philosophy are for the entire hospital, not just the specific nursing unit. Unit policies and procedures will not give the nurse a good idea about the units values and beliefs.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 226 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 11.A registered nurse (RN) works on a unit with other registered nurses, licensed practical nurses (LPN), and nursing assistive technicians. Usually a RN, LPN, and nursing assistive technician provide direct care for a group of patients. The RN coordinates all of the care the others provide. Which type of nursing care delivery models is the RN using? a.Team nursing b.Case management c.Primary nursing d.Total patient care ANS: A In team nursing the RN leads a team of other RNs, practical nurses, and unlicensed assistive personnel (UAP).

Team members provide direct patient care under supervision of the RN. The team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. Total patient care is a nurse delivering total care to one or two patients. Case management is one nurse managing care for a specific type of patient from admission to discharge to home. The case management nurse does not provide direct patient care. When one primary RN assumes responsibility for a caseload of patients with the help of associate nurses, primary nursing is being implemented.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 227 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12.A nurse works in a critical care area caring for two patients during a day shift and is accountable for all their care. Which type of nursing care delivery model is the nurse using? a.Team nursing b.Case management c.Primary nursing file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

d.Total patient care ANS: D During total patient care, a registered nurse is responsible for all aspects of care for one or more patients during an assigned shift. In team nursing the RN leads a team of other RNs, practical nurses, and unlicensed assistive personnel (UAP). Team members provide direct patient care under the supervision of an RN. The team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. Case management is one nurse managing care for a specific type of patient from admission to discharge to home. The case management nurse does not provide direct patient care. When one primary RN assumes responsibility for a caseload of patients with the help of associate nurses, primary nursing is being implemented.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 227 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13.A registered nurse who works in a womens hospital assumes care for the same patients from the time they are admitted to the time they are discharged home. The nurse has associate nurses helping with the care. Which type of nursing care delivery model is the nurse using? a.Team nursing b.Primary care nursing c.Case management d.Total care ANS: B Primary nursing is a model of care delivery in which a registered nurse assumes responsibility for a caseload of patients over time (e.g., a length of stay in a hospital or a series of home care visits). Typically the registered nurse selects the patients for his or her caseload and cares for the same patients during their hospitalization or stay in the health care setting. Associate nurses help with patient care. During total patient care, a registered nurse is responsible for all aspects of care for one or more patients during an assigned shift. In team nursing the RN leads a team of other RNs, practical nurses, and unlicensed assistive personnel (UAP). Team members provide direct patient care under the supervision of the RN. The team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. Case management is one nurse managing care for a specific type of patient from admission to discharge to home. The case management nurse does not provide direct patient care.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 227 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14.A registered nurse has a patient assignment of caring for six postoperative patients in the orthopedic unit. The nurse completes the patient assessments, distributes medications, and provides care to the patients as outlined within the job (position) description. Which term best describes the nurses behavior? a.Interprofessional collaboration b.Responsibility c.Interprofessional rounding d.Case management ANS: B Responsibility refers to the duties and activities that an individual is employed to perform. A position description outlines a professional nurses responsibilities in patient care and in participating as a member of the nursing unit. file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. Members of the health care team round on patients and share patient information, answer questions asked by other team members, discuss patients clinical progress, plan of discharge, and focus all team members on the same patient goals during interprofessional rounding. What is unique about case management is that clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific case types.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 228 OBJ: Describe the elements of decentralized decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 15.A nurse works in a trauma intensive care unit in a busy urban hospital. Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. The patients family can be included in the discussion if it is approved by the patient. This is best described as which of the following? a.Nursing practice b.Staff communication c.Interprofessional collaboration d.Staff education ANS: C Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. This brings different points of view to the table to identify, clarify, and solve complex patient problems. Nursing practice is all nursing areas involved in ones professional career. Staff communication involves sending a clear, accurate, and timely message to all members of the nursing staff; it focuses on nurses. Staff education involves planning in-service training sessions, sending staff members to professional conferences, and having staff members present case studies or practice issues during staff meetings.

PTS:1DIF:Cognitive Level: Applying (Application) REF:229 OBJescribe the process of interprofessional collaboration among nurses and health care providers.TOP:Nursing Process: Planning MSC: NCLEX: Management of Care 16.A nursing student is seeing a patient for the first time this morning. Which action should the nursing student perform first? a.Focused patient assessment b.Patient health history c.Medication administration d.Documentation ANS: A When beginning a patient assignment, always conduct a focused but complete assessment of the patients condition and ask what outcomes the patient expects in his or her care. A patient health history is usually taken upon admission. Medication administration and documentation will occur after an assessment.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:231 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice. file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 17.A registered nurse is prioritizing care for four patients. Which patient should the nurse see first ? a.A 44-year-old woman 1 day postoperative b.A 64-year-old man who had a stroke 2 days ago c.A 56-year-old woman with an acute asthma attack d.A 67-year-old man with a fractured hip ANS: C An acute asthma attack is a disruption in oxygen and must be addressed first. According to Maslow, meet the patients physiological needs such as oxygen, food, water, sleep, and elimination first. After meeting the physiological needs, meet the patients higher-level needs of safety, security, belonging, esteem, and selfactualization. A postoperative patient, a stroke, and a fractured hip are not as important as an acute asthma attack.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:231 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 18.A new nurse is learning how to prioritize time. One of the best ways that this can be accomplished is for the new nurse to focus on which of the following? a.Nursing tasks b.Patient priorities c.Medication schedule d.Ancillary procedures ANS: B Because nurses have a limited amount of time with patients, it is essential to remain goal oriented and focused on patients priorities. For example, priorities of care help you determine which procedures you perform first, patient assessments that you will do on an ongoing basis, and the anticipated response of your patient to care activities. The better you manage yourself leads to better management of your time. Patient priorities take precedence over nursing tasks, medication schedules, and ancillary procedures.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:232 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 19.A staff nurse is caring for six patients and is working with nursing assistive personnel. Which task can the nurse safely delegate to the nursing assistive personnel? a.Patient assessment b.Patient discharge teaching c.Patient bed bath d.Patient medication administration ANS: C Daily, repetitive tasks of care such as basic hygiene, specimen collection, and feeding patients can be delegated. file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

Delegation is the process of assigning part of one persons responsibility to another qualified person in a specific situation. The nurse cannot delegate assessments or discharge teaching. Some medication administration can be delegated to licensed practical nurses, but not to nursing assistive personnel.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:234-235 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20.A registered nurse requests that a nursing assistant give a patient a bath in the morning because the patient is going to surgery. As the nurse prepares the patient for surgery, the nurse notes that the patient has not received the bath, and it is too late to give one because surgery is calling for the patient. The nurse needs to give feedback to the nursing assistant. Where would be the most appropriate place for the nurse to provide the nursing assistant this feedback? a. In the hallway b. At the nurses station

c.In the patients room d.In a private conference room ANS: D Give feedback in private to preserve the staff members dignity. If the staff members performance is not satisfactory, give constructive and appropriate feedback. Feedback given should be specific in regard to any mistakes that the staff members make, explaining how to avoid the mistake or a better way to handle the situation.

When giving feedback, make sure to focus on things that are changeable, choose only one issue at a time, and give specific details. The hallway, nurses station, and patients room are too public for effective constructive feedback.

PTS:1DIF:Cognitive Level: Applying (Application) REF:235 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 21.A nurse is teaching a patient the side effects of a medication as the nurse is giving the medication to the patient.

Which attribute did the nurse display? a.Efficient care b.Effective care c.Using resources d.Using team communication ANS: A The nurse used efficient care. Efficient care conserves effort and minimizes interruptions. One way to be efficient is by combining various nursing activities (i.e., doing more than one thing at a time). This takes practice. For example, during medication administration or while obtaining a specimen, combine therapeutic communication skills, teaching interventions, and assessment and evaluation. Effective care is doing the right things, whereas efficient care is doing things right. The nurse did not use resources (equipment, other staff nurses) or team communication (talking to other nursing personnel) in this scenario.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:231-232 file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22.Which action indicates the new nurse is fulfilling entry-level competencies? a.Acts as a patient advocate b.Develops a theoretical framework for how to practice c.Manages care of one patient d.Establishes a quality improvement plan for the unit ANS: A One of the competencies of an entry-level nurse is to be a patient advocate. Developing a theoretical framework is not a competency of a new nurse; that comes with experience and advanced education. An entry-level nurse should be able to care for several patients, not one. Establishing a quality improvement plan for the unit is a nurse managers role, not an entry-level competency.

PTS:1DIF:Cognitive Level: Applying (Application) REF:226 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 23.A nurse is assuming responsibility for a caseload of patients over a period of time. Which type of nursing care delivery models is the nurse practicing? a.Team nursing b.Primary nursing c.Interprofessional collaboration d.Decentralized management ANS: B Primary nursing is a model of care delivery in which a registered nurse assumes responsibility for a caseload of patients over time (e.g., a length of stay in a hospital or a series of home care visits). In team nursing, licensed vocational nurses/licensed practical nurses and assistive personnel work under the direction of the registered nurse.

Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. Decentralized management includes decision making, which is moved down to the level of staff, involving all employees at all levels of activities.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 227 OBJ: Differentiate among the types of nursing care delivery models.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 24.A nurse must give feedback to a nursing assistant that did not take vital signs. How should the nurse give feedback? a.How can I trust you when things dont get done like I asked? b.You are a bad assistant because you didnt do your tasks. c.The vital signs were not taken. What happened? d.Where did you learn to take vital signs?

ANS: C

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The best approach is: The vital signs were not taken. What happened? When you give feedback, make sure to focus on things that are changeable, choose only one issue at a time, and give specific details. Feedback given should be specific regarding any mistakes that staff members make, explaining how to avoid the mistake or a better way to handle the situation. Saying, How can I trust you? and You are a bad assistant. are both derogatory and they do not tell what specific task was not done. Where did you learn to take vital signs is not something that can be changed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:235 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A newly graduated nurse has been assigned to work with one assistive personnel staff member. When delegating skills, which guidelines should the nurse use? (Select all that apply.) a.Assign just bed making skills and feeding tasks. b.Assess the knowledge of the assistive personnel. c.Match tasks to the assistants skills. d.Have the nursing assistant document assessment findings. e.Assess skill levels of assistive personnel.

ANS: B, C, E The guidelines for delegation include the following: assess the knowledge and skills of the person to whom you are delegating; match tasks to the assistants skills; and provide feedback. It is the nurses responsibility, not the assistants, to complete documentation of assessment findings. The nurse can assign/delegate more than just bed making skills and feeding tasks.

PTS:1DIF:Cognitive Level: Applying (Application) REF:235 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2. Nurses working at a progressive health care organization participate in a decentralized decision-making

framework where they are actively involved in nursing unit decisions. These nurses know that decentralization decision making includes which key elements? (Select all that apply.) a.Autonomy b.Prioritization c.Responsibility d.Authority e.Accountability ANS: A, C, D, E Decentralized decision making includes responsibility, autonomy, authority, and accountability. Prioritization is not a key element but does help with organizing care.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 228 OBJ: Describe the elements of decentralized decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

3. Which leadership skills should a nursing student use when caring for patients? (Select all that apply.)

a.Priority setting b.Time management c.Case management d.Delegation e.Team communication ANS: A, B, D, E Priority setting, time management, delegation, and team communication are all leadership skills. Student nurses do not perform case management and case management is not a leadership skill but an approach to delivery of patient care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:230-234 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 4. Which competencies should the nurse follow to be an effective team member in interprofessional collaboration?

(Select all that apply.)

a.Work to maintain a climate of mutual respect. b.Use your role specific knowledge to address health care needs. c.Apply relationship-building values and principles of team dynamics. d.Use a top-down communication strategy. e.Support a team approach to the maintenance of health.

ANS: A, B, C, E Competencies needed for effective interprofessional collaboration include: 1. Work with individuals of other professions to maintain a climate of mutual respect and shared values.

2. Use the knowledge of ones own role and those of other professions to appropriately assess and address the health care needs of patients and populations served.

3. Communicate with patients, families, communities and other health care professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and treatment of disease.

4. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient- and population-centered care that is safe, timely, efficient, effective, and equitable.

Using a top-down communication strategy does not apply as a team approach, but is needed for interprofessional collaboration.

PTS:1DIF:Cognitive Level: Applying (Application) REF:230 OBJescribe the process of interprofessional collaboration among nurses and health care providers.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care file:///D|/...ssentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-13-managing-patient-care.html[21/04/2019 17:42:23]

Chapter 14: Infection Prevention and Control Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not

been ill from the bacteria, the nurses nasal cavity can best be described as a: a.susceptible host. b.reservoir. c.portal of entry. d.mode of transmission.

ANS: B

A place in which microorganisms survive, multiply, and wait to transfer to a susceptible host is called a reservoir .

Common reservoirs are humans and animals (hosts), insects, food, water, and organic matter on inanimate surfaces (fomites). Frequent reservoirs for health careacquired infections (HAIs) include health care workers (especially their hands), patients body excretions and secretions, equipment, and the health care environment. A susceptible host is one who will get an infection. Susceptibility to an infection depends on the individuals degree of resistance to pathogens. The fact that the nurse has not become ill indicates that he or she is not very susceptible. Portal of entry describes how the organism entered the body. Although the MRSA may have used the nasal cavity as the portal of entry, it now resides there so the nasal cavity is now the reservoir. Mode of transmission refers to how the organism is passed from one person to another. This can be from touch, sneezing, coughing, and so on. The nasal cavity is a place, not a mode of transmission.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 240 | 241 OBJ: Describe characteristics of each link of the infection chain.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 2. The nursing assistive personnel (NAP) is working on a busy pediatric unit in a hospital. She has a cut on her hand

that has not been kept covered. It hurts her to wash her hands or sanitize them, so she has been providing patient care without performing hand hygiene. Several of the patients on the pediatric unit have suffered hospitalassociated infections of rotavirus. This was thought to be a result of the NAPs lack of hand hygiene. This type of disease transmission can best be described as: a.indirect. b.natural active immunity. c.direct. d.natural passive immunity.

ANS: C

Hands of health care workers often transmit microorganisms. This mode of transmission is called direct transmission . Indirect transmission occurs when microorganisms are transferred to health care workers hands from contaminated items that are part of patient care, such as a blood pressure cuff or a bedside table. Natural active immunity results from having a certain disease, such as measles, and mounting an immune response that usually lasts a lifetime. Natural passive immunity is the acquisition of an antibody by one person from another, such as a baby born with its mothers antibodies. The baby acquires these antibodies through the placenta during the last months of pregnancy. This type of immunity is of short duration, usually lasting only a few weeks to months.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 241 | 242 OBJ: Identify the bodys normal defenses against infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

3. The nurse is working for a postsurgical unit. He is caring for four postsurgical patients, all of whom have been in

the hospital for 3 days or more. Which of the following patients should he be most concerned about regarding a health careassociated infection? a.An asymptomatic elderly patient with bacteria in his urine b.A middle-aged woman with a white blood cell count of 10,000/mm 3 c.A young adult woman who is 1 day postoperative with redness at incision site d.A middle-aged man with temperature of 101.3 F and complaints of malaise ANS: D

By assessing existing signs and symptoms (e.g., the condition of a wound, the presence of fever), you will determine whether a patients clinical condition indicates the onset or extension of a systemic infection. The patient with an elevated temperature such as 101.3 F and a feeling of malaise is demonstrating signs of infection. When assessing laboratory data, consider the age of the patient. For example, in an older adult, bacterial growth in urine without clinical symptoms does not always indicate the presence of a urinary tract infection. Normal white blood cell count is 5000 to 10,000/mm 3 , so a patient with that level would not be showing a sign of infection unless he or she were already immunosuppressed. Redness at the incision site is a sign of inflammation, and the bodys inflammatory response is a protective reaction that neutralizes pathogens and repairs body cells.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:243 | 245 | 246 OBJ:Assess patients at risk for acquiring an infection.

TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 4.A patient with a history of poor nutrition and chronic illness is admitted to the medical unit. The nurse caring for this patient is preparing to provide the patient with a bed bath and recalls that normal body flora: a.are only found on the skin surface. b.are beneficially aided by the use of antibiotics. c.are primary sources of infection when balanced. d.help to maintain health.

ANS: D Normal flora usually does not cause disease, but instead help to maintain health. The number and variety of flora maintain a sensitive balance with other microorganisms to prevent infection. The bodys normal flora is made up of a large numbers of microorganisms residing on the surface and deep layers of the skin, in the saliva and oral mucosa, and in the intestinal walls. Any factor that disrupts this balance places a person at increased risk for infection. For example, the use of broad-spectrum antibiotics for the treatment of infection eliminates or changes normal bacterial flora, often leading to suprainfection. Microorganisms resistant to antibiotics then cause serious infection.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:243 OBJ: Explain conditions that promote development of health careassociated infections.

TOP: Nursing Process: Planning MSC: NCLEX: Safety and Infection Control 5. An emergency department nurse is caring for a patient with a laceration on the lower leg that has become infected. On assessment the nurse realizes that a sign of an inflammatory response consists of:

a.wound blanching. file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

b.coolness at the site of injury. c.a vascular reaction that delivers fluid, blood, and nutrients to the area. d.decreased pain sensation.

ANS: C Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to interstitial tissues in an area of injury. This process neutralizes and eliminates pathogens or necrotic tissues and establishes a means of repairing body cells and tissues. Signs of inflammation include swelling, redness (not blanching), heat, pain or tenderness, and loss of function in the affected body part.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:243 OBJ: Explain conditions that promote development of health careassociated infections.

TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. There was an outbreak of Salmonella poisoning at a nursing home. Several residents were hospitalized as a result of their infections. What is the best term to describe this infection? a. Exogenous infection b.Endogenous infection c.Community-acquired infection d.Asepsis

ANS: A An exogenous infection comes from microorganisms found outside the individual, such as Salmonella , Clostridium tetani , and Aspergillus . They do not exist as normal flora. An endogenous infection occurs when part of the patients flora becomes altered and overgrowth results (e.g., staphylococci, enterococci, yeasts, streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter normal flora. When sufficient numbers of microorganisms normally found in one body site move to another site, an endogenous infection develops. A community-acquired infection is one that was present at the time of admission to a health care setting. The term asepsis means the absence of disease-producing microorganisms.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:243 OBJ: Explain conditions that promote development of health careassociated infections.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 7.A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should: a.insert indwelling catheters to prevent incontinence. b.use aseptic technique when performing procedures. c.use barriers sparingly to reduce the patients sense of isolation. d.keep mucus membranes dry to prevent maceration.

ANS: B Invasive treatment devices such as intravenous (IV) catheters or indwelling urinary catheters impair or bypass the bodys natural defenses against microorganisms. Because of increased attention to the prevention of infection, the file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

Centers for Disease Control and Prevention (CDC) (2007) and the Occupational Safety and Health Administration (OSHA) (1991) have stressed the importance of barrier protection. Efforts to minimize the onset and spread of infection are based on the principles of aseptic technique. Aseptic technique is an effort to keep the patient as free from exposure to infection-causing pathogens as possible. The term asepsis means the absence of diseaseproducing microorganisms. When a person ages, normal physiological changes occur that influence susceptibility to infection. These changes include decreased immunity, dry mucous membranes, decreased secretions, and decreased elasticity in tissues. Because of these changes, the older adult is predisposed to infections.

PTS:1DIF:Cognitive Level: Applying (Application) REF:243 | 247 OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 8.The infection control nurse is presenting an in-service presentation on infection prevention and control. A participating nurse identifies what patient as most susceptible to acquiring an infection? a.An 81-year-old patient with a fractured hip b.A 10-month-old patient with a first-degree burned hand c.A 40-year-old patient with a recent uncomplicated laparoscopic cholecystectomy d.A 16-year-old athlete with a repair of the medial collateral ligament ANS: A When a person ages, there are normal physiological changes that influence susceptibility to infection. First-degree burns leave the skin intact and do not breach the barrier to infection. Any surgical procedure involves a break in the bodys defenses against infection, and procedures such as cholecystectomy and ligament repair pose a risk for infection; however, the age of the patients place them at a lower level of risk.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 247 OBJ: Assess patients at risk for acquiring an infection.

TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 9.A senior nursing student is working on a community health project for the local homeless shelter. There are several indigent men who come to the shelter in cold weather to sleep for the night. The student nurse knows that these men do not bathe on a regular basis. One of the men has been sick several times recently with skin infections.

Which of the following is the best way for the student nurse to explain the importance of personal hygiene to this individual? a.You dont have to shower every day. You only need to take a shower when you feel like youre going to be sick. b.Take a shower. If you dont take a shower, you will continue to get sick. c.Showering regularly will remove germs that cause skin infections. What do you think we should do about these skin infections of yours? d.Showering with warm water is enough to wash away bacteria. Soap is not needed if you dont like it.

ANS: C Identify patients expectations about their care, and involve them in planning their care. Encourage patients to verbalize their expectations so that you are able to establish interventions to meet patients priorities. Waiting until you feel like youre going to be sick may be too late. Telling the patient that he will get sick may sound like a threat and cause the patient to withdraw. Use soap and water to remove drainage, dried secretions, or excess perspiration.

PTS:1DIF:Cognitive Level: Applying (Application) REF:247 | 251 file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

OBJ: Explain conditions that promote development of health careassociated infections.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 10. The student nurse who is developing a plan of care for a postoperative patient who underwent abdominal surgery to remove a tumor. The student has chosen Risk for Infection as a nursing diagnosis. Which of the following is the most appropriate goal for this diagnosis?

a.The patients wound drainage will decrease in 2 days. b.The patient will report decrease in incisional pain by discharge. c.The progression of infection will be controlled or decreased. d.The patient will describe signs/symptoms of wound infection.

ANS: C In an acute care setting the goal for the diagnosis Risk for Infection is to control or decrease the progression of infection. An outcome is The patients wound drainage will decrease in 2 days. Decreased incisional pain is an expectation postsurgically and not directly related to infection. Having the patient describe the signs/symptoms of infection will aid in early detection, but not in preventing infection.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 248 OBJ: Assess patients at risk for acquiring an infection.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 11. The student nurse caring for a postsurgical patient who has developed a health careacquired wound infection that has become systemic. Which of the following should be the student nurses top priority?

a.Providing emotional support b.Managing vital signs c.Providing patient education d.Providing personal hygiene ANS: B Give special attention to any urgent needs the infection creates. For example, if the patients infection becomes systemic, a nurse will need to manage fever and prevent dehydration. Once the infection begins to resolve and vital signs are stable, then the priorities are hygiene, patient education, and emotional support.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:248 OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 12.A nursing student is working on a surgical unit in the hospital. Included in her job description is to assist in the cleaning and disinfection of equipment stored on the unit. Which of the following is the best explanation of disinfection? a.Removing organic material b.Removing inorganic material c.Eliminating almost all pathogenic organisms d.Destroying all forms of microbial life ANS: C file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

Disinfection eliminates almost all pathogenic organisms, with the exception of bacterial spores. Sterilization eliminates or destroys all forms of microbial life, including spores. Cleaning involves removing organic material such as blood or inorganic material such as soil from objects. Generally this involves the use of water, a detergent/disinfectant, and proper mechanical scrubbing action. Cleaning occurs before disinfection and sterilization procedures.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 250 OBJ: Identify principles of medical and surgical asepsis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 13.A patient is admitted for treatment of a home-acquired pressure ulcer. The patient is incontinent of urine and has Alzheimer disease. A Foley catheter is inserted. The nurse recognizes that the best way to break the infection chain is to: a.discontinue the Foley as soon as possible. b.wear a mask when working with the patient if she or he has a cold. c.wear sterile gloves if there is a chance of contact with blood. d.use surgical asepsis when handling body fluids.

ANS: A To control or eliminate infection in reservoir sites, eliminate sources of body fluids, drainage, or solutions that possibly harbor microorganisms such as a Foley collection bag. Try not to work with patients who are highly susceptible to infection if you have a cold or other communicable infection. Another way of controlling the exit of microorganisms is by using standard precautions when handling body fluids such as urine, feces, and wound drainage. Wear clean gloves if there is a chance of contact with any blood or body fluids, and perform hand hygiene after providing care. Be sure to bag contaminated items appropriately.

PTS:1DIF:Cognitive Level: Applying (Application) REF:250 OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14. The nurse and is very concerned about infection control in the Surgery Department. Recently she provided

education to the surgery staff on ways to eliminate transient hand flora. The most precise description for this is hand: a.hygiene. b.washing. c.antisepsis. d.rub.

ANS: C Hand hygiene is a general term that applies to hand washing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. Hand washing refers to washing hands with plain soap and water. An antiseptic handwash means washing hands with water and soap or other detergents containing an antiseptic agent. An antiseptic hand rub means to apply an antiseptic hand rub product, such as alcohol, to all surfaces of the hands to reduce the number of microorganisms present. Surgical hand antisepsis is an antiseptic handwash or antiseptic hand rub that surgical personnel perform preoperatively to eliminate transient and reduce resident hand flora.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 251 OBJ: Perform proper procedures for hand hygiene. file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15. Standard precautions involve using personal protective equipment with all patients regardless of the presence of

infections. Therefore when obtaining a blood sample, the nurse must wear: a.a mask. b.gloves. c.gloves and a mask. d.gloves, a mask, and a gown.

ANS: B

Apply disposable gloves when there is a risk for exposing the hands to blood as in blood drawing, body fluids, mucous membranes, non-intact skin, or potentially infectious material on objects or surfaces. In addition, use gloves when you have scratches or breaks in the skin and when performing venipuncture or finger or heel sticks.

Wear a mask or respirator if you anticipate splashing or spraying of blood or body fluids. This is not common when drawing blood. The mask also protects you from inhaling microorganisms from a patients respiratory tract and prevents the transmission of pathogens from your respiratory tract. Gowns should be worn if soiling of the skin or clothing is likely from contact with blood, body fluids, or if patient has uncontained secretions. You may wear gloves alone or in combination with other PPE; however, obtaining a blood sample does not usually require more than gloves.

PTS:1DIF:Cognitive Level: Applying (Application) REF:259 | 260OBJerform proper barrier isolation techniques.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 16. The nurse has noticed slight redness when washing her hands. She is concerned about developing a latex allergy. To prevent this, the nurse should:

a.wear only powdered gloves to help protect her skin. b.wear gloves constantly to decrease the number of handwashings. c.apply only oil-based hand care products to her hands. d.report to employee health services and/or seek immediate medical care.

ANS: D The Association of Perioperative Registered Nurses (2009) suggests that nurses report to employee health services to seek medical treatment immediately if a reaction or dermatitis occurs. They are also advised to wear powder-free gloves whenever possible (they are lower in protein allergens), wear gloves only when indicated, wash with a pHbalanced soap immediately after removing gloves, and apply only nonoil-based hand care products (oil-based products break down latex allergens).

PTS:1DIF:Cognitive Level: Applying (Application) REF:260OBJerform proper barrier isolation techniques.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 17. Which of the following situations is most likely to contribute to a health careacquired infection?

a.A closed urinary drainage system b.Use of aseptic technique during dressing changes c.Foley catheter drainage bag touching the floor d.Changing IV access site when site is red and warm ANS: C file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

Causes of health careacquired infection include contact between drainage bag port and contaminated surface, an open urinary drainage system, failure to use aseptic technique during dressing changes, and failure to change IV access site when inflammation first appears.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:245 OBJ: Explain conditions that promote development of health careassociated infections.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 18.A nurse is concerned with the chain of infection when taking care of contaminated care items. Semicritical items that require disinfection include: a.linens. b.bedpans. c.blood pressure cuffs. d.gastrointestinal endoscopes.

ANS: D Semicritical items are objects that come in contact with mucous membranes or nonintact skin and present a risk.

These objects must be free of all microorganisms (except bacterial spores). Semicritical items must be high-level disinfected (HLD) or sterilized. Some of these items include respiratory and anesthesia equipment, endoscopes, endotracheal tubes, gastrointestinal endoscopes, and diaphragm fitting rings. After rinsing, items must be dried and stored in a manner to protect from damage and contamination. Noncritical items are objects that come in contact with intact skin but not mucous membranes and must be clean. Noncritical items must be disinfected. Some of these items include bedpans, blood pressure cuffs, bed rails, linens, and stethoscopes.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:250 OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 19.A nurse is coaching a student on the proper method of applying surgical gloves. One step in the proper donning of sterile gloves requires the nurse to: a.with thumb and first two fingers of nondominant hand, touch only the gloves outer surface. b.with gloved dominant hand, slip fingers inside the second glove and pull onto the nondominant hand. c.carefully pull the glove over the dominant hand, leaving a cuff and being sure the cuff rolls up over the wrist. d.carefully pull the glove over the dominant hand, leaving a cuff and being sure the cuff does not roll up over the wrist.

ANS: D Carefully pull glove over dominant hand, leaving a cuff and being sure the cuff does not roll up wrist. With thumb and first two fingers of the nondominant hand, grasp the edge of the cuff of the glove for the dominant hand and touch only the gloves inside surface. With the gloved dominant hand, slip the fingers underneath the second gloves cuff.

PTS:1DIF:Cognitive Level: Applying (Application) REF:263 OBJ: Apply and remove a surgical mask and gloves using correct technique. file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20. An 89-year-old patient who lives in a nursing home has been admitted to the hospital for observation after falling, and is exhibiting confusion and malaise in the nursing home. He had a urinary catheter inserted 2 weeks ago when he complained of difficulty urinating. Lab work was ordered and the nurse notes that his neutrophil count is elevated. She knows that this, combined with the other clinical signs and symptoms, most likely indicates what condition?

a.Tuberculosis b.Parasitic infection c.Acute bacterial infection d.Viral infection ANS: C Neutrophil counts are elevated in the presence of acute bacterial infection. Lymphocytes are increased in viral infections. Monocytes are elevated in tuberculosis infections. Eosinophils are usually elevated in parasitic infections.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 247 OBJ: Identify the bodys normal defenses against infection.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 21. The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection isolated in his stage III pressure ulcer. The nurse places the patient on:

a.contact precautions. b.airborne precautions. c.droplet precautions. d.protective environment.

ANS: A Contact precautions (direct patient or environmental contact) is used for patients with colonization or infection with multidrug-resistant organisms such as VRE and MRSA, Clostridium difficile , shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); or respiratory syncytial virus in infants, young children, or immunocompromised adults. Airborne precautions (droplet nuclei smaller than 5 microns) are used for patients who have measles; chickenpox (varicella); disseminated varicellazoster; pulmonary or laryngeal tuberculosis. Droplet precautions (droplets larger than 5 microns; being within 3 feet of the patient) is used for patients with diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mumps, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, or pneumonic plague. A protective environment is used to protect patients receiving allogeneic hematopoietic stem cell transplants.

PTS:1DIF:Cognitive Level: Applying (Application) REF:255 OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse sets up a sterile field. A break in the sterile field occurs when the nurse does which of the following?

(Select all that apply.) file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

a.Drops a sterile capped needle onto the sterile field b.Spills solution onto the sterile field c.Keeps the top of the table above waist level d.Keeps sterile objects within a 1-inch border of the field ANS: B, D A sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact with a wet contaminated surface. Moisture seeps through a sterile packages protective covering, allowing microorganisms to travel to the sterile object. When stored sterile packages become wet, discard the objects immediately or send the equipment to be sterilized again. Spilling solution over a sterile drape contaminates the field unless the drape cannot be penetrated by moisture. The edges of a sterile field or container are contaminated. A 2.5-cm (1-inch) border around a sterile towel or drape is considered contaminated . A sterile object remains sterile only when touched by another sterile object. Place only sterile objects, such as sterile needles, on a sterile field. A sterile object or field out of the range of vision or an object held below a persons waist is contaminated. Never turn your back on a sterile tray or leave it unattended. Any object held below waist level is considered contaminated because you cannot view it at all times. Keep sterile objects either on or out over the sterile field.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 262 | 264 OBJ: Identify principles of medical and surgical asepsis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

file:///D|/...20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-14-infection-prevention-and-control.html[21/04/2019 17:42:18]

Chapter 15: Vital Signs Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nursing student is obtaining the patients vital signs. The patient has gone to the clinic seeking help because

she is having chest pain. Which of the following vital signs are most important to obtain? a.Temperature, pulse, respirations b.Temperature, pulse, respirations, oxygen saturation c.Temperature, pulse, respirations, blood pressure, oxygen saturation d.Temperature, pulse, respirations, blood pressure, oxygen saturation, pain ANS: D

The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patients pain helps a nurse understand the patients clinical status and progress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:270 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 2. Upon a patients admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurses responsibility regarding delegating this task?

a.This is inappropriate delegation; the nurse should always take the vital signs. b.Have the NAP repeat the measurement if vital signs appear abnormal. c.The nurse should review and interpret the vital sign measurements. d.This task has been delegated so the nurse is not responsible.

ANS: C A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel.

However, it is the nurses responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:271 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 3.A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next? a.Call the health care provider because the patients values differ from the standard range. b.Immediately call the health care provider and request antihypertensive medication. c.Ask the patient what his blood pressure normally measures for comparison.

d.Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

ANS: C Know the patients usual range of vital signs. A patients usual values sometimes differ from the standard range for that age or physical state. Use the patients usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patients blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:271 | 282 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 4.A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.6 F. Which of the following is the best reason why the patient should not receive an antipyretic at this time? a.A temperature of 100.3 F is within the normal range. b.Shivering is a more effective way to dissipate heat energy. c.Corticosteroids are safer to use than antipyretics. d.Mild fevers are an important defense mechanism of the body.

ANS: D Fever, or pyrexia, is an important defense mechanism. Therefore most health care providers will not treat an adults fever until it is higher than 39 C (102.2 F). For healthy young adults the average oral temperature is 37 C (98.6 F).

In the elderly population, the average core temperature ranges from 35 to 36.1 C (95 to 97 F) because of decreased immunity. Shivering is counterproductive because of the heat produced by muscle activity. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 173 | 174 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 5.A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through which of the following? a.Convection b.Radiation c.Conduction d.Evaporation ANS: C Heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact.

When the warm skin touches a cooler object, heat transfers from the skin to the object until temperatures equalize.

Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. Radiation is the transfer of heat between two objects without physical contact. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:273 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 6.A 6-year-old was taken to the hospital after having a seizure at home. The patients mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patients mother believes that the seizure was caused by a fever of 99.5 F, which the patient had during the course of her illness. What is the nurses best response? a.With a temperature that high, we can only hope that there is no permanent damage. b.Fevers in this range are part of the bodys natural defense system c.Febrile seizures are common in children Nancys age. d.The child will need antibiotics. Does she have any allergies?

ANS: B Fever serves as an important defense mechanism. Therefore most health care providers will not treat an adults fever until it is greater than 39 C (102.2 F). A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 274 | 275 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 7.A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5 F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, the patients mother was asked to help reduce the fever by limiting the number of blankets covering the patient. After interventions, the childs temperature is 100.5 F. The nurse recognized that the mother has an understanding of the patients condition when she states which of the following? a.The high temperature is useful in fighting bacteria and viruses as long as its not too high. b.You need to get her temperature down quickly. Shes so uncomfortable. c.Her fever is dropping because she is shivering. She must be cold. d.She probably picked up a bacteria. Thats what kids do. Thats why they get infected.

ANS: A A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. Increased temperature reduces the concentration of iron in the blood plasma, causing bacterial growth to slow. Fever also fights viral infections by stimulating interferon, the bodys natural virus-fighting substance. The goal is a safe rather than a low temperature. A true fever results from an alteration in the hypothalamic set point. To reach the new set point, the body produces and conserves heat. The patient experiences chills, shivers, and feels cold, even though the body temperature is rising. Most fevers in children are of viral origin, lasting only briefly, and have limited effects PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 8.The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girls temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill.

Which of the following is the best response?

a.Children usually run lower rather than higher temperatures when ill. b.Because of her age, it is probably a bacterial infection. c.Rectal temperatures are higher than temperatures obtained orally. d.When taking multiple temperatures, the sites should be rotated.

ANS: C Depending on the site, temperatures will normally vary between 36 C (96.8 F) and 38 C (100.4 F). It is generally accepted that rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures. Children have immature temperature control mechanisms, so temperatures sometimes rise rapidly. Most fevers in children are of viral origin, lasting only briefly, and have limited effects. Use the same site when repeated measurements are needed.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:273 | 274 | 275 OBJiscuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 9.A 6-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following? a.Dehydration b.An allergic response to the prescribed medication c.Febrile seizures d.Fever of unknown origin (FUO) ANS: B Sometimes a fever results from a hypersensitivity response to a medication, especially when the medication is taken for the first time. These fevers are often accompanied by other allergy symptoms such as rash, hives, or itching. Treatment involves stopping the medication responsible for the reaction. Dehydration and febrile seizures occur during rising temperatures in children between 6 months and 3 years of age. Febrile seizures are unusual in children greater than 5 years of age. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 10.A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2 F after caring for her 5-yearold granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first? a.Administer antibiotic. b.Administer antipyretic. c.Draw blood cultures. d.Apply water cooled blankets.

ANS: C Before antibiotic therapy, obtain blood cultures when ordered. Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Antipyretics are medications that reduce fever. It is important to note that these drugs mask signs of infection by suppressing the immune system. Physical cooling,

including the use of water-cooled blankets, is appropriate when the patients own thermoregulation fails or in patients with neurological damage (e.g., spinal cord injury).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:274 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 11.A 26-year-old man was helping a friend replace a roof on his backyard shed after work on a hot July afternoon.

His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused.

Which of the following should the admitting nurse do first when assessing the patient? a.Place the patient in a tub of iced water. b.Take the patients temperature. c.Remove fans to prevent premature chilling. d.Apply a hyperthermia blanket to lower temperature slowly.

ANS: B Assessment includes taking the patients temperature. The nurse then uses that measurement to guide care of that patient. Placing the patient in a tub of iced water, removing fans to prevent premature chilling, and applying a hyperthermia blanket to lower temperature slowly are not assessments but interventions. Prolonged exposure to the sun or high environmental temperatures overwhelms the bodys heat loss mechanisms. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40 C (104 F) or higher. Signs and symptoms of heat stroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heat stroke is hot, dry skin. A heat stroke can be fatal. Cool the person quickly. Ways to cool include placing wet towels over the skin, placing the person in a tub of tepid (not iced) water or into a tepid shower, spraying the person with cool water from a garden hose, and placing oscillating fans in the room. Emergency medical treatment includes applying hypothermia blankets, giving intravenous (IV) fluids, and irrigating the stomach and lower bowel with cool solutions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:275 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12.A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. The patient is still unconscious. Which of the following interventions should the admitting nurse do first? a.Have the patient drink hot liquids. b.Wrap the girl in warm blankets. c.Uncover the head to allow the head to warm. d.Place heating pads on the bottom of the feet.

ANS: B The priority treatment for hypothermia is to prevent a further decrease in body temperature. Removing wet clothes, replacing them with dry ones, and wrapping the patient in blankets are strategic nursing interventions. In emergencies, when a patient is not in a health care setting, place the patient under blankets next to a warm person.

A conscious patient benefits from drinking hot liquids such as soup, while avoiding alcohol and caffeinated fluids.

An unconscious patient should not be given any fluids. Keeping the head covered, increasing room temperature, or

placing heating pads next to areas of the body (head and neck) that lose heat the quickest helps. The severity of the hypothermia dictates the treatments performed.

PTS:1DIF:Cognitive Level: Applying (Application) REF:275 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13.A senior nursing student is doing her community clinical rotation. When visiting a young family to whom she has been assigned, the mother of a 3-year-old child states that her daughter does not feel well. The nursing student feels her skin, which is warm. She asks the mother if she has taken her temperature to which the mother replies, Yes, I used the same thermometer that was my great-grandmothers; it has been used by my family for years. Her oral temperature was 102.3 F. The most important action for the nursing student to perform is to do which of the following? a.Teach that temporal artery thermometers are more accurate than others. b.Tell the mother that hospitals still use mercury thermometers. c.Ask to see the thermometer. d.Recommend a chemical thermometer for greater accuracy.

ANS: C Inspect the thermometer to make sure that it is mercury. The mercury-in-glass thermometers are obsolete in the health care setting because of the environmental hazards of mercury. However, some patients still use mercury-inglass thermometers at home. If you find a mercury-in-glass thermometer in the home, teach the patient about safer temperature devices and encourage him or her to take the thermometer to a neighborhood hazardous disposal location. There is a growing bed of research supporting the discontinuation of temporal artery thermometers in the clinical setting because of reported inaccurate readings. Chemical thermometers are useful for screening temperatures, especially in infants and young children. You need to confirm readings with electronic thermometers when treatment decisions need to be made.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:277 | 278 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 14.A 38-year-old postoperative patient is suddenly unresponsive but is still breathing. The nurse will use which site to assess the patients pulse? a.Apical artery b.Radial artery c.Carotid artery d.Brachial artery ANS: C When a patients condition suddenly deteriorates, use the carotid site to quickly locate a pulse. Assess any accessible artery for pulse rate; however, use the radial or carotid arteries most often because they are easy to locate and palpate. The radial and apical locations are the most common sites for pulse rate assessment. Use the radial or carotid pulse when teaching patients how to monitor their own heart rates. The brachial artery is not usually a primary site for checking pulse.

PTS:1DIF:Cognitive Level: Applying (Application) REF:279 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 15.A man has been admitted to the hospital with lethargy. He was placed on the telemetry unit and is being continuously monitored. He is due to receive his dose of digoxin. The nurse knows that the medication is to be held if the pulse rate is less than 60 beats per minute. The nurse will use which site to assess the patients pulse? a.Apical b.Radial c.Brachial d.Carotid ANS: A When a patient takes a medication that affects the heart rate, the apical pulse provides a more accurate assessment of heart rate. The radial pulse is the most common site used to assess character of pulse peripherally and assesses the status of circulation to the hand. The brachial site is used to assess upper extremity blood pressure; used during infant CPR. PTS:1DIF:Cognitive Level: Applying (Application) REF:279 | 280 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 16.The nurse is having difficulty hearing his patients apical pulse with his stethoscope. Which of the following would best maximize the sound quality of what is heard through the stethoscope? a.Positioning the diaphragm very lightly on the area to which he is listening b.Placing the stethoscope chest piece directly on the patients skin c.Make sure that the earpieces fit loosely in the ear canals d.Use a stethoscope with the longest tubing available ANS: B Always place the stethoscope directly on the skin because clothing obscures the sound. Position the diaphragm to make a tight seal against the patients skin. Exert enough pressure on the diaphragm to leave a temporary red ring on the patients skin when the diaphragm is removed. Make sure the plastic or rubber earpieces fit snugly in the ear canal and that the binaurals are angled and strong enough so the earpieces stay firmly in place without causing discomfort. The polyvinyl tubing is flexible and 30 to 45 cm (12 to 18 inches) in length. Longer tubing decreases sound wave transmission.

PTS:1DIF:Cognitive Level: Applying (Application) REF:279 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care

17.A nurse notices that a patient has an irregular pulse. The nurse should do which of the following? a.Count the number of lub-dubs occurring in 30 seconds. b.Assess how often the dysrhythmia is occurring. c.Assess the radial pulse for a pulse deficit. d.Chart the abnormally low heart rate as tachycardia.

ANS: B A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia alters cardiac function, particularly if it occurs repetitively. If your patient has a dysrhythmia you need to assess how often it is occurring. After properly positioning the bell or the diaphragm of the stethoscope on the chest, try to identify the first and second heart sounds (S 1 and S 2 ). At normal slow rates, S 1 is low pitched and dull, sounding like a lub. S 2 is a higher pitched and shorter sound and creates the sound dub. Count the number of lub-dubs occurring in 1 minute. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, ask another nurse to assess the radial pulse rate while you assess the apical rate. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 279 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 18.The nurse is taking the pulse of an adult patient and finds that the patients heart rate is 48. He knows that this is considered: a.tachycardia. b.bradycardia. c.a normal heart rate for an infant. d.a normal heart rate for an adult.

ANS: B Tachycardia is an abnormally elevated heart rate, greater than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults; 120 to 160 beats per minute is a normal heart rate for an infant. The normal heart rate for an adult is 60 to 100 beats per minute.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 19.A 45-year-old mother of three children is at the doctors office and her blood pressure 152/92. This is the first time that she has ever shown an elevated reading. She is concerned that she has hypertension. The nurses best response would be: a.A single reading may not mean anything. We will take it again at your next visit. b.It looks like you have high blood pressure now. Well check it again in 3 months. c.Fortunately, hypertension isnt related to other diseases and is easily treated. d.You may have hypertension, but there is little else that can be done except medicines.

ANS: A The diagnosis of hypertension in adults is made on the average of two or more readings taken at each of two or more visits after an initial screening. One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (for example, 150/90 mm Hg), encourage the

patient to return for another checkup within 2 months. Hypertension is a known risk factor for cardiovascular morbidity and mortality. Obesity, cigarette smoking, excessive alcohol intake, elevated blood cholesterol, and continued exposure to stress are also linked to hypertension. Controlling these factors may reduce blood pressure.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 20.The patient has just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the nurse notes that the patients systolic blood pressure had dropped by 30 points. In addition to the drop in systolic blood pressure, the patients skin is pale and clammy. The nurse should do which of the following? a.Report the findings to the health care provider immediately. b.Understand that the patients arteries are constricting, causing pallor. c.Wait to see if the blood pressure increases in 30 minutes. d.Nothing; this is a normal occurrence following a thoracic surgery.

ANS: A Signs and symptoms associated with hypotension include pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, and decreased urine output. Hypotension is usually life threatening and needs to be reported immediately to the patients health care provider. Doing nothing can lead to the patients death. Hypotension occurs when arteries dilate; the peripheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide adequate cardiac output.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 21.A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following? a.Accurate readings as long as it is 20% of the circumference of the midpoint of the limb. b.Indistinct readings if the bladder encircles 80% of the adults arm. c.A falsely low reading if the cuff is wrapped too loosely around the arm. d.Inaccurate readings and needs to be replaced with a larger cuff.

ANS: D When the incorrect size cuff is used, it is possible to obtain a false reading. The size selected is proportional to the circumference of the limb being assessed. Ideally select a cuff that is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb being used to be obtain measurements. The bladder, enclosed by the cuff, encircles at least 80% of the arm of an adult and the entire arm of a child. A cuff that is wrapped too loosely or unevenly will yield false-high readings.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 285 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 22.A woman has been hospitalized with pneumonia. She has had oxygen on via nasal cannula at a rate of 2 L per minute. A nursing student is taking her vital signs. She notes that her respirations are labored and the rate is 32 respirations per minute. The nursing student recognizes this as which of the following?

a.Normal. b.Tachypnea. c.Bradypnea. d.Apnea.

ANS: B Tachypnea is a respiratory rate greater than 20, and a rate less than 12 per minute or lower than acceptable limits is bradypnea. Apnea is the lack of respiratory movements. A normal respiratory rate for an adult is 12 to 20 breaths per minute.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 289 | 290 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 23.The patients temperature has reached 103.4 F. The nurse prepares to draw a blood culture before giving the patient an antipyretic medication. What is the best reason to draw a blood culture before giving an antipyretic medication? a.The causative organism is most prevalent during a spike in temperature. b.Elevated temperatures slow metabolic rate and improve blood oxygenation. c.Increased blood flow leads to moist mucous membranes making blood draws easier. d.Venous distention is greater because of fluid retention secondary to hyperthermia.

ANS: A Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent.

Satisfy requirements for increased metabolic rate. Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells. Encourage oral hygiene because oral mucous membranes dry easily from dehydration and have increased potential for bacterial invasion. Replace fluids lost through insensible water loss and sweating.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:274 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 24.A nurse is ready to take the temperature of an adult patient rectally. The nurses realizes that rectal temperatures are which of the following? a.Preferable to oral temperatures b.Safer than oral temperatures if the patient has neutropenia c.The best way to obtain temperatures in newborns d.That readings can be influenced by impacted stool ANS: D Rectal temperature readings are sometimes influenced by impacted stool. A rectal temperature is argued to be more reliable than alternative sites when oral temperature is difficult or impossible to obtain, but are not used for patients with diarrhea or those who have had rectal surgery, rectal disorders, bleeding tendencies, or neutropenia, and are not used for routine vital signs in newborns.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 276 | 277 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 25.A nurse delegates the task of obtaining vital signs to a nursing assistant. The nurse reminds the nursing assistant that blood pressure: a.will be lower if the cuff is too wide. b.is not affected by cuff length. c.should be taken slowly for more accuracy. d.should be taken with the arm above heart level.

ANS: A A bladder or cuff that is too wide will yield false-low readings. A cuff that is wrapped too loosely or unevenly will yield false-high readings. Deflating a cuff too slowly will produce false-high diastolic readings. The arm should be at the level of the heart. Having the arm above heart level will produce a false-low reading.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 285 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 26.To determine the patients actual temperature, the nurse is aware that: a.the patients core temperature is not affected by environmental temperature b.surface temperatures are the most stable c.circadian rhythms keep the body temperature stable throughout the day. d.gender and age have no effect on body temperature.

ANS: A Despite environmental temperature extremes and physical activity, temperature-control mechanisms of human beings keep the bodys core temperature , or temperature of deep tissues, relatively constant during sleep, exposure to cold, and strenuous exercise. However, surface temperature fluctuates, depending on blood flow to the skin and the amount of heat lost to the external environment. Time of day also affects body temperature with the lowest temperature at 6 AM and the highest body temperature at 4 PM in healthy people. The circadian rhythm alters body temperature about 0.5 C (0.9 F) throughout each day. An acceptable temperature range for adults depends on age, gender, range of physical activity, and state of health.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 272 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 27.One of the ways the body increases heat production is through: a.convection. b.radiation. c.shivering. d.evaporation.

ANS: C Shivering is an involuntary body response to temperature differences in the body. Shivering can increase heat production 4 to 5 times greater than normal. Radiation is the transfer of heat between two objects without physical contact. Heat radiates from the skin to any surrounding cooler object. Up to 85% of the human bodys surface area

radiates heat to the environment. A small amount of heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object, heat transfers from the skin to the object until the temperatures equalize. Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. The rate of heat loss increases when moist skin comes into contact with slightly moving air. Through evaporation, heat energy transfers from a liquid to a gas state. The body continuously loses heat by evaporation; approximately 600 to 900 mL of water evaporates daily from the skin and lungs.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 272 | 273 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 28. When the fever breaks, the temperature returns to an acceptable range and the patient becomes:

a.febrile. b.afebrile. c.fever of unknown origin (FUO). d.pyrexic.

ANS: B When the fever breaks, the temperature returns to an acceptable range and the patient becomes afebrile (a- means not or without, so afebrile means without fever ). A true fever results from an alteration in the hypothalamic set point. Substances that trigger the immune system, such as bacteria or viruses, stimulate the release of hormones in an effort to promote the bodys defense against infection. These hormones also trigger the hypothalamus to raise the set point, inducing a febrile episode. Febrile means the patient does have a fever. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined. The condition of pyrexia or fever occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 273 | 274 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 29. What term refers to a fever whose cause cannot be determined?

a.Febrile b.Afebrile c.Fever of unknown origin (FUO) d.Pyrexic ANS: C The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined. When the fever breaks, the temperature returns to an acceptable range and the patient becomes afebrile (a- means not or without , so afebrile means without fever ). A true fever results from an alteration in the hypothalamic set point. Substances that trigger the immune system, such as bacteria or viruses, stimulate the release of hormones in an effort to promote the bodys defense against infection. These hormones also trigger the hypothalamus to raise the set point, inducing a febrile episode. The condition of pyrexia or fever occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. Febrile means the patient does have a fever.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 273 | 274 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 30. Medications that reduce fever by interfering with the hypothalamic response include:

a.salicylates. b.acetaminophen. c.ibuprofen. d.corticosteroids.

ANS: D Antipyretics are medications that reduce fever. Nonsteroidal drugs such as acetaminophen, salicylates, indomethacin, ibuprofen, and ketorolac reduce fever by increasing heat loss. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:274 | 275 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 31. An elevated body temperature related to the bodys inability to promote heat loss or reduce heat production is

known as:

a.hyperthermia. b.heat stroke. c.hypothermia. d.fever of unknown origin.

ANS: A An elevated body temperature related to the bodys inability to promote heat loss or reduce heat production is hyperthermia (hyper- means excessive ; therm means heat ). Prolonged exposure to the sun or high environmental temperatures overwhelms the bodys heat loss mechanisms. Heat also depresses hypothalamic function. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40.2 C (104.4 F) or more. Heat loss during prolonged exposure to cold overwhelms the bodys ability to produce heat, causing hypothermia. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 274 | 275 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 32.A regular interval interrupted by an early beat, late beat, or missed beat indicates an abnormal rhythm or: a.dysrhythmia. b.tachycardia. c.bradycardia. d.a pulse deficit.

ANS: A A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults. An inefficient contraction of

the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 33. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates:

a.dysrhythmia. b.tachycardia. c.bradycardia. d.a pulse deficit.

ANS: D An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 34. Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as:

a.diastolic pressure. b.pulse pressure. c.hypertension. d.systolic pressure.

ANS: D Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure.

When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. The difference between systolic and diastolic pressure is the pulse pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure (BP). Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 35. When the ventricles relax, the blood remaining in the arteries exerts a minimum or:

a.diastolic pressure. b.pulse pressure. c.hypertension. d.systolic pressure.

ANS: A

When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure. The difference between systolic and diastolic pressure is the pulse pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure (BP). Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 36.What is the difference between systolic and diastolic pressure? a.Diastolic pressure b.Pulse pressure c.Hypertension d.Systolic pressure ANS: B The difference between systolic and diastolic pressure is the pulse pressure. For a blood pressure (BP) of 120/80 mm Hg, the pulse pressure is 40. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated BP. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 37.A systolic blood pressure (BP) less than 90 mm Hg or a diastolic BP less than 60 mm Hg is known as: a.hypertension. b.hypotension. c.orthostatic hypotension. d.postural hypotension.

ANS: B Hypotension is a systolic blood pressure (SBP) less than 90 mm Hg or a diastolic blood pressure (DBP) less than 60 mm Hg. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure. Hypertension is defined as SBP greater than 140 mm Hg, DBP greater than 90 mm Hg. Orthostatic hypotension, also referred to as postural hypotension, is a reduction of SBP of at least 20 mm Hg or reduction of DBP of at least 10 mm Hg within 3 minutes of quiet standing. It occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and is associated with symptoms of lightheadedness or dizziness.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 38.When patients with normal blood pressure experience a drop in blood pressure upon rising to an upright

position and have symptoms of light-headedness or dizziness, the condition is known as: a.hypertension. b.hypotension. c.orthostatic hypotension. d.the pulse pressure.

ANS: C Orthostatic hypotension , also referred to as postural hypotension, is a reduction of systolic blood pressure (SBP) of at least 20 mm Hg or reduction of diastolic blood pressure (DBP) of at least 10 mm Hg within 3 minutes of quiet standing. It occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and it is associated with symptoms of lightheadedness or dizziness. Hypotension is a SBP less than 90 mm Hg or a DBP less than 60 mm Hg. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated BP. Hypertension is defined as SBP greater than 140 mm Hg, DBP greater than 90 mm Hg. The difference between systolic and diastolic pressure is the pulse pressure.

For a blood pressure of 120/80 mm Hg, the pulse pressure is 40.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 39.The mechanical movement of gases into and out of the lungs is known as: a.respiration. b.ventilation. c.perfusion. d.eupnea.

ANS: B Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells.

Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O 2 ] and carbon dioxide [CO 2 ] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries). The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 40. The movement of oxygen and carbon dioxide between the alveoli and the red blood cells is known as:

a.diffusion. b.perfusion. c.respiration. d.eupnea.

ANS: A Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells.

Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O 2 ] and carbon dioxide [CO 2 ] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries). The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 41. What term refers to the distribution of red blood cells to and from the pulmonary capillaries? a. Diffusion b.Perfusion c.Respiration d.Eupnea

ANS: B Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells.

Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O 2 ] and carbon dioxide [CO 2 ] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries). The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. The bodys tissues and cells function efficiently within a relatively narrow temperature range, from 36 to 38 C

(96.8 to 100.4 F). Factors that cause fluctuations in body temperature include which of the following? (Select all that apply.) a.The bodys core temperature b.Age c.Time of day d.Circadian rhythm e.physical activity ANS: B, C, D, E The bodys tissues and cells function efficiently within a relatively narrow temperature range, from 36 to 38 C (96.8 to 100.4 F), but no single temperature is normal for all people. For healthy young adults the average oral temperature is 37 C (98.6 F). In the elderly population, the average core temperature ranges from 35 to 36.1 C (95.0 to 97.0 F) because of decreased immunity. Time of day also affects body temperature with the lowest temperature at 6 AM and the highest body temperature at 4 PM in healthy people. The circadian rhythm alters body temperature about 0.5 C (0.9 F) throughout each day. An acceptable temperature range for adults depends on age, gender, range of physical activity, and state of health. Despite environmental temperature extremes and physical activity, temperature-control mechanisms of human beings keep the bodys core temperature , or temperature of deep tissues, relatively constant during sleep, during exposure to cold, and during strenuous exercise.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 272 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 2.A registered nurse is caring for a patient who was admitted to the hospital after being involved in a motor vehicle

accident. The patient has undergone two surgeries and now has a health careacquired infection. Multiple medications were ordered. Which of the following would be appropriate for the nurse to administer to reduce the fever without masking signs of infection? (Select all that apply.) a.Acetaminophen b.Corticosteroid c.Ibuprofen d.Indomethacin e.Salicylates ANS: A, C, D, E Nonsteroidal drugs such as acetaminophen, salicylates, indomethacin, ibuprofen, and ketorolac reduce fever by increasing heat loss. Health care providers order antipyretics if a fever is greater than 39 C (102.2 F). Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:274 | 275 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3. Any injury to the hypothalamus impairs heat loss mechanisms. Educate patients at risk for hyperthermia to do

which of the following? (Select all that apply.)

a. Avoid strenuous exercise in hot, humid weather. b. Avoid exercising in areas with poor ventilation.

c.Drink clear fluids before and after exercising, not during. d.Wear light, loose-fitting clothing. e.Do not visit hot climates.

ANS: A, B, D Any injury to the hypothalamus impairs heat loss mechanisms. Educate patients at risk for hyperthermia to do the following: avoid strenuous exercise in hot, humid weather; avoid exercising in areas with poor ventilation; drink fluids such as water and clear fruit juices before, during, and after exercise; wear light, loose-fitting, light-colored clothing; wear a protective covering over the head when outdoors; and expose themselves to hot climates gradually.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:275 OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 4. Core temperatures are obtained via which of the following? (Select all that apply.)

a.Axillae b.Rectal c.Oral d.Pulmonary artery e.Urinary bladder ANS: D, E

The core temperatures of the pulmonary artery, esophagus, and urinary bladder are often used in critical care settings and require continuous invasive monitoring devices placed in arteries or internal orifices. The most common sites for intermittent temperature measurements are surface sites, such as the tympanic membrane, temporal artery, mouth, rectum, and axilla.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:275 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 5. Blood pressure depends on the interrelationships of which of the following? (Select all that apply.)

a.Cardiac output b.Peripheral vascular resistance c.Blood volume d.Blood viscosity e.Pulse pressure ANS: A, B, C, D Blood pressure depends on the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity. The difference between systolic and diastolic pressure is the pulse pressure.

For a BP of 120/80 mm Hg, the pulse pressure is 40.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 6. The nurse has assessed the need to check the patient for orthostatic hypotension. Conditions that would cause the

nurse to be concerned about this would be which of the following? (Select all that apply.) a.Dehydration b.Obesity c.Recent blood loss d.Cigarette smoking e.Prolonged bed rest ANS: A, C, E

Fluid volume deficit from decreased blood volume, dehydration, or recent blood loss, as well as prolonged bed rest, anemia, or antihypertensive medications, place patients at risk for orthostatic hypotension. Obesity, cigarette smoking, excessive alcohol intake, elevated blood cholesterol, and continued exposure to stress are also linked to hypertension.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 7. While being tested for orthostatic hypotension, the patient stands up and begins to feel light-headed and feels

faint. The nurse should do which of the following? (Select all that apply.)

a.Have the patient lie down. b.Report findings to the health care provider. c.Have the nursing assistive personnel (NAP) check orthostatic blood pressure. d.Instruct the patient not to get out of bed without assistance. e.Take the BP in each arm and use the arm with the lowest systolic reading.

ANS: A, B, D Orthostatic hypotension occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and is associated with symptoms of lightheadedness or dizziness. If orthostatic signs or symptoms such as dizziness, weakness, lightheadedness, feeling faint, or sudden pallor occur, stop BP measurement and return patient to a supine position. Report the findings of orthostatic hypotension or orthostatic signs or symptoms to the nurse in charge or the health care provider. Instruct the patient to ask for assistance when getting out of bed if orthostatic hypotension is present or orthostatic signs or symptoms occur. The skill of measuring orthostatic blood pressure (BP) cannot be delegated to nursing assistive personnel (NAP) in an unstable patient. With the patient supine, take a BP reading in each arm. Select the arm with the highest systolic reading for subsequent measurements.

PTS:1DIF:Cognitive Level: Applying (Application) REF:284 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8. The nurse is obtaining an oxygen saturation reading from a female patient who was brought in after collapsing at

a party. Factors that may lead to inaccurate SpO 2 readings include which of the following? (Select all that apply.) a.Using a pulsatile area to attach the probe b.The patient wearing fingernail polish c.Measuring the level intermittently d.The patient being anemic e.Measuring the level continuously ANS: B, D

A vascular, pulsatile area (e.g., fingertip or earlobe) is needed to detect the degree of change in the transmitted light. Factors that affect light transmission (e.g., sensor movement, fingernail polish) or peripheral arterial pulsations (e.g., hypotension, anemia) also affect the measurement of SpO 2 . An awareness of these factors allows for accurate interpretation of abnormal SpO 2 measurements. Measuring SpO 2 can be conducted intermittently or continuously to assess ongoing therapies.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 290 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 9.Two common abnormalities in heart rate are: a.dysrhythmia. b.apical pulse. c.tachycardia. d.bradycardia. e.pulse deficit.

ANS: C, D

Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia . Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults.

Bradycardia is a slow rate, less than 60 beats per minute in adults. A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. The apical pulse is located on the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

Chapter 16: Health Assessment and Physical Examination Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during

inspiration and expiration. These sounds can best be described as which of the following? a.Crackles b.Rhonchi c.Wheezes d.A friction rub ANS: B

Rhonchi are loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration. They may be cleared by coughing. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Moist crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. A pleural friction rub has a dry, grating quality heard during inspiration; does not clear with coughing; heard loudest over lower lateral anterior surface.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:344 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2. The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate the patients abdomen?

a.Palpate tender areas last. b.Palpate tender areas first to get it over. c.Palpate tender areas before inspection. d.Palpate before auscultation.

ANS: A Because palpation involves the use of the hands to touch body parts and make sensitive assessments, palpate tender areas last . Palpation typically occurs right after inspection. When examining the abdomen, however, palpation occurs after auscultation. Palpate the abdomen for tenderness, distention, or masses.

PTS:1DIF:Cognitive Level: Applying (Application) REF:317 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 3. The registered nurse is precepting a first-year nursing student. She is demonstrating how to appropriately auscultate. Auscultation is defined as which of the following?

a.Listening with a stethoscope to sounds produced by the body file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

b.Tapping the body with the fingertips to produce a vibration c.Becoming familiar with the nature and source of body odors d.Using the hands to touch body parts to make a sensitive assessment ANS: A Auscultation is listening for sounds produced by the body. Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues. Olfaction, or smelling, helps to detect abnormalities not recognized by other means. Unusual smells lead to detection of serious abnormalities. Palpation involves the use of the hands to touch body parts and make sensitive assessments.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:317 | 318 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 4.A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment.

After using light palpation to examine the patient, the nurse uses deep palpation. With deep palpation the nurse does which of the following? a.Performs a completely safe method of examination b.Should use two hands only c.Uses the upper hand to exert an upward pressure d.Can examine the condition of organs ANS: D After light palpation, use deeper palpation to examine the condition of organs. Depress the area you are examining deeply and evenly. Caution is the rule. To avoid injuring a patient, do not try deep palpation without clinical supervision. Apply deep palpation with one hand or both hands (bimanually). Bimanual palpation involves one hand placed over the other while applying pressure. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.

PTS:1DIF:Cognitive Level: Applying (Application) REF:317 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 5.A nurse is preparing to perform a physical examination on a patient who has mobility issues. In preparing for the examination, the nurse should do which of the following? a.Be sure that a well-equipped examination room is available. b.Tune the radio to the nurses favorite station to relax the patient. c.Perform thorough hand hygiene before preparing equipment. d.Instruct the patient on the safest way to transfer onto the examination table.

ANS: C Perform hand hygiene before equipment preparation and the examination. A well-equipped examination room is preferable, but often the examination occurs in the patients room. In the home you may perform the examination in the patients bedroom. Be sure to eliminate other sources of noise, take precautions to prevent interruptions, and make sure the room is warm enough to maintain comfort. Patients with mobility impairments require safe transfer to an examination table. The patient is the expert and should be asked how to safely move from the bed to the file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

table, either with a standing assisted transfer or by being lifted, as with a child or small adult.

PTS:1DIF:Cognitive Level: Applying (Application) REF:319 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 6.A registered nurse is preparing to perform a physical examination on a 5-year-old child. To make the child feel safer during the examination the nurse should do which of the following? a.Examine the childs fingernails before listening to his breath sounds. b.Question only the child so as to avoid unwanted parental influence. c.Perform palpation before visual inspection. d.Calls the parents by their first names to establish a more trusting bond.

ANS: A Children will feel safer during an examination if it is initiated from the periphery and then moves to the central. For example, examine the extremities before moving to the chest. It also helps to perform parts of the examination that you can do visually before actually touching the child. When obtaining histories of infants and children, gather all or part of the information from parents or guardians. Call children by their preferred name, and address parents formally (e.g., as Mr. and Mrs. Brown) rather than by first names.

PTS:1DIF:Cognitive Level: Applying (Application) REF:320 | 321 OBJ:List techniques to promote the patients physical and psychological comfort during an examination.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A nurse is preparing to perform a physical exam on a patient. She has found that it is best to perform the physical with a head-to-toe approach. Why is this important? a.The head-to-toe format excludes unnecessary body systems. b.It is a methodical way to include all body systems. c. It reduces time by allowing examination of only one side. d. It requires that painful procedures be done first.

ANS: B A head-to-toe approach includes all body systems and helps to anticipate each step. In an adult, a nurse begins by assessing the head and neck, progressing methodically down the body to include all body systems. Both sides of the body must be compared for symmetry. Any painful procedures should be performed near the end of the examination.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:322 OBJ:List techniques to promote the patients physical and psychological comfort during an examination.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 8.A nurse is admitting a 79-year-old woman with a fractured hip to the orthopedic unit. Her husband states that she file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

broke her hip when she tripped in her garden. Upon examination, the nurse notes purple, green, and yellow bruises on the back and arms. The patient states that those were received when she fell. The nurse should do which of the following? a.Ask the husband to wait in the waiting room. b. Ignore the bruises because the patient has provided an explanation. c.Realize that the patient may be abused, but that is a family issue. d.Prepare to discharge the patient home once treatment is complete.

ANS: A Patients are more likely to reveal problems when the suspected abuser is not present in the room. Psychological abuse as well as obvious physical injury or neglect (e.g., evidence of malnutrition or presence of bruising on the extremities or trunk) should be assessed. If you have suspicion of abuse, find a way to interview the patient privately. If you assess a pattern of findings indicating abuse, most states mandate a report to a social service center. (Refer to state guidelines.) Obtain immediate consultation with a health care provider, social worker, and other support staff to facilitate placement in a safer environment .

PTS:1DIF:Cognitive Level: Applying (Application) REF: 323 OBJ: Communicate abnormal findings to appropriate personnel.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 9. The student nurse has been assigned to the pediatric unit for her clinical training this semester. She is assisting

with the admission of a 5-month-old infant admitted with pneumonia. The student nurse is responsible for taking the childs vital signs and weighing and measuring the child. The infants mother is very concerned when the student nurse tells her that the baby weighs 14 pounds. The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home. What is the student nurses best response to the mothers concern? a.To get an accurate weight, babies are weighed at different times of the day. b.Variations occur because we place our hand firmly on the child. c. Even if we use the same scale, the variation can be 1 to 2 pounds. d.Weight measurements can vary with different scales.

ANS: D Different scales can give different weights for patients. To ensure accurate clinical decisions, weigh patients at the same time of day, on the same scale, and in the same clothes. Hold a hand lightly above the infant to prevent accidental falls. The scale can measure in weight increments to the nearest 0.1 pound or 0.1 kg.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 10. An older adult African-American woman has gone to the clinic where a RN volunteers twice a week. She is a diabetic and has some skin breakdown on the calf of her right leg. Her skin is very darkly pigmented. To best examine the patients skin, the nurse should use which of the following?

a.Halogen lighting b.Artificial warming to increase room temperature c.Natural sunlight d. Air conditioning to lower room temperature ANS: C file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

The recommended light is natural sunlight, with halogen lighting being another option. Sunlight is the best choice for detecting skin changes in patients with darker skin. A room that is too warm causes superficial vasodilation, resulting in an increased redness of the skin. Patients who become too cold by air conditioning can develop cyanosis (bluish color) around the lips and nail beds.

PTS:1DIF:Cognitive Level: Applying (Application) REF:325 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 11. An older adult patient complains of thirst, headache, and weight loss. The patient appears emaciated. On

physical assessment the nurse finds that the patients skin does not return to normal shape after being assessed. This finding is consistent with which of the following? a.Pallor b.Cyanosis c.Erythema d.Poor skin turgor ANS: D Turgor is the skins elasticity. To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Normally the skin lifts easily and snaps back immediately to its resting position.

The skin stays pinched or tented when turgor is poor. You can see pallor (unusual paleness) more easily in the face, buccal mucosa (mouth), conjunctivae, and nail beds. Localized skin changes, such as pallor or erythema (red discoloration), often indicate circulatory changes or are caused by localized vasodilation resulting from sunburn or fever. Observe for cyanosis (bluish discoloration) in the lips, nail beds, palpebral conjunctivae, and palms.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:325 | 326 | 328 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 12.A student nurse is helping admit a 77-year-old man to the surgical floor of an acute care hospital. The patient has an abdominal tumor that is scheduled to be removed. He has had nothing by mouth (NPO) since midnight in preparation for his surgery. The student nurse notes that the patients skin is very dry and scaly. Which of the following should the student nurse investigate further as the most likely cause for the patients dry skin? a. Excess humidity in the patients living environment b.The use of excessive soap when bathing c.Lack of sun exposure leading to decreased stimulation of sweat glands d.Decreased levels of stress

ANS: B Excessively dry skin is common in older adults and persons who use excessive amounts of soap during bathing.

Other factors causing dry skin include lack of humidity, exposure to sun, smoking, stress, excessive perspiration, and dehydration. Excessive dryness worsens existing skin conditions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:327 file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 13. The patient recently had a cast applied to his left lower leg after a football injury in which he broke his tibia.

After the application of the cast, the nurse felt the toes of his left and right feet. To assess circulation in the left foot, the nurse should do which of the following? a.Use the tips of her fingers to assess temperature. b. Expect that the temperature in the left leg will be lower than that in the right. c. Expect that the temperature of the left foot to be the same as the right foot. d. Expect that the left foot will be warmer than the left.

ANS: C

Compare symmetrical body parts, which should be the same in assessment. Always assess skin temperature for patients at risk for impaired circulation, such as after a cast application or vascular surgery. Normally the skin temperature is warm. Skin temperature is the same throughout the body. Accurately assess temperature by palpating the skin with the dorsum , or back, of the hand.

PTS:1DIF:Cognitive Level: Applying (Application) REF:327 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 14. An RN is assessing an 87-year-old patient who has gone to the clinic to see the health care provider for a follow-up appointment. The nurse notes that the patient looks tired and has dark circles under her eyes. She assesses her skin turgor, which is poor. She is concerned because she knows that poor skin turgor can predispose the patient to which of the following?

a.Dehydration b.Edema c.Skin breakdown d.Direct trauma ANS: C A decrease in turgor predisposes a patient to skin breakdown. Turgor is the skins elasticity. Normally the skin loses its elasticity with age. Edema or dehydration diminishes turgor. Direct trauma and impairment of venous return are two common causes of edema.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:328 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 15.A single mother with three school-age children has recently noticed that the second child has been scratching his head and complains that it itches. She asks the school nurse to examine him. The school nurse notes that the child has head lice. Which of the following is the best description of head lice? a. Lice are easy to see and look like little white crabs. b. Lice are difficult to see, but their eggs are small oval particles. c. Lice and their eggs are on the hair shafts and look like dandruff. file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

d.Treatment for lice can wait until the entire family can be checked.

ANS: B Head and crab lice attach their eggs to hair. Lice eggs look like oval particles of dandruff. The lice themselves are difficult to see. Observe for bites or pustular eruptions in the follicles and in areas where skin surfaces meet, such as behind the ears and in the groin. The discovery of lice requires immediate treatment and family education.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:329 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 16.The nurse is assessing an older adult who has smoked for the past 47 years and has been diagnosed with chronic obstructive pulmonary disease. Which of the following would the nurse expect to see upon physical examination of the patient? a.Pallor and hardening of the nail bed b.Jaundice in the nail bed c.An angle greater than 160 degrees between the nail and nail bed d.An angle less than 160 degrees between the nail and nail bed ANS: C Inspection of the angle between the nail and nail bed normally reveals an angle of 160 degrees. A larger angle and softening of the nail bed indicate chronic oxygenation problems. An ongoing bluish or purplish cast to the nail bed occurs with cyanosis. A white cast or pallor results from anemia. Observe for jaundice (yellow-orange), which indicates liver disease.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:330 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 17.A 47-year-old patient is being treated for hyperthyroidism. When she goes to the health care provider for a check-up, the nurse in the clinic expects to see which of the following physical symptoms? a.Exophthalmos b.Strabismus c.Photophobia d.Diplopia ANS: A Bulging eyes (exophthalmos) usually indicate hyperthyroidism. The crossing of eyes (strabismus) results from neuromuscular injury or inherited abnormalities. Assess for common symptoms of eye disease such as eye pain, photophobia (sensitivity to light), burning, itching, excessive tearing, diplopia (double vision), blurred vision, or visual disturbances (e.g., flashing lights, halos, or film over vision field).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:331 OBJiscuss normal physical findings for patients across the life span. file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 18.The nurse is assessing an elderly patient and notices a significant drooping of the eyelid. The nurse recognizes this as which of the following? a.Ectropion of the eyelid b.Entropion of the eyelid c.Impairment of the fourth cranial nerve d.Ptosis of the eyelid ANS: D An abnormal drooping of the lid over the pupil is called ptosis , caused by edema or impairment of the third cranial nerve. In the older adult, ptosis results from a loss of elasticity that accompanies aging. An older adult frequently has lid margins that turn out (ectropion) or in (entropion).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:332 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 19.A 17 year old was taken to the emergency department when his mother found him unresponsive. Upon examination, his pupils were found to be pinpoints. This is a common sign of which of the following? a.Opioid intoxication b.Arcus senilis c.Cataracts d.Opioid withdrawal ANS: A Pinpoint pupils are a common sign of opioid intoxication. A thin white ring along the margin of the iris, called an arcus senilis, is common with aging but is abnormal in anyone less than age 40. Cloudy pupils indicate cataracts.

Continuous dilation of pupils results from neurological disorders, glaucoma, trauma, eye medication, or withdrawal from opioids.

PTS:1DIF:Cognitive Level: Applying (Application) REF:333 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 20.On examination of an 18-month-old child, the nurse found the right eardrum pink and bulging. How should a normal eardrum appear? a.Pink b.Red c.Pearly gray d.White ANS: C The normal eardrum is translucent, shiny, and pearly gray. It is free from tears or breaks. A pink or red bulging membrane indicates inflammation. A white color reveals pus behind it. The membrane is taut, except for the small file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

triangular pars flaccida near the top. If cerumen is blocking the tympanic membrane, warm water irrigation will safely remove the wax.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:335 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 21.A woman went to the public health clinic with a fever that had persisted for several days. Upon palpation of the neck, a registered nurse found several large lymph nodes. What is the nurses best response to this patient upon palpating her lymph nodes? a.There is no need to worry; enlarged lymph nodes are normal findings. b.Lymph nodes are not really significant because they really have no function. c.Most people have a few enlarged lymph nodes. d.Enlarged lymph nodes sometimes indicate an infection.

ANS: D Lymph nodes that are large, fixed, inflamed, or tender indicate a problem such as local infection, systemic disease, or neoplasm. Enlarged lymph nodes are not normal. Normally lymph nodes are not easily palpable. An extensive system of lymph nodes collects lymph from the head, ears, nose, cheeks, and lips.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:339 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 22.A 45-year-old gay man who lives with a partner of 19 years recently has developed a persistent cough and night sweats from which he wakes up soaked. The nurse who is caring for the man should be most concerned about which of the following conditions? a.Lung cancer b.Tuberculosis c.Orthopnea d.Cardiopulmonary disease ANS: B Persistent cough and night sweats are symptoms of tuberculosis (TB). Review risk factors for TB and/or HIV infection and assess for symptoms, including persistent cough, hemoptysis, unexplained weight loss, fatigue, anorexia, night sweats, and fever. Ask the patient about persistent cough (productive or nonproductive), bloodstreaked sputum , voice change , chest pain , shortness of breath, orthopnea (must be in upright position to breathe), dyspnea (breathlessness) during exertion or at rest, poor activity tolerance, or recurrent pneumonia or bronchitis .

This may reveal cardiopulmonary problems or warning signs for lung cancer (symptoms in italics).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:341 | 342 OBJiscuss normal physical findings for patients across the life span.

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23.A nurse inspects the thorax of an older adult patient who has chronic lung disease. An expected finding would be a(n): a.round shape of the chest. b.barrel-shaped chest. c. AP diameter greater than the transverse diameter. d. AP diameter less than the transverse diameter.

ANS: B In adults, a barrel-shaped chest (AP diameter = transverse) characterizes chronic lung disease. Normally the chest is symmetrical, with the anteroposterior diameter one third to one half the size of the transverse diameter. Infants have an almost round shape with a 1:1 ratio between the AP and transverse diameters. In addition, a more rounded chest is associated with older age.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:342 OBJiscuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 24.A nurse can best auscultate the point of maximum impulse (PMI) in a teenager at the midclavicular line.

intercostal space,

a.fifth; left b.fourth; left c.fifth; right d.fourth; right ANS: A The point of maximal impulse (PMI) is palpable at the fifth intercostal space at the left midclavicular line in adults and children older than 7 years of age. In children younger than age 7 the PMI is at the fourth intercostal space at the left midclavicular line PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:345 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 25. At a point during the admission process of a young female patient, the nurse asks the patient about whether or not she performs self-breast examinations. The patient asks about the best time of the month to perform this examination. What is the best response?

a.Usually the first day of your menstrual period is best. b.At the same time every month. c. If youre pregnant there is no need to do it. d. A few days after your menstrual period ends.

ANS: D The best time for BSE is when the breasts are not tender or swollen, usually a few days after a menstrual period ends. If the woman is postmenopausal, advise her to check her breasts on the same day each month. A pregnant woman should also check her breasts on a monthly basis. file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:353 OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 26. The nurse is caring for a 22-year-old woman who has come in for a routine examination. The patient asks about how often she should perform breast self-examinations and get a mammogram. The nurse should inform the patient of which of the following?

a.Monthly breast self-examinations are optional for women in their twenties and thirties. b.Women less than 40 need a clinical breast exam by a health care provider yearly. c.Asymptomatic women need mammograms yearly until age 40. d.Women greater than age 40 need mammograms every 6 months.

ANS: A Monthly BSE is an option for women in their twenties and thirties. Women 20 years of age and older need to report any breast changes to a health care provider immediately. Women need a clinical breast examination by a health care provider every 3 years from age 20 to 40, and yearly for women greater than age 40. Women with a family history of breast cancer need a yearly examination by a health care provider. Asymptomatic women need a screening mammogram by age 40; women age 40 and older need an annual mammogram. For women with an increased risk, the ACS recommends discussion of screening options and additional testing with a health care provider.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:353 OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 27.A nurse uses four basic skills during a physical assessment. While assessing the abdomen the nurse must begin with which of the following skills? a.Light palpation b.Inspection c.Deep palpation d.Auscultation ANS: B The order of abdominal assessment differs from previous assessments. First the nurse begins by inspection, followed by auscultation. By using auscultation before palpation (light or deep), there is less chance of altering the frequency and character of bowel sounds.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:358 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 28.An adolescent is examined and told that she has a sexually transmitted disease (STI). The patient is shocked and states, How can that be. I would know if I had a problem down there wouldnt I? What is the most appropriate response by the nurse? file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

a.You should have known. Its pretty hard to miss. b.Usually STIs show up within 2 to 3 days of exposure. c. If youd like, we can teach you some self-examination techniques. d. Its just bad luck. Well clear this up and that will be the end of it.

ANS: C Patients who are at risk for contracting STIs need to learn to perform a genital self-examination. The purpose of the examination is to detect any signs or symptoms of STIs. Many persons do not know they have an STI (e.g., chlamydial infection), and some STIs (e.g., syphilis) can remain undetected for years. Therefore it is essential to stress the importance of regular screening for STIs in sexually active individuals.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:362 OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 29.A nurse is assisting with a female genitalia examination. The nurse will assist the patient to which position? a.Supine b.Lithotomy c.Knee-chest d.Dorsal recumbent ANS: B The lithotomy position provides maximal exposure of the rectal area. The supine position is used to assess the head, neck, anterior thorax, lungs, breasts, axillae, heart, abdomen, extremities, and pulses. It is the most normally relaxed position. The knee-chest position is used to examine the rectum. The dorsal recumbent position is used to assess the head, neck, anterior thorax, lungs, breasts, axillae, heart, and abdomen. This position is used for abdominal assessment because it promotes relation of abdominal muscles.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:321 OBJ: Describe proper positioning for the patient during each phase of the examination.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 30.A patient is complaining of nonspecific abdominal pain. What is the technique the nurse uses to assess tenderness? a.Palpation b.Percussion c.Auscultation d.Olfaction ANS: A Palpation primarily detects areas of abdominal tenderness, distention, or masses. Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues. The resulting sounds give information about the location, size, and density of underlying structures and help verify abnormalities assessed by palpation and auscultation. Auscultation is listening for sounds produced by the body and is not used to assess tenderness. Olfaction, or smelling, helps to detect abnormalities not recognized by other means. Unusual smells can file:///D|/...ursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-16-health-assessment-and-physical-examination.html[21/04/2019 17:43:17]

lead to detection of serious abnormalities.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:317 | 318 | 319 OBJescribe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is meeting a patient for the first time. The importance of establishing baseline data is that it will enable the nurse to assess which of the following? (Select all that apply.) a.Know the baseline information about the patients health status. b.Supplement, confirm, or refute information learned during the history taking. c.Identify or confirm nursing diagnoses. d.Assess the patients understanding of the disease process. e.Focus on a specific body system.

ANS: A, B, C, D Use a physical assessment to gather baseline information about the patients health status, supplement, confirm, or refute information learned during the history taking, identify or confirm nursing diagnoses, make clinical judgments about the patients current or changing health status and ability to manage it, and evaluate the outcomes of care. A focused health assessment is selected to gather information related to a specific body system, as happens when a patient first presents to the hospital or for a specific screening purpose, such as for cholesterol or blood glucose levels.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 315 | 316 OBJ: Discuss the purposes of the health assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2.A patient is admitted from the emergency department. The nurse notices that the patient and family are anxious.

During the admission process the nurse should do which of the following? (Select all that apply.) a.Continue with the examination even if the patient is anxious to get it done. b.Disregard cultural differences to gather therapeutic data. c.Provide a thorough explanation of the purpose of each assessment. d.Provide a thorough explanation of the steps of each assessment. e.Maintain a formal professional approach.

ANS: C, D Many patients find an examination tiring or stressful, or they experience anxiety about possible findings. A thorough, simple, and clear explanation of the purpose and steps of each assessment lets patients know what to expect and helps them cooperate with each step. As you examine each body system, give a detailed explanation.

Convey an open, professional, and relaxed approach. A stiff, formal approach will inhibit the patients ability to communicate, but being too casual will not give the patient confidence in your ability. It is sometimes necessary to stop the examination and ask how the patient feels. Do not force a patient to continue. Findings will be more accurate if you postpone for when the patient can cooperate and relax. Remember that cultural differences influence a patients behavior. Consider the patients health beliefs, use of alternative therapies, nutritional habits, relationships with family, and comfort with your physical closeness during the examination and history taking. If necessary, obtain a medical translator who can correctly interpret to a patient who does not speak English.

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REF:316 | 320 OBJ: Prepare a therapeutic environment before the physical examination.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3.Risk factors for breast cancer in women include which of the following? (Select all that apply.) a.Age greater than 40 b.BRCA 1 and 2 gene mutations c.Late onset menarche d.Early menopause e.Use of contraceptives ANS: A, B, E Risk factors include being a woman greater than age 40, a personal or family history of breast cancer, especially with the BRCA1 and BRCA2 inherited gene mutations. Also early-onset menarche (before age 12), or late-age menopause (after age 55) affect risk. Other risk factors include never having children, giving birth to the first child after age 30, recent use of oral contraceptives, previous chest radiation, alcohol use, and being overweight.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:353 OBJ: Identify data to collect from the nursing history before an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

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Chapter 17: Administering Medications Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A registered nurse for more than 15 years was concerned when she learned that her hospital was going to let unlicensed nursing assistants start IVs on patients. The nurse knew this was in violation of the scope of nursing practice in her state. Which of the following organizations defines the scope of nursings professional functions and responsibilities? a.The US Food and Drug Administration (FDA) b.The MedWatch program c.Employee assistance programs (EAP) d.State Nurse Practice Acts ANS: D State Nurse Practice Acts have the most influence over nursing practice because they define the scope of nurses professional functions and responsibilities. The primary intent of state Nurse Practice Acts is to protect the public from unskilled, undereducated, and unlicensed nurses. The FDA ensures that all medications on the market undergo rigorous review before allowing manufacturers to distribute them to the public. In 1993, the FDA instituted the MedWatch program. This voluntary program encourages nurses and other health care professionals to report when a medication, product, or medical event causes serious harm to a patient. Mandatory reporting is required for medication manufacturers, distributors, and packers. A wide variety of programs to help people who abuse medications are offered through an institutions employee assistance program (EAP), the State Board of Nursing, and community agencies.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:378 | 379 OBJ: Discuss legal responsibilities in medication prescription and administration.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 2.A 34 year old has been on morphine for 6 months after back surgery and has gone to multiple health care providers to obtain prescriptions. Which term best describes this situation? a.Medication dependence b.Medication abuse c.Medication misuse d.Medication underuse ANS: B Medication abuse happens when patients repeatedly use an addictive substance (e.g., opioids or alcohol).

Medication dependence happens when a patient experiences withdrawal symptoms when the medication is stopped abruptly. Medication misuse includes overuse, underuse, erratic use, and contraindicated use of medications.

Patients of all ages misuse medications. Some people use medications for purposes other than their intended effect.

Medication underuse occurs when people use medications less than the amount intended when symptoms subside PTS:1DIF:Cognitive Level: Applying (Application) REF:379 OBJ: Discuss legal responsibilities in medication prescription and administration. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 3.A patient calls to say that he is unable to pay for the medication from a specific manufacturer that was prescribed. The health care provider gives another name for the medication and suggests the patient look for this name instead. The new name was probably which of the following? a.Generic b.Trade c.Chemical d.Proprietary ANS: A The trade or brand name (e.g., Tylenol) is the name under which a manufacturer markets a medication. The trade name has the symbol to the upper right of the name, indicating that the manufacturer has registered the

medications name.

Acetaminophen is an example of a generic name. It is the generic name for Tylenol. A medication sometimes has as many as three different names. A medications chemical name is an exact description of the medications composition and molecular structure. In clinical practice, health care workers rarely use chemical names. An example of a chemical name is N -acetyl- para -aminophenol, which is commonly known as Tylenol. The manufacturer who first develops the medication gives the generic or nonproprietary name with United States Adopted Names Council (USANC) approval. The generic name becomes the official name that is listed in publications such as the United States Pharmacopeia (USP).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:379 OBJ: Discuss legal responsibilities in medication prescription and administration.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 4.A patient is unable to swallow pain medication following oral surgery. What would be the appropriate form of the medication to use to administer the drug using the rectal route? a.Tablet b.Elixir c.Capsule d.Suppository ANS: D Medications are available in a variety of forms or preparations. The form of the medication determines its route of administration. Manufacturers make many medications in several forms, such as tablets, capsules, elixirs, and suppositories. Suppositories are solid dosage form mixed with gelatin and shaped in the form of a pellet for insertion into a body cavity (rectum or vagina). A suppository melts when it reaches body temperature, allowing the medication to be absorbed. A tablet is a powdered medication compressed into a hard disk or cylinder and designed to be taken orally. An elixir is a clear fluid containing water and alcohol; designed for oral use; usually sweetener has been added. A capsule is medication encased in a gelatin shell and taken orally.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:379 | 380 | 385 file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

OBJ: Describe factors to consider when choosing routes of medication administration.

TOP:Nursing Process: Diagnosis

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MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 5.A 12-year-old patient has undergone knee surgery. She has an order for pain medication, which can be given by several different routes. Which of the following routes of administration will provide the fastest pain relief? a.Transcutaneous b.Intravenous c.Oral d.Rectal ANS: B Intravenous (IV) injection produces the most rapid absorption because medications given in this route are immediately absorbed into the systemic circulation. When you place medications on the skin (transcutaneous), absorption is slow because of the physical makeup of the skin. The body also absorbs oral medications at a slow rate because these medications have to pass through the gastrointestinal (GI) tract. The body absorbs medications through the mucous membranes (rectal and buccal) and respiratory airways quickly because these tissues contain many blood vessels, but the intravenous route is fastest.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:379 | 380 OBJ: Describe factors to consider when choosing routes of medication administration.

TOP:Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 6.The nurse is preparing oral medications for a patient. In preparing these medications the nurse is aware of which of the following? a.Acidic medications are absorbed slowly by the gastric mucosa. b.Alkaline medications are absorbed rapidly by the gastric mucosa. c.Solutions and suspensions are more difficult to absorb than capsules. d.Alkaline medications are absorbed in the small intestine.

ANS: D The ability of an oral medication to dissolve depends largely on its formulation or preparation. Acidic medications are absorbed in the gastric mucosa rapidly, whereas medications that are alkaline are not absorbed until reaching the small intestine. Solutions and suspensions are already in a liquid state and are easier for the body to absorb than tablets or capsules.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 380 | 381 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 7.A nurse is caring for a patient with kidney disease. The nurse needs to make more focused assessments when administering medications to this patient because the patient may experience problems with the process of: a.excretion. b.absorption. c.distribution. d.metabolism.

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ANS: A The kidneys are the main organs that excrete medications. Some medications escape extensive metabolism and exit unchanged in the urine. Other medications undergo biotransformation in the liver before the kidneys excrete them.

If renal function declines, a patient is at risk for medication toxicity. Absorption refers to the passage of medication molecules into the blood from the site of administration. Medication is distributed within the body to tissues and organs to specific sites. After the medication reaches its site of action, it becomes metabolized (biotransformation).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 380 | 381 OBJ: Discuss factors that influence medication actions.

TOP:Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 8. The nurse is preparing to give an intramuscular (IM) injection of pain medication. The nurse prepares this medication knowing which of the following? a. Intramuscular (IM) medications are absorbed faster than subcutaneous medications.

b.Medication absorption is faster with subcutaneous medications. c.Blood supply to the subcutaneous tissue is richer than to muscle. d.Muscle tissue has a less developed vascular system than subcutaneous tissue.

ANS: A

The blood supply to the site of administration determines how quickly the body absorbs a drug. Sites with rich blood supplies absorb medications more quickly. For example, the body absorbs a medication administered in the muscle (intramuscular [IM] route) faster than a medication administered in the subcutaneous tissue (subcutaneous route) because the blood supply to muscle is richer than the blood supply to subcutaneous tissue.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:381 OBJ: Describe factors to consider when choosing routes of medication administration.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 9.A nurse is working with the pharmacist to determine when a patients medications should be given. Several medications are due to be given in the morning. What is the most important reason to appropriately schedule the patients medications? a.Some medications are absorbed more quickly on an empty stomach. b.All medications are hindered by the presence of gastric contents. c.If given at the same time, all medications will be absorbed at the same rate. d.The nurse must schedule medications to fit the pharmacys schedule.

ANS: A Some oral medications are absorbed more quickly on an empty stomach; other medications are unaffected by gastric contents. In addition, some medications interfere with the absorption of other medications if given at the same time. A nurse uses knowledge about the factors that alter or impair absorption of medications to develop a medication administration schedule that ensures optimal absorption of patients drugs.

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REF: 381 OBJ: Discuss factors that influence medication actions.

TOP:Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 10.A patient is hospitalized with a central nervous system infection that needs to be treated with water-soluble antibiotics. The medications will be instilled into the subarachnoid space via an epidural catheter. Why is this the best route of administration for this patient? a.Intravenous water-soluble antibiotics cannot pass through the blood-brain barrier. b.Only water-soluble medications can pass into the brain and cerebrospinal fluid. c.Older patients better tolerate lipid soluble medications than younger patients. d.Lipid soluble medications are safer for patients who are pregnant.

ANS: A To be distributed to an organ, a medication needs to pass through all the biological membranes of that organ. Some membranes serve as barriers to the passage of medications. For example, the blood-brain barrier allows only lipidsoluble medications to pass into the brain and cerebrospinal fluid. Therefore central nervous system (CNS) infections sometimes require treatment with antibiotics injected directly into the subarachnoid space in the spinal cord. Older patients often experience adverse effects (e.g., confusion) because they experience a change in the permeability of the blood-brain barrier, which enhances the passage of fat-soluble medications into the brain.

Lipid-soluble, nonionized drugs easily cross the placenta and can cause serious harm to the fetus.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:381 OBJ: Describe factors to consider when choosing routes of medication administration.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 11. Which of the following patients is most at risk for theophylline toxicity due to decreased biotransformation ability?

a.A 45-year-old man with renal insufficiency b.A 59-year-old man with chronic obstructive airway disease c.A 53-year-old woman who smokes and has asthma d.A 49-year-old woman with chronic obstructive airway disease and hepatitis ANS: D Biotransformation occurs when enzymes detoxify (remove toxic qualities), degrade (break down), and remove biologically active chemicals. Most biotransformation occurs within the liver, although the lungs, kidneys, blood, and intestines also metabolize medications. The liver is especially important because its specialized structure oxidizes and transforms many toxic substances. The liver degrades many harmful chemicals before they become distributed to the tissues. If a decrease in liver function occurs, such as with aging or liver disease, the body slowly eliminates a medication, resulting in a buildup of the medication. When organs that metabolize medications do not function correctly, patients are at risk for medication toxicity.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 381 OBJ: Discuss factors that influence medication actions.

TOP:Nursing Process: Assessment

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MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 12. Which of the following patients is most at risk for digoxin toxicity resulting from impaired excretion?

a.A 56-year-old man with coronary artery disease b.A 24-year-old woman with cystic fibrosis c.A 53-year-old woman with renal disease d.A 57-year-old man with a hemorrhagic stroke ANS: C The kidneys are the main organs that excrete medications. Some medications escape extensive metabolism and exit unchanged in the urine. Other medications undergo biotransformation in the liver before the kidneys excrete them.

If renal function declines, a patient is at risk for medication toxicity.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 381 OBJ: Discuss factors that influence medication actions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 13.A woman has been prescribed a daily iron supplement by her health care provider. She recently became constipated, most likely related to the iron supplement. Which of the following best describes this response? a.Therapeutic effect b.Adverse reaction c.Side effect d.Toxicity ANS: C A side effect is a predictable and often unavoidable secondary effect produced at a usual therapeutic dose. Each medication has a therapeutic effect, the intended or desired physiological response of a medication. Undesired, unintended, and often unpredictable responses to medication are referred to as adverse effects . Toxic effects are capable of causing injury or death. They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 14.A postoperative patient is receiving morphine sulfate from a patient-controlled analgesia device. On assessment, the nurse notes that the patients respirations are depressed. The nurse realizes the effect of morphine sulfate infusion can be labeled as which of the following? a.Toxic b.Allergic c.Therapeutic d.Idiosyncratic ANS: A file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. When patients become immunologically sensitized to a medication after taking at least one dose, allergic reactions occur. When a patients immune system causes abnormal reactions to a medication, the patient has a medication allergy. Each medication has a therapeutic effect, the intended or desired physiological response of a medication. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 15.A patient states that aspirin upsets her stomach. This is known as a(n): a.allergic response. b.toxic effect. c.idiosyncratic reaction. d.side effect.

ANS: D A side effect is a predictable and often unavoidable secondary effect produced at a usual therapeutic dose. Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 16.A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed shortness of breath and had difficulty breathing. The nurse recognized this was most likely a(n): a.idiosyncratic reaction. b.toxic effect. c.side effect. d.anaphylactic reaction.

ANS: D Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath characterize severe or anaphylactic reactions. In anaphylaxis a patient becomes severely hypotensive, necessitating emergency resuscitation measures. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

what is expected. Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. A side effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 17.The nurse is medicating the patient daily with warfarin (Coumadin). The patient is having blood levels drawn daily to determine the dose needed. The nurse realizes that the goal is to reach which of the following? a.The minimum effect concentration (MEC) in the plasma b.Reach the peak concentration level of the medication c.The level that falls between the MEC and toxic level d.An adequate trough level in the plasma ANS: C The goal of medication therapy is to achieve a constant, therapeutic level, which falls between the MEC and the toxic concentration. As patients take medication doses over time, the plasma level of the medication fluctuates constantly between doses. The minimum effect concentration (MEC) is the plasma level below which a patient does not experience the effect of a medication. The peak concentration is the highest plasma level, whereas the trough concentration is the lowest plasma level.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 383 | 384 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 18.A patient with a respiratory infection asks the nurse why some antibiotics are prescribed to be taken every 12 hours and some have to be taken 4 times a day. What is the nurses best response? a.The time between doses changes because any medications half-life varies so much. b.We need to vary the times to keep the blood values fluctuating. c.We try to give the next dose of medication only after the last dose is gone. d.Regular doses are given based on the half-life to maintain a therapeutic plateau.

ANS: D All medications have a biologic half-life, which is the time it takes for the body to lower the amount of unchanged medication by half. A drug with a short half-life (e.g., 2 to 3 hours) needs to be given more frequently than a drug with a longer half-life (e.g., 10 to 12 hours). A medications half-life does not change with the dose of the medication; its half-life is always the same no matter how much medication is administered. To maintain a therapeutic plateau, a patient receives regular fixed doses at specific intervals that correspond with their half-life.

The goal of medication administration is to achieve a therapeutic plateau, a point at which the blood level of a medication remains consistent. After an initial medication dose, the patient receives each successive dose when the previous dose reaches its half-life.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

REF: 384 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 19.A patient has an order for a subcutaneous injection of insulin. The nurse will prepare to give this injection into which of the following tissues? a. Into a large muscle b. Into the connective tissue beneath the dermis c. Into a vein using a pump

d.Between the epidermis and dermis ANS: B

Subcutaneous = injection into tissues just below the dermis of the skin Intramuscular (IM) = injection into a muscle Intravenous (IV) = injection into a vein Intradermal (ID) = injection into the dermis just under the epidermis Insulin could be given into a vein using an infusion pump, but the question states it is an injection. Insulin should not be given into an artery.

PTS:1DIF:Cognitive Level: Applying (Application) REF:386 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC:NCLEX: Integrity: Pharmacological and Parenteral Therapies 20.A patients health care provider wrote a prescription for an antibiotic for an upper respiratory infection.

According to safe medication practice standards, the nurse should transcribe the order as which of the following? a..5 mg b.5.0 mg c.mg d.0.5 mg ANS: D Follow practice standards when medications are ordered to prevent medication errors. For example, to make the decimal point more visible, a leading zero is always placed in front of a decimal (e.g., use 0.5, not .5). On the other hand, do not use a trailing zero, a zero after a decimal point, because if a health care worker does not see the decimal point, the patient may end up receiving 10 times more medication than what is prescribed (e.g., use 5 not 5.0). Always give fractions in decimal form.

PTS:1DIF:Cognitive Level: Applying (Application) REF:387 OBJ: Identify and implement nursing actions that prevent medication errors.

TOP:Nursing Process: Implementation file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 21.A nurse working in a clinic is teaching a patient how much cough syrup to take. The cough syrup comes in a 250-mL bottle, and the dosage is 10 mL every 4 hours. How many teaspoons should she instruct the patient to take? a.1 b.2 c.3 d.4 ANS: B When the accuracy of a medication dose is not critical, it is safe to use household measures. For example, you can safely measure many OTC medications by this method. In this case 5 mL = 1 teaspoon, so 10 mL would equal 2 teaspoons.

PTS:1DIF:Cognitive Level: Applying (Application) REF:387 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 22.A nurse is working in a newborn special care unit that has numerous premature infants. She recently transferred to this unit from an adult intensive care unit. The nurse is very cautious in administering medications because premature newborns are especially vulnerable to medication errors. Why is this true? a.Premature infants excrete urine more quickly than older infants. b.Premature infants metabolize medications more quickly than older children. c.Premature infants require more frequent dosing to achieve desired effects. d.Premature infants have less mature livers and kidneys.

ANS: D A childs age, weight, and maturity of body systems affect the ability to metabolize and excrete medications. For example, premature infants have underdeveloped livers and kidneys, which makes them especially susceptible to the harmful effects of medications. As children develop out of the newborn period, they metabolize medications quicker, resulting in the need for more frequent dosing of medications to achieve the medications desired effect.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:390 OBJiscuss developmental factors that influence pharmacokinetics.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 23.A nurse is assigned to care for a pediatric patient. The most common method for calculating pediatric medication dosage is based on the childs: a.age. b.height. c.weight. d.body surface area. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

ANS: C Different methods are used to calculate childrens medication dosages. Most of the time, you use a childs weight to calculate the dose. You can use the ratio and proportion method, the formula method, or dimensional analysis to calculate a pediatric dose using body weight. Body surface area (BSA) is used in rare situations (e.g., determining chemotherapy doses). Refer to a pediatric or pharmacology resource and consult with a patients health care provider or pharmacist if you have to calculate medications doses for a child. Age and height are not used directly in the calculation.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 390 OBJ: Calculate prescribed medication dosages correctly.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 24. The patient is admitted to the cardiac unit. Everyone admitted to the cardiac unit will have an EKG done unless

otherwise ordered. This is an example of which type of order? a.PRN b.Standing c.One-time d.STAT ANS: B

With standing orders, you carry out a standing order until the health care provider cancels it by another order or until a prescribed number of days elapses. A PRN order is one in which the health care provider orders a medication to be given only when a patient requires it. Single (one-time) orders happen when a prescriber orders a medication to be given only once at a specified time. A STAT order means that you give a single dose of a medication immediately and only once.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:391 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 25. The patient is vomiting and complaining of severe chest discomfort. The nurse calls the health care provider in an attempt to obtain which of the following type of order?

a.PRN b.Standing c.One-time d.STAT ANS: D A STAT order means that you give a single dose of a medication immediately and only once. With standing orders 4 you carry out a standing order until the health care provider cancels it by another order or until a prescribed number of days elapses. A PRN order is an order in which the health care provider orders a medication to be given only when a patient requires it. Single (one-time) orders happen when a prescriber orders a medication to be given only once at a specified time.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

REF:391 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 26. The health care provider orders pain medication to be given to a patient when the patient needs it to control

pain. What is this called? a. PRN order b.Standing order c.One-time order d.STAT order

ANS: A A PRN order is one in which the health care provider orders a medication to be given only when a patient requires it. With standing orders, you carry out a standing order until the health care provider cancels it by another order or until a prescribed number of days elapses. Single (one-time) orders happen when a prescriber orders a medication to be given only once at a specified time. A STAT order means that you give a single dose of a medication immediately and only once.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:391 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 27. Nurses are legally required to document medications administered to patients. The nurse is mandated to

document which of the following?

a.Medication after administration b.Medication before administration c.Rationale for giving a questionable incorrect dosage d.Concerns about giving the medication ANS: A Record the administration of each medication on the MAR immediately after administration. Never document that you have given a medication until you have actually given it. If you ever have questions about a medication order, contact the health care provider immediately to verify the order before giving your patient the medication.

PTS:1DIF:Cognitive Level: Applying (Application) REF:397 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 28.A nurse is caring for a patient who is to be discharged with a prescription for eye drops. The nurse knows that the patient understands how to administer eye drops correctly when the patient states that eye drops should be instilled on the: file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

a.sclera. b.cornea. c.conjunctival sac. d.area between the iris and lower eyelid.

ANS: C With the dominant hand resting on the patients forehead, hold a filled medication eye dropper or ophthalmic solution approximately 1 to 2 cm ( to inch) above the conjunctival sac. Drop the prescribed number of medication drops into the conjunctival sac. Avoid instilling any form of eye medication directly onto the cornea. The cornea of the eye has many pain fibers and is thus very sensitive to anything applied to it. Place intraocular disks in the conjunctival sac so that it floats on the sclera between the iris and lower eyelid PTS:1DIF:Cognitive Level: Applying (Application) REF:409 | 434 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 29.A patient is to receive two different kinds of insulin. What is the nurses most appropriate action? a.Prepare the regular (clear) insulin first. b. Mix Lantus and Lente insulin in the same syringe. c. Administer the rapid-acting insulin within 30 minutes of a meal. d.Verify insulin dosage with another nurse after administration.

ANS: A If regular and intermediate-acting insulin are ordered, prepare the regular insulin first to prevent contamination with the intermediate-acting insulin. Never mix insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin. Inject rapid-acting insulins mixed with NPH insulin within 15 minutes before a meal. Verify insulin dosages with another nurse while you prepare them if required by agency policy.

PTS:1DIF:Cognitive Level: Applying (Application) REF:417 | 418 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 30.A patient is to receive a medication that is irritating to muscle tissue. The most appropriate injection technique involves which of the following? a.Z-track technique of injection b.Subcutaneous technique of injection c.Use of the vastus lateralis in adults d.Use of the deltoid muscle in children less than 12 months old ANS: A It is recommended that you use the Z track injection method when giving IM injections to minimize irritation by sealing the medication in muscle tissue. You only give small subcutaneous doses (0.5 to 1.5 mL) of watersoluble medications to adults because subcutaneous tissue is sensitive to irritating solutions and large volumes of medications. You may use the vastus lateralis in children less than 12 months and the deltoid in file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

patients older than 12 months.

PTS:1DIF:Cognitive Level: Applying (Application) REF:419 | 422 | 447 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 31. The intended or desired physiological response of a medication is known as a(n)

effect.

a.adverse b.side c.therapeutic d.toxic ANS: C Each medication has a therapeutic effect, the intended or desired physiological response of a medication.

Undesired, unintended, and often unpredictable responses to medication are referred to as adverse effects. A side effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose. Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 32. Undesired, unintended, and often unpredictable responses to medication are referred to as

effects.

a.Adverse b.Side c.Therapeutic d.Toxic ANS: A Undesired, unintended, and often unpredictable responses to medication are referred to as adverse effects.

Each medication has a therapeutic effect, the intended or desired physiological response of a medication. A side effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose. Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

33.A(n) dose.

effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic

a.adverse b.side c.therapeutic d.toxic ANS: B A side effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose.

Undesired, unintended, and often unpredictable responses to medication are referred to as adverse effects.

Each medication has a therapeutic effect, the intended or desired physiological response of a medication.

Toxic effects are capable of causing injury or death. They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies effect(s) is/are capable of causing injury or death . They often develop after prolonged intake of a 34. medication or when a medication accumulates in the blood because of impaired metabolism or excretion. a.An adverse b.A side c.Therapeutic d.Toxic ANS: D Toxic effects are capable of causing injury or death . They often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. A side effect is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose.

Undesired, unintended, and often unpredictable responses to medication are referred to as adverse effects.

Each medication has a therapeutic effect, the intended or desired physiological response of a medication.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:382-383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 35. Unpredictable effects of some medications in which a patient overreacts or underreacts to a medication or

has a reaction different from what is expected are known as: a.medication allergies. b.anaphylactic reactions. c.medication interactions. d.idiosyncratic reactions.

file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

ANS: D Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected. When a patients immune system causes abnormal reactions to a medication, the patient has a medication allergy. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions. A medication interaction occurs when one medication modifies the action of another medication.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 36. When a patients immune system causes abnormal reactions to a medication, the patient has a(n):

a.medication allergy. b.anaphylactic reaction. c.medication interaction. d.idiosyncratic reaction.

ANS: A When a patients immune system causes abnormal reactions to a medication, the patient has a medication allergy. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions. A medication interaction occurs when one medication modifies the action of another medication.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 37. Allergic symptoms vary, depending on an individual and the medication; they range from mild to severe.

Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath are characteristics of a(n):

a.medication allergy. b.anaphylactic reaction. c.medication interaction. d.idiosyncratic reaction.

ANS: B Allergic symptoms vary, depending on an individual and the medication; they range from mild to severe.

Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions. When a patients immune system causes file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

abnormal reactions to a medication, the patient has a medication allergy. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected. A medication interaction occurs when one medication modifies the action of another medication.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 38.A(n)

occurs when one medication modifies the action of another medication.

a.medication allergy b.anaphylactic reaction c.medication interaction d.idiosyncratic reaction ANS: C A medication interaction occurs when one medication modifies the action of another medication. Allergic symptoms vary, depending on an individual and the medication; they range from mild to severe. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions. When a patients immune system causes abnormal reactions to a medication, the patient has a medication allergy. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 39.When the effect of two medications combined is greater than the effects of the medications when given separately, the two medications are said to have a(n): a.synergistic effect. b.anaphylactic reaction. c.medication interaction. d.idiosyncratic reaction.

ANS: A When two medications have a synergistic effect, the effect of the two medications combined is greater than the effects of the medications when given separately. A medication interaction occurs when one medication modifies the action of another medication. Allergic symptoms vary, depending on an individual and the medication; they range from mild to severe. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath all characterize severe or anaphylactic reactions. Some medications cause unpredictable effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected. file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:383 OBJ: Compare and contrast the different types of medication effects and reactions.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. Pharmacokinetics is the study of which of the following? (Select all that apply.)

a.Absorption b.Distribution c.Metabolism d.Excretion e.Serious harm to patients ANS: A, B, C, D Pharmacokinetics is the study of four major processes: medication absorption, distribution, metabolism, and excretion. In 1993, the FDA instituted the MedWatch program. This voluntary program encourages nurses and other health care professionals to report when a medication, product, or medical event causes serious harm to a patient.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 380 | 381 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Factors that influence medication absorption are known as which of the following? (Select all that apply.)

a.Ability of a medication to dissolve b.Blood flow c.Body surface area d.Water solubility of a medication e.Lipid solubility of a medication ANS: A, B, C, E Factors that influence medication absorption are the route of administration, ability of a medication to dissolve, blood flow to the site of administration, body surface area, and lipid solubility of a medication.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 380 | 381 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 3.Which of the following are topical medications? (Select all that apply.) a.Intradermal medications b.Throat swabs and eye drops file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

c. Vaginal and rectal suppositories d.Ear drops and bladder instillations e.Nasal sprays

ANS: B, C, D, E Topical medications are applied to the skin and mucous and respiratory membranes. You can apply topical medications to mucous membranes in a variety of other ways, including the following: (1) By directly applying a liquid or ointment (e.g., eye drops, gargling, swabbing the throat). (2) By inserting a medication into a body cavity (e.g., placing a suppository in rectum or vagina, inserting medicated packing into vagina).

(3) By instilling fluid into a body part or cavity (e.g., ear drops, nose drops, bladder or rectal instillation [fluid is retained]). (4) By irrigating a body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum with medicated fluid [fluid is not retained]). (5) By spraying a medication into a body cavity (e.g., instillation into nose and throat). Intradermal (ID) medications are injected into the dermis just under the epidermis and are considered parenteral medications.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:386 OBJ: Describe factors to consider when choosing routes of medication administration.

TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which of the following are the basic units of measurement in the metric system? (Select all that apply.)

a.Meter b.Teaspoon c.Liter d.Tablespoon e.Gram ANS: A, C, E The basic units of measurement in the metric system are the meter (length), liter (volume), and gram (weight). Household measures include drops, teaspoons, tablespoons, and cups for volume and pints and quarts for weight.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:387 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 5. The nurse is preparing to administer medications to a patient. In doing so the nurse should do which of the following? (Select all that apply.)

a.Monitor medication effects. b.Assess the patients ability to self-administer medications. c.Determine if the patient should receive the medication. d.Educate the patient and family about medication administration. e.Delegate administration to nursing assistive personnel (NAP).

ANS: A, B, C, D file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

When you administer medications to patients, you need knowledge and a set of skills that are unique to nursing. Responsibilities of medication administration include administering medications correctly, monitoring their effects, assessing a patients ability to self-administer medications, and determining whether a patient should receive a medication at a given time. Patient and family education about proper medication administration and monitoring is an integral part of your role. Never delegate this to nursing assistive personnel (NAP). Use the nursing process to integrate medication therapy into care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:393 OBJ: Describe the roles and responsibilities of the prescriber, pharmacist, and nurse in medication administration. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 6. The passage of medication molecules from the site of administration into the blood is known as absorption.

Factors that affect the rate of absorption include which of the following? (Select all that apply).

a.The ability of a medication to dissolve b.Blood flow to the site of administration c.Body surface area d. Lipid solubility e.The rate of distribution ANS: A, B, C, D Absorption refers to passage of medication molecules from the site of administration into the blood. Factors that influence medication absorption are the route of administration, ability of a medication to dissolve, blood flow to the site of administration, body surface area, and lipid solubility of a medication. After a medication is absorbed, it moves throughout the body. The rate and extent of distribution depend on the physical and chemical properties of medications and the physiology of the person taking the medication.

PTS:1DIF:Cognitive Level: Applying (Application) REF:450 | 451 OBJ:List the six rights of medication administration and implement their use in clinical practice.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies OTHER 1.A nurse is preparing to administer a medication by IV bolus through an existing IV line. What is the correct order for administering the medication? (Separate letters by a comma and space as follows: A, B, C, D.) a.Perform hand hygiene and apply gloves. b.Aspirate for blood return before injecting the medication. c.Occlude the IV line by pinching the tubing just above the injection port. d. Verify the specified time recommendation for administration of this medication.

ANS: D, A, C, B file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

Check accuracy and completeness of each MAR with the prescribers original medication order. Perform hand hygiene. Occlude the IV line by pinching the tubing just above the injection port. Pull back gently on the syringes plunger to aspirate for blood return.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 380 | 381 OBJ: Describe the physiological mechanisms of medication action.

TOP:Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies

file:///D|/...ntials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-17-administering-medications.html[21/04/2019 17:43:14]

Chapter 18: Fluid, Electrolyte, and Acid-Base Balances Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is caring for a patient who is suffering from kidney failure and is receiving peritoneal dialysis. The nurse explains that peritoneal dialysis works by instilling a solution into the abdomen that contains dextrose that will pull extra fluid into the abdominal cavity. What is the name of this process? a.Diffusion b.Osmosis c.Filtration d.Active transport ANS: B Osmosis is movement of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration. Diffusion is passive movement of electrolytes or other particles from an area of higher concentration to an area of lower concentration. In other words, the electrolytes move down their concentration gradient until the electrolyte concentration is equal in all areas. Electrolytes cannot diffuse across cell membranes unless the membranes have proteins that serve as ion channels. Filtration is the net effect of several forces that tend to move fluid across a membrane. Active transport is the energy-requiring movement of electrolytes or other substances across cell membranes against their concentration gradient (from an area of low concentration to an area of higher concentration).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:465 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2.A patient has been admitted to the postsurgical nursing unit after surgery. The health care provider has ordered the patient to have an IV of 0.9% sodium chloride. The nurse who is caring for the patient recognizes this as what type of solution? a.Hypotonic b.Isotonic c.Hypertonic d.Hypnotic ANS: B Fluids that have the same osmolality as normal blood are called isotonic. Intravenous (IV) solutions are hypertonic, isotonic, or hypotonic. Isotonic solutions such as 0.9% sodium chloride (same osmolality as normal blood) expand the bodys extracellular fluid volume without causing water to shift in or out of cells. There is no hypnotic solution.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:465 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity ]

3. The patient is in a coma after a motor vehicle accident. In addition to IV medications, the patient is receiving an isotonic IV fluid. The primary purpose for this fluid infusion is to:

a.cause cells to shrink and reduce swelling. b.move fluid from intravascular space into cells. c.pull fluid from cells into the intravascular space. d.expand the bodys intravascular fluid volume.

ANS: D Fluids that have the same osmolality as normal blood are called isotonic. Intravenous (IV) solutions are hypertonic, isotonic, or hypotonic. Isotonic solutions such as 0.9% sodium chloride (same osmolality as normal blood) expand the bodys extracellular fluid volume without causing water to shift in or out of cells. Infusion of hypertonic intravenous solutions (more concentrated than normal blood), such as 3% sodium chloride, pulls fluid from cells by osmosis, causing them to shrink. Physiologically hypotonic solutions (less concentrated than normal blood after they are infused) move water from the extracellular compartment into the cells by osmosis, causing them to swell.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:465 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. Two nursing students were having pizza one evening as they were studying. One student remarked that whenever

she ate pizza, she was incredibly thirsty. The second student explained that this thirst was caused by: a.colloid osmotic pressure. b.osmoreceptors. c.oncotic pressure. d.hydrostatic pressure.

ANS: B

Thirst, a conscious desire for water, regulates fluid intake when plasma osmolality increases (osmoreceptormediated thirst) or the blood volume decreases (baroreceptor-mediated thirst and angiotensin IImediated thirst).

The thirst-control mechanism is in the hypothalamus of the brain. Osmoreceptors there continually monitor plasma osmolality; when osmolality increases, the hypothalamus stimulates thirst. Colloid osmotic pressure (oncotic pressure) is an inward-pulling force caused by the presence of protein molecules. Hydrostatic pressure is the force of a fluid pressing outward against the walls of its container. Thus capillary hydrostatic pressure is an outwardpushing force.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:465 | 466 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5.A 7-year-old patient was admitted to the hospital with a high fever. The nurse caring for the child knows that the child has increased insensible water loss resulting from the fever and should receive additional water to prevent hypernatremia. Insensible water loss occurs through which organ? a.Kidneys b.GI tract ]

c.Skin d.Stomach ANS: C Fluid output normally occurs through four organs: the skin, lungs, GI tract, and kidneys Insensible water loss is not visible; it is continuous and occurs through the skin and lungs. Output of insensible water also increases with fever.

Visible perspiration (sweat) is secreted by the sweat glands. The GI tract plays a vital role in fluid balance.

Approximately 3 to 6 L of fluid move into the GI tract daily and return again to the ECF. However, diarrhea causes a large fluid output from the GI tract. The kidneys are the major regulator of fluid output because they respond to hormones that influence urine production. When healthy people drink more water, they make a larger urine volume to maintain fluid balance. In patient situations, fluid loss occurs abnormally, such as through vomiting (stomach), wound drainage, and hemorrhage.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:466 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6.A patient presents to the emergency department complaining of increased urine output. The patient has been drinking alcohol and is still visibly impaired. He is aware of his condition and apologizes, stating that he has never gotten drunk before and if he survives he never will again, but he knows that if he drinks too much he will lose potassium and die. The nurse realizes that the patient is dealing with: a.antidiuretic hormone (ADH) suppression. b.ADH stimulation. c.insensible water loss. d.angiotensin II release.

ANS: A Ethyl alcohol decreases ADH release, which is why people urinate frequently when they drink alcoholic beverages.

Antidiuretic hormone acts on the kidneys, causing them to reabsorb water. With ADH stimulation a patient will experience a decrease in urinary output; volume is returned to systemic circulation, diluting the blood and decreasing osmolarity. Insensible water loss is continuous and nonperceptual. Lungs expire water daily through respiration. Angiotensin II causes vasoconstriction of many blood vessels, which helps regulate blood pressure, and it stimulates the release of aldosterone, which assists fluid homeostasis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:466 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 7.The bodys fluid and electrolyte balance is maintained partially by hormonal regulation. The nurse conveys an understanding of this mechanism in which statement? a.The pituitary gland secretes aldosterone. b.The kidney secretes antidiuretic hormone. c.The adrenal cortex secretes antidiuretic hormone. d.The pituitary gland secretes antidiuretic hormone. ]

ANS: D The hypothalamus controls release of ADH from the posterior pituitary gland. Antidiuretic hormone circulates to the kidneys, where it acts on the collecting ducts, causing them to reabsorb water. The adrenal cortex releases aldosterone in response to increased plasma potassium concentration or as the end product of the renin-angiotensinaldosterone system (RAAS).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:466 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8.A 15-year-old patient suffered a head injury as the result of a bicycle accident. The nurse is concerned about potential fluid complications caused by the injury. What should the nurse monitor most closely? a.Aldosterone release b.Urine output c.Renin release d.Body temperature ANS: B Antidiuretic hormone regulates osmolality of body fluids by influencing how much water is excreted in urine. The hypothalamus controls release of ADH from the posterior pituitary gland. Head injury may cause altered urine output by injuring the hypothalamus or pituitary. A head injury would not involve the adrenal gland. The adrenal cortex releases aldosterone in response to increased plasma potassium concentration or as the end product of the renin-angiotensin-aldosterone system (RAAS). Renin, released by the kidneys, acts on the inactive protein angiotensinogen to produce angiotensin I. Other enzymes in the lung capillaries convert to angiotensin II. Again, there is no direct correlation to head injury. Body temperature does not reflect fluid imbalance directly.

PTS:1DIF:Cognitive Level: Applying (Application) REF:466 OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is taking furosemide (Lasix) and has been complaining of muscle weakness. The nurse should be most concerned about which imbalance?

a.Hyponatremia b.Hypokalemia c.Hypochloremia d.Hyperchloremia ANS: B Hypokalemia causes muscle weakness and if severe, cardiac dysrhythmias. Sodium concentration imbalances really are water imbalances. With hyponatremia, water enters cells by osmosis, causing them to swell. Signs of cerebral dysfunction occur when brain cells swell. Hypochloremia always occurs with other imbalances and has no unique signs and symptoms. Hyperchloremia is abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. It also has no unique signs and symptoms.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) ]

REF:468 OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 10. The patient is on a ventilator. The health care provider has indicated concern about the patients acid-base status.

The nurse anticipates that the health care provider will determine the acid-base levels via:

a.PaO 2 measurement. b.SaO 2 levels. c.chloride levels. d.arterial blood gas analysis.

ANS: D Arterial blood gas (ABG) analysis is an effective method of evaluating acid-base balance and oxygenation. PaO 2 is the partial pressure of oxygen in arterial blood. When PaO 2 is within normal range, it has no primary role in acidbase regulation. SaO 2 is the percentage of hemoglobin molecules that are carrying as much oxygen as is possible (saturated). SaO 2 , however, has no direct effect on acid-base balance. Hypochloremia is abnormally low blood chloride level. Hyperchloremia is an abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. Neither has unique signs and symptoms.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:468 | 471 OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11.A 76-year-old patient is hospitalized with pneumonia and has become increasingly confused throughout the shift. The nurse becomes concerned about the patients condition and contacts the health care provider, who orders arterial blood gas analysis. The blood gas report shows a pH of 7.33, PaCO 2 of 47, PaO 2 of 78, and bicarbonate of 26. This indicates which imbalance? a.Respiratory alkalosis b.Respiratory acidosis c.Metabolic alkalosis d.Metabolic acidosis ANS: B Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45).

Respiratory acidosis is an increased PaCO 2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H 2 CO 3 ) in the blood. Hypoventilation produces respiratory acidosis, which causes the cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of consciousness.

Respiratory alkalosis is a decreased PaCO 2 and increased pH (above 7.45) that reflect the deficit of carbonic acid (H 2 CO 3 ) in the blood. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). The bicarbonate level is always low because the bicarbonate system buffers metabolic acids. Metabolic alkalosis results from a gain of bicarbonate or excessive excretion of metabolic acid.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances. ]

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 12.A college freshman has bulimia. She vomits after eating and has recently noticed tingling of her fingers and toes and muscle cramps. Her roommate is a nursing student and is concerned about which imbalance? a.Respiratory acidosis b.Metabolic acidosis c.Respiratory alkalosis d.Metabolic alkalosis ANS: D Metabolic alkalosis results from acid loss from the body or an increase in levels of bicarbonate. The most common causes are vomiting and gastric suction. Respiratory acidosis results from respiratory diseases or other conditions that reduce alveolar ventilation (hypoventilation), preventing excretion of the carbonic acid continuously produced by cells. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). Diabetic ketoacidosis is a common cause of metabolic acidosis. Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkalotic, decreasing the level of consciousness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 13.A patients arterial blood gas levels indicate a pH of 7.51, PaCO 2 of 40 mm Hg, PaO 2 of 85 mm Hg, and HCO 3 of 32 mEq/L. The patient has been vomiting. The nurse knows the patient has which imbalance? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis ANS: B Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45).

Metabolic alkalosis results from acid loss from the body or an increase in levels of bicarbonate. Normal range of bicarbonate (HCO 3 ) is 22 to 26 mEq/L. A level above 26 mEq/L indicates metabolic alkalosis. The most common causes are vomiting and gastric suction. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). Diabetic ketoacidosis is a common cause of metabolic acidosis. Hypoventilation produces respiratory acidosis, which causes cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of consciousness. Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkalotic, decreasing the level of consciousness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 14.Which patient has the greatest risk for ECV deficit? a.A 4-month-old infant with fever and vomiting b.A 17-year-old adolescent with acute appendicitis ]

c.A 28-year-old woman with Crohns disease d.A 63-year-old man with peptic ulcer disease

]

ANS: A Fever increases insensible water loss through the skin and lungs. Infants and very young children have relatively more body surface area and higher percentage of body water than older children and adults. They have greater water needs and immature kidneys. Infants are at greater risk fo r ECV deficit and hypernatremia because their body water loss is proportionately greater per kilogram of weight. Although acute appendicitis may cause vomiting and an active episode of Crohns disease may cause diarrhea, adolescents and young adults have less risk of ECV deficit than an infant. An older adult has increased risk of ECV deficit if there is a large fluid output; however, peptic ulcer disease ordinarily does not cause a large fluid output.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:473 OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15.A patient has heart failure. The patients medications include an angiotensin-converting enzyme (ACE) inhibitor, a beta blocker, and a diuretic. To keep the patient safe, the nurse should: a.weigh the patient daily using different scales for comparison. b.monitor daily weight, comparing with the previous days weight. c.teach that daily weights are done in hospitals, but not at home. d.weigh the patient at different times of the day to determine trends.

ANS: B Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid gained or lost. Weigh heart failure patients daily, as well as other patients who are at high risk for or actually have ECV excess. Obtain the weight at the same time each day with the same calibrated scale after a patient voids. Teach heart failure patients to take and record daily weights at home and to contact their health care provider if weight increases suddenly according to parameters their providers set. Classic research shows that heart failure patients who are hospitalized for decompensated heart failure often experience steady increases in daily weights during the week before hospitalization.

PTS:1DIF:Cognitive Level: Applying (Application) REF:474 OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16.Which measurement can the nurse delegate to nursing assistive personnel? a.Oral fluid intake b.Intravenous fluid intake c.Tube drainage output d.Nasogastric tube intake ANS: A You can delegate portions of I&O measurement to nursing assistive personnel (NAP). In many agencies, NAP can record oral intake but not intake through tubes or IVs and can record urine, diarrhea, and vomitus output, but not drainage through tubes.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) ]

REF:477 OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17.A 27-year-old patient has seen a health care provider at the local clinic because he has had diarrhea for the past week. The health care provider instructed the patient to drink plenty of fluids, and the nurse clarifies these instructions by advising him to avoid which item as long as he has diarrhea? a.Ice chips b.Pedialyte c.Coffee d.Tap water ANS: C When replacing fluids by mouth in a patient with ECV deficit, choose fluids that contain Na + (e.g., Pedialyte and Gastrolyte). Liquids containing lactose, caffeine, or low Na + content are not appropriate when a patient has diarrhea. Strategies to encourage fluid intake include offering small sips of fluid frequently, popsicles, and ice chips.

PTS:1DIF:Cognitive Level: Applying (Application) REF:481 OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18.A patient has recently been diagnosed with heart failure and has been put on a low sodium diet in the hospital.

In addition, the patient has a fluid restriction. The nurse should suggest that half the total oral fluid allotment occur between which two times? a.7 AM ; 7 PM b.3 AM ; 3 PM c.7 AM ; 3 PM d.3 PM ; 7 AM ANS: C In acute care settings, fluid restrictions often allot half the oral fluids between 7 AM and 3 PM , the period when patients usually are more active, receive two meals, and take most of their oral medications. Offer the remainder of the fluid allowance during the evening and night shifts.

PTS:1DIF:Cognitive Level: Applying (Application) REF:482 OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is unable to eat and there are no bowel sounds, indicating that his bowels are not functioning. The best approach to providing nourishment would be: ]

a.intravenous crystalloids. b.blood product administration. c.parenteral nutrition (PN). d.colloid administration.

ANS: C Parenteral nutrition (PN) is a nutritionally adequate solution consisting of glucose, other nutrients, and electrolytes administered through a central venous catheter. This intervention meets nutritional needs when the GI tract is nonfunctional. Fluid and electrolytes may be replaced through infusion of fluids intravenously (IV), meaning directly into veins. Parenteral replacement includes PN, IV fluid and electrolyte therapy (crystalloids), and blood product (colloids) administration. The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:482 OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 20. The nurse works on the cardiac unit of a hospital. The health care provider has ordered 20 mEq of KCl per L to be added to the fluids that the patient is receiving. The patient currently has a bag of D 5 W IV fluid infusing.

Which action is most appropriate?

a.Administer 20 mEq KCl diluted in 5 mL of fluid by IV push in 5 minutes. b.Estimate the amount of fluid in the IV bag and add KCl to equal 20 mEq/L. c.Give the KCl undiluted by IV push in 5 minutes for the most rapid action. d.Check the patients potassium level before hanging the new IV solution.

ANS: D Remember that failure to verify that a patient has adequate renal function and urine output before administering an IV solution containing potassium could cause hyperkalemia. Under no circumstances should KCl be given in an IV push. A direct IV infusion of KCl may be fatal. Intravenous administration of KCl requires dilution in solution and infusion slowly over a period of time. In most hospitals, nurses do not add KCl to IV bags. Usually a pharmacist prepares the solution.

PTS:1DIF:Cognitive Level: Applying (Application) REF:483 OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21.A 15-year-old adolescent has been recently diagnosed with cancer. The patient will be receiving IV chemotherapy for several weeks. Which vascular access device should be used for short-term administration of his IV fluid? a.Implanted port b.Peripherally placed IV catheter c.Central line d.Peripherally inserted central catheter ANS: B ]

Peripheral catheters are for short-term use (e.g., to restore fluid volume). Devices for long-term use include central lines, peripherally inserted central catheters (PICCs), and implanted ports. These devices are more effective than peripheral catheters for administering PN and medications and solutions that are irritating to veins.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:482 | 483 OBJescribe purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22.The nurse is caring for an 84-year-old patient who gets hemodialysis 3 days a week. He is taking corticosteroids and has multiple bruises on his extremities. The patient needs an IV started. When starting the IV, the nurse should: a.attempt to start the IV in the dorsum of the patients hand. b.avoid areas of skin that are red and warm to the touch. c.use the arm on the side of the patients dialysis fistula. d.start the IV in the patients foot after patient teaching.

ANS: B When assessing patients for potential venipuncture sites, consider conditions that exclude certain sites. For example, because older adults and patients receiving corticosteroids have fragile veins, avoid sites that are easily bumped or moved, such as the dorsal surface of the hand. Venipuncture is contraindicated in a site that has signs of inflammation, infiltration, or thrombosis. An infected site is red, tender, swollen, and possibly warm to the touch.

Avoid using an extremity with a vascular (dialysis) graft or fistula or on the same side as a mastectomy (breast surgery). Intravenous insertion in a foot vein is used with children but should be avoided in adults because of the danger of thrombophlebitis.

PTS:1DIF:Cognitive Level: Applying (Application) REF:483 | 484 OBJescribe the purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23.A nurse is mentoring a new nurse who is learning to start IVs. The nurse tells the new nurse that in case the patient needs subsequent venipuncture sites, the best place to initially start an IV is the: a.antecubital vein of the patients nondominant arm. b.most appropriate distal vein on the nondominant arm. c.most appropriate proximal vein available on either arm. d.antecubital vein of the patients dominant arm.

ANS: B Initially place IV catheters at the most distal point, which allows for the use of proximal sites later if the patient needs a venipuncture site change (INS, 2011). Use the most distal site in the nondominant arm, if possible.

Vascular access device placement in the dominant arm interferes with activities of daily living.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:483 | 484 | 497 OBJescribe purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: ]

Planning MSC: NCLEX: Physiological Integrity 24. During a clinical rotation at an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool and pale. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

a.Phlebitis b.Infiltration c.Thrombophlebitis d.Local inflammation ANS: B An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein. Phlebitis can be dangerous because blood clots (thrombophlebitis) can form, increasing the risk for an embolus, a clot that becomes dislodged and can travel to the lungs. Local infection at the VAD site is possible. The insertion site will be red and/or edematous; exudate may occur.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:487 | 488 OBJ: Discuss complications of intravenous therapy and what to do if they occur.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 25. When a nurse is selecting a vein for IV placement, what is the most appropriate action?

a.Select a vein that appears to be well dilated. b.Elevate the extremity to visualize the vein. c.Tap and rub the vein vigorously with friction. d.Stroke from proximal to distal above the site.

ANS: A Use the most distal site in the nondominant arm, if possible. Select a well-dilated vein. Methods to foster venous distention include place the extremity in a dependent position if possible and stroke from distal to proximal below the proposed venipuncture site. Apply warmth to the extremity for several minutes, for example, with a warm washcloth. Vigorous friction and multiple tapping of a vein, especially in older adults, can cause hematoma and/or venous constriction. Avoid vein selection in areas with tenderness, pain, infection, or wounds, or extremities affected by previous stroke (CVA), paralysis, mastectomy, or dialysis graft. Choose a site that will not interfere with the patients activities of daily living (ADLs).

PTS:1DIF:Cognitive Level: Applying (Application) REF:497 | 498 OBJescribe the purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity ]

26. The nurse suspects that the patient is experiencing a blood transfusion reaction. The nurse stops the infusion but is concerned about losing the IV line if blood clots in the catheter. The nurse should:

a.replace the entire transfusion line with a new set primed with normal saline. b.turn off the blood and turn on the normal saline infusion to flush the tubing. c.discontinue the IV and start a new IV of lactated Ringers in the other extremity. d.maintain the patency of the current IV line by hanging a new IV bag of D 5 W. ANS: A Remove the blood component and tubing containing the blood product. Replace them with new primed tubing with a container of 0.9% sodium chloride (normal saline). Connect tubing to hub of IV catheter. Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set.

This would cause blood remaining in the Y-tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction. Keep the IV site in case it becomes difficult to start another. Maintain a patent IV line using 0.9% normal saline.

PTS:1DIF:Cognitive Level: Applying (Application) REF:489 OBJescribe the procedure for initiating a blood transfusion and complications of blood therapy.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity SHORT ANSWER 1.A patient is diagnosed with renal insufficiency. The results of an ABG analysis indicate metabolic acidosis. In metabolic acidosis, the nurse would expect the pH to decrease to less than and the bicarbonate level to decrease to less than .

ANS: 7.35; 22 The normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). The normal range of bicarbonate (HCO 3 ) is 22 to 26 mEq/L. Levels below 22 mEq/L usually indicate metabolic acidosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:471 OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 2.Yesterday morning the patient weighed 169.4 lb (77 kg). This morning the patient weighs 171.6 lb (78 kg). The nurse determines that the patient has gained liter(s) of fluid.

ANS: 1 Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid gained or lost. ]

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

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REF:474 OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1.A nurse is caring for a patient after a bowel resection. The nurse plans assessment based on the knowledge that body fluids maintain balance through homeostasis, which includes what processes? (Select all that apply.) a.F luid intake b.Fluid distribution c.Fluid output d.Fluid catabolism

ANS: A, B, C Fluid homeostasis is the dynamic interplay of three processes: fluid intake and absorption, fluid distribution, and fluid output. Our daily fluid output consists of hypotonic sodium-containing fluid. To maintain fluid balance, we must have an intake of an equivalent amount of hypotonic sodium-containing fluid (water plus foods with some salt). Fluid is not catabolized (broken down into components to release energy) in the body.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:466 OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2.The nurse is working for a medical unit in a hospital. The nurse is responsible for obtaining intake and output measurements for patients. What items should be considered intake? (Select all that apply.) a.G elatin eaten as a snack or for lunch or dinner b.Water used to flush tubing between jejunostomy feedings c.Amount of fluid contained in the gastric suction container d.Volume of the blood components that were given IV e.Volume of the postsurgical wound drainage

ANS: A, B, D Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, broth), drinks (e.g., juice, coffee, tea, water), or receives through nasogastric or jejunostomy feeding tubes. Intravenous fluids (continuous and intermittent) and blood components also count as intake. A patient receiving tube feedings may receive numerous liquid medications; water will be used to flush the tube before and/or after the medications. Liquid output includes urine, diarrhea, vomitus, gastric suction, and blood and drainage from postsurgical wounds, burns, or other tubes.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:474 | 476 OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity ]

3.A patient has a peripheral IV. The nurse should assess the IV site for what primary signs and symptoms of

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infiltration? (Select all that apply.) a.Redness b.Swelling c.Pallor d.Warmth e.Red streaks ANS: B, C An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:487 OBJ: Discuss complications of intravenous therapy and what to do if they occur.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4.A patient complains of chills, dizziness, and feeling hot during a blood transfusion. What are the nurses most appropriate actions? (Select all that apply.) a.Check the patients vital signs. b.Stop the blood transfusion. c.Slow the rate of infusion. d.Notify the physician and blood bank.

ANS: A, B, D STOP (do not slow down) the transfusion immediately even when you just suspect a reaction. Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Immediately notify the health care provider or emergency response team and the blood bank.

PTS:1DIF:Cognitive Level: Applying (Application) REF:489 OBJescribe the procedure for initiating a blood transfusion and complications of blood therapy.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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Chapter 19. Complementary, Alternative, and Integrative Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE Identify the choice that best completes the statement or answers the question. ____ 1. A patient is receiving acupuncture therapy in addition to analgesics for chronic pain. How should the nurse document the use of acupuncture for pain control? a. Alternative therapy b. Mainstream therapy c. Complementary therapy d. Unconventional therapy ____ 2. The nurse is using a mind-body approach to help a patient reduce the pain during labor and delivery. Which type of therapy is the nurse using? a. Massage b. Muscle relaxant c. Guided imagery d. Non-narcotic pain reliever ____ 3. During an assessment, the nurse learns that a patient only uses traditional medicine approaches to treat illnesses or diseases. How should the nurse document the health care approach that the patient uses? a. Ayurveda b. Allopathy c. Osteopathy d. Chiropractic ____ 4. A patient tells the nurse that a chiropractor has been used to help with chronic neck and lower back pain.

Which principle of chiropractic medicine should the nurse use to supplement this patients plan of care? a. Maintain health by keeping the body and mind in balance with nature b. Remove interference with nerve function, so the body can heal itself c. Promote healing and prevent illness through the use of nutrition, botanical medicine, and hydrotherapy d. Relieve symptoms by administering tiny doses of substances that create symptoms of disease in a healthy person ____ 5. A patient scheduled for spinal surgery the following day lists ginkgo and ginger on a home medication assessment. How should the nurse respond to this information? a. What dose of each herb do you take? b. For what effects do you take the herbs? c. How many times per day do you take each herb? d. Have you told your surgeon that you take these herbs? ____ 6. The nurse learns that a patient plans to try St. Johns wort for depression. How should the nurse respond to the patient about this herbal remedy? a. Some people believe it can be helpful for depression. Because it is an herb, it would be safe to try it. b. Herbs are medicines. You should not try anything without first consulting your primary care provider.

c. Herbs can be dangerous. You should avoid taking them while you are on other medications, because interactions could occur. d. St. Johns wort has been shown in research to be safe and effective for treating depression. Be sure to follow the package instructions. ____ 7. A patient wants to try acupressure techniques in addition to conventional treatment for headaches and asks, What is so good about Western medicine anyway? Which response by the nurse is best? a. Western medicine uses natural remedies that are less likely to cause long-term side effects. b. Western medicine is based on research, which means treatments are more likely to have consistent results. c. Western medicine has fewer regulations and restrictions, so practitioners are able to choose the best treatments for you. d. Western medicine is based primarily on nutrition and exercise therapies that are safer than potentially toxic medications. ____ 8. A patient with advanced cancer decides to discontinue chemotherapy treatment and try an alternative therapy that has not been proven effective. The nurse, whose mother recently died of the same type of cancer, strongly disagrees with the patients choice. How should the nurse respond when the patient asks for an opinion about the alternative therapy? a. Im sorry, but I dont feel prepared to answer your question. I would prefer you ask your physician that question. b. My mother died recently of the same type of cancer you have. I would be very careful before stopping the therapy. c. Because your disease is so advanced and traditional treatments have failed, I think trying the alternative treatment can do no harm. d. As a nurse, I am obligated to encourage you to seek the best treatment possible. I cannot in good conscience advise you to have the alternative treatment. ____ 9. During an assessment, the nurse learns that a patient sees a practitioner who is balancing the patients qi and vital energy. Which type of medicine should the nurse document that the patient is using? a. Ayurvedic medicine b. Naturopathic medicine c. American Indian medicine d. Traditional Chinese medicine ____ 10. The staff development instructor is preparing a presentation on the different types of medicine being used by the patients cared for in the organization. Which definition should the instructor use to describe the allopathic system or philosophy of health care? a. A system that holds that disease is a result of nerve dysfunction b. A system that maintains that illness is the result of falling out of balance with nature c. A method of treating disease with remedies that produce effects different from those caused by the disease d. A system that uses tiny doses of a substance that create the symptoms of disease in a healthy person to relieve those symptoms in a sick person ____ 11. The nurse is assisting a patient to use guided imagery. Which health problem is the patient most likely experiencing? a. Gallstones b. Hypertension c. Hyperthyroidism

d. Diabetes mellitus ____ 12. The nurse is identifying research-based interventions when planning a patients care. Which type of health care is the nurse planning to provide to the patient? a. Allopathy b. Osteopathy c. Naturopathy d. Homeopathy ____ 13. A patient is prescribed antiplatelet therapy to treat a health problem. Which herbal preparation should the nurse instruct the patient to avoid while taking the prescribed antiplatelet medication? a. Garlic b. Gingko c. Ginseng d. Vitamin C ____ 14. During a health history, the nurse learns that a patient follows a specific diet, detoxification program, exercise, and breathing patterns recommended by a natural health practitioner. In which type of medical therapy should the nurse realize the patient is participating? a. Chinese b. Ayurveda c. Chiropractic d. Homeopathy ____ 15. The nurse educator is preparing a seminar on alternative and complementary therapies for the nursing staff.

Which therapy should the nurse explain as having principles that support wellness and health promotion applicable to all patients? a. Chinese b. Osteopathic c. Chiropractic d. American Indian ____ 16. The nurse is reviewing a patients medication history and becomes concerned about the use of an herbal preparation. Which medication-herb interaction should the nurse discuss with the primary care provider? a. Garlic and CO Q 10 b. St. Johns wort and digoxin (Lanoxin) c. Vitamin C and ampicillin (Amoxicillin) d. Chamomile and hydrochlorothiazide (HCTZ) Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 17. The nurse is caring for a patient experiencing poor appetite, nausea, and vomiting from chemotherapy. Which herbs should the nurse suggest the patient use to help with these symptoms? (Select all that apply.) a. Kava b. Ginger c. Ginkgo

d. Feverfew e. Echinacea ____ 18. The nurse is caring for a patient who is of American Indian descent. Which rituals and practices should the nurse assess as being used by this patient? (Select all that apply.) a. Acupuncture b. The sweat lodge c. Herbal remedies d. Spinal manipulation e. The medicine wheel ____ 19. A patient with arthritis asks the nurse what can be used to reduce pain and inflammation without having to take prescribed medication. What should the nurse recommend to the patient? (Select all that apply.) a. Aloe vera b. Capsaicin c. Chamomile d. Aquatherapy e. Biofeedback ____ 20. The health care provider suggests a patient with fibromyalgia engage in mind-body therapy. Which therapies should the nurse review with the patient? (Select all that apply.) a. Reiki b. Art therapy c. Music therapy d. Guided imagery e. Meditation and relaxation ____ 21. A patient is concerned about the frequency of colds during the past winter season. What herbs should the nurse discuss as having the potential to lessen the symptoms of colds and other viral infections? (Select all that apply.) a. Feverfew b. Echinacea c. Bee pollen d. Chamomile e. St. Johns wort ____ 22. The nurse is considering instructing a patient with chronic pain on an energetic therapy approach. Which therapies should the nurse include in this teaching? (Select all that apply.) a. Reiki b. Biofeedback c. Magnet therapy d. Guided imagery e. Therapeutic touch ____ 23. A patient is considering the use of alternative therapy to treat lumbar stenosis. What should the nurse recommend that the patient complete before beginning this type of therapy? (Select all that apply.) a. Find out the costs of the therapy. b. Talk about the therapy with the primary care practitioner.

c. Look at the conditions of the alternative practitioners practice setting. d. Check the background and qualifications of the alternative practitioner. e. Call the Centers for Disease Control and Prevention (CDC) for additional information. ____ 24. The nurse reviews a list of patients scheduled for appointments in a cancer clinic and notes the types of treatments each patient is using. Which patients are using complementary therapy? (Select all that apply.) a. A 74-year-old with leukemia uses self-hypnosis prior to a bone marrow biopsy. b. A 17-year-old with sarcoma practices relaxation and imagery during radiation therapy. c. A 66-year-old with lymphoma uses headphones to listen to music during chemotherapy. d. A 41-year-old with breast cancer chooses to have radiation therapy instead of a mastectomy. e. A 52-year-old with colon cancer stops chemotherapy and goes to Mexico for shark cartilage therapy. ____ 25. The nurse is identifying ways to help a patient with chronic pain release the natural production of endorphins.

On which strategies should the nurse focus to help the patient achieve this physiological response? (Select all that apply.) a. Use of electrical nerve stimulation devices b. Health food stores that sell quality probiotics c. Types of physical exercise the patient likes to perform d. Suggestions to use when engaging in guided imagery e. Locations of qualified acupuncturists in the patients neighborhood ____ 26. A patient is scheduled to see an acupuncturist as complementary treatment for back pain. What should the nurse instruct the patient to expect when seeing the acupuncturist for the first time? (Select all that apply.) a. The patients tongue will be examined. b. The patients pallor will be assessed. c. The patients voice and scent will be assessed. d. The patients blood pressure will be measured. e. The patients peripheral pulse will be checked. ____ 27. The community health nurse learns that a naturopathic doctor is opening a practice in the neighborhood strip mall. What should the nurse do to ensure the safety of the community members? (Select all that apply.) a. Find out the state in which the doctor is licensed. b. Make an appointment to be evaluated for health problems. c. Petition city hall to prevent the doctor from opening the practice. d. Ask what types of needles are being used for acupuncture treatments. e. Find out the school of naturopathic medicine that the person attended.

Chapter 19. Complementary, Alternative, and Integrative Answer Section MULTIPLE CHOICE 1. ANS: C C. Complementary therapy refers to a therapy used in addition to a conventional therapy. A. B. D. Alternative therapy, sometimes called unconventional therapy, refers to a therapy used instead of conventional or mainstream therapy.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 2. ANS: C C. Guided imagery is an example of a mind-body approach. A. Massage is a manipulative and body-based approach.

B. D. Muscle relaxants and non-narcotic pain relievers are examples of conventional or mainstream approaches.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 3. ANS: B B. Another term for traditional health care in the United States is allopathy. A. Ayurveda is the ancient Hindu system of medicine. C. The osteopathic philosophy involves treating the whole person; recognizes the bodys ability to heal itself; and stresses the importance of diet, exercise, and fitness with a focus on prevention. D. Chiropractic medicine approaches illness as a result of nerve dysfunction.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 4. ANS: B B. The main treatment modality of chiropractors is manual adjustment and manipulation of the vertebral column and the extremities. Chiropractors use direct hand contact and mechanical and electrical treatment methods to manipulate joints. The goal is to remove interference with nerve function, so the body can heal itself. A. Ayurveda maintains that illness is the result of falling out of balance with nature. C. Naturopathy primarily uses natural therapies, such as nutrition, botanical medicine (herbs), hydrotherapy (water-based therapy), counseling, physical medicine, and homeopathy, to treat disease, promote healing, and prevent illness. D. Homeopathy is based on the principle that like cures like; in other words, that tiny doses of a substance that creates the symptoms of disease in a healthy person will relieve those symptoms in a sick person.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 5. ANS: D D. Herbal remedies can interact with other medications and can be potentially harmful in surgery. A. B. C. Knowing why the patient takes them, how often, or in what doses is secondary, because the surgeon needs to be informed to either stop the use of these remedies or delay surgery if necessary.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application 6. ANS: B B. Any herb can be effective for some and dangerous for others, depending on medical history and other prescribed medications. The primary care provider should always be consulted before the patient tries something new. A. Not all

herbal remedies are safe for all people. C. Some herbal preparations are safe to take with prescribed medications. D. The patient needs to discuss the use of this herbal remedy with the primary care provider before ingesting.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application 7. ANS: B B. Western medicine uses scientific data to determine the validity of a diagnosis and the effectiveness of treatment. In other words, it is evidence-based medicine. Several other systems use more natural and nutrition-based therapies.

Western medicine is self-regulated by the American Medical Association (AMA) as well as the government. A. Western medicine does not use natural remedies. C. Western medicine is highly regulated. D. Western medicine is not based on nutrition and exercise therapies.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 8. ANS: A A. The role of the nurse is to teach, not to give an opinion. B, C, and D give opinions. In light of the nurses own recent loss, it is best to defer the question to the physician, who can provide an expert medical opinion.

PTS: 1 DIF: Difficult KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application 9. ANS: D D. The diagnosis and treatment of disturbances of qi are characteristic of Chinese medicine. A, B, and C do not treat disturbances of qi.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 10. ANS: C C. Allopathy is a method of treating disease with remedies that produce effects different from those caused by the disease. A. Chiropractic treats nerve dysfunction. B. Ayurvedic medicine believes that illness results from falling out of balance with nature. D. Homeopathy uses tiny doses of substances that create symptoms.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 11. ANS: B B. Guided imagery is often used to alleviate stress and to treat stress-related conditions such as insomnia and high blood pressure. A. C. D. Gallstones, diabetes, and hyperthyroidism require medical intervention, although guided imagery may help relieve some of the patients distress related to these conditions.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis 12. ANS: A A. Allopathic medicine uses scientific data to determine the validity of a diagnosis and the effectiveness of treatment.

B. C. D. Naturopathy, osteopathy, and homeopathy also may use research-based interventions, but allopathic medicine has the largest body of research and is committed to using evidence-based therapies.

PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application 13. ANS: A A. Garlic can increase the risk of bleeding when taken with anticoagulant or antiplatelet medications. B. Gingko may improve memory and help cognitive function in Alzheimers disease. C. Ginseng may reduce stress and increase alertness. D. Vitamin C is not an herbal preparation but a vitamin supplement.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application 14. ANS: B B. Ayurveda is the ancient Hindu system of medicine and is based upon metabolic body types. Treatment involves a specific diet, herbal remedies, breath work, physical exercise, yoga, meditation, massage, and a rejuvenation or detoxification program. A. Traditional Chinese medicine involves practices such as acupuncture, acupressure, herbs, massage, and qi gong. C. The main treatment modality of chiropractors is manual adjustment and manipulation of the vertebral column and the limbs. D. Homeopathy uses tiny doses of a substance that create the symptoms of disease in a healthy person to relieve those symptoms in a sick person.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis 15. ANS: B B. The osteopathic philosophy involves treating the whole person; recognizes the bodys ability to heal itself; and stresses the importance of diet, exercise, and fitness with a focus on prevention. A. Chinese medicine involves diagnosis and treatment of disturbances of qi or vital energy. C. Chiropractic medicine is based on the belief that illness is a result of nerve dysfunction. D. American Indian medicine is a community-based system with rituals and practices.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 16. ANS: B B. St. Johns wort can interact adversely with digoxin (Lanoxin). A. Garlic and Co Q 10 are both herbal supplements.

C. Vitamin C is not documented as adversely affecting the action of ampicillin (Amoxicillin). D. Chamomile is not documented as adversely affecting the action of hydrochlorothiazide (HCTZ).

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis MULTIPLE RESPONSE 17. ANS: B, D B. D. Ginger may be effective for nausea and vomiting. Feverfew is used to stimulate appetite. A. Kava is for anxiety or insomnia. C. Ginkgo may help memory. E. Echinacea is an antiviral.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application 18. ANS: B, C, E B. D. E. American Indian medicine is a community-based system with rituals and practices such as the sweat lodge, herbal remedies, and the medicine wheel. A. Acupuncture is practiced in traditional Chinese medicine. D. Spinal manipulation is done by chiropractors.

PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 19. ANS: B, D B. D. Capsaicin is an herb that may be administered for tenderness and pain of osteoarthritis, fibromyalgia, diabetic neuropathy, and shingles. Aquatherapy is used to provide pain relief and relaxation for people with arthritis. A. Aloe vera is a soothing topical agent used for skin lesions. C. Chamomile may be used for anxiety or stomach distress. E. Biofeedback is used for stress-related conditions such as high blood pressure, insomnia, migraines, and asthma.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application 20. ANS: B, C, D, E B. C. D. E. Mindbody therapies include art and music therapies, meditation, and guided imagery. A. Reiki is an energetic modality.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 21. ANS: B, E B. E. Echinacea is an antiviral and may lessen cold or other viral symptoms; St Johns wort is also used for viral infections, including HIV and herpes. A. Feverfew is an anti-inflammatory agent. C. Bee pollen is used to increase energy, strength, and stamina. D. Chamomile may be helpful for anxiety or stomach distress.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

22. ANS: A, B, C, E A. B. C. E. Reiki, magnet therapy, biofeedback, and therapeutic touch are among the energetic therapies. D. Guided imagery is a mindbody therapy.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 23. ANS: A, B, C, D A. B. C. D. Before beginning an alternative therapy, the patient should learn the cost of the therapy, discuss the therapy with the primary care provider, look at the conditions of the alternative practitioners practice setting, and check the background and credentials of the alternative practitioner. E. The CDC is a federal agency responsible for tracking disease in the United States; it does not focus on alternative medicine practices.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application 24. ANS: A, B, C A. B. C. Complementary therapy refers to a therapy used in addition to a conventional therapy. Guided imagery, selfhypnosis, music, and relaxation techniques are all examples of complementary therapy. D. Radiation is a conventional medical treatment option. E. Shark cartilage in place of chemotherapy is considered alternative therapy.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis 25. ANS: A, C, E A. C. E. The most recognized methods to release naturally occurring endorphins are physical exercise, acupuncture, and electrical nerve stimulation. B. Probiotics are used to improve digestion, help with constipation, or reduce diarrhea.

D. Guided imagery involves using mental images to promote physical healing or changes in attitudes or behaviors.

PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 26. ANS: A, B, C, E A. B. C. E. Acupuncturists claim to be able to tell much about a patients state of health by checking pulses, looking at the color of the tongue, checking facial color, assessing voice and smell, and asking a variety of questions. D. Acupuncturists do not measure blood pressure.

PTS: 1 DIF: Moderate KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application 27. ANS: A, E A. E. Naturopathic physicians have a doctor of naturopathy (ND) degree and can be licensed in 17 states. There are three schools of naturopathic medicine in the United States. The nurse should find out where the doctor attended school and the state in which the license has been obtained. B. Seeing the naturopathic doctor for a personal health

problem will not necessarily determine if the practice is safe for others. C. The nurse has no evidence to petition the city council to stop the practice from opening. D. Acupuncture is not a treatment modality of naturopathy.

PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

Chapter 20: Caring in Nursing Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is working in a health care clinic. She loves her work because of all the different people she meets. She professes to care for all of them and states that she understands them because she realizes which of the following is true? a.Basically all patients are the same. b.Each person has a unique background. c.Caring for people requires very little experience. d.There are standard solutions to most health care problems.

ANS: B Patients are not all the same. Each person brings a unique background of experiences, values, and cultural perspectives to a health care encounter. Caring is always specific and relational for each nurse-patient encounter.

As nurses acquire more experience, they learn that caring helps them to focus on the patients for whom they care.

Caring facilitates a nurses ability to know a patient, allowing the nurse to recognize a patients problems and to find and implement individualized solutions.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:51BJescribe ways to express caring in practice.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 2. Madeleine Leininger identifies the concept of care as the essence and unifying domain that sets nursing apart from other health care disciplines. Which of the following is true in her view?

a.Care and cure are synonymous. b.Care is designed to focus only on individuals. c.Caring acts are independent of patient values. d.Caring depends on communication.

ANS: D Caring is very personal. One challenge is to find ways to communicate with patients so as to learn the culturally specific behaviors and words that reflect human caring. Care is an essential human need, necessary for the health and survival of all individuals. Care, unlike cure, assists an individual or group in improving a human condition. A caring act depends on the needs, problems, and values of a patient.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 519 OBJ: Describe the commonalities among theories of caring.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 3. Nurses care for a variety of patients. What is an activity that best demonstrates the caring role of a nurse?

a.Staying with a patient and developing a plan of care before surgery b.Performing IV insertion with confidence c.Assessing the patients entire health history d.Inserting a urinary catheter using aseptic technique ANS: A

Caring is highly relational. A nurse and a patient enter into a relationship that is much more than one person simply doing tasks for another. There is a mutual give-and-take that develops as nurse and patient begin to know and care for one another. As a nurse-patient relationship forms, a nurse becomes a coach and partner rather than a detached provider of care. Performing an IV insertion, assessing a health history, and inserting a catheter are all tasks that can be accomplished with or without a caring nurse-patient relationship being developed.

PTS:1DIF:Cognitive Level: Applying (Application) REF:520 | 521OBJescribe ways to express caring in practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. Which of the following would indicate that the nurse has established a level of mutual problem solving?

a.The nurse helps the patient develop questions to ask the health care provider. b.The nurse tells the patient what needs to be done to resolve health problems. c.The nurse is seen as the authority when it comes to health care issues. d.The nurse excludes the family from health discussions to protect privacy.

ANS: A A caring nurse helps hospitalized patients understand how to think about their health and illness and to figure out questions to ask of their health care providers. In addition, a caring nurse helps patients explore options for resolving health problems and provides information and instruction. Using evidence in practice is an aspect of mutual problem solving, with a nurse continuously learning and engaging patients and families in discussions about their health issues. Basic to nursing practice is the inclusion of family members in a patients care.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:521 | 522 OBJ: Discuss the role that caring plays in building nurse-patient relationships.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. The patient was hospitalized with pneumonia. He had always been very healthy and was concerned that now his

family would have to take care of him. During one conversation the nurse said to him, This gives the ones who love you a chance to show you how much they care for you. The comment that the nurse made best demonstrated which behavior? a.Human respect b.Encouraging manner c.Healing environment d.Affiliation needs ANS: B

When a nurse remains poised and cheerful and points out the good in a difficult situation, patients perceive these behaviors as caring. Having an encouraging manner also involves helping a patient deal with negative feelings.

Having an encouraging manner also involves helping patients deal with bad feelings. Human respect refers to nurses being able to appreciate the value of human beings and displaying behaviors that demonstrate value, such as accepting or paying attention to a patient. By showing respect, a nurse honors the worth of individuals. Although the nurse in this case is not disrespectful, the primary concept being demonstrated is an encouraging manner. It is important to note that concepts are not necessarily exclusive. A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, reduce noise, and treat the body carefully. Affiliation needs refer to the inclusion of family members in a patients care. It is a key element in discharge planning.

Hospitalized patients perceive nurses as caring when they are responsive to patients families and allow them to be involved in the patients health care situation. In this scenario, the patients family is not involved.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:522 | 523 OBJ: Discuss the evidence that exists about patients perceptions of caring.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6.A registered nurse who works for an orthopedic unit of an acute care hospital makes hourly rounds on his patients. He also closes the door and pulls the curtains around the beds of patients in semiprivate rooms before exposing them for treatments. This is an example of which of the following behaviors? a.Human respect b.Encouraging manner c.Healing environment d.Affiliation needs ANS: C A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, and treat the body carefully. Such an environment leads patients to a sense of security and protection from harm.

Human respect refers to nurses being able to appreciate the value of human beings and displaying behaviors that demonstrate value, such as accepting or paying attention to a patient. By showing respect, a nurse honors the worth of individuals. Having an encouraging manner also involves helping patients deal with bad feelings. Affiliation needs refers to inclusion of family members in a patients care. It is a key element in discharge planning.

Hospitalized patients perceive nurses as caring when they are responsive to patients families and allow them to be involved in the patients health care situation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:522 | 523OBJescribe ways to express caring in practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7.A registered nurse who worked in an extended care facility could see that a patient was in the process of dying.

The lab technician came to draw his blood. The nurse requested that the blood draw be postponed for a while so that the patients wife, who was at his bedside, could spend some quiet time with her husband. This is an example of which caring behavior? a.Providing presence b.Encouraging manner c.Healing environment d.Affiliation needs ANS: A Providing presence is a person-to-person encounter conveying closeness and a sense of caring. Presence occurs within an atmosphere of intimacy and sensitivity and is characterized by open and honest interactions. An encouraging manner occurs when a nurse is poised and cheerful and points out the good in a difficult situation, patients perceive these behaviors as caring. Having an encouraging manner also involves helping patients deal with bad feelings. A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, reduce noise, and treat the body carefully. Attending to affiliation needs occurs in nursing practice with the inclusion of family members in a patients care. It is a key element in discharge planning. Hospitalized patients perceive nurses as caring when they are responsive to patients families and allow them to be involved in the patients health care situation. Often these behaviors overlap.

PTS:1DIF:Cognitive Level: Applying (Application) REF:522 | 523

OBJ: Explain the relationship between knowing a patient and clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8.A female patient has just found a large lump in her breast. The health care provider needs to perform a breast biopsy. The nurse assists the patient into the proper position and offers support during the biopsy. What is the nurse doing? a.Creating a healing environment b.Fulfilling affiliation needs c.Providing a sense of presence d.Demonstrating an encouraging manner ANS: C A sense of presence is something a nurse offers to patients with the purpose of achieving some goal, such as support, comfort, or encouragement; to diminish the intensity of unwanted feelings; or for reassurance.

Establishing presence when patients are experiencing stressful events or situations is very important. A nurses presence calms anxiety and fear related to stressful situations. Giving reassurance and thorough explanations about a procedure, remaining at a patients side, and coaching a patient through the experience all convey a presence that is invaluable to a patients well-being. A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, reduce noise, and treat the body carefully. Affiliation need in nursing practice occurs with the inclusion of family members in a patients care. It is a key element in discharge planning. Having an encouraging manner occurs when a nurse is poised and cheerful and points out the good in a difficult situation.

Patients perceive these behaviors as caring.

PTS:1DIF:Cognitive Level: Applying (Application) REF:522 | 523OBJescribe ways to express caring in practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 9.A nurse enters a patients room and is very methodical in her assessment skills and in providing a safe environment, but only speaks with the patient when necessary to gather data. This nurse is: a.uncaring and probably always will be. b.most likely a product of a less caring environment. c.probably more caring with other patients. d.a product of a caring environment.

ANS: B There are no known ways that will ensure you will become a caring professional. For those who find caring a normal part of their life, caring is a product of their culture, values, experiences, and relationships with others.

Persons who do not experience care in their lives often find it difficult to act in caring ways. As nurses deal with health and illness in their practice, most grow in the ability to care. Caring nurses use a caring approach in each patient encounter.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:523 OBJ: Discuss the evidence that exists about patients perceptions of caring.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10. The patient was admitted to the hospital with advanced-stage cancer. As the nurse was admitting her, the patient

told her about how her little dog learned a new trick, and could play dead when she said bang-bang. Why did the nurse listen attentively to the patients story?

a.She knew it was easy to do and she had nothing else to do at that time. b.It was little more than two people talking back and forth. c.She knew it was probably not going to affect the patient-nurse relationship. d.She knew it was a way to know and respond to what matters to the patient.

ANS: D True listening leads to knowing and responding to what really matters to a patient and family. Learning to listen to a patient is sometimes difficult. It is easy to become distracted by tasks at hand, colleagues shouting instructions, or other patients waiting to have their needs met. Caring is an interpersonal interaction that is much more than two persons simply talking back and forth. In a caring relationship a nurse establishes trust, opens lines of communication, and listens to what a patient has to say. Listening to the meaning of what a patient says creates a mutual relationship.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 524 | 525 OBJ: Describe the therapeutic benefit of listening to patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 11. When individuals become ill, there may be a story about the meaning of the illness. When a nurse listens, the

patient is:

a.able to break the distress of illness. b.unable to express what he actually needed when he was ill. c.usually not able to determine what is at stake because of his illness. d.able keep the nurse from prying into his more personal life.

ANS: A When an individual becomes ill, he or she usually has a story to tell about the meaning of the illness. Being able to tell that story helps a patient break the distress of illness. He needs to be able to express what he needs when ill.

The personal concerns that are part of a patients illness story determine what is at stake for the patient. Caring through listening enables you to participate in a patients life.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 524 | 525 OBJ: Describe the therapeutic benefit of listening to patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 12. One of the five caring processes described by Swanson (1991) is knowing the patient. The concept comprises both a nurses understanding of a specific patient and subsequent selection of interventions. To become adept at knowing patients early, what should the nurse do?

a.Check on patients at irregular times so they do not get used to a routine. b.Depend on other nurses assessments to evaluate your own. c.Assume that your interventions are effective because they have been ordered. d.Reflect about your patient interactions and evaluations.

ANS: D Reflect about what you have learned, each time you either assess or evaluate a patient. Routinely round on patients at the beginning of a work shift and ongoing as appropriate. Do not depend on others observationsbe thorough and make your own assessment. Always go back and observe how a patient responded to your interventions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:525

OBJ: Explain the relationship between knowing a patient and clinical decision making.

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 13. The relief of pain and suffering give a patient comfort, dignity, respect, and peace. To enhance the therapeutic environment, what should the nurse do?

a.Make the environment as noise free as possible. b.Remove personal items so that the environment is as clinical as possible. c.Focus on removing negative physical stimuli. d.Make the environment a place to soothe mind, body, and spirit.

ANS: D The relief of pain and suffering are caring nursing actions that give a patient comfort, dignity, respect, and peace.

By ensuring that the patient care environment is clean, reasonably quiet, and pleasant and inclusive of personal items, you make the physical environment a place that soothes and heals the mind, body, and spirit.

PTS:1DIF:Cognitive Level: Applying (Application) REF:525OBJescribe ways to express caring in practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. The ANA, National League for Nursing, AONE, and American Association of Colleges of Nursing recommend strategies to reverse the current nursing shortage. A number of the strategies have potential for creating work environments that enable nurses to demonstrate more caring behaviors. Which of the following provisions is advocated to create a more desirable work environment?

a.Provide nurses with autonomy over their practice. b.Increase the rigor in the work environment structure. c.Increase the availability of technology. d.Stress the cost-effectiveness of health care.

ANS: A To create environments conducive to caring, health care organizations must introduce greater flexibility into the work environment structure, reward experienced nurse mentors, offer programs for compassion fatigue, improve nurse staffing, and provide nurses with autonomy over their practice. A reliance on technology and cost-effective health care strategies and efforts to standardize and refine work processes all undermine the nature of caring.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:526 OBJ: Describe how health care institutions stress the importance of caring practices in achieving patient satisfaction. TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Nurses demonstrate caring behaviors when they do which of the following? (Select all that apply.) a. Give clear explanations. b.Make the patient do everything for himself or herself. c.Tell the patient that getting pain medication depends on his or her cooperation. d.Share information about the patients responses with other staff members. e.Ask permission before doing something to the patient.

ANS: A, E Caring behaviors include being honest, advocating for the patients care preferences, giving clear explanations, keeping family members informed, asking permission before doing something to a patient, and providing comfort: Offering a warm blanket, finding food a patient can swallow, rubbing a patients back, reading patients passages from religious texts, a favorite book, cards or mail, providing for and maintaining patient privacy, assuring patients that nursing services will be available, helping patients to do as much for themselves as possible, and teaching families how to keep patients physically comfortable.

PTS:1DIF:Cognitive Level: Applying (Application) REF:526OBJescribe ways to express caring in practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Chapter 21: Cultural Competence Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.The nurse is attempting to teach a patient how to perform wound care for when he goes home. Using the teach back method the nurse should do which of the following? a.Repeat the instructions until the patient understands. b.Present the information and clarify with closed-ended questions. c.Ask the patient if he understands the instructions. d.Ask if the patient has any questions about the technique.

ANS: A The teach back technique is an ongoing process of asking patients for feedback, through explanation or demonstration, and presenting information in a new way until you feel confident that you communicated clearly and patients have a full understanding of the information presented. Using teach back can also help you identify explanations and communication strategies that patients most commonly understand. When using the teach back technique, do not ask the patient, Do you understand? or Do you have any questions? Instead you should ask openended questions to verify the patients understanding.

PTS:1DIF:Cognitive Level: Applying (Application) REF:539 OBJ: Analyze the impact of culture on health, illness, and caring patterns.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 2.A student nurse is caring for a patient of Mexican descent. In an attempt to become culturally aware, the student should consciously think about which of the following? a.What people of Mexican descent believe b.The relationship between culture and ethnicity c.The fact that the patient belongs to an isolated social group d.Where the person is in the intersections of socially constructed categories ANS: D We must understand a persons location in the intersections of socially constructed categories of privilege and oppression (e.g., race, class, gender, age, sexual orientation). This is necessary in order to, fully understand a persons actions, choices and outcomes. Culture has historically been associated with norms, values, and traditions passed down through generations. Culture has also been perceived as synonymous with ethnicity, race, nationality, and language. These outdated ideas about culture lead to statements such as, Mexicans believe this or Chinese patients are like this. In reality, culture is much more dynamic and includes race, ethnicity, gender, sexual orientation, class, immigration status, and other axes of identification. All of us are members of multiple social groups at the same time. These intersecting identities impact our experience of the world around us.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 532 OBJ: Describe steps toward developing cultural competence.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. When dealing with cultural awareness, the nurse realizes that the term oppression involves which of the following?

]

a.Maintaining advantages based on social group membership b.Systems that maintain disadvantages aimed purely at individuals c.Intentional discrepancies alone d.Issues at institutional levels independent of individual or cultural factors ANS: A Oppression involves systems that maintain advantages and disadvantages based on social group membership and operate intentionally and unintentionally, at individual, cultural, and institutional levels.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 532 OBJ: Use cultural assessment to plan culturally competent care.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 4. The student nurse has been studying different cultures in relationship to nursing. She understands that transcultural nursing has been developed as a distinct discipline and can be defined as which of the following?

a.Understanding that cultural patterns are generated from predetermined criteria b.Knowing that culturally congruent care is based on health care system values c.Understanding cultural similarities and differences among groups of people d.The realization that illness and disease are the same ANS: C Leininger defines transcultural nursing as a comparative study of cultures to understand similarities (culture universal) and differences (culture-specific) across human groups. The goal of transcultural nursing is culturally congruent care, or care that fits a persons life patterns, values, and a set of meanings. Patterns and meanings are generated from people themselves rather than predetermined criteria. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. To provide culturally congruent care, it is important for you to distinguish between disease and illness . Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:533 | 534 OBJ: Describe social and cultural influences in health, illness, and caring patterns.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 5. Cultural competence is the ongoing process in which a health care professional continuously strives to achieve the ability to work effectively within the cultural context. To do this effectively, what must the nurse do?

a.Understand the cultural norms of the patients community. b.See herself or himself as being culturally competent. c.Face the reality that cultural competence can take up to a year to achieve. d.View herself or himself as becoming culturally competent.

ANS: D Cultural competence is the ongoing process in which a health care professional continuously strives to achieve the ability to work effectively within the cultural context of a patient (individual, family, and community). There are a variety of models for how to acquire cultural competence. One model requires nurses to see themselves as becoming culturally competent rather than being culturally competent. It is a developmental process that evolves over a lifetime. Cultural competence goes beyond just understanding cultural norms with a patients communitythis is only a component of competence.

]

PTS:1DIF:Cognitive Level: Applying (Application) REF:535 OBJiscuss research findings applicable to culturally competent care.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 6.A student nurse assigned to a female, observant Muslim patient noticed her discomfort with several of the male health care providers. She wonders if this discomfort is related to the patients religious beliefs. In her preparation for clinical, she learned that Muslims differ in their adherence to tradition, but that modesty is the overarching Islamic ethic pertaining to interaction between the sexes (Rabin, 2010). The student nurse states which of the following to the patient? a. Im going to request that you only have female physicians see you. Does having male nurses bother you as well? b. I know that its hard to get used to, but you just have to get used to it. Thats how it is in America.

c.It must be difficult for people like you to adjust to our ways, but there are limitations for all of us. d.I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable?

ANS: D

Delivering culturally congruent care to individuals and communities requires specific knowledge, skills, and attitudes. Nurses who provide culturally competent care bridge cultural gaps to provide meaningful and supportive care for all patients. The student nurse states to the patient, I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable? The student did not assume that the information will automatically apply to this patient. Instead, the student combined her knowledge about a cultural group with the attitude of helpfulness and flexibility so as to provide quality patient-centered culturally congruent care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:535 OBJ: Describe social and cultural influences in health, illness, and caring patterns.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse is caring for a patient of a culture different from her own. To provide culturally competent care for this

patient, what does the nurse need to do?

a.Not be curious about other ways of being in the world b.Understand the forces that influence her own world view c.Recognize that she must not hold any bias toward the patient d.Have no predispositions relative toward the patients culture ANS: B Although curiosity about other ways of being in the world is an important attitude for cultural competence, it is also important for a nurse to understand the forces that influence his or her own world view. Everyone holds biases about human behavior. Bias means a predisposition to see people or things in a certain light, positive or negative (Aguilar, 2006). Becoming more aware of ones biases and attitudes about human behavior is the first step on the ladder of cultural competence that can lead to positive change.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 535 OBJ: Use cultural assessment to plan culturally competent care.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity ]

8. The current focus on promoting a culturally competent health care environment is on which of the following?

a.The health care providers efforts to become self-aware b.The health care provider learning about other cultures c.Avoiding the systematic provision of care d.Ensuring that cultural competence is integrated into administrative processes ANS: D The current focus is toward systemic approaches to ensure that cultural competence is integrated into the administrative processes and the provision of care, rather than avoidance of systematic approaches. In the past, many of the methods to promote a culturally competent health care environment focused on health care providers efforts to become self-aware and learn about other cultures.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 536 OBJ: Use cultural assessment to plan culturally competent care.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. The nurse is performing a cultural assessment on a patient. What does the nurse know about cultural assessments?

a.They are intrusive and time consuming. b.They are not dependent on a trusting relationship. c.They are rarely plagued by miscommunication. d.They are based in similarities of behavior.

ANS: A In contrast to other types of interviews, cultural assessment is intrusive and time consuming and requires a trusting relationship between participants. Miscommunication commonly occurs in intercultural transactions. This is because of language communication differences between and among participants and differences in interpreting each others behaviors. Nurses use transcultural communication skills to interpret a patients behavior within his or her own context of meanings and to behave in a culturally congruent way.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 538 | 539 OBJ: Use cultural assessment to plan culturally competent care.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1.A nurse is in the process of admitting an ethnically diverse patient. To plan culturally competent care, what must the nurse do? (Select all that apply.) a.Assume that cultural processes are the same within a social group. b.Conduct a systematic cultural assessment. c.Communicate effectively. d.Negotiate world view differences.

ANS: B, C, D Critical to success is your ability to conduct a systematic cultural assessment, communicate effectively, and have the skills to negotiate world view differences with others. Cultural processes frequently differ within the same social group (a family, a group of white people, a group of women friends, an immigrant family, a group of nurses) because of differences, for example, in age, gender, political association, class, or religion. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF: 536 OBJ: Use cultural assessment to plan culturally competent care.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 2. Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care. Some examples of such organizational policies and practices include which of the following? (Select all that apply.) a. Instituting a requirement for all staff to be trained in cultural competence b.Maintaining the traditional description of family in written policies c.Enforcing strict visitation policies and practices d.Ensuring that persons who are deaf or speak limited English have access to an interpreter e.Embedding health literacy principles in written and verbal communication

ANS: A, D, E Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care. Some examples of such organizational policies and practices include: instituting a requirement for all staff to be trained in cultural competence, embedding a broad description of family in written policies, expanding visitation policies and practices to include a patients preferences, requiring nursing staff to conduct and document a cultural assessment on all patients within the clinical documentation system, ensuring that persons who are deaf or speak limited English have access to an interpreter, and embedding health literacy principles in written and verbal communication.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 536 OBJ: Describe steps toward developing cultural competence.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 3. Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic

groups that are often exacerbated by which of the following? (Select all that apply.) a.Social status b.Economics c.Environment d. Improved access to health care ANS: A, B, C

Healthy People 2020 defines a health disparity as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Poor access to health care is one social determinant of health that contributes to health disparities.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:531OBJescribe health disparities.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

]

Chapter 22: Spiritual Health Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. An elderly patient is dying, and begins talking to loved ones who have died before him. The nurse feels a sense

of inner peace as his patient quietly dies. What is the best term for this feeling of peace? a.Self-transcendence b.Intrapersonal connectedness c.Interpersonal connectedness d.Transpersonal connectedness ANS: A

Self-transcendence refers to connecting to your inner self, which allows you to go beyond yourself to understand the meanings of experiences, whereas transcendence is the belief that there is a positive force outside of and greater than oneself that allows you to develop new perspectives that are beyond physical boundaries. Examples of transcendent moments include the feelings of awe when holding a new baby or watching the sun rise over the mountains. Spirituality offers a sense of connectedness intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with God, the unseen, or a higher power).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:548 OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. The nurse is caring for a patient who states that he does not believe in the existence of God. The nurse realizes that this person: a. is not a spiritual person. b. is an agnostic.

c.believes that people bring meaning into the world. d.finds meaning in life through work and relationships.

ANS: D Atheists search for meaning in life through their work and relationships with others. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Spirituality is an important concept for individuals who either do not believe in the existence of God (atheist) or who believe that any ultimate reality is unknown or unknowable (agnostic). It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that we, as people, bring meaning to what we do.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:549 OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 3.A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a: ]

a.system of organized beliefs and worship. b.relationship with a higher power, authority, or spirit. c.source of energy needed to cope with difficult situations. d.multidimensional concept that gives comfort while a person endures hardship.

ANS: B Faith is a relationship with a divinity, higher power, authority, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Hope is multidimensional and gives comfort while a person endures hardship and personal challenges.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:549 OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4.A patient has been diagnosed with a terminal disease. Hope may be used effectively with this type of patient.

Nurses can support a patients use of hope because hope provides a: a.system of organized beliefs and worship. b.belief in a higher power, spirit guide, God, or Allah. c.cultural connectedness, structure, and guidance in difficult times. d.motivation to achieve and the resources to use toward that achievement.

ANS: D Hope is energizing, giving individuals a motivation to achieve and the resources to use toward that achievement.

Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Faith involves a belief in a higher power, spirit guide, God, or Allah. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:550 OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5.When caring for patients, a nurse must understand the difference between religion and spirituality. Religious care helps patients maintain their faithfulness to: a.their belief systems and worship practices. b.a relationship to a higher being or life force. c.a sense of connectedness. d.the awareness of ones inner self.

ANS: A Religious care helps patients follow their belief systems and worship practices. Spirituality is an awareness of ones inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being. ]

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 550 OBJ: Compare and contrast the concepts of religion and spirituality.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6.A patient who has been diagnosed with terminal liver cancer states that he does not believe in God, but he has had a meaningful life by contributing to the lives of those around him. This person is most likely which of the following? a.Buddhist b.Christian c.Agnostic d.Atheist ANS: D Atheists search for meaning in life through their work and relationships with others. It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are.

They believe that we, as people, bring meaning to what we do. A Buddhist turns inward, valuing self-control, whereas a Christian looks to the love of God to provide enlightenment and direction in life.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 549 OBJ: Compare and contrast the concepts of religion and spirituality.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 7.A nurse is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery. To help this patient cope with this experience, what is the best thing for the nurse to do? a.Recommend that the patient not discuss the experience with family. b.Assume that the near death experience was a positive experience. c.Explain that people who have not had that experience will not understand. d.Explore what happened with the patient.

ANS: D After patients have survived a near death experience (NDE), promote spiritual well-being by remaining open, giving patients a chance to explore what happened, and supporting patients as they share the experience with significant others. Patients who have an NDE are often reluctant to discuss it, thinking family or caregivers will not understand. Isolation and depression often occur. Furthermore, not all NDEs are positive experiences. However, individuals experiencing an NDE who discuss it openly with family or caregivers find acceptance and meaning from this powerful experience.

PTS:1DIF:Cognitive Level: Applying (Application) REF:552 OBJ: Discuss the relationship of spirituality to an individuals total being.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8.A nurse who works in a neonatal intensive care unit is caring for a critically ill infant with a poor prognosis. She is Christian and feels responsible to care for both the physical and spiritual needs of the infant and his parents.

What is the best statement for the nurse to make to the parents of the infant? a.You should have the child baptized so that its soul will be saved. ]

b.W ould you like me to call the chaplain to christen your child at the bedside? c.What can I do to support your spiritual needs? b.Xhave asked my pastor to stop by and talk to you.

ANS: C Differentiate your personal spirituality from that of the patient. Your role is not to solve the spiritual problems of patients, but to provide an environment for your patients to express their spirituality. Having the child baptized or asking your pastor to come talk to the patient is applying your spiritual values on the patient. Asking permission to call the chaplain is assuming that the patient has value regarding that religious denomination.

PTS:1DIF:Cognitive Level: Applying (Application) REF:552 OBJ: Discuss the relationship of spirituality to an individuals total being.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 9.A patient refuses to remove a specific spiritual garment for daily bathing. The most appropriate action for the nurse would be to: a.remove the article anyway because the garment hinders daily care delivery. b.respect the patients wishes and work around it. c.explain to the patient that the garment has no real spiritual value. d.identify the refusal as a sign of spiritual distress.

ANS: B To care for and meet the spiritual needs of your patients, it is essential to respect each patients personal beliefs.

People experience the world and find meaning in life in different ways and the spiritual garment has meaning for the patient. Caring for your patients spiritual needs requires you to be compassionate and remove any personal biases or misconceptions. You need to recognize that not all patients have spiritual problems. Patients bring certain spiritual resources that help them assume healthier lives, recover from illness, or face impending death.

PTS:1DIF:Cognitive Level: Applying (Application) REF:554 OBJ: Discuss the relationship of spirituality to an individuals total being.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 10.To assess, evaluate, and support a patients spirituality the best action a nurse should take includes: a.recognizing that spirituality does not enhance therapeutic relationships. b.performing a definitive spiritual assessment once because spirituality does not vary. c.focusing the assessment on religious doctrine and faith. d.remembering that spirituality is very subjective.

ANS: D Remember that spirituality is very subjective and has different meanings for different people. You are able to gather an accurate assessment of your patients spirituality when you take time to build therapeutic relationships with them. Conduct an ongoing spiritual assessment the entire time you care for a patient. Focus your assessment on aspects of spirituality most likely to be influenced by life experiences, events, and questions in the case of illness and hospitalization.

PTS:1DIF:Cognitive Level: Applying (Application) ]

REF: 554 OBJ: Compare and contrast the concepts of religion and spirituality.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Interventions a nurse can use to establish presence with a patient include which of the following? (Select all that

apply.)

a. Giving attention b.Answering questions c.Listening d.Administering medication e.Speaking with the family

ANS: A, B, C Behaviors that establish your presence include giving attention, answering questions, listening, and having a positive and encouraging (but realistic) attitude. Presence is part of the art of nursing that involves being with a patient versus doing for a patient, as in administering medication and speaking with the family. Presence is being able to offer closeness with the patient, which helps to prevent emotional and environmental isolation.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:561OBJ:Establish presence with patients.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

]

Chapter 23: Growth and Development Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A student nurse who works in a pediatric clinic is assisting with an assessment on a young child who is not yet walking. She knows that it is considered a delayed gross motor ability if the child does not walk by months. a.16 b.18 c.20 d.22 ANS: C A critical period of development refers to a specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development. For example, if a child does not walk by the age of 20 months, there is delayed gross motor ability, which slows exploration and manipulation of the environment. The success or failure experienced within a phase affects the childs ability to complete the next phases.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 2. According to one growth and development theorist, individuals need to accomplish a particular task before successfully completing the stage of growth and development. Each task is framed with opposing conflicts, such as trust versus mistrust. Who developed this theory? a. Sigmund Freud

b.Jean Piaget c.Erik Erikson d.Lawrence Kohlberg ANS: C Erik Erikson divided life into eight stages, known as Eriksons eight stages of development. According to this theory, individuals need to accomplish a particular task before successfully completing each stage. Each task is framed with opposing conflicts, such as trust versus mistrust. Each stage builds upon the successful attainment of the previous developmental conflict. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and instinctive forces. Each of the five stages is associated with a pleasurable zone, serving as the focus of gratification. Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world. The theory includes four periods: sensorimotor, preoperational, concrete operations and formal operations. Lawrence Kohlberg (1927-1987) expanded on Piagets work. According to Kohlberg (1964), moral development is one component of psychosocial development. It involves the reasons an individual makes a decision about right and wrong behaviors within a culture.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 | 570 OBJ: Compare the frameworks for growth and development as described by major developmental theorists. TOP: Nursing Process: Diagnosis ]

MSC: NCLEX: Health Promotion and Maintenance 3. This model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Who is responsible for developing this theory? a. Sigmund Freud b.Jean Piaget c.Erik Erikson d.Lawrence Kohlberg

ANS: A Sigmund Freud (1856-1939) provided the first formal structured theory of personality development. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world. The theory includes four periods: sensorimotor, preoperational, concrete operations, and formal operations. Erik Erikson divided life into eight stages, known as Eriksons eight stages of development.

According to this theory, individuals need to accomplish a particular task before successfully completing each stage. Each task is framed with opposing conflicts, such as trust versus mistrust. Each stage builds upon the successful attainment of the previous developmental conflict. Lawrence Kohlberg (1927-1987) expanded on Piagets work. According to Kohlberg (1964), moral development is one component of psychosocial development.

It involves the reasons an individual makes a decision about right and wrong behaviors within a culture.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 | 570 OBJ: Compare the frameworks for growth and development as described by major developmental theorists. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 4. Which of the following people developed the theory of cognitive development that describes childrens intellectual

organization and how they think, reason, and perceive the world? a. Sigmund Freud b.Jean Piaget c.Erik Erikson d.Lawrence Kohlberg

ANS: B Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world. Sigmund Freud (1856-1939) provided the first formal structured theory of personality development. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Erik Erikson divided life into eight stages, known as Eriksons eight stages of development.

According to this theory, individuals need to accomplish a particular task before successfully completing each stage. Each task is framed with opposing conflicts, such as trust versus mistrust. Each stage builds upon the successful attainment of the previous developmental conflict. Lawrence Kohlberg (1927-1987) expanded on Piagets work. According to Kohlberg (1964), moral development is one component of psychosocial development.

It involves the reasons an individual makes a decision about right and wrong behaviors within a culture.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 | 570 ]

OBJ: Compare the frameworks for growth and development as described by major developmental theorists. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 5. According to one theorist, moral development depends on the childs ability to accept social responsibility and to integrate personal principles of justice and fairness. Which of the following individuals is responsible for the theory of moral development? a. Sigmund Freud

b.Jean Piaget c.Erik Erikson d.Lawrence Kohlberg ANS: D According to Kohlberg (1964), moral development is one component of psychosocial development. It involves the reasons an individual makes a decision about right and wrong behaviors within a culture. Moral development depends on the childs ability to accept social responsibility and to integrate personal principles of justice and fairness. Sigmund Freud (1856-1939) provided the first formal structured theory of personality development.

Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world. Erik Erikson divided life into eight stages, known as Eriksons eight stages of development. According to this theory, individuals need to accomplish a particular task before successfully completing each stage. Each task is framed with opposing conflicts, such as trust versus mistrust. Each stage builds upon the successful attainment of the previous developmental conflict. Lawrence Kohlberg (1927-1987) expanded on Piagets work.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 | 570 OBJ: Compare the frameworks for growth and development as described by major developmental theorists. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 6.A patient is experiencing incisional pain after an operation. When using Maslows hierarchy of needs, the nurse realizes that for the patient to return to a prehospitalized status, the patient needs to progress beyond which of the following? a.Belonging b.Self-esteem c.Self-actualization d.Safety and security ANS: D Maslow described an ordering (hierarchy) of needs that motivate human behavior. This ordering is often depicted as a pyramid composed of five levels. When the most basic needs, such as hunger and oxygen, are met, the person strives to satisfy those needs for safety and security on the next highest level. Disturbances at lower levels interfere with the highest level, self-actualization or the realization of ones potential. Individuals need to satisfy each level before moving on to the next. Belonging occupies the third stage, where threats to relationships create anticipatory loneliness and alienation. Self-esteem occupies the fourth stage, and threats create alienation. Self-actualization is the highest level that one can achievethe realization that one has reached his or her highest potential. Safety and security occupies the second stage, and threats to security (such as pain) produce feelings of insecurity.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) ]

REF:570 | 588 OBJ: Use knowledge of growth and development to enhance use of the nursing process for individuals across the life span. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 7.The nurse is providing prenatal education to a patient whose pregnancy has been confirmed. This is the patients first pregnancy and she is in her first trimester. The nurse instructs the patient that she should stop smoking, avoid alcohol, and avoid eating king mackerel because of the high mercury content in the fish. Although this advice should be followed during the entire pregnancy, the fetus is most vulnerable to adverse effects in the trimester. a.first b.second c.third d.final ANS: A Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased during the first trimester when fetal cells are differentiating and organs are forming.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:571 OBJ:Identify specific nursing interventions for the health promotion of patients across the life span.TOP:Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 8.A pregnant teenager asks the clinic nurse why she cannot smoke during the first trimester. Remembering growth and development, what is the nurses best response? a.Smoking is a bad habit, but it probably wont affect the baby. b.Smoking may affect organ systems that are beginning to develop. c.Smoking will only affect the baby in the third trimester. d.Smoking mothers usually produce overweight babies ANS: B Teratogens are chemical or physiological agents capable of having adverse effects on the fetus. Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased during the first trimester when fetal cells are differentiating and organs are forming. In addition, there is evidence that mothers who smoke deliver infants with lower birth weights than nonsmoking mothers.

PTS:1DIF:Cognitive Level: Applying (Application) REF:571 OBJ:Use critical judgment to determine appropriate teaching topics for individual patients across the life span.TOP:Nursing Process: Implementation MSC:NCLEX: Reduction of Risk Potential 9.A student nurse is in her community health clinical rotation. She is visiting a family with a new baby. Which of the following statements made by the mother of a 1-month-old infant indicates the need for client education? ]

a.My baby should double his birth weight by the time he is 6 months old. b.I shouldnt give my baby any cows milk until he is at least a year old. c.My baby has been fussy lately; I believe he is probably cutting his teeth. d.I shouldnt put my baby on a fluffy pillow to sleep.

ANS: C The first tooth to erupt is usually one of the lower central incisors at the average age of 7 months. Most babies have six teeth by their first birthday. Typically infants double their birth weight by 5 to 6 months and triple it by 12 months. Infants should not have any type of cows milk during the first year because the high protein content may increase the chance of food allergies. The American Academy of Pediatrics recommends infants not sleep with a blanket until they are a year old.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:572 | 573 OBJ:Use critical judgment to determine appropriate teaching topics for individual patients across the life span.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10.The mother of a toddler is concerned that her son is not eating enough, although he has not lost any weight. She tells the nurse that her son used to have a very good appetite, but now does not eat as much as he did a couple of months ago. What is the best response for the nurse to provide? a.You need to make him eat. At this stage, he is growing too fast to not eat. b.I could show you a growth chart, but each child is different so it doesnt mean much. c.Toddlers have periods when they arent growing as fast and they dont need to eat as much. d.Make him eat with a spoon and dont feed him snacks. He will be hungrier at meal time.

ANS: C Slower growth rates often occur with a decrease in caloric needs and a smaller food intake. Confirming the childs pattern of growth with standard growth charts is reassuring to parents concerned about their toddlers decreased appetite (physiological anorexia). Encourage parents to offer a variety of nutritious foods, in reasonable servings, for mealtime and snacks. Finger foods allow the toddler to be independent.

PTS:1DIF:Cognitive Level: Applying (Application) REF:573 OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11.A nurse is caring for a 5-year-old child who is hospitalized for stabilization of asthma. To provide age-specific care, which of the following is the most appropriate action by the nurse? a.Allow the child to handle medical equipment. b.Have a parental presence at all times. c.Have the child lie flat and still during procedures. d.Tell the child as little as possible about expectations and care.

ANS: A These strategies can be used to reduce preschoolers fears when they are hospitalized: allowing children to sit up when performing assessments and procedures; allowing the child to see and handle equipment; allowing the child to ]

assist with the procedure if appropriate; giving simple and factual information to these children because they have a great sense of imagination. Although preschoolers have developed object permanence and recognize their parents still exist when out of sight, most tolerate only short absences without becoming distressed. Encourage parents to tell the child when they are leaving and when they will return in terms the child can understand (e.g., I am leaving and will be back after lunch.).

PTS:1DIF:Cognitive Level: Applying (Application) REF:575 OBJ:Identify specific nursing interventions for the health promotion of patients across the life span.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. An 11-year-old boy is being seen at the clinic for his annual check-up. As part of anticipatory guidance, the nurse instructs the boys father that accidents and injuries are major health problems affecting school-age children and that the number one cause of death is in this age group is which of the following?

a.Drowning b.Motor vehicle accidents c.Fire d.Firearms ANS: B Accidents and injuries are major health problems affecting school-age children and are the causative factor in a large number of deaths in this age group. Motor vehicle accidents, followed by drowning, fires, burns, and firearms are the most frequent fatal accidents.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:576 OBJ:Identify specific nursing interventions for the health promotion of patients across the life span.TOP:Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. The mother of an 8-year-old girl has brought her daughter to the health clinic for her annual check-up. She is

concerned about the high blood pressure in her family and asks the nurse if there is some way to know if the child is at risk for hypertension. What is the nurses best response? a.Blood pressure elevation in childhood is the single best predictor of adult hypertension. b.Well lets take her blood pressure and see if its up. If it is, she has hypertension. c.She looks pretty plump to me, and that indicates good health. As long as shes eating, she should be OK. d.If you think that shes gaining weight, put her on an exercise program, but wait until shes in her teens.

ANS: A Blood pressure elevation in childhood is the single best predictor of adult hypertension. This recognition has reinforced the significance of making blood pressure measurement a part of every annual assessment of the child.

Measure on at least three separate occasions with the appropriate-size cuff and in a relaxed situation before concluding that the childs blood pressure is elevated and needs further medical attention. Childhood obesity is a prominent health problem, which increases the childs risk for hypertension, diabetes, coronary artery disease, and other chronic health problems. Daily exercise and maintaining normal body weight are important as both interventions and prevention even while in the preteen years.

PTS:1DIF:Cognitive Level: Applying (Application) ]

REF:576 OBJ:Identify specific nursing interventions for the health promotion of patients across the life span.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. The transition from childhood to adulthood, in terms of the psychological maturation of the individual, is known as which of the following?

a.Puberty b.Adolescence c.Menarche d.Preadolescence ANS: B The term adolescence refers to the psychological maturation of the individual, whereas puberty refers to the point at which reproduction is possible. Menarche refers to the onset of menstruation. The transitional period between childhood and adolescence is preadolescence. Others refer to this period as late childhood, early adolescence, pubescence, and transescence.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:577 OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15.A recent graduate nurse has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes during the climacteric signify which of the following? a.A characteristic of young adulthood b.The increased reproductive ability of the older adult c.A time of significant change in cognitive performance in middle age d.A decline of reproductive capacity caused by a decrease in sexual hormones ANS: D Climacteric is a term used to describe the decline of reproductive capacity and accompanying changes brought about by the decrease in sexual hormones. This affects men and women differently. Men begin to experience decreased fertility, but they are able to continue to father children. Menopause, when a woman stops ovulating and menstruating, occurs only when 12 months have passed since the last menstrual flow. Climacteric is a characteristic of middle adulthood usually referring to those years between 40 and 65. Changes in the cognitive function of middle-age adults are few except during illness or trauma.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:580 OBJ: Use knowledge of growth and development to enhance use of the nursing process for individuals across the life span. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is caring for an older adult who seems depressed and states that I hate going to Bingo. Id really like to get back in shape. Maybe if I could join a health club, I could get back to feeling like myself. The nurse should do ]

which of the following? a.Inform the patient that at his age its probably not a good idea to join a health club. b.Recommend that the patient have a complete physical examination. c.Explain that physical impairments would prevent any worthwhile exercising. d.Tell the patient that at his age he would probably hurt himself.

ANS: B It is not too late for an older person to begin an exercise program; however, older adults need to have a complete physical examination, which usually includes a stress cardiogram or stress test. Assessment of activity tolerance will help you and the patient plan a program that meets physical needs while allowing for physical impairments.

Most older adults are capable of taking charge of their lives and assume responsibility for preventing disability.

PTS:1DIF:Cognitive Level: Applying (Application) REF:585 OBJ:Use critical judgment to determine appropriate teaching topics for individual patients across the life span.TOP:Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17.

is the measurable aspect of a persons increase in physical dimensions.

a.Growth b.Development c.Maturation d.The latency stage of development ANS: A Growth is the measurable aspect of a persons increase in physical dimensions. Measurable growth indicators include changes in height, weight, teeth and bone, and sexual characteristics. Development is an interaction of biological, sociological and psychological forces. It occurs gradually and refers to changes in skill and capacity to function. These changes are qualitative in nature and difficult to measure in exact units. Maturation is the biological plan for the predictable milestones for growth and development. Physical growth and motor development are a function of maturation. The latency stage of development is part of Freuds psychoanalytic model of personality development. In the latency stage, Freud believed that the sexual urges from the earlier phallic stage are repressed and channeled into productive activities that are socially acceptable.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:568 | 569 OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18.

is an interaction of biological, sociological, and psychological forces.

a.Growth b.Development c.Maturation d.The latency stage of development ANS: B

]

Development is an interaction of biological, sociological, and psychological forces. It occurs gradually and refers to changes in skill and capacity to function. These changes are qualitative in nature and difficult to measure in exact units. Growth is the measurable aspect of a persons increase in physical dimensions. Measurable growth indicators include changes in height, weight, teeth and bone, and sexual characteristics. Maturation is the biological plan for the predictable milestones for growth and development. Physical growth and motor development are a function of maturation. The latency stage of development is part of Freuds psychoanalytic model of personality development. In the latency stage, Freud believed that the sexual urges from the earlier phallic stage are repressed and channeled into productive activities that are socially acceptable.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:568 | 569 OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 19.A specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development is referred to as: a.Freuds psychoanalytic model of personality. b.a critical period of development. c.Eriksons stages of development. d.Piagets theory of cognitive development.

ANS: B A critical period of development refers to a specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development. For example, if a child does not walk by 20 months, there is delayed gross motor ability, which slows exploration and manipulation of the environment. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and instinctive forces. Erik Erikson (1902-1994) expanded Freuds psychoanalytic stages into a psychosocial model that covered the whole life span. In this theory, Erikson divided life into eight stages, known as Eriksons eight stages of development. Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:569 | 570 OBJ: Use knowledge of growth and development to enhance use of the nursing process for individuals across the life span. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. Preconception counseling is a growing trend in health care with the goal being to secure the best outcome for

mother, fetus, and significant others through good prenatal care and teaching that: a.teratogens can affect fetal development during any trimester. b.the placenta prevents teratogens from passing to the fetus. c.teratogens are all man-made, preventable, and do not include viruses or bacteria. d.smoking has been shown to have no effect on fetal development.

ANS: A

Teratogens are chemical or physiological agents capable of having adverse effects on the fetus. Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased ]

during the first trimester when fetal cells are differentiating and organs are forming. Because the placenta is extremely porous, teratogens pass easily from mother to fetus. Some examples of teratogens are viruses, drugs (prescribed, over-the-counter, and street drugs), alcohol, and environmental pollutants, such as lead. The fetal effect of these harmful agents depends on the developmental stage in which exposure takes place. In addition, there is evidence that mothers who smoke deliver infants with lower birth weights than nonsmoking mothers.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:571 OBJ: Identify factors that promote or interfere with normal growth and development of individuals at each stage of life. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. Postmenopausal women are at risk for skeletal changes. When developing a plan of care for postmenopausal women, a nurse should remember which of the following? a. Exercise provides little benefit for the middle-age adult. b. Middle-age women should avoid dietary calcium to prevent osteoporosis.

c.Exercise and fitness clubs have limited activities. d.Physical activities help improve balance and coordination.

ANS: D

When middle-age adults seek health care, nurses need to develop goals for positive health behaviors. Simple things like increasing dietary calcium and calcium supplements are effective. In addition, exercise and fitness clubs, for example, give men and women the opportunity to participate in many physical activities. These activities help improve balance, coordination, and activity tolerance.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:582 OBJ: Identify factors that promote or interfere with normal growth and development of individuals at each stage of life. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22.A 90-year-old patient constantly tells the nurse stories about life many years ago. The nurse encourages this behavior because reminiscence or life review is: a.a technique that prepares the individual for the end of life. b.a review of dispelling past experiences as meaningless. c.helpful although it is unnatural in the older adult. d.a way for the elderly to realize that conflicts cannot be reconciled.

ANS: A Reminiscence, or life review, is a technique that facilitates the individuals preparation for the end of life. It is an adaptive function of older adults that allows them to recall the past for the purpose of assigning new meaning to past experiences. Reminiscence is the natural way older adults revive their past in an attempt to establish order and meaning and to reconcile conflicts and disappointments as they prepare for death.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:585 OBJ:Identify specific nursing interventions for the health promotion of patients across the life span.TOP:Nursing ]

Process: Assessment MSC: NCLEX: Physiological Integrity 23.Polypharmacy is: a.the use of unprescribed medication for recreational use. b.the prescription, use, or administration of more medications than are needed. c.very rare in older adults. d.rarely a problem as long as the medications are taken together.

ANS: B Polypharmacy, the prescription, use, or administration of more medications than are indicated clinically, is a common problem of older adults. The combined use of multiple drugs causes serious problematic effects.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:586 OBJ: Identify factors that promote or interfere with normal growth and development of individuals at each stage of life. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1.A nurse is caring for a group of 6 and 7 year olds. The nurse remembers that, according to Kohlberg, moral development is a component of psychosocial development. Moral development depends on the childs ability to do which of the following? (Select all that apply.) a.Accept social responsibility. b.Respect the integrity and rights of others. c.Integrate principles of justice and fairness. d.Use symbols and objects on the way to abstract thinking. e.Perform repetitive motion responses.

ANS: A, B, C Moral development depends on the childs ability to accept social responsibility and integrate personal principles of justice and fairness. In addition, the childs knowledge of right and wrong and behavioral expression of this knowledge must be founded on respect and regard for the integrity and rights of others. Piagets theory, not Kohlbergs, states that as the child grows from infancy into adolescence, the intellectual development progresses, starting with reflex and repetitive motion responses, to the use of symbols and objects from the childs point of view, to logical thinking, and finally to abstract thinking.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:570 OBJ: Compare the frameworks for growth and development as described by major developmental theorists. TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 2.The patient has been diagnosed with progressive Alzheimers disease. Characteristics of this disease include which of the following? (Select all that apply.) a.Delirium b.Agnosia ]

c.Apraxia d.Aphasia e.Amnesia ANS: B, C, D, E Alzheimers disease is the most common form of dementia. Alzheimers disease is a progressive loss of memory (amnesia), loss of ability to recognize objects (agnosia), loss of the ability to perform familiar tasks (apraxia), and loss of language skills (aphasia). As the disease progresses, some patients also experience changes in personality and behavior, such as anxiety, suspiciousness, or agitation, as well as delusions or hallucinations. Delirium is an acute confusional state and requires prompt assessment. It is a potentially reversible cognitive impairment that is often a result of physiological causes. Some of these causes include electrolyte imbalance, hypoglycemia, infection, and medications.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:584 OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3.A nurse is performing an admission assessment on a middle-age patient. A normal change seen in this age group includes which of the following? (Select all that apply.) a.A progressive decrease in skin turgor b.Decreased visual acuity c.Decreased ability to solve practical problems d.Decreased strength of abdominal muscles e.Loss of accommodation ANS: A, B, D, E Middle adulthood usually refers to those years between 40 and 65. Expected physical changes include a slow, progressive decrease in skin turgor, decreased abdominal strength, decreased visual acuity, and loss of accommodation of lens to focus light on near objects. The ability to solve practical problems based on experience peaks at midlife because of the ability for integrative thinking.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:580 | 581 OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

]

Chapter 24: Self-Concept and Sexuality Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The patient is a 66-year-old patient who has been admitted to the hospital for a transient ischemic attack (TIA).

Her health care provider has told her that she should consider retiring from her high-stress position as a hospital administrator. The patient is distraught over this suggestion. The nurse caring for her recognizes the most likely cause of distress is a result of a change in which of the following? a.Body image b.Role performance c.Self-esteem d.Identity ANS: B

Role performance is the way in which a person views his or her ability to carry out significant roles. This patient is being told that she will have to give up her role as an administrator. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. There are no overt bodily changes here. Self-esteem is an individuals overall sense of personal worth or value. This could be an issue, but it is based in the change in her role. Identity involves the sense of individuality and being distinct and separate from others. Being oneself or living a life that is genuine and authentic is the basis of true identity. What was true of self-esteem can be true of identity.

PTS:1DIF:Cognitive Level: Applying (Application) REF:598 | 599 OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 2. The patient is a 16-year-old teenager who is in the clinic for his annual check-up. During the assessment, the nurse asks the patient about his use of tobacco. Although he denies smoking, he tells the nurse that he dips snuff.

He tells the nurse that he started last year because all his friends do it. The nurse recognized this as a stressor of which of the following?

a.Body image b.Identity c.Role performance d.Sexuality ANS: B Identity involves the sense of individuality and being distinct and separate from others. Cultural identity develops from identifying and socializing within an established group and through incorporating the responses of individuals who do not belong to that group into ones self-concept. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband. Sexuality is a broad term that refers to all aspects of being sexual. Our sexual health is based on our ability to form healthy relationships with others.

PTS:1DIF:Cognitive Level: Applying (Application) REF:596 | 598 | 599 ]

OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. Body image is an important concept relative to psychosocial development. In dealing with body image issues, the nurse must do which of the following?

a.Understand that skinny people always see themselves as thin. b.Realize that body image is never associated with self-esteem. c.Recognize that physical changes always lead to changes in body image. d.Be aware that female adolescents more frequently struggle with issues than males.

ANS: D The development of secondary sex characteristics and changes in body fat distribution has a tremendous impact on the self-concept of an adolescent. Female adolescents struggle more with body image issues than do their male counterparts. Body image depends only partly on the reality of the body. When physical changes occur, individuals may or may not incorporate these changes into their body image. For example, people who have experienced significant weight loss do not perceive themselves as thin and may still tell you there is still a fat person inside.

Body image issues are often associated with negative self-concept and self-esteem.

PTS:1DIF:Cognitive Level: Applying (Application) REF:599 OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. After a large weight loss a patient tells the nurse, There still is a fat person inside of me. This type of statement

illustrates a flaw in what self-concept component? a.Role performance b.Identity stressor c.Self-esteem d.Body image ANS: D

Body image depends only partly on the reality of the body. When physical changes occur, individuals may or may not incorporate these changes into their body image. For example, people who have experienced significant weight loss do not perceive themselves as thin and may still tell you there is still a fat person inside. Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband, daughter or son, sister or brother, employee or employer, and nurse or patient. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence. Self-esteem is an individuals overall sense of personal worth or value.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:599 OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 5.A nurse is caring for an adult patient who retired last year. While rendering care, the nurse identifies that the ]

patient is struggling emotionally with this change. This situation is most likely associated with what self-concept component? a.Role performance b.Identity stressors c.Self-esteem d.Body image stressors ANS: A Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband, daughter or son, sister or brother, employee or employer, and nurse or patient. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence.

Self-esteem stressors vary with developmental stages. Potential self-esteem stressors in older adults include health problems, declining socioeconomic status, spousal loss or bereavement, loss of social support. Body image stressors involve attitudes related to the body, including appearance, femininity and masculinity, youthfulness, health, and strength.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:599 OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6. The mother of a 7-year-old boy asked the nurse what factors tended to increase self-esteem in boys. Which of

the following is the nurses best response?

a.Positive family communication supporting the childs self-worth. b. It does not really matter because self-esteem varies widely throughout life. c. Avoid situational crises because they lead to permanent changes in self-esteem. d.Let the child know that it is OK to be incompetent.

ANS: A Self-esteem is an individuals overall sense of personal worth or value. Self-esteem is positive when one feels capable, worthwhile, and competent. Once established, basic feelings about the self tend to be constant, even though there is sometimes a little fluctuation. A situational crisis, like a hospitalization, often temporarily affects ones self-esteem.

PTS:1DIF:Cognitive Level: Applying (Application) REF:599 OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance. TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 7. As a nurse caring for a patient with a colostomy that resulted from the treatment of a benign tumor of the bowel.

The most appropriate classification of this self-concept component is which of the following? a.Role performance stressor b.Sexuality stressor c.Identity stressor d.Body image stressor ]

ANS: D Changes in the appearance or function of a body part require an adjustment in body image. An individuals perception of the change and the relative importance placed on body image in the individuals self-concept will affect the significance of the loss or change. Throughout life a person undergoes many role changes. Normal changes associated with maturation result in changes in role performance. Sexuality stressors are issues related to sexuality on a regular basis. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:599 | 600 | 601 OBJ: Identify stressors that affect self-concept, self-esteem, and sexuality.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 8.A male patient shares that, although he has a satisfying relationship with his wife, he is also attracted to men. He is confused and does not know how to deal with this issue. The nurse should do which of the following? a.Explain that the patients problem is one of orientation and high risk. b.Tell the patient that he has a sexual dysfunction and needs medication. c.Inform the patient that having relationships with other men is normal and risk free. d.Teach that STIs are fewer with men because most STIs are spread vaginally.

ANS: A Lesbian, gay, bisexual, or transgender (LGBT) individuals have unique stressors related to their sexual orientation.

Peer, family, and social support is often lacking for this population that is at high risk for health issues such as STIs, HIV, depression, and victimization. Sexual dysfunction interferes with sexual health and is a problem with desire, arousal, or orgasm. Sexually transmitted infections (STI) are infections spread through oral, anal, or vaginal activity. The use of latex condoms can reduce the risk of STIs via any route of transmission.

PTS:1DIF:Cognitive Level: Applying (Application) REF:601 | 602 OBJ: Discuss your role in maintaining or enhancing a patients sexual health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 9. The nurse is caring for a 34-year-old woman, who was admitted to the hospital with multiple rib fractures. The patient states, I fell down the stairs. It was all my fault. I can be so stupid at times. The nurse notices healing bruises on the patients back and buttocks. The patients husband seems very caring, always holding her hand and often answering questions for her. The nurse should do which of the following? a. Direct her questions toward the husband because he answers most of them anyway. b.Accept the patients report on how she received her broken ribs. c.Ask the husband to step into the waiting room while the patient is examined. d.Treat the patients wounds and discharge her home.

ANS: C If you suspect abuse, interview the patient privately. A patient will probably not admit to problems of abuse with the abuser present. Sexual abuse, assault, and rape are also stressors that affect self-concept. Be alert to clues that suggest abuse. In addition, observe the interaction between the patient and partner for additional clues. Controlling behaviors such as speaking for the person or refusing to leave him or her alone with a caregiver are suggestive of emotional and perhaps physical or sexual abuse. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF:602 OBJ: Identify stressors that affect self-concept, self-esteem, and sexuality.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 10. The nurse is caring for a patient who has been diagnosed with chronic pain. The nurse is especially concerned about the patients self-concept because chronic pain does which of the following?

a.Normally has no effect on the ability to function once patients learn to deal with it b.Can often cause increased irritability that can affect self-concept c.Often leads to increased sleep as patients try to escape the pain d.Requires pain medication that prevents self-concept alterations ANS: B When you care for patients who have alterations in self-concept, be particularly alert to the patient who is experiencing chronic pain. Chronic pain predisposes a person to decreased ability to function, irritability, and decreased sleep. These changes negatively affect self-concept. Many medications have actions and side effects that influence a patients self-concept and sexuality.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:604 OBJ: Apply the nursing process to promote a patients self-concept and sexual health.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 11. The nurse is attempting to obtain a sexual history on a patient who is being evaluated for a possible

hysterectomy. The nurse should do which of the following?

a.Assume that the patient will not appreciate questions about sexual practices. b.Avoid information relative to medication effect on sexuality. c.Use specific gender terms to emphasize sexuality. d.Recognize that many patients welcome the chance to talk about their sexuality.

ANS: D With experience you will come to recognize that many patients welcome the opportunity to talk about their sexuality, especially when they are experiencing difficulty in sexual functioning. Once you approach the topic, the patient is able to talk about concerns and explore possible ways to resolve the problem. You may worry that the patient will not appreciate being asked about sexuality and sexual practices. However, patients want to know how medications, treatments, and surgical procedures influence their sexual relationships. Use gender-neutral terms and questions when completing the sexual history.

PTS:1DIF:Cognitive Level: Applying (Application) REF:605 OBJ: Apply the nursing process to promote a patients self-concept and sexual health.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12.Reviewing sexuality changes associated with aging is important because: a. very few older women experience any type of sexual problems. b. in older men, the penis does not become firm as quickly. ]

c.ejaculation remains the same throughout life. d.ejaculation is quicker with aging.

ANS: B Approximately 50% of older women experience some type of sexual problem such as low desire or vaginal dryness. In men, the penis does not become firm as quickly and is not as firm as it is at a younger age. Ejaculation takes longer to achieve and is shorter in duration, and the erection often diminishes more quickly.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:606 OBJ: Discuss your role in maintaining or enhancing a patients sexual health.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 13. The nurse is caring for a 65-year-old mother of three who recently underwent abdominal surgery and has a colostomy as a result. The patient has a history of multiple surgeries, including a tracheostomy after lung surgery about 20 years earlier that has since healed over. To determine how to best work with this patient, the nurse should do which of the following?

a.Determine how the patient dealt with her previous surgeries. b.Realize that past coping mechanisms are always positive in nature. c.Approach care in a standard method because all patients are the same. d.Avoid using family input in determining the course of care.

ANS: A Your nursing assessment includes consideration of previous coping behaviors. Knowing how a patient has dealt with self-concept stressors in the past provides insight into the patients style of coping. Not all patients address issues in the same way, but often a person uses a familiar coping pattern for newly encountered stressors. As you identify previous coping patterns, it is useful to determine whether these patterns have contributed to healthy functioning or created more problems. Exploring resources and strengths, such as availability of significant others or prior use of community resources, is important when formulating a realistic and effective plan.

PTS:1DIF:Cognitive Level: Applying (Application) REF:606 OBJ: Apply the nursing process to promote a patients self-concept and sexual health.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 14. The nurse is caring for an elderly patient who has a urinary catheter in place and is showing signs of altered

self-concept. In dealing with this age group it is probably safe to assume which of the following? a.Sexuality concerns are not an issue. b.Sexual activity is probably harmful. c.Sexually active seniors are always heterosexual. d.Sexually active elderly adults have better overall health.

ANS: D

Give priority to patients in middle and older adulthood when you address sexuality concerns caused by illness, medications, or physical changes. Research has shown middle and older age adults who are sexually active have greater independence, better overall health, and longer life expectancy. In addition, you should not assume all older patients are heterosexuals. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF:612 | 613 OBJ: Discuss ways in which your self-concept and nursing actions affect your patients self-concept and selfesteem. TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. The student nurse is discussing her 4-year-old patient with her nursing instructor. The instructor asks her about how Eriksons Developmental Tasks have an impact on a 4-year-old childs self-concept and sexuality. What is the best response? a. Mike identifies with his father. b. Mike likes to help dress himself. c. Mike is aware that he is too small to play football. d. Mike is looking forward to going to college when he gets bigger.

ANS: A Identifying with his father shows that the patient is in the proper stage for his age. In the Initiative Versus Guilt (3 to 6 years) the individual takes initiative, identifies with a gender, enhances self-awareness, and increases language skills, including identification of feelings. In the Autonomy Versus Shame and Doubt (1 to 3 years) the individual begins to communicate likes and dislikes, becomes increasingly independent in thoughts and actions, and appreciates body appearance and function (including dressing, feeding, talking, and walking). In the Industry Versus Inferiority stage (6 to 12 years) the individual incorporates feedback from peers and teachers, increases selfesteem with new skill mastery (e.g., reading, math, sports, music), strengthens sexual identity, and becomes aware of strengths and limitations. In the Identity Versus Role Confusion stage (12 to 20 years) the individual accepts body changes/maturation, examines attitudes, values, and beliefs; establishes goals for the future, and feels positive about expanded sense of self.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:598 OBJescribe the components of self-concept as each relates to Eriksons developmental stages.TOP:Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 16.A 35-year-old new mother returns to the clinic for her 6-week postpartum check. When discussing questions regarding the patients sexual health the nurse should do which of the following? a.Assume that permission to discuss sexuality issues is implied. b.Seek knowledge about sexual health in general. c.Make therapeutic suggestions early and adjust as needed. d.Refer the patient to a professional with advanced training if necessary.

ANS: D The PLISSIT Assessment of Sexuality method suggests that the nurse gain permission to discuss sexuality issues, limit information to sexual health problems being experienced, make specific suggestion only when the nurse is clear about the problem, and refer the patient to professionals with advanced training if necessary.

PTS:1DIF:Cognitive Level: Applying (Application) REF:605 OBJ: Apply the nursing process to promote a patients self-concept and sexual health. ]

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 17.A middle-age single woman has breast cancer and needs a mastectomy. She is concerned with future male relationships. She is crying and indicates that her life is over. According to Erikson, she occupies which stage? a. Intimacy versus Isolation

b.Autonomy versus Shame and Doubt c.Identity versus Role Confusion d.Ego Integrity versus Despair ANS: A Intimacy versus Isolation (mid-20s to mid-40s): Intimate relationships with family and significant others; has stable, positive feelings about self; experiences successful role transitions and increased responsibilities. Autonomy versus Same and Doubt is usually found in children (1 year old to 3 years old) and involves increasing independence in thoughts and actions. In the Identity versus Role Confusion stage (usually in people 12 to 20 years of age) the individual accepts body changes/maturation, examines attitudes, values and beliefs, and feels positive about an expanded sense of self. In the late 60s until death, the person is usually in the Ego Integrity versus Despair stage and is interested in providing a legacy for the next generation.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:598 OBJescribe the components of self-concept as each relates to Eriksons developmental stages.TOP:Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1.A middle-age female model is admitted for a double mastectomy. On admission the nurse notes that she is depressed and withdrawn. The most appropriate patient-centered nursing intervention(s) might be which of the following? (Select all that apply.) a.Use a positive and matter-of-fact approach to care. b.Include the patient in decision making about her care. c.Be aware of nonverbal behaviors when providing care. d.Focus on the task when an unpleasant task must be done. e.Focus matter-of-fact statements on positive aspects of patient healing.

ANS: A, B, C, E A positive and matter-of-fact approach to care provides a model for the patient and family to follow. General nursing interventions, such as appropriately including the patient in decision making, supports most patients selfconcept. Your nonverbal behavior conveys the level of caring that exists for your patient and affects your patients self-esteem. For example, when an incontinent patient perceives that you find the situation unpleasant, this threatens the patients self-concept. Anticipate your own reactions, acknowledge them, and focus on the patient instead of the unpleasant task or situation. Matter-of-fact statements such as, This wound is healing nicely or This looks healthy enhance the body image of the patient.

PTS:1DIF:Cognitive Level: Applying (Application) REF:603 OBJ: Apply the nursing process to promote a patients self-concept and sexual health.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity ]

Chapter 25: Family Context in Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.The student nurse is talking to her friends about holiday plans with their families. One friend described her family as her mother, brother, and sister-in-law. Another stated her family consisted of her mother, father, grandmother, and her aunt. The student nurses family is her mother, stepfather, sister, and stepsister. The uniqueness of these families is known as which of the following? a.Family resilience b.Nuclear family c.Family diversity d.Family durability ANS: C Family diversity is the uniqueness of each family. Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family durability is the intrafamilial system of support and structure that extends beyond the walls of the household. A nuclear family consists of a husband and wife (and perhaps one or more children).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 617 | 619 OBJ: Discuss common family forms and their health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2.A woman is making plans for her holiday dinner and shares with her butcher that she will be inviting her family.

When the butcher asks who will be coming, she replies, My two children and their spouses, my ex-son-in-law is bringing my grandson, and my ex-mother-in-law is coming. This is an example of which of the following? a.Family durability b.Family resiliency c.Family diversity d.Nuclear family ANS: A Family durability is the intrafamilial system of support and structure that sometimes extends beyond the walls of the household. Through divorce, remarriages, or cohabitation new members are added to a family. In addition, an extended family also includes contact with former spouses or partners. Family diversity is the uniqueness of each family. Family resiliency is the ability of the family to cope with expected and unexpected stressors. A nuclear family consists of husband and wife (and perhaps one or more children).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:617 | 619 OBJiscuss how the term family is defined to reflect family diversity.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3.A nurse is caring for a patient. Visitors at the bedside include the patients life partner, widowed mother, sister, and nephew. The nurse acknowledges that current trends in American families include which of the following? a.Couples deciding to have many children b.A declining divorce rate

c.Changing family patterns d.Fewer people choosing to live alone ANS: C Families are constantly changing. People may marry later, delay childbirth, and couples choose to have fewer children or none at all. The number of people living alone is expanding and accounts for approximately 26% of households. Divorce rates have tripled since the 1950s, and although the rate appears to have stabilized, it is estimated that 54% of all marriages will end in divorce.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 619 OBJ: Examine current trends in the American family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4.In regard to American families, the nurse understands that which of the following is true? a.The number of single-parent families is increasing. b. Single fathers head most single-parent families. c.Most single parent families are the result of the death of one parent. d.Father-only families are on the rise.

ANS: D Although mothers head 83% of single-parent families, father-only families are on the rise. The number of singleparent families appears to be stabilizing at about 26% of all families with children. Forty-one percent of children are living with mothers who have never married; many of these children result from an adolescent pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 619 OBJ: Examine current trends in the American family.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 5.A nurse is admitting a teen-aged woman to the Labor and Delivery unit to have her baby. She is not married but is holding hands with her boyfriend who is the babys father. The nurse realizes that: a.adolescent pregnancy is a decreasing concern in modern society. b.teenage pregnancies are little more than a temporary bump in the road of life. c.increased numbers of children mean greater income and a way out of poverty. d.teenage pregnancies affect teenage fathers as well as mothers.

ANS: D Teenage fathers also have stressors placed on them when their partner becomes pregnant. These young men have poorer support systems and fewer resources to teach them how to parent. As a result, both of these adolescent parents often struggle with the normal tasks of development and identity, but are also forced to accept a responsibility that they are not ready for physically, emotionally, socially, and/or financially. Adolescent pregnancy is an ever-increasing concern. The majority of these adolescents continue to live with their families. A teenage pregnancy tends to have long-term consequences for the mother and often severely stresses family relationships and resources. In addition, there is an increased risk for continued poverty for the family.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:619 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 6.A student nurse is working on a community health project with her peers. One of the concerns in her community is the rise in homelessness resulting from the economy. The student nurse understands that which of the following is true? a.Almost all homeless families are made up of single-parent families. b.Children in homeless families are usually in good health. c.Families with children are the fastest growing segment of the homeless population. d.Children in homeless families have no way to attend school so are illiterate.

ANS: C The fastest growing segment of the homeless population is families with children. This includes complete nuclear families and single-parent families. More than 794,000 homeless are enrolled in the public school systems.

Children of homeless families are often in fair or poor health and have higher rates of asthma, ear infections, stomach problems, mental illness, and have poor immunization documentation. As a result, usually the only access to health care for these children is through the emergency department.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 619 | 620 OBJ: Examine current trends in the American family.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 7. The nurse is caring for a 78-year-old patient with liver cancer. The patient and his wife live at home. In addition

to caring for the patient, the nurse also assesses caregiver stress in the patients wife. Which of the following indicates caregiver stress? a. Increased visits from church members b.Asking her daughter for help with shopping c.Remaining cheerful and without depression d.Contracting pneumonia

ANS: D Assess for caregiver stress, such as tension in relationships with family and care recipient, changes in level of health, changes in mood, and anxiety and depression. Contracting pneumonia could be a sign of caregiver stress because it is a change in the level of health. Visits from church members and shopping with her daughter demonstrate good relationships with family and friends.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 631 OBJ: Discuss the role of families and family members as caregivers.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 8. The family is the primary social context in which health promotion and disease prevention take place. Placed in

this context, it is reasonable for the nurse to assume which of the following is true? a.The familys beliefs, values, and culture strongly influence health behaviors. b.Families function haphazardly without creating goals. c.Good health is always highly valued in family settings. d.The long-term habits of one family member has no effect on the others.

ANS: A

The familys beliefs, values, culture, and practices strongly influence the health-promoting behaviors of its members. When the family satisfactorily meets its goals through adequate functioning, its members tend to feel

positive about themselves and their family. Conversely, when they do not meet goals, families view themselves as ineffective. Good health is not always highly valued; in fact, harmful practices are acceptable in some families.

Some of these practices might include poor dietary habits, such as high-calorie, high-fat diets. A long-term illness in one of the family members affects the well-being and health of the entire family. In addition, long-term habits such as smoking also influence the health of members in the family unit.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:621 OBJ:Compare family as context to family as patient and family as system and explain the way that these perspectives influence nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 9. The parents of an 18-year-old who joined the military and is being deployed overseas, discuss with him how they plan to stay in touch and purchase a laptop computer for him to take with him so they can e-mail and use the webcam to see each other. What approach to stress does this family exhibit?

a.Resiliency b.Hardiness c.Heredity d.Genetics ANS: B Family hardiness is the internal strengths and durability of the family unit. A sense of control over the outcome of life, a view of change as beneficial and growth producing, and an active rather than passive orientation in adapting to stressful events characterize family hardiness. Resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events. Resources and techniques a family or individuals within the family use to maintain a balance or level of health assist in understanding a familys level of resiliency. Genetic factors reflect a familys heredity or genetic susceptibility to a disease that may or may not result in actual development of the disease.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:621 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 10.What should the nurse do when planning goals for a family? a.View the family as a group of individuals rather than a system. b.Make the goals as vague as possible so that they are attainable. c.Be flexible since families are continually changing. d.Recognize that, although individuals go through developmental stages, families do not.

ANS: C Families are continually changing. As a result, the need for family support changes over time, and it is important for you to understand that the family is more complex than simply a combination of individual members. Family nursing practice has three levels of approaches: (1) family as context, (2) family as patient, and (3) family as system. The goals need to be concrete, realistic, compatible with the familys developmental stage and expectations, and acceptable to the family. Although families are far from identical to one another, they have a basic pattern and similarity in experiences, resulting in predictable stages. Each of these developmental stages has its own challenges, needs, and resources and includes tasks that need to be completed before the family is able to

successfully move on to the next stage.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:621 | 622 | 623 | 626 OBJ:Compare family as context to family as patient and family as system and explain the way that these perspectives influence nursing practice.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 11.A student nurse is caring for a 4-year-old patient who has been admitted to the pediatric unit with acute asthma.

As the student nurse admits the patient, he learns that both parents smoke in the home. The nurse plans to discuss with the parents the implications of smoking around the patient and to provide them with information on smoking cessation. This is an example of what approach to family nursing? a.Family as context b.Family as patient c.Family as system d.Family as a stagnated group ANS: A When you view the family as context, your primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient). Although you focus the nursing process on the individuals health status, you will also assess the extent to which the family provides the individuals basic needs.

When you view the family as patient, the family processes and relationships (e.g., parenting or family caregiving) are your primary focus of care. When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all community, social, and psychosocial resources.

Families are continually changing. As a result, the need for family support changes over time, and it is important for you to understand that the family is more complex than simply a combination of individual members.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:622 | 623 OBJ:Compare family as context to family as patient and family as system and explain the way that these perspectives influence nursing practice.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 12.A patient comes from a close-knit extended family. If the patients family functions as context, what does the nurse need to evaluate? a.Attainment of health of an individual member in a specific environment b.Family processes c.Family relationships d.The family member and unit ANS: A When you view the family as context, your primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patients family). When you view the family as patient, the family processes and relationships (e.g., parenting or family caregiving) are your primary focus of care. Focus your nursing assessment on the family patterns versus individual member characteristics. When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all community, social, and psychosocial resources.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:623 OBJ:Compare family as context to family as patient and family as system and explain the way that these perspectives influence nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 13.When a family is in a transitional phase of the life cycle perspective (e.g., birth of a first child), it is important for the nurse to do which of the following? a.Accept that this is usually a time of decreased stress and anxiety. b.Use the knowledge of stress and coping to assist in family care. c. Explain that the health of one family member does not depend on the family system. d.Draw on psychological theory as the major basis for family care.

ANS: B Your knowledge of stress and coping will assist in family care. When a family is in a transitional phase of the life cycle perspective (e.g., birth of a first child) or there is an additional stressor to the family unit (e.g., chronic illness), it creates considerable anxiety and stress within the family system. The health and functioning of each member in the family to some degree depends on the health of the family system as a whole. Family care draws on knowledge from growth and development, psychology, communication, family theories, sociology, and the family life cycle.

PTS:1DIF:Cognitive Level: Applying (Application) REF:623 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14.A nurse is attempting to complete the nursing admission data on a patient. To complete the admission and formulate a plan of care, the nurse needs to do which of the following? a.Know that the individual is the same as the family as a whole. b.Realize that family health is the summation of the health of all members. c.Evaluate the form, structure, and function of the family. d. Discount negative views by the patient toward the family.

ANS: C Areas included in family assessment are the form, structure, and function of the family; its developmental stage; and its progress toward or accomplishment of developmental tasks. It is essential to assess the patient and family thoroughly. The family as a whole differs from individual members. The measure of family health is more than a summation of the health of all members. Begin assessment by considering the views of the patient toward the family.

PTS:1DIF:Cognitive Level: Applying (Application) REF:624 OBJ: Use the nursing process to provide for the health care needs of the family.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse is admitting a Hispanic patient to the oncology unit of the hospital. To provide culturally competent care, the nurse needs to determine the influence of culture on the patients family. Which of the following questions

would best accomplish this? a.What types of foods do you eat? b. Since youre Hispanic, would you like to order beans for supper? c. I am assuming that youre Catholic. Do you want to see the priest? d. Hispanics have large families. Do you have questions about visitation policies?

ANS: A To determine the influence of culture on a family, you might want to ask the patient about his or her cultural background. Then ask questions concerning cultural practices. For example, What type of foods do you eat? Who cares for sick family members? Overgeneralizations in terms of racial and ethnic group characteristics do not lead to greater understanding of the culturally diverse family.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 625 OBJ: Discuss the role of families and family members as caregivers.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 16. The nurse is admitting a 45-year-old patient and asks about her family. The patient states that she lives with her daughter and son-in-law. The nurseknows that this is an example of which of the following family forms?

a.Nuclear b.Extended c.Blended d.Alternate pattern relationship ANS: B The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family.

The nuclear family consists of husband and wife (and perhaps one or more children). The blended family is formed when parents bring unrelated children from prior or foster parenting relationships into a new, joint living situation.

Alternate pattern relationships include multi-adult households, skip-generation families (grandparents caring for grandchildren), and communal groups with children, nonfamilies (adults living alone), and cohabitating.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 619 OBJ: Discuss common family forms and their health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 17.A nursing instructor is raising her two granddaughters after her daughter and son-in-law were killed in a motor vehicle accident. How is this family form best described? a. Extended family b.Single-parent family c.Blended family d.Alternative pattern of relationship

ANS: D Alternate patterns of relationships include multi-adult households, skip-generation families (grandparents caring for grandchildren), communal groups with children, nonfamilies (adults living alone), and cohabitating partners. The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The single-parent family is formed when one parent leaves the nuclear family because of death, divorce, or desertion or when a single person decides to have or adopt a child. The blended family is formed when parents bring unrelated children from prior or foster parenting relationships into a new, joint living situation.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 619 OBJ: Discuss common family forms and their health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18.A married couple takes four children to an immunization clinic. The nurse notes that the childrens permission slips include three children with one last name and one child with a different last name. On questioning the parents the nurse discovers that this family group is an example of a(n) family. a.nuclear b.blended c.extended d.single-parent ANS: B The blended family is formed when parents bring unrelated children from prior or foster parenting relationships into a new, joint living situation. A nuclear family consists of husband and wife (and perhaps one or more children). The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The single-parent family is formed when one parent leaves the nuclear family because of death, divorce, or desertion or when a single person decides to have or adopt a child.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 619 OBJ: Discuss common family forms and their health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 19.The nurse is caring for a family within an impoverished community. What is it important for the nurse to understand about families? a.They are made up of a set of interacting individuals related by blood, marriage or adoption. b.They are comprised of a group of individuals living together who may not be related. c.They all have one unique form independent of cultural or ethnic orientations. d.They all have the same strengths, weaknesses, resources and challenges.

ANS: A A family is a set of interacting individuals related by blood, marriage, or adoption who usually live together and fulfill functions of socialization, division of labor, economic provisions, and cooperatively meet affective and emotional needs of the individuals within the family unit. In addition, individuals living together, regardless of their relationship or whether they fulfill common social functions, constitute a household. When you provide individualized family care, understand that families take many forms and have diverse cultural and ethnic orientations. In addition, no two families are alike. Each has its own strengths, weaknesses, resources, and challenges.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:619 OBJiscuss how the term family is defined to reflect family diversity.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.When providing care for families, of what should the nurse be aware? (Select all that apply.) a.Family hardiness is the internal strength and durability of the family.

b.Resiliency helps to evaluate healthy responses in stressful times. c.Good health is always highly valued within the family unit. d.Along-term illness in one family member affects the entire family e.Family members may be a primary force for coping.

ANS: A, B, D, E Family hardiness is the internal strengths and durability of the family unit. A sense of control over the outcome of life, a view of change as beneficial and growth producing, and an active rather than passive orientation in adapting to stressful events characterize family hardiness. Resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events. Resources and techniques a family or individuals within the family use to maintain a balance or level of health assist in understanding a familys level of resiliency. Good health is not always highly valued; in fact, harmful practices are acceptable in some families. Some of these practices might include poor dietary habits, such as high caloric, high fat diets. A long-term illness in one of the family members affects the well-being and health of the entire family. In addition, long term habits, such as smoking also influence the health of members in the family unit. Although illness strains relationships, research indicates that family members have the potential to be a primary force for coping.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:621 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 2.Domestic violence includes which of the following? (Select all that apply.) a.Only live-in partners b.Dating relationships c.Spouses d.The elderly almost exclusively e.Child abuse ANS: B, C, E Domestic violence includes not only intimate partner relationships of spousal, live-in partners, and dating relationships, but also familial, elder, and child abuse.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:620 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 3. The nurse is caring for a patient who gives indications of being a victim of abuse. The nurse understands that

abuse is which of the following? (Select all that apply.) a.Can be physical battering b. Is sometimes manifested as sexual assault c.Generally declines over a period of time d.Is sometimes classified as emotional abuse e.Can be psychological in nature ANS: A, B, D, E

Abuse generally falls into one or more of the following categories: physical battering, sexual assault, and emotional or psychological abuse; and it generally escalates over a period of time.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:620 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4. The cause of family violence is complex and multidimensional. Factors associated with family violence include

which of the following? (Select all that apply.) a.Stress b.Peer pressure c.Psychopathology d.Learned family behavior e.Wealth ANS: A, C, D

The cause of family violence is complex and multidimensional. Stress, poverty, social isolation, psychopathology, and learned family behavior are all factors associated with violence.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:620 OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within the family as well as the family as a whole.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. Homeless children are more likely to do which of the following? (Select all that apply.)

a.Drop out of school. b.Develop risky behaviors. c.Become more employable because of life experience. d.Develop long-term health problems. e.Be better supervised after school.

ANS: A, B, D Homeless children face barriers, such as meeting residency requirements for public schools and inability to obtain previous enrollment records, when enrolling and attending school. These children frequently lack adult supervision to assist them with homework and other school-related projects and issues. As a result, these children are more likely to drop out of school, develop risky behaviors, and become unemployable. Homeless families and their children are at serious risk for developing long-term health, psychological, and socioeconomic problems, thus posing a major challenge for our entire society.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 619 | 620 OBJ: Examine current trends in the American family.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

Chapter 26: Stress and Coping Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A patient who was injured in a motor vehicle accident is taken via ambulance to the emergency department. The nurse performing the physical assessment knows that, according to the general adaptation syndrome, the patient should be expected to exhibit: a.increased blood flow to the intestines. b.increased heart rate. c.decreased blood pressure. d.decreased blood glucose levels.

ANS: B In the early part of the twentieth century, the fight-or-flight response was described. This arousal of the sympathetic nervous system prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, heart rate, respiratory rate, and blood glucose levels.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 638 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 2. The nurse is administering flu vaccines. One of the children who is scheduled to receive the vaccine is afraid of needles and is tearful, and his younger brother is trying to calm him down. The nurse knows that the tearful child has evaluated this event as challenging and therefore is experiencing psychological stress caused by which of the following?

a.Primary appraisal b.Coping c.Secondary appraisal d.Dissociation ANS: A When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Coping refers to strategies or practices that help people deal with stress. Following the recognition of stress, secondary appraisal focuses on the resources or coping strategies that can meet the stress. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 638 | 640 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 3. The nurse is assigned a patient who has experienced the alarm reaction and continues to recover. The nurse knows that the primary hormone impacting the stress response in the resistance stage of the general adaptation syndrome is: a. vasopressin. b.adrenaline. c.noradrenaline. ]

d.cortisol.

ANS: D Corticotropin stimulates the adrenal gland to increase the production of corticosteroids, including cortisol, the primary hormone impacting the stress response. Cortisol increases blood glucose, enhances the brains use of glucose, and increases the availability of substances for tissue repair. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. The adrenal gland also releases catecholamines, adrenaline, and noradrenaline, which are important parts of the alarm reaction.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 638 | 639 OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 4. The nurse is talking to a patient who was involved in a motor vehicle accident. The patient asks the nurse why there was no sensation of pain at the time of the accident. The best explanation would be: a. Vasopressin was released to decrease pain sensation. b.Endorphins are released during a time of stress to reduce pain. c.Alcohol reduces the perception of stress when injury occurs. d.You probably have chronic high levels of cortisol to help with chronic pain.

ANS: B Endorphins are hormones that interact with the opiate receptors in the brain to reduce our perception of pain and produce a sense of well-being. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. It has no effect on pain sensation. Unhealthy coping choices, such as the use of alcohol or tobacco, negatively affect a persons health as well as increasing the perception of stress.

Persistent elevated cortisol levels are associated with chronic health conditions, such as obesity, heart disease, depression and anxiety, diabetes, and osteoporosis.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 638-640 OBJ: Identify how stress and coping relate to health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 5. The nursing student has severe test anxiety. When he receives a test in class, his heart rate increases, he feels more mentally alert, and his pupils dilate. According to the general adaptation theory, the nursing student should identify this response as what stage of the bodys reaction to stress?

a.Alarm b.Resistance c.Adaptation d.Exhaustion ANS: A During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine levels, heart rate, blood flow to muscles, oxygen intake, and mental alertness. In addition, the pupils of the eyes dilate to produce a greater visual field. During the resistance stage the body stabilizes and responds in an opposite manner to the alarm reaction. In the adaptation stage, antiinflammatory adrenocortical hormones are released, and healing occurs. However, if the stressor remains and adaptation does not happen, the person enters the third stage, exhaustion. The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) ]

REF: 639 OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 6. An older adult patient in a long-term care facility recently had a stroke after experiencing a myocardial infarction. The patient is not speaking or eating. The nurse notices an adverse change in vital signs. When a patient is unable to resist the effects of a stressor, the nurse can identify this stage of the general adaptation system as:

a.an alarm reaction. b.the resistance stage. c.the exhaustion stage. d.a fight-or-flight response.

ANS: C The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. The physiological response intensifies, but the person has so little energy left that adaptation to the stressor diminishes. The body can no longer defend itself against the impact of the event, and if the stress continues, it damages the heart along with other bodily organs and lowers resistance to illness. In the alarm stage, rising hormones result in an increased blood pressure, blood glucose levels, epinephrine and norepinephrine levels, heart rate, blood flow to muscles, oxygen intake, and mental alertness. This change in body systems prepares an individual for fight or flight and lasts from 1 minute to many hours. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm stage.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 639 OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 7.A 48-year-old nurse is complaining of being continually exhausted because of the workload on her unit. She states that the patients are getting heavier and the halls are getting longer. Sometimes I just dont think I can get through the day. The nurse is dealing with stress caused by: a.situational factors. b.maturational factors. c.sociocultural factors. d.compassion fatigue.

ANS: A Situational factors include work stress that happens with work overload (patient load, distractions, conflicting priorities), heavy physical work, long hour work shifts, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Compassion fatigue is a term used to describe a state of burnout and secondary traumatic stress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:641 | 642OBJefine stress and coping.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 8.A nurse works on an oncology unit and has a lot of stress in her life. Which of the following situational factors would be considered work stress? a.Caring for a family member who has Alzheimers disease b.Being diagnosed with a chronic back injury ]

c.Finding out that a parent has lung cancer d.Having a disagreement with her nurse manager ANS: D Work stress for nurses happens with work overload, heavy physical work, shift work, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff.

Adjusting to chronic illness can result in situational stress, but is not work related. Furthermore, the stress experienced while caring for someone with a chronic illness (such as Alzheimers disease) can lead to adverse health consequences but is also not work related. Another nonwork-related stressor would be caring for a family member who has cancer. Those family members caring for cancer patients have been shown to display immunologic changes that can contribute to the development of inflammatory disease.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:641OBJefine stress and coping.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9.A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is caused by: a.situational factors. b.maturational factors. c.sociocultural factors. d.compassion fatigue.

ANS: A Situational factors include work-related stress. Coping strategies vary with the individual and the situation.

Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Compassion fatigue is a term used to describe a state of burnout and secondary traumatic stress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 641 | 642 OBJ: Identify how stress and coping relate to health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 10.A new nurse is looking for a staff nurse position. She had several instances during clinical rotations in nursing school in which she was late because she studied until the early hours of the morning. According to her circadian rhythm she would be best suited for which of the following positions? a.Full-time 8-hour day/evening rotation b.Part-time 12-hour day/night rotation position c.Full-time 12-hour night position d.Full-time 8-hour day position ANS: C In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible. Some nurses often ease their coping with shift work by knowing their own circadian rhythms. A nurse who typically thinks well at night and tends to sleep late in the morning will adapt better to night shift than to day shift. Rotating shifts prevent establishment of a consistent sleep and mealtime schedule.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 641 OBJ: Identify how stress and coping relate to health. ]

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 11.A patient complains of pain. The nursing order calls for pain medication via injection. The patient is afraid of needles. The nurse can assist the patient through this stressful incident by encouraging the patient to think of a relaxing situation. The nurses actions can be identified as: a.restorative care. b.cognitive therapy. c.assertiveness training. d.progressive muscle relaxation.

ANS: B Cognitive therapy teaches patients how certain thinking patterns cause symptoms of stress or depression. Cognitive therapy focuses on changing ways of thinking so that a patient feels empowered and in control of his or her own life. Restorative care occurs when a person has recovered from a stressful situation, and is taught stress management skills to reduce the number and intensity of stress responses in future situations. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress. When a group leader teaches assertiveness, the effects of interacting with other people increase the benefits of the experience. Progressive muscle relaxation diminishes physiological tension through a systematic approach to releasing tension in major muscle groups.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:648 | 649 OBJ:Identify stress management techniques used in coping with stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12.The patient, a busy executive who works 80 hours a week, is admitted for angina. The patient is demonstrating physical signs of stress related to the work environment. An appropriate nursing intervention for this patient includes releasing muscle tension every 2 hours. This type of intervention is best known as: a.regular exercise. b.assertiveness training. c.cognitive therapy. d.progressive muscle relaxation.

ANS: D Muscles tense in the presence of anxiety-provoking thoughts and events. With progressive muscle relaxation physiological tension diminishes through a systematic approach to releasing tension in major muscle groups. A regular exercise program improves muscle tone and posture, controls weight, reduces tension, improves circulation, triggers release of endorphins, and promotes relaxation. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:648 | 649 OBJ:Identify stress management techniques used in coping with stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13.A nurse has been working overtime because of high hospital census and a decreased work force. The nurse is concerned about the danger of work-related burnout or compassion fatigue. To combat this risk, the nurse should: ]

a.increase nursing responsibilities at work. b.take control over new areas at work to reduce stress. c.strengthen relationships outside of the hospital. d.hang out with co-workers when not at work.

ANS: C Compassion fatigue occurs as a result of chronic stress and is often associated with the human service professions.

Make a clear separation between work and home life. Strengthening friendships outside of the workplace, socially isolating oneself for personal recharging of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Identify the limits and scope of your responsibilities at work. Recognize the areas over which you have control and the ability to change and those for which you do not have responsibility.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 642 | 650 OBJ: Discuss the relevance of compassion fatigue for healthcare.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14.A patient telephones a crisis intervention hotline. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take? a.Take control of the situation and tell the patient what needs to be done. b.Define the problem at hand and ensure that the patient is safe. c.Ask the patient how he would like to handle the crisis and follow through. d.Ask the patient to list all of his problems and prioritize which to deal with first.

ANS: B Crisis intervention begins with defining the problem, ensuring patient safety, and providing support. First determine that a patient is safe and is not at risk for injury to self or others, and then use crisis intervention to examine alternatives, make plans, and obtain a commitment to positive action from the patient. Ideally these last three steps are completed collaboratively with a patient, but a patient in crisis may be unable to participate actively and may need a very directive approach or a crisis interventionist. Emphasize focusing on the specific problem, and help a patient to avoid all-encompassing, catastrophic interpretations.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 650 OBJ: Develop a care plan for a patient experiencing stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. The student nurse was late for clinical rounds because she had to change the tire on her car. She is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the medication that she is preparing. The student nurse is very frustrated, becomes tearful, and states, I cant seem to crush this tablet correctly. This reaction to the instructor is most likely a result of what ego-defense mechanism?

a.Compensation b.Displacement c.Denial d.Dissociation ANS: B Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings. ]

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 640 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 16. The nurse works in a small clinic with two other nurses and a nurse practitioner. Recently the nurse has been staying at work longer than usual. His neighbor, a patient at the clinic, asks one of the other employees at the clinic how the nurse is coping since his wife left him. The nurse had not shared this information with his co-workers. The nurse may be coping with his loss with which of the following?

a.Compensation b.Conversion c.Denial d.Dissociation ANS: C Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 640 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 17.A 4-year-old boy has been admitted to the hospital with pneumonia. He has been in the hospital for 3 days and has suddenly started to become incontinent of urine. The nurse knows that this is most likely a result of what egodefense mechanism? a.Compensation b.Conversion c.Denial d.Regression ANS: D Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period.

Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 640 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 18.The nurse has recently been promoted to a new management position in her hospital. She is concerned about her new responsibilities and has found that she is having difficulty sleeping at night. This is an example of what egodefense mechanism? a.Compensation b.Denial ]

c.Conversion d.Displacement ANS: C Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. ( Example: A person transfers anger over a job conflict to a malfunctioning computer.)

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 640 OBJ: Formulate nursing diagnoses based on assessment data.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. The patient has severe injuries. The nurse knows that the general adaptation syndrome (GAS) was viewed as a

reaction to stress consisting of: (Select all that apply.) a.a pattern of alarm. b.deleterious consequences. c.a stage of resistance. d.developmental impairment. e.a state of exhaustion.

ANS: A, C, E

The GAS was viewed as a reaction to stress consisting of three distinct stages; a pattern of alarm, followed by a stage of resistance as a person attempts to compensate for changes induced by the alarm stage. A state of exhaustion follows if the person cannot successfully adapt during the stage of resistance or if stress remains unrelieved. When stress reaches chronic, harmful levels, deleterious consequences follow, from compromised immune function to weight gain to developmental impairment. Deleterious consequences and developmental consequences, then, are a product of unsuccessful GAS, not a part of the syndrome.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 638 OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 2. The nurse is interviewing a patient who claims to be in the middle of a crisis situation. The nurse should: (Select

all that apply.)

a.determine the patients view of the situation. b.be aware that denial is never a coping mechanism for people in crisis. c.point out that the patient is repeating information and ask him to stop. d.assess for the potential for suicide/homicide. e.assess coping mechanisms and support systems.

ANS: A, D, E Use the interview to determine a patients view of the situation that provoked stress, assess safety issues, coping resources, any possible maladaptive coping, and adherence to prescribed medical recommendations, such as medication or diet. If your patient is experiencing a crisis, assess safety concerns such as potential for suicide or homicide and ability to care for ones own activities of daily living. Finally, assess alternatives, coping mechanisms, ]

and support systems. If the patient uses denial as a coping mechanism, be alert to whether the person overlooks necessary information. Listen for any recurrent themes in the patients conversation.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 643 | 644 OBJ: Develop a care plan for a patient experiencing stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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Chapter 27: Loss and Grief Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A businessman who had been employed at one company since graduating from college was recently downsized at work and is unemployed. He was always very proud of this job and is grieving the loss. What type of loss is this? a.Maturational b.Situational c.Actual d.Perceived ANS: C People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:655OBJiscuss five categories of loss.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 2.A nursing student, who maintained a 4.0 GPA since starting nursing school, started working the past semester, is planning a wedding, and has moved into a new home. The student has not been able to maintain the 4.0 GPA this semester, and as a result is feeling like a failure. How is this loss best described? a.Maturational b.Situational c.Actual d.Perceived ANS: D Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:655OBJiscuss five categories of loss.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity ]

3.A parent of three children has the oldest child start school this year, and the parent cries as the child is left at kindergarten on the first day. How is the loss that the parent is experiencing best described? a.Maturational b.Situational c.Actual d.Perceived ANS: A People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include the loss job. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:655OBJiscuss five categories of loss.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4.A recently widowed mother of two worked with her late husband while he was starting his own business and was managing the accounting paperwork. The family had no life or health insurance. When her husband suddenly died, she was left with a large hospital bill, funeral expenses, unemployment, and no means of support. How are the multiple losses that this woman is experiencing best described? a.Maturational b.Situational c.Actual d.Perceived ANS: B Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include the loss job. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:656OBJiscuss five categories of loss.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 5.A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered. The nurse identifies that this patient is experiencing the second stage of Kbler-Ross stages of dying.

What is the second stage? ]

a.Anger b.Denial c.Bargaining d.Acceptance e.Depression ANS: A Kbler-Ross (1969) classic theory identifies five responses to loss: denial, anger, bargaining, depression, and acceptance. Individuals in the denial stage act as though nothing has changed. They cannot believe or understand that a loss has occurred. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6.Bowlbys phases of mourning are founded on which of the following human instincts? a.Attachment b.Numbing c.Searching d.Grief ANS: A Attachment, the foundation of Bowlbys (1980) four phases of mourning, is an instinctive behavior, which leads to the development of life-long bonds of affection between children and their primary caregivers. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 7.A widow, whose spouse died 3 years ago, has recently started dating and is thinking about going back to school to complete a degree she had started at an earlier age. Which of Bowlbys phases of mourning best describes this behavior? a.Numbing b.Yearning and searching c.Disorganization and despair d.Reorganization ANS: D During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, ]

people need to experience this painful phase of grief. During the phase of disorganization and despair an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 8. The parent of a child who drowned in a neighbors pool that was not secured, would most likely file a wrongful death lawsuit against the neighbor during which of Bowlbys phases of mourning?

a.Numbing b.Yearning and searching c.Disorganization and despair d.Reorganization ANS: C During the phase of disorganization and despair an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 9. The nurse is admitting a 75-year-old patient into the gastrointestinal laboratory for a routine colonoscopy. During

the assessment, the nurse learns that the patients spouse died 4 months earlier because of stomach cancer and that the patient has not been sleeping well. Which phase of Bowlbys mourning phases does the nurse suspect? a.The numbing phase b.The yearning/searching phase c.The disorganization phase d.The reorganization phase ANS: B

The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. Common physical symptoms include tightness in the chest and throat, shortness of breath, a feeling of weakness and lethargy, insomnia, and loss of appetite. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The person often expresses anger at anyone he or she believes to be responsible. During the final phase of reorganization, the person accepts unaccustomed roles, acquires new skills, and builds new relationships.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10.A nurse who grew up in Korea has been in the United States for the past 4 years. The nurse is especially sensitive about the differences in how mourning is different between the native culture and that of Western society. ]

The nurse should use which model of mourning to help understand an action-oriented process of grieving? a.Bowlbys Four Phases b.Wordens Four Tasks c.Randos R Process d.Kbler-Ross Five Stages ANS: C Randos R Process Model of mourning is specific to Western society. Mourning is an action-oriented process involving recognizing the loss, reacting to the pain of separation, reminiscence, relinquishing old attachments, and readjusting to life after loss. Attachment, the foundation of Bowlbys (1980) four phases of mourning, is an instinctive behavior, which leads to the development of life-long bonds of affection between children and their primary caregivers. The four tasks of mourning theory (Worden, 1982) describes how individuals help themselves through mourning and ask others for help. Kbler-Ross (1969) classic theory identifies five responses to loss: denial, anger, bargaining, depression, and acceptance.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:657OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 11.A young widower who lost his wife in Afghanistan has worked through the first task of Wordens mourning theory. He asks you if he will ever feel able to move forward with his life. According to Wordens theory, what is your best response? a.You will never love anyone as much as your wife. b.Nobody will ever be able to take your wifes place. c.It takes time to adjust to this type of loss, typically at least a year. d.Some people are able to move forward faster by suppressing the pain.

ANS: C Although the time needed varies from person to person, moving through Wordens tasks typically takes a minimum of 1 year. The other responses are not helpful to the patient.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 12.A patients daughter died in a ski accident. The patient stated, I cannot believe my daughter has died. According to Wordens tasks of mourning, the patient is experiencing task: a.I. b.II. c.III. d.IV. ANS: A Task II is working through the pain of grief. It is impossible to experience a loss without some degree of emotional pain. Individuals who deny or suppress the pain often prolong their grief. Task I occurs when the individual accepts the reality of the loss. Task III occurs when people adjust to the environment in which the deceased is missing.

Task IV occurs when the person emotionally relocates the deceased and moves on with life.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) ]

REF:656OBJ:Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 13.A patient has been suffering from liver cancer for more than a year. The family has requested hospice services.

The family members are taking turns staying with the patient. They have been reminiscing with the patient about her life and are now saying their good-byes. The type of grief that this family is experiencing is best described as which of the following? a.Normal b.Anticipatory c.Complicated d.Disenfranchised ANS: B The process of letting go that occurs before an actual loss or death has occurred is called anticipatory grief. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:657OBJescribe types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 14.A 45-year-old widow, who is being seen in a mental health clinic for clinical depression and alcohol dependency, lost her husband and her son in a boating accident 10 months earlier, and has become increasingly despondent and withdrawn. She verbalizes that she feels overwhelmed by her loss. Her daughter urged her mother to seek help. Which type of complicated grief best explains Eleanors behavior? a.Chronic b.Delayed c.Exaggerated d.Masked ANS: C People having an exaggerated grief response are overwhelmed by their loss, have difficulties functioning, and display significant behavioral dysfunction. Chronic grief occurs when the active acute mourning experienced in normal grief reactions does not decrease and continues over long periods of time. When people consciously or unconsciously avoid the pain of loss and do not experience common grief reactions at the time of the loss, they have a delayed grief reaction. Masked grief occurs after a significant loss in which some people are unable to recognize that the behaviors making normal functioning difficult are a result of their loss. For example, a person who loses a pet develops changes in sleeping patterns but does not see the connection between the two events.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:657OBJescribe types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 15.A 34-year-old single mother of three had been involved in a secret relationship with her boss, a married man who was 24 years her senior. When her boss suddenly died as the result of a heart attack, the woman had difficulty expressing the extent of her loss. The grief that she was experiencing could best be described as which of the following? ]

a.Disenfranchised b.Complicated c.Normal d.Anticipatory ANS: A Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid. For example, a grieving woman does not experience support from her parents when experiencing the loss of her exhusband. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away.

Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of letting go before an actual loss or death has occurred is called anticipatory grief.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:657OBJescribe types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16.A nurse is caring for a 3-year-old niece whose mother has recently died of cancer. Because of the childs stage of development, the nurse expects that the child will most likely see the loss of her mother as which of the following? a.An opportunity to re-examine their lives b.A threat to her self-concept c.Temporary d.A challenge to her emerging identity ANS: C Expressions of grief evolve as individuals mature. Toddlers, for example, cannot understand the permanence of death but feel anxiety over loss of objects and separation from parents. School-age children, although able to understand the significance of loss more completely, see their loss as a challenge to their emerging identity or selfconcept. Middle-age adults often use grief experiences to re-examine or reprioritize their lives. Older adults anticipate grief as they encounter declining physical function or life opportunities, give up employment or social status, or lose loved ones.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 658 OBJ: Discuss variables that influence a persons response to grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 17. The patients home has been demolished by a tornado. The patients spouse and child were killed and the spouse

is in need of a leg amputation. The nurse realizes that which of the following is true? a.The patient will deal with his losses using usual coping strategies. b.A patients normal coping strategies are always adequate. c.Patients usually seek new strategies to deal with loss. d.At the end of life, people still rely on the usual coping strategies.

ANS: A

Individuals respond to loss by using their usual coping strategies. Sometimes when people experience multiple losses or lose something of great significance, their usual coping strategies are inadequate. At the end of life, people often find new coping mechanisms and new resources to maintain control and stability. ]

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 658 OBJ: Discuss variables that influence a persons response to grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18. The nurse is caring for a patient of the Chinese community who is dying. The nurse needs to understand the Chinese communitys beliefs regarding death, but it is most important to keep in mind which of the following?

a.Most survivors in Chinese society wail loudly to communicate their loss. b.People in the Chinese culture believe that talking about death is healthy. c.Chinese people are strong believers in reincarnation. d.Regardless of cultural or religious beliefs, people respond to death in their own unique way.

ANS: D In Western societies, many people grieve privately and restrain their emotions. In other cultures, survivors wail loudly and publicly display their sorrow to communicate the significance of their loss to others. Some Chinese communities consider death to be a taboo subject and believe that discussion of the topic brings bad luck. Most people practicing the Hindu religion believe in reincarnation and use those beliefs to interpret events surrounding the death of a loved one. Although members of a cultural or religious group often share similar beliefs, people still respond in their own unique way.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 658-659 OBJ: Discuss variables that influence a persons response to grief.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 19.A patient has been admitted to the hospital with advanced colon cancer and is receiving palliative care at this time. The nurse feels anxious in caring for this patient, but realizes which of the following? a.The patient needs the nurses presence and personal connection. b.Remaining silent would signify a noncaring attitude. c.All people react to loss in the same way. d.Reminiscing only makes a difficult situation worse.

ANS: A Many nurses become anxious when caring for dying patients or people coping with grief and loss. Confidence helps you to understand that even if there is nothing you can do or say to change the situation, the patient needs your compassionate presence and a personal connection. Confidence helps you accept the responsibility to remain present even in difficult situations. By silently sharing a moment of sadness with a patient or family member, you communicate caring and send the message that you respect and accept their feelings in the moment. Do not assume that other people react to loss or grief as you do or that a particular behavior necessarily indicates grief.

Encouraging patients to tell stories about their loved one gives them an opportunity to provide information in a natural, unstructured, and meaningful way.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:659 OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 20.Which of the following would not be appropriate for a patient undergoing palliative care? a.Insertion of a peripherally inserted central line ]

b.Chemotherapy c.Radiation treatment d.Knee replacement surgery ANS: D Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. The insertion of a peripherally inserted central line would be beneficial to provide the patient with medications to ease discomfort. Chemotherapy and radiation therapy would be useful in reducing disease symptoms. Knee replacement surgery would not be appropriate for an end-of-life patient.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 666 OBJ: Discuss principles of palliative and hospice care.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 21.A patient suffering from lung cancer experiences nausea and vomiting. When rendering palliative care, the nurse knows that this type of care: a. is only done in intensive care units. b. is for the elderly.

c.requires an interdisciplinary team. d.utilizes standard medical treatments to provide care.

ANS: C Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. People of any age or diagnosis receive palliative care at any time and in any setting. Expert palliative care involves an interdisciplinary team composed of health care professionalsnurses, social workers, spiritual care professionals, nutritionists, physicians, psychologists, and pharmacists. Therapists who use complementary healing interventions (e.g., massage, music, healing touch, or aromatherapy) also work with palliative care PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 666 OBJ: Discuss principles of palliative and hospice care.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 22.A nurse is caring for a patient with a terminal illness whose prognosis is grim. The nurse informs the family about hospice care. What should the nurse let them know about hospice care? a. It is designed for people who have less than a 6-month life expectancy. b. It is provided in the hospital setting. c. It helps to hasten the death process to relieve suffering. d. It has predetermined goals that will be explained at the right time.

ANS: A Hospice care provides services for patients who are at the end of life. Patients who meet the criteria for hospice care generally have less than 6 months to live. Hospice teams provide care in many settingshome, hospital, or extended care facilitiesand provide physical, emotional, and spiritual care for patients and family members. Hospice care focuses exclusively on palliative care interventions to relieve the symptoms and burdens of illness or treatment and help patients live as fully as possible until death. Nurses base hospice care on a patients goals and support patient and family preferences for maintaining comfort and a high quality of life.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) ]

REF: 666 OBJ: Discuss principles of palliative and hospice care.

TOP:Integrated Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 23.Which of the following is true for a patient to receive home hospice care? a.A primary caregiver must be living in the home. b.Caregiver support is available 9 AM to 5 PM daily. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care.

ANS: A For a patient to receive home hospice care, a primary caregiver must be living in the home. The primary caregiver receives support from professional and volunteer hospice team members who are available 24 hours a day. If a patient receiving home hospice care goes to the hospital for the management of acute symptoms, a hospice nurse coordinates care between the home and hospital settings.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 666 OBJ: Discuss principles of palliative and hospice care.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 24.A businessman has been diagnosed with multiple sclerosis and has poor prognosis because the disease is progressing very quickly. To help the patient maintain a sense of hope, what should the nurse do? a.Help the patient set realistic goals. b.Assure the patient that he will be well cared for and does not need to do anything. c.Impress on the family the importance of limiting visiting hours to provide rest. d.Withhold negative information about the patients disease processes.

ANS: A To help patients feel more hopeful, remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. Patients feel more hopeful when they have a sense of control. Family members of dying persons identified the importance of maintaining connections. When people have strong relationships and a sense of emotional connectedness to others, they know that help is available. Offer information to patients about their illness, correct misinformation, and clarify patients perceptions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:667 OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 25.A woman is attending a nurse-facilitated grief support group. The womans son was killed in Iraq 18 months earlier. She confides that while at the gravesite yesterday, she broke down and the feelings of hurt were as deep as the day she found out about the death. She states, I will never get over this feeling of intense grief. The nurse discovers that yesterday would have been her sons 21st birthday. What is the nurses best response? a.That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction. b.W hat happened to you yesterday is understandable and common in people who have lost loved ones. b.X find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after ]

such a long time. d.The fact that you reacted so strongly is concerning to me. This could be the beginning of some bigger issues.

ANS: B Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have anniversary reactions (heightened or renewed feelings of loss or grief) months or years after a loss.

They worry that they are losing ground when signs of grief reappear after a period of relative calm. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence.

PTS:1DIF:Cognitive Level: Applying (Application) REF:667 OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP:Integrated Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 26. An older extended care resident was dying. The family came to visit, but one of the great-granddaughters had

difficulty accepting the impending death. What is the best thing that the nurse can do to help her feel more comfortable? a.Telling her that she probably should not visit if it upsets her so much. b.Tell her to avoid talking about the past and focus on the present. c.Ask her if she would like to brush the residents hair. d.Ask the family to leave at the end of visiting hours so that they can rest.

ANS: C

Suggest simple and appropriate tasks for family members to perform (e.g., offering help with meals, simple hygiene or comfort activities, or filling out a menu). Family members who are having difficulty accepting the patients impending death sometimes avoid visits. When family members visit, reassure them that their presence is important, encourage interaction, and offer information about what the patient was talking about or has recently experienced. Encourage family members to discuss normal family activities, reminisce about enjoyable times, and ask about the patients concerns. Some people feel lonely or fearful at night and want a family member to stay with them. In acute care settings or extended care facilities, allow visitors to remain with patients who are dying, and relax other visiting restrictions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:669 OBJ: Identify ways to educate and involve family members in providing palliative care.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 27. The charge nurse on the evening shift of a busy medical unit in an acute care hospital received a call from a

physicians office that they are admitting a patient who is dying of lung cancer. She is told that the patients family is out of town and is not expected to make it to the hospital before the patient expires. What is the best room for the nurse to place this patient? a.A private room near the nurses station b.A semiprivate room halfway down the hall with another terminally ill patient c.A private room at the end of the hall d.A semiprivate room with instructions for staff to enter only when necessary ANS: B ]

Unless family members need privacy or are remaining with the patient around the clock, avoid placing patients in a private room. Patients who are dying often feel a sense of involvement and companionship when sharing a room and have more opportunities to interact with staff and visitors.

PTS:1DIF:Cognitive Level: Applying (Application) REF:669 OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 28. The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do?

a.Provide a private area to discuss organ donation. b. Explain that as long as the heart is beating, the patient is alive. c. Inform the family that the organs will be harvested when he is off the ventilator. d.Stress the importance of leaving the patient on the ventilator to harvest the corneas.

ANS: A Provide a private area for the family to discuss organ donation if this is an option. Many people do not understand brain death. Family members often believe that the person is still alive because his or her heart is still beating. For their loved one to donate major organs (e.g., heart, lungs, liver), the body must be kept in good functional condition so the organs will not become damaged before donation. The patient remains on a ventilator until his or her organs are removed. Nonvital tissues such as corneas, skin, long bones, and middle ear bones can be removed at the time of death without maintaining vital functions.

PTS:1DIF:Cognitive Level: Applying (Application) REF:670 OBJ: Identify ways to educate and involve family members in providing palliative care.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 29.A nurse is assigned to care for a dying patient. To deal with this experience and future experiences with dying patients, the nurse should do which of the following? a.Avoid going to funerals of former patients. b.Develop a hard shell against emotional stress to avoid compassion fatigue. c.Understand that people dying is part of the job to get used to. d.Frequently evaluate his or her own emotional well-being.

ANS: D Frequently evaluate your own emotional well-being. We all have feelings and memories about previous illnesses and death. Knowing more about your own grief and past experiences will help you care for others more insightfully. Being a professional caregiver involves knowing when to get away from a situation and how best to take care of ones self. Many nurses, especially those who routinely provide hospice care, attend a viewing at the mortuary or the funeral to show support for the family, honor the deceaseds memory, and cope with their own grief. Develop your own support systems, take restful time away from your work, and find a person with whom you can safely share your feelings and concerns. Experiencing repeated deaths of patients can feel overwhelming at times. If you work in an area in which you experience multiple losses and fail to acknowledge your own feelings of loss, you may begin to feel overwhelmed by intense emotions (e.g., frustration, anger, guilt, sadness, or dissatisfaction with life) and become vulnerable to compassion fatigue.

PTS:1DIF:Cognitive Level: Applying (Application)

]

REF:672 OBJ: Discuss nurses experiences of loss when caring for dying patients.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 30.The nurse is caring for a patient with terminal lung cancer. The patient is in a great deal of pain and is anxious.

The nurse contacts the health care provider to request pain medication for the patient and is given an order for morphine, but the family of the patient refuses to let the patient have it based on religious grounds. This is most likely because the patient and family are members of which of the following faiths? a.Jewish b.Hindu c.Catholic d.Christian ANS: B Members of religious faiths that believe in reincarnation (e.g., Hindu religion) support refusal of nourishment and pain medications because of the implications for the dying persons next life. Orthodox Jews stay with a person who is dying throughout the entire process and have community members (minyan) praying at the bedside. Members of the Catholic Church often receive an anointing by a priest and Holy Communion. Christians usually believe in heaven or an afterlife.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 658 OBJ: Discuss variables that influence a persons response to grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 31.A nurse is caring for a patient who has become depressed because her children have gone away to college. The nurse assesses this type of depression as what type of loss? a.Actual b.Perceived c.Maturational d.Situational ANS: C People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include the loss of a body part, pet, friend, life partner, or job. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had the loss. For example, a person perceives that she is less loved by her parents and experiences a loss of self-esteem. Situational loss occurs as a result of an unpredictable life event.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:655-656OBJiscuss five categories of loss.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 32. The nurse is caring for a terminally ill patient. In order to provide optimal care, the nurse tries to anticipate patient needs. What does the nurse understand about this patient?

a.As patients approach death, they breathe more through their nose. ]

b.Eye blinking may increase as well as tear production. c.Immobility and opioid medications can lead to diarrhea. d.Anxiety in the dying may have a physical cause.

ANS: D Anxiety has physical causes such as shortness of breath, pain, fear of death, spiritual concerns, and relationship concerns. As patients approach death, they breathe through the mouth, the tongue becomes dry, and lips become dry and cracked. Blinking reflexes diminish near death; and eyes often remain open, causing drying of cornea.

Opioid medications and immobility slow peristalsis.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 668 OBJ: Discuss principles of palliative and hospice care.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 33. The nurse is caring for a patient who has just passed away. What should she do?

a.Provide postmortem care in a manner consistent with religious or cultural beliefs. b.Place the body in a supine position to prevent disfigurement. c.Ask family to leave the room since they do not know how to provide care. d.Remove all tubes before determining if an autopsy will be done.

ANS: A A nurse assumes responsibility for postmortem care (i.e., care of the body after death). Give postmortem care with dignity and sensitivity and in a manner consistent with a patients religious or cultural beliefs. Because a body undergoes many physical changes after death, elevate the head of the bed to 30 degrees or place the patients head on pillows to prevent pooling of blood, which can discolor the face. Ask family members if and how they would like to help care for the body. Make arrangements for a member of the professional staff (e.g., spiritual care provider) to stay with family members if they do not wish to participate in body care. Remove all catheters, tubes, or indwelling devices from the patients body, except in the case of autopsy. In that case leave medical devices in place.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 671 OBJ: List the steps in caring for a body after death.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When a person has difficulty progressing through his or her loss experience, he or she experiences complicated

grief. What are the types of complicated grief? (Select all that apply.) a.Chronic b.Delayed c.Exaggerated d.Masked e.Disenfranchised ANS: A, B, C, D

The four types of complicated grief are chronic, delayed, exaggerated, and masked. Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid. This is not a type of complicated grief.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) ]

REF:657OBJescribe types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. What should the nurse caring for a dying patient understand about the patient? (Select all that apply.)

a.The patient has the right to be in control. b.The patient must be compliant with his medical regimen. c.The patient should expect to be free from pain. d.The patient should be lied to so as to maintain his sense of hope. e.The patient has the right to die in peace and dignity.

ANS: A, C, E The Dying Persons Bill of Rights states that the patient has the right to be treated as a living human being until he dies, be in control, express his feelings and emotions about his approaching death in his own way, be free from pain, have his questions answered honestly and not be deceived, and die in peace and dignity.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 660 OBJ: Discuss principles of palliative and hospice care.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. For a nurse to be effective in assisting patients with problems associated with loss and grief, what should the

nurse do? (Select all that apply.)

a.Help people acknowledge the reality of their loss. b.Encourage the use of a support network. c.Reinforce that people all grieve in the same way. d.Assure people that it will take a year to get over the loss, but it will end. e.Provide continuing support even after an extended time.

ANS: A, B, C, E Nursing interventions help people acknowledge the reality of their loss. Encourage them to rely on their support network of family members, friends, professionals, and community resources. Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have anniversary reactions (heightened or renewed feelings of loss or grief) months or years after a loss. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence. Provide continuing support. If you see the patient or family after an extended time, it is appropriate to ask them how they are doing after the loss. This gives them the opportunity to talk and lets them know that their loved one is remembered. The nurse should not tell people there is a specific timeline for grieving.

PTS:1DIF:Cognitive Level: Applying (Application) REF:667 OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

]

Chapter 28” Activity and Exercise Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse working on an orthopedic unit has to assist many of the patients because of limited mobility. The

nurses goal is to maintain a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. What is the term that best describes this goal? a.Body alignment b.Posture c.Center of gravity d.Balance ANS: B The term posture means maintaining optimal body position. It means a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. Center of gravity refers to the term that describes how body balance is achieved, over a wide stable base of support. Body alignment refers to the relationship of one body part to another body part along a horizontal or vertical line. Correct alignment reduces strain on musculoskeletal structures, maintains adequate muscle tone, and contributes to balance.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:678 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 2. The nurse is taking care of a 78-year-old comatose patient. The nurse has placed the patient in a supine position.

To prevent foot drop, the nurse applies which of the following? a. Pillows to dorsiflex the foot b.Trochanter rolls to the feet c.Foot boots as ordered d.Pillows to elevate the feet

ANS: C Avoid pressure on the back of the legs and heelspillows elevating the feet or dorsiflexing the foot may cause increased pressure. Use a foot boot to prevent footdrop, maintain proper alignment, and provide freedom of movement for the feet. When a patient is immobile, use pillows, trochanter rolls, and hand rolls or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system.

PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3.A nurse who works on the orthopedic unit knows that in addition to providing support, bones perform other functions in the body. Besides support, which of the following is an important bone function used during activity ]

and exercise? a.Hematopoiesis b.Protection c.Mineral storage d.Movement ANS: D Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis (blood cell formation). Two of these functionssupport and movementare most important during activity and exercise. In support, bones serve as the framework and contribute to the shape, alignment, and positioning of the body parts. In movement, bones with their joints constitute levers for muscle attachment. Hematopoiesis and mineral storage are not involved with bone function during activity and exercise.

PTS:1DIF:Cognitive Level: Applying (Application) REF:679 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. The patient has been diagnosed with a progressive neuromuscular disease and is having difficulty walking and

has decreased awareness of the bodys position. What is the term that best describes this phenomenon? a.Balance b.Proprioception c.Posture d.Hemiplegia ANS: B

Proprioception is the awareness of the position of the body and its parts and is dependent on impulses from the inner ear and from receptors in joints and ligaments. The nervous system also regulates posture. Posture is incorrect because it requires coordination of proprioception and balance. Balance is incorrect because it is controlled by the inner ear and the cerebellum. Hemiplegia is incorrect because this term is used to describe paralysis on one side of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 5. As the result of a brain tumor, a patient is having trouble with balance. The patients significant other is concerned

and asks the nurse how a tumor could affect the patients balance. The nurse explains that the tumor is growing in the part of the brain that is responsible for balance. The significant other asks, Which part of the brain controls balance? The nurses response would be which of the following? a.Pons b.Cerebrum c.Cerebellum d.Hypothalamus ]

ANS: C The cerebellum and the inner ear control balance through the nervous system. The major function of the cerebellum is to coordinate all voluntary movement. The pons deals with levels of arousal, consciousness, and sleep. The cerebrum controls thoughts, memory, decision making, and communication. The hypothalamus controls the autonomic functions of the peripheral nervous system.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 6. Which group of muscles is involved with joint stabilization?

a.Skeletal muscles b.Antigravity muscles c.Synergistic muscles d.Antagonistic muscles ANS: B Antigravity muscles are involved with joint stabilization. Skeletal muscles support posture and carry out voluntary movement. Antagonistic muscles bring about movement at the joint. Synergistic muscles contract to accomplish the same movement. When you flex your arm, you increase the strength of the contraction of the biceps brachii by contraction of the synergistic muscle, the brachialis.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:681 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 7. The patient is a 46-year-old woman who is a devout Muslim and who is being evaluated for weight-loss surgery.

One aspect of the comprehensive bariatric program is that clients begin an exercise program. The patient is selfconscious about her weight and concerned about maintaining her modesty. Which of the following exercise programs would be the best choice for the nurse to suggest?

a.A private trainer at a local fitness center b.An aerobics class at the local YMCA c.The evening yoga class at a local country club d.Walking 30 minutes a day at the mall with a friend ANS: D Exercise and physical fitness are beneficial to all people. When developing a physical fitness program for culturally diverse populations, consider what motivates individuals to exercise and what activities will be appropriate and enjoyable. Modesty and discretion are highly valued in the Muslim culture. Public aerobics and yoga classes may make the devout Muslim uncomfortable and violate her sense of modesty. Based on her religious and cultural background, the use of a private trainer, an aerobics class at the local YMCA, or yoga classes at the local country club are incorrect choices for this patient.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) ]

REF:681 OBJ: Write a nursing care plan for a patient with impaired body alignment and activity.

TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 8.A small business owner has noted an increase in back injuries at his company in recent years. During a discussion with an occupational health nurse, knowledge of statistical information regarding this trend throughout the country is exchanged. The occupational health nurse explains that the most common back injury is caused by a strain to which of the following muscle groups? a.Lumbar b.Cervical c.Thoracic d.Trapezius ANS: A The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Injury to these areas affects the ability to bend forward, backward, and side to side. This also decreases the ability to rotate the hips and lower back. The cervical response is incorrect because it refers to the neck region of the back. The thoracic response is incorrect because it refers to the rib/chest area of the back which has decreased movement. The trapezius is incorrect because it refers to a muscle in the back over the scapula.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 9.The nurse is assigned to a 79-year-old patient who has decreased mobility resulting from a stroke. The nurse understands the interventions to prevent skin breakdown for this bedfast patient is to include repositioning of the patient at least every hour(s). a.1 b.2 c.3 d.4 ANS: B In general, you reposition patients as needed and at least every 2 hours if they are in bed and every 1 hour if they are sitting in a chair.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:689 OBJ: Evaluate the nursing care plan for maintaining body alignment and activity.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. The nurse is assigned to take care of a 56-year-old patient with COPD. The patient does not tolerate a supine

position for sleeping. In what position should the nurse place the patient? ]

a.Lateral b.Prone c.Semi-Fowlers d.Sims ANS: C In semi-Fowlers position the head of the bed is at a 30-degree angle. Use this position for patients who cannot tolerate a supine position, such as those with cardiac and respiratory problems. Prone position is incorrect because it can compromise lung expansion. Lateral position is incorrect because patients who are obese or older do not tolerate this position for any length of time. Sims position is incorrect because it is a semi-prone position that can compromise lung expansion.

PTS:1DIF:Cognitive Level: Applying (Application) REF:689 | 691 OBJ: Write a nursing care plan for a patient with impaired body alignment and activity.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. The nurse is assigned to a 67-year-old comatose patient. To minimize the risk for aspiration, the nurse should avoid placing the patient in what position?

a.Semi-Fowlers b.Sims c.Supine d.Lateral ANS: C The risk for aspiration is greater in the supine position; thus avoid this position when the patient is confused, agitated, experiencing a decreased level of consciousness, or is at risk for aspiration. Semi-Fowlers is an incorrect answer because that is the position of choice to prevent aspiration. Sims is incorrect because it is a semi-prone position that would allow the stomach contents to exit the body if the patient experienced emesis. Lateral is incorrect because the patient would be placed on his or her side, which would promote the exit of stomach contents if the patient experiences emesis.

PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC:Client Needs: Reduction of Risk Potential 12.A 19-year-old patient with cerebral palsy has been admitted to the hospital with pneumonia. The patient has limited voluntary motor control. The student nurse caring for this patient, knows that the easiest intervention to maintain joint mobility would be to perform which of the following exercises? a.Active range-of-motion exercises b.Weight-bearing exercises c.Aerobic exercises d.Passive range-of-motion exercises ]

ANS: D For the patient who does not have voluntary motor controls, passive range-of-motion exercises are the exercises of choice. Because of limited voluntary motor control, active range of motion exercises, aerobic exercises, and weightbearing exercises are incorrect responses for this patient.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:692 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 13.A patient has been hospitalized for 5 days after pancreatic surgery. The nurse is preparing the patient to ambulate for the first time. What is the best action for the nurse to perform to prevent the patient from suffering orthostatic hypotension? a.Have him sit up in bed for a few minutes before standing. b.Have him sit up with his legs dangling over the side of his bed for a few minutes before standing. c.Place him in a high-Fowlers position for a few minutes before standing. d.Place him in a low-Fowlers position for a few minutes before standing.

ANS: B When preparing a patient for ambulation, dangling is an important technique. You assist the patient to a sitting position with the legs dangling off the side of the bed and have the patient rest for 1 to 2 minutes before standing.

When the patient has been flat for extended periods, blood pressure drops when the patient stands. Dangling helps to prevent this. Sitting up in bed or placing the patient in high- or low-Fowlers position does not allow for the changes in circulation to occur before ambulation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:692 | 693 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 14.A student nurse is assisting a patient who is ambulating with a new walker. Which of the following is appropriate information for student nurse to provide to the patient? a.The top of the walker should line up with the crease on the inside of your elbows. b.You should walk behind the walker to maintain balance. c.You should lean forward over the walker to maintain balance. d.When walking, you should take a step, move the walker forward, and take another step.

ANS: D When the person relaxes the arms at the side of their body, the top of the walker should line up with the crease on the inside of the wrist. A walker is fitted correctly by having the patient step inside the walker. The persons elbow should bend comfortably, about 30 degrees, while holding onto the grips. When walking, the patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes another step. The patient should not lean over the walker or walk behind it; otherwise he or she might lose balance and fall.

PTS:1DIF:Cognitive Level: Applying (Application) ]

REF:693 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 15.A student nurse is caring for 67-year-old patient who is experiencing left-sided weakness caused by a stroke.

The student nurse is providing patient teaching regarding the use of a quad-cane for ambulation. Which of the following statements is correct? a.You should use the cane on the stronger side of the body. b.Move the stronger leg with the cane. c.When walking, advance the weaker leg past the cane. d.Your body weight should be supported by the cane and stronger leg.

ANS: A Make sure the patient keeps the cane on the stronger side of the body. The patient moves the weaker leg to the cane, which divides body weight between the cane and the stronger leg. The patient then advances the stronger leg past the cane so the weaker leg and the body weight is supported by the cane and weaker leg.

PTS:1DIF:Cognitive Level: Applying (Application) REF:694 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16.Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches? a.The axillae should support all your body weight. b.Your elbows should be straight when your hands are on the crutch handgrips. c.The distance between the crutch pad and axillae should be three to four finger widths. d.Your elbows should be flexed about 45 degrees when the handgrip position is correct.

ANS: C Make sure you position the handgrips so the axillae do not support all patients body weight. Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. You determine the correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed (20 to 25 degrees). You verify elbow flexion with a goniometer. When you have determined the height and placement of the handgrips, you again verify that the distance between the crutch pad and the patients axilla is three to four finger widths.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:693-694 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 17.A nurse is teaching a crutch walking technique that requires weight bearing on both legs. Each leg is moved ]

alternately with each opposing crutch so that three points of support are on the floor at all times. What is the term for this gait? a.Four-point gait b.Three-point gait c.Two-point gait d.Three-point alternating gait ANS: A Four-point alternating or four-point gait gives stability to the patient but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. The two-point gait requires at least partial weight bearing on each foot. Three-point alternating or three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg, and then repeats the sequence. The affected leg does not touch the ground during the early phase of the three-point gait. Gradually the patient progresses to touchdown and full weight bearing on the affected leg.

PTS:1DIF:Cognitive Level: Applying (Application) REF:696 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 18.The nurse is in charge of caring for five orthopedic patients during ashift. Nursing assistive personnel are available to assist the nurse with care of the patients. Which of the following tasks is most appropriate for the nurse to delegate to the nursing assistive personnel? a.Moving a 45-year-old patient who had a CVA toward the head of the bed b.Transferring an 85-year-old patient for the first time after a total hip replacement c.Providing discharge teaching for a 49-year-old patient who had a stroke d.Preparing a 77-year-old patient for hip replacement surgery ANS: A The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel. Patients whom you are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma require supervision by professional nurses. Nursing assistive personnel are unable to give preoperative teaching or discharge teaching to a patient.

PTS:1DIF:Cognitive Level: Applying (Application) REF:707 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 19.A nurse and another staff member are preparing to reposition a patient in bed. To prevent back strain, these two health care providers must do which of the following? a.Keep their knees stiff to enhance their lifting strength potential. b.Keep the weight of the patient as close to their bodies as possible. c.Loosen their stomach muscles to keep from injuring the pelvic region. d.Twist their upper torsos to enhance the use and strength of their upper extremities. ]

ANS: B To prevent lifting-related injuries, always follow these steps: 1. Keep weight as close to the body as possible.

2. Bend at the knees.

3. Tighten abdominal muscles, and tuck pelvis.

4. Maintain the trunk erect and knees bent.

PTS:1DIF:Cognitive Level: Applying (Application) REF:681 | 708 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 20.A nurse is caring for a patient who has pneumonia. To facilitate respiration and lung drainage this patient should be placed in what position? a.Sims b.Prone c.Lateral d.Supine ANS: B When prone, the patient is in the face-down position. This facilitates respiration and drainage of oral secretions.

Place a pillow under the head for comfort and relief from pressure. The Sims position is used to place the patient in a semiprone position on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed.

In the lateral position, the patient is placed in a side-lying position, supported on the right or left side. This position can compromise chest expansion. In the supine position the patient rests on the back. The risk for aspiration is greater with this position; thus avoid the supine position when the patient is confused, agitated, experiencing a decreased level of consciousness, or at risk for aspiration.

PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 21.A patient presents to the emergency department with a fractured leg that requires a full leg cast. The nurse needs to teach the patient to ambulate with crutches using which of the following? a.Two-point gait b.Three-point gait c.Four-point gait d.Tripod alternating position ANS: B ]

Three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg. A two-point gait requires at least partial weight bearing on each foot. A four-point gait gives stability to the patient but requires weight bearing on both legs. The tripod position is the basic crutch stance.

PTS:1DIF:Cognitive Level: Applying (Application) REF:696 OBJ: Assess patients for impaired body alignment, exercise, and activity.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 22.A nurse is caring for a patient with a neuromuscular condition. The nurse needs to assess the patients muscle movement and strength. In doing so, the nurse recalls that chemicals that transfer electrical impulses from the nerve across the myoneural junction are called which of the following? a.Isometrics b.Synergistics c.Proprioceptors d.Neurotransmitters ANS: D Transmission of the impulse from the nervous system to the musculoskeletal system is an electrochemical event that requires a neurotransmitter, a chemical that transfers the electric impulse from the nerve to the muscle.

Isometrics is a type of exercise using muscles. Synergistics are opposite effects. Proprioceptors are located in nerve endings.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:679 | 680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 23.A nurse is assisting a patient with right-sided hemiplegia to transfer from the bed to a chair. The most appropriate action for the nurse is to do which of the following? a.Use a transfer belt. b.Grab the patient under the arms while assisting with the transfer. c.Stand on the unaffected side of the patient to ensure less strain on the nurses back. d.Encourage the patient not to use the hand rests because of their restrictions on movement.

ANS: A A patient with neurological deficits sometimes has paresis (muscle weakness) or paralysis unilaterally or bilaterally, which complicates safe transfer. A flaccid arm sustains injury during transfer if unsupported. As a general rule, use a transfer belt and obtain assistance for mobilization of such patients. Use patient-handling equipment and devices, such as height-adjustable beds, ceiling-mounted lifts, friction-reducing slide sheets, air-assisted devices, and encourage the patient to help as much as possible. Grasping the patient under his or her arms could cause damage to this delicate area and does not allow for a firm hold, as the arms could lift up. A transfer belt is more secure.

Always be aware of the patients motor deficits, ability to aid in transfer, and body weight. As a rule of thumb, GET HELP to transfer a patient.

PTS:1DIF:Cognitive Level: Applying (Application) ]

REF:692 | 693 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 24.A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist joints. To determine the degree of limitation or injury, the nurse can assess which of the following? a.Posture b.Activity tolerance c.Body mechanics d.Range of motion ANS: D The easiest intervention to maintain or improve joint mobility for patients and one that you are able to coordinate with other activities is the use of range-of-motion exercises. Joints that are not moved periodically develop contractures, a permanent shortening of a muscle followed by the eventual shortening of associated ligaments and tendons. Over time the joint becomes fixed in one position, and the patient loses normal use of the joint. The term posture means maintaining optimal body position. Activity tolerance assesses the patients ability to become fatigued, lightheaded, dizzy, or short of breath related to activity. Body mechanics require knowledge of proper walking, turning, and lifting and carrying objects in a way to prevent injury.

PTS:1DIF:Cognitive Level: Applying (Application) REF:692 OBJ: Assess patients for impaired body alignment, exercise, and activity.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 25.The nurse delegates the task of ambulating a patient to the assistive personnel. The nurse ascertains that the assistive personnel understands how to intervene when the patient complains of dizziness when the assistive personnel verbalizes which of the following? a.I call for help. b.I gently lower the patient to the floor. c.I support the patient and walk quickly back to the room. d.I lean the patient against the wall and wait until the episode passes.

ANS: B When a patient begins to fall, the nurse should assume a wide base of support with one foot in front of the other to support the patients weight, gently lower the patient to the floor, and protect the patients head. Assess the patient for injuries at this time and notify the patients health care provider. Even if the patient is stable, get the assistance of a lift team to help you get the patient off the floor and back in bed or a chair.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:693 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment ]

26.A nurse is caring for a patient with osteogenesis imperfecta. The nurse needs to assess the patients muscle movement and strength. In doing so, the nurse recalls that osteogenesis imperfecta is characterized by fractures and bone deformities. This condition is known as which of the following? a.A form of osteoporosis b.A form of arthritis c.A congenital defect d.A neurological defect ANS: C Osteogenesis imperfecta is a congenital defect that affects the bone. Osteoporosis is a well-known and wellpublicized disorder of aging in which the density or mass of bone is reduced. Inflammatory and noninflammatory joint diseases and articular disruption all alter joint mobility. Some characteristics of inflammatory joint disease (e.g., arthritis) are inflammation or destruction of the synovial membrane and articular cartilage and systemic signs of inflammation. Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment and mobility.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 27.A nurse is caring for a patient with a broken tibia and fibula. The patient is in a half cast to his knee and is unable to bear weight. The nurse has instructed the patient on how to walk and climb stairs with his injuries. What is the best way to assess the patients knowledge of how to ascend and descend stairs? a.Incorrectly re-demonstrate the procedure and have the patient point out any errors. b.Have the family member explain the procedure. c.Have the patient explain the procedure. d.Have the patient demonstrate the procedure.

ANS: D Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patients priorities of care and preferences, and use the best evidence when making decisions about your patients care. Explain the procedure, and describe what you expect of the patient. Demonstration is the most accurate way for the nurse to assess understanding of the skill.

PTS:1DIF:Cognitive Level: Applying (Application) REF:697 OBJiscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which of the following actions are effective in reducing friction when repositioning a patient in bed? (Select all that apply.) a. Lifting rather than pushing

b.Pushing the patient up in bed file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

c.Asking the patient to bend his or her knees and lift the hips when moving up in bed d.Asking the patient to lie still as you reposition him or her; even when the patient offers to help e.The use of a draw sheet f. The use of a transfer board ANS: A, C, E, F You reduce friction by lifting rather than pushing a patient. Lifting has an upward component and decreases the pressure between the patient and the bed or chair. The use of a draw sheet reduces friction because you are able to move the patient more easily along the beds surface. However, there are several commercially available products to assist in the task of positioning and moving patients in bed such as transfer boards and Maxi Slides. Pushing the patient up in bed is incorrect because pushing increases the friction between the patient and the bed. Asking the patient to lie still is incorrect because a passive or immobilized patient produces greater friction to movement.

PTS:1DIF:Cognitive Level: Applying (Application) REF:679 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. The nurse manager is concerned with the safety of the staff as they transfer patients. Facility policy reinforces the principles of appropriate body mechanics, which include which of the following? (Select all that apply.)

a.A wide base of support increases stability b.A higher center of gravity increases stability c.Facing the direction of movement prevents abnormal twisting of the spine d.Pivoting requires less work than lifting e.Manually lift the patient in sections f. Dividing balanced activity between arms and the legs ANS: A, C, D, F Principles of body mechanics include the following: A wide base of support increases stability; a lower center of gravity increases stability; the equilibrium of an object is maintained when the line of gravity passes through its base of support; facing the direction of movement prevents abnormal twisting of the spine; dividing balanced activity between arms and legs reduces the risk for back injury; and leverage, rolling, turning, or pivoting requires less work than lifting. Manual lifting is the last resort, and it is only used when it does not involve lifting most or all of the patients weight.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 | 681 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3. Which of the following trouble points are common in the side-lying position? (Select all that apply.)

a.Lack of support for the feet b.Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles c.Adduction of the shoulder and hip joints d.Hyperextension of the neck file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

e.Spinal curves out of normal alignment ANS: A, B, C, E The following are trouble points that are common in the side-lying position: Lateral flexion of the neck Spinal curves out of normal alignment Shoulder and hip joints internally rotated, adducted, or unsupported Lack of support for the feet Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:691 OBJescribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

Chapter 29: Immobility Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. An elderly patient was admitted to the hospital after falling in the nursing home. The patient has a fractured right

femur and is awaiting surgery. The surgeon orders bed rest. The patient asks the nurse what this means. What is the nurses best explanation? a.You are to be immobile. b.You cannot move. c.You need restraints. d.You have to remain in bed.

ANS: D A patients mobility can be restricted for therapeutic reasons, such as when bed rest is ordered. Therapeutic reasons for bed rest include decreasing the bodys oxygen needs, reducing cardiac workload, reducing pain, and allowing the debilitated or ill patient to rest. The duration of bed rest depends on the type and nature of the illness or injury and the patients prior state of health. Bed rest does not mean immobile, cannot move, or that restraints are needed.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1035OBJescribe mobility and immobility.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. The patient is recovering from a cerebrovascular accident (stroke). The patient is having problems with balance and coordination. The patient asks the nurse what part of the brain has been damaged. How should the nurse respond?

a.The hypothalamus has been damaged. b.The cerebellum has been damaged. c.The thalamus has been damaged. d.The medulla oblongata has been damaged.

ANS: B Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. The hypothalamus controls temperature. The thalamus controls the five senses: hearing, seeing, taste, smell, and touch. The medulla oblongata is part of the brainstem and controls breathing, heart rate, and digestion.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1033 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3.A student nurse is caring for a young adult patient who is immobile with a back injury. On auscultation, the student nurse hears rhonchi in the lower lobes. The student nurse reports this symptom because the patient is developing which complication? a.Increased lung expansion ]

b.Hypostatic pneumonia c.Aspiration pneumonia d.Increased diuresis ANS: B Decreased, not increased, lung expansion, generalized respiratory muscle weakness, and dependent stasis of secretions occur with immobility. These conditions often contribute to the development of atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Aspiration pneumonia results from aspiration, not from immobility. Diuresis is increased urine excretion.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1035 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4.A young adult patient was involved in a motorcycle accident. The patient was in the intensive care unit of the hospital for 2 months with immobility and was just discharged to a rehabilitation hospital. The patient asks the nurse, Why am I so weak? What is the best response from the nurse? a.When you are in bed for a long time, your body begins to break down its own protein. b.When you dont use it, you lose it. c.You havent eaten much for the past couple of months. d.Your body has spent energy trying to heal itself by increasing the metabolic rate.

ANS: A Immobility disrupts normal metabolic functioning, decreasing the metabolic rate and altering the metabolism of carbohydrates, proteins, and fats. A patients basal metabolic rate (BMR) decreases in response to reduced cellular energy because of the bodys decreased ability to produce insulin and metabolize glucose. The body then begins to breakdown its protein stores for energy resulting in a negative nitrogen balance and increased oxygen demands.

However, in the presence of an infection, immobilized patients have an increased BMR. It is the immobility that has caused the weakness, not what was eaten. Not using it leads to losing it is a clich and should be avoided. The metabolic rate is decreased in immobility not increased.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1035 OBJ: Identify changes in metabolic rate associated with immobility.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which information indicates the nurse needs more teaching about the factors in Virchows triad?

a.One of the factors is loss of integrity of the vessel wall. b.One of the factors is abnormalities of blood flow. c.One of the factors is alterations in blood constituents. d.One of the factors is atrophy of the muscles.

ANS: D Three factors contribute to venous thrombus formation: (1) loss of integrity of the vessel wall (e.g., injury), (2) abnormalities of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are referred to as Virchows triad . Disuse, atrophy, and shortening of muscle fibers and surrounding joint tissues cause joint contracture, not deep vein thrombosis. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF:1036 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 6. An elderly nursing home resident fell 2 weeks ago and has been on bed rest. The patient has become increasingly fatigued during activities of daily living (ADLs). The family is concerned about the patients declining condition.

The best explanation that the nurse can give the family is that the patients fatigue is caused by which of the following?

a.Decreased muscle endurance caused by immobility b.Advanced age c.Increased metabolism d.Urinary stasis ANS: A The body loses muscle strength when muscles are inactive. The rate of muscle decline varies with the degree of immobility, but it is rapid while mobility and weight bearing are restricted. These effects are devastating to patients who are marginally functional with their ADLs. This fatigue is a result of the bed rest, not from advanced age or urinary stasis. Reduced metabolism, not increased, leads to a loss of muscle and body mass, causing fatigue with prolonged activity. Urinary stasis does not affect activity level, but can lead to urinary tract infections.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1035 | 1036 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7.Which patient is at greatest risk for developing a pressure ulcer? a.Young adult paraplegic with pneumonia b.Middle age adult that can turn by self in bed c.Teenager with a sprained ankle on crutches d.Middle-age adult with breast cancer ANS: A The paraplegic (paralyzed) is most at risk. The direct effect of pressure on the skin by immobility is compounded by metabolic changes. Older adult patients and patients with paralysis have a greater risk for developing pressure ulcers. A breast cancer patient is mobile as is the teenager on crutches, which decreases their risk. The middle-age adult is turning, decreasing the risk of pressure ulcers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1049 OBJ: Discuss factors that contribute to pressure ulcer formation.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8.Which patient is most at risk for developing a urinary tract infection? a.Teenage comatose patient on a ventilator lying supine b.Middle-age adult after abdominal surgery sitting in a chair c.Elderly adult with Alzheimer disease who is wandering at night ]

d.Middle-age adult postcardiac catheterization being discharged home ANS: A The patient most at risk is the teenage comatose patient on a ventilator lying supine. When the patient is in bed, the kidneys and ureters move toward a more level plane, and urine tries to move from the kidney to the bladder against gravity. Because the peristaltic contractions of the ureters are not strong enough to overcome gravity when the patient is reclining, the renal pelvis fills before urine enters the ureters, which increases the patients risk for urinary tract infection (UTI) and renal calculi. The elderly adult with Alzheimer and the middle-age adult post cardiac catheterization are both upright, which decreases chance for UTI. The middle-age adult after abdominal surgery is sitting in a chair, which decreases chance for UTI because gravity is helping the ureters drain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1050 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 9. The nurse working with a new nursing assistive personnel (NAP), is explaining about the importance of

repositioning immobile patients to prevent pressure ulcers. At a minimum, the nurse tells the NAP to reposition patients how often? a. Every 2 hours b. Every 3 hours c. Every 4 hours

d.Once every shift ANS: A Immobilized patients require vigilant nursing care, such as repositioning at least every 2 hours, to avoid physical complications. Every 3 or 4 hours or once every shift is too long.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1049 OBJ: Discuss factors that contribute to pressure ulcer formation.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 10. Which patient is most likely to have developmental effects due to prolonged immobility?

a.Toddler patient in traction for a congenital skeletal anomaly b.Young adult patient with burns on the hands c.Teenage patient with a bacterial infection in isolation d. Middle-age adult patient with a fractured ankle on crutches ANS: A The toddler would be most affected because of the prolonged immobility. Developmental effects of immobility more commonly affect the very young and the older adult. When the infant, toddler, or preschooler is immobilized, it is usually because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays the childs motor skill and intellectual development. The immobilized young or middle-age adult experiences few, if any, developmental changes. The young and middle adult patients are mobile, not immobile. The teenage patient may have developmental effects due to the isolation but the question asked for prolonged immobility, which this patient does not have.

]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1050 OBJ: Describe psychosocial and developmental effects of immobilization.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 11. The nurse is observing a patients posture while sitting, standing, and assessing gait. What is the rationale for the nurses assessment?

a.To determine type of assistance with anthropometric measurements b.To determine type of assistance with joint mobility c.To determine type of assistance with range of motion (ROM) d.To determine type of assistance with ambulation ANS: D Observing the patients posture while sitting and standing and assessing gait helps to determine the type of assistance the patient requires for ambulation or transfer. Assessment of ROM is important as a baseline measurement to compare and evaluate whether loss in joint mobility has occurred. Anthropometric measurements are for nutrition, not for mobility. Anthropometric measurements include height, weight, mid upper-arm circumference, and triceps skinfold measurements.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1038 OBJ: Discuss the appropriate decision-making process when choosing equipment needed for safe patient handling and movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 12. Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?

a.Maintain complete bed rest. b.Place tight clothing on the legs and waist. c.Put pillows under the knees. d.Position properly with use of antiembolic stockings.

ANS: D Proper positioning used with other therapies (e.g., anticoagulants and antiembolic stockings) helps reduce thrombus formation. When positioning patients, use caution to prevent pressure on the posterior knee and deep veins in the lower extremities. Teach patients to avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs. Complete bed rest increases the chance for thrombus formation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1042 | 1049 OBJ:List appropriate nursing interventions for an immobilized patient.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 13.A nurse is caring for an immobile patient. What is the most appropriate nursing intervention to implement? ]

a.Turn the patient every 4 hours. b.Apply an abdominal binder while the patient is lying in bed. c.Encourage the regular use of incentive spirometry while awake. d.Maintain the patients maximum fluid intake of 1000 mL daily.

ANS: C You can also promote lung expansion through regular deep breathing exercises, use of an incentive spirometer, and forceful coughing. Changing the position of the patient at least every 2 hours, not 4, allows the dependent lung regions to re-expand, maintains the elastic recoil property of the lungs, and clears the dependent lung regions of pulmonary secretions. Your assessment will determine if patients need more frequent position changes. An application of an abdominal binder will restrict chest expansion. Make sure that the immobile patient has a fluid intake of at least 2000 mL per day, if not contraindicated, to help keep mucociliary clearance intact.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1048 OBJ:List appropriate nursing interventions for an immobilized patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14.A nurse notes a typical cardiovascular change in an immobilized postoperative patient. Which of the following did the nurse find upon assessment? a.Atelectasis b.Negative nitrogen balance c.Orthostatic hypotension d.Bleeding ANS: C Orthostatic hypotension, a common cardiovascular response, occurs in patients on bed rest and after prolonged sitting. Orthostatic hypotension is an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure when the patient rises from a lying or sitting position to a standing position. Respiratory changes, not cardiovascular, include decreased lung expansion, generalized muscle weakness, and stasis of secretions. These conditions are consistent with the development of atelectasis. Three factors contribute to thrombus formation (not bleeding), which include loss of integrity of vessel wall, abnormalities of blood flow, and changes in clotting factors/increased platelet activity.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1035 | 1036 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 15.A nurse is caring for a patient in Bucks traction on bed rest for a fracture of the femur. Which action should the nurse take to help preserve skin integrity? a.Provide meticulous skin care. b.Use pain medication to prevent excessive movement. c.Limit range of joint motion so the patient is not disturbed. d.Reduce the amount of protein intake so renal function can be preserved.

ANS: A Interventions aimed at prevention of pressure ulcers are positioning, skin care, and the use of pressure-relief ]

devices. Change the immobilized patients position according to the patients activity level, perceptual ability, status of peripheral circulation, treatment protocols, and daily routines. A patient needs adequate, not reduced, protein intake to ensure wound healing and tissue growth and to prevent a negative nitrogen balance. Patients whose mobility is restricted require ROM to reduce the hazards of immobility; ROM should not be limited. Pain medication is to relieve pain, not to prevent excessive movement.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1042 OBJ:List appropriate nursing interventions for an immobilized patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16.Nurses implement therapeutic immobilization for patients to achieve which result? a.Reducing pain b.Restraining an unstable patient in bed c.Increasing active movement of the body d.Strengthening joints and muscles ANS: A Therapeutic reasons for bed rest include decreasing the bodys oxygen needs, reducing cardiac workload, reducing pain, and allowing the debilitated or ill patient to rest. Restraining an unstable patient in bed is not a reason for therapeutic immobilization. Restraining is a last resort. The body loses muscle strength when muscles are inactive; therapeutic immobilization does not strengthen joints and muscles. Bed rest is to limit active movement of the body, not to increase it.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1035 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 17. Which assessment finding should the nurse expect to observe on an immobilized patient?

a.Increased serum glucose levels b.Decreased urine excretion c.Positive nitrogen balance d.Increased serum potassium levels ANS: A A patients basal metabolic rate (BMR) decreases in response to reduced cellular energy because of the bodys decreased ability to produce insulin and metabolize glucose. In the immobilized patient, a major shift in blood volume occurs, which causes diuresis (increased urine excretion). Diuresis causes the body to lose electrolytes, such as potassium and sodium. When the body is unable to metabolize glucose, it begins to break down protein stores for energy, resulting in negative nitrogen balance, not positive.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1035 OBJ: Identify changes in metabolic rate associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18. While planning care for an immobilized patient, which physiological process will the nurse consider about the patients musculoskeletal system? ]

a.Increased muscle mass b.Decreased rate of bone resorption c.Muscle atrophy d.Bone tissue density elevated ANS: C During immobility, the muscle atrophies, and the size of the muscle decreases. As immobility progresses and muscles are not exercised, muscle mass continues to decrease, not increase. Immobilization increases (not decreases) the rate of bone resorption, which results in reduced (not elevated) bone tissue density.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1036 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 19.A patient is recovering from an abdominal aortic bypass graft. To reduce the effects of orthostatic hypotension, what is the most appropriate action for the nurse to take? a.Encourage moving positions slowly. b.Perform isometric exercises. c.Decrease the number of ankle pumps. d.Participate in chest physiotherapy.

ANS: A Moving positions slowly will help with orthostatic hypotension by allowing the body to adapt. Orthostatic hypotension is an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure when the patient rises from a lying or sitting position to a standing position. Isometric exercises, which are activities that involve muscle tension without muscle shortening, do not have any effect on preventing orthostatic hypotension, but improve activity tolerance. Ankle pumps help to prevent deep vein thrombosis. Participating in chest physiotherapy assists patients with decreasing effects of pulmonary complications.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1035 | 1036 | 1045 OBJ:List appropriate nursing interventions for an immobilized patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 20.A nurse has finished preoperative teaching for a surgical patient. Which statement by the patient indicates teaching was successful about the use of elastic stockings? a.I do not have to worry about wrinkles. b.I can roll them no lower than my calf. c.I will massage my legs regularly. d.I should remove and reapply them every 8 hours.

ANS: D Remove and reapply elastic stockings at least every 8 hours. Elastic stocking aid in maintaining pressure on the muscles of the lower extremities and promote venous return. Rolled-down stockings constrict the vessels and impede venous return. The elastic stocking should be smooth, not wrinkled. The legs should not be massaged. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1042 | 1053 OBJ: Evaluate nursing care for the immobilized patient.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 21.A young adult was involved in a motor vehicle accident and suffers from brain trauma. The patient has decrease mobility in all joints. The nurse should assess for which common, debilitating contracture? a.Lordosis b.Bowlegs c.Footdrop d.Kyphosis ANS: C One common and debilitating contracture is footdrop. When footdrop occurs, the foot is permanently in plantar flexion. Patients are no longer able to walk when this occurs. Lordosis is the exaggeration of the anterior convex curve of the lumbar spine caused by a congenital condition or a temporary condition such as pregnancy. Bowlegs (genu varum) is one or both legs bent outward at the knee, which is normal until 2 to 3 years of age and is caused by a congenital condition or rickets. Kyphosis is the increased convexity in curvature of thoracic spine for a congenital condition, rickets, osteoporosis, or tuberculosis of the spine.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1034 | 1036 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 22.A patient has decrease mobility in all joints. Because of the lack of mobility, the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage? a.Oral anticoagulant b.Aspirin c.Low-molecular-weight heparin d.Unfractionated heparin ANS: C Newer low-molecular-weight (LMW) heparins such as ardeparin and enoxaparin are being prescribed in place of older forms of unfractionated heparin. The LMW heparins have a more predictable anticoagulant effect. Lowmolecular-weight heparin compared with unfractionated heparin reduces the occurrence of major hemorrhage as a side effect.

Heparin is an anticoagulant that suppresses clot formation. This therapy requires a health care providers order.

Aspirin and oral anticoagulants increase the risk for hemorrhage.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1052 OBJ:List appropriate nursing interventions for an immobilized patient.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

Chapter 30: Safety Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The patient has recently moved into a newly renovated home in the inner city. The patient is being seen in the

clinic for complaints of ongoing headaches, nausea, dizziness and fatigue. The symptoms started shortly after moving into the new home. As the nurse gathers information, which of the following questions would be most appropriate to ask the patient? a.Have you changed the battery in your smoke alarm recently? b.Have you changed your diet since moving? c.What type of furnace do you have? d.When was the last time your house was painted?

ANS: C

A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment. This gas binds strongly with hemoglobin; preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to the tissues. Low concentrations cause nausea, dizziness, headache, and fatigue. The importance of having a proper working smoke detector will decrease the chance of smoke inhalation and potential death owing to a fire but does not produce the symptoms listed. A balanced diet and proper storage of food is essential to decrease the chance of infection to the gastrointestinal system but does not produce the symptoms listed. Painting would not produce the symptoms listed even if the paint is old and contains lead as it must be ingested.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:721 OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 2. The registered nurse from the home health agency is performing an initial assessment on a 72-year-old patient

who was released from a nursing home. The patient had been admitted to the nursing home for therapy after surgery for repair of a fractured left hip. During a survey of the home environment, which finding would cause the nurse to intervene? a.Bedside lamp plugged into the wall outlet behind the bed b.Handrail on one side of the stairs only c.Throw rugs in the bedroom d.No handrail near the toilet ANS: C Common physical hazards that lead to falls in the home include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices. All other answers do not indicate a safety risk to the home.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:721 | 722 | 726 OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment 3. Of the following, who is most at risk for accidental poisoning?

a.Supervised 16-month-old toddler eating dry cereal in the highchair b.Unsupervised 2-month-old infant left near a closed bottle of prescription medication c.Unsupervised 4-year-old child playing dress-up with mothers makeup d.Supervised 6-year-old child playing with watercolor paints ANS: C In the home, accidental poisoning is a greater risk for the toddler, preschooler, and young school-age child, who often ingest household cleaning solutions, medications, or personal hygiene products. Two of the responses have the word supervised in the response, which makes them incorrect for an accidental poisoning. The response which has the childs age of 2 months decreases the chance of accidental poisoning due to lack of coordination and dexterity (a 2-month-old cannot open a closed medication bottle).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:722 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4.A nursing student is volunteering with a local agency to help prepare the community for a potential bioterrorist attack. On which of the following threats would be the nursing students primary focus? a.Hurricane b.Earthquake c.Anthrax d.Tornado ANS: C A new potential environmental health threat is the possibility of a bioterrorist attack. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur. The other responses (hurricane, earthquake, and tornado) are classified as natural disasters.

PTS:1DIF:Cognitive Level: Applying (Application) REF:723 OBJescribe environmental hazards that pose risks to patient safety.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 5.All hospital employees are concerned about the safety of patients in the hospital, especially regarding the transmission of pathogens. What is the most common means of transmission of pathogens in this environment? a.Contaminated blood products b.Enteric transmission c.Insufficient hand hygiene d.Aerosols

ANS: C A pathogen is any microorganism capable of producing an illness. The most common means of transmission of pathogens is by the hands. Pathogens are also transmitted through a humans blood and body fluids and by insects (e.g., mosquitoes carrying malaria) and rodents. Although the other responses could spread pathogens, the most correct answer and most common method is insufficient hand hygiene.

PTS:1DIF:Cognitive Level: Applying (Application) REF:723 OBJescribe environmental hazards that pose risks to patient safety.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 6.A registered nurse works in a small rural health clinic. During a routine well baby visit, a new mother questions the need to have her infant immunized. Which of the following is the best explanation for why it is recommended that her child receive immunizations? a. Immunization increases resistance to an infectious disease. b. It provides a small amount of a live, strong organism to protect against disease.

c.Immunization will definitely keep your child well. d.It will provide active immunity by providing antibodies to your child.

ANS: A

Immunization is the process by which resistance to an infectious disease is produced or increased. A weakened or dead organism and modified toxins from the organism is injected into the body, not a live, strong organism.

Immunizations do not definitely keep a child well. Passive immunity occurs when antibodies produced by other people or animals are introduced into a persons bloodstream, whereas active immunity is from a weakened or dead organisms or modified toxins from the organism.

PTS:1DIF:Cognitive Level: Applying (Application) REF:723 OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 7.A nurse is giving anticipatory guidance to the mother of a 10-month-old child. The nurse is focusing on providing a safe environment for the child. Which of the following is the best statement regarding childhood safety? a.The car seat should be placed in a forward-facing position. b.The majority of deaths in children between the ages of 1 and 3 years old are caused by contagious diseases. c.Injuries are a major cause of death during infancy, especially for children 6 to 12 months old. d.Measles causes more deaths in children younger than 5 years old than all other diseases combined.

ANS: C Injuries, not contagious diseases, are a major cause of death during infancy, especially for children 6 to 12 months old. The leading causes of injury to infants are falls, ingestion injuries (poison, foreign body ingestion, and medication), and burns. Aspiration often occurs from the ingestion of foreign material such as small toys and food items. The question is asking for a safe environment assessment and childhood safety; measles is an illness/disease

caused by a pathogen and does not relate to providing a safe environment or information about childhood safety.

All infants and toddlers should ride in a rear-facing car safety seat until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of the car seat.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:723 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 8.The parent of a 13-year-old boy is concerned because the teenager wants to hang out with friends all the time and has stated that he wants to get his ear pierced because all his friends have piercings. What is the best response from the nurse? a.I think you need to seek counseling for your son. b.I think this is just a phase that will quickly pass. c.Your son needs to find new friends. d.Your sons behavior is normal; he is trying to assert his independence.

ANS: D As children enter adolescence, they develop greater independence and a sense of identity. The adolescent begins to separate emotionally from the family, and the peer group begins to have a stronger influence. To relieve the tensions associated with the physical and psychosocial changes, as well as peer pressure, adolescents often engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. This increases the risk for accidents such as drowning and motor vehicle accidents. Counseling and finding new friends are not needed because the boy is demonstrating normal signs of development. Adolescence does not quickly pass.

PTS:1DIF:Cognitive Level: Applying (Application) REF:724 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 9.A 16-year-old patient is being seen in the emergency department (ED) after being involved in a minor motor vehicle accident. The guardian has voiced that the patient has been spending more time in his or her room, has difficulties getting along with friends, and has declining grades over the past 3 months. The patient seems distant and angry all the time. Which of the following topics is most important for the nurse to discuss with the guardian? a.Accident prevention measures b.Enrolling the patient in a defensive driving course c.The possibility of substance abuse d.The importance of automobile insurance ANS: C To assess for possible substance abuse, have parents look for environmental and psychosocial clues. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia, blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships. Fatal crash rates for teens are high largely because of

their immaturity combined with driving inexperience. Accident prevention measures, a defensive driving course, and automobile insurance are not the most important topics. Accident prevention, defensive driving, and insurance will not be effective if substance abuse is not addressed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:724 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 10.A female 36-year-old bank executive was recently promoted to vice president. She and her husband have two school-age children. The patient is being seen at the clinic and reports severe abdominal pain with diarrhea. During the assessment, the patient explains to the health care worker that she and her family will be moving to another state because of her promotion. Her children are upset about leaving their friends. The health care worker recognizes that which of the following information is a priority for patient teaching? a.Providing growth and development information about the school-age child b.Recommending a gastroenterologist c.Offering to call a moving company d.Discussing how a high level of stress can cause illness ANS: D An adult experiencing a high level of stress is at a greater risk for accidents and certain stress-related illnesses such as headaches, depression, gastrointestinal disorders, and infections. Although it is important to give the patient information regarding normal stages of growth and development in school-age children; this is not the cause of the symptoms. Referral to a gastroenterologist would occur after stress management techniques have been tried; or symptoms become worse. Calling a moving company does not address the real problem of stress.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:724 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 11.An 85-year-old retired man with arthritis has recently been prescribed a new medication by his health care provider for pain management. The health care provider identifies that the patient is currently taking 13 different medications on a daily basis. The health care provider is concerned about the patients safety in the home. Which of the following is most important to assess? a.Marital status b.Potential for falls c.Skin breakdown d.Cultural beliefs ANS: B The physiological changes associated with aging (85 years old), effects of multiple medications (13 different medications), psychological factors, and acute or chronic disease (arthritis) increase the older adults risk for falls and other types of accidents. Fear of falling is common among community-dwelling older adults, who both do and do not have a history of falling. As a result of their fear, many older adults avoid activities or change the way in

which they walk and position themselves, making them more at risk for falling. It is important to learn what conditions increase a persons fear of falling so that steps can be taken to remove or change any hazards in the home. Marital status and cultural beliefs are not priority assessment issues for home safety. Skin breakdown could occur if the patient was immobile but this is not the priority home safety issue for this patient and there is no data in the question to indicate the patient is immobile.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:724 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 12.A nursing student is undergoing a community health clinical rotation. One of the patients is a 53-year-old grandmother who has recently assumed custody of her daughters two young children, ages 3 and 5 years old.

Regarding the childrens welfare, which of the following is most important for the nursing student to assess on this visit? a.The patients financial ability to care for two young children b.The patients knowledge of safety precautions for young children c.The patients emotional stability d.The patients feelings regarding taking on this responsibility ANS: B Some patients are unaware of safety precautions, such as keeping medicine, poisonous plants, or other poisons away from children or reading the expiration date on food products. A nursing assessment will identify the patients level of knowledge regarding home safety so that safety problems can be corrected with an individualized care plan. Although the other responses are important, they are not the focus of home safety issues, but financial and emotional aspects of care.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:724 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 13.A 75-year-old patient in an acute care hospital who underwent surgery for an abdominal aneurysm developed a urinary tract infection 3 days after placement of a Foley catheter. The nurse believes that this is a reportable incident, and which of the following will happen as a result? a.Medicare will be denied to the patient. b.Medicare will take the hospital to court. c.Nothing; it is not a reportable incident. d.Medicare will not reimburse the hospital for this infection.

ANS: D The Centers for Medicare and Medicaid Services (CMS) names select serious reportable events (SREs) as Never Events (adverse events that should never occur in a health care setting) (US Department of Health and Human Services, 2008). The CMS now denies payment to hospitals for any hospital-acquired conditions resulting from or complicated by the occurrence of certain Never Events that were not present on admission. Many of the hospital-

acquired conditions are nurse-sensitive indicators, meaning that nursing interventions directly affect their development. Medicare is not denied to the patient and this is a reportable incident. Medicare does not take hospitals to court; it just denies payment for the Never Event.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:719 | 721 OBJ: Explain the concept of Never Events and a nurses role in prevention.

TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 14.The nurse is concerned because a 77-year-old patient is weak after abdominal surgery. Which of the following should be done to ensure that one of the preventable conditions identified by the Centers for Medicare and Medicaid does not occur? a.Use the rights of medication administration. b.Provide frequent opportunities to use the bathroom. c.Document thoroughly. d.Complete discharge teaching as quickly as possible.

ANS: B Providing frequent opportunities to use the bathroom helps prevent pressure ulcers, falls, trauma, and even may help prevent an infection from the insertion of a catheterall are listed on the preventable conditions. The Centers for Medicare and Medicaid Services (CMS) names select serious reportable events (SREs) as Never Events (adverse events that should never occur in a health care setting) (US Department of Health and Human Services, 2008). The CMS now denies payment to hospitals for any hospital-acquired conditions resulting from or complicated by the occurrence of certain Never Events that were not present on admission. Many of the hospital-acquired conditions are nurse-sensitive indicators, meaning that nursing interventions directly affect their development. Whereas the rights of medication administration demonstrates safety it does not relate to the preventable conditions identified by CMS, but does relate to the National Patient Safety Goals. Thorough documentation is a legal issue, not a CMS preventable condition. Discharge teaching is not listed on the preventable list and it should not be done quickly.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:719 | 721 OBJ: Explain the concept of Never Events and a nurses role in prevention.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 15.A 5-year-old child was admitted to the pediatric unit of the hospital with the diagnosis of fever of unknown origin. Currently the patients temperature is 105 F. Which of the following is the best way to prevent a patientinherent accident from occurring? a.Keep all electric receptacles covered in the patients room. b.Clean up patient spills as they occur. c.Pad all bed side rails. d.Do not allow the child in the playroom.

ANS: C One of the more common precipitating factors for a patient-inherent accident is a seizure. Place patients with a seizure disorder on seizure precautions, which are designed to protect patients when seizures occur. Keeping

electric receptacles and cleaning up patient spills, and not allowing the child to play in the playroom are all extrinsic factors that are environmentally related and include room clutter, loose electrical cords, and spills.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:725 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 16. In an outpatient surgery center, the preoperative nurse has the responsibility of starting IVs prior to the patients

surgeries. One of the surgeons who works at the center orders a different type of IV fluid than the rest of the surgeons. Which of the following should the nurse be most concerned about in this situation? a.Procedure-related accident b.Patient-inherent accident c.Patient confusion from medications d.Potential electrolyte imbalance ANS: A

Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and improper performance of procedures such as dressing changes.

Following an organizations policies and procedures and standards of nursing practice helps prevent procedurerelated accidents. Patient-inherent accidents are those in which a patient is the primary reason for the accident. The primary issue is a procedure-related accident because of the surgeons use of a different type of IV, which could cause the nurse to improperly administer the medication; it is not an electrolyte imbalance or confusion. Electrolyte imbalance and confusion from medications are all potential issues that are out of the nurses control.

PTS:1DIF:Cognitive Level: Applying (Application) REF:725 OBJ: Assess risks to patients safety within health care settings and the home.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 17. The nurse identifies that one of the IV pumps has been malfunctioning and was placed outside a patient room until it could be repaired. To prevent an equipment-related accident from occurring, which action should the nurse take first?

a.Tag the pump and remove it from the area. b.Initiate a work order on the pump. c.Clean the pump and put it in the equipment closet. d.Call the pump manufacturer.

ANS: A Initiating the work order on the pump is important, but the first priority is to tag and remove the pump from service. Leaving the pump in the equipment closet could allow the pump to mistakenly be put back into service without be fixed. It is not the nurses job to call the pump manufacturer to report the issues. Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid accidents, do not operate medical equipment without adequate instruction. If you discover a faulty piece of equipment, replace it with the proper working equipment, place a tag on the faulty one, take it out of service and

promptly report any malfunctions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:725 OBJ: Describe nursing interventions specific to the patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 18.A patient who underwent surgery for a bowel obstruction yesterday has become confused and has made several attempts to climb out of bed. The nurse is considering options to prevent the patient from harm. Which of the following actions could be delegated to assistive nursing personnel working with the nurse? a.Assessing the patient for appropriateness of restraints b.Calling the physician for an order for a restraint alternative c.Discussing the need for restraints with the patients family d.Applying restraints after orders received by the nurse ANS: D The skill of applying a restraint can be delegated to trained nursing assistive personnel. However, the nurse is responsible for assessing a patients behavior, determining the need for restraint, the type of restraint to use, and performing patient assessments while restraints are in place. Patients, who are confused, disoriented, or who repeatedly fall or try to remove medical devices (e.g., IV lines or dressings) may require the temporary use of restraints to keep them safe. Restraints are not a solution to a patient problem but rather a temporary means to maintain patient safety. All alternatives must be used before placing patients in restraints. Performing an assessment, obtaining orders from the physician and including the family in the discussion of why restraints are necessary are all jobs that cannot be delegated to a nursing assistive personnel (NAP); and must be performed by the nurse.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:726 | 727 | 738 OBJ:Identify factors to consider in the use of restraints.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 19.A student nurse has been asked by the registered nurse with whom the student nurse is working to apply wrist restraints to a patient who is confused and is trying to remove the endotracheal tube. The student nurse knows that it is important to tie the restraints to which part of the bed? a.Side rails b.Part of bed frame that moves up and down with the patient c.Footboard d.Headboard ANS: B Attach restraint straps to the portion of the bed frame that moves when raising or lowering the head of the bed. Do not attach to the side rails. Attaching the restraint straps to a portion of the bed frame that does not move (headboard or footboard) will injure the patient.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 740 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 20.A patient is confused and has been restrained to prevent injury. Which of the following is a priority as the nurse plans care for the shift? a.Calling the physician for an order for a chemical restraint b.Applying the most restrictive restraint to prevent injury c.Removing the restraints on the patient at least every 2 hours d.Checking on the restrained patient last ANS: C Assess proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part. Remove restraints at least every 2 hours or more frequently as determined by agency policy. If patient is violent or noncompliant, remove one restraint at a time and/or have other staff present while removing restraints.

Chemical restraints are medications, such as anxiolytics and sedatives, used to manage a patients behavior and are not a standard treatment for a patients condition. Always attempt restraint alternatives before using a restraint. If a restraint is needed, always use the least restrictive device. Checking restrained patients last is not appropriate.

Legislation emphasizes reducing the use of restraints. The Joint Commission and Centers for Medicare and Medicaid Services enforce standards for the safe use of restraint devices.

PTS:1DIF:Cognitive Level: Applying (Application) REF:735 | 736 | 741 OBJ:Identify factors to consider in the use of restraints.

TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 21.A nurse working on the medical unit mistakenly administers the wrong medication to a patient. This type of error would be classified as which of the following? a.Poisoning accident b.Equipment-related accident c.Procedure-related accident d.Accident related to time management ANS: C A procedure-related accident is caused by health care providers and includes medication and fluid administration errors, not putting external devices on correctly, and improperly performing procedures such as dressing changes.

A poisoning accident is related to inhaled or ingested substances. An equipment-related accident results from misuse, disrepair, malfunction, or electrical hazard. An accident related to time management deals with the nurses inability to follow an organizations policy and procedures.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:722 | 725 OBJ: Assess risks to patients safety within health care settings and the home.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

22.A confused patient was found wandering in the hallways several times during the shift. What is the most appropriate nursing intervention to prevent a fall by this patient? a.Reassigning the patient to a room closer to the nursing station b.Using an electronic monitor that sounds an alarm when the patient reaches a near-vertical position c.Raising two or four side rails d.Placing wrist restraint on the patient during the nighttime hours of sleep ANS: B Alarm devices warn nursing staff that a patient is attempting to leave a bed or chair unassisted. There are a variety of types, including a device with a knee band that sounds an alarm when the patient reaches a near-vertical position. An infrared type of alarm is affixed to a headboard or bed frame, allowing a patient to move freely within a bed. If a patient tries to leave the bed, the infrared beam detects motion and sends out an alarm tone. Moving the patient to a room closer to the nursing station does not solve the problem. Raising side rails has the potential to trap parts of the patients body, producing a hazard. The use of side rails alone for a disoriented patient often causes more confusion and further injury. Restraints are not a solution to a patient problem, but a temporary means to patient safety. Restraints are a last resort to prevent injury.

PTS:1DIF:Cognitive Level: Applying (Application) REF:734 OBJ: Describe nursing interventions specific to the patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 23.A toddler is ready to be discharged home after outpatient surgery. When conducting a home safety assessment the childs guardian states, I keep the cleaning supplies under the sink for easy access, and how soon can the child resume swimming in the local pond? Based on this statement, what is the most important safety issue for the nurse to identify? a.Standing water in the neighborhood b.Reasons for outbursts in behavior c.Storage of cleaning supplies in the house d.Childs use of safety equipment when riding or skating ANS: C Growing, curious children need adults to protect them from injury. Educate young parents or guardians about reducing risks of injuries to children, and teach ways to promote safety in the home. An example is preventing access to poisonous substances like cleaning supplies. Standing water, reasons for outbursts, and use of safety equipment are not issues based upon the guardians response, which focuses on cleaning supplies and swimming.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:722-724 OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24.A pediatric nurse is assessing a patient for a routine physical. The nurse identifies that the parents need additional safety teaching when the parents mentions which of the following? a.A 2-year-old child can safely sit in the front seat of a car.

b.Teenagers need to practice safe sex. c.Children need to wear a helmet and safety pads when in-line skating. d.Children need to learn to swim even if parents do not have a swimming pool.

ANS: A A 2-year old cannot sit in the front seat safely, so the nurse needs to correct this misinformation. All children 2 years or older, or those younger than 2 years who have outgrown the rear-facing weight or height limit for their car safety seat (CSS), should use a forward-facing CSS with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their CSS. Teenagers practicing safe sex, children wearing a helmet and safety pads when skating, and children learning to swim even if a home pool is not present are all correct and do not need additional teaching.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:722 OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 25.A fire erupts in a hospital waste receptacle in the hallway. What is the nurses first response? a.Report the fire. b.Attempt to extinguish the fire. c.Assist any patients to a safe area. d.Close the door to contain the fire.

ANS: C Use the mnemonic RACE to set priorities in case of fire: RRescue and remove all patients in immediate danger.

AActivate the alarm. Always do this before trying to extinguish even a minor fire.

CConfine a fire by closing doors and windows and turning off oxygen and electrical equipment.

EExtinguish a fire using an appropriate extinguisher.

Reporting, attempting to extinguish, and closing the door all occur after assisting patients to a safe area.

PTS:1DIF:Cognitive Level: Applying (Application) REF:737 OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 26.A health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges which of the following? a.Restraints are used on an as-needed basis. b.No orders or patient consents are needed. c.Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition.

d.An order for restraints may be used indefinitely until the patient no longer needs to be restrained.

ANS: C Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition. Restraints are only used when other less restrictive measures fail to prevent interruption of therapies. The physicians or health care providers orders are necessary. The need for restraints must be reevaluated every 24 hours.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 734-736 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 27.A patient in the intensive care unit requires mechanical ventilation, a wound VAC system, patient-controlled analgesia, and an intravenous infusion device. Which safety precaution should the nurse implement in the health care setting? a.Using two-pronged plugs b.Never operating equipment without previous instruction c.Using an extension cord to accommodate plugs for all the equipment d.Never using equipment without having another nurse assist ANS: B To avoid accidents, do not operate medical equipment without adequate instruction. Decrease the incidence of electrical hazards by using a three-pronged grounded plug. Many types of equipment have both electric outlet and battery power sources. Extension cords are a common cause for falls. If an extension cord must be utilized, it should be placed next to the wall to decrease tripping. Using equipment without having another nurse assist is safe behavior.

PTS:1DIF:Cognitive Level: Applying (Application) REF:725 OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 28.A nurse is working in a health facility that creates a culture of safety. Which behavior will the nurse use in this type of facility? a.Find blame when problems occur. b.Reprimand co-workers when a mistake is made. c.Maximize adverse events. d.Focus on performance improvement efforts.

ANS: D These types of organizations foster a patient-centered safety culture by continually focusing on performance improvement efforts, risk-management findings, and safety reports to design a safe work environment. Health care organizations strive to create a culture of safety, one that consistently minimizes, not maximizes, adverse events despite carrying out complex and hazardous work. A culture of safety requires the determination to achieve consistently safe operations and a blame-free environment in which individuals can report errors without fear or reprimand.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 719 OBJ: Describe factors that create a culture of safety.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1.A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing and a wrist restraint is applied after an order is received.

Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take?

(Select all that apply.) a.Remove the restraint immediately. b.Remind the patient this will decrease with time. c.Notify the health care provider. d.Medicate the patient for pain. e.Stay with the patient.

ANS: A, C, E If a patient has altered neurovascular status (tingling and numbness) remove the restraint immediately, stay with the patient, and notify the health care provider. Tingling and numbness will not decrease with time; it will continue to cause damage. The patient does not need pain medication; the restraint is too tight and needs to be removed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 742 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2.A group of teenagers are attending a preparation class for babysitters. Which statements by the teenagers indicate a correct understanding of the teaching about safety issues? (Select all that apply.) a.Home fires are a major cause of death and injury. b.Bacterial food contamination cannot be controlled. c.There should be working batteries in the smoke detector. d.Temperature changes do not affect the childs safety. e.Toddlers are very curious and like to put objects in their mouths.

ANS: A, C, E The best intervention is to prevent fires. Home fires are a major cause of death and injury. Another problem related to fatal fires is a failure to keep fresh batteries in home smoke detectors. The improper use of cooking equipment and appliances, particularly stoves, is another source for in-home fires. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas. Children at these early stages are curious; they explore their environment, and because of an increase in oral activity, put objects in their mouths. If food is prepared and stored properly, food poisoning risk can be decreased. Temperature changes can lead to hypothermia and/or heatstroke or heat exhaustion.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:721 | 723

OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment

Chapter 31: Hygiene Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is working on a long-term rehabilitation unit, is providing care for a 46-year-old woman who was the

victim of a violent crime and suffered a head injury. The patient has an endotracheal tube, which is secured with tape. The tape is crusted with dried secretions. The nurse is providing personal hygiene for the patient and needs to replace the tape. What is the best way for the nurse to remove the tape? a.Soak it with warm moist washcloths. b.Pull it gently away from the skin. c.Saturate it with denatured alcohol. d.Soak it with adhesive remover.

ANS: A When patients have nasogastric, feeding, or endotracheal tubes inserted through the nose, change the tape, anchoring the tube at least once a day. When the tape becomes moist from nasal secretions, the skin and mucosa can easily become macerated (softened by soaking). Friction from a tube causes tissue injury. Anchor tubing correctly with tape or fixative devices to minimize tension or friction on the nares. Pulling away gently is preferred after soaking with warm moist clothes. Alcohol and adhesive remover are not recommended.

PTS:1DIF:Cognitive Level: Applying (Application) REF:773 OBJ: Correctly perform hygiene procedures for the care of the patients skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation MSC:Client Needs: Management of Care 2. The student nurse caring for a 56-year-old patient with acquired immunodeficiency syndrome (AIDS). While

providing oral care for the patient the student nurse notes that the gums are reddened and bleed easily. The student nurse identifies this as a sign of what condition? a.Dental caries b.Gingivitis c.Oral herpes d.Thrush ANS: B Gingivitis is inflammation of the gums, and dental caries is tooth decay produced by interaction of food with bacteria that forms plaque. Thrush is a yeast infection in the mouth and oral herpes are open sores in the mouth around the mucous membrane.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:748-749 OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Nursing Process: Assessment MSC: Client Needs: Basic Care and Comfort 3.A 25-year-old patient was admitted to the surgical floor wearing contact lenses. Assistive personnel ask the nurse if contact lenses need special attention. The nurse informs the assistive personnel that nonextended-wear contacts left in the eyes for an extended period of time can cause which of the following?

a.Blindness b.Corneal injury c.Otitis externa d.Otitis media ANS: B Corneal injury can occur in patients who leave their contacts in for an extended period of time. Patients are admitted to hospitals or agencies in unresponsive or confused states. Remove contact lenses, and rinse lenses and eyes with a sterile saline solution. Physical limitations create inability to safely insert or remove contact lenses or to cleanse the lenses. Contact lenses cannot cause blindness, otitis externa, or otitis media.

PTS:1DIF:Cognitive Level: Applying (Application) REF:772 OBJ: Correctly perform hygiene procedures for the care of the patients skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation MSC:Client Needs: Reduction of Risk Potential 4.A 45-year-old woman with diabetes who has been hospitalized with diabetic ketoacidosis. Which of the following is most important for the nurse to assess during bath time? a.Skin bruising b.Condition of teeth c.Sensation to the foot d.Skin folds for dirt ANS: C Assess patients with diseases that affect peripheral circulation and sensation for the adequacy of circulation and sensation of the feet. Palpate the dorsalis pedis and posterior tibial pulses and assess for intact sensation to light touch, pinprick, and temperature. Foot ulceration is the most common single risk factor for lower extremity amputations among persons with diabetes. The other responses are necessary to assess but not the highest priority for this patient with a diabetic diagnosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:754 OBJ:Explain the importance of foot care for the patient with diabetes.

TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5.A nursing student who is working on a postsurgical unit assisting patients with personal hygiene plans to provide a back rub to each of her patients. The nursing student discusses the importance of this activity because research demonstrates that it enhances patient comfort and relaxation with the nurse assigned to these patients. The nurse instructs her that back rubs would be contraindicated on which of the following patients? a.A 56-year-old patient with a colon resection b.A 45-year-old patient with a spinal cord injury c.A 67-year-old patient with an appendectomy d.A 24-year-old patient with an abdominal hysterectomy ANS: B

Consult a patients record for any contraindications to a massage such as spinal cord injury, rib fractures, or other painful conditions. Research shows that slow-stroke back massages of 3 minutes duration and hand massages of 10 minutes significantly improve both physiological and psychological indicators of relaxation in older persons.

Always ask whether a patient would like a back rub or if he or she prefers gentle instead of deep massage because some patients dislike physical contact.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:771 OBJerform a comprehensive assessment of a patients hygiene needs.

TOP: Nursing Process: Planning MSC: Client Needs: Basic Care and Comfort 6.A nurse who works for a pediatric clinic is preparing a 13-year-old patient with strep throat for the health care provider. Which of the following is the most important patient teaching information to prevent re-infection? a.Replace your toothbrush. b.Floss thoroughly after each meal. c.Store your toothbrush with a toothbrush cover. d.Gargle with antiseptic mouthwash.

ANS: A Instruct patients to obtain a new toothbrush every 3 months or after a cold or strep throat to minimize growth of microorganisms on the brush surfaces. Avoid using toothbrush covers, which can create a moist enclosed environment that promotes bacterial growth. Dental flossing removes plaque and tartar between teeth. Instruct patients that flossing once a day is recommended. When teaching patients about mouth care, recommend that they not share toothbrushes with family members or drink directly from a bottle of mouthwash. Cross-contamination occurs easily. Antiseptic mouthwash is recommended for general use, but does not have an effect on the reinfection of strep.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 764 OBJ: Describe factors that influence personal hygiene practices.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 7.The nursing assistive personnel (NAP) has been delegated the task of changing a postsurgical patients bed. The NAP miscalculated the amount of linen needed and took more than needed. What is the best thing for the NAP to do with the unused linen? a.Replace it in the linen closet. b.Leave it in the room on the bedside table. c.Use it in another patients room. d.Place it in a laundry bag to be laundered.

ANS: D Because of the importance of cost control and prevention of infection transmission, avoid bringing excess linen into a patients room. Once you bring linen into a patients room, even if the linen is not used, it must be laundered before being used by another patient. Do not place back into the linen area or use in another patients room. Excess linen lying around a patients room creates clutter and obstacles for patient care activities.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 779 OBJ: Make an occupied and unoccupied hospital bed.

TOP:Nursing Process: Implementation MSC:Client Needs: Safety and Infection Control 8.A student nurse is bathing a patient with right lower lobe pneumonia. The student nurse is concerned with maintaining the patients dignity, warmth, and safety. Which of the actions will prevent the spread of microorganisms? a.Use superfatted soap. b.Wash from the cleanest to the contaminated body part. c.Use gloves when washing the patients face. d.Moving the call light out of reach of the patient to prevent it from becoming wet.

ANS: B Always perform hygiene measures moving from the cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Use of superfatted soap will prevent skin breakdown. Use of gloves when washing the patients face decreases the patients dignity. For safety, the patient should have access to the call light at all times.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:781 OBJ: Correctly perform hygiene procedures for the care of the patients skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation MSC:Client Needs: Safety and Infection Control 9.A student nurse is caring for four patients in her senior clinical rotation. The patients are scheduled for baths that include washing their hair. Which of the patients will the student nurse need a health care providers order to shampoo the hair? a.A 56-year-old man with diabetic ketoacidosis b.A 45-year-old woman with a neck injury c.A 34-year-old man with facial laceration d.A 67-year-old woman with pneumonia ANS: B You will need a health care providers order to shampoo the hair of patients with neck injuries. In situations in which bending is limited, teach the patient and family caregivers the degree of bending allowed. Assessment of the patients activity tolerance and balance should be assessed before washing the hair to determine the best mode to complete the activity. There is no need for a specific order in patients who are a diabetic, have pneumonia, or have facial lacerations.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:773 | 775 OBJerform a comprehensive assessment of a patients hygiene needs.

TOP: Nursing Process: Assessment MSC: Client Needs: Management of Care 10. The nurse is caring for a 64-year-old patient who is hospitalized after surgery for a left total knee replacement.

While preparing the patients personal care items for oral care, the patient states, I have noticed a lot of plaque formation between professional teeth cleanings. Which of the following foods would the nurse suggest to help reduce plaque formation?

a.Soda b.Whole grain breads c.Citrus fruits d.Processed sugar snacks ANS: C Teach a patient that diet influences plaque formation and development of dental caries. Acidic fruits in the patients diet will reduce plaque formation. To prevent tooth decay, patients sometimes need to change eating habits (e.g., reducing intake of carbohydrates, consumption of soda, and especially sweet snacks between meals).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 764 OBJ: Describe effect of oral hygiene on periodontal disease.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. The health care provider orders meticulous foot care on a patient with diabetes. What is the best rationale for the nurse to assess the patient for complications?

a.Poor hygienic practices in patients with diabetes b.Vascular changes, which reduces circulation c.The aging process, which causes skin breakdown and ulceration d.Limited joint range of motion, which makes caring for feet difficult ANS: B People with diabetes develop many different foot complications associated with nerve damage and poor blood flow to the lower extremities. Foot injuries in the patient with diabetes can quickly turn into a serious problem with slow healing, infection, and the possibility of amputation. According to the American Diabetes Association (2012a) more than 60% of lower limb amputations for nontraumatic reasons are associated with diabetes. If a patient has diabetes or any other condition affecting peripheral circulation or sensation, recommend a podiatrist for regular examinations and trimming of nails. Also instruct these patients to report any of the following to their health care provider: abnormalities or changes in the nail, including changes in nail shape or color; bleeding around the nails; thinning or thickening of the nails; redness, swelling, or pain around the nails. Poor hygienic practices, the aging process, and limited movement are all good reasons to assess the foot of a diabetic patient, but because of the specific complications related to the vascular changes that occur with diabetes, this is the best rationale to assess for complications.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:764 | 765 OBJ:Explain the importance of foot care for the patient with diabetes.

TOP:Nursing Process: Assessment MSC:Client Needs: Reduction of Risk Potential 12. An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first

do which of the following?

a.Assess the patient for a gag reflex. b.Position the patient in a prone position. c.Have an operational suction machine nearby. d.Retract the upper and lower teeth with a padded tongue blade.

ANS: A If the patient does not have a gag reflex he or she is at an increased risk of aspiration. If no gag reflex is present two people may be needed, one to perform oral care and the other to suction the patients mouth to prevent aspiration of fluid. The prone position is face down, which is not the position of choice. After you check for the gag reflex, a suction machine is necessary to remove secretions. A padded tongue blade is used to hold the mouth open.

PTS:1DIF:Cognitive Level: Applying (Application) REF:768 OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP:Nursing Process: Implementation MSC:Client Needs: Reduction of Risk Potential 13.A patient requires toenail care. While the nurse performs nail care and nail care education the patient is instructed to always do which of the following? a.Use clippers or manicure scissors to trim the nails straight across. b.Apply a hot water bottle to the feet before foot care to soften the tissues. c.Apply over-the-counter preparations to any foot fungus or disease. d.Apply moist wet-to-dry dressing on any cuts and cover with socks.

ANS: A Demonstrate proper trimming and filing techniques. For ongoing home care, instruct patients or their family caregivers to use sharp manicure scissors or clippers to trim the nails straight across, then round the tips by filing in a gentle curve. Explain that trimming is easiest when the nails are soft, such as after a bath, but be sure the nails have dried before filing to prevent splitting. Never recommend soaking the nails if a person has diabetes. Applying a hot water bottle, over-the-counter preparations, and moist wet-to-dry dressing are not standard during foot care.

PTS:1DIF:Cognitive Level: Applying (Application) REF:764 | 765 OBJ: Correctly perform hygiene procedures for the care of the patients skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation MSC:Client Needs: Basic Care and Comfort 14. The nursing student is caring for a patient with a hearing aid. The nursing student sees that the patient has taken out his or her hearing aid and set it on the windowsill. What should be the nursing students next intervention?

a.Remove the battery from the hearing aid because it is not in use. b.Cover the hearing aid with a lint-free cloth to protect it from the heat. c.Remove the hearing aid from the windowsill because heat can change the shape of the ear mold, causing the appliance not to fit properly. d.Remind the patient to put the hearing aid back in before meals.

ANS: C Do not store the aid in a warm place such as a windowsill or in a car. The heat can change the shape of the ear mold, causing the aid to not fit properly. Remove the battery from the hearing aid when it is not being used for a day or longer. Avoid dropping the aid or twisting the cord. Remove the aid before radiological examination or radiation therapy to avoid damage. Protect the aid from water, alcohol, aerosol sprays, perspiration, and cologne.

Use the manufacturer-recommended cleaning solution and a soft, lint-free cotton cloth to clean the ear mold.

PTS:1DIF:Cognitive Level: Applying (Application) REF:777 OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp and their related interventions. TOP: Nursing Process: Implementation MSC:Client Needs: Reduction of Risk Potential 15. Older adult patients produce less sebum and perspire less than younger patients. Therefore when providing personal hygiene the nurse should do which of the following?

a.Use hot water and regular soap. b.Use plain water and a soft towel. c.Provide a total bed bath every day. d.Use warm water and a mild cleansing agent.

ANS: D Older patients skin is more fragile; therefore avoid hot water (warm water is preferred) and use a mild cleansing agent. Some authorities suggest using bath oils; however, this increases the danger of falling in a slippery tub.

Advise against the use of hot water for bathing as well as too lengthy bathing sessions to prevent loss of oils and excessive drying of skin. Also encourage patients to consume a balanced diet including foods rich in antioxidants, vitamins, and minerals, and to consume adequate fluids. Stress safety concerns in the home such as failure to adjust the water temperature when bathing or showering or slipping on wet surfaces in the bathroom.

PTS:1DIF:Cognitive Level: Applying (Application) REF:777 OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Adaptation 16.A patient is nonEnglish speaking and unable to answer questions. When preparing to bathe this patient the nurse needs to remember which of the following? a.Use soaps which contain deodorant to help control body odor. b.Cultural heritage influences hygiene practices. c.Shave facial hair to make the patient more presentable. d.Diaphoresis will prevent skin breakdown and infection, so the patient should only be bathed once a day.

ANS: B A patients cultural beliefs and personal values influence hygiene care. Maintaining cleanliness may not have the same importance for some ethnic groups as it does for others. In some cultures, it is customary to completely bathe only once a week. Never shave facial hair or hair without the patients permission. Use only mild cleansers; avoid deodorant bars, perfumed soaps, and any products with alcohol. Clean the skin at the time of any soiling and at routine intervals. Problems such as incontinence, wound drainage, or excessive diaphoresis require more frequent cleansing to promote comfort and prevent skin breakdown and infection.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 766 | 777 OBJ: Describe factors that influence personal hygiene practices.

TOP: Nursing Process: Implementation MSC: Client Needs: Basic Care and Comfort 17.A bedridden patient with long hair may experience problems with matting. What is the most appropriate nursing action?

a.Cut the matted hair away. b.Braid the hair to reduce the tangles. c.Use a thick, commercial product to grease the hair. d.Keep the hair dry by applying powder every morning.

ANS: B Braiding helps to avoid repeated tangles. Ask permission before braiding or cutting a patients hair. Do not apply powder every morning. Moistening the hair with water or an alcohol-free detangle product makes the hair easier to comb.

PTS:1DIF:Cognitive Level: Applying (Application) REF:773 OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp and their related interventions. TOP: Nursing Process: Implementation MSC:Client Needs: Basic Care and Comfort 18. Which of the following interventions will decrease the chance of dry skin?

a.Daily baths in a soaker tub for 30 minutes b.Inadequate fluid and nutrition c.Leave moisturizing soap on the body d.Use of superfatted soap ANS: D To minimize drying of the skin use warm, not hot, water and use superfatted soap (e.g., Dove) for cleansing.

Effective treatment of dry skin does not require limiting frequency of bathing. Bathing daily for limited time (10 minutes or less) can assist with hydration. Rinse body of all soap well because residue left can cause irritation and breakdown. Use a humidifier to add moisture to air. Increase fluid intake when skin is dry. Use moisturizing lotion to aid healing process; lotion forms protective barrier and helps maintain fluid within skin.

PTS:1DIF:Cognitive Level: Applying (Application) REF:755 OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is caring for a patient who is on a heparin drip for a deep vein thrombosis (DVT). During the bath,

the nurse will wash the lower extremities using which of the following? a.Circular motion to massage the legs b.Long, firm strokes toward the heart c.Short, firm strokes toward the heart d.Short, light strokes ANS: D

In a patient with a current DVT, light short strokes are recommended. Because of the risk of dislodging a deep vein thrombosis, do not use long, firm strokes to wash the lower extremities of patients with a deep vein thrombosis or blood-clotting disorder. Use short, light strokes instead. Avoid massaging the legs.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:786 OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is assigned to assist a 59-year-old woman who has suffered a stroke and has limited mobility. The nurse is performing perineal care and understands that the best way to prevent disease transmission to the perineum is that it should be cleaned:

a.from the rectal area to the urinary meatus. b.from the urinary meatus to the rectal area. c.in a circular motion. d.only twice a day.

ANS: B Perineal care involves thorough cleansing of the patients external genitalia and surrounding skin. Skin folds may contain body secretions that harbor microorganisms. Wiping front to back reduces chance of transmitting fecal organisms to urinary meatus. Cleaning from the rectal area to the urinary meatus or in a circular motion is incorrect because this will cause cross contamination with urine, drainage or feces.

PTS:1DIF:Cognitive Level: Applying (Application) REF:786 | 787 OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Chapter 32: Oxygenation Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which term should the nurse use to best describe the movement of air in and out of the patients lungs? a. Ventilation

b.Diffusion c.Respiration d.Perfusion ANS: A The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:800 OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The nurse is educating a patient who has recently been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse explains how the gasses in the lungs move between the air spaces and the bloodstream. Which process is the nurse describing? a. Ventilation b.Diffusion c.Respiration d.Perfusion

ANS: B Diffusion is the movement of gases between air spaces and the bloodstream. One of the primary functions of the lungs includes ventilation, the movement of air in and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS:1DIF:Cognitive Level: Applying (Application) REF:800 OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The exchange of oxygen and carbon dioxide during cellular metabolism is best described as which of the following? a. Ventilation b.Diffusion c.Respiration d.Perfusion ]

ANS: C Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:800 OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 4. When giving CPR, compressions are causing the heart to pump blood into and out of the lungs to the bodys organs. This movement of oxygenated blood is best described as which of the following? a. Ventilation b.Diffusion c.Respiration d.Perfusion

ANS: D The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body. The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism.

PTS:1DIF:Cognitive Level: Applying (Application) REF:800 OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 5. The patient is experiencing shortness of breath. Which of the following lab tests indirectly indicates the oxygen level in the blood system?

a.Hemoglobin b.White blood cell count c.Electrolytes d.Creatinine ANS: A Hemoglobin transports most oxygen and serves as a carrier for both oxygen and carbon dioxide. White blood cell count is a lab test to measure infection. Electrolytes do not indicate oxygen levels but do indicate electrolytes like sodium and potassium. Creatinine levels measure kidney function.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:801 OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory ]

gases.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 6. The nurse is admitting a patient with chronic obstructive pulmonary disease (COPD). During the initial head-to-

toe assessment the patients pulse oximetry reading is 89% on room air. What is the nurses first priority? a.Administer oxygen immediately @ 4L/NC. b.Call the primary health care provider for an order for oxygen. c.Assist the patient into a recumbent position. d.Determine the patients normal pulse oximetry reading.

ANS: D

The nurse must determine what is normal for this patient. The patient has COPD and the breathing stimulus is low oxygen, not increased carbon dioxide. When caring for patients with COPD and chronically elevated PaCO 2 levels, remember that inappropriate administration of excessive oxygen will result in hypoventilation. Patients with COPD and hypercapnia (high carbon dioxide levels) have adapted to the higher carbon dioxide level. The carbon dioxidesensitive chemoreceptors are no longer sensitive to increased carbon dioxide as a stimulus to breathe. Their stimulus to breathe is a decreased PaO 2 . The most effective position for patients with cardiopulmonary diseases is the 45-degree semi-Fowlers position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm. Administering excessive oxygen to patients with COPD satisfies the oxygen requirement of the body and negates the stimulus to breathe. High concentrations of oxygen (e.g., greater than 24% to 28% [1 to 3 L/min]) prevent the PaO 2 from falling. As a result, this suppresses the stimulus to breathe, resulting in hypoventilation.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:802 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Planning MSC:Client Needs: Physiological Integrity 7.A 36-year-old patient diagnosed with meningitis has a fever of 102.3 F. A family member verbalizes a concern that the patient is breathing fast. Upon assessment, the nurse notes a respiratory rate of 20 breaths/min, pulse oximetry is 92% on 2L/O 2 , and lungs clear to auscultation. What is the best explanation for the rapid respiratory rate that the nurse can give the family member? a.He is most likely anxious because he is in the hospital.

b. His fever has increased his metabolic rate and is causing him to breathe faster.

c.He is hyperventilating because he needs more oxygen. d.He has an acid-base imbalance, which is causing him to hyperventilate.

ANS: B

An increase of 1 F in body temperature causes a 7% increase in the metabolic rate, thereby increasing carbon dioxide production. The clinical response is increased rate and depth of respiration. Anxiety is not the reason for increased respirations in this scenario. The fever (102.3 F) is the cause of the increased respirations. The patient may have increased breathing but the patient is not hyperventilating. Hyperventilation occurs when the respiratory rate is greater than 20 breaths per minute in an adult, causing an increase in carbon dioxide elimination.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:802 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue ]

oxygenation.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 8.What is the best indicator the nurse can use to determine the adequacy of a patients cardiac output? a.Stroke volume b.Myocardial contractility c.Afterload d.Cardiac index ANS: D Cardiac index is a measure of adequacy of the cardiac output. It equals the cardiac output divided by the patients body surface area. This calculation provides the caregiver with a more accurate calculation of blood flow by considering the patients body surface area. Stroke volume (SV) is the amount of blood ejected from the ventricle with each contraction. The normal range for a healthy adult is 50 to 75 mL per contraction. Myocardial contractility is the ability of the heart to squeeze blood from the ventricles and prepare for the next contraction. This is difficult to measure because preload, afterload, and heart rate must remain constant. Afterload is the resistance to the ejection of blood from the left ventricle. The left ventricular pressure must be greater than the aortic pressure to eject blood from the heart.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:803 OBJescribe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 9.A patient has been admitted to the cardiac unit with the diagnosis of bradycardia. The patient states I am confused about what the doctor said is wrong with me, he said my pacemaker is not working. I dont have a pacemaker. What is the nurses best response? a.The sinoatrial node is the pacemaker of your heart. b.Myocardial contractility determines your heart rate. c.The atrioventricular node is the pacemaker of your heart. d.The ventricular Purkinje network determines your heart rate.

ANS: A The conduction system originates with the sinoatrial node, the pacemaker of the heart. Electrical impulses are then transmitted along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulse transmission between the atria and the ventricles. Delaying the impulse at the AV node before transmitting it through the bundle of His and ventricular Purkinje network. The heart rate is regulated by the sympathetic and parasympathetic systems, not by myocardial contractility and ventricular Purkinje network. Myocardial contractility is the ability of the heart to squeeze blood from the ventricles and prepare for the next contraction. This is difficult to measure because preload, afterload, and heart rate must remain constant.

PTS:1DIF:Cognitive Level: Applying (Application) REF:803 | 804 OBJescribe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity

]

10.A 45-year-old patient was diagnosed with an anterior myocardial infarction. The patient asks the nurse why his chest hurt when he had his heart attack. What is the best response from the nurse? a.One of your heart valves wasnt working properly and caused an obstructed blood flow. b.One of your coronary arteries had a spasm, and your heart muscle wasnt able to get enough blood. c.Your heart muscle was deprived of oxygen, which caused chest pain. d.The heart muscle is sensitive to changes in electrical conduction.

ANS: C When decreased myocardial blood perfusion is extensive or perfusion is completely blocked, the tissue becomes necrotic and a myocardial infarction occurs. Angina or angina pectoris is the result of decreased blood flow to the myocardium as a result of coronary artery spasms or temporary constriction. When stenosis occurs in the aortic and pulmonic valves, the adjacent ventricles work harder to move the ventricular volume beyond the stenotic valve.

When regurgitation occurs, there is a backflow of blood into an adjacent chamber, which causes either pulmonary or systemic congestion. A dysrhythmia is a disturbance in the electrical impulse of the heart rhythm. Any rhythm not generated at the sinoatrial node is classified as such. Dysrhythmias are primary conduction disturbances that occur as a response to ischemia, valvular abnormalities, anxiety, and drug toxicity (e.g., digoxin toxicity).

PTS:1DIF:Cognitive Level: Applying (Application) REF:804 | 805 OBJescribe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 11.A patient was admitted to the surgical unit after surgical removal of an abdominal tumor. As the nurse performs a postsurgical assessment, the patients blood pressure is 90/54, heart rate is 94, and respiratory rate is 22. Based on these values, the nurse should be most concerned with which of the following conditions? a.Hypovolemia b.Left-sided heart failure c.Right-sided heart failure d.Hypervolemia ANS: A Hypovolemia is a reduced circulating blood volume resulting from extracellular fluid losses that occurs in conditions such as shock and severe dehydration. If the fluid loss is significant, the body tries to adapt by increasing the heart rate and constricting peripheral vessels to increase the volume of blood returned to the heart and increase the cardiac output. The patient is experiencing shock (low blood pressure, increased pulse and respirations). Left-sided heart failure is characterized by impaired functioning of the left ventricle. This is usually caused by increased preload (fluid volume overload) or afterload (increased systemic vascular resistance such as hypertension). Right-sided heart failure results from impaired functioning of the right ventricle, which is typically caused by pulmonary disease or pulmonary hypertension. Fluid volume overload or hypervolemia may lead to vascular congestion in patients with heart, kidney, or lung diseases. The patient has lost fluid, not gained fluid.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:805 OBJ:Identify and describe clinical outcomes as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 12.The guardians of a premature infant who was delivered at 31-weeks gestation is expected to be discharged from ]

the hospital within the next few days. The guardians have voiced concern regarding how to prevent respiratory syncytial virus (RSV) exposure to the baby. What is the best response from the nurse? a.You will need to limit the babys exposure to crowds of people. b.You need to make sure that the car seat is facing backward in the back seat of your car. c.You do not need to be concerned; the baby has a natural protection against this disease. d.You must sterilize all the bottles for the first 6 months.

ANS: A Premature infants are at risk for development of respiratory illnesses such as respiratory syncytial virus (RSV) as a result of the underdevelopment of the lung. Limiting exposure to crowds of people will limit the exposure to respiratory viruses. Premature infants do not have protection against this virus. The virus is respiratory, so the car seat and bottles will not affect this illness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:808 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 13.A 3-month-old infant is being seen for a well-child check at the pediatric clinic. The nurse is assessing the guardians knowledge level about the infants growth and development. One of the topics that the nurse has chosen to address in this session is the risk for airway obstruction. What is the main reason that the nurse has chosen this topic? a. Infants can have severe allergic reactions to food based on exposure to secondhand smoke. b. Infants are prone to lower airway infections that can become obstructive. c. Infants have a tendency to place foreign objects in their mouths. d. Infants can have airway obstruction from excessive drooling associated with teething.

ANS: C Infants and toddlers are at risk for airway obstruction because of their tendency to place a foreign object in their mouth. Infants and toddlers are at risk for upper respiratory tract infections, not allergic food reactions, as a result of frequent exposure to other children and exposure to secondhand smoke. During the teething process some infants develop nasal congestion, which encourages bacterial growth and increases the risk for respiratory tract infection, but not for airway obstruction. Infants are prone to upper respiratory tract infections, not lower airway infections, which usually are not dangerous, and infants and toddlers recover with little difficulty.

PTS:1DIF:Cognitive Level: Applying (Application) REF:808 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14.A patient who is 7 months pregnant with her first child is visiting the health care provider for her scheduled prenatal checkup. She tells the nurse that she is short of breath and fatigued. What is the best response from the nurse? a.You should have let us know immediately instead of waiting until your appointment. b.Ill make a note of it on your chart. c.That is normal; your uterus is causing pressure on your diaphragm, making it more difficult to breathe. ]

d.Oxygen is needed for you and the baby. I will give you some oxygen to help you.

ANS: C Pregnancy causes changes in ventilation. As the fetus grows during pregnancy, the greater size of the uterus pushes abdominal contents up against the diaphragm. During the last trimester of pregnancy the inspiratory capacity declines, resulting in dyspnea on exertion and increased fatigue. Letting the nurse know immediately and applying oxygen are not needed because this is a normal finding. Making a note of it on the chart does not address the patients need.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:808 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 15.A 58-year-old Caucasian woman is at the clinic for her annual check-up. She tells the nurse that she noticed her blood pressure is higher than it was when she was younger. She asks the nurse why this would happen. What is the nurses best response? a.Your race and gender are predisposing factors for heart disease. b.Well, if you stop smoking your blood pressure would go down. c.As we age, our blood vessels become less elastic, which causes higher blood pressure. d.I dont think its anything to worry about.

ANS: C Arterial vessels in the older adult become calcified and lose elastin. This may lead to hypertension and a rise in systolic blood pressure. Both of these normal changes of aging place the older adult at risk for heart failure. Do not be judgmental about smoking and the question does not indicate the female is a smoker. Males, not females, are more prone to heart disease. African-Americans, American Indians, and Mexican-Americans are at greater risk than Caucasians for developing heart disease. Telling the patient to not worry is not therapeutic.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:809 | 810 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16.A healthy 33-year-old mother of three children reports having no energy. She asks the nurse, how she could increase her energy level. What is the best response for the nurse to give? a.You should decrease iron intake. b.Daily exercise has been shown to increase a persons energy level. c.Energy caffeinated drinks are a good substitute for exercise. d.Try to exercise 90 minutes every other day.

ANS: B A physical exercise program has many benefits. People who exercise daily for 30 to 60 minutes, not 90, have a lower heart rate, lower blood pressure, decreased cholesterol, increased blood flow, and greater oxygen extraction by working muscles. Fully conditioned people are able to increase oxygen consumption by 10% to 20% because of increased cardiac output and efficiency of the myocardium. If the diet does not supply iron needed for hemoglobin ]

synthesis, RBC synthesis is reduced, and oxygen-carrying capacity decreases. A risk factor for cardiopulmonary disease is excessive use of caffeinated energy drinks.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:808 | 809 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 17.The family member of a 73-year-old patient with chronic obstructive pulmonary disease (COPD) is concerned about the patients recent weight loss. When questioned by the nurse, the patient denies any change in diet or activity, but admits to losing 10 lb in the past 6 weeks. What is the nurses best response to the family members concern? a.Maybe the patient has a higher metabolic rate than you. b.It doesnt seem fair that some people can lose weight so easily. c.This disease affects the respiratory system and causes the body to burn more calories to supply the energy to breathe. d.You need to discuss this with the health care provider so testing can be ordered for tuberculosis.

ANS: C A patient with chronic lung disease usually requires a diet higher in calories because of the increased work of breathing. Inadequate nutrition occurs when nutritional intake does not meet nutritional needs. Without essential nutrients, a patient may experience respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. One symptom of tuberculosis is rapid weight loss, which is not appropriate based on the question. The effort of breathing, not metabolic rate, is the reason for the weight loss. Saying that it doesnt seem fair does not address the family members concern.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:808 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 18.A college student who smokes asks a healthcare professional if there really is a connection between smoking and lung cancer. What is the healthcare workers best response? a.The risk for lung cancer for smokers than for nonsmokers is 5 times greater. b.The risk for lung cancer for smokers than for nonsmokers is 10 times greater. c.The risk for lung cancer for smokers than for nonsmokers is 50 times greater. d.Lung cancer affects smokers and non-smokers equally due to occupational hazards.

ANS: B The risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer in the nonsmoker and worsens other pulmonary problems such as asthma or COPD: 5 times is too small; 50 times is too great. Lung cancer does not affect smokers and nonsmokers equally PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:809 ]

OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 19.A patient on the surgical unit is 1 day postoperative for surgery to remove stomach cancer. In addition to the physiological stress this patient has undergone, the nurse recognizes that this patient will have to deal with the psychological stress of finding out that the cancer has metastasized to the liver. Which physiological change would the nurse expect to see as a response to stress? a.Decreased heart rate b.Increased hemoptysis output c.Increased respiratory rate d.Decreased cardiac output ANS: C A continuous state of stress increases the bodys metabolic rate and the oxygen demand. The body responds to stress by an increased rate and depth of respiration and increased cardiac output. Hemoptysis, bloody sputum, does not occur in stress.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:809 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 20.A 47-year-old woman with a history of diabetes and hypertension calls the clinic complaining of epigastric pain and shortness of breath with activity. She has taken antacids with no relief. What type of pain is the patient experiencing? a.Pericardial pain b.Pleuritic chest pain c.Musculoskeletal pain d.Cardiac pain ANS: D Some women have epigastric pain, complaints of indigestion, or a choking feeling and dyspnea when experiencing cardiac pain. Cardiac pain does not occur with respiratory variations. Cardiac pain is most often substernal and typically radiates to the left arm and jaw in men. Pericardial pain resulting from an inflammation of the pericardial sac is usually nonradiating and often occurs with inspiration or when leaning forward. Pleuritic chest pain is peripheral and usually radiates to the scapular regions. Inspiratory maneuvers such as coughing, yawning, and sighing aggravate pleuritic chest pain. An inflammation or infection in the pleural space usually causes pleuritic chest pain. Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes.

Inspiratory movements aggravate the pain and are easily confused with pleuritic chest pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:812 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity ]

21.A patient has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia and history of chronic obstructive pulmonary disease (COPD). During the initial assessment the nurse notes that the patient has a respiration rate of 18 with retractions, tachycardia, and complains of dyspnea and dizziness. The nurse identifies that these are clinical signs of which condition? a.Paroxysmal nocturnal dyspnea b.Orthopnea c.Hemoptysis d.Hypoxia ANS: D Dyspnea is a clinical sign of hypoxia. Dyspnea is the subjective sensation of breathlessness as perceived by the patient. Hypoxia is inadequate tissue oxygenation with a deficiency in oxygen delivery or oxygen utilization at the cellular level. Signs and symptoms of hypoxia include tachycardia, peripheral vasoconstriction, dizziness, and mental confusion. Dyspnea that occurs when a patient is sleeping is called paroxysmal nocturnal dyspnea. The patient awakens in a panic, feels as if he or she is suffocating, and has a strong need to sit up to relieve the breathlessness. Orthopnea is an abnormal condition in which a patient has difficulty breathing when lying down and has to use multiple pillows or sit to breathe. Hemoptysis is bloody sputum. It is associated with coughing and bleeding from the upper respiratory tract, from sinus drainage, or from the gastrointestinal tract.

PTS:1DIF:Cognitive Level: Applying (Application) REF:802 | 812 OBJ:Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 22.A health care worker received an annual tuberculosis test administered 56 hours ago. The injection site is very red and flat. The certified nurse who is reading the test should take which action? a.Advise the health care worker another test must be done because the test was not read within the proper time. b.Tell the health care worker the results are positive and cannot return to work. c.Document the results as a negative reaction. d.Measure the area in millimeters.

ANS: C A reddened flat area is not a positive reaction, and you do not need to measure it.

Tuberculosis skin testing positive results is a palpable, elevated, hardened area around the injection site, caused by edema and inflammation from the antigen-antibody reaction, measured in millimeters. Tuberculin skin tests are read between 48 and 72 hours so the health care worker came at the right time (56 hours).

PTS:1DIF:Cognitive Level: Applying (Application) REF:815 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 23. The nursing student is formulating a nursing care plan for a patient with pneumonia. The care plan is directed toward meeting the potential oxygenation needs of the patient. Which of the following examples would be the best way for the nursing student to write an expected outcome for the care plan? ]

a.The patient will have less pain. b.The patient will be able to breathe better. c.The patients pulse oximetry reading will remain greater than 92%. d.The patients interactions will be normal.

ANS: C All goals need to have measurable outcomes for you to be able to determine whether they have been met. These include objective data, such as oxygen saturation levels, arterial blood gas levels, laboratory findings, chest radiographs, electrocardiogram patterns, blood pressure, and pulse. Quantify subjective findings, such as the reported degree of breathlessness or pain on visual analog scales. Less pain, breathe better, and normal interactions do not include objective data, making them hard to measure.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:815 | 816 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Planning MSC:Client Needs: Physiological Integrity 24. The RN and nursing assistive personnel (NAP) are caring for six patients on the pulmonary unit. Which of the following tasks would be most appropriate for the nurse to delegate to the NAP?

a.Taking vital signs on a 56-year-old man with severe dyspnea b.Suctioning a patient with hemoptysis c.Encouraging a postoperative patient to use the incentive spirometer d.Performing chest percussion on a patient with atelectasis ANS: C Base your decision to delegate responsibility to nursing assistive personnel (NAP) on your assessment of the patient and the type of care the patient will receive. Consider which tasks are safe to delegate within the skill set of the NAP and how the patient will feel about the care that you have delegated. Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is an effective method for promoting deep breathing to prevent or treat atelectasis in the postoperative patient. Incentive spirometry encourages patients to breathe to their normal inspiratory capacities and can be delegated to a NAP. The priority is to maintain or improve the patients oxygenation and meet the patients needs. You are ultimately responsible for all the total patient care. In all the other responses the patient is experiencing difficulties that require the nurses attention: severe dyspnea (difficulty breathing), hemoptysis (bloody sputum), and chest percussion (done by nurses or respiratory therapists).

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:812 | 815 | 825 | 827 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 25.A student nurse caring for a patient with a chest tube has been asked what equipment should be at the bedside to assess for an air leak. Which information indicates the student nurse has a correct understanding of the equipment needed? a.Suction equipment wrapped in plastic to keep instrument clean b.Hemostat covered with gauze to prevent penetration of the chest tube c.Cup of water to place the end of the chest tube ]

d.Petroleum gauze to use as a dressing ANS: B Covered hemostats are used to assess for air leaks, not a cup of water, suction equipment, or petroleum gauze.

Hemostats have a covering to prevent hemostat from penetrating the chest tube. The use of these hemostats or other clamp prevents air from re-entering the pleural space. Suctioning does not determine an air leak; it is used to clear secretions. If there is a break in the chest drainage device, place the end of the chest tube in a bottle of sterile saline, not water. If a chest tube becomes dislodged apply pressure to chest tube site wound using petroleum gauze, a dry gauze dressing, and adhesive tape.

PTS:1DIF:Cognitive Level: Applying (Application) REF:839 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 26.A nurse is being oriented to work for an intensive care unit. The hemodynamic data indicate that the patient has a decreased preload. Which information indicates the nurse has a correct understanding of the concept of preload? a. It is the amount of blood ejected from the left ventricle each minute. b. It is the amount of blood in the heart at the end of ventricular diastole. c. It is the resistance to the ejection of blood from the left ventricle. d. It is the rhythmic relaxation and contraction of the heart chambers.

ANS: B Preload is the amount of blood at the end of ventricular diastole. Cardiac output is the amount of blood ejected from the left ventricle each minute. Cardiac conduction is the rhythmic relaxation and contraction of the atria and ventricles dependent on transmission of electrical impulses. Afterload is the resistance of the ejection of blood from the left ventricle.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:803 OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 27.A patient with pulmonary congestion needs to cough to clear secretions. The nurse instructs the patient to inhale and perform a series of coughs during exhalation. What type of cough did the nurse teach the patient? a.Quad b.Huff c.Cascade d.Splinting ANS: C With the cascade cough a patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. He or she then opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. A quad cough is used for patients who have a spinal cord injury and no use of their abdominal muscles. While the patient breathes out with a maximal expiratory effort, the patient or you push inward ]

and upward on the abdominal muscles toward the diaphragm, causing the cough. A huff cough stimulates a natural cough reflex. While exhaling, a patient opens the glottis by saying the word huff. Splinting occurs when the patient supports the abdomen when coughing; it is not a type of cough.

PTS:1DIF:Cognitive Level: Applying (Application) REF:823 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 28.The nurse is evaluating a patient who has a chest tube. To properly maintain chest tube function, what is the nurses best action? a.Strip the tube every hour to maintain drainage. b.Place the device below the patients chest. c.Double clamp the tubes except during assessments. d.Remove the tubing from the drainage device to check for proper suctioning.

ANS: B Observe the chest drainage system to be sure it is upright and below the level of tube insertion. Most institution have stopped stripping the chest tube because this greatly increases intrapleural pressure unless the patient is fresh from postoperative thoracic surgery or has chest trauma. Chest tubes are only clamped under specific circumstances per health care providers order or nursing policy to assess for an air leak, to quickly empty or change disposable drainage systems, or to assess if the chest tube is ready to be removed. Clamping the chest tube is not recommended because it may result in a tension pneumothorax, a life-threatening event. Removing the tubing would cause a disruption in the suctioning of the chest tube and should not be done.

PTS:1DIF:Cognitive Level: Applying (Application) REF:829 | 842 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 29.A patient presents with an acute myocardial infarction that resulted in right ventricular damage. The nurse needs to assess the patient for right-sided heart failure, which includes which of the following? a.Crackles on auscultation b.Jugular neck vein distention c.Increased myocardial perfusion d.Orthopnea ANS: B Right-sided heart failure causes distended jugular veins and peripheral edema. Right-sided heart failure results from impaired functioning of the right ventricle, which is typically caused by pulmonary disease or pulmonary hypertension. An increase in pressure in the pulmonary system causes increased resistance in the right ventricle.

The right ventricle fails as a result of this pressure. Left-sided heart failure results in crackles on auscultation and patient complaints of fatigue, dyspnea, and orthopnea. Increased myocardial perfusion does not occur.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:805 ]

OBJ:Identify and describe clinical outcomes as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 30.A patient reports chest pain. The nurse is attempting to assess the pain to differentiate the pain as cardiac, respiratory, or gastrointestinal. The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain: a.does not occur with respiratory variations. b. is peripheral and may radiate to the scapular areas. c. is aggravated by inspiratory movements. d. is nonradiating and occurs during inspiration.

ANS: A Cardiac pain does not occur with respiratory variations. Cardiac chest pain is most often substernal and radiates to the left arm and jaw in men, but some women have epigastric pain, complaints of indigestion, or a choking feeling and dyspnea. Pericardial pain results from an inflammation of the pericardial sac and is usually nonradiating and often occurs with inspiration. Pleuritic chest pain is peripheral and usually radiates to the scapular region.

Inspiratory maneuvers aggravate pleuritic chest pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:812 OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 31.A patient with a tracheostomy is experiencing thick and tenacious secretions. To maintain this patients airway, what is the most appropriate action for the nurse? a.Tracheal suctioning b.Oropharyngeal suctioning c.Nasotracheal suctioning d.Orotracheal suctioning ANS: A Tracheal suctioning is performed through an artificial airway such as a tracheostomy. Oropharyngeal suctioning clears secretions from the mouth and upper airway. Nasotracheal suctioning introduces the catheter through the naris into the trachea. Orotracheal suctioning introduces the catheter through the mouth into the trachea.

PTS:1DIF:Cognitive Level: Applying (Application) REF:824 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 32.The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations. The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves. The rate is 116 beats per minute and regular. The nurse identifies this rhythm as which of the following? ]

a. Sinus bradycardia b.Ventricular tachycardia c.Sinus tachycardia d.Normal sinus rhythm

ANS: C Sinus tachycardia is a rate between 100 and 180 beats per minute with normal P, QRS, and T waves. Ventricular Tachycardia has a rhythm slightly irregular, rate 100 to 200 beats/min, P wave absent, QRS complex wide and bizarre, greater than 0.12 sec. Sinus bradycardia is a rate less than 60 beats per minute with normal P, QRS, and T waves. Normal sinus rhythm is a rate between 60 and 100 beats per minute with normal P, QRS, and T waves.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:805 | 806 OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. On entering the room, a nurse finds the patient sitting upright in bed with the upper torso resting on the over-bed table. The nurse assesses that this patient is experiencing acute hypoxemia. Which of the following are symptoms of acute hypoxemia? (Select all that apply.)

a.Cyanosis b.Arrhythmias c.Eupnea d.Restlessness e.Diaphoresis ANS: A, B, D, E Symptoms of acute hypoxemia include changes in respiration (tachypnea, dyspnea); blood pressure (hypertension, hypotension); color (pallor, cyanosis); mental status (headache, anxiety, impaired judgment, confusion, euphoria, lethargy); motor function (loss of coordination, weakness, tremors, hyperactive reflexes, restlessness, stupor, coma [around 30 mm Hg], death); arrhythmias (tachycardia, bradycardia), diaphoresis, blurred or tunnel vision, and nausea/vomiting. Eupnea is a normal breathing rate.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:802 OBJ:Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 2. The home care nurse is admitting a patient with COPD. The primary healthcare provider has ordered O 2 /nasal

cannula at 3 L/min. To promote safety, the nurse would instruct the patient on which of the following safety measures? (Select all that apply.)

a.Place No smoking signs in all areas where oxygen will be used. b. Instruct family and visitors who smoke that they must smoke a minimum of 10 feet from the patient. c.Store tanks in a small closet, trunk of a car, or near the hot water heater. d.Oxygen tanks should stay a minimum of 6 feet from space heaters, fireplaces, and appliances with an electric motor. ]

e.Know the exit routes and where the fire extinguisher are located in the home.

ANS: A, D, E Promote safety by using the following measures: Place No smoking signs on the patients room door, over the bed, and in every room of the home where oxygen is used. Inform the patient, visitors, roommates, and all personnel that smoking is not permitted in areas where oxygen is in use.

Determine that all electrical equipment in a health facility room or patients home is functioning correctly and is properly grounded.

Know the fire procedures and the location of the closest fire extinguisher.

Check the oxygen level of portable tanks before transporting to ensure that there is enough oxygen in the tank.

Store oxygen tanks in secure holders to prevent them from being knocked over.

Store oxygen tanks 6 feet away from toys with electric motors, electric space heaters, fireplaces, electric blankets, hair dryers, or other appliances. Do not store in a trunk box or small closet.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:820 OBJescribe the effects of a patients health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3.An adult collapsed at the grocery store. Before being transported to the emergency department, an automated external defibrillator (AED) was used. The nurse remembers learning that the AED is effective in saving a life because of which factors? (Select all that apply.) a.Use of an AED strengthens the chain of survival. b.The AED can be used by nonmedical personnel. c.The AED sends heart rhythm to the closest emergency room (ER) for the physician to analyze and give orders. d.Every minute without defibrillation decreases the survival rate by 7% to 10%. e.The AED will automatically deliver a shock to the victim after announcing, Everyone stand back.

ANS: A, B, D The following is information on the use of an automated external defibrillator (AED): The automated external defibrillator (AED) is a device used to administer an electrical shock through the chest wall to the heart.

The AED has a built-in computer that assesses the victims heart rhythm and determines if defibrillation is needed.

The rescuer delivers a shock to the victim after announcing, Everyone stand back.

The AED can be used by nonmedical personnel.

Use of an AED strengthens the chain of survival. Every minute of a sudden cardiac death without defibrillation decreases the survival rate by 7% to 10% (American Heart Association, 2005).

PTS:1DIF:Cognitive Level: Applying (Application) REF:830 ]

OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

]

Chapter 33: Sleep Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A college student who is working in northern Alaska during the summer reports that he or she has an increase in difficulty sleeping since moving north. During a pre-employment physical, the patient asks the health care provider what could be causing this. The health care provider suspects the sleep disturbance is most likely because of which factor? a.Stress of the new job b. Increased daylight hours in Northern Alaska c.Physical demands of the new job d.Change in diet ANS: B Northern Alaska has extended daylight hours. Light and temperature affect all circadian rhythms, including the sleep-wake cycle. The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm. When the sleep-wake cycle becomes disrupted (e. g., by working rotating shifts), other physiological functions change as well. Stress of the new job, physical demands of the new job, and a change in diet are not the issues. The patient stated that the difficulty started when he or she moved north.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:847 OBJ: Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The health care provider is seeing a 16-year-old boy at the local clinic. The guardian is concerned about the patients lack of sleep. The guardian states that the patient goes to school, works at a part-time job until 10 PM , and then stays up doing homework until after midnight. I am worried that he is not getting enough sleep. What is the best response for the health care provider to give the patient and his guardian?

a.I dont get enough sleep either; I spend most of my time studying. b.You need to discuss this with the primary health care provider. c.Sleep deprivation can cause a person to get sick or have excessive daytime sleepiness. d.High school is a tough time in life, but Im sure he will be fine.

ANS: C Adolescents need between 8 and 9 hours of sleep each night; however, the typical teenager gets about 7 hours of sleep per night. At a time when sleep needs actually increase, the typical adolescent is subject to a number of changes that often reduce the time spent sleeping, such as the time when school starts, after-school social events, part-time jobs, and extracurricular activities. The shortened sleep time in adolescents often results in excessive daytime sleepiness (EDS), which can reduce performance in school, increase risk of accidents, increase the use of alcohol, and lead to behavior and mood problems. Sleep deprivation affects immune functioning, metabolism, nitrogen balance, protein catabolism, and quality of life. Saying, I dont get enough sleep either or You need to discuss this with the primary health care provider is not focusing on the guardians question. Saying the boy will be fine is false reassurance.

PTS:1DIF:Cognitive Level: Applying (Application) REF:849 OBJ: Compare and contrast the characteristics of sleep for different age groups. ]

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 3. During a sleep study test, the patient states, I never dreams anymore. The health care provider tells the patient

that everyone dreams, but most people forget about them upon awakening. The health care provider tells the patient that the best way to remember dreams is to do which of the following? a.Eat spicy food before going to sleep. b.Avoid caffeine in the afternoon. c.Consciously think about the dreams upon awakening. d.Become more creative.

ANS: C To remember a dream, a person must consciously think about it on awakening. People who recall dreams vividly usually awaken just after a period of rapid eye movement (REM) sleep. Personality influences the quality of dreams; for example, a creative person may have very vivid, unusual dreams, whereas a depressed person may have dreams of helplessness. Eating a large, heavy, and/or spicy meal within 3 to 4 hours of bedtime sometimes results in indigestion that interferes with sleep. Alcohol consumed in the evening has insomnia-producing and diuretic effects. Coffee, tea, cola, and chocolate contain caffeine and xanthines that cause sleeplessness as a result of central nervous system stimulation. Avoiding caffeine and becoming more creative do not increase a persons memory for dreams.

PTS:1DIF:Cognitive Level: Applying (Application) REF:849OBJescribe the normal stages of sleep.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4.A new mother has brought in her week-old infant to the health care provider for a 1-week well-baby checkup.

She is breastfeeding and has only been sleeping a couple of hours at a time during the night between feedings. She asks the nurse, When can I expect the baby to sleep through the night? What is the nurses best response? a.Are you feeling tired, maybe you are experiencing depression. b.Most children begin to sleep through the night around 3 months. c.Most children begin to sleep through the night around 6 months. d.Are you feeling tired? Maybe you are anemic?

ANS: B Infants usually develop a nighttime pattern of sleep by 3 months of age. The neonate and infant up to the age of 3 months average about 16 hours of sleep a day. A symptom of anemia or depression is fatigue, but this does not focus on the question the new mother asked about the baby sleeping.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:849 OBJ: Compare and contrast the characteristics of sleep for different age groups.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5.A 6-year-old girl is being seen at the clinic for a well-child checkup. The guardian tells the nurse that the child is having difficulty getting to sleep at night and asks for suggestions. What is the nurses best response? ]

a.You should play an active game with her like basketball to wear her out. b.It would be a good idea to save homework until right before bedtime. c.Quiet activities like reading sometimes help to settle down children her age. d.Try to delay dinner time until later to help make her sleepy.

ANS: C A 6-year-old child averages 11 to 12 hours of sleep nightly. Encouraging quiet activities usually persuades the 6- or 7-year-old child to go to bed. Playing an active game, doing homework right before bed, and delaying dinner are not quiet activities.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:849 OBJ: Discuss differences in sleep interventions for patients of different age groups.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6.A 67-year-old farmer is at the clinic because he has been sleepy during the day. Which sleep change occurs with age? a.Older adults spend more time in stage 3. b.Older adults spend more time in REM sleep. c.Older adults spend more time in falling asleep. d.Older adults spend more time in deep sleep.

ANS: C Older adults awaken more often during the night, and it takes more time for them to fall asleep. To compensate they increase the number of naps taken during the day. Older adults spend more time in stage 1 and have less stages 3 and 4 NREM sleep; some older adults have almost no NREM stage 4 or deep sleep. Episodes of REM sleep tend to shorten, and there is less deep sleep and more lighter sleep.

PTS:1DIF:Cognitive Level: Applying (Application) REF:850 OBJ: Compare and contrast the characteristics of sleep for different age groups.

TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7.A 73-year-old patient reports to the nurse about waking up early and not being able to return to sleep. The patient states, I do not go to bed until after the evening news. What is the best advice for the nurse to give this patient to encourage a good nights sleep? a.Take a nap in the afternoon. b.Go to bed earlier. c.Go to bed later. d.Take a benzodiazepine.

ANS: B Older patients become sleepier in the early evening (going to bed when the body is naturally sleepy is beneficial) and wake earlier in the morning, but still require the necessary 7 to 8 hours of sleep a day. Going to bed later ]

would not be beneficial. Research indicates that exercise is beneficial, particularly for older adults, to improve nighttime sleep. General recommendations include increasing daytime activity or exercise, not taking a nap. The use of benzodiazepines in the older adult population is potentially dangerous. Long-term use and high doses in this population have been associated with suicidal ideation.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:850 | 851 | 854 OBJ: Discuss differences in sleep interventions for patients of different age groups.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8.The nurse manager for a busy medical unit in an acute care hospital noticed a trend of complaints regarding the restful environment of the unit in the patient satisfaction reports. At the staff meeting, this issue was discussed with the staff, and they decide that the best thing to do is which of the following? a.Administer sleeping medications at 2200 hours. b.Cluster nursing activities at night. c.Turn off all alarms after 2200. d.Keep lights on in the main hallway for safety reasons.

ANS: B A challenge in the hospital is controlling noise. Because many patients spend only a short time in hospitals, it is easy to forget the importance of establishing good sleep conditions.

In the hospital setting, plan nursing care activities to avoid awakening patients. Try to schedule assessments, treatments, procedures, and routines for times when patients are awake. Perform nursing activities before the patient receives sleeping medication or begins to fall asleep. For example, you have a patient who has had surgery. Before the patient gets ready for bed, change the surgical dressing, reposition the patient, administer pain medication, and check vital signs (clustering nursing activities). Turning alarms off is a violation of safety protocols in most hospitals because of patient safety concerns. Lights on in the hallway can cause distraction to sleep patterns.

Regular use of any sleep medication leads to tolerance, and withdrawal causes rebound insomnia.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 852 OBJ: Identify factors that promote or disrupt sleep.

TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 9.A 57-year-old patient is concerned about the inability to fall/stay asleep at night. This started about 3 months ago.

The nurse asks about recent changes in lifestyle and activities of daily living. Which of the following changes is probably most responsible for the change in sleeping pattern? a.Changing to a later evening mealtime b.Using blackout blinds c. Exercising 3 hours before bed time d.Buying a new support mattress ANS: A Alterations in routine that disrupt sleep patterns include performing unaccustomed heavy work or exercise, engaging in late-night social activities, and changing evening mealtime. Eating a large, heavy, and/or spicy meal within 3 to 4 hours of bedtime sometimes results in indigestion that interferes with sleep. The physical environment ]

in which a person sleeps has a significant influence on the ability to fall and remain asleep. Exercising 2 or more hours (patient exercised 3 hours) before bedtime allows time for the body to cool and maintain a state of fatigue that promotes relaxation. A new support mattress will promote relaxation and sleep. Proper ventilation, a comfortable temperature, and a darkened (blackout blinds) or softly lit room are essential for restful sleep.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 852 OBJ: Identify factors that promote or disrupt sleep.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10.When visiting the clinic, a nurse takes the patients sleep history and notes the appearance of a deviated septum.

The nurse knows that this structural abnormality predisposes the patient to which condition? a.Narcolepsy b.Cataplexy c.Obstructive sleep apnea d.Insomnia ANS: C Structural abnormalities such as a deviated septum, nasal polyps, narrow lower jaw, or enlarged tonsils sometimes predispose a patient to obstructive sleep apnea. Insomnia is a symptom rather than the name of a disease and is common among patients suffering from depression. It is experienced by patients who have chronic difficulty falling asleep, frequent awakenings from sleep, and/or a sleep or a nonrestorative sleep. Narcolepsy is a rare central nervous system dysfunction of mechanisms that regulate sleep and wake states; during the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 852-854 OBJ: Discuss characteristics of common sleep disorders.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 11.A primary health care provider has diagnosed the patient with having a parasomnia. The patient asks the nurse to explain what that means. What is the best explanation? a.A person is unable to breathe and sleep at the same time. b. It is a sleep disorder that produces abnormal sleep movements. c. It is a rare dysfunction of the mechanism that regulates sleep and wake states. d. It is a sudden muscle weakness occuring during intense emotions.

ANS: B The parasomnias are sleep disorders that can occur during arousal from REM or partial arousal from NREM sleep.

They include sleep walking, night terrors, nightmares, teeth grinding, and bed-wetting. Narcolepsy is a rare central nervous system dysfunction of mechanisms that regulate sleep and wake states. Excessive daytime sleepiness is the most common complaint associated with narcolepsy. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day. If the cataplectic attack is severe, the patient loses voluntary muscle control and falls to the floor. Sleep apnea is a disorder in which the individual is unable to breathe and sleep at the same time.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 854 OBJ: Discuss characteristics of common sleep disorders.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity ]

12.Which of the following data are most important to assess if a patient is receiving sufficient sleep? a.Hours of sleep each night b.Sleep-wake pattern c.Whether the patient feels rested d.Number of times the patient awakens during sleep ANS: C Because sleep is a subjective experience, only the patient is able to report whether it is sufficient and restful.

Patients are your best resource for describing a sleep problem and any change from their usual sleep and waking patterns. Number of hours of sleep, sleep-wake pattern, and number times awakes while sleeping are not the most important to assess to determine effectiveness of the patients sleep, the subjective experience of the patient is the most important.

PTS:1DIF:Cognitive Level: Applying (Application) REF:855OBJ:Conduct a sleep history.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 13.A primary health care provider prescribes eszopiclone (Lunesta) for a patient. Which classification of drug will the nurse be administering to the patient? a.Benzodiazepine b.Melatonin agonist c.L-tryptophan antagonist d.Nonbenzodiazepine, benzodiazepine receptor agonist ANS: D The nonbenzodiazepine, benzodiazepine receptor agonists are newer medications that appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). Benzodiazepines are a common classification of drug used to treat sleep problems when a change in sleep hygiene is not effective. Examples of benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). A new class of drugs called melatonin agonists promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize circadian rhythm and sleep-wake cycles. Ramelteon (Rozerem) belongs to this drug class. There is no such classification as L-tryptophan antagonist. L-tryptophan is thought to promote sleep.

PTS:1DIF:Cognitive Level: Applying (Application) REF:863 OBJescribe interventions appropriate to promoting sleep for patients with various sleep disorders.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 14.A nurse is admitting a patient to the hospital. The patient admits to a history of sleep problem. Which of the following questions will help the nurse understand the severity of the patients sleep problem? a.How long does it take you to fall asleep? b.Tell me why you think you have a sleep problem. c.Have you been told that you snore loudly? d.When did you notice the problem? ]

ANS: A Severity questions include: How long does it take you to fall asleep? How often during the week do you have trouble falling asleep or staying asleep? Nature of the problem question includes: Tell me what type of problem you have with your sleep. Signs and symptoms question includes: Have you been told that you snore loudly? Onset and duration question includes: When did you notice the problem?

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:856OBJ:Conduct a sleep history.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 15.A patient recently came to the clinic with complaints of having difficulty sleeping. After the primary health care provider assesses the patient the nurse instructs the patient and partner on how to keep a sleep-wake diary. Entries in the diary often include of sleep-wake activities. a.24 hours b.72 hours c.1 to 2 weeks d.7 to 9 hours ANS: A Entries in the diary often include 24-hour information on waking and sleeping activities such as exercise, work activities, mealtimes, and alcohol and caffeine intake. They should also include time and length of daytime naps, evening and bed routines, the time the patient tries to fall asleep, time and number of awakenings, and the time of morning awakening. 72 and 1 to 2 weeks are too long, whereas 7 to 9 hours is not long enough.

PTS:1DIF:Cognitive Level: Applying (Application) REF:856OBJ:Conduct a sleep history.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16.A 45-year-old obese patient has been scheduled for cardiac bypass surgery. The nurse who is preparing the patient for surgery asks, Do you have a history of sleep apnea? This is important to know before surgery because patients with sleep apnea: a.are prone to snore after surgery and require a private room. b.who receive general anesthesia have a greater risk for airway obstruction. c.generally need additional pain medication. d.usually require sleep aids to provide more restful sleep.

ANS: B If a patient is scheduled for surgery, be sure to ask about a history of sleep apnea. Patients with sleep apnea who receive general anesthesia and pain medications after surgery have increased risk for developing airway obstruction during recovery. A private room is not necessary. Sleep apnea does not require a patient to need additional pain medication or sleep aids after surgery.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:857OBJ:Conduct a sleep history.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 17.A nurse is caring for an elderly patient with a sleeping disorder. When formulating a care plan for this patient it ]

was determined that the goal will be that the patient establishes a healthy sleep pattern. Which of the following is the best example of a measurable outcome to meet this goal? a.The patient will fall asleep more easily. b.The patient will sleep longer throughout the night. c.The patient will have less than two awakenings throughout the night. d.The patient will wake up more refreshed in the morning.

ANS: C Outcomes serve as measurable guidelines to determine goal achievement. Less than two awakenings is a measurable goal. The other responses are subjective (more easily, sleep longer, more refreshed) and do not have a measurable outcome.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 858 OBJ: Describe ways to evaluate the effectiveness of sleep therapies.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 18.The long-term care facility nurse is assessing the patients sleep environment for safety. Which finding will cause the nurse to intervene as it is an unsafe situation for the patient? a.A small night light left on in the bedroom b.All clutter removed between the bed and the bathroom c.Bed in high position with side rails up d.Call bell at the bedside for the patient to alert family members ANS: C A bed in high position with side rails up is a safety hazard. Safety precautions are important for patients who awaken during the night to use the bathroom and for those with excessive daytime sleepiness. Set beds lower to the floor to lessen the chance of the patient falling when first standing. Remove clutter, and move equipment from the path a patient uses to walk from the bed to the bathroom. If patient needs assistance in ambulating from the bed to the bathroom, make sure the call light is within the patients reach. The call light helps alert the nursing staff, not the family. A small night light is beneficial to help with vision PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:861 OBJ: Discuss differences in sleep interventions for patients of different age groups.

TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 19.A patient has been hospitalized with pneumonia. The patient has had some difficulty sleeping while in the hospital. The patient would like to avoid taking medication for sleep because there have been problems with sleeping pills in the past. Which action by the nursing assistant personnel will cause the nurse to intervene? a.Encouraging the patient to void before bedtime b.Offering to give the patient a backrub c.Giving the patient an extra blanket when cold d.Providing a warm cup of hot cocoa before bedtime ANS: D Coffee, tea, cola, and chocolate cause a person to stay awake or awaken throughout the night. Promote comfort by ]

encouraging the patient to wear loose-fitting nightwear, void before bedtime, give a relaxing back rub, and offer an extra blanket to prevent chilling when trying to fall asleep.

PTS:1DIF:Cognitive Level: Applying (Application) REF:861-863 OBJescribe interventions appropriate to promoting sleep for patients with various sleep disorders.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 20. While making night shift rounds, the nursing assistive personnel become concerned when a patient stops breathing from 1 to 2 minutes several times during the shift. The nurse informs the nursing assistive personnel that this condition is known as which of the following?

a.Cataplexy b.Insomnia c.Narcolepsy d.Sleep apnea ANS: D Sleep apnea is a disorder in which the individual is unable to breathe and sleep at the same time and has periods of apnea throughout the night. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day. Insomnias are primary disorders related to difficulty falling asleep.

Narcolepsy is a central nervous system dysfunction of mechanisms that regulate sleep and wake states.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 852-854 OBJ: Discuss characteristics of common sleep disorders.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. An older adult widow reports having problems sleeping at night and states, I miss my spouse. The nurse also recognizes that older patients:

a.are difficult to assess. b.take less time to fall asleep. c.may suffer from emotional stress or depressive mood problems. d.require less sleep than middle-age adults.

ANS: C The elderly frequently experience losses, such as retirement and death of a loved one, which may lead to emotional stress or depressive mood problems that affect sleep efficacy. Older adults have a harder time falling asleep and more trouble staying asleep than do young adults. Sleep studies on older adults show a decline in REM sleep and an increase in nighttime awakenings. It is a common misconception that sleep needs decrease with aging. Older adults still need 7 to 8 hours of sleep a day, just like middle-aged adults. Older adults are not more difficult to assess.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:857 OBJ: Compare and contrast the characteristics of sleep for different age groups.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity ]

22.A 2-year-old child in the pediatric unit resists going to sleep. To promote sleep, which is the best action for the

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nurse to take? a.Eliminate a daytime nap. b.Offer the child warm chocolate milk. c.Maintain the childs home bedtime routine. d.Allow the child to sleep longer in the morning.

ANS: C A bedtime routine (e.g., same hour for bedtime or quiet activity) used consistently helps toddlers and preschool children avoid delaying sleep. Parents need to reinforce patterns of preparing for bedtime. Reading stories, allowing children to sit in a parents lap while listening to music or praying, and coloring are routines associated with preparing for bed. Toddlers still need naps. Sleeping longer will continue to disrupt the normal routine. Chocolate can cause a person to stay awake or wake up throughout the night.

PTS:1DIF:Cognitive Level: Applying (Application) REF:861-862 OBJ: Discuss differences in sleep interventions for patients of different age groups.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23.A patients vital signs are significantly lower than normal while sleeping. The nurse understands this to be a normal finding when the patient is in what stage of the sleep cycle? a.1 b.2 c.3 d.4 ANS: D Vital signs are significantly lower in stage 4 sleep than during waking hours. During stage 1, a gradual fall in vital signs and metabolism begins; during stage 2, body functions continue to slow; during stage 3, vital signs decline but remain regular. During stage 4, vital signs significantly lower. A healthy adults normal heart rate throughout the day averages 70 to 80 beats per minute. However, during sleep the heart rate normally falls to 60 beats per minute or less, thus preserving cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:84BJescribe the normal stages of sleep.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 24.The nurse encourages a postoperative patient to get adequate amounts of sleep after discharge from the health care facility. When the patient asks why, how should the nurse respond? a.Sleep restores biological processes. b.Sleep stimulates appetite on waking. c.Sleep causes a mental and physiological calm. d.Sleep produces dreams that decrease epinephrine.

ANS: A Because the patient is postoperative, the primary reason for sleep it to help the body to heal by restoring biological processes. Sleep allows the body to restore biological processes. During deep slow-wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as ]

brain cells. Protein synthesis and cell division for the renewal of tissues also occur during rest and sleep. The basal metabolic rate is lowered during sleep, which conserves the bodys energy supply. REM sleep is important for cognitive restoration. During REM sleep patients experience rapid eye movement, fluctuation in heart and respiratory rate, increased/fluctuating blood pressure, loss of skeletal muscle tone, and increase in gastric secretions. (This is not a mental and physical calm.) During REM sleep there is increased oxygen consumption and epinephrine is released, not decreased. Sleep does not cause an increase in appetite as the metabolic rate slows down.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:849OBJ:Explain the functions of sleep.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25.A patient asks the nurse to explain how sleep occurs. The nurse explains to the patient that the physiology of sleep is a complex process. However, in simple terms, what is the nurses best response? a.Circadian sleep rhythm controls sleep. b.Sleep occurs when a persons basal metabolic rate falls. c.Sleep is a dreaming process. d.Interrelated mechanisms of the brain control wake and sleep cycles.

ANS: D The major sleep center in the body is the hypothalamus. The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control the rhythm of the sleep-wake cycle and coordinate this cycle with other circadian rhythms.

Researchers believe that the ascending reticular activating system located in the upper brainstem contains special cells that maintain alertness and wakefulness. Circadian rhythms influence the 24-hour pattern of major biological and behavioral functions such as the predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood. Sleep causes the basal metabolic rate to fall; falling of the metabolic rate does not cause sleep. Normal sleep involves two phases: nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:847 | 84BJiscuss mechanisms that regulate sleep.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 26.Which of the following bedtime snack(s) helps to promote sleep in a patient? a.Cereal and milk b.A full meal c.Chips and cola d.Coffee and toast ANS: A A bedtime snack containing protein and carbohydrates such as cereal and milk or cheese and crackers, which contain L-tryptophan, may help to promote sleep. A full meal before bedtime often causes gastrointestinal upset and interferes with the ability to fall asleep. Coffee, tea, cola, and chocolate cause a person to stay awake or wake up throughout the night.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 863 OBJ: Identify factors that promote or disrupt sleep.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

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27.A patient arrives at the ambulatory clinic for a routine physical. The nurse inquires about the patients sleep pattern. The patient has a history of sleep pattern disturbances. The nurse evaluates that the patient is sleeping better when he or she states which of the following? a.I dont take melatonin as frequently. b.I increased my alcohol consumption before bedtime. c.I decreased my activity level. d.I take more daytime power naps.

ANS: A Melatonin is a neurohormone produced in the brain that helps control circadian rhythms. It is a popular nutritional supplement in the United States used to aid sleep. The recommended dose is 0.3 to 1 mg taken 2 hours before bedtime. Alcohol interrupts sleep cycles and reduces the amount of deep sleep. Early morning and late afternoon napping interferes with sleeping. Exercise is beneficial to improve nighttime sleep.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 863 OBJ: Describe ways to evaluate the effectiveness of sleep therapies.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 28.A patient has returned from back surgery. The family has brought in the patients continuous positive airway pressure (CPAP) machine. What is the best rationale for allowing the patient to use the CPAP machine at night? a. It will keep the patient in deep levels of REM, which will decrease the need for pain medication. b. It will help decrease hospital noise that will keep the patient awake.

c.The patient needs ventilator support owing to the increased chance of postoperative respiratory complications. d.The patient needs to follow the same bedtime routine to promote a safe environment for sleep.

ANS: C These patients need ventilator support in the postoperative period because obstructive sleep apnea is linked to increased postoperative respiratory complications. After surgery the patient achieves very deep levels of REM sleep that lead to muscle relaxation and airway obstruction. In these patients the anesthesia in combination with pain medications used after surgery reduces the patients defenses against airway obstruction. Make sure that patients use their home CPAP equipment. Use pain medication carefully in these patients. Promoting the home bedtime routine is beneficial, but that is not the primary reason for using the CPAP; it is to prevent complications from surgery.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:864 OBJescribe interventions appropriate to promoting sleep for patients with various sleep disorders.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity MULTIPLE RESPONSE 1.A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, what are the most appropriate nursing interventions? (Select all that apply.) a.Straighten and change any soiled bed linens. b.Synchronize the medication, treatment, and vital signs schedule. c.Provide personal hygiene before bedtime. d.Discuss with the patient the benefits of beginning a long-term nighttime medication regimen. e.Assist the patient to use the toilet before bed. ]

ANS: A, B, C, E You will make the patient more comfortable in an acute care setting by providing personal hygiene before bedtime.

A warm bath or shower is very relaxing. Offer patients restricted to bed the opportunity to wash their face and hands. Tooth brushing and care of dentures also help to prepare the patient for sleep. Have patients void before going to bed so they are not kept awake by a full bladder. While a patient prepares for bed, help to position the patient off any potential pressure sites. Offering a back rub or massage helps relax the patient. Removal of irritating stimuli is another way to improve the patients comfort for a restful sleep. Diaphoretic patients will benefit from a cool bath and dry clothes or linens. Perform nursing activities before the patient receives sleeping medications or begins to fall asleep. Long-term nighttime medication regimen can lead to abuse and dependence and is to be avoided.

PTS:1DIF:Cognitive Level: Applying (Application) REF:864 | 865 OBJescribe interventions appropriate to promoting sleep for patients with various sleep disorders.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 2.A nurse has been temporarily assigned to the night shift. A change in this circadian rhythm may cause which of the following? (Select all that apply.) a.Anxiety b.Weight gain c.Decreased appetite d.Increased periods of sleep e.Impaired judgment ANS: A, C, E When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions change as well. For example, a new nurse who starts working the night shift experiences a decreased appetite and loses weight, not weight gain. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Decreased, not increased, periods of sleep can occur. Failure to maintain an individuals usual sleep-wake cycle negatively influences the persons overall health.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:847 OBJ: Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3.The nurse is triaging a patient for an annual check-up with the health care provider. When questioned about changes in sleep habits the patient replies, Since my spouse passed away last month, I have not been sleeping well at all. What are the most appropriate interventions for the nurse to make? (Select all that apply.) a.Speaking to the health care provider for a benzodiazepine sleeping aid b.Contacting a pastoral care professional c.Consulting with a psychiatric clinical nurse specialist d.Consulting with a clinical psychologist e.Referring the patient for evaluation to the sleep clinic ANS: B, C, D The nature of a sleep disturbance determines whether referrals to additional health care providers are necessary. For ]

example, if a sleep problem is related to a situational crisis or emotional problem, refer the patient to a psychiatric clinical nurse specialist, pastoral care professional or clinical psychologist for counseling. When chronic insomnia is the problem, a medical referral or referral to a sleep center is beneficial. Benzodiazepine can lead to tolerance, abuse, and dependence.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:860 OBJescribe interventions appropriate to promoting sleep for patients with various sleep disorders.TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

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Chapter 34: Pain Management Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A patient is admitted to the trauma unit with the diagnosis of spinal cord injury resulting from an ATV accident.

The health care provider has diagnosed the patient as a paraplegic. Which of the following is one of the most important topics for patient teaching to prevent further injury to the patient? a.Reminding him that he can be injured and not feel pain below his waist b.Suggesting that his parents purchase a motorized wheelchair to prevent arm muscle strain c.Reminding the patient to decrease fluid intake due to lack of mobility d.Reminding the patient to drink plenty of fluids to maintain hydration ANS: A Some patients such as those with spinal cord injuries are unable to sense painful stimuli. You must take special precautions to protect them from additional injury. Safety is the number one priority for this patient due to lack of sensation and movement in the lower extremities. Providing precautions against taking too much pain medication and reminding the patient to drink plenty of fluids to maintain hydration are important interventions. Determination of which type of wheelchair the patient will need would be determined by the health care team closer to discharge.

Pain processes require an intact peripheral nervous system and spinal cord. Common factors that disrupt the pain experience include trauma, drugs, tumor growth, and metabolic disorders.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:871OBJescribe the physiology of pain.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2.A graduate nurse is working for a diabetes unit. The nurse manager has prepared a very thorough orientation, which includes check-offs for taking vital signs. The nurse manager has informed the graduate nurse that their hospital has adopted the Joint Commissions pain standard and that they will be assessing five vital signs. The graduate nurse knows that the fifth vital sign is which of the following? a.Arterial blood gasses b.Blood sugar c.Blood pressure d.Pain ANS: D National and international organizations have made efforts to correct this problem. The Joint Commission (2013) has a pain standard for health care workers to assess all patients for pain on a regular basis. Many health care institutions have adopted this standard by recommending that pain be assessed as the fifth vital sign.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:874OBJ:Assess a patient experiencing pain.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3.A registered nurse working for the emergency department sees a lot of patients who seek services because of pain. The nurse is aware that pain is which of the following? a.Caused by a single physiological sensation ]

b.Caused by a specific stimulus c.Subjective d.Universally the same for everyone ANS: C Pain is more than a single physiological sensation caused by a specific stimulus. It is subjective and highly individualized. The person having pain is the only authority on it.

According to McCafferys classic definition, Pain is whatever the experiencing person says it is, existing whenever he says it does.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:870OBJ:Assess a patient experiencing pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4.A registered nurse, who has practiced for more than 20 years and has had a lot of experience caring for postsurgical patients, was questioned by a student nurse about why many nurses do not give the full amount of pain medication ordered by surgeons. The nurse replied that the literature shows that many nurses do not give the full amount of pain medication because they: a.do not believe that the patient is experiencing that much pain. b.do not want to contribute to pain medication addiction. c.believe that limiting the amount of pain medication lowers costs. d.are concerned about drug interactions with pain medication and other postsurgical medications.

ANS: B Many nurses avoid acknowledging a patients pain because of their own fear of contributing to addiction. These fears and beliefs lead to mistrust between the nurse and patient, increased patient recovery time, increased complications and mortality, increased psychological problems, and increased cost.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 874 OBJ: Discuss nursing implications for administering analgesics.

TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 5. When a person touches a hot stove, the resulting cellular damage causes a reaction that converts the stimuli into a pain impulse. What is the term for this conversion?

a.Transduction b.Transmission c.Perception d.Modulation ANS: A Transduction converts energy produced by these stimuli into electrical energy. The process begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of a pain impulse begins. Transmission is the cellular damage from thermal, mechanical, or chemical injury results in the release of excitatory neurotransmitters such as prostaglandins, histamine, bradykinin, and substance P. Perception occurs when the pain impulse ascends to the brain, the central nervous system extracts information such as location, duration, and quality of the pain impulse. Modulation occurs when a person perceives a harmful impulse, the brain releases inhibitory ]

neurotransmitters such as endogenous opioids, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA).

The neurotransmitters hinder the transmission of pain to help produce an analgesic effect.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:870 | 871OBJescribe the physiology of pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6. When a person cuts a finger, nerve impulses travel to the spinal cord along afferent peripheral nerve fibers. What is this process?

a.Transduction b.Transmission c.Perception d.Modulation ANS: B Transmission is the cellular damage from thermal, mechanical, or chemical injury results in the release of excitatory neurotransmitters such as prostaglandins, histamine, bradykinin, and substance P. These pain-sensitizing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response. The pain stimulus enters the spinal cord via the dorsal horn and travels one of several routes until ending within the gray matter of the spinal cord. At the dorsal horn substance P is released, causing a synaptic transmission from the afferent (sensory) nerve to spinothalamic tract nerves, which cross to the opposite side. Transduction converts energy produced by these stimuli into electrical energy. The process begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of a pain impulse begins.

Perception occurs when the pain impulse ascends to the brain, the central nervous system extracts information such as location, duration, and quality of the pain impulse. Modulation occurs when a person perceives a harmful impulse, the brain releases inhibitory neurotransmitters such as endogenous opioids, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA). The neurotransmitters hinder the transmission of pain to help produce an analgesic effect.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:870 | 871OBJescribe the physiology of pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 7. Pain impulses are sent to the brain, where the central nervous extracts information regarding location, duration and quality of the pain impulse. What is this process?

a.Transduction b.Transmission c.Perception d.Modulation ANS: C Perception occurs when the pain impulse ascends to the brain, the central nervous system extracts information such as location, duration, and quality of the pain impulse. Modulation occurs when a person perceives a harmful impulse, the brain releases inhibitory neurotransmitters such as endogenous opioids, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA). The neurotransmitters hinder the transmission of pain to help produce an analgesic effect. Transmission is the cellular damage from thermal, mechanical, or chemical injury results in the release of excitatory neurotransmitters such as prostaglandins, histamine, bradykinin, and substance P. These painsensitizing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response. The pain stimulus enters the spinal cord via the dorsal horn and travels one of several routes until ending within the gray matter of the spinal cord. At the dorsal horn substance P is released, causing a ]

synaptic transmission from the afferent (sensory) nerve to spinothalamic tract nerves, which cross to the opposite side. Transduction converts energy produced by these stimuli into electrical energy. The process begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of a pain impulse begins.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:870 | 871OBJescribe the physiology of pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. When a person accidentally touches a hot pan, their protective reflex causes them to immediately withdraw their

hand from the hot pan. This protective reflex is known as which of the following? a.Transduction b.Transmission c.Perception d.Modulation ANS: D

Modulation is a protective reflex response also occurs with pain. When a person is injured, a noxious stimulus from the skin travels along sensory neurons to the dorsal horn of the spinal cord where it synapses with spinal motor neurons. The impulse continues to travel along the spinal nerve to the skeletal muscle, causing the person to withdraw from the source of the pain. Perception occurs when the pain impulse ascends to the brain, the central nervous system extracts information such as location, duration, and quality of the pain impulse. Transmission is the cellular damage from thermal, mechanical, or chemical injury results in the release of excitatory neurotransmitters such as prostaglandins, histamine, bradykinin, and substance P. These pain-sensitizing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response. The pain stimulus enters the spinal cord via the dorsal horn and travels one of several routes until ending within the gray matter of the spinal cord. At the dorsal horn substance P is released, causing a synaptic transmission from the afferent (sensory) nerve to spinothalamic tract nerves, which cross to the opposite side. Transduction converts energy produced by these stimuli into electrical energy. The process begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential.

Once transduction is complete, transmission of a pain impulse begins.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:870 | 871OBJescribe the physiology of pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 9. The patient who has undergone triple cardiac bypass surgery 1 week ago is being seen for a follow up appointment at their health care facility. The incisions are healing well, but the patient is complaining of pain at the incision sites on his legs. The nurse knows that this is pain.

a.acute b.chronic/persistent noncancer c.chronic episodic d.idiopathic ANS: A Acute pain is protective, usually has an identifiable cause, is of short duration, and has limited tissue damage and emotional response. It is common after acute injury, disease, or surgery. Acute pain warns people of injury or disease; thus it is protective. It eventually resolves after the damaged tissue heals. Chronic/persistent noncancer pain is prolonged, varies in intensity, and usually lasts longer (typically at least 6 months) than is typically expected or predicted . It does not always have an identifiable cause and leads to great personal suffering. ]

Examples of chronic noncancer pain include arthritis, low back pain, myofascial pain, headache, and peripheral neuropathy. Chronic episodic pain is pain that occurs sporadically over an extended period of time is episodic pain.

Pain episodes last for hours, days, or weeks. Examples are migraine headaches and pain related to sickle cell crisis.

Idiopathic pain is chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition. An example of idiopathic pain is complex regional pain syndrome (CRPS).

PTS:1DIF:Cognitive Level: Applying (Application) REF:873 | 874OBJ:Assess a patient experiencing pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10.A student nurse is caring for an elderly patient with rheumatoid arthritis. The patient states that he or she experiences constant pain, is having difficulty sleeping, and has lost weight over the past 2 months. The patient is very tearful and states, Im not sure how long I can keep going with this pain. What is the most important question for the student nurse to ask the patient? a.Have you started a new diet? b.Have you ever thought of suicide? c.What are you taking for your pain? d.Do you take naps during the day?

ANS: B Chronic pain affects a patients activity (eating, sleeping, hygiene, social interactions), thinking (confusion, forgetfulness, helplessness), or emotions (anger, depression, irritability, frustration) and quality of life and productivity. The incidence of depression is very high in patients with chronic pain. They experience many losses, such as their ability to enjoy life, to be in control, to work, to socialize, and to be independent. Suicidal thoughts are relatively common; therefore you need to routinely assess for suicidal tendencies.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:872 | 876OBJ:Assess a patient experiencing pain.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 11.An older adult nurse has been seeing a rheumatologist for the management of Rheumatoid Arthritis (RA). The patient also uses herbal remedies and seeks acupuncture for pain relief and reads the latest research regarding RA. This coping style is best described as a(n) loci of control. a.external b.interior c.internal d.exterior ANS: C Patients with internal loci of control perceive themselves as having personal control over their environments and the outcome of events. They ask questions, desire information, and like having choices for treatment. Patients with external loci of control perceive other factors in their environments such as nurses as being responsible for the outcome of events. These patients tend to be less demanding, follow directions, and are more passive in managing their pain. They want specific instructions but become anxious if you give them too much information. Interior and exterior loci are not a copying style. ]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:876OBJ:Assess a patient experiencing pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12.A student nurse is assessing the pain of a teenage patient with cancer. The student nurse ask the patient about precipitating factors, quality, relieving factors, where the pain is, the severity of pain, and the effect of the pain has on the patient. What is the other indicator that the student nurse should make part of this pain assessment? a.Medications the patient is taking for pain b.Timing of the pain c.Side effects of the patients chemotherapy d.The patients ability to take oral pain medication ANS: B The comprehensive assessment of pain aims to gather information about the cause of a persons pain and determine its effect on his or her ability to function.

Palliative or provocative factors What makes your pain worse or better?

Quality How do you describe your pain?

Relief measures What do you take at home to gain pain relief?

Region (location) Show me where you hurt.

Severity On a scale of 0 to 10, with 10 being worst, how bad is your pain now?

Timing (onset, duration, and pattern)Is your pain constant, intermittent, or both?

U (effect of pain on patient)What are you not able to do because of your pain?

PTS:1DIF:Cognitive Level: Applying (Application) REF:877 | 87BJ:Assess a patient experiencing pain.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 13.A patient has a morphine sulfate patient controlled analgesia (PCA) to control postoperative pain. When the nurse enters the room, the patient complains of pain. The nurses first response is which of the following? a.Stop the infusion. b.Call the physician or health care provider immediately. c.Ask the patient to describe the pain. d.Speak to the patient in a calming tone to reduce anxiety.

ANS: C Nurses need to assess the patient first. Next, assess the lines, catheter, and infusion pump. Notify the physician or health care provider or follow protocols should a problem exist. Speaking in a calm voice demonstrates caring behavior.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 897 OBJ: Discuss nursing implications for administering analgesics. ]

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14.A patient in sickle cell crisis states that the pain is lessened when watching television. The patients physiological response is best attributed to which of the following? a.The perception of pain b.Nociceptor stimulation c.A negative protective reflex response d.The application of the gate control theory ANS: D The gate control theory gives you a way to understand pain-relief measures. The gate control theory of Melzack and Wall (1996) suggests that gating mechanisms along the central nervous system can regulate and possibly block pain impulses. The gating mechanism occurs within the spinal cord, thalamus, reticular formation, and limbic system. Closing the gate is the basis for nonpharmacological pain-relief interventions. The gate control theory suggests the importance of psychological variables (thoughts and feelings) and physiological sensations in the perception of pain. Pain is perceived in the central nervous system (CNS). The CNS extracts information such as location, duration, and quality. Nociceptors, the receptors that respond to harmful stimuli, convert the original stimuli into a pain impulse (transduction). A positive protective response occurs with pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:872 OBJ:Explain how the gate control theory relates to the selection of nursing therapies for pain relief.TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 15. According to established standards, nurses must frequently assess patients experiencing pain. The most

appropriate action for the nurse to take when assessing a patients pain is which of the following? a.Ask what precipitates pain. b.Question the patient about the location of the pain. c.Offer the patient a pain scale to objectify the patients response. d.Use closed-ended questions to find out about the patients sensations.

ANS: C

One of the most subjective and therefore most useful characteristics for reporting pain is its severity or intensity.

Nurses use a variety of pain scales to help patients communicate pain intensity. Asking what precipitates pain helps the nurse to plan interventions. Location of the pain is part of the PQRSTU. The use of the pain scale is subjective and will assist the nurse in implementing a plan of care. Closed-ended question does not encourage an open dialogue to discuss the patients pain.

PTS:1DIF:Cognitive Level: Applying (Application) REF:879 | 880OBJ:Assess a patient experiencing pain.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. An adult patient has just undergone surgery for repair of a torn left knee anterior cruciate ligament (ACL).

When informing the patient of several pain relief interventions, the nurse most appropriately urges the patient to select which of the following?

a.NSAIDs b.Nonopioids c.Adjuvant therapy ]

d.Patient-controlled analgesia pain management ANS: D In patient-controlled analgesia (PCA), patients benefit from having control over their pain therapy. Patientcontrolled analgesia (PCA) is a safe method for a variety of painful conditions, including but not limited to postoperative, traumatic, sickle cell crisis, cancer, and burns. NSAIDs are nonsteroidal anti-inflammatory agents, which are effective in treating mild to moderate pain. NSAIDs act by inhibiting synthesis of prostaglandins and by inhibiting the cellular responses during inflammation. Adjuvants or coanalgesic agents, such as sedatives, anticonvulsants, steroids, antidepressants, antianxiety agents, and muscle relaxants, have analgesic properties, enhance pain control, or relieve symptoms.

PTS:1DIF:Cognitive Level: Applying (Application) REF:889-891 OBJescribe interventions for the relief of acute pain following operative or medical procedures.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 17.A smiling and cooperative patient complains of severe pain. Nurses caring for patients who report pain need to recognize and avoid common misconceptions and myths about pain. To properly care for patients in pain, nurses need to remember which of the following? a.Chronic pain is psychological in nature. b.Patients are the best authority of their pain experience. c.Regular use of narcotic analgesics leads to drug addiction. d.The amount of tissue damage is reflected in the severity of the pain perceived.

ANS: B Chronic pain is prolonged, varies in intensity, and usually lasts longer (typically at least 6 months) than is typically expected or predicted. It does not always have an identifiable cause and leads to great personal suffering. Examples of chronic noncancer pain include arthritis, low back pain, myofascial pain, headache, and peripheral neuropathy.

Health care providers are usually less willing to treat chronic pain with opioids, although a policy statement supports the use of opioids for it. Common biases and misconceptions about pain include administering analgesics regularly leads to patients tolerance and drug dependence. Another common misconception is that the amount of tissue damage in an injury accurately indicates pain intensity. Nurses need to discourage patients from having multiple health care providers for treating pain and refer them to specialists. Pain centers use nonpharmacological and pharmacological strategies for a holistic approach to pain management.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 873 OBJ: Discuss common misconceptions about pain.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18.A patient with developmental disabilities and poor verbal communication skills has been admitted for observation after a motor vehicle accident. The patient has been moaning, facial grimacing, and restless since being admitted to the floor. The nurse needs to first assess the patient for which of the following? a.Safety, because the patient will not use the call light b.Hydration, because the patient is not able to verbally communicate his or her needs c.Bathroom privileges, because of lack of communication skills d.Pain, because the patient is unable to communicate effectively ANS: D

]

Patients unable to communicate effectively often require special attention during assessment. Some examples are the following: Infants and children Patients who are critically ill and/or unconscious Patients with dementia Patients who are mute or aphasic Patients with an intellectual disability Patients at the end of life These patients all require different assessment approaches. However, be alert for subtle behaviors that indicate pain. Note a patients vocal response (e.g., moaning, crying, gasping), facial movements (e.g., grimacing, clenched teeth, tightly closed eyes), and body movements (e.g., restlessness, increased hand and finger movements, pacing), or inactivity. While the other responses are appropriate, the patient is currently exhibiting signs of pain, making it the priority.

PTS:1DIF:Cognitive Level: Applying (Application) REF:879OBJ:Identify components of the pain experience.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19.Aspirin and ibuprofen are classified as: a.narcotics. b.nonopioids. c.opioids. d.nonsteroidal antiinflammatory analgesics.

ANS: B The most common method of pain relief is analgesics. There are three types of analgesics: (1) nonopioids, including acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs); (2) opioids (traditionally called narcotics); and (3) adjuvant or coanalgesics, a variety of medications that enhance analgesics or analgesic properties that were originally unknown. Nonselective NSAIDs such as aspirin and ibuprofen provide relief for mild-to-moderate acute intermittent pain such as that from headache or muscle strain.

PTS:1DIF:Cognitive Level: Applying (Application) REF:889 OBJescribe applications for use of pharmacological pain therapies.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 20.A terminally ill patient with cancer is experiencing increased pain. Nursing implications used to care for this patient include which of the following? a.Giving medications as needed b.Using the World Health Organization three-step approach c.Using a holistic approach to pain management d.Holding regular doses to prevent life-threatening side effects ANS: B ]

Administering analgesics to treat cancer-related pain requires applying principles different from those used to treat acute pain. The WHO (1990) has recommended a three-step approach to managing cancer pain. Therapy begins with NSAIDs and/or adjuvants and progresses to strong opioids if pain persists. Side effects of opioids such as nausea and constipation are treated aggressively so patients are able to continue using them. Patients usually become tolerant to their side effects, with the exception of constipation. For patients with cancer the aim of drug therapy is to anticipate and prevent or minimize pain. Therefore it is necessary to give required analgesic dosages regularly, even when pain subsides. Regular administration maintains blood levels for ongoing pain control.

PTS:1DIF:Cognitive Level: Applying (Application) REF:893 | 895 OBJifferentiate the nursing implications associated with managing cancer pain versus noncancer pain.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 21.A patient is started on morphine via patient-controlled analgesia (PCA) to control persistent cancer pain. The nurse knows that to prevent central nervous system (CNS) depression the patient should do which of the following? a.Monitor IV site for patency. b.Monitor the patient closely for the 15 minutes. c.Record baseline blood pressure and respiratory rates before the start of the medication. d.Give a small dose of naloxone prior to starting the morphine.

ANS: C Another measure for treating severe persistent cancer pain is morphine given by continuous IV drip or intermittently by a PCA pump. When a patient starts on IV morphine, you need to prevent overdose and central nervous system depression. Record baseline blood pressure and respiratory rates before the infusion begins.

Monitor the patient closely for the first hour of the infusion and then according to agency policy. If the patients blood pressure or respirations decrease, reduce the infusion rate according to the health care providers order or agency policy. Small IV doses of naloxone can be ordered for severe respiratory depression and to increase respiratory rate and depth but not to reverse the pain relief PTS:1DIF:Cognitive Level: Applying (Application) REF: 895 OBJ: Evaluate a patients response to pain therapies.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 22.The hospice nurse is assessing the patient at home for the first time. The patient has a lot of questions regarding what the role hospice will have as the illness progresses. The patient states, I dont want to be in pain and kept alive, but Im not ready to die either. What is the best response that will educate the patient of the role hospice will play in his or her care? a.Hospice will make sure you are pain free, how long you live is up to you and the doctor. b.Hospice focuses on the quality of life, including pain management, rather than how long you will live. c.Hospice will give you enough pain medication to keep you pain free. This is a higher priority than quality of life. d.Hospice allows you time to get your affairs in order.

ANS: B Hospice programs care for the terminally ill by helping patients continue to live at home in comfort and privacy with the help of a health care team. The emphasis is on quality of life over quantity, and pain control is a priority.

Under the guidance of hospice nurses, families learn to monitor patients symptoms and become the primary caregivers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) ]

REF: 896 OBJ: Evaluate a patients response to pain therapies.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1.A patient presents to the emergency department with a large leg laceration received in a bicycle accident. The nurse knows that the physician or health care provider chose a local anesthetic because of which of the following?

(Select all that apply.) a.The patient appears very apprehensive. b.It has very few side effects. c.The potential for hemorrhage precludes the use of IV anesthesia. d. It produces temporary loss of sensation by inhibiting nerve conduction. e. It allows sedative effects to calm the patient.

ANS: B, D Health care providers use local anesthetic (e.g., lidocaine, bupivacaine, ropivacaine) during brief surgical procedures such as removing a skin lesion or suturing a wound. The drugs produce temporary loss of sensation by inhibiting nerve conduction. Local anesthetics also block motor and autonomic functions, depending on the amount used and the location and depth of an injection. Smaller sensory nerve fibers are more sensitive to local anesthetics than large motor fibers. Thus a patient loses sensation before losing motor function; conversely motor function returns before sensation. Local anesthetics cause side effects, depending on their absorption into the circulation.

Itching or burning of the skin or a localized rash is common after topical applications. Apprehension can be alleviated when a nurse uses guided imagery. This patient is a candidate for local anesthesia because a specific body part needs to be localized. Epidural Analgesia has the occurrence of minimal sedation.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:891 | 892 OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The student nurse is working on the surgical floor. The student nurse is assigned to take care of a patient with

hemiplegia and communication deficits from a previous stroke. The patient is 1-day postoperative from abdominal surgery. Which of the following interventions would promote comfort and help the patient remain pain free?

(Select all that apply.) a.Keep the bed sheet wrinkle free. b.Only change wet dressings or bed linens once a shift. c.Remove noxious stimuli from the room. d.Continue to use the establish pain scale for this patient. e.Give pain medication after ambulation down the hall.

ANS: A, C, D One simple way to promote comfort is to remove or prevent painful stimuli. For example, tighten and smooth wrinkled bed linen and be sure to position patients off tubing and other equipment. Change wet dressings or bed linen immediately. Removing noxious stimuli is especially important for patients who are immobile. You can prevent pain by anticipating painful activities (e.g., ambulation, turning). Before performing a procedure, consider the patients condition, aspects of the procedure that are painful, and ways to avoid causing pain. Always use an established pain scale to promote accurate assessment of pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:887

]

OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The patient is being seen for chronic back pain. The patient states, Im always in pain, and I dont like taking the

pain medication because it makes me sleepy. I have to work to support my family. The nurse is aware that this patient may be a candidate for cutaneous stimulation. Cutaneous stimulation includes which of the following?

(Select all that apply.) a. TENS unit

b.NSAIDs c.Massage d.Yoga e.Ice bags

ANS: A, C, E Cutaneous stimulation of the skin helps to relieve pain. A massage, warm bath, ice bag, and transcutaneous electrical nerve stimulation (TENS) are simple ways to reduce pain perception. How cutaneous stimulation works is unclear, but it may cause release of endorphins, thus blocking transmission of painful stimuli. NSAIDs are nonsteroidal anti-inflammatory drugs that can help relieve chronic back pain through pharmaceutical therapy. Yoga is used as a diversional or holistic therapy.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:887 | 888 OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

]

Chapter 35: Nutrition Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A patient who has high cholesterol asks the nurse if there is a need to limit all fat in the diet to lower cholesterol.

What is the nurses best response? a.You should limit the amount of monounsaturated fats. b.You should limit the amount of unsaturated fatty acids. c.You should limit the amount of saturated fats. d.You should not limit the amount of any kind of fat.

ANS: C Ingestion of saturated fatty acids appears to increase blood cholesterol levels. Monounsaturated fatty acids appear to lower blood cholesterol levels. Ingestion of unsaturated fatty acids has a minimal effect on blood cholesterol.

Saturated fats should be limited to lower cholesterol.

PTS:1DIF:Cognitive Level: Applying (Application) REF:906 OBJ:Explain the significance of saturated, unsaturated, and polyunsaturated lipids in nutrition.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2.The nurse who works on the oncology unit understands the importance of nutrition and the disease process.

Which patient should the nurse be most concerned about from a nutritional standpoint? a.A patient with cervical cancer b.A patient with liver cancer c.A patient with prostate cancer d.A patient with colon cancer ANS: B Absorbed nutrients are carried to the liver, where major metabolic processes occur. The liver also regulates energy through its control of glucose metabolism. Glucose is the primary fuel for the body. The liver and muscles store glucose in the form of glycogen via a process called glycogenesis . The prostate does not contribute to the digestion system. Cervical cancer does not contribute to digestion but does affect the reproductive system. The colon is used to eliminate solid waste material from the body.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:907 OBJ: Identify nutritional problems and describe a patient at risk for these problems.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3.A 14-year old patient with cancer is concerned about diet, and questions the need for vitamins to supplement the diet. The patient states, I dont think my diet alone is providing the upper intake levels (ULs) of vitamins that I need. What is the best response from the nurse? a.You should try to get your vitamins from food, rather than a supplement. b.You should be trying to achieve the recommended dietary allowances (RDA). ]

c.You should compare your diet to the UL for children, not the UL for adults. d.You shouldnt worry about vitamins as long as you are getting enough calories.

ANS: B The tolerable UL is the highest level that likely poses no risk for adverse health events. It is not a recommended level of intake. There are four components to the DRIs: estimated average requirement (EAR), recommended dietary allowances (RDAs), adequate intakes (AIs), and tolerable upper intake levels (ULs). The EAR is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gender. The RDA is the average needs of 98% of the population, not the exact needs of an individual. The AI is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes by groups and is provided when there is insufficient evidence to set an RDA. You shouldnt worry is false reassurance and should not be used. The patient needs to be educated on not using the ULs as a measure of intake, not that vitamins from food are better than supplements.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:90BJ:Explain dietary guidelines.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4.A student nurse is completing a community health rotation. One of the clients is a pregnant teen. The student nurse has been teaching the client about infant nutrition. Which statement indicates to the student nurse that the client needs additional teaching? a.Breast milk is all my baby will need for the first 4 to 6 months. b.Breast milk should be the major source of nutrition for the first year. c.My baby wont need as many calories per kilogram as I will. d.Breastfeeding my baby will decrease the chances for food allergies.

ANS: C The baby needs more calories than the mother, so this misinformation needs to be clarified. The woman who is lactating needs 500 kcal/day above the usual allowance because the production of milk increases energy requirements. Infants need an energy intake of approximately 108 kcal/kg of body weight in the first half of infancy and 98 kcal/kg in the second half. Infants need about 100 to 120 mL/kg/day of fluid because a large portion of total body weight is water. The American Academy of Pediatrics recommends breast milk or formula as the major source of food for up to 1 year in age. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The benefits of breastfeeding include reduced food allergies and intolerances, fewer infant infections, and easier digestion. In addition, breast milk is convenient, fresh, always the correct temperature, and economical, because it is less expensive than formula. Infants should not have regular cows milk during the first year of life. Infants receiving cows milk have been found to have lower intakes of iron, linoleic acid, and vitamin E; and excessive amounts of sodium, potassium, and protein.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:910 OBJ:Establish a plan of care to meet the nutritional needs of a patient.

TOP:Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 5.A nurse is asked how many kilocalories per gram (kcal/g) carbohydrates and protein can provide. How should the nurse reply? ]

a.2 kcal/g b.4 kcal/g c.9 kcal/g d.12 kcal/g ANS: B Carbohydrates and protein are sources of energy, each providing 4 kilocalories per gram (kcal/g). Lipids are a source of energy, providing 9 kcal/g. Two kcal/g is too small; 12 kcal/g is too high.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:905 OBJ: List the end products of carbohydrate, protein, and lipid metabolism.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. Which information from the patient indicates teaching by the nurse was successful about the vitamin that is

synthesized in the intestine? a. It is vitamin A. b. It is vitamin B 6 . c. It is vitamin K. d. It is vitamin D.

ANS: C The body is unable to synthesize vitamins in the required amounts and depends on dietary intake. The exception to this is vitamin K, which the body synthesizes by bacteria in the intestine. In addition, the body produces vitamin D as a response to sunlight exposure. Vitamin A and B 6 must be obtained from the diet.

PTS:1DIF:Cognitive Level: Applying (Application) REF:906OBJ:Explain dietary guidelines.

TOP:Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 7. The patient has been admitted to the cardiac unit with a diagnosis of heart failure. The patient is currently

receiving furosemide (Lasix) and is on a low-sodium diet. Which of the following is the best way for the nurse to determine if the patient is retaining fluid? a. Figuring the patients body mass index b.Calculating the patients ideal body weight c.Recording daily weights during hospitalization d.Measuring all fluid intake

ANS: C Serial measures of weight over time provide more useful information than one measurement. When collecting serial measurements of weight, weigh the patient about the same time each day, on the same scale, and with the same amount of clothing. In some patients, a weight change of 2 pounds in 24 hours is significant because 1 pound is roughly equivalent to 500 mL of fluid. Ideal body weight is a standard for height-weight relationships, not fluid.

Body mass index is a standard for weight and body fat, not fluid. Measuring all fluid intake does not include the whole picture because this must be related to the output to determine if the patient is retaining fluid. ]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:915 OBJ:Establish a plan of care to meet the nutritional needs of a patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. The patient was admitted with the diagnosis of a stroke. The patient experiences dysphagia and right side

paralysis and needs assistance with activities of daily living (ADLs). The nurse caring for the patient has assigned the task of feeding the patient to the new nursing assistant personnel (NAP), and is concerned about aspiration. The nurse knows additional teaching is necessary when NAP states which of the following? a.I will remind the patient to tilt the head backward when drinking fluids. b.Thin fluids like water and fruit juice will need to be thickened. c.I need to watch for pocketing food as I feed the patient. d.It will take much longer to feed the patient than it did before the stroke.

ANS: A Remind the patient to not tilt head backward when eating or while drinking because this may cause food and liquid to be misdirected into the airway. Thin liquids such as water and fruit juice are difficult to control in the mouth and pharynx and are more easily aspirated so these need to be thickened. It will take much longer to feed and pocketing food are both correct.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:933 | 934 OBJ: Discuss methods for feeding patients who require assistance with oral intake.

TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 9.A 34-year-old mother delivered her third child 1 year ago. She tells the nurse that her New Years resolution is to lose the 15 pounds that she gained with this pregnancy over the next month. Which of the following is the best statement that the nurse can make to help the patient achieve her weight loss goal? a.I dont think you need to lose the weight; you look fine as you are. b.The weight will come off by itself because you are breastfeeding. c.Lets talk about giving yourself a realistic timeframe to lose it. d.That is a realistic, healthy goal for you to have.

ANS: C Helping the patient set a realistic time frame will be most therapeutic. Patients often have unrealistic expectations about nutritional needs or dieting in reference to weight gain or loss. Help patients understand this concept by asking them to reflect on their rate of weight gain or loss. Changes in weight usually occur over months or years unless an acute illness has occurred. I dont think you need to lose the weight is the nurses opinion and is not therapeutic. The child is 1 year old, breastfeeding probably is not occurring, and it is not an accurate statement. It is not healthy or realistic to lose weight fast; recommended weight loss is to 1 lb per week.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:921 OBJ:Establish a plan of care to meet the nutritional needs of a patient. ]

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 10.A patient wants to lose 17 pounds. The nurse is aware that the most successful long-term weight loss programs are which of the following? a.Programs that get the weight off quickly b.Programs that include awareness of portion sizes c.Programs that focus on reducing bad carbohydrates d.Programs that use purchased premeasured food ANS: B A successful weight-loss plan involves sustainable lifestyle modifications that include physical activity, selfmonitoring, portion control, and knowledge of energy content of food. Getting the weight off quickly is not healthy. The Dietary Approaches to Stop Hypertension has shown to reduce blood pressure and focuses on reducing the bad cholesterol, not the bad carbohydrates. There is a lack of good evidence evaluating the effectiveness of commercial weight-loss programs.

PTS:1DIF:Cognitive Level: Applying (Application) REF:907 | 908 | 921 OBJ: Explain the importance of a balance between energy intake and output.

TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 11.A patient with head trauma is scheduled for a gastrostomy tube to be inserted. The spouse asks the nurse why an intravenous (IV) cannot be used. What is the nurses best response? a.The gastrostomy tube will allow us to give medications as well as feedings. b.Research has shown that a gastrostomy tube is safer for patients and maintains function of the gut. c.It will be more expensive in the long run to use a gastrostomy tube than an IV. d.The gastrostomy placement is noninvasive, and the patient will be more content being fed through the stomach.

ANS: B Research has demonstrated a beneficial effect of enteral nutrition over parenteral routes in patients with a functional GI tract. Therefore enteral feeding is preferred over parenteral nutrition (intravenous nutrition) because it improves use of nutrients, is generally safer for patients, maintains structure and function of the gut, decreases the risk for infection and sepsis, and is less expensive, not more expensive. Medications can also be given through an IV, so this does not answer the spouses question. The gastrostomy placement is invasive as the tube is inserted directly into the stomach.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:926 OBJ: Discuss methods for feeding patients who require assistance with oral intake.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12.A patient is receiving intermittent enteral tube feedings. When introducing a feeding to this patient, what is the first thing the nurse needs to do? a.Place the patient in a supine position. b.Irrigate the tube with normal saline. ]

c.Check to see that the tube is in the proper position. d.Introduce a small amount of fluid into the tube before the tube feeding.

ANS: C The first step is verify tube placement; feedings instilled into a misplaced tube can cause serious injury or death.

You will place the patient in Fowlers or high-Fowlers position, not supine, before starting the feeding. After checking for residual, flush the feeding tube with 30 mL of water, not normal saline. Fluid is not inserted until placement is verified.

PTS:1DIF:Cognitive Level: Applying (Application) REF:924 | 942 OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13.A new mother is breastfeeding her infant. The nurse asks the mother if she is getting the correct amounts of dietary reference intakes. Which statement from the mother indicates a correct understanding of dietary guidelines? a.I am not concerned about dietary guidelines or a strict diet. b.I am taking the vitamin doses according to the television advertisements. c.I am only taking one multiple vitamin a day and eating whatever I want. d.I am eating the correct amount of food according to the recommended dietary allowances and adequate intakes.

ANS: D When the mother said recommended dietary allowance, it indicated that she knew about the RDAs and the adequate intakes indicates she knew about the AI. In 1997 the Food and Nutrition Board of the National Institute of Medicine/National Academy of Sciences, in partnership with Health Canada, initiated dietary reference intakes (DRIs) in response to the increased public use of nutritional supplements. There are four components to the DRIs: estimated average requirement (EAR), recommended dietary allowances (RDAs), adequate intakes (AIs), and tolerable upper intake levels (ULs). Saying, I am not concerned about dietary guidelines or taking vitamin according to the television advertisements and eating whatever I want does not indicate a correct understanding of the DRIs. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:90BJ:Explain dietary guidelines.

TOP:Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 14.A patient presents to an ambulatory care clinic reporting a lack of energy and tiredness. One of several assessments the nurse wants to make is a diet history. To perform a home diet history the nurse instructs the patient to keep a journal of which of the following? a.All food for the last 5 days b.Only solid food for 3 days c.All food for 3 days, including one weekend day d.Only solid food for 3 days, including one weekend day ANS: C The home diet history is conducted over a 3-day period of time, including one weekend day. All food ingested is measured. Three-day food records require the use of measuring cups and scales. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF: 912 OBJ: Discuss the major areas of nutritional assessment.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 15.A nurse is caring for a patient who is receiving intermittent gravity feedings through a gastrostomy tube. The patient experiences abdominal discomfort. Which action is best for the nurse to take? a.Cool the formula. b.Readjust the tube. c.Decrease the administration rate. d.Increase the concentration of the formula.

ANS: C Gradual emptying of tube feeding by gravity reduces risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. It is the patients meal and should be delivered in the amount of the time a well-tolerated meal is eaten. Feedings should be at room temperature. Cold formula causes gastric cramping and discomfort. Always determine tube placement, not readjustment, before beginning tube feedings. Always administer feedings as prescribed to ensure that the patient is receiving the ordered nutrients. Increasing the concentration of the formula will cause the patient to receive an inappropriate amount.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:942 | 944 OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16.A patient needs nutritional counseling after a myocardial infarction to assist in reducing cholesterol level. The nurse would recommend that the patient should eat foods that are high in which type of fat? a.Animal fat b.Trans fat c.Triglyceride fat d.Vegetable fat ANS: D Most vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids, which have a minimal effect on blood cholesterol. Animal fats are high in saturated fatty acids, which increase blood cholesterol.

Approximately 98% of all lipids in food and 90% of all lipids in the human body are in the form of triglycerides, which have been linked to cardiovascular disease. Trans fatty acids are created when vegetable oils are hydrogenated in food processing; they raise bad cholesterol while lowering good cholesterol.

PTS:1DIF:Cognitive Level: Applying (Application) REF:906 OBJ:Explain the significance of saturated, unsaturated, and polyunsaturated lipids in nutrition.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 17.During a nutritional assessment the nurse finds that a patients energy needs exceed nutritional intake. What other assessment finding will the nurse observe? a.Weight gain ]

b.Weight loss c.Anabolism d.Excessive adipose tissue ANS: B When patients energy needs exceed nutritional intake, weight loss will occur. Energy balance occurs when energy requirements equal energy intake. In general, when a person exceeds his or her energy needs or his or her needs are insufficient, the person either gains or loses weight, respectively. Weight is gained when nutritional intake is more than the body needs. Anabolism is the production of more complex chemical substances by synthesis of nutrients needed to build or repair body tissue; this patient will experience catabolism. Excessive adipose tissue will occur when intake exceeds energy needs; this patient would have insufficient or a lack of adipose tissue. When the body has unused energy, it is stored principally in fat/adipose tissue.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:907 OBJ: Explain the importance of a balance between energy intake and output.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18.A patient is receiving parenteral nutrition (PN). While caring for the patient receiving PN what is the nurses best action? a.Begin the infusion at 150 mL/hour. b.Maintain a consistent infusion rate. c.Touch the insertion site itself with a clean-gloved hand. d.Monitor the laboratory values on a weekly basis.

ANS: B The solution is provided at a specified rate using an infusion pump over the course of the day to meet the patients nutritional needs. Parenteral nutrition is usually started at a lower rate, for example, 40 to 60 mL/hour, and then advanced to meet the patients goal rate as tolerance is demonstrated. If the site itself must be touched, wear a sterile glove, not a clean glove. Frequent laboratory measurements for metabolic or electrolyte abnormalities as well as assessment of fluid balance, weight trend, and the ability to heal should occur during administration.

Laboratory monitoring includes frequent blood glucose testing because the high dextrose (glucose) content of the solution can easily lead to hyperglycemia and require supplemental insulin as needed. Monitoring laboratory values on a weekly basis is too long and could lead to complications.

PTS:1DIF:Cognitive Level: Applying (Application) REF:929 OBJ: Describe the procedure for initiating and maintaining parenteral nutrition.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19.A college student visits the student health center. The student has become a vegan. The nurse assesses that the student is deficient in protein intake. Which food should the nurse suggest as a source of protein? a.Plant-based protein b.Poultry-based protein c.Egg-based protein d.Milk-based protein ANS: A

]

Vegans eat only foods of plant origin; therefore only plant-based protein can be eaten. Ovolactovegetarians avoid meat, fish, and poultry but eat eggs and milk. Lactovegetarians drink milk but avoid eggs and other animal-based foods.

PTS:1DIF:Cognitive Level: Applying (Application) REF:909 OBJ: Identify nutritional problems and describe a patient at risk for these problems.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 20. The nurse caring for a patient with dysphagia has assigned the task of feeding the patient to the new nursing assistant personnel (NAP). The nurse asks the NAP how long the patient should be upright after eating. Which answer indicates the NAP has a correct understanding?

a.2 hours after meal time b.30 minutes after meal time c.20 minutes after meal time d.10 minutes after meal time ANS: B The patient should remain sitting upright for at least 30 to 60 minutes after the meal. Remaining upright after meals or snack reduces chance of aspiration by allowing food particles remaining in pharynx to clear. Ten to twenty minutes is not enough time, whereas 2 hours is too long.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:935 OBJ: Discuss methods for feeding patients who require assistance with oral intake.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 21. The nurse has to insert a nasogastric tube for the purpose of temporary tube feedings. To determine the length of the tube, the nurse should use which measurement? a. Tip of the nose to the xiphoid process of the sternum and add an additional 20 cm b. Tip of the chin to the earlobe to xiphoid process of the sternum c. Tip of nose to the earlobe to xiphoid process of the sternum d. Tip of the earlobe to the nose to the umbilicus

ANS: C Determine the length of the tube you will insert, and mark location on the tube or mark with tape. Measure the distance from the tip of nose to earlobe to xiphoid process of the sternum. Adding an additional length of half the distance from the xiphoid process to the umbilicus may aid in seating the tube further into the stomach. Add an additional 20 to 30 cm (8 to 12 inches) for a nasointestinal tube. Chin to the earlobe to the xiphoid process and the tip of the earlobe to the nose to the umbilicus will provide an inaccurate length.

PTS:1DIF:Cognitive Level: Applying (Application) REF:937 OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity ]

22. The nurse needs to verify feeding tube placement using the gastrointestinal (GI) pH measurement test. The NG

tube placement was confirmed via x-ray 6 hours ago. After several attempts, the nurse is unable to aspirate GI fluid from the tube. The tube is secure and the external marking of the tube are in the original place. The patient appears to be tolerating the tube feedings and is not experiencing any distress. What should the nurse do? a.Contact the health care professional to order another x-ray for placement verification. b.Instill 60 mL of air to check the placement with a stethoscope. c.Increase the amount of water given to the patient to prevent GI distress. d.Assume the tube is in the correct place.

ANS: D If, after repeated attempts, it is not possible to aspirate fluid from a tube that was originally established by x-ray examination to be in desired position, and (a) there are no risk factors for tube dislocation, (b) there is no change in the external marked tube length, and (c) patient is not experiencing difficulty, assume the tube is correctly placed.

Another x-ray is not needed. Flushing the tube with 30 ml, not 60, of air is to help obtain the aspirate, not to check placement. Checking for placement with air is an outdated process. Increasing the water will not check placement.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:928 OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1.A patient is having a problem with wound healing. The nurse assesses the patients tray and finds that only 25% of all meals are eaten. The nurse teaches the patient that protein intake is important for what reasons? (Select all that apply.) a. It is essential for body tissue growth. b. It is essential for tissue maintenance.

c.Essential amino acids can only be obtained from dietary sources. d.It is essential for repair. e.Negative nitrogen balance is needed for wound healing.

ANS: A, B, C, D Protein provides energy, but because of the essential role of protein in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. The body is unable to synthesize some amino acids, such as essential amino acids. The body can only obtain these from daily food sources. The body needs a positive nitrogen balance, not negative, for growth, maintenance of lean muscle mass and vital organs, and wound healing.

PTS:1DIF:Cognitive Level: Applying (Application) REF:905 OBJ: List the end products of carbohydrate, protein, and lipid metabolism.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2.A school nurse is presenting a class on nutritional needs to a group of 16-year-old adolescents. When discussing a balanced diet, the objectives for Healthy People 2020 , and the goals of the ChooseMyPlate program, the nurse explains to this age group that nutritional goals should include which of the following? (Select all that apply.) a.To balance energy expenditure and caloric intake to increase weight gain ]

b.To promote food choices for a healthy lifestyle c.To decrease the intake of vitamins and minerals d.To reduce chronic disease related to diet and weight e.To limit fast foods because of increase in salt, fat, and calories ANS: B, D, E Healthy People 2020 continues the overall goal to promote health and reduce chronic disease related to diet and weight. Vitamins and mineral should not be decreased in adolescence. Calcium is essential for the rapid bone growth of adolescence. Boys also need adequate iron for muscle development. B-complex vitamins are necessary to support heightened metabolic activity during adolescence. Fast food is common and adds extra salt, fat, and kilocalories. ChooseMyPlate is directed at helping the obese and overweight population choose healthier foods and confront the obesity epidemic by providing a basic, visual guide for making food choices for a healthy lifestyle.

PTS:1DIF:Cognitive Level: Applying (Application) REF:907 | 908 OBJ: Describe the basic food groups and their value in planning meals for good nutrition.

TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3.Which patients should be assessed for nutritional deficiencies? (Select all that apply.) a.Patient who scored a 13 on the mini-nutritional assessment b.Elderly patient on bed rest after surgery on the small intestines c.Patient receiving an IV of 5% dextrose d.School-aged patient with positive nitrogen balance e.Middle-age patient with rashes and easily pluckable hair ANS: B, C, E These types of patients should be assessed for nutritional deficiencies: congenital anomalies and surgical revisions of the gastrointestinal tract (surgery on the small intestines) interfere with normal function; patients receiving only intravenous infusion of 5% to 10% dextrose are at risk for nutritional deficiencies. The skin and hair are primary areas that reflect nutrient and hydration deficiencies. Be alert for rashes; dry, scaly skin; poor skin turgor; skin lesions; hair loss; easily pluckable hair; hair without luster; and an unhealthy scalp as these could indicate nutritional deficiencies. A person who scores 12 to 14 points on the mini-nutritional assessment has a normal nutritional status. A person in positive nitrogen balance is healthy; the body needs a positive nitrogen balance for growth, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance would be a cause to assess for nutritional deficiencies.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:915 OBJ: Identify nutritional problems and describe a patient at risk for these problems.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

]

Chapter 36: Urinary Elimination Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. An 80-year-old woman with a history of diabetes and arthritis has made an appointment with her health care

provider for complaints of urinary incontinence (UI). The patient states that she has recently become incontinent of urine and thinks it is because of her age. What is the best response from the nurse? a.That is not normal. You must have a UTI. b.You need to decrease your fluid intake so you dont have to go to the bathroom as often. c.Are you having issues with walking to the bathroom or toileting? d.As you get older the sensations that your bladder is full become hypersensitive and cause a person to go to the bathroom more frequently.

ANS: C Functional UI is caused by factors that prohibit or interfere with a patients access to the toilet or other acceptable receptacle for urine. It is a significant problem for older adults who experience problems with mobility or the dexterity to manage their clothing and toileting behaviors. Functional UI may also be caused by poor motivation for continence, as seen in severe depression or by cognitive decline that has impaired the ability to sense and act upon the urge to void in an appropriate manner. Functional UI can be associated with underlying stress, urge, or mixed UI. In many cases functional incontinence is the direct result of caregivers not responding in a timely manner to requests for help with toileting.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 953-954 OBJ: Identify factors that commonly influence urinary elimination.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. At a recent staff meeting the staff educator discussed the importance of catheter care for the prevention of urinary tract infections (UTI). What percentage of health careassociated infections result from indwelling catheter use? a. 0%

b.60% c.70% d.80%

ANS: D Eighty percent of health careassociated infections are associated with indwelling catheter use.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 953 OBJ: Discuss nursing measures to reduce urinary tract infections.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 3.A 56-year-old patient, who has recently become postmenopausal, made an appointment with her health care provider for symptoms of an UTI. The patient has had three previously diagnosed UTIs in the past 4 months. She asks the nurse if this is a normal occurrence with postmenopausal women. What is the best response from the nurse? ]

a.Yes, because as women go through menopause, the lining of the urethra becomes more susceptible to infections. b.No, but why dont you ask your health care provider for some antibiotics to keep on hand? c.Yes, and this must be frustrating because as we become older our body starts to cause us more problems. d.Yes, and this is why Im not looking forward to going through menopause.

ANS: A There is a decrease in estrogenization of perineal tissue in women that increases the risk of urinary tract infection.

The vaginal tissue of postmenopausal women may be dryer and less pink than in younger women. Health care providers would not give antibiotics to keep on hand. Nurses should not imply that a UTI is an expected problem of aging. Relaying what the nurse thinks about aging is not appropriate to voice to the patient.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 953 | 962 OBJ: Discuss nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4.A mother has brought her 3-year-old child to the clinic for an annual well-child checkup. The mother tells the nurse that the child is in the process of being potty trained. The child will state that the need to go to the bathroom, but refuses to go on the toilet. What is the nurses best response? a.This occurs because the child might be frightened of falling in the toilet. b. It is recommended that you try putting her in time-out if she continues to refuse to sit on the toilet. c.Sometimes children at that age see urine and feces as part of themselves. d.Stop, your child is too young to worry about potty-training.

ANS: C When children begin to achieve bladder control and learn the appropriate skills, they sometimes resist urinating on the toilet. Children often associate their urine and feces as extensions of self, and they do not want to flush part of themselves away. The neurological system is not well developed until 2 to 3 years of age. Up until this time, the small child is not able to associate the sensations of filling and urge with urination. When the child recognizes feelings of urge, he or she can hold urine for 1 to 2 hours, and is able to communicate a need to eliminate, toilet training becomes successful. Fear of falling in the toilet may be a concern, but it is not the most appropriate answer for this question.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 957 OBJ: Identify factors that commonly influence urinary elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. The nurse on a rehabilitation unit is caring for a 77-year-old patient who had undergone total knee replacement

surgery. Since surgery, the patient has had several instances of urinary incontinence. The health care provider is contemplating the order of a Foley catheter. What is the nurses best response to this suggestion? a.Perhaps you could order intermittent straight catheter insertions instead? b.I think it would be better to put a disposable undergarment on her. c.Could we try a toileting schedule before you order the Foley? d.I think that is a good idea; it will prevent skin breakdown.

ANS: C

You are in a strategic position to serve as a patient advocate by suggesting noninvasive alternatives to catheterization use. For example, you may decrease the risk for UTI by suggesting the use of a bladder scanner to evaluate bladder urine volume without invasive instrumentation or implement a toileting schedule for the incontinent patient. Be aware of indications for catheter insertion and be prepared to advocate for the patient if the indications do not meet accepted guidelines. ]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:975 | 977 OBJ: Discuss nursing measures to promote normal urination and to control incontinence.

TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 6. The nurse is assessing a 76-year-old man in a nursing home with a diagnosis of UTI. The nurse notes that the

patient is complaining of right flank pain. To assess for tenderness, the nurse should gently do which of the following? a.Auscultate the costovertebral angle. b.Palpate the tenth intercostal space. c.Percuss the costovertebral angle. d.Palpate the area above the ischial spine.

ANS: C

If the kidneys become infected or inflamed, flank pain typically develops. You assess for tenderness early in the disease by gently percussing the costovertebral angle (the angle formed by the spine and twelfth rib). Inflammation of the kidney results in pain on percussion.

PTS:1DIF:Cognitive Level: Applying (Application) REF:959 OBJ: Perform a beginning physical assessment related to urinary elimination.

TOP:Nursing Process: Assessment MSC:Client Needs: Reduction of Risk Potential 7.A male patient has been admitted with a fever and malaise. The health care provider has ordered a clean catch midstream specimen for urinalysis on this patient. To collect the urine specimen, the nurse should instruct the patient to do which of the following? a.Return to bed to obtain the specimen using a straight catheter insertion. b.Use sterile gloves to cleanse his penis and collect the specimen in a sterile cup. c.Ask the patient to void into a cup or urine collection container. d.Cleanse his penis, begin his stream, and then void into a sterile cup.

ANS: D Male patients should be instructed to retract the foreskin, if not circumcised, and cleanse the meatus in a circular motion moving from the center of the meatus to the outside. After cleansing, have the patient open the sterile urine cup and caution the patient to not touch the inside of the cup. To collect the specimen, instruct the patient to start voiding in the toilet or other receptacle, stop the stream, position the sterile cup to collect urine and then continue voiding into the cup. When finished, the lid should be put on the cup and the specimen processed per laboratory instruction. A simple urinalysis does not require a sterile urine specimen or sample. Obtaining the specimen from a straight catheter would occur if there was an issue with urinary retention or the patient is unable to void.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:964 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity ]

8.The health care provider ordered a 24-hour urine specimen to test the renal function of a patient admitted with acute renal failure. The nurse has prepared all the necessary equipment and has asked the patient if he or she needs to void. The nurse knows that the 24-hour collection period will begin: a.after the first voided specimen is discarded. b.with the first morning voided specimen. c.after the second voided specimen is collected. d.as soon as the necessary equipment arrives.

ANS: A In most 24-hour specimen collections, you will need to discard the first voided specimen and then start collecting urine in a special container that already has a preservative added. Depending on the test, the urine container may need to be kept cool by placing it in a container of ice. Patient education must include an explanation of the test, an emphasis on the need to collect all urine voided during the prescribed time period, and how to avoid contaminating the specimen with stool or toilet paper. Careful documentation of the start and stop time of the test, as requested by the laboratory, will improve testing accuracy. A 24-hour specimen can be started at any time after obtaining and discarding the first voided specimen.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:964 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP:Nursing Process: Implementation MSC:Client Needs: Physiologic Integrity: Reduction of Risk Potential 9.A 34-year-old patient is being seen in the ED for complaints of severe flank pain lasting for 2 days. The ED physician suspects that the patient has hydroureter. Which of the following tests would the nurse expect the health care provider to order? a.KUB (kidney, ureter, bladder) radiography b.IVP (intravenous pyelogram) c.Endoscopy d.Ultrasound renal bladder ANS: D Health care providers use the x-ray examination to determine the size, shape, and location of the kidneys, ureters, and bladder structures. It is also useful in visualizing calculi (stones) or tumors in these organs. Common uses of endoscopy include: microscopic hematuria, detect/obtain specimens from bladder tumors, and obstruction of the bladder outlet and urethra. Common uses for IVP include: detect and measure urinary calculi, tumors, hematuria, and obstruction of the urinary tract. Doing an ultrasound renal bladder would detect masses, obstruction, the presence of hydronephrosis or hydroureter, abnormalities in the bladder wall, calculi, and measure postvoid residual.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:966 | 967 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP:Nursing Process: Assessment MSC:Client Needs: Physiologic Integrity: Reduction of Risk Potential 10.A 57-year-old woman has been incontinent of urine for the past 2 months. Her health care provider has ]

scheduled her to have a test to check for stress urinary incontinence. For which of the following tests should the nurse prepare the patient? a.Abdominal radiograph b.Intravenous pyelogram c.Endoscopy d.Ultrasound renal bladder ANS: D Ultrasound renal bladder common uses: detect masses, obstruction, presence of hydronephrosis or hydroureter, abnormalities in the bladder wall, calculi, and measure postvoid residual. Common uses of endoscopy include: microscopic hematuria, detect/obtain specimens from bladder tumors, and obstruction of the bladder outlet and urethra. Common uses for IVP include: detect and measure urinary calculi, tumors, hematuria, and obstruction of the urinary tract. Abdominal roentgenogram (plain film; kidney, ureter, bladder [KUB] or flat plate) are commonly used to detect and measure the size of urinary calculi.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:966 | 967 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP:Nursing Process: Assessment MSC:Client Needs: Physiologic Integrity: Reduction of Risk Potential 11.The nurse is caring for a 45-year-old patient with a suspicious tumor in the bladder. The health care provider has ordered a procedure to identify the tumor tissue. Which test is done to collect tissue specimens? a.Abdominal radiograph b.Intravenous pyelogram c.Endoscopy/cystoscopy d.Ultrasound renal bladder ANS: C Common uses of endoscopy include: microscopic hematuria, detect/obtain specimens from bladder tumors, and obstruction of the bladder outlet and urethra. Common uses for IVP include: detect and measure urinary calculi, tumors, hematuria, and obstruction of the urinary tract. Abdominal roentgenogram (plain film; kidney, ureter, bladder [KUB] or flat plate) are commonly used to detect and measure the size of urinary calculi. Ultrasound renal bladder common uses: detect masses, obstruction, presence of hydronephrosis or hydroureter, abnormalities bladder wall, calculi, and measure postvoid residual.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:966 | 967 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 12.A patient has just been diagnosed with diabetes mellitus. The patient voices concerns about possible kidney disease in the future. The patient asks, In which part of the kidney is urine produced? The nurses response is that urine is formed in the: a.ureter. ]

b.bladder c.nephron. d.glomerulus.

ANS: D One percent of the glomerular filtrate is excreted as urine. The ureter is attached to the kidney pelvis and carries urinary wastes into the bladder. The kidneys are reddish-brown, bean-shaped organs that filter the blood waste products. The nephrons remove waste products from the blood and regulate water and electrolyte concentrations in body fluids. The bladder is a hollow, distensible, muscular organ that holds urine.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:952 OBJ: Explain the structures of the urinary system, including function and role in urine formation and elimination.

TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 13.A nurse suspects that a patient may be experiencing urinary retention. What should the nurse expect to find on assessment of this patient? a.Spasms and difficulty urinating b.Pain in the umbilical region c.Large amounts of voided cloudy urine d.Small amounts of urine voided 2 to 3 times per hour ANS: D The patient is only able to partially empty the bladder. Because of a distended bladder, the patient experiences pressure, discomfort, and tenderness over the suprapubic area. Urinary output is also an indicator of bladder function. Patients who have not voided for longer than 3 to 6 hours, and have had fluid intake recorded should be evaluated for urinary retention. In some patients just helping them to a normal position to void prompts voiding.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:963 OBJiscuss common alterations associated with urinary elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14.A patient with congestive heart failure reports experiencing increased urination when taking the prescribed medication. The nurse explains that which of the following is true? a.The patient is probably taking a diuretic. b.The patient is probably taking an anticholinergic. c.The patient is probably taking an antispasmodic. d.The patient probably has a UTI. ANS: A Diuretics increase urinary output by preventing resorption of water and certain electrolytes. Some drugs change the color of urine (e.g., phenazopyridine, orange; riboflavin, intense yellow). Anticholinergics (e.g., atropine, overactive bladder [OAB] agents) may increase the risk for urinary retention by inhibiting bladder contractility.

Hypnotics and sedatives (e.g., analgesics, antianxiety agents) may reduce the ability to recognize and act on the urge to void. ]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 954 OBJ: Identify factors that commonly influence urination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 15.A patient calls the office to tell you that his or her urine has changed to an orange color. The best response of the nurse is which of the following? a. Did you recently start a new prescription for Pyridium? b. Did you recently drink a lot of cranberry juice?

c.Have you noticed any blood on the tissue when you wipe yourself? d.Please make an appointment with the office right away.

ANS: A Various medications and foods change the color of urine. For example, patients taking phenazopyridine, a urinary analgesic, void urine that is bright orange. Eating beets, rhubarb, and blackberries causes red urine. The kidneys excrete special dyes used in IV diagnostic studies, which discolor the urine. Patients with liver disease who have high concentrations of bilirubin (urobilinogen) often have dark amber urine. Report unexpected color changes to the health care provider.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 964 OBJ: Describe characteristics of normal and abnormal urine.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16.A 20-year-old female college student who suffers from frequent UTIs visits the student health clinic. The student asks how to decrease the frequency of UTIs. What is the nurses most appropriate response? a.Drink at least 6 to 8 glasses of water daily. b.Increase your fluid intake by drinking caffeinated beverages. c.Cleanse the perineal area from anus to urethral meatus. d.Take an over-the-counter urinary tract cleanser.

ANS: A Drinking 6 to 8 glasses of water a day is recommended. Spread it out evenly throughout the day. Avoid or limit drinking beverages that contain caffeine (coffee, tea, chocolate drinks, and soft drinks). To avoid UTIs and contamination, women should cleanse themselves from the meatus toward the rectum. Proper hand washing and perineal care will greatly reduce the incidence of UTIs. PTS:1DIF:Cognitive Level: Applying (Application) REF: 970 OBJ: Discuss nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17.The nurse is caring for a patient from a long-term care facility who has a Foley catheter. The urine in the bag is dark yellow and has a cloudy appearance and a strong odor. According to the transfer sheet, the Foley was placed 5 weeks before the hospital admission. What should the nurse do? a.Contact the health care provider for an order to change the catheter and provide an update on the appearance of the urine. b.Request an order for a urine for culture and sensitivity but do not change the catheter; the catheter can remain in place for another week per protocol. c.Contact the health care provider for an order to remove the catheter. ]

d.Do nothing; the catheter can remain in place for another week per protocol.

]

ANS: A For patients requiring long-term catheterization, catheter changes should be individualized, not routine. In many cases, catheters need to be changed every 4 to 6 weeks. Long-term catheters should be changed for leaking, blockage, and before obtaining a sterile specimen for urine culture. Long-term catheterization should be avoided because of its association with urinary tract infection. Make every attempt to remove catheters as soon as the patient can void.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 973 OBJ: Identify factors that commonly influence urinary elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18.A patient is scheduled for an intravenous pyelogram (IVP). What should the nurse do for this diagnostic examination? a.Make no special preparations before the examination. b.Push oral fluids before the examination. c.Have the patient fast after the procedure. d.Assess the patient for an allergy to iodine before the examination.

ANS: D Patients need to be assessed for iodine or shellfish allergies before the test because the contrast media is iodine based. Before an IVP procedure, bowel preparation is required. The patient is NPO for at least 4 hours before the procedure. After the procedure the patient is encouraged to push fluids to reduce the nephrotoxic effects of the contrast material.

PTS:1DIF:Cognitive Level: Applying (Application) REF:966 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19.A patient with a Foley catheter needs a urine sample for culture and sensitivity. What is the most appropriate action for the nurse to take? a.Disconnect the drainage tube from the catheter. b.Open the drainage bag and withdraw urine. c.Withdraw urine from the closed system drainage bag. d. Insert a sterile blunt cannula in the catheter port to withdraw urine.

ANS: D Disconnecting the drainage tube from the catheter breaches sterile technique and can cause introduction of bacteria into the system. Because urine in the drainage bag can rapidly grow bacteria, never take a urine sample from the drainage bag.

PTS:1DIF:Cognitive Level: Applying (Application) REF:964 OBJ: Describe nursing implications of common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE ]

1. Patients with urinary incontinence are unable to completely empty their bladder. The nurse can assist a patient to

void by using which of the following methods? (Select all that apply.) a.Completing manual bladder compression b.Having the patient assume the normal position for voiding c.Telling the patient to void only when he or she has the urge d.Pressing down on the right and left flanks of the patient e.Running water in the sink ANS: A, B, E

To promote relaxation and stimulate bladder contractions, use sensory stimuli (e.g., turning on running water, putting a patients hand in a pan of warm water, or stroking the female patients inner thigh) and providing privacy.

A strategy to promote relaxation and stimulate bladder contractions is to help patients assume the normal position for voiding. Encourage patients to attempt voiding according to the clock, not urge.

PTS:1DIF:Cognitive Level: Applying (Application) REF:971 OBJ: Discuss nursing measures to promote normal urination and to control incontinence.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity OTHER 1.A patient needs to have a Foley catheter inserted. Place the following steps into the correct order for this procedure. (Separate letters by a comma and space as follows: A, B, C, D.) a.Apply sterile gloves. b.Open the catheterization kit. c.Wash the perineal area with soap and water. d.Position the patient. e.Drape the perineum. f. Clean the urethra.

ANS: D, C, B, A, E, F Positioning permits visualization of the perineal structures. Washing reduces microorganisms. The catheterization kit contains materials necessary to insert the catheter. Apply sterile gloves to prevent infection, drape the perineum, and clean urethra with antiseptic solution to prevent infection.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 979-983 OBJ: Apply or insert an external or indwelling catheter.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

]

Chapter 37: Bowel Elimination Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A student nurse is caring for a patient who has dehydration as a result of diarrhea. Diarrhea is a result of abnormally fast peristalsis in what organ? a.Jejunum b.Stomach c.Duodenum d.Colon ANS: D The large intestine is the primary organ of bowel elimination. If peristalsis is abnormally fast in the colon, there is less time for water to be absorbed and the stool will be watery. The stomach is part of the upper GI system. The duodenum and jejunum are part of the small intestines.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:994 OBJ: Explain the physiology of digestion, absorption, and bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The labor/delivery nurse is caring for a 33-year-old who is in labor with her first child. The patient complained to the nurse about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks, what can I do to prevent future problems with hemorrhoids? What is the nurses best response?

a.Hemorrhoids are caused by defecation of stools that are loose and watery. b.You need to soften your stools by drinking plenty of fluids. c.You should eat less carbohydrates. d.There is nothing that you can do to prevent hemorrhoids.

ANS: B Hemorrhoids are dilated, engorged veins in the lining of the rectum. Increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses, such as congestive heart failure and chronic liver disease, are causative factors. A hemorrhoid forms either within the anal canal (internal) or through the opening of the anus (external). Passage of hard stool causes hemorrhoid tissue to stretch and bleed. Hemorrhoid tissue becomes inflamed and tender, and patients complain of itching and burning. Because pain worsens during defecation, the patient sometimes ignores the urge to defecate, resulting in constipation.

PTS:1DIF:Cognitive Level: Applying (Application) REF:997 | 1013 OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse caring for several patients on the surgical unit of the hospital. The nurse knows that constipation can be a significant health hazard and encourages the postoperative patients to drink fluids. Which one of the following patients is most at risk from complications related to constipation? ]

a.A 35-year-old man with back surgery b.A 47-year-old woman with an abdominal hysterectomy c.A 29-year-old women with carpal tunnel surgery d.A 77-year-old man with hip surgery ANS: B Constipation is a significant health hazard. Straining during defecation causes problems for patients with recent abdominal, gynecological, or rectal surgery. An effort to pass a stool can cause sutures to separate, reopening a wound. In addition, patients with cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver.

Constipation is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (e.g., unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:994 | 996 OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4.A patient will be undergoing abdominal surgeries, which will most likely result in an ostomy. The patient asks the nurse, What will the stool from my ostomy look like? What is the best answer? a.Your stools wont change from what they currently are. b.The consistency of your stools will be very soft. c.The consistency of your stools will be liquid. d.The consistency of your stools will depend on the location of stoma (ostomy).

ANS: D The location of an ostomy determines stool consistency. The more intestine remaining, the more formed and normal the stool. For example, an ileostomy bypasses the entire large intestine, creating frequent, liquid stools. A person with a sigmoid colostomy will have a more formed stool.

PTS:1DIF:Cognitive Level: Applying (Application) REF:997 | 998 OBJescribe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5.A patient was involved in a motor vehicle accident and underwent a loop colostomy. The patient questions the nurse about what is draining out of each side of the colostomy. What is the nurses best response? a.There is stool draining out of both sides. b.Stool is draining out the stomach side and mucus is draining from the rectum side. c.There is mucus and stool draining from both sides. d.There is stool draining out of the stomach side and nothing draining out of the rectum side.

ANS: B Loop colostomies are frequently performed on an emergency basis and are temporary large stomas constructed in the transverse colon. The loop ostomy has two openings through the stoma. The proximal end drains stool, and the distal portion drains mucus.

]

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:998 OBJescribe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity 6.A 45-year-old Catholic Hispanic-American patient has been admitted to the hospital with pneumonia. On admission, the patient did not identify any food preferences or food allergies. The nurse notes that the patient has requested that the family provide all meals during the hospital stay. This is most likely related to which of the following? a.Food preferences b.Hispanic cultural traditions c.Religious preferences d.Food sensitivities ANS: B The intake of certain foods also reflects the patients culture or beliefs. Foods in various cultures have different status relating to religion, availability, cost, and tradition. For example, some Hispanic-Americans use certain hot foods (e.g., chocolate, cheese, eggs) for conditions producing fever, and cold foods (e.g., fresh vegetables, dairy foods, honey) for disorders such as cancer or headaches. Understand the patients cultural heritage and the role diet plays in health promotion and maintenance.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:999 OBJ: Explain the physiology of digestion, absorption, and bowel elimination.

TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. The home health nurse is visiting a 67-year-old widow who lives at home by herself. The patient voices a concern about constipation. What is the best way for the nurse to approach the patients concern?

a.Tell me why you think you are constipated. b.Have you noticed that your stools are hard? c.How frequently are you having a bowel movement? d.What color is your stool?

ANS: A In determining the patients bowel habits, remember normal is unique to each individual. Far too often nurses do not acknowledge an older adults problems with intestinal elimination as an important consideration in their care.

Remember that what appears at the outset to be a trivial complaint may be a significant problem physically and/or psychologically. Apply this knowledge in preparing questions for the patient interview to determine the presence and extent of GI alterations. Although the other questions will help determine if there is a problem, having the patient voice her concern will direct future questions. Determine your patients usual pattern of bowel elimination.

Usual frequency and time of day are important, but also determine if any changes in elimination patterns have occurred. Ask the patient to make suggestions about the reason for any change.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1000 OBJ: Assess a patients bowel elimination pattern. ]

TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patients recent lab work,

which lab test would the nurse expect to be decreased? a.Total bilirubin b.Hemoglobin and hematocrit c.Serum amylase d.Ova and parasites ANS: B

There are no blood tests to specifically diagnose most gastrointestinal disorders, but hemoglobin and hematocrit may be done to determine if anemia from gastrointestinal (GI) bleeding is present. Liver function tests such as bilirubin and serum amylase to assess for hepatobiliary diseases and pancreatitis are possible tests that may be ordered by the health care provider. A stool sample is needed to test for ova and parasites.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1001 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 9. The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color change may be the result of which of the following?

a.Absence of bile b.Malabsorption of fat c.Diarrhea d.Iron supplements or GI bleeding ANS: D Blood in the stool or melena causes stool to turn black and sticky, hence the term tarry stools . Ingestion of iron supplements can also cause the stool to turn black. Stool that is white or clay-color is caused by the absence of bile.

Stool that is oily or pale in color is caused by the malabsorption of fat. Liquid brown or yellow stool is caused by diarrhea.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1001-1003 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity 10.A student nurse is assisting with colon cancer screening at the local health care clinic. The student is completing fecal occult blood testing on the stool specimens. This test is also referred to as a(n) test. a.melena b.guaiac c.amylase ]

d.alkaline phosphatase ANS: B A common test is the fecal occult blood test (FOBT) or guaiac test, which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer. Melena refers to blood in the stool that causes stool to turn black and sticky. Amylase and alkaline phosphatase are blood tests.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1002 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11.A patient is concerned about intermittent constipation and is confused about all the laxatives that are available.

One of the laxatives that the patient has used in the past was mineral oil. The nurse explains that this type of laxative is an example of a(n) laxative. a.stimulant b.osmotic agent c.emollient d.lubricant ANS: D Cathartics are classified by the method by which the agent promotes defecation. Stimulant cathartics cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit reabsorption of water in the large intestine. Saline or osmotic agents contain a salt preparation that the intestines do not absorb. The cathartic draws water into the fecal mass. This osmotic action increases the bulk of the intestinal contents and enhances lubrication.

Emollient or wetting agents are detergents and act as stool softeners to lower the surface tension of feces, allowing water and fat to penetrate the fecal material. Bulk-forming cathartics absorb water and increase solid intestinal bulk. The fecal bulk stretches the intestinal walls, stimulating peristalsis. Lubricants soften the fecal mass, thus easing the strain of defecation. The only lubricant laxative available is mineral oil.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1010 | 1011 OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized

following surgery. The nurse recognizes that this condition most likely a result of which of the following? a.Diarrhea b.Flatulence c.Fecal impaction d.The Valsalva maneuver ANS: C An obvious sign of impaction is the inability to pass a stool for several days, despite a repeated urge to defecate.

Continuous oozing of liquid stool after several days with no fecal output may indicate an impaction. Loss of ]

appetite, abdominal distention and cramping, nausea and/or vomiting, and rectal pain also occur. Diarrhea is an increased frequency in the passage of loose stools. Flatulence is a sense of bloating and abdominal distention usually accompanied by excess gas. The Valsalva maneuver occurs when pressure is exerted to expel feces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 996 OBJ: Assess a patients bowel elimination pattern.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 13. To maintain normal elimination patterns in a hospitalized patient, why should the nurse encourage the patient to take time to defecate 1 hour after meals?

a.The presence of food stimulates peristalsis. b.Mass colonic peristalsis occurs at this time. c.Irregularity helps to develop a habitual pattern. d.Neglecting the urge to defecate can cause diarrhea.

ANS: B Defecation is most likely to occur after meals. If the patient attempts to defecate during the time when mass colonic peristalsis occurs, the chances of successfully evacuating the rectum are greater. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. Establishing a consistent time for bowel hygiene is one evidenced-based practice to avoid constipation. Ignoring the urge to defecate and not taking time to defecate completely are common causes of constipation.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:994 OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14. The health care provider orders a patient to have a fecal occult blood test. To obtain an accurate result, the nurse instructs the patient to do which of the following?

a.Submit one sample for analysis. b.Take extra amounts of vitamin C supplements. c.Stop taking aspirin 14 days prior to the beginning of the test. d.Refrain from ingesting red meats for 3 days before testing.

ANS: D The patient needs to repeat the test at least three times on three separate bowel movements while the patient refrains from ingesting foods and medications that cause a false-positive or false-negative result. Foods to avoid include red meat, vitamin C, and citrus fruit and juices for 3 days. Medication such as aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs should be avoided for 7 days.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:1001-1004OBJerform a fecal occult blood test.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 15. The nurse receives a patient from the emergency department with the diagnosis of ileus. The nurse expects the health care provider to order NPO for dietary status, and insert a nasogastric tube. The nurse knows that the purpose of the nasogastric tube is to do which of the following? ]

a.Decompress the stomach until peristalsis returns. b.Provide tube feedings until peristalsis resumes. c.Allow for the release of flatulence. d.To keep the stomach expanded until peristalsis resumes.

ANS: A A patient cannot eat or drink fluids without causing abdominal distention and nausea and vomiting to occur. The insertion of a nasogastric (NG) tube into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. Flatulence (having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. Normally, intestinal gas escapes through the mouth (belching) or the anus.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:1011 OBJescribe common physiological alterations in bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 16. Elevating the head of the bed to the maximum allowed amount of 30 degrees for a patient in balanced suspension traction helps to promote normal elimination by which of the following?

a.Decreasing peristaltic movement b.Promoting contraction of the thigh muscles c.Strengthening the resistance of the internal and external sphincters d.Exerting increased pressure on the rectum ANS: D To help patients evacuate contents normally and without discomfort, recommend interventions that stimulate the defecation reflex or increase peristalsis. Helping the patient into an upright sitting position increases pressure on the rectum and facilitates use of intraabdominal muscles. Patients who have had surgery have muscular weakness or mobility limitations and benefit from the use of elevated toilet seats.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:1009 OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1.A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The assistive personnel demonstrates understanding of the procedure when she states which of the following? (Select all that apply.) a.I will lower the enema when the patient complains of cramping. b.I will speed up the enema administration when the patient complains of cramping. c.I will withdraw the tube when the patient complains of cramping. d.I will clamp the tubing when the patient complains of cramping. e.I will fill the bag with hot water because it will cool while I am administering the enema. f. I will have the patient sit on the toilet while I am administering the enema.

ANS: A, D

]

When the enema is instilled too rapidly, the instillation will cause pain and cramping. The instillation should be slowed down. When a patient complains of cramping, lower the container, clamp the tube, or temporarily stop the instillation. Filling the bag with hot water demonstrates that the assistive personnel does not understand the directions for this procedure. Having the patient sit on a toilet demonstrates that the assistive personnel does not understand the proper position for administering an enema.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1023OBJ:Administer an enema.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 2.Which of the following conditions could affect the function of the digestive process? (Select all that apply.) a.Increase in mobility b.Diagnostic testing c.Increase in nutrition d.Medications e. Increase in fluid intake f. Surgery ANS: A, B, D, F Individuals of any age sometimes experience changes in intestinal elimination. These changes are often the result of illness, medications, diagnostic testing, or surgical intervention. Aging when accompanied by chronic illness, cognitive decline, decreased mobility, and a decrease in food and fluid intake will change digestive system function, but aging alone does not necessarily alter the digestive process.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:992 OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3.A patient with colon cancer has recently undergone surgery to remove a portion of the colon. The patient asks how often the colostomy pouching system should be changed. What is the best response by the nurse? a. Every 3 to 7 days b. Every 10 to 14 days

c.When the pouch is one third to one half full of stool d.Not until the system starts to leak or smell bad ANS: A, C An ostomy is managed with an odor-proof pouch with a skin barrier surrounding the stoma. Empty the pouch when it is one third to one half full. Change the pouching system approximately every 3 to 7 days, depending upon the patients individual needs.

PTS:1DIF:Cognitive Level: Applying (Application) REF:998 OBJescribe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance ]

MULTIPLE RESPONSE

file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

1. When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema

includes which of the following? (Select all that apply.) a.Face b.Feet c.Sacrum d.Abdomen e.Legs ANS: B, C, E

Because edema moves to dependent body regions as a result of gravity, assessment of the immobilized patient includes the sacrum, legs, and feet. Face and abdomen are not dependent areas.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1042 OBJ: Complete a nursing assessment of an immobilized patient.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. Immobilized patients often become depressed. A nurse can best combat this effect of immobilization by doing

which of the following? (Select all that apply.)

a. Limiting visitors so the patient is not bothered b. Involving the patient in planning time for care and activities

c.Placing the patient in a private room to reduce the interruptions by a roommate d.Encouraging the patient to comb hair, wear make-up, and/or use cologne if appropriate e.Having the patient in a room with another patient who is interactive.

ANS: B, D, E Involve patients in their care whenever possible. For example, have the patient determine when the bed should be made. Some patients rest better during the night when fresh sheets are put on in the evening rather than in the morning. Keep hygiene and grooming articles within easy reach. Encourage patients to wear their glasses or artificial teeth and to shave or apply makeup. These are normal activities to enhance body image, thus improving the patients outlook. If possible, place the patient in a room with others who are mobile and interactive. If a private room is required, ask staff members to visit throughout the shift to provide meaningful interaction. Limiting visitors is not beneficial.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1042 | 1055 | 1056 OBJ: Describe psychosocial and developmental effects of immobilization.

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 3. The patient was involved in a motor vehicle accident. The patient has a fractured right hip and is on bed rest.

Because of the prolonged immobility the nurse is concerned about complications such as which of the following?

(Select all that apply.) a.Decreased nutrients/fluids b.Increased disuse osteoporosis c.Increased gastrointestinal motility d.Decreased lung expansion e.Decreased pooling of lung secretions ANS: A, B, D

file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

Physiological outcomes from immobility include: decreased nutrients/fluids, decreased lung expansion, increased (not decreased) pooling of lung secretions, and increased disuse osteoporosis. Decreased (not increased) gastrointestinal motility occurs.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1035 OBJ: Describe common physical and physiological changes associated with immobility.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

file:///D|/...t%20bank/Essentials%20for%20Nursing%20Practice%208th%20Ed%20TEST%20BANK%20PDF/chapter-36-immobility.html[21/04/2019 17:44:03]

Chapter 38 Skin Integrity and Wound Care Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse

notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color. How should the nurse document the tissue condition? a.Reactive hyperemia b.Blanchable hyperemia c.Nonblanchable hyperemia d.Tissue ischemia ANS: C Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage. When you press a finger against the red or purple area, it does not turn lighter in color. Deep tissue damage is present and is commonly the first stage of pressure ulcer development. Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries. Reactive hyperemia blanches. In blanchable hyperemia, the area that appears red and warm will blanch (turn lighter in color) following fingertip palpation. Tissue ischemia, decreased blood flow to tissue, usually results in tissue death and occurs when capillary blood flow is obstructed, as in the case of pressure.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1062 OBJ: Describe risk factors for pressure ulcer development.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed. The student nurse

instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation? a.Friction b.Shear c.Moisture d.Tunneling ANS: B

Shear is the force exerted against the skin while the skin remains stationary and the bony structures move. For example, when the head of the bed is elevated, gravity causes the bony skeleton to pull toward the foot of the bed, while the skin remains against the sheets. Friction is surface damage caused by the skin rubbing against another surface that often results in an abrasion. Friction would result if the patient is dragged across the sheets. Skin moisture increases the risk for ulcer formation as moisture softens the skin and reduces its resistance to other physical factors such as pressure or shear. Moisture comes from many sources such as wound drainage, perspiration, and/or fecal and urinary incontinence. With continuous pressure over the area, deep tissue destruction continues, which often results in larger pockets of necrotic tissue beneath the opening of the main wound that resemble a tunnel; this is referred to as tunneling.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1062 | 1063 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment ]

3. An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer?

a.A diet low in protein b.Braden Scale results of 22 c.Primary health care provider orders that read activity as tolerated d.Being repositioned every 2 hours ANS: A Poor nutrition, specifically severe protein deficiency, causes soft tissue to become susceptible to breakdown. Low protein levels cause edema or swelling, which contributes to problems with the transportation of oxygen and nutrients. A hospitalized adult with a score of 16 or below and an older adult at 18 or below are at risk for pressure ulcer development; a score of 22 does not place the patient at risk. A patient with decreased mobility, inadequate nutrition, excessive skin moisture, decreased sensory perception, or decreased activity is at risk for pressure ulcer development. Repositioning a patient every 2 hours will help prevent pressure ulcers. Activity as tolerated will help prevent pressure ulcers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1063 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4.A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone.

The nurse should document this pressure ulcer at what stage? a.Stage I b.Stage II c.Stage III d.Stage IV ANS: D Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling PTS:1DIF:Cognitive Level: Applying (Application) REF:1063 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5.A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus. The admitting nurse notes that an area of redness on the right malleolus is nonblanchable. The nurse correctly identifies this pressure ulcer at what stage? ]

a.Stage I b.Stage II c.Stage III d.Stage IV ANS: A Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling PTS:1DIF:Cognitive Level: Applying (Application) REF:1063 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6.An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework. During a bath, the assistive nursing personnel noticed that there was a large blister on the patients right heel. The patient denies knowledge of having injured self. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer? a.Stage I b.Stage II c.Stage III d.Stage IV ANS: B Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling PTS:1DIF:Cognitive Level: Applying (Application) REF:1063 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7.A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan. The admitting diagnosis is failure-to-thrive. On admission, the patient was found to ]

have a wound on the right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any

]

bone, tendon, or muscle. This was correctly identified as what stage of a pressure ulcer? a.Stage I b.Stage II c.Stage III d.Stage IV ANS: C Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling PTS:1DIF:Cognitive Level: Applying (Application) REF:1063 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8.A patient is being seen in the Emergency Department for a puncture wound on the foot. The patient was walking in a construction site, but is unsure what caused the injury. During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame? a. Within the past year b. Within the last 3 years c. Within the last 5 years d. Within the last 10 years

ANS: D When an injury results from trauma from a dirty penetrating object, determine if the patient has received a tetanus toxoid injection within the last 10 years. Within the past year, 3 years, or 5 years is too early.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1072 OBJ: Discuss common complications of wound healing.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 9. An elderly patient who resides in a nursing home is suffering from a respiratory infection. During the illness, the patient has become incontinent of both urine and stool. The nursing staff used a special cleanser on the perineum, put a moisture barrier on the exposed area, and used absorbent briefs to prevent the skin from becoming soft because of the moisture. What was the staff trying to prevent?

a.Maceration b.Dehiscence c.Evisceration d.Debridement ]

ANS: A The staff is preventing maceration. For a patient who is incontinent of stool or urine, use a specialized incontinence cleanser. To protect the skin you apply a moisture barrier product (generally petrolatum or dimethicone based) liberally to the exposed area. Select underpads, diapers, or briefs that are absorbent to wick incontinence moisture away from the skin versus trapping the moisture against the skin, which causes maceration (softening of the skin because of moisture). To maintain a stable environment it is important to control infection and promote cleansing, debride (remove) necrotic tissue, provide exudate management, control dead space, and provide wound protection.

Dehiscence is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. Evisceration occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1066 | 1077 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 10. The nurse is caring for a patient with a necrotic hip wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

a.Dry gauze b.Transparent film c.Hydrogel d.Hydrocolloid ANS: C Hydrogel dressings are available in sheets or in a gel in a tube (amorphous). They contain a high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue). Gauze dressings are best for wounds with moderate drainage, deep wounds, undermining, and tunnels. Transparent film dressings are used as a primary dressing in wounds with minimal tissue loss that have very little wound drainage. Hydrocolloid dressings are used for stage I, II, and III pressure ulcers.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1077 OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 11. The nurse is preparing to change a large wound dressing on the patients buttock. Which intervention should the nurse address first ?

a.Inspect the dressing for drainage. b.Medicate appropriately before performing the dressing change. c.Observe wound edges and if staples or sutures are intact. d.Assess the insertion site of the drain(s).

ANS: B When you plan a dressing change, consider giving the patient an analgesic at least 30 minutes before exposing a wound. Then assess the appearance of the wound. Next, assess the character of wound drainage by noting the amount, color, odor, and consistency. Then assess the drains. Drains lie within tissue, extend from the skin, and are connected to a drainage bag or suction apparatus or allowed to drain into a dressing. Most drains attach to a collection device. First, observe the security of the drain and its location with respect to the wound. Next, note the ]

character and amount of drainage if there is a collecting device. In the case of a surgical wound, inspect the staples, sutures, or wound closures for irritation, and note whether the wound edges are intact.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1073 OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. Which therapy should the nurse choose that will improve a patients circulation, relieve edema, and promote

concentration of pus and drainage? a.Warm soaks b.Warm moist compresses c.Sitz baths d.Cold moist compresses ANS: B

A warm moist compress improves circulation, relieves edema, and promotes concentration of pus and drainage.

Warm soaks involve the immersion of a body part in a warmed solution that promotes circulation, lessens edema, increases muscle relaxation, and allows application of medicated solution. The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a sitz bath, a bath in which only the pelvic area is immersed in warm fluid. Cold moist compresses are used to relieve inflammation and swelling.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1090 | 1091 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13.A patient who has undergone a colectomy is demonstrating wound healing. The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following? a.Proliferative phase b.Inflammation phase c.Hemostasis phase d.Secondary intention phase ANS: A The proliferative phase, in wound healing by primary intention, causes new capillary networks to form that provide oxygen and nutrients for new tissue and contribute to the synthesis of collagen. In the inflammation phase the goal is to establish a clean wound bed and obtain bacterial balance. If exudate brings white blood cells to the area, a scab will form. When wounds involve loss of tissue, such as a severe laceration or chronic wound, these heal by secondary intention. Hemostasis phase controls bleeding.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1066 OBJ: Discuss the response of the body during each phase of the wound healing process.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity ]

14.A surgical wound requires a hydrogel dressing. What is the primary advantage of a hydrogel dressing? a. It provides an absorbent to collect wound drainage. b. It provides a negative pressure to promote healing. c. It provides protection from the external environment. d. It provides moisture needed for wound healing.

ANS: D Hydrogels maintain moisture in some wounds for 1 to 3 days. Hydrogel dressings are available in sheets or in a gel in a tube (amorphous). They contain a high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue).

Negative pressure wound therapy (NPWT) uses negative pressure to assist wound healing. Negative pressure wound therapy supports wound healing by evacuating wound fluids, stimulating granulation tissue formation, reducing the bacterial burden of a wound, and maintaining a moist wound environment. Gauze dressings are best for wounds with moderate drainage, deep wounds, undermining, and tunnels. You apply gauze either moist or dry.

The moistened gauze increases the absorptive ability of the dressing to collect exudate. A transparent or hydrocolloid dressing protects against the external environment.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1083 OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 15.A patient is wearing an abdominal binder after abdominal surgery. What does the nurse need to assess and document about the patient? a.Neurological response b.Respiratory status c.Lymphatic status d.Genitourinary response ANS: B Evaluate the patients ability to ventilate properly, including deep breathing and coughing. An abdominal binder supports a large incision that is vulnerable to stress when a patient moves or coughs. Neurological, lymphatic, and genitourinary responses are not affected by the abdominal binder.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1087 OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 16.A patients draining wound is pale and watery with a combination of plasma and red cells. How should the nurse document this finding? a.Serous drainage b.Purulent drainage c.Sanguineous drainage d.Serosanguineous drainage ANS: D Serosanguineous is pale, more watery, and a combination of plasma and red cells, which may be blood streaked. ]

Serous is clear, watery plasma. Purulent is thick, yellow, green, or brown, indicating the presence of dead or living organisms and white blood cells. Sanguineous is fresh bleeding.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1073 OBJ: Describe wound assessment criteria: anatomical location, size, type, and percentage of wound tissue, volume and color of wound drainage, and condition of surrounding skin.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17.A postoperative patient visits the ambulatory care clinic complaining of just not feeling well. The patient has an elevated temperature. Which assessment finding should indicate to the nurse that the wound has become infected? a.Negative culture b.No odor c.Presence of fluid around the edges d.Purulent drainage coming from the incision area ANS: D Purulent drainage indicates an infection as it contains dead or living organisms and white blood cells and is often yellow, green, or brown. If the drainage has a pungent or strong odor, an infection is likely. No odor indicates normal healing. When an infection develops, the wound edges are usually brightly inflamed, warm, tender, and swollen. Culture results would come back positive for bacteria if an infection is present; a negative culture indicates no infection is present.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1073 OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18.Which patient is best suited for heat therapy? a.A patient with low back pain b.A patient with suspected appendicitis c.A patient with first-degree burn d.A patient with active bleeding ANS: A Low back pain treatment of heat is used to promote muscle relaxation, and reduces pain from spasm or stiffness.

Do not apply heat over an active area of bleeding (risk for continued bleeding) or an acute localized inflammation such as appendicitis (risk for rupture). Cold therapy, not heat, is indicated for a first-degree burn.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1088 | 1089 OBJ: Describe the differences in therapeutic effects of heat and cold TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 19. The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a

severe strain. The nurse has instructed the patient on proper application of the elastic bandage. Which statement indicates the patient needs more teaching? a.I need to wrap the bandage toward my toes. b.I need to make sure the bandage is smooth. c.I need to watch my toes for swelling and feeling cold. ]

d.I need to take the bandage off and call the physician if I experience increased pain.

ANS: A The response: I need to wrap the bandage toward my toes is the correct answer because the patient is wrapping the bandage from the proximal boundary to the distal boundary. Proper application of the bandage is from distal point toward proximal boundary, stretching the dressing slightly, using a variety of bandage turns to cover various body shapes. Prevent uneven dressing tension or circulatory impairment by overlapping turns by one-half to two-thirds width of dressing roll. Be sure the bandage is smooth (without creases). Evaluate circulation to dressing area every 4 hours by palpating distal pulse, palpating skin, noting temperature and observing skin color. Saying, make sure the bandage is smooth, watch my toes for swelling and feeling cold, and call the physician if I experience increased pain are all correct and require no teaching.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1088 OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 20. Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention.

The nurses best response is that healing by primary intention occurs when the skin edges:

a.are approximated. b.overlap each other. c.appear slightly red and moist. d.cannot come together.

ANS: A A wound with little or no tissue loss, such as a clean surgical incision, heals by primary intention. The skin edges approximate, or close together (not overlapping), and the risk for infection is minimal. In contrast, a wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by secondary intention. The skin edges cannot come together because of the extensive tissue loss, and healing occurs gradually.

A layer of granulation tissue, which is red, moist tissue consisting of blood vessels and connective tissue, covers the wound base in secondary intention.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1064 OBJ: Differentiate healing by primary and secondary intention.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this pressure

ulcer?

a.Stage/Category III b.Unstageable c.Suspected deep tissue injury d.Stage/Category IV ANS: B Unstageable: Full-thickness tissue loss-depth unknown.

Stage/Category III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. ]

Suspected Deep Tissue InjuryDepth Unknown: Purple or maroon localized area of discolored intact skin or bloodfilled blister owing to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue.

Stage/Category IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1063 OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 22.A patients full-thickness wound is establishing a clean wound bed and obtaining bacterial balance. This patient is in which phase of wound healing? a.Hemostasis phase b.Proliferative phase c.Inflammation phase d.Remodeling phase ANS: C Inflammation Phase: The goal of this phase is to establish a clean wound bed and obtain bacterial balance.

Hemostasis Phase: A full-thickness wound healing by primary intention first goes through the hemostasis phase, which controls bleeding.

Proliferative Phase: The key events are production of new tissue, epithelialization, and contraction.

Remodeling Phase: This phase may last up to 1 year, and reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1066 OBJ: Discuss the response of the body during each phase of the wound healing process.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1.On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.) a.Mobility b.Nutrition c.Infection d.Friction and shear e.Sensory perception ANS: A, B, D, E The Braden Scale is a highly reliable scale that uses six subscales to identify patients at greatest risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Infection is not an area that is assessed on the Braden Scale. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF:1067 OBJ:Complete an assessment for a patient with impaired skin integrity.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2.A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should assess which parameters for a wound assessment? (Select all that apply.) a. Size b. Viable versus nonviable tissue c. Tissue type involvement

d.Preventive measures e.Anatomical location ANS: A, B, C, E

Wound assessment (regardless of cause) includes the following parameters: anatomical location, extent of tissue involvement (full or partial thickness loss), size (dimensions and depth of wound), tissue type (viable or nonviable) and percentage of wound tissue (e.g., viable vs. nonviable), volume and color of wound exudate, and condition of surrounding skin.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1064 OBJ: Describe wound assessment criteria: anatomical location, size, type, and percentage of wound tissue, volume and color of wound drainage, and condition of surrounding skin.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3.A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed owing to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.) a.Dehiscence b.Evisceration c.Erythema and edema at the suture site d.Hemostasis e.Hemorrhage ANS: A, B, E Complications of wound healing include any of the following: hemorrhage, hematoma, infection, dehiscence, and evisceration. Hemostasis is a normal response to healing, not a complication. Erythema and edema at the suture site is a normal response that occurs in the inflammation phase; it is not a complication.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1066 OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

]

Chapter 39: Sensory Perceptions Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A 63-year-old welder who has gone to the clinic for an annual checkup. The patient shares a concern regarding difficulty hearing conversations at the coffee shop in the mornings. After looking in his ears to determine if there is a build-up of cerumen, the nurse tells the patient that the hearing loss may be associated with his occupation or it may be associated with aging. The nurse is aware that hearing loss associated with the aging process is known as which of the following? a.Tinnitus b.Mnires disease c.Presbycusis d.Presbyopia ANS: C Hearing changes often associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination, which is referred to as presbycusis. Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over background noise. A decrease in active sebaceous glands causes the cerumen to become dry and completely obstruct the external auditory canal. Tinnitus is commonly caused by ototoxicity and patients experience the sensation of ringing in the ears. Presbyopia refers to the gradual decline in ability of the lens to accommodate or focus on close objects and reduces ability to see near objects clearly. Although the cause of Mnires disease is unknown the symptoms include progressive low-frequency hearing loss, vertigo, tinnitus, and a full feeling or pressure in the affected ear.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 1113 | 1114 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2.A 64-year-old house painter who is seeing his health care provider for his annual checkup. When the nurse asks the patient if they have any health concerns, the patient states, I dont think my vision is as good as it used to be, things look more yellow than they used to. The nurse knows that this is a visual change in older adults caused by which of the following? a.Iris yellows b.Lens yellows c.Retina is hypersensitive d.Need for less light to see than when they were in young adulthood ANS: B Visual changes often include reduced visual fields, increased glare sensitivity, impaired night vision, reduced accommodation, reduced depth perception, and reduced color discrimination. Many of these symptoms occur because the pupils in the older adult take longer to dilate and constrict secondary to weaker iris muscles. Color vision decreases because the retina is duller and the lens yellows. Eventually, older adults may require three times as much light to see things as they did when they were in young adulthood.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1113 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3.A family member is accompanying the elderly patient to their follow-up appointment after a recent ]

hospitalization for gastrointestinal problems. The nurse interrupts a discussion between the family member and the patient regarding rancid food in the patients refrigerator. The family member looks at the nurse and states, She was trying to eat spoiled food for lunch, it spelled terrible, and she still wanted to eat it. What is the most likely physiological reason that the patient not realizes that the food is spoiled? a.She has xerostomia. b.She has a diminished sense of smell. c.She has a diminished sense of taste. d.She has a limited vision.

ANS: B Olfactory changes begin around age 50 and include a loss of cells in the olfactory bulb of the brain and a decrease in the number of sensory cells in the nasal lining. Reduced sensitivity to odors is common. A small decrease in the number of taste cells occurs with aging, beginning around age 60. Reduced sour, salty, and bitter taste discrimination is common. The ability to detect sweet tastes seems to remain intact. Xerostomia is the decrease in salivary production that leads to thicker mucus and a dry mouth. This interferes with the ability to eat and leads to appetite and nutritional problems.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1113 | 1114 | 1124 OBJiscuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4. The patient has a methicillin-resistant Staphylococcus aureus (MRSA) infection in an abdominal surgical wound.

The patient is in a private room, is receiving vancomycin (Vancocin) for the MRSA, and pain is well controlled with a morphine sulfate patient-controlled analgesia (PCA) pump, and is receiving docusate sodium (Colace) to prevent constipation. During the nurses rounds, the patient begins complaining of ringing in the ears. Which is the most likely cause for the patients tinnitus?

a.Surgical anesthesia b.Morphine sulfate c.Vancomycin d.Docusate sodium ANS: C Ototoxic medications, such as analgesics, antibiotics (such as vancomycin and aminoglycosides), or diuretics, affect hearing acuity, balance, or both, with the most common symptom being tinnitus (ringing in the ears).

Surgical anesthesia, morphine, and docusate sodium do not have the side effect of ototoxicity or tinnitus.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1114 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5. An elderly patient with diabetes is seeing the health care provider for complaints of visual changes. The patient

explains to the nurse that visual changes include distortion that makes the edges of objects appear wavy. The nurse knows that this is an early sign of which of the following? a.Cataracts b.Glaucoma c.Diabetic retinopathy d.Age-related macular degeneration ]

ANS: D Age-related macular degeneration occurs when the macula (specialized portion of the retina responsible for central vision) degenerates as a result of aging and loses its ability to function efficiently. An early sign includes distortion that causes edges or lines to appear wavy. In later stages, patients may see dark or empty spaces that block the center of vision. Cataract is clouding of the lens in the eye that affects vision. Interferes with passage of light through the lens and reduces the light that reaches the retina. Cataracts usually develop gradually and often result in cloudy or blurry vision, glare, double vision, and poor night vision. Glaucoma is a slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve. At first, vision stays normal, and there is no pain. If left untreated, there may be a loss of peripheral (side vision). Diabetic retinopathy are pathological changes of the blood vessels of the retina secondary to increased pressure resulting in hemorrhage, macular edema, and reduced vision or vision loss.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1114 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6.A nursing student is assisting with ambulation of a blind patient. The patient has hemiplegia of the right side. The best position for the student nurse to assume when ambulating is by standing on the patients side and walking a half step the patient. a.left; ahead b.right; ahead c.left; behind d.right; behind ANS: A You will need to assist patients with acute visual impairments with walking. Stand on the patients dominant, stronger, or uninjured side. The patient grasps your elbow or upper arm. You then walk one half step ahead and slightly to the patients side. The patients shoulder is directly behind your shoulder. Relax and walk at a comfortable pace.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1125 OBJ: Discuss ways to maintain a safe environment for patients with sensory alterations.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 7.A 16-year-old mother and her newborn come into the clinic for a routine checkup. The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age. The nurse hits a buzzer and the baby turns toward the sound. The nurse assures the mother that the baby can hear because the baby: a.was discharged from the hospital without any known problems. b.is producing ear wax. c.responds to loud noises. d.is too long young to determine any type of hearing loss.

ANS: C Neonates without hearing impairments respond to loud noises. Atrophy of the cerumen glands, seen mainly in older adults, cause thicker and dryer wax, which is more difficult to remove and may completely obstruct the auditory canal. Hearing loss can be determined at any age with additional testing by an EENT specialist. ]

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1113 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. The spouse of a homebound elderly patient voices a concern to the visiting nurse, Im having a hard time getting the patient to eat a balanced diet. All the patient wants to eat are sweets. What is the best explanation the nurse can give to the spouse?

a.Maybe she has a sweet tooth. b.Older adults seem to be able to taste sweet foods best. c.I wouldnt worry about it as long as she is eating something. d.She is probably getting all the nutrients that she needs.

ANS: B A small decrease in the number of taste cells occurs with aging, beginning around age 60. Reduced sour, salty, and bitter taste discrimination is common. The ability to detect sweet tastes seems to remain intact. Promote sense of taste through good oral hygiene, serving well-seasoned and differently textured foods, chewing food thoroughly, and avoiding blending or mixing foods. Enhance the sense of smell by removing unpleasant odors from the environment and introducing pleasant smells such as mild room deodorizers or fragrant flowers.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1113 | 1123 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 9. The school nurse is performing periodic screening on preschool children. She is aware that the most common

visual problem in childhood is which of the following? a.Refractive errors b.Strabismus c.Congenital blindness d.Color blindness ANS: A

Periodic screening of all children, especially newborns through preschoolers, should be performed for congenital blindness and visual impairment caused by refractive errors and strabismus. The most common visual problem during childhood is a refractive error such as nearsightedness. The school nurse is usually responsible for vision testing of school-age and adolescent children. Your role as a nurse is one of detection, education, and referral.

Parents need to know the signs of visual impairment such as failure to react to light and reduced eye contact from the infant. Instruct parents to report signs of visual impairment to their health care provider.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1122 OBJ: Discuss ways to maintain a safe environment for patients with sensory alterations.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 10.A nurse is caring for a patient who signs and lip reads. When communicating, the most appropriate nursing action is to do which of the following? ]

a.Rely on family members to interpret. b.Speak louder and more distinctly than normal. c.Sit facing the patient when speaking. d.Repeat the entire conversation if it is not understood the first time.

ANS: C Nurses can use a variety of communication techniques, including reading notes and writing notes, as well as reading lips and signing. When communicating, nurses should speak slowly and articulate clearly. When you are not understood, rephrase rather than repeating the entire conversation. Some patients with hearing impairments are able to speak normally. To more clearly hear what a person communicates, family and friends need to learn to move away from background noise, rephrase rather than repeat sentences, be positive, and have patience. On the other hand, some deaf patients have serious speech alterations. Patients who are deaf use sign language, read lips, write with pad and pencil, or learn to use a computer for communication PTS:1DIF:Cognitive Level: Applying (Application) REF:1124 OBJescribe nursing interventions with rationale that promote effective communication with patients who have sensory alterations.

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 11. An older adult patient has been admitted to a busy medical unit. To control environmental stimuli a nurse should do which of the following?

a.Leave the hospital room lights on at all times. b.Turn off bedside equipment not in use. c.Leave the window curtains closed at all times. d.Leave the door open so the patient can hear the staff and feel secure.

ANS: B Try to control extraneous noise in and around a patients room, such as television volume and visitors. Turn off bedside equipment not in use. Close a patients room door if necessary. Hospital staff members need to control loud laughter or conversation at the nurses station. In addition to controlling excess stimuli, try to introduce meaningful stimulation that makes the environment pleasing and comfortable. Open drapes and close door if indicated. Control extraneous noise in and around room such as television volume and visitors. Turn off bedside equipment not in use.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1125 OBJescribe conditions in the health care agency or patients home that you will adjust to promote meaningful sensory stimulation.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 12. The student nurse is assisting an elderly patient to get ready for bed. The patient states, Please make sure you clean my hearing aids. The student nurse knows it is important to keep in mind which of the following when cleaning a hearing aid?

a.Keep the battery in the machine when turned off. b.Store the hearing aid on the overnight table for easy access at night. c.Clean the hearing aid with hot water. ]

d.Use a soft dry cloth to wipe the hearing aid.

ANS: D Care for hearing aids include: Make sure your fingers are dry and clean before handling hearing aids.

Insert and remove the hearing aid over a soft surface.

Place the battery in the hearing aid when it is turned off.

Remove the hearing aid battery when not in use and store it in a marked container in a safe place.

Protect hearing aids from water and excessive heat or cold.

Use a soft dry cloth to wipe hearing aids and a soft brush to clean difficult to reach areas.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: 1123 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 13.A school nurse performs a routine screening on a newly transferred school-age child. This nurse is especially interested in discovering the childs medical history regarding middle ear infections. The nurse knows that chronic ear infections are a major contributing factor to which of the following? a.R espiratory diseases b.Strep throat c.High fevers d.Hearing impairment

ANS: D Hearing impairment is common in the United States. At-risk children include those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, or cytomegalovirus), low birth weight, chronic ear infections, and Down syndrome. Children need periodic auditory testing. Advise pregnant women of the importance of early prenatal care, avoidance of ototoxic drugs, and testing for syphilis and rubella. Strep throat, high fevers, and respiratory diseases are potential contributing factors for chronic ear infections.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1122 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14.An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances. A nurse must be alert to the effects of sensory deprivation that are associated with which of the following? a.S table affect b.Altered perception c. Improved task completion d.Decreased need for social interaction

ANS: B Sensory deprivation sometimes produces cognitive changes such as the inability to solve problems, poor task performance, and disorientation. It also can cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor ]

coordination, confusion of sleeping and waking states). Patients may withdraw from social situations because of their inability to handle stimuli.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1112 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 15.A patient with poor vision is ready to be discharged. The nurse is educating the patient and family regarding ways to improve vision. The nurse teaches the patient and family to avoid reading materials with shiny surfaces.

The rationale for this intervention is which of the following? a.Glare causes headaches. b.Glare will reduce visual acuity. c.Shiny surfaces reflect damaging rays. d.Too much light is damaging to the eyes.

ANS: B When a patient ages, the pupil loses the ability to adjust to light. Therefore reducing the amount of bright light in the patients environment will assist vision. Reduce glare by eliminating waxed floors and shiny surfaces exposed to bright sunlight, tint glass, install sheer curtains over windows, and use soft and diffused lighting.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1123 OBJ: Develop a nursing care plan for patients with visual, auditory, tactile, gustatory, and olfactory alterations.

TOP: Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity 16.A home care nurse visits a new patient. The family asks how the home can be made safer. The nurses best advice includes which of the following? a.Using throw rugs to prevent tripping b.Installing extra incandescent lighting c.Painting the floor black and white to add perception d.Installing handrails painted the same color as the walls ANS: B Good lighting at front and back entrances and light switches at the top and bottom of stairwells and long hallways add an additional safety element. Throw rugs, footstools, and electrical cords present tripping hazards. Handrails painted the same color as the walls may pose a problem for the visually impaired. Using color contrasts such as tape, paint, or nail enamel can highlight items.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1119 | 1120 OBJescribe conditions in the health care agency or patients home that you will adjust to promote meaningful sensory stimulation.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment ]

17.A patient has been hospitalized for 5 days and has had no visitors. The nurse observes the patient to be bored,

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restless, and anxious. The nurse identifies this behavior as which of the following? a.Sensory deficits b.Sensory overload c.Sensory deprivation d.Changes in attitudes ANS: C Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs a patients perception. It can cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor coordination, confusion of sleeping and waking states). Sensory deficits such as low vision and blindness are very common forms of disability. When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli, leading to sensory overload. A person with sensory overload no longer perceives the environment in a way that makes sense. Sensory deprivation can be caused from living in a nonstimulating environment. Ask the patient how to improve the quality of stimulation in the environment.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1112 OBJ: Differentiate the processes of reception, perception, and reaction to sensory stimuli.

TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1.A nursing student is concerned with sensory deprivation among the patients in the nursing home during the clinical rotation. Which of the following could be caused by sensory deprivation? (Select all that apply.) a.Confusion b.Anxiety c.Disorientation d.Panic e.Aggressiveness ANS: A, B, C Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs perception. These effects sometimes produce cognitive changes, such as the inability to solve problems, poor task performance, and disorientation. Affective changes, which include boredom, restlessness, increased anxiety, or emotional ability, can occur. Symptoms of sensory overload include panic, confusion, and aggressiveness.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1112 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2.A home care nurse is conducting a home assessment. The nurse is looking for the presence of sensory alterations.

Factors to assess include if any changes have occurred in which of the following? (Select all that apply.) a.Activities of ADLs b.Health promotion c.Has person had visitors d. Is person wearing hearing aids and glasses e.Ability to follow a conversation ]

ANS: A, B, C, D, E When assessing for sensory alterations, home care nurses need to assess sensory status, self-care management, and health promotion activities, as well as lifestyle and socialization.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1117 OBJ:Identify factors to assess in determining a patients sensory status.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3.A middle-age patient was admitted to the trauma intensive care unit after a motor vehicle accident. The nurse notes that the patient becomes increasingly agitated when visitors stay for an extended period or after nursing interventions. The nurse identifies this as sensory overload. Which of the following would most likely help the patient? (Select all that apply.) a.Reducing the number of visitors to her room b.Performing dressing changes with the bath c.Providing a dedicated period of rest time each afternoon d.Requesting that health care providers do rounds when the family is available e.Coordination with other departments for tests and examinations ANS: A, B, C, E Reduce sensory overload by organizing the patients care to control for excessive stimuli. Combining activities such as dressing changes, bathing, and vital sign assessment in one visit prevents the patient from becoming overly fatigued. Coordination with other departments will reduce the time needed for tests and examinations. The patient needs time for rest and quiet. Although it is important for health care professionals to communicate to family members, it will not likely reduce sensory overload for the patient.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1116 | 1125 OBJ: Describe behaviors indicating sensory alterations.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

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Chapter 40: Surgical Patient Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A 57-year-old patient who is being admitted for an appendectomy. The patient is a 2-pack-a-day smoker, has a history of diabetes, and is 20 pounds overweight. Which of the following potential postoperative complications should be the nurses highest concern for prevention? a.Atelectasis b.Negative nitrogen balance c.Delayed wound healing d.Hyperthermia ANS: A There is a significant association between smoking and postoperative pulmonary complications, specifically pneumonia and atelectasis. Chronic smoking increases the amount and thickness of mucous secretions in the lungs.

Patients who are obese are more susceptible to developing atelectasis. Hyperthermia is incorrect because general anesthetics inhibit shivering, a protective reflex to maintain body temperature, and anesthetics cause vasodilation, which results in heat loss. Malnourished patients are more likely to have poor tolerance of anesthesia, negative nitrogen balance, delayed postoperative recovery, infection, and delayed wound healing.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1131 OBJ: List factors to include in the preoperative assessment of a surgical patient.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2.The nurse working on a medical/surgical floor knows that pulmonary embolisms can be a deadly complication after surgery. Which of the following patients is most likely to develop a pulmonary embolism? a.45-year-old patient after bariatric surgery b.23-year-old patient with pneumonia c.13-year-old patient after appendectomy d.57-year-old patient after cholecystectomy ANS: A A patient who is obese usually has reduced ventilatory capacity because of the upward pressure against the diaphragm caused by an enlarged abdomen. There is also an increased risk for aspiration during the administration of anesthesia. The recumbent and supine positions required on the operating bed (table) for surgery further limit a patients ventilation. The increased workload of the heart and atherosclerotic blood vessels often results in compromised cardiovascular function. Because of these physiological changes, patients who are obese often have difficulty resuming normal physical activity after surgery. Hypertension, coronary artery disease, type 2 diabetes mellitus, and heart failure are common in this population. They are also more susceptible to developing embolism, atelectasis, and pneumonia after surgery than patients who are not obese.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1131 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3.A 45-year-old woman has been admitted for surgery to remove a cancerous abdominal tumor. She has been on chemotherapy and recently radiotherapy to shrink the tumor without success. To best facilitate wound healing,

when is the best time for her to undergo surgery? a.During the radiotherapy treatments b.Immediately after the radiotherapy treatments c.2 to 3 weeks after radiotherapy treatments d.4 to 6 weeks after radiotherapy treatments ANS: D Ideally surgery takes place 4 to 6 weeks after the completion of radiation treatments to avoid wound-healing problems. The patient with cancer may have radiotherapy before surgery to reduce the size of a cancerous tumor to remove it surgically. Radiation causes fibrosis and vascular scarring in the radiated area. This causes tissues to become fragile and poorly oxygenated, increasing the risk for wound infection.

PTS:1DIF:Cognitive Level: Applying (Application) REF: 1132 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 4.Which of the following patients is most at risk for hypovolemic shock after emergency surgery? a.14-year-old adolescent with gastroenteritis b.59-year-old patient with pneumonia c.12-year-old patient with H1N1 flu d.28-year-old patient with a fractured ankle ANS: A Patients with gastroenteritis have gastrointestinal problems and are at greater risk of complications. Patients with preexisting renal, fluid and electrolyte, gastrointestinal, respiratory, or cardiovascular problems are at greatest risk for operative complications. For example, a patient who is dehydrated from vomiting preoperatively is at greater risk for hypovolemic shock.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1133 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5.A 56-year-old nondiabetic patient is undergoing orthopedic surgery. The perioperative nurse is monitoring the blood glucose level. What is the main rationale for monitoring his blood glucose level during surgery? a.She does not want the patient to develop an embolism. b.Research shows a strong relationship between wound infections and hyperglycemia. c.She knows that normal glucose levels promote platelet production. d.She is monitoring to prevent embolism.

ANS: B Evidence has shown that there is a relationship between wound and tissue infection and blood glucose levels. Poor control of blood glucose levels (specifically hyperglycemia) during and after surgery increases the risk for wound infection and patient mortality in certain types of surgery. PT and APTT blood tests are monitored to prevent embolism. Perioperative nurses work with their medical colleagues to maintain normal glucose levels in the postoperative period to reduce the risk for wound and tissue infection.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1133

OBJ: Describe intraoperative factors that affect a patients postoperative course.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6. The perioperative nurse is admitting a patient for an elective surgery. She questions the patient about issues with

anesthesia, to assess the patient for malignant hyperthermia. Which of the following is a late sign of malignant hyperthermia? a. High CO 2 levels

b.Tachycardia c.Elevated temperature d.Tachypnea ANS: C Malignant hyperthermia is a life-threatening complication. Early signs of malignant hyperthermia include high levels of CO 2 , tachypnea, and tachycardia. Elevated temperature occurs in the late stages.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1135 OBJ: Describe intraoperative factors that affect a patients postoperative course.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 7.A 44-year-old patient with breast cancer who is scheduled to undergo a right-side mastectomy. Ideally when should preoperative teaching begin? a.As soon as she is diagnosed with breast cancer b.One week before surgery c.The day before surgery d.The day of surgery ANS: B Preoperative teaching is most useful when started the week before admission and reinforced immediately before surgery. Teaching performed when the patient is less anxious will result in more effective learning. Anxiety and fear are barriers to learning.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1144OBJrepare a patient for surgery.

TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8.The preoperative nurse who is providing patient teaching to a 49-year-old patient who is scheduled to undergo a right-side inguinal surgery repair. The nurse informs the patient that the American Society of Anesthesiologists recommend that patients undergoing surgery with a general anesthesia fast from meat and fried foods for how many hours before surgery? a.2 b.4 c.6 d.8 ANS: D

The American Society of Anesthesiologists (ASA) provides recommendations on fluid and food intake before procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. The ASA recommendations include fasting from intake of clear liquids for 2 or more hours, and a light meal of toast and clear liquids for 6 hours. The patient also cannot have any meat or fried foods 8 hours before surgery, unless explicitly specified by the anesthesiologist or surgeon.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1145OBJesign a preoperative teaching plan.

TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 9.A nurse working in an ambulatory care surgery center is preparing to discharge a postoperative patient. The nurse knows that the convalescence period will occur: a.1 to 2 hours after surgery. b.at home. c.once the patient has been monitored overnight in the hospital. d.2 to 4 hours after surgery.

ANS: B For a patient following ambulatory surgery, convalescence will occur at home, the immediate recovery period normally lasts only 1 to 2 hours. For a hospitalized patient the immediate postoperative period often lasts a few hours, with convalescence taking 1 or more days, depending on the extent of surgery and a patients response.

Patient who are admitted to stay overnight at the hospital are not classified as ambulatory care surgery center.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1153 OBJ: Explain the differences in caring for a patient undergoing outpatient surgery versus a patient undergoing inpatient surgery. TOP: Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity 10.The nurse instructs the postoperative patient to perform leg exercises every hour in order to do which of the following? a.Maintain muscle tone. b.Increase venous return. c.Exercise fatigued muscles. d.Assess range of joint motion.

ANS: B The number one priority in a surgical setting is to prevent deep vein thrombosis (DVT) complications. By increasing venous return there is less stasis therefore decreasing the risk of DVT. Early measures directed at preventing venous stasis are aimed at preventing DVT during convalescence. On the surgical nursing unit, begin these interventions as soon as possible. Encourage patients to perform leg exercises at least every hour while awake unless contraindicated by surgery. Maintaining muscle tone, exercising fatigued muscles, and assessing range of joint motion are all reasons to perform leg exercises.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1162

OBJescribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity 11.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The nurse explains to the family that major surgery: a. is an excision or removal of a diseased body part. b. involves extensive surgery to reconstruct body parts. c. is not necessary but may prevent additional problems. d. is a surgical exploration that allows the physician or health care provider to confirm a diagnosis.

ANS: B Major surgery involves extensive reconstruction or alteration in body parts; poses great risks to the patients wellbeing. Urgent surgery is necessary for the patients health and will possibly prevent additional problems from developing. Elective surgery is performed on a basis of the patients choice. It is not always essential, and it is not always necessary for health. Diagnostic surgical exploration allows the physician or health care provider to confirm a diagnosis.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1132 OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 12.A patient is awaiting surgery. The nurses best rationale for assessing vital signs is to do which of the following? a.Assess the patients anxiety level. b.Determine the patients basal temperature. c.Establish a baseline for vital signs comparisons. d.Assess for any changes that may indicate infection.

ANS: C Preoperative vital signs provide a baseline for intraoperative and postoperative comparison, because anesthetic agents and medications can alter vital signs. Preoperative assessment of vital signs is also important to detect fluid and electrolyte abnormalities. An elevated temperature is cause for concern. If a patient has an underlying infection, elective surgery will often be postponed until the infection is treated or resolved.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1138 OBJ: List factors to include in the preoperative assessment of a surgical patient.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 13.The operating room environment is deliberately kept cool. When the nurse assesses the patient in the post anesthesia care unit, the patient is shivering. The nurse needs to understand that shivering may do which of the following? a.Be a side effect of anesthesia. b. Indicate a problem of the hypothalamus. c. Indicate the beginning of the infectious process. d.Be a normal response to stabilize blood pressure.

ANS: A The operating room environment is cool, and the patients depressed level of body function results in a lowering of metabolism and fall in body temperature. When patients begin to awaken, they often complain of feeling cold and uncomfortable. Shivering is not always a sign of hypothermia, but rather a side effect of certain anesthetic agents.

If a patient develops a fever, notify the surgeon immediately. The chances of the shivering being a problem with the hypothalamus, indicating infection (such as fever with sepsis) are very low in this case.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1154 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 14.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The family asks the nurse what type of anesthesia the patient will receive. The best response is which of the following? a.Local anesthesia b.Regional anesthesia c.Moderate sedation d.General anesthesia ANS: D General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Local anesthesia involves loss of sensation at the desired surgical site by inhibiting peripheral nerve conduction. It is used during minor procedures performed in ambulatory surgery. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia. Intravenous moderate sedation/analgesia or conscious sedation is routinely used for diagnostic or therapeutic procedures (e.g., colonoscopy or certain laparoscopies) that do not require complete anesthesia but simply a decreased level of consciousness.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1152 OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 15. All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient,

the most appropriate action for the nurse to take is which of the following? a.Leaving all of the patients jewelry in place b.Removing the patients makeup and nail polish c.Providing the patient with sips of water for a dry mouth d.Removing the patients hearing aid before transport to the operating room ANS: B

Jewelry is removed so it can be safeguarded. In addition, swelling may occur postoperatively. Makeup and nail polish are removed so the patients skin and mucous membranes can be assessed to determine oxygenation, saturation of blood, and application of a pulse oximeter. Patients are to maintain NPO to prevent postoperative GI complications and to prevent aspiration because the gag reflex is suppressed. Although patients need to remove hearing aids, do not have them do this until immediately before surgery; allowing the patient to wear hearing aids

will facilitate communication between the patient and health care providers.

PTS:1DIF:Cognitive Level: Applying (Application) REF:114BJrepare a patient for surgery.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. Intraoperatively, the circulating nurse observes a member of the surgical team breach aseptic technique. As a result of this incident the postoperative patient can be at risk for which of the following?

a.Paralytic ileus b.Malignant hyperthermia c.Development of infection d.Alteration in pulmonary hygiene ANS: C The circulating nurse assists the anesthesia provider with endotracheal intubation, calculating blood loss and urinary output, and administering blood. This nurse monitors sterile technique of surgical team members and a safe OR environment. A nurse also assists the surgeon and scrub nurse by operating nonsterile equipment, providing additional instruments and supplies, maintaining accurate and complete documentation, and tracking sponge, needle, and instrument counts. Paralytic ileus is a loss of function of the intestine, which causes abdominal distention. Anesthetic agents slow gastrointestinal functioning. Malignant hyperthermia results from administration of certain anesthetic agents. Alteration in pulmonary hygiene occurs when the postoperative patient does not cough and deep breathe.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1150 OBJ: Describe intraoperative factors that affect a patients postoperative course.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 17.A patient asks a nurse to explain the differences between general anesthesia and regional anesthesia. What is the correct response relating to general anesthesia? a.General anesthesia inhibits peripheral nerve conduction. b.Under general anesthesia all sensation and consciousness is lost. c.Under general anesthesia there is a loss of sensation in a specific area of the body. d.General anesthesia is routinely used for procedures that only require a decreased level of consciousness.

ANS: B General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1152

OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 18.The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, I use this device to: a.help my cough reflex. b.expand my lungs after surgery. c.increase my lung circulation. d.keep me from coughing.

ANS: B To facilitate deep breathing the incentive spirometer encourages forced inspiration to prevent atelectasis. Every preoperative teaching program includes explanation and demonstration of postoperative exercises, which include: diaphragmatic breathing, incentive spirometry, controlled coughing, turning, and leg exercises. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. A patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is difficult.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1146 OBJescribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. When is it appropriate to ask a surgeon to clarify information for a patient who is undergoing surgery? (Select all

that apply.)

a.Before the informed consent has been signed b.When a patient is confused about the reason for the procedure c.When a patient understands the risks involved in a procedure d. If there is confusion about the procedure after the informed consent is signed e.After the surgery has been performed ANS: A, B, D Patients need to sign all consent forms before you administer any preoperative medications that alter the patients consciousness. The primary responsibility for informing the patient rests with the surgeon and anesthesia care personnel. However, if the patient is confused or uncertain about a procedure, you are ethically obligated to contact the surgeon and/or anesthesia care provider so that further discussion and clarification are provided to meet the patients needs. The patient always has the right to refuse surgery or treatment even after giving written consent.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1142 | 1144OBJrepare a patient for surgery.

TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of the

following statements is/are true regarding the use of postoperative analgesia? (Select all that apply.) a.Analgesics will not provide adequate relief if you wait until the pain becomes excruciating before using them. b.Pain control will help you recover from surgery quicker. c.You shouldnt be concerned about becoming addicted to your pain medications immediately after surgery. d.You will remain pain-free as long as you take your pain medications as prescribed. e.A PCA pump is commonly used to help patients control their pain. f. Take pain medication carefully as it will lengthen your recovery period.

ANS: A, B, C, E Analgesics will not provide adequate pain relief if the patient waits until the pain becomes excruciating before using or requesting an analgesic. Even though around-the-clock (ATC) analgesia is more effective, most patients still have analgesics ordered prn (as needed). Pain control is essential for a surgical patient to recover quickly.

Encourage the patient to use analgesics as needed and not be fearful of any dependence on pain medications after surgery. Patient-controlled analgesia (PCA) is common and provides patients with control over pain. Explain to a patient how to operate a pump and the importance of administering medication as soon as pain becomes persistent.

The patient also needs to know it takes time for a drug to act and that the drug will rarely eliminate all the discomfort. Pain medication will not lengthen the recovery period, it will shorten it.

PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1146OBJesign a preoperative teaching plan.

TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3.A student nurse has been assigned to a 67-year-old patient who is undergoing thoracic surgery to remove a tumor. As part of the preoperative teaching, the student nurse discusses the importance of coughing. Which of the following statements is true regarding why postoperative coughing is important? (Select all that apply.) a.Coughing assists in removing retained mucus in the airways. b.It wont hurt to cough with adequate pain control. c.You can splint your incision when coughing to minimize pain. d.Deep breathing and coughing will remove anesthesia gases from your lungs. e.Deep breathing involves fast, shallow, breaths and then one big breath. f. Coughing is not encouraged because of the potential or dehiscence at the surgical site.

ANS: A, C, D A patient learns to use the diaphragm during deep breathing to take slow, deep, and relaxed breaths. Eventually a patients lung volume improves. Deep breathing also helps to clear any anesthetic gases from the airways. To facilitate deep breathing a health care provider often orders an incentive spirometer for a patient. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. Teach the patient to splint an abdominal or thoracic incision to minimize pain during coughing. Pain control is essential for effective deep breathing and coughing; educate the patient to ask for pain medications as needed.

Deep breathing also helps to clear any anesthetic gases from the airways. The patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is painful. Deep breathing is not fast and shallow, it is slow and deep. Coughing and deep breathing are encouraged even if dehiscence is a possibility, teaching them to splint wound.

PTS:1DIF:Cognitive Level: Applying (Application) REF:1146 | 1169 OBJescribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Planning

MSC:Client Needs: Physiological Integrity